Nursing Process

Nursing Process Steps

AD PIE Assessment Problem Identification (Nursing Diagnosis) Planning Implementation Evaluation

ANA Standards of Nursing Practice 2

ANA Standards of Nursing Practice 2. Diagnosis: The registered nurse analyzes the assessment data to determine the diagnoses of issues. The registered nurse: Derives the diagnoses or issues based on assessment data. Validates the diagnoses or issues with the patient, family, and other health care providers when possible and appropriate. Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan. Keep in mind that nurses do not make medical diagnoses. They assess and monitor their patient's condition closely, they compare the signs and symptoms against the medical diagnosis. The problem describes the patient's response or current state (The nursing diagnosis) The etiology describes the cause or causes of the response. (Related to) The signs and symptoms look at the defining characteristics or observable signs and symptoms that the patient describes or demonstrates. Nursing Diagnosis: Impaired physical mobility related to incisional pain as evidenced by restrictive turning and positioning.

NANDA Common Format

(Nursing Diagnosis) related to (cause/related factors) as evidenced by (symptoms/defining characteristics).

Assessment

-Interview -Physical Assessment -Lab & Diagnostic Studies -Environmental data -Organizing information elements The nursing process begins with assessment or gathering information. The nurse makes clinical judgements about the patient's response to health problems. It defines nursing diagnosis Nursing assessment is a two step process: the first step involves collection and verification of data from a primary source (the patient) and secondary sources (family and medical records, etc.). The second step involves the analysis of data on the basis for developing nursing diagnoses and an individualized plan of care for the patient.

Unmet Outcomes

-Were outcomes realistic? -Was the patient involved? -Does the patient believe outcomes were important? -Does patient know why outcomes were not met? -Have all interventions been carried out? -Were new problems/adverse responses detected early enough? Don't assume that your treatment approaches will be successful Patients with the same health care problems are not treated the same way

Steps of the Nursing Process

1. Assessment 2. Diagnosis (Analysis) 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation The steps are followed in sequence from assessment to evaluation Once the nursing process beings it is continuous It is the fundamental blue print for how to care for patients It helps us to organize and prioritize nursing care for the patient Sometimes the plan you lay out for your patient doesn't work and then you have to evaluate and modify the plan

ANA Standards of Nursing Practice 1

1. The registered nurse collects comprehensive data, pertinent to the patient's health or the situation. The registered nurse: -Collects data in a systematic and ongoing process. -Involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection. -Prioritizes data collection activities based on the patient's immediate condition, or anticipated needs of the patient or situation. -Uses appropriate evidence--based assessment techniques and instruments in collecting pertinent data. -Uses analytical models and problem-solving tools. -Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances. -Documents relevant data in a retrievable format.

Risk Nursing Diagnosis

2-part statement. Diagnostic label. Risk factors. Risk for impaired skin integrity r/t immobility, poor nutrition, and decreased fluid intake. NO AEB (as evidence by!!!) (because it hasn't happened, has not happened, only potential problem) Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community Key to this type of diagnosis is the presence of data revealing risk factors that support the patient's vulnerability. Risk diagnoses do not have defining characteristics or related factors because they have not yet occurred. Risk diagnosis has risk factors. Risk factors are environmental, physiological, genetic, or chemical elements that place a person at risk for a health problem.

Actual Nursing Diagnosis

3-part statement. -Diagnostic label. -Related factors (etiology). -Signs & symptoms (AEB). Describes human responses to health conditions/life processes that exist in an individual, family, or community. It is supported by defining characteristics that cluster in patterns of cues.

ANA Standards of Nursing Practice 3

3. Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation. The registered nurse: Involves the patient, family, and other health care providers in formulating expected outcomes when possible and appropriate. Considers associated risks, benefits, costs, current scientific evidence, and clinical expertise when formulating expected outcomes. Defines expected outcomes in terms of the patient, patient values, ethical considerations, environment, or situation with such consideration as associated risks, benefits and costs, and current scientific evidence. Includes a time estimate for attainment of expected outcomes. Develops expected outcomes that provide direction for continuity of care. Modifies expected outcomes based on changes in the status of the patient or evaluation of the situation. Documents expected outcomes as measurable goals.

