Nursing Process & SBAR

Nursing Diagnoses

-A common language for nurses (NANDA), identifies pt problems and provides basis for interventions -Can be actual diagnoses or risk diagnoses

Nursing Interventions Should Be....

-Appropriate to the diagnosis and outcomes -Consistent with research findings and standards of care -Realistic in terms of abilities, time, and resources available to the nurse and patient -Compatible with patient's values, beliefs, and psychosocial background -Compatible with other planned therapies

Nursing Interventions

-Direct patient care activities -Assist the patient to meet specific outcomes -Promote continuity of care -Focus Documentation requirements

Purpose of Assessment

-Establish Baseline -Determine normal function -Determine presence of dysfunction (things you can fix vs. can't) -Appraisal of total patient situation (physical, psychological, emotional, sociocultural, spiritual) -Synthesize data to determine nursing diagnoses

Outcomes & Patient Goals

-Goals relate directly to nursing diagnoses -Realistic, Patient Centered, and Measurable -Written as behavioral statements

Types of Nursing Interventions

-Independent Nursing Action -Physician initiated interventions -Collaborative interventions

Evaluation

-Indicate if the outcomes/goals were met, partially met, or unmet -Indicate actual behavior as supporting evidence -If goal was partially met or not met, make recommendations for revising the plan of care

Correctly Writing Nursing Interventions

-It is what the nurse will do -Clearly and concisely describe nursing action (who, what, where, when and how) -Begin statements with action verb -Date when written and when plan is reviewed -Signed by nurse initiating the intervention -Use only acceptable abbreviations -Always include a rationale for the action

Type of Outcome Criteria

1. Cognitive: patient shows an increase in knowledge about condition 2. Psychomotor: patient can perform a skill correctly 3. Affective: patients demonstrates a change in attitude, values, or beliefs 4. Physiologic: physical changes in patient are targeted

Risk Nursing Diagnoses

2 parts: Diagnostic Label and Related factors (etiology), NO MANIFESTATIONS -E.g. Risk for peripheral neurovascular dysfunction r/t fall and cast on RLE causing immobilization

Actual Diagnoses

3 Parts: Diagnostic Label, Related Factors (etiology), Defining Characteristics (signs/symptoms, validates diagnoses) -E.g. Impaired physical mobility r/t right tibial fracture AEB RLE cast and need to use crutches to ambulate

Characteristics of the Nursing Process

Assessment, diagnosing, outcome identification, implentating, evaluation 1. Framework for providing nursing care to patients, families, and communities 2. Based on relationships 3. Orderly and systematic 4. Interdependent 5. Provides individualized care 6. Patient centered 7. Used for all ages

Objective Data

CAN be verified -BP 170/110, diaphoresis, equal pupillary reaction, slurred speech

Background

Deliver concise history -What led to current situation -Include pertinent background information (admitting diagnoses and date of admission, current meds, allergies, IV fluids, most recent vitals, current labs, code status, other)

Situation

Describe the situation -What is going on now (one sentence) -Identify self, unit, patient, room number (e.g. I am calling about _________, The problem I am calling about is _____)

Diagnostic Label

Describes the essence of the problem

Secondary Source of Data

Lab values, relatives (if needed)

Different Assessments

Medical Assessment: Fractured Hip Nursing Assessment: Pain, ROM, bed sores, ambulating ***Nurses care about pt's response the illness

Parts of Outcome Criteria

Patient centered, specific, measurable, and realistic -Who: starts with pt as subject -What Action: contains action verb -How Well: contains performance criteria -When: have time frame E.g.: Patient will heal without complications to circulation, sensation or mobility by the time the cast is taken off

SBAR

Situation, Background, Assessment, Recommendation -Communication framework used to: coordinate patient care, ensure safe medication administration, competently conduct transfers, report on a patient's status

Why SBAR?

Support for standardized communication by: -The Joint Commission/National Patient Safety Goals (NPSG) -Quality & Safety Education for Nurses (QSEN) -Institute for Healthcare Improvement (IHI)

Assessment

Use your best judgement -What do you think is wrong (problem seems to be cardiac, respiratory, infection .... etc)

Recommendation

What needs to happen -What would you suggest -Do you need any test like ____ -Order change (obtain clarification and parameters of new orders)

Primary Source of Data

What patient says or guardian says

Subjective Data

What the pt says; things that CANNOT be validated -headache, nausea, tingling sensation, dizziness, takes medication on regular basis