NURSING PROCESS

A. Nursing Process

– Assessment

– Nursing Diagnosis (as a concept and process)

– Planning ( long-term, short-term, priority setting, formulation of objectives)

– Intervention (collaborative, independent nursing interventions)

– Evaluation (formative, summative)

– Documentation of plan of care/reporting

NURSING PROCESS

• According to American Nurses’ Association, it is a critical thinking model for nursing

• It encompasses all significant actions taken by the registered nurses and forms the foundation for decision making

• Nursing consists of 5 interrelated steps: assessment, diagnosis, planning, implementation and evaluation

PURPOSES

• Organize and prioritize patient care

• Keep the focus on what’s important –the patients health status and the quality of life

• Form thinking habits that help you gain confidence and skills you need to think critically in the clinical setting

CHARACTERISTICS

• PURPOSEFUL AND DELIBERATE

• HUMANISTIC

• SYSTEMATIC

• STEP BY STEP YET DYNAMIC

• OUTCOME FOCUSED (RESULT ORIENTED)

• PROACTIVE

• EVIDENCED-BASED

• INTUITIVE-LOGICAL

• REFLECTIVE, CREATIVE AND IMPROVEMENT ORIENTED

ULTIMATE GOALS OF NURSING

• To prevent illness and promote, maintain or restore health (in terminal illness: to control and promote comfort and well being until death)

• Maximize sense of well being and ability to function in desired roles

• Provide cost-effective efficient care that pays attention to individual wants and needs

• Find ways to improve consumer satisfaction with health care delivery

WHY DO I NEED TO STUDY IT?BENEFITS IN USING THE NURSING PROCESS

1. Speeds up the diagnosis add treat ment of actual and potential health problems, reducing the incidence of (and length of) hospital stays

2. Creates a plan that’s cost effective, both in terms of human suffereing and monetary expense

3. Promotes quality of life4. Has precise documentation

requirements designed to a. improve communicationb. leave a paper trail

5. Prevents clinicians from losing sight of the importance of human factor

6. Promotes flexibility and independent thinking

7. Tailors interventions for individual8. Helps patient realize their input is

important and helps nurses have satisfaction of getting results

NURSING PROCESS VS PROBLEM SOLVING

NURSING PROCESS VS MEDICAL PROCESS

Critical Thinking in Nursing:

• Is based on principles of nursing process and scientific method (eg, making judgments based on evidence, rather than guesswork)

• Entails purposeful, informed, outcome-focused (results-oriented) thinking that requires careful identification of key problems, issues, and risks involved.

• Is driven by patient, family, & community needs.

• Uses both logic & intuition

• Requires knowledge, skills, and experience.

• Calls for strategies to maximize human potential (eg, use of tools to jog mind)

• Requires reflection, self-correction, and a desire to improve

• Is guided by professional standards and ethics codes.

Critical Thinking: Picture This CRITICAL THINKING

• Develop critical thinking attitudes, characteristics and behaviors

• Acquire theoretical and experiential knowledge as well as intellectual skills

• Gain interpersonal skills

• Practice technical skills

Critical Thinking Indicators ™Behaviors that evidence suggests promote critical thinking in clinical practice.

• Give concrete descriptions and examples.

• Listed in context of what’s likely to be observed when a nurse is thinking critically in the clinical setting. Three Categories of CTIs

• General characteristics/attitudes promoting critical thinking

• Knowledge required

• Intellectual skills/competencies required

Examples of CTIs™ Demonstrating CT Characteristics / Attitudes

• Self-aware: Clarifies biases, inclinations, strengths, and limitations.

• Curious and inquisitive: Looks for reasons, explanations, and meaning; seeks new information to broaden understanding.Examples of Knowledge CTIsClarifies:

• nursing vs. medical and other models, roles, and responsibilities.

• signs and symptoms of common problems

and related potential complications.

Examples of CTIs Demonstrating Intellectual Skills/Competencies

• Assesses systematically & comprehensively

• Identifies assumptions

• Detects bias; determines credibility of information sources

TOP 10 REASONS TO IMPROVE THINKING

#10. Things aren’t what they used to be, nor what they will be. #9. People are sicker with multiple

problems #8 More consumer involvement (patients & families). #7 Nurses must be able to move from one setting to another.# 6 Rapid change and information explosion require us to develop new learning and workplace skills.# 5 Consumers and payers demand to see evidence of benefits, efficiency, and results.# 4 Today’s progress often creates new problems that can’t be solved by old ways of thinking. # 3 Redesigning care delivery and nursing

curricula is useless if nurses don’t have the thinking skills required to deal with today’s world. # 2 It can be done, and it doesn’t have to be that difficult.# 1 Your ability to clearly and quickly focus your thinking to get the results you need can make the difference between whether: You succeed Or Fail

Are you ready?What will happen in the steps of the Nursing Process?

ASSESSMENT:You collect and record all the

information needed to be able to:

Predict, detect, prevent, manage or eliminate health problems

Clarify expected outcomes

Develop a comprehensive plan

DIAGNOSIS:You analyze assessment data, draw

conclusions, and determine: Actual and potential health problem and their cause Presence of risk factors

Resources, strengths and use of healthy behaviors Health states that are satisfactory but could be improved

PLANNING:You clarify expected outcomes, set

priorities and determine interventions. The interventions are designed to: Detect, prevent and manage health problem and risk factors Promote optimum function, independence and sense of well being Achieve the expected outcomes safely and efficiently

IMPLEMENTATIONYou put the plan into action by:

Assessing appropriateness of (and readiness for) interventions

Performing interventions, then reassesing to determine initial responses

Making immediate changes as needed

Charting to monitor progress

EVALUATIONYou assess the patient to decide

whether expected outcomes have been met. Then you decide whether to:

Discharge the patient or

Modify the plan as appropriate

Plan for ongoing continuous assessment for risk factors for problems

RELATIONSHIPS

INTERRELATIONSHIPS

EXAMPLEASSESSMENT:

Mr. Santa is 80 years old and lives alone. He wants to be independent and keeps an immaculate home. However, today he has a cold, is weak and states that he is feeling very tired. Other than that, his health is unchanged.