ANA Standards of Nursing Practice 4

4. Planning: The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. The registered nurse: Develops an individualized plan considering patient characteristics or the situation (e.g., age and culturally appropriate, environmentally sensitive). Develops the plan in conjunction with the patient, family, and others, as appropriate. Includes strategies within the plan that address each of the identified diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury , and disease. Provides for continuity within the plan. Incorporates an implementation pathway or timeline within the plan. Utilizes the plan to provide direction to other members of the health care team. Defines the plan to reflect current statutes, rules, and regulations, and standards. Integrates current trends and research affecting care in the planning process. Integrates current trends and research affecting care in the planning process. Considers the economic impact of the plan. Uses standardized language or recognized terminology to document the plan. Prioritization With priority the nursing diagnoses are ranked in order of importance. It is important to establish priorities because it helps the nurse sequence nursing interventions whenever the patient has multiple problems. The nurse and the patient select agreed -on priorities that get based on urgency of the problem, the patient's safety and desires, nature of the treatment indicated, and relationship among the diagnoses. Priorities are classified in high, intermediate, and low order. High - can occur in both physiological and psychological dimensions. Ex. Impaired Gas Exchange Intermediate -involves nursing diagnoses that are non-emergent, non-life threatening. Ex. Ineffective peripheral tissue perfusion Low - addresses patient's needs that may not be directly related to a specific illness or prognosis but may affect the patient's future well being. There are three subsets with planning: Setting the priorities, writing expected outcomes, and establishing a target date. And establishing target dates.

ANA Standards of Nursing Practice 5

5. Implementation: The registered nurse implements the identified plan. The registered nurse: Implements the plan in a safe and timely manner. Documents implementation and any modifications, including changes to or omissions of the identified plan. Utilizes evidence-based interventions and treatments specific to the diagnosis or problem. Utilizes community resources and systems to implement the plan. Collaborates with nursing colleagues and others to implement the plan. Ex: If a patient is ordered both tylenol and demerol by the Dr. If a nurse decides to administer tylenol... That is implementation!

ANA Standards of Nursing Practice 6

6. Evaluation: The registered nurse evaluates progress towards attainment of outcomes. The registered nurse: Conducts a systematic, ongoing, and criterion-based evaluation of the outcomes in relation to the structures and processes prescribed by the plan and the indicated timeline. Includes the patient and others involved in the care or situation in the evaluative process. Evaluates the effectiveness of the planned strategies in relation to patient responses and the attainment of the expected outcomes. Documents the results of the evaluation. Uses ongoing assessment data to revise the diagnoses, outcomes, the plan, and the implementation as needed. Disseminates the results to the patient and others involved in the care or situation, as appropriate, in accordance with state and federal laws and regulations.

Altered

A change from baseline

Critical Thinking

A critical thinker identifies and challenges assumptions, considers what is important in a situation, imagines and explores alternatives, applies reason and logic, and thus makes informed decisions. When a nurse applies critical thinking in their work the focus is on options for problem solving and making decisions. The decisions are not made in a hasty manner Learning to think critically enables the nurse to be a patient advocate and to make better informed decisions about their patient's care

Nursing Process

A decision-making approach that promotes critical thinking in the clinical setting Nursing process focuses on the human response to medical treatment, problems, and changes in the patient's life Requirement set forth by the National Practice Standards (ANA) Basis for State Board questions

Critical Thinking

Ability to think critically through the application of knowledge and experience, problem solving, and decision making. Central to professional nursing practice. The active, organized, cognitive process used to carefully examine one's thinking and the thinking of others. Nurses need to think critically, solve problems, and find the best solution for the patient's needs to assist the patient in maintaining, regaining, or improving their health. The mind is used in forming conclusions, making decisions, drawing inferences and reflecting. Remember that every patient with problems are unique and may be a product of many factors. It is a way to solve problems using reasoning. It is a systematic, ordered approach to gathering data and solving problems.

