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Unformatted text preview: Nursing Process Overview *Planning *Interventions/Implementing *Evaluation Planning The process of developing a plan of care that prescribes interventions to attain expected outcomes Stages of Planning Establish priorities Any problems that need immediate attention? What happens if I delay? Apply nursing standards (MGL, ANA, local agency) Establish client goals/expected outcomes Determine nursing actions/interventions Evaluate the clients progress towards goal Document the plan of nursing care ANA Standards For Planning Outcome Identification Derived from diagnoses Individualized to the client's condition or needs Mutually formulated with the client/family and health care providers, when possible Realistic in relation to the client's present and potential problem
ANA Standards for Nursing Practice, 1991 ANA Standards (Cont.)
Includes a time estimate for attainment Attainable in relation to resources available to the client Reflects current nursing practice Provides direction for the continuity of care Documented as measurable goals Goals/Outcomes for Problem Types Problems Pt. Response Nursing Focus Actual Reduction or Reduction or resolution resolution Risk Problem not Prevention and developed detection Possible No patient Confirm/rule out response Collaborative Problem not Detection and developed prevention Wellness Achieve higher Health promotion level of wellness Priorities--Which Comes First? Potential Fluid Volume Deficit related to increased metabolic needs Potential blockage of Foley Catheter related to the passage of large clots Potential for inadequate ventilation Potential Impaired Skin Integrity related to fragile skin and immobility Dehydration related to persistent vomiting ClientCentered Goals The subject of a clientcentered goal must be either the patient, or a part of the patient Examples: Ms. Michaels will lose 5 lbs in 3 weeks (by 7/31) Mrs. Matthews will walk unassisted with crutches with crutches by 2/6 Mr. Daniels will demonstrate sterile injection technique by 9/18 Classification of Outcomes "Nursing Outcome Classifications" (NOCs) Goal: 1. ID, label, validate , classify Nsg sensitive pt outcome and indicators. 2. Evaluate the validity & usefulness of the classification in clinical field testing 3. Define and test measurement procedures for outcomes and measurements Writing Goals One goal for every nursing diagnosis-- directly from the nursing diagnostic statement Ask: If the problem is solved, how will the patient (part of patient) look? Goal should demonstrate an improvement or resolution of the nursing diagnosis Ex: Risk for impaired skin integrity related to immobility Goal: Skin will remain intact, with no redness over bony prominences Goal Statement Include the Who, What, When, Where, and How Use specific, measurable verbs Ex: Mr. Smith will walk with a cane at least to the end of the hall and back this afternoon Measurable: walk Nonmeasurable: appreciate Use one behavior (cognitive, affective, psychomotor) per outcome Ex: Client will discuss the role of insulin in diabetes Client will give his own insulin Goal Statement Combine broad goal and specific outcome Broad goal: What is to be accomplished "Will demonstrate effective airway clearance" Specific outcome: What you expect to observe or hear that indicates that the client is achieving the goal "As evidenced by clear lungs, ability to bring forth sputum with cough, and absence of fever" Verbs Measurable Nonmeasurable Identify Cough Know Describe Express Understand Perform Stand Appreciate Relate Discuss Think State Share Accept List Hold Feel Exercise Communicate Verbalize Demonstrate Outcome Domains Cognitive: Associated with acquired knowledge or intellectual abilities Learning the s/s of diabetic shock Affective: Changes in attitude, feelings, or values Deciding that smoking is harmful Mastering walking with crutches Psychomotor: Developing motor skills Goal Statement Goal must contain a timeframe Shortterm goals--less than one week Longterm goals--weeks or months Ex: Mrs. Smith will demonstrate how to hold her newborn infant by tomorrow Ex: Sue will walk with crutches with assistance by 3 days after surgery Ex: Mr. Jones' incision will heal without signs of infection by end of shift Nursing Diagnostic Statements Constipation related to insufficient roughage intake in diet.... Altered mucous membrane related to poor oral hygiene Potential impaired skin integrity related to draining abdominal incision Pain related to surgical incision Client Outcomes Mrs. Pierce will demonstrate normal bowel function as evidenced by having one soft, formed bowel movement every 12 days, beginning Thursday Specific: Mrs. Pierce will report having one soft, formed bowel movement Diane will exhibit intact oral mucous membranes a/e/ b pink and healthylooking gums (by 10/28) Specific: Diane will exhibit pink and healthylooking gums (by 10/28) Client Outcomes Mr. Culp's skin will remain intact a/e/b a clean, dry incision, with no signs of redness or irritation by discharge (10/1) Mr. Noll will demonstrate effective pain management a/e/b reporting relief after prescribed measures, increased mobility, and a decrease of pain from 8/10 to 0 in one hour Mr. Noll will report to the nurse a decrease in pain from 8/10 to 0 in one hour. Mr. Culp's incision will be clean, with no signs or redness or irritation by discharge (10/1) Nursing Interventions "Any treatment based on clinical judgment or knowledge that a nurse performs to enhance/client outcomes." Taylor, p. 315 Specific nursing actions or activities that a nurse must perform to prevent complications, provide for comfort, or maintain and restore health Nursing Intervention Structure "Nursing Intervention Classification" (NICs) Editions '92, `96, '04, '06 a report of research to construct a taxonomy of Nsg. interventions. See pp 312313 for