DIAGNOSIShe is at risk for falls

Strength: He desires for independenceWeakness: His independence is also a weakness because he might nor ask for help****Make it known to him

PLANNING:Plan for outcome with Mr. Santa:

He will be free of injury with educed risk factors for fallsPlan for prevention of falls:

arrange furniture, stress importance of nutrition and hydration, decide to m,onitor bp

IMPLEMENTATION:Monitor him closelyCheck vital signsMonitor food and fluid intakeFind out if he has help each dayStress the importance of accepting help

from othersEncourage to keep his strength by

avoiding being in bed all day

EVALUATIONAssess Mr. Santa and determine

whether he is free from injury and whether risk factors of weakness and fatigue are still present.

If strength is regained: encourage to continue

if not: reassess and make changes in the plan.

1. ASSESSMENT

Definition of Terms

• Assessment the deliberate and systematic collection

of data to determine a client’s current, past, and functional health status and to evaluate the client’s present and past coping patterns

Assessment

– It is the first step in determining the health status

– It involves physical examination, interview, and gathering of information necessary to get a clear picture of the patient’s health status.

FIVE PHASES

• COLLECTING DATA (COLLECTING DATA)

• VALIDATING (VERIFYING DATA)

• ORGANIZING DATA (CLUSTERING)

• IDENTIFYING PATTERNS AND TESTING FIRST IMPRESSIONS

• DECIDING WHAT TO RECORD AND REPORT

FIVE PHASES

1. Collecting data (Gathering Data)

• It is an ongoing process

• It begins the first time you meet the patient and it continues until the patient is discharged

• The resources to use include (consumer - patient, family, and community, significant others, nursing and medical records, verbal and written consultations, diagnostic and laboratory studies)

• The data that are classified are of 2 categories:

direct data – from the patientindirect data – data gained from other

sources

• Comprehensive data collection happens in 3 phases :

before you see the person when you see the personafter you see the person

TWO TYPES OF ASSESSMENTData-base Assessment – comprehensive gathering of information done on initial contact with the client to assess all aspects of the health status

Focus Assessment – part of comprehensive data-base assessment used to monitor specific problems or aspects of care.

Data – base assessment

Most facilities have data – base forms to collect information. The data-base tools usually contain the following :

• needs and problems commonly encountered

• nursing model or theory adopted by the facility

• the standards of care.

Focus-AssessmentAlthough there are some forms that guide focus assessment, often there is no guide. The 4 key questions to ask are : • what is the current status of the problem, compared with the baseline data?• is the problem worse, same, or better?• What factors are contributing to the problem?• what is the patient’s perspective on the status of the problem and how is it being managed ?

TYPES OF DATASubjective data refer to what the person states verbally (Ex. : “I feel like my heart is racing.

Objective data is what you observe (Ex. : Pulse 150 beats, regular, and strong

SOURCES OF DATA Client – best source of data Support People – can supplement or

verify the information Client records – information

documented by health care professionals, types are medical records, records of therapies and laboratory records

Health care professionals – verbal reports

Literature – can provide additional information for database

DATA COLLECTION METHODS1. observing – gathering date by the use of

the senses2. interviewing – planned communication

or conversation with a purpose3. examining – systematic data collection

that uses observation to detectc health problems

OBSERVATIONUsing the senses to observe client data

vision – overall appearce, signs of distress or discomfort facial and body gestures, skin color and lesions, abnormalities of movement, nonverbal demeanor, religious or cultural artifacts

smell – body or breath odor hearing – lung and heart sounds, bowel

sounds, ability to communicate, language spoken, ability to initiate conversation, ability to respond when spoken to, orientation to time person and place, thoughts and feelings about self others and health status

touch – skin temperature and moisture, muscle strength, pulse rate rhythm and volume, palpatory lesions

INTERVIEW

• Ethical, spiritual, and cultural considerations during interview :– Provide services with respect to human dignity– Safeguard the patient’s right to privacy– Be honest– Respect individual cultural and religious beliefs (biological variations, comfortable communication patterns, family organization and practices, beliefs whether people are able to control nature and influence their ability to be healthy. The person’s concept about God.

Guidelines in promoting a caring interview

• Get organized, don’t rely on memory, plan enough time, ensure privacy, get focused, visualize yourself as being confident, warm, and helpful

• When you begin the interview: give your name and position, verify the person’s name and ask how he prefers to be called, briefly explain your purpose

• During the interview: give the person your full attention, don’t hurry, sit down.

• How to listen: be an empathic listener, use short supplementary phrases, listen for feelings as well as words, let the person know when you see body language that sends a message that conflicts with what is being said, be patient if the person has a memory block, avoid the impulse to interrupt, allow for pauses in conversation

• How to ask questions: ask about the person’s main problem first, focus your questions to be able to gain specific information on signs and symptoms, don’t use leading questions, do use exploratory statements, use communication techniques (use phrases that help you see the other person’s perspective, restate the persons words, ask open-ended questions), avoid close-ended questions

• How to observe: carefully assess areas connected to verbal complaints, use your senses, note general appearance, observe body language, notice interaction patterns

• How to terminate interviews: give warning if the session has been a long one, ask the person to summarize her most important concerns, ask if there were concerns that were not discussed, Offer yourself as a resource and answer questions that may arise, explain care routines and provide information about who is accountable for nursing care decisions, end on a positive note.