Criteria for Nursing Interventions

Action Verb Quantity Condition Time

Implementation

Activity prescribed by the nurse to assist the patient to achieve outcome criteria and prevent, resolve, or control problems. Also known as interventions Taking appropriate action demonstrates the implementation step of the nursing process. Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. They are evidenced based. Direct and indirect care measures aimed at individuals, families, and /or the community.

Collaborative Problems

An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status Nursing intervene in collaboration with personnel from other health care disciplines. They are often interdisciplinary interventions. In collaboration with the interdisciplinary health care team interventions are carried out to resolve a problem. Nursing diagnoses and collaborative problems represent the range of patient conditions that require nursing care.

Data Clustering

Analyzing Organizing the information into meaningful clusters A cluster is a set of signs or symptoms that are grouped together in a logical order Data clustering help to generate a nursing diagnosis Cluster in a logical way, such as systems when clustering, you start to see patterns Consider age, culture, developmental status, disease process, occupation, socioeconomic status When the nurse clusters the data, certain cues will alert the nurse more than others. The cues help to form the nursing diagnoses You want to validate the assessment data with another source. This helps to develop accuracy. Validate findings from the physical examination and observation of patient behavior by comparing data in the medical record. You can also consult with other nurses or health care team members

Goals/Outcomes

Are the measuring sticks of the success of the plan of care. Direct interventions (need to know what you are trying to accomplish before you can decide how to accomplish it.). Set time frame. Should be patient-centered. An expected outcome is a specific measurable change in a patient's status that is expected in response to nursing care. Do not state your intentions, but the desired patient results. The expected outcome statement gets written in measurable terms. -Incorrect: patient will have less pain. -Correct: patient will report pain acuity less than 4 on a scale of 0 to 10 in 24 hours patient outcomes must be selected before the interventions.

Nursing Process

Assess: Father information about the patient's condition Diagnose: identify the patient's problem Plan: set goals of care and desired outcomes and identify appropriate nursing actions Implement: perform the nursing actions identified in planning Evaluate: determine if goals and expected outcomes are achieved

Standard of Nursing Interventions

Clinical Practice Guidelines and Protocols - systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about health care for specific clinical situations. Standing Order - Preprinted document containing orders for routine therapies, monitoring guidelines, and /or diagnostic procedures for specific patients with identified clinical problems. Directs patient care in a specific clinical setting. Standards of Practice - Nurses use the ANA Standards of Professional Nursing Practice as evidence of the standard of care provided to the patient. Quality and Safety Education for Nurses (QSEN) - Standard competencies that are established regarding knowledge, skills, and attitudes for the preparation of future nurses. QSEN prepares nurses so they can continuously improve the quality and safety of health care systems within which they work.

Signs & Symptoms (AEB)

Clustering. -Minimum of 3 signs & symptoms. Supports selected nursing diagnosis. Objective data should validate subjective data. The symptoms will delineate the defining characteristics or observable signs and symptoms demonstrated or described by the patient

Modification

Continuous process Reassessment Goal revision Add or delete goals. Positive evaluations Negative evaluations You can make modifications based on your evaluation and revise the care plan Positive evaluations occur when desired results are achieved making the nursing intervention effective. Negative evaluations are undesirable results. This indicates that the interventions were not effective in resolving the actual problem.

Complex Critical Thinking

Critical thinkers begin to separate themselves from experts. They analyze and examine choices more independently. Nurse learns that alternative and perhaps conflicting solutions exist. Each solution has benefits and risks that you weigh before making the final decision. Thinking becomes more creative and innovative. They analyze the clinical situation and examine choices more independently. They are willing to consider different options from routine procedures when complex situations develop. The nurse learns a variety of different approaches for the same therapy.

Critical Thinking

Critical thinking competencies are the cognitive processes a nurse uses to make judgments Specific critical thinking competency in nursing is the nursing process Critical thinking involves recognizing an issue ( Ex. patient problems) exists, analyzing the information about the issue (Ex. Clinical data about the patient), evaluating the information (reviewing assumptions and evidence) and making conclusions. A good critical thinker considers what is important in a situation, imagines, and explores, alternatives, considers ethical principles, and then makes informed decisions.

