The Nursing Process and Care Planning

Process Used for Generating and Selecting Interventions

1. Review the nursing diagnosis 2. Review the desired client outcomes 3. Identify several interventions/ actions. 4. Choose the best interventions for this client. 5. Individualize the standardized interventions.

Two Part Statements

"Risk" nursing diagnoses has two parts. The validation for a risk nursing diagnosis is the presence of risk factors. The risk factors are the second part (etiologies) ~Example~ Risk for impaired skin integrity related to immobility.

Evolution of Nursing Diagnosis

"The diagnosis and treatment of human response to actual or potential health problems." (ANA, 1980) 1980s: Most state nurse practice acts began to designate nursing diagnosis as an exclusive responsibility of registered professional nurses.

problem

(Diagnostic Label) The problem statement, or diagnostic label, describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely in a few words.

Human responses to Health Problems

-A health problem is any condition that requires intervention in order to promote wellness or to prevent or resolve disease/illness -Decide how to treat it: independently or collaboratively

Reflecting on the Assessment

-Are my data complete, accurate, validated? -Did I record data, not conclusions? -Did I follow up with special needs assessment if indicated? -Think about the client interview -Review the physical assessment, observation, and examination

Analyzing Data

-Identify significant data -Cluster cues -Identify data gaps and inconsistencies -Draw conclusions about health status -Make inferences -Identify problem etiologies -Verify problems with the patient

What is Planning?

Planning can be formal or informal " Formal Planning is a conscious, deliberate activity involving decision making, critical thinking, and creativity" (Wilkinson et al..., 2016) Informal planning: Making mental notes or plans

Medical Diagnosis

A medical diagnosis is made by a physician and refers to a condition that only a physician can treat. Describes a disease, illness or injury.

nursing diagnosis

A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently. Responces

intervention

A nursing intervention is "any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes".

What Is the Nursing Process?

A systematic problem-solving process that guides all nursing actions

Activity and Exercise Functional Health Pattern

Activity and Exercise Assessment is focused on the activities of daily living requiring energy expenditure, including self- care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.

Types of Nursing Diagnosis

Actual: An actual nursing diagnosis describes a clinical judgment that the nurse has validated because of the presence of a major defining characteristic. Risk: A risk nursing diagnosis describes a clinical judgment that an individual/ group is more vulnerable to develop the problem than others in the same or a similar situation because of risk factors. Possible Syndrome Wellness: A wellness diagnosis is a clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness

Three Part Statements

An actual nursing diagnosis consists of three parts: Diagnostic label/ category Contributing Factors/ etiologies Signs and symptoms/ clinical manifestations ~Example~ Impaired skin integrity related to immobility as evidenced by a 2cm wound on the left foot.

actual health care problems

An actual nursing diagnosis is based on the presence of associated signs and symptoms.

Theory of Integral Nursing

An integral worldview and approach that can help each nurse and student nurse increase her or his self-awareness, as well as awareness of how one's self-affects others-- the patient, family, colleagues, the workplace, and the community."

assessment

Assessing is the systematic and continuous collection, organization, validation, and documentation of date. 4 types of assessments. * Initial nursing assessment * Problem-focused assessment * Emergency assessment * Time-lapsed assessment

What are the Phases of the Nursing Process?

Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation

Nursing Process: Assessment (cont'd)

Assessment includes: Collecting data Using a systematic and ongoing process Categorizing data Recording data

Nursing Process: Assessment

Assessment is the systematic gathering of information related to the physical, Mental, Spiritual, Socioeconomic, and cultural status of an individual group, or community.

Implementation Phase

Doing, delegating, and documenting

projected outcomes

Begin with "Patient will..." Desired outcome ("...attain ____..." or "...maintain ____...") and explicit evaluation criteria ("...as evidenced by...") Time Frame ("...by...")

activities of daily living

Behaviors related to personal care that typically include bathing, dressing, eating, toileting, getting in or out of a bed or a chair, and walking.

Reflecting Critically About Expected Outcomes/Goals

Is each expected outcome: Appropriate for the nursing diagnosis? Derived from only one nursing diagnosis? Descriptive of only one client response/behavior? Stated as a client behavior, not a nurse activity?

Intuitive Thinking

Collection and evaluation of information and patient data from an intuitive, nonverbal (right brain) mode. Emerges when the nurse is open and present to the patient's subtle clues. Allows a nurse to know something immediately without consciously using reason

problem-solving

Depending on the type of client problem, the nurse writes interventions for observation, prevention, treatment, and health promotion.

outcome criteria

Descriptions of specific patient behaviors or responses that demonstrate meeting of or achievement of goals related to each nursing diagnosis. These statements, like goals, should be verifiable, framed in behavioral terms, measurable, and time specific. Outcome criteria are considered to be specific, whereas goals are broad.

Relation to Other Steps

Diagnosis * Data are used to identify the client's actual or potential health problems and strengths. Planning outcomes and interventions * Data helps you formulate realistic goals and choose the interventions most likely to be acceptable to and effective for the client.