Common Communication Errors– Using first names without permission– Using endearing names– Talking down– Using medical terminology with lay people– Using communication techniques you’re comfortable with, without paying attention to the person’s response.

NURSING HEALTH HISTORY

Components of Nursing Health History

Biographic DataClient’s name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care

Chief complaint of reason for visitThe answer given to the question “what is troubling you?” or “Can you tell me the reason you came to the hospital or clinic today?” The chief complaint should be recorded in the client’s own words.

History of present illness When the symptoms started

Whether the onset of symptoms was sudden or gradual

How often the problem occurs Exact location of the distress Character of the complaint (e.g.

intensity of pain or quality of sputum, emesis or discharge)

Activity in which the client was involved when the problem occurred

Phenomena or symptoms associated with the chief complaint

Factors that aggravate or alleviate the problem

Past History Childhood illnesses, such as chicken

pox, mumps, measles, rubella (German measles), rubeola (red measles), streptococcal infections, scarlet fever, rheumatic fever, and other significant illnesses

Childhood immunizations and the date of the last tetanus shot

Allergies to drugs, animals, insects, or other environmental agents, the type of reaction that occurs, and how the reaction was treated.

Accidents and injuries: how, when, and where the accident occurred, type of injury, treatment received, and any complications

Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery performed, course of recovery, and any complications

Medications: all currently used prescription and all over the counter medications such as aspirin, nasal spray, vitamins, or laxatives

Family History of Illness To ascertain factors for certain

diseases, the ages of siblings, parents, grandparents and their current state of health or if they are deceased, the cause of death are obtained. Particular attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism and any mental health disorders

Lifestyle Personal habits: The amount,

frequency, and duration of substance

use (tobacco, alcohol, coffee, cola, tea and illicit or recreational drugs)

Diet: description of a typical diet on a normal day or any special diet, number of meals and snacks per day, who cooks and shops for food, ethnically distinct food patterns, and allergies

Sleep/rest patterns: usual daily sleep/wake times, difficulties sleeping, and remedies used for difficulties

Activities of daily living (ADLs): any difficulties experienced in the basic activities of eating, grooming, dressing, elimination, and locomotion

Instrumental activities of daily living: any difficulties experienced in food preparation, shopping, transportation, housekeeping, laundry and ability to use the telephone, handle finances, and manage medications

Recreation/hobbies: exercise activity and tolerance, hobbies and other interests and vacations

Social data Family relationships/friendships: the

client’s support system in times of stress (who helps in time of need), what effect the client’s illness has on the family, and whether any family problems are affecting the client.

Ethnic affiliation: health customs and beliefs; cultural practices that may affect health care and recovery

Educational history: Data about the client’s highest level of education attained and any past difficulties with learning

Occupational history: Current employment status, the number of days missed from work because of illness, any history of accidents on the job, any occupational hazards with a potential for future disease or accident, the client’s need to change jobs because of past illness, the employment status of spouses or partners and the way child care is handled, and the client’s overall satisfaction with the work

Economic status: Information about how the client is paying for medical care (including what kind of medical and hospitalization coverage the client has), and whether the client’s illness presents financial concerns

Home and neighborhood conditions: Home safety measures and adjustments in physical facilities that may be required to help the client manage a physical disability, activity intolerance, and activities of daily living; the availability of neighborhood and community services to meet the client’s needs

Psychological Data Major stressors experienced and the

client’s perception of them Usual coping pattern with a serious

problem or a high level of stress Communication style: ability to

verbalize appropriate emotion; non-verbal communication – such as eye movements, gestures, use of touch, and posture; interactions with support persons; and the congruence of nonverbal behavior and verbal expression

Patterns of health careAll health care resources the client is currently using and has used in the past. These include the primary care provider, specialists (e.g. ophthalmologist, gynecologists), dentists, folk practitioners (e.g. herbalist or curandero), health clinic, or health center; whether the client considers the care being provided adequate; and whether access to health care is a problem

PHYSICAL ASSESSMENT

Physical Assessment Skills Inspection – observing carefully by

using your fingers, eyes, ears and sense of smell

Auscultation – listening with a stethoscope

Palpation – touching and pressing to test for pain and feel inner structures, such as the liver

Percussion – directly or indirectly tapping a body surface to determine reflexes or to determine whether are contains fluid

Organization of Assessment is influenced by two things

1. the person’s condition2. your own preference

GUIDELINES IN PERFORMING PHYSICAL ASSESSMENT

promote communication provide privacy don’t rely on memory choose a way to organize your

assessment and use it consistently

DIAGNOSTIC STUDIES

• Identifying cues and making Inferences (how you interpret or perceive a cue, the conclusion you draw about a cue. The nurses ability to make inferences is influenced by : observational skills, nursing knowledge, and clinical expertise

2. Validating (Verifying data) is checking if the data are factual and complete. It helps one to avoid making assumptions, missing pertinent information, misunderstanding situations, jumping to conclusions or focusing in the wrong direction making errors in problem identification.

Guidelines in validating data :1. data that can be measured accurately

can be accepted as factual 2. data that someone else observes may

be or may not be true3. validate questionable information4. Look for factors that may alter accuracy5. ask someone else preferably an expert,6. double-check information that is

extremely abnormal, clarify statements and verify your inferences.