Evaluation

Determining whether desired outcomeshave been met A continuous process essential to assuring the quality and appropriateness of the care. Met Partially met Not met This is the final step in the nursing process. It is crucial to determine that after applying the nursing process if the patient improves. In this final step of the nursing process, the nurse uses the evaluation to document whether the plan requires revision. It should also be noted when the outcomes were met and this would indicate when a particular diagnosis is no longer relevant to the patient's plan of care.

Guideline: Avoiding Errors When Writing Diagnostic Statements

Don't identify a medical diagnosis, identify the patient's response. A medical diagnosis requires medical interventions -Incorrect: pain related to myocardial infarction. -Correct: acute pain related to physical exertion Don't identify a symptom, identify a NANDA International diagnostic statement. One symptom is insufficient for problem identification. -Ex.: Shortness of breath, pain on inspiration, and productive cough with thick secretions -Correct: Ineffective breathing pattern related to increased airway secretions Don't write a nursing diagnosis based on value judgments. -Ex: Incorrect: Spiritual Distress related to atheism as evidenced by statements that she has never believed in God. -Correct: There may be no diagnosis in this situation. The person may be at peace with her beliefs (not with yours). Don't use legally inadvisable statements. Watch out for statements that imply blame, negligence, or malpractice. -Incorrect: Recurrent angina related to insufficient medication. -Correct: Chronic pain related to improper use of medication. Don't state two problems at the same time. -Ex: Incorrect: Pain and Fear related to diagnostic procedures. -Correct: Fear related to unfamiliarity with diagnostic procedures. Pain related to diagnostic procedures.

Health Promotion Nursing Diagnosis

Express readiness to enhance specific health behaviors. Diagnosis may apply to any individual, family, group, or community. Has only defining characteristics. Related to factors can be used to improve understanding of diagnosis. Health Promotion nursing diagnosis is a clinical judgment concerning a patient's motivation and desire to increase well-being and actualize human health potential. Patients need to express a readiness to enhance specific health behaviors.

Nursing Diagnosis

Identifies a response to illness Focuses on the physical, psychosocial, and spiritual needs of the patient Addresses potential and actual problems Is validated with the patient if possible Uses individualized outcomes and interventions Can usually be resolved Compared to scientific method of solving problems, expect that scientist identifies he problem and gathers data while the nurse collects the data and then determines the problem The Nursing Process is often compared to the Scientific Method of solving problems. Both the Nursing Process and the Scientific Method are very similar in the fact that the steps proceed from the identification to evaluation of a solution Doctors want just the facts

Etiology (Related To)

Identifies the cause/contributing factor responsible for the presence of a specific patient problem/need. Includes four categories: -Pathophysiological ( biological or psychological), treatment related, situational ( environmental or personal), and maturational. Identify the related factor from your patient's assessment data

Medical Diagnosis

Identifies the pathologic basis for the illness Focuses on the physical condition of the patient Addresses actual, existing problems Is not validated with the patient Uses standardized goals and treatments May not always be resolved

Diagnostic Label

Identify patient's actual or potential problems or human responses -Concise statement of a patient problem (actual or potential) that interferes with basic needs -Can be treated by nursing action Formulate nursing diagnosis to provide effective nursing care. Incorrect nursing diagnosis = inappropriate care Look at the clusters and determine if abnormal, normal, altered, at risk or possible altered function. The more evidence of each, the more likely you are to be correct. The problem describes the patient's response or current state (Nursing Diagnosis). Nursing Diagnoses includes a problem and related contributing conditions.