NANDA-I Nursing Diagnosis: Components

Diagnostic label Definition Defining characteristics Related factors Risk factors

Documenting Data

Document as soon as possible Write legibly without using acronyms Avoid using inferences ("just the facts") Use the client's own words Record only pertinent, important, and relevant data

Why is a written nursing care plan important?

Ensures care is complete Provides continuity of care Promotes efficient use of nursing efforts Provides a guide for assessing and charting Meets requirements of accrediting agencies

Common Errors of Evaluation

Failing to evaluate systematically Failing to record results Failing to use reassessment data to reexamine and modify the care plan

Planning Client Goals/Outcomes

Goals: Describe the changes in client health status you hope to achieve Nursing-sensitive outcomes: Those that can be influenced by nursing interventions

Organizing our Thinking

Gordon's Functional Health Patterns *Describe common patterns of behavior that can be functional or dysfunctional *Model intended for nursing assessment. *Functional Health Pattern are major model concepts.

Holistic Diagnosis - the holistic nurse analyzes assessment data to determine the diagnosis or issues expressed as actual or potential patterns, problems, needs, and/ or health issues.

Identification of the patterns, needs & challenges obtained from the assessment data to provide an understanding of the client's experience. * it is easier to see patterns in others rather than ourselves Identification of client risk factors that influence health. The focus is on the client's goals to increase well-being and health

How to Choose a NANDA-I Label

Identify the broad topic (or domain) that seems to fit the cue cluster Narrow your search (to the class or most likely labels) Use a nursing diagnosis handbook; compare definitions and defining characteristics of the diagnostic labels with your cue cluster

Relation to Other Steps (cont'd)

Implementation * You gather data by observing the client's responses as you perform interventions. Evaluation * You assess client responses to interventions; client responses are data.

Holistic Evaluation

In partnership with the client and others, the holistic nurse..... Evaluates if care is effective Notes changes in the health experience of the individual Realizes that outcomes are continuous and that frequent changes occur with illness and health. Monitors if the outcomes were successfully achieved.

assessment data

Information about a client's health status

Type of Nursing Assessments

Initial Ongoing Comprehensive Focused Special Needs

Basic Physical Assessment Techniques

Inspection Palpation Percussion Auscultation

Intuitive Perception & Intuition

Intuitive Perception: allows one to know something without consciously using reason. Intuition: the perceived knowing of things and events without the conscious use of rational processes; using all of the senses to receive information Clinical Intuition: "process by which we know something about a client that cannot be verbalized, or is verbalized poorly, or for which the source of the knowledge cannot be determined."

Reflecting Critically About Expected Outcomes/Goals (cont'd)

Is Each expected outcome: Stated in positive terms? Measurable or observable? Given specific and concrete performance criteria?

What is the difference between Medical assessments and Nursing Assessments?

Medical Assessments focus on disease and pathology. Nursing Assessments focus on the client's responses to illness.

Holistic Assessment - The holistic nurse collects comprehensive data pertinent to the person's health and/ or the situation

Nurse and client identify health patterns and prioritize health concerns. *A continuous process Includes physical, functional, psychological, mental emotional, cultural, spiritual, transpersonal, and energy field assessment of the whole person. Involves scientific and intuitive approaches (analytical and "gut feelings")

Organizing Data How do we organize data?

Nursing Models Non-Nursing Models

Wellness Diagnosis

One Part Statement Diagnostic label/ category "Readiness for Enhanced ________________" (e.g. Readiness for enhanced self-care management) A client has a desire to increase wellness in a particular area and the client is currently functioning effectively in a particular area.

Maslow- Prioritization

Organize and prioritize care to the framework of Maslow

Prioritizing Problems

Places problems in order of importance Does not mean that you must resolve one problem before attending to another Determined by the theoretical framework you use

Collecting Data

Primary data: directly from the client Secondary data: from a family member or another person

Core Value 2: Holistic Caring Process

Provide care that recognizes the totality of the human being using an integrated and comprehensive approach. A 'circular' process way of thinking. Holistic nurses focus on care interventions that promote healing, peace, comfort, and a subjective sense of well-being for the person.

What are Nursing Interventions?

Purpose: to achieve client outcomes Also called nursing actions, measures, strategies, activities Based on clinical judgment and nursing knowledge Reflect direct and indirect care

The Nursing interview

Purposeful communication Structured communication Involves questioning the client The purpose is to gather subjective data for the nursing database

Reflective Practice

Reflective practice is a mindful process of self-observation in the midst of an experience, as well as after an experience..... for the purpose of resolving values and practice contradictions, to gain new self-insight and empowerment, and to respond more congruently in future situations.

Evaluating and Revising the Care Plan

Relate outcome to interventions Draw conclusions about problem status Revise the care plan

Checklist for Evaluating the Care Plan

Review assessment Review diagnosis Review planning outcomes Review planning interventions Review implementation

potential health care problems (high risk for....)

Risk factors indicate that a problem is likely to develop unless nurses intervene.