3. Organizing (Clustering ) data Cluster or organize using the following:

• According to a Nursing Model Many nurses use the functional health patterns by Gordon

• According to Body Systems

• According life-threatening

What are the 12 FUNCTIONAL HEALTH PATTERNS?(Please refer to your copy)

GORDON’S FUNCTIONAL HEALTH PATTERN

HEALTH-PERCEPTION/ HEALTH-MANAGEMENT PATTERNDescribes the client’s perceived pattern of health and well-being and how health is managed

NUTRITIONAL AND METABOLIC PATTERNDescribes the clients pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supplyELIMINATION PATTERNDescribes the pattern of excretory function (bowel, bladder and skin)ACTIVITY-EXERCISE PATTERNDescribe the pattern of exercise, activity, leisure and recreationSLEEP-REST PATTERNDescribes pattern of sleep, rest and recreationCOGNITIVE-PERCEPTUAL PATTERNDescribes sensory-perceptual and cognitive patternsSELF-PERCEPTION / SELF-CONCEPT PATTERNDescribed the client’s self concept pattern and perceptions of self (e.g. self-conception/worth, comfort, body image, feeling state)ROLE-RELATIONSHIP PATTERNDescribes the client’s pattern of role participation and relationshipsSEXUALITY-REPRODUCTIVE PATTERNDescribes the client’s pattern of satisfaction and dissatisfaction with sexuality pattern; describes reproductive patternsCOPING-STRESS TOLERANCE PATTTERN Describes the client’s general coping pattern and the effectiveness of the pattern in terms of stress tolerance VALUE BELIEF PATTERNDescribes the patterns of values, beliefs (including spiritual) and goals that guide the client’s choices or decisions

4. Identifying Patterns and Testing first Impressions

• Get some initial impression of patterns of health functioning

• Determine what is relevant and irrelevant

• Remember cause and effect

5. Deciding what to record and report

• The final phase of assessment is recording and reporting

• Reporting data in a timely fashion expedites diagnosis and treatment of urgent problems

• Guidelines for reporting significant findings:

– If you find yourself thinking, “ I am not sure if there is anything abnormal here to report,” you probably don’t have enough knowledge to make the decision. You need help

– Report abnormal findings as soon as possible

– Before reporting, take a moment to be sure you have all the necessary information readily at hand

– If you’re nervous about giving the report jot your report in order of importance and read.

• Give precise information State the facts rather than how you interpret the facts

DIAGNOSIS

FIVE PHASES

• Creating a list of suspected problems/diagnoses

• Ruling out similar problems/diagnoses

• Naming actual and potential problems/diagnoses and clarifying what’s causing or contributing to them

• Determine risk factors that must be managed

• Identifying resources, strengths and areas of health promotion

TERMINOLOGIES

• Competency – knowledge, skills, and behaviors necessary to perform actions safely and efficiently in various patient situations.

• Nursing Domain – actions which a nurse is qualified to perform.

• Medical Domain – activities and actions a medical doctor is qualified to perform.

• Accountable – being responsible and answerable for something

• Definitive Intervention – the most specific treatment required to prevent, resolve, or manage a health problem.

• Taxonomy – is a classification system or set of categories arranged based single principle or set of principles

• Outcome – The result of prescribed interventions or plan of care. Usually it is referred to as desired interventions.

• Diagnose – make judgment and name actual and potential health problems or risk factors based on evidence from an assessment

• Diagnosis – may mean two things : the process of analyzing data and putting related cues together to make judgments about health status or it is the result of diagnostic process

• Life Processes – events or changes that happen during one’s lifetime

• NANDA – North American Nursing Diagnosis Association

• Diagnosing – reasoning process

• Nursing Diagnosis – a clinical judgment about an individual, family, or community response to actual and potential health problems and life processes.

• Medical Diagnosis – health problem that requires definite diagnosis by a qualified primary care provider ( physicians, nurses or physicians’ assistants

• Potential Complications- organ or system problems that may arise because of the presence of certain diagnoses or treatment modalities.

• Carpenito (2000) uses the term collaborative problem to address potential physiologic complications

• Multidisciplinary Problem – a problem requiring treatment by more than 1 discipline.

• Related Factor – something known to be associated with a specific health problem

• Risk Factor – something known to cause or contribute to specific problem. The terms related and risk factors are often used interchangeably

• Etiology – something known to cause a disease or problem. The terms risk factor and etiology are oftentimes used interchangeably. To completely understand a problem, one must know its cause.

• Risk (Potential ) Diagnosis – a health problem that may develop[p if preventable if preventive actions are not taken.

• Wellness Diagnosis – a clinical judgment by an individual, family, or community in transition from a specific level of wellness to a higher level of wellness.

• Sign – objective data that have been known to signify a health problem

• Symptom – subjective data that have been known to signify a health problem.

• Defining characteristics a cluster of signs and symptoms and risk factors usually present patients with specific nursing diagnosis.

• Cues – signs, symptoms, and defining characteristics noted in a patient.

• Diagnose – make judgment and name actual and potential health problems or risk factors based on evidence from assessment

• Nursing Diagnosis (NANDA, 1990) – clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.

Over time, literatures reveal that Nursing Diagnosis had been and is being used in 3 contexts :1. As the second step of the nursing process 2. As a list of diagnostic labels or titles3. As a one-part, two-part, or three-part statement

1. As the second step of the nursing process

• The nurse analyzes data collected during assessment and evaluates the client’s health status

• Some conclusions resulting from data analysis lead to nursing diagnoses; while others do not

• Recognize that the outcome of this process can include problems treated primarily by

• nurses (INDEPENDENT)

• problems requiring treatment by professionals from several disciplines (DEPENDENT AND INTERDEPENDENT) Ex. While assessing, the nurse may record observations that point to medical problems of seizures, pneumonia, and hypertension, as well as nursing diagnosis of risk for injury)

• Using the term nursing diagnosis to designate the 2nd step of the nursing process may be confusing and have the undesirable effect of leading nurses to try to state all conclusions or problems as nursing diagnoses,

• After the 1st conference on nursing diagnosis in 1973, the term nursing diagnosis

was applied to specific labels describing health states that nurses could legally diagnose and treat