the reasons why there are advantages for NSG. Interventions! Physiologic: Basic (physiologic function) Physiologic: Complex(homeostatic regulation) Behavioral: psychosocial fx & lifestyle changes Safety: protection against harm Family: supporting the family unit Health System: effective use of healthcare delivery system Community: Care that supports health of the NICs Five Domains Types of Nursing Interventions Nursing assessments to ID new problems and determine the status of existing problems Patient teaching to help clients gain new knowledge concerning their own health Counseling clients to make decisions about their own health Consulting and referring to other health care providers Performing specific treatment actions to reduce, remove, or resolve health problems Assisting clients to perform selfcare Types continued... Direct intervention Indirect intervention Community (or public health) Intervention These Interventions may be initiated either by nursing or in collaboration another discipline. They may also be under the guidance of Protocols or Standing Orders. Planning Nursing Interventions Identify focus assessments of the problem (diagnosis) before determining appropriate nursing interventions Look for interventions that will reduce or eliminate the cause of the problem Consider the expected outcome to be sure all your interventions are specific for that particular patient Nursing Interventions (cont) ID strengths of the client and his family (cohesiveness, support systems, communication) Individualize nursing actions Be realistic. Interventions should Consider client's limitations, age/development Be within the nurse's knowledge/expertise Be congruent with other therapies Provide safe and therapeutic environment Utilize appropriate resources (people, supplies, Nursing interventions (cont) Utilize scientific rationale to underpin actions Create opportunities for teaching and learning whenever possible (teach the reasons for the interventions) Consult other professionals when indicated (e.g., pastoral care, dietitian Cultural, spiritual, ethical consideration Lack of family support Lack of understanding about the benefits of compliance Low value attached to outcomes or related interventions Adverse physical or emotional effects of treatment Inability to afford treatment Limited access to treatment KNOW BOX 153 !!! P. 324 * When a pt. fails to cooperate with the Plan of Care Practice Questions A school nurse notices that Kenny is losing weight and wants to perform a focused assessment on Kenny's nutritional status, focusing, fearing that he might have an eating disorder. How should the nurse proceed? A. Perform the focused assessment. This is an independent Nsg. Intervention. B. Request an order from the nutritionist. This is a Collaborative Intervention. C. Request a physician's order. This is a Physiciandriven Intervention. D. Request a physician's order. This is a Physiciandriven Intervention. CONTINUED You are a novice nurse. When you orient to a new nursing unit that is currently understaffed, you are told that the UAP's have been trained to obtain the initial nursing assessment. What is the nest response? A. Contact your labor representative and complain. B. Do your own admission assessments but don't interfere with the practice of other professional RNs who seem comfortable with the practice. C. Allow the UAPs to do the admission and assessment and report the finding to you. D. Tell the charge nurse that you are choosing no to delegate the admission assessment at this time until you can get further clarification from admission. Before Doing the Job C= Check the orders and equipment W=Wash your hands I=Identify the patient P=Provide for safety and privacy A=Assess the problem T=Tell the person of Teach the person about what you are going to do Doing the Job Reassess the patientongoing! Is intervention still needed? Patient's condition changed? Determine your need for assistance Size/condition of patient; your knowledge deficit Implementing issues Confidentiality, safety, privacy, dignity, and advocacy Delegate or assign: BOX 153 p.324 UAPs! Reassessing the Patient Be sure the Nsg. Intervention is supported by a sound scientific rationale as demanded by an evidenced based practice, standards of care, policies and procedures, patient safety & pt preference, and you clarify questionable orders. Promote SelfCare: Teach, Counsel, Advocate Nurses can fail patients by doing too much for them and by encouraging negative, sickrole behaviors such as inappropriate dependence. Assist the pt. to meet Health Outcomes by creating a detailed, followed, wellconstructed plan. Evaluation "Assessing the client's progress toward goal achievement" "The client's progress , or lack of progress, toward goal achievement directs reassessment, reordering or priorities; new goal setting; and revision of the plan of nursing care." ANA standards of practice, 1973 Types of Evaluation Ongoing: while or immediately after intervention Intermittent: Specified intervals--to determine extent of progress toward goal achievement Correct deficiencies/modify care plan Terminal: Client's condition at discharge Status of goal achievement Selfcare abilities related to followup care Evaluation Evaluation depends on Effectiveness of prior steps Accurate/complete assessments Outcomes stated in concrete behavioral terms Evaluation coincides with assessment Evaluation must involve consideration of cultural, spiritual, ethical issues Evaluation guidelines Establish outcome criteria--list the goals Assess patient's current status--collect data Evaluate goal achievement--compare data with outcomes Goal not met/partially met/met Discuss the goals with the client/family Determine variables affecting goal achievement-- draw conclusions about problem status Modify plan of care/terminate Document ...
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- Spring '08