Organizing Our Thinking: Gordon's Functional Health Patterns

Sexuality-Reproductive Cognitive-Perceptual Psychosocial (Role-relationship, Self-perception, Value- belief) Activity Exercise/ Sleep Rest Health Perception-Health Managment Nutritional-Metabolic/Elimination Supports (Coping-Stress Tolerance) Remember+ things can fall into more than one place of data

Validating Data- When to Validate

Subjective/objective data do not agree or make sense Client's statements differ at different times in the interview Data are far outside normal range Factors are present that interfere with accurate measurement

Documentation

The final step of implementation Records the nursing activities and client's response

Evaluation

The final step of the nursing process * Evaluate *Client's progress towards goals *Effectiveness of nursing care plan *Quality of care in the healthcare setting

Holistic Care Planning - Develops a plan with strategies and alternatives to attain expected outcomes.

The holistic nurse creates a care plan that... Respects the client's experience and the uniqueness of each healing journey. uses both biomedical treatments and conventional care in conjunction with complementary/ integrative care and therapies.

Holistic Outcomes Identification - Identifies expected outcomes for an individualized plan to the person and/or situation.

The holistic nurse identifies outcomes... Based on the client's values and beliefs, preferences, age, spiritual practices, environment, ethical considerations, and or situations. Partners with the person to identify realistic goals based on the persons present and potential capabilities and quality of life.

Holistic Nurse Caring Process

The nursing process and the standard of Practice for Holistic Nursing define what holistic nurses do: Assessment Diagnosis (pattern, problem, need, health, issue) Planning/ Outcomes Identification Implementation Evaluation

What is the " General Survey"?

The overall impression of the client. * It begins at first contact and continues throughout the exam. First Impressions Facial Characteristics Body Type and Posture Dress, Grooming, and Hygiene Cultural Considerations Signs of Distress

How Nursing Diagnosis Relates to Outcomes and Interventions

The problem suggests the goal. The etiology suggests interventions.

inspection

The skill of observing the client in a deliberate, systematic manner

Holistic Implementation/ Intervention - The holistic nurse implements the identified plan in partnership with the person.

The therapeutic use of self is one of the best ways a nurse can help/ intervene and promote healing for clients. Also includes: * Coordination of care * Health Teaching/ Promotion * Consultation * Treatment (referrals, therapies)

Core Value 1: Holistic Philosophy, Theories, Ethics

Theory of Integral Nursing A comprehensive way to organize multiple phenomena of human experience related to four perspectives of reality.

What is the Purpose of the Nursing Process?

To help the nurse provide goal-directed, client-centered care

What is Diagnosing?

Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status Includes strengths, problems, and factors contributing to the problems

Knowledge Check

When gathering admission assessment data, the nurse obtains a weight of 200 pounds. The client States, "I've never weighed that much!" The nurse should? a. Explain to the client how weight gain occurs. b. Check the calibration and re-weigh the client. c. Document the weight as 200 pounds. d. Instruct the nursing assistant to re-weigh the client in 2hrs.

Knowledge Check

Which action by the nurse may be a barrier to obtaining complete and reliable information from an interview with a client? a. Nothing that the client's body language indicates that he or she is fatigued. b. Maintaining eye contact with the client if it is not culturally inappropriate to do so. c. Carefully guiding the conversation so that important topics are discussed d. Asking the client directly, "Why are you not taking your insulin?"

nursing care plan

Written guidelines of nursing care that document specific nursing diagnoses for the client and goals, interventions, and projected outcomes.

planning

a deliberate, systematic phase of the nursing process that involves decision making and problem solving.

nursing process

a systematic, rational method of planning and providing individualized nursing care

standing order

a written document about policies, rules, regulations, or orders regarding client care.

dependent interventions

activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses. Example~ Medical Doctor perscribes a patient a medication.

interdependent interventions

also called collaborative interventions. Actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, pharmacists and primary care providers.

Objective data

also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled and are obtained by observation or physical examination. ~Example~ labs or temperature

Subjective data

also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. For example: itching, pain, feelings of worry.

implementation

consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.

database

contains all the information about a client; it includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

nursing health history

data about the client's current level of wellness - included a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness

physical exam

head to toe, skin color, hygiene, mental status, movement, posture

patient-centered goals

in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions.

auscultation

listening to sounds within the body (usually with a stethoscope)

protocol

predeveloped to indicate the actions commonly required for a particular group of clients.

preventive nursing action

promote health and prevent illness to avoid the need for acute or rehabilitative health care

quality assurance

refers to evaluation of the level of care provided in a health care agency, but it may be limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country.

audit

refers to the examination or review of records.

priority

status established in order of importance or urgency

percussion

tapping a part of the body for diagnostic purposes

rationale

the evidence-based principle given as the reason for selecting a particular nursing intervention.

priority setting

the process of establishing a preferential sequence for addressing nursing diagnoses and interventions.

independent interventions

those activities that nurses are licensed to initiate on the basis of their knowledge and skills. Example~ home meal plan

palpation

to examine by touch

evaluation

to measure if goals in the planning step were met; a step in the nursing process