Data Gathering Methods

Interview Observation Physical Examination A patient centered interview becomes the basis for forming trust and effective long term therapeutic relationships with patients

Intuitive Judgment

Intuition is the ability to understand immediately without using formal analysis Intuition is based on experience and knowledge Helps the nurse to act quickly if necessary Always remember that a nurse can not act on intuition alone, it is critical to understand the knowledge that we possess; it is also important to understand what we do not know

Critical Thinking

Is a continual process characterized by open-mindedness, continual inquiry, and perseverance. Willingness to look at each unique patient situation and determine which assumptions are true and relevant. Critical thinking will encourage you to ask about a situation: why?, what am I missing, what do I really know about this patient's situation?, and what are my options? What are some examples? Discussing alternative pain techniques Use to make sure given thing is correct and appropriate for the given situation

Basic Critical Thinking Level

Learner trusts that experts have a right answer for every problem. Thinking is concrete and is based on a set of rules/principles. Basic critical thinking is an early step in developmental reasoning. Basic critical thinker should accept the diverse opinions and values of experts. Ex: A nursing student uses a hospital procedure manual to confirm how to insert a Foley Catheter. In the beginning students make a conscious effort to apply critical thinking because students are task oriented. They are likely to follow procedures step by step because they do not have enough experience to anticipate how to individualize procedures when problems arise. They will be likely to follow the procedure step by step without adjusting it to meet the patient's unique needs. There is not enough experience to anticipate to individualize the procedure. Keep in mind that inexperience, weak competencies, and inflexible attitudes can restrict person's ability to move to move onto the next level.

Medical Diagnosis vs. Nursing Diagnosis

Medical. -Defines the actual illness or pathology. -Focus on correction or prevention of the pathology of specific organs/body systems. -Problems with structure/function -Does not usually change Nursing -Identifies a human response to an actual or potential health problem or life process -Changes as the patient's situation or perspective changes The primary distinction between nursing diagnosis and medical diagnosis is that nursing identifies patient problems that nurse can treat independently

Interventions

Nurse-initiated interventions: are independent responses of the nurse to the patient's health care needs and nursing diagnoses Physician-initiated interventions: are based on a physicians response to treat or manage a medical diagnosis (The nurse intervenes by carrying out the orders that are written by the physician) Collaborative interventions: interventions requiring the knowledge, skill, and the expertise from multiple health professionals Selection of interventions: the nurse does not select the interventions hastily When choosing the interventions as a new nurse it is suggested that the stated interventions should answer the following questions: -What is the intervention? -When should each intervention be implemented? -How should the intervention be performed for this specific patient? -Who should be involved in each aspect of intervention? A nurse is able to act within his or her own scope of practice to intervene on the patient's behalf

Components of a Nursing Diagnosis

Nursing diagnosis are presented in a two part format. Diagnostic Label Related Factors Nursing diagnosis are presented in a two-part format: The diagnostic label followed by a statement of a related factor. The diagnostic label is the actual name of the nursing diagnosis as it is approved by NANDA International. Describe the essence of the patient's response to a health condition in very few words. Descriptors are used that give additional meaning to the diagnosis. Ex. Impaired mobility - Impaired describes the nature or change in mobility. Stress this point on how to pick your nursing diagnoses Related factors are causative or other contributing factors that have influenced the patient's actual or potential response to the health problems and can be changed by the interventions. Related factors includes four categories: pathophysiological (biological or psychological), treatment-related, situational ( environmental or personal), and maturational. Impaired physical mobility related to limited range of motion

North American Nursing Diagnosis Association- NANDA

Patient Problem -Use NANDA approved list -Do NOT use medical diagnoses The term Nursing Diagnosis was acknowledged and endorsed in 1973 by the ANA when they published their Standards of Nursing Practice. In 2003 NANDA change its name to NANDA International to better reflect the international utility of nursing diagnoses for the health care community that is global. The official definition of nursing diagnosis approved by NANDA in 1990 - " A nursing diagnosis is a clinical judgment about an individual, family, or community response to actual or potential health problems/ life processes which provides the basis for definitive therapy toward achievement of outcomes for which the nurse is accountable." (Carpenito, 1995) The NCSBN (National Council of State Boards of Nursing, which administers the NCLEX defines the nursing process as scientific, clinical reasoning approach to patient care that includes assessment, analysis, planning, implementation, and evaluation. The use of tern ANALYSIS instead of diagnosis places emphasis on analytical work need to form correct nursing diagnoses. Think of a nursing diagnosis as being the basis for nursing interventions.