• These labels are concise descriptors of a cluster of signs and symptoms such as Anxiety or Risk for Injury

2. As a list of diagnostic labels or titles

• An individual, family, or group’s response to a situation or health problem

Thus it is necessary for us to be clear on what context are we using the term Nursing Diagnosis

Diagnosis: A Pivotal Point This is because of 3 reasons :– The accuracy and relevance of the entire plan of care depends on the nurse’s ability to clarify and specifically identify both the problems and what is accusing them. – Creating a proactive plan that promotes health and prevents problems before they begin depends on your ability to recognize risk factors – The resources and strengths you identify are key to reducing costs and maximizing efficiency.There are major factors that impact on the nurses’ diagnosis- role today, as follows :– Shift from diagnosis and treat (DT) to Predict, Prevent, Manage (PPM) approach– Development and refinement of Critical Pathways (Clinical Pathways, Care Maps)– Computer-assisted Diagnosis– Emphasis on the importance of collaborative and multidisciplinary approach– A greater awareness that nursing’s scope of practice has a flexible boundary that responds to the changing needs of society and its expanding knowledge base.

Diagnose & Treat (DT) versus Predict, Prevent, Manage, Promote (PPMP)

Shift to Predictive Model

PredictPrevent

Manage

Promote

Key Points

• The PPMP model is more proactive than

the DT model.

• It’s based on evidence and applies

technology

TYPES OF NURSING DIAGNOSIS

• ACTUAL DIAGNOSIS

• POSSIBLE DIAGNOSIS

• RISK DIAGNOSIS

• SYNDROME DIAGNOSIS

• WELLNESS DIAGNOSIS

1. ACTUAL NURSING DIAGNOSIS

• Actual Nursing Diagnosis- represents a problem that had been validated by the presence of major defining characteristicsPARTS OF ACTUAL NURSING DIAGNOSIS• Diagnostic label or label (such as those developed by NANDA) is a concise term that convey the meaning of the diagnosis.• Defining characteristics are signs and symptoms that, when seen together, represent the nursing diagnosis• Major defining characteristics – for nonresearched diagnosis, at least 1 must be present for validation of the diagnosis and for researched diagnosis, at least 1 must be present 80-100% of the time.• Minor defining characteristics – characteristics provide supporting evidence but may not be present.• Related Factors – in actual nursing diagnosis, these are contributing factors that have influenced the change in health status.

There are 4 categories :

1. Pathophysiologic (Biologic or Psychological) Ex. Compromised immune system. Inadequate circulation2. Treatment-Related – Ex. Medications, diagnostic studies, surgery, and treatments3. Situational – Ex. Enviornmental, home, community, instituion, personal, life experiences, and roles

4. Maturational – age related influences

• Risk Factors – represent those situations that increase the vulnerability of the client or group.

The related factors for risk nursing diagnosis are the same risk factors previously explained for actual nursing diagnosis. That is why the terms related and risk factors are used interchangeably

• Etiology is something known to cause a disease or problem. The terms risk factor and etiology are often used interchangeably.

• Unknown Etiology – if the defining characteristics of a nursing diagnosis are present, but the etiologic and contributing factors are unknown. Ex. Fear related to unknown etiology as evidenced by rapid speech, pacing, and “I am worried.” The use of unknown etiology alerts the physician or the nurse to assess for contributing factors as they intervene.

2. RISK NURSING DIAGNOSIS

• the person’s data base contains evidence of the related (risk) factors of the diagnosis but no evidence of defining characteristics.The concept of “at risk” is useful clinically because, it allows nurses to routinely prevent problems in people who are at high risk.

• All operative patients are at risk for infection related to loss of protective barrier secondary to incision. This generic diagnosis for all surgical clients is routine, as such nurses do not (actually) need to include it in the client’s plan of care in the hospitals because it is part of the unit’s standard of care.

• In contrast, a patient with diabetes who has undergone emergency surgery for a perforated gastric ulcer may have a nursing diagnosis of High risk for infection related to the surgical incision and impaired healing secondary to diabetes mellitus and blood loss

• The “at risk concept is also very useful for healthy individuals who are vulnerable because of age or a condition such as pregnancy Pregnant women are not at high risk for injury but are at risk during the third semester

3. POSIBLE NURSING DIAGNOSIS

• the person’s data base does not demonstrate the defining characteristics or related factors of the diagnosis but your intuition tells you that the diagnosis may be present

• Statements that describe a suspected data but require additional data. It is unfortunate that nurses had been socialized to avoid appearing tentative.

• In scientific decision-making a tentative approach is not a sign of weakness or indecision, but an essential part of the process.

• The nurse should delay a final diagnosis until he / she has gathered and analyzed all necessary information to arrive at a sound scientific conclusion

4. WELLNESS NURSING DIAGNOSIS

• recognizing when healthy clients indicate a desire to achieve a higher level of functioning in a specific area.

• Clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness.

• Diagnostic statements for wellness nursing diagnosis are one-part, containing the label only (which begins with Potential for enhanced…….) followed by the higher level wellness that individuals or groups desire (readiness for enhanced family processes)

• It does not contain a related factor

• The NANDA taxonomy (2001)uses “readiness for enhanced” as a prefix for wellness diagnosis. In most acute e care settings, however only the actual and potential diagnoses are addressed but there is more opportunitit6esyto focus wellness diagnoses. 5. SYNDROME NURSING DIAGNOSIS

• Used when the diagnosis is associated with a cluster of other diagnoses

• They comprise a cluster of predictive actual or high- risk nursing diagnosis related to a certain event or situation.

• The clinical advantage of a syndrome diagnosis is that it alerts the nurse o a complex clinical condition requiring expert nursing assessment and intervention.