Types of Nursing Diagnoses

Problem- focused nursing diagnosis: clinical judgement concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community -Defining characteristics: supports each problem focused diagnostic judgment. Selection of problem focused nursing diagnosis indicates that there are sufficient assessment data from the defining characteristics to establish that particular nursing diagnosis -Related Factor (Etiology): an etiological or causative factor for the diagnosis (or data that appeared to show some type of patterned relationship for with a nursing diagnosis) Risk nursing diagnosis Health promotion nursing diagnosis

Nursing Care Plan

Promotes communication between caregivers. Directs care and documentation. Creates a record that can be later used for evaluation, research, and legal purposes. Provides documentation of health care needs for insurance reimbursement purposes. Laws & standards mandate that the care plan be specific, clear, and consistent. The written care plan is designed to direct clinical care and to decrease the risk of incomplete, incorrect, or inaccurate care. The plan is organized so that any nurse can quickly identify the patient's nursing diagnosis, goals, outcomes, and nursing interventions to be delivered. It directs that nursing actions.

Recognizing Data Clusters

Recognizing patterns or trend Examines clusters of data Relationship forms between and among assessment findings Clusters of data will often contain defining characteristics When you start to recognize patterns or trends, they get compared with standards; you start to come to conclusions about the patient's response to health problems. Clusters of data are examined and are a set of signs and symptoms grouped together in a logical order. Alone the signs and symptoms may not mean a whole lot to you but, grouped together, the nurse should start to see relationships between and among the assessment findings. Defining characteristics are the clusters and patterns of data that contain the clinical criteria or assessment finding to validate the actual nursing diagnosis The clusters start to clearly define a patient's health problems

Acute

Severe but of short duration

Goal/Outcome Setting

Short term: before discharge or usually within 24 hours Long term: may not be achieved before discharge; may require continues attention post-discharge The purposes for writing goals and expected outcomes are: to provide direction for the selection and use of nursing interventions and to provide focus for evaluation of the effectiveness of the interventions. Goals and outcomes will meet standards by the following: being relevant to the patient's needs, specific, singular, observable, measurable, and time-limited. Short-Term Goal -It is a goal that is expected to be achieved within a short time frame. -Ex. patient will achieve comfort within 24 hours postoperatively. Long-Term Goal -This is expected to be achieved over a longer time frame. -The goals focus on prevention, rehabilitation, discharge and health education. -Appropriate for problem resolution after discharge. -More appropriate for patients in home care settings, or those that are adapting to chronic illnesses and reside in long term care facilities. -Ex. patient will adhere to postoperative activity restrictions for 1 month.

Decreased

Smaller, lessened; in size, degree; diminished; lesser amount

Intermittent

Stopping and starting again at intervals, periodic, cyclic

Data Collection: Types

Subjective: What the patient reports, believes, or feels and cannot be measured; Statements and symptoms Objective: Observable & measurable Two primary sources of data Subjective data should be validated with objective data Only validated data can be accepted as fact

Standards of Nursing Practice

The six Standards of Practice describe a competent level of nursing care Demonstrated by the critical thinking model known as the nursing process (critical thinking and nursing process go hand and hand) The nursing process is the foundation of clinical decision making Assessment: The RN collects comprehensive data pertinent to the patient's health or the situation Diagnosis: The RN analyzes the assessment data to determine the diagnoses and issues (nursing diagnosis) Outcomes Identification: The RN identifies expected outcomes for a plan individualized to the patient or the situation (Goal Setting) Planning: The RN developed a plan that prescribes strategies and alternatives to attain expected outcomes Implementation: The RN implements the identified plan Evaluation: The RN evaluates progress toward attainment of outcomes

Levels of Critical Thinking in Nursing

There are 3 basic levels to critical thinking: Basic, Complex, and Commitment Expert nurses will think critically automatically Students are more task oriented in the beginning

Commitment

This is the third level of critical thinking. Person anticipates when to make choices without assistance from others and accepts accountability for decisions. Nurse chooses an action or belief based on available alternative and supports it. Accountability for the decision is taken, decision results are considered and determined if its appropriate.