• Examples are : Rape Trauma Syndrome, Disuse Syndrome, Post Trauma Syndrome

3. As a one-part, two-part, or three-part statement

One-Part (Problem or Diagnostic Label)1. Wellness diagnosis 2. Syndrome diagnosis

Two-Part (Problem or Diagnostic Label + Risk Factor)

1. Risk Diagnosis2. Possible Diagnosis

Three-Part (Problem or Diagnostic Label + Etiology+Symptom) 1. Actual

COMPONENTS OF NANDA NURSING DIAGNOSIS

• The problem

• The etiology

• The defining characteristics

THE PROBLEMDescribes the client’s health problem or response for which nursing therapy is givenDescribes the client’s health status briefly and concisely in a few wordsPURPOSE: to direct the formation of client goals and desired outcomes and may also suggest some nursing interventionsSpecifyWhen the word specify follows the NANDA label the nurse states the area in which the problem occurs:Example: Deficient Knowledge (Medications)Qualifiers Words that have been added to some NANDA labels to give additional meaning to the diagnostic statementEXAMPLEDeficient – inadequate in amount, quality or degree, not sufficient, incompleteImpaired – made worse, weakened, damaged, reduced, deterioratedDecreased – lesser in size, amount or degreeIneffective – not producing the desired effectCompromised – to make vulnerable to threatNANDA approved meaning All diagnostic labels have meaning that clarifies the definition of eachExample:

Open your NANDA list Dx Handbook recite the meaning of…Ineffective Breathing PatternImbalanced Nutrition: less than body requirements

THE ETIOLOGYIdentifies one or more probable causes of the health problem, gives direction to required nursing therapy and enables the nurse to individualized client careExample:Recite the etiologies of the following:Sleep DisturbanceDeficient Fluid Volume

THE DEFINING CHARACTERISTICSAre the cluster of signs and symptoms that indicate the presence of the diagnostic labelCharacteristics are listed separately according to whether they are subjective or objective in natureIn actual nursing dx, the defining characteristics are the signs and symptomsIn risk nursing dx, no subjective or objective signs are present

Writing Diagnostic Statements

Problem Etiology Symptom(Diagnostic Contributing Factor Signs & Symptoms Label)

ONE-PART STATEMENTDiagnostic labels that are well refined and does not need etiologyWellness diagnosis: Readiness for Enhanced + desired higher level of functioningExample: Readiness for enhance ParentingOr with descriptorHealth Seeking Behavior (Low-Fat Diet)

TWO-PART STATEMENT

• Problem (P) – statement of the client’s response (NANDA label)

• Etiology (E) – factors contributing to or probable causes of the responses

Use “related to” to join 2 parts, because this implies relationshipExample:

Risk for infection related to _____________

THREE-PART STATEMENT

• Problem (P)

• Etiology (E)

• Signs and Symptoms (S) – defining characteristics as manifested by the clientExample: Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as manifested by verbalization “I can’t live without sugar in my food”

VARIATIONS FROM BASIC FORMAT1. unknown etiology- when the defining characteristics are present but the nurse does not know the contributing factorsExample: Noncompliance (Medication Regimen) related to unknown etiology

2. complex factors – when there are too many etiologic factors or they are to complex to state in a brief phraseExample:Chronic Low Self-Esteem related to complex factors

3. possible – when the nurse believes more data are needed about the client’s problem or etiology Example: Possible low self-esteem related to loss of job and rejection by familyAltered thought processes possible related to unfamiliar surroundings

4. secondary to – to divide the etiology in 2 parts, thereby making the statement more descriptive and useful Example:Risk for impaired skin integrity related to decreased peripheral circulation secondary to diabetes

5. using descriptors – making it more precise and specificExample: Impaired skin integrity (Left Lateral Ankle)

AVOIDING ERRORS IN DIAGNOSTIC REASONING Verify

Build a good knowledge base and acquire clinical experience Have a working knowledge of what is normal Consult resources

Base diagnosis on patterns—that is, on behavior over time—rather than on an isolated incident Improve critical-thinking skills

GUIDELINES FOR WRITING NURSING DIAGNOSTIC STATEMENTS

GUIDELINE #1State in terms of a problem, not a need.

CORRECT STATEMENTDeficient Fluid Volume (problem) related

to feverINCORRECT OR AMBIGUOUS STATEMENT

Fluid Replacement (need) related to fever

GUIDELINE #2Word the statement so that it is legally

advisable.CORRECT STATEMENT

Impaired Skin Integrity related to immobility (legally acceptable)INCORRECT OR AMBIGUOUS STATEMENT

Impaired Skin Integrity related to improper positioning (implies legal liability)

GUIDELINE #3Use nonjudgmental statements.

CORRECT STATEMENTSpiritual Distress related to inability to

attend church services secondary to immobility (nonjudgmental)INCORRECT OR AMBIGUOUS STATEMENTSpiritual Distress related to strict rules necessitating church attendance (judgmental)

GUIDELINE #4Make sure that both elements of the

statement do not stay the same thingCORRECT STATEMENT

Risk for Impaired Skin Integrity related to immobilityINCORRECT OR AMBIGUOUS STATEMENT

Impaired Skin Integrity related to ulceration of sacral area (response and probable cause are the same)

GUIDELINE #5

Be sure that the cause and effect are correctly stated (i.e., the etiology causes the problem or puts the client at risk for the problem).CORRECT STATEMENT

Pain: Severe headache related to fear of addiction to narcoticsINCORRECT OR AMBIGUOUS STATEMENT

Pain related to severe headache

GUIDELINE #6Word the diagnosis specifically and

precisely to provide direction for planning nursing interventionCORRECT STATEMENT

Impaired Oral Mucous Membrane related to decreased salivation secondary to radiation of neck (specific)INCORRECT OR AMBIGUOUS STATEMENT