Criteria for Nursing Interventions Example

offer 100cc of fluid of patient's choice q hour

Dysfunctional

Abnormal, impaired, or incomplete functioning

Nursing Process

Framework for contemporary nursing practice An organized, systematic approach used by nurses to meet the individualized health care needs of their patients, families, and communities A systematic method of giving humanistic care that focuses on desired outcomes in cost-effective manner As nursing became more recognized as a profession, defining exactly what nursing is about was important Professional practice includes knowledge from social and behavioral sciences, biological and physiological sciences, and nursing theories

Data Base

History Physical Exam Diagnostic Studies This is the purpose of the assessment. A database is established to meet the patient's perceived needs, health problems, and response to the problems

Measurable Verbs

Identify Describe Perform Relate State List Verbalize Hold Demonstrate Will lose Will gain Has an absence of

Increased

Larger, enlarged, greater in size, amount, or degree

Chronic

Lasting a long time, recurring, habitual, constant

Impaired

Made worse, weakened, damaged, reduced, deteriorated

Ineffective

Not producing the desired effect

Writing Outcomes Example

Patient will report absence of pain based on scale of 0 to 10 in 24 hours urine output will be at least 100 cc/hr within 24 hours

Data Collection: Sources

Primary: patient Secondary: diagnostic tests, consults, labs, PMH, family Data may be organized in a variety of methods After you have collected the data, it needs interpreted and validated to ensure a complete database. In clinical it is often collected by body systems Always identify a nursing diagnosis from the data, not the reverse Some other secondary sources of data collection are: Health care team, medical records, other records and the scientific literature, and nurse's experience

Planning

Prioritization according to Maslow Goal/outcome setting Writing a nursing care plan Discharge planning

Nursing Diagnosis: PES Format

Problem - NANDA 1- Example: Impaired physical mobility (NANDA Approved Nursing Diagnoses) Etiology ( or related to factor) - Example Incisional pain Signs & Symptoms (or defining characteristics) -As evidenced by... restricted turning and positioning -AEB (as evidence by)

Nursing Process

Remember: Be Specific! The Purpose of Nursing Care Plans: To identify nursing actions to be delivered....not a part of documentation!

Scientific Rationale

Scientific explanation for the intervention Use references, such as textbook, drug book, etc. A scientific rationale is the reason that, based on supporting literature, a specific nursing action was chosen. If possible it is always good to provide a reference for your rationale, this helps to cite a source from scientific literature. It also reinforces evidenced based nursing practice. Scientific explanation for how the intervention helps

Reassessment

The appropriateness of the nursing action The need to revise the interventions The development of new patient problems/needs The need for referral to other resources The need to rearrange priorities

Non-Measurable Verbs

know understand appreciate think accept feel

Guidelines for Writing Goals and Expected Outcomes

patient-centered: the error that commonly occurs is when the goals are written to reflect the nurse's goals or outcomes Singular goal or outcome: goals an expected outcome statements should address one behavior or response at a time Observable: The nurse needs to be able to determine through observation if change has taken place. Changes that are observable can occur in physiological findings, the patient's level of knowledge, perceptions or expressed feelings, and behaviors Measurable: goals and expected outcomes should be stated in measurable terms and this allows the nurse to quantify changes in the patient's condition. Common mistakes are using normal, stable, acceptable, or sufficient in the expected outcome statement. The nurse needs to utilize terms that describe, quality, quantity, frequency, length, or weight Time-limited: time frames are essential because they help the nurse and patient to determine if progress has been made at a reasonable rate. As the date of evaluation arrives, the nurse assesses the patient to determine whether the particular outcome has been reached Mutual Factors: the mutual set goals ensure that the nurse and the patient agree on the direction and time limits of care. As a nurse you may need to direct some of the foals and expected outcomes to keep the patient physically and emotionally stable and safe Realistic: The goals and expected outcomes that are set must have the ability to be achieved It is important to write goals and outcomes clearly so that all members of the health care team understand the plan of care

Writing Outcomes

subject measurable verb outcomes criteria target time be specific!