Impaired Oral Mucous Membrane related to noxious agent (vague)

GUIDELINE #7Use nursing terminology rather than

medical terminology to describe the client’s response.CORRECT STATEMENT

Risk for Ineffective Airway Clearance related to accumulation of secretion in lungs (nursing terminology)INCORRECT OR AMBIGUOUS STATEMENT

Risk for Pneumonia (medical terminology)

GUIDELINE #8Use nursing terminology rather tha

medical terminology to describe the probable cause of the client’s response.CORRECT STATEMENT

Risk for Ineffective Airway Clearance related to accumulation of secretions in lungs (nursing terminology)INCORRECT OR AMBIGUOUS STATEMENT

Risk for Ineffective Airway Clearance related to emphysema (medical terminology)PLANNING

DEFINITION OF TERMS

PLANNING- Is a deliberative, systematic phase of the nursing process that involves decision making and problem solving CONCEPT MAP – a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows.

NURSING CARE PLAN – end product of the planning phase, include the actions nurses must take address the client’s nursing diagnoses and produce desired outcomes.INFORMAL NSG CARE PLAN – is a strategy for action that exists in the nurse’s mind.FORMAL NSG CARE PLAN – is a written or computerized guide that organizes information about the client’s care.STANDARDIZED CARE PLAN – is a formal care plan that specifies the nursing care for groups of clients with common needs.INDIVIDUALIZED CARE PLAN – is tailored to meet the unique needs of a specific client – needs that are not addressed by the standardized plan.MULTIDISCIPLINARY CARE PLAN (collaborative care plans/critical pathway) – is a standardized plan that outlines the care required for clients with common, predictable – usually medical – conditions.GOAL – (intent) what you intend to doEXPECTED OUTCOME – (results) what you expect the patient to be able to doINDICATOR is “a more concrete individual, family, or community state, behavior, or perception that serves as a cue for measuring an outcome.”GOAL/ OBJECTIVES/ OUTCOMES/ INDICATORS may be used interchangeablyDEFINITION OF TERMSPRIORITY SETTING – is the process of establishing a preferential sequence for addressing nursing diagnosis and interventionsNURSING INTERVENTION – any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.RATIONALE – is the scientific principle given as the reason for selecting a particular nursing intervention.

Purposes of Planning

• Promote communication among caregivers

• Direct care and documentation

• Create a record that can later be used for evaluation, research, and legal reasons.

• Provide documentation of health care needs for insurance reimbursement purposes

TYPES OF PLANNING1. Initial Planning

- Planning should be initiated as soon as possible after the initial assessment. The nurse has the benefit of the slient’s body language as well as some intuitive kinds of info that are not available solely from the written database.2. Ongoing Planning - occurs at the beginning of a shift as the nurse plans the care to be given that day. As nurses obtain new information and evaluate the client’s responses to care to be given that day.3.Discharge Planning – the process of anticipating and planning for the needs after discharge. Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs.

FORMAT OF NURSING CARE PLAN

• NURSING DIAGNOSIS

• GOALS / EXPECTED OUTCOME

• NURSING INTERVENTIONS

• EVALUATION

Major Components of Care Plans Expected (desired) outcomes : What results do you expect and when do you expect to see these results ? Actual and Potential Problems : What are the actual and potential diagnoses and problems that must be addressed to ensure safe and efficient care ? Specific Interventions : What is going to be done to prevent or manage the major problems and achieve the expected objectives ? Evaluation / Progress Notes : Where can you find out how the person is responding to the plan of care ?

Steps in Planning1. Setting priorities2. Establishing expected outcomes3. Deciding problems that must be recorded4. Determine Interventions5. Ensuring plan is adequately recorded

1. Setting priorities– is an essential critical thinking skill that requires you to be able to decide : Which problems need immediate attention, which ones can wait ?

Which problems are your responsibility and which do you need to refer to someone else ? Which problems will be dealt with by using standard plans Which problems aren’t covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge ?

Priority-Setting PrinciplesIn setting priorities, be guided by the following principles :• Choose a method of assigning priorities and use it consistently• Assign a high priority to problems that contribute to other problems • Your ability to understand priorities is influenced by your understanding of the patient’s understanding of priorities, the whole picture of problems, patient’s overall health status, expected length of stay, and whether there are standard plans that apply***In developing plans, applies laws and standards practice

Basis for PRIORITIZATION

• Maslow’s Hierarchy of Needs

• Airway, Breathing, Circulation

• Urgency ( life-threatening / health threatening )

MASLOW’S HIERARCHY OF NEEDSPriority 1. PHYSIOLOGIC NEEDS

- eg, problems with breathing, circulation, nutrition, hydration, elimination, temperature regulation, physical comfort Priority 2. SAFETY AND SECURITY

- eg, environmental hazards, fearPriority 3. LOVE AND BELONGING

- eg, isolation or loss of a loved onePriority 4. SELF-ESTEEM

- eg, inability to perform normal activitiesPriority 5. SELF-ACTUALIZATION

- Problems posing a threat to the ability to achieve personal goals

ABCFor identifying initial urgent priorities, some nurses use the ABC method ( make sure the patient has no threats to his..

A – Airway

B – BreathingC – Circulation

LIFE THREATENNG/HEALTH-THREATENINGAssign high priority problems that contribute to other problems.Example :

if someone has chest pain and difficulty breathing, pain management is a high priority because pain causes increased stress and oxygen demand.

ADDITONAL 3 STRATEGIES FOR SETTING PRIORITIES

Ask, “What problems need immediate attention and what could happen if I wait until later to attend to them?”

Identify problems with simple solutions and initiate actions to solve them

Develop an initial problem list, identifying actual and potential problems, and their causes, if known.

CRITICAL THINKING DURING PLANNING: TEN KEY QUESTIONS

1. What major outcomes (observable beneficial results) do we expect to see in this particular person, family, or group when the plan of care is terminated?

2. What problems, risks, or issues must be addressed to achieve the major outcomes?

3. What are the circumstances (what is the context)?

4. What knowledge is required? 5. How much room is there for an error?6. How much time do I/we have?7. What resources can help?8. What perspectives must be considered?9. What’s influencing thinking?10. What must we do to prevent, manage,

or eliminate the problems, issues, and risks identified in #2 above?

2. Determine OutcomesOutcomes describe what you expect to observe in the patient that will demonstrate that he has been benefited by nursing care. Indicators are specifically measurable data that will indicate that the outcome had been achieved. Oftentimes, these two words are used interchangeably.

OUTCOME: Patient’s skin remains intact INDICATORS:

• Skin shows no sign of discoloration or irritation

• Control of listed risk factors (nutrition, hydration, skin care every 8 hours)EXAMPLESOUTCOME: With the help of printed materials, the patient will demonstrate knowledge of medication regimen by dischargeINDICATORS:

• Lists drug names, doses, actions, administration routes and side effects

• Demonstrates special administration techniques

• Lists reportable signs and symptoms

3 Purposes of Outcomes

• There are the measuring sticks of the plan of care

• They direct interventions

• They are motivating factors

Standards for Outcomes: Derived from the diagnoses

Documented using measurable terms

Mutually formulated with the clients and health care provider, when possible. Realistic in terms of client’s present and potential capabilities Attainable in relation to resources available to the patent. Written in such a way that they include a time estimate for attainment and provide direction for continuity of care

TYPES OF OUTCOMES• Clinical Outcomes describe the expected status of medical, nursing, or multidisciplinary problems at certain points in time, after treatments had been given. They resolve whether the problems are resolved or to what degree they are resolved. Ex : chest tube out 3rd post-op day, lungs clear, absence of signs of infection

• Functional Outcomes describe the person’s ability to function in relation to desired usual activities. Ex : Four days after total knee replacement, Mr. Palmer will be discharged to a

rehabilitation facility able to perform straight leg raises and range of motion exercises twice a day.

• Quality of Life Outcomes focus on key factors that affect someone’s ability to be physically and spiritually comfortable. Ex. : absence of depression, absence of depression, usual sleep patterns, able to perform work and leisure activities

PRINCIPLES OF PATIENT-CENTERED OUTCOMESPRINCIPLE 1: Outcomes describe specific benefits you see in the patient after care has been given (short term or long term)

eg, “Father will safely bathe the newborn.”

Short term outcomes – describe early expected benefits of nursing intervention.eg, Will be able to walk to the bathroom tomorrow unassisted.

Long term outcomes – describe the benefits expected to be seen at a certain point in time after the plan has been implementedeg, Will be able to walk independently to the end of the hall, 3 times within 10 days after the surgery

PRINCIPLE 2: Outcomes relate to problems or interventions (intervention outcomes, problem outcomes)

Problem outcomes – state what you expect to observe in the patient when the problems are resolved or controlledeg, The patient will not have signs and symptoms of infection

Intervention outcomes – state the benefit you expect to observe in the patient after an intervention is performedeg, Breath sounds will clear after suctioning

PRINCIPLE 3: Outcome statements are very specific which include the following components: subject, verb, condition, performance criteria, time

Example: Parents will bathe the newborn in room s v cindependently by May 17 pc t

PRINCIPLE 4: Use measurable verbsExample:

suppose you write an outcome for a woman that says, “Will understand how to use sterile technique.”

The only way you can really know how well she understands is if she actually verbalizes or demonstrates sterile technique Examples:Measurable:

identify state describe perform list, express share verbalize exercise hold,

perform cough demonstrate communicate

Non-measurable: Know understand acceptThink appreciate feel

PRINCIPLE 5: Consider cognitive, affective, and psychomotor outcomes

Affective domain: associated with changes in attitudes, feelings, or valueseg, Identifies old eating habits that are to be changed

Cognitive domain: dealing with acquired knowledge or intellectual skillseg, Enumerates signs ad symptoms of diabetic shock

Psychomotor domain: dealing with developing motor skillseg, Demonstrates how to walk with crutches

GUIDELINES IN DETERMINING PATIENT-CENTERED OUTCOMES

Be realistic and consider: Patient’s health state, overall prognosis Expected length of stay Growth and Development Patient values and cultural considerations Other planned therapies for the patient Available human, material, and financial resources Risks, benefits, and current scientific evidence Changes in status that indicate you need to modify usual expected outcomes

GUIDELINES IN DETERMINING PATIENT-CENTERED OUTCOMES Partner with patients and families, determining outcomes together and involving other key members of the health care team In complex cases, develop both short- and long-term outcomes Be sure the outcomes and indicators are measurable: that they describe something you can hear, see, feel, or smell in the person to demonstrate that the outcomes are achieved

GUIDELINES IN DETERMINING PATIENT-CENTERED OUTCOMES

Consider the five components – subject, verb, condition, performance criteria, target time

Identify only one behavior per indicator

Sometimes outcomes and indicators already will be developed for your patient’s problems in standard plans

GUIDELINES FOR WRITING GOALS AND DESIRED OUTCOMES

1. Write goals and outcomes in terms of client responses, not nurse activities.

2. Be sure that desired outcomes are realistic for the client’s capabilities, limitations, and designated time span, if is indicated.

3. Ensure that the goals and desired outcomes are compatible with the therapies of other professionals.

4. Make sure that each goal is derived from only one nursing diagnosis.

5. Use observable, measurable terms of outcomes. Avoid words that are vague and require interpretation or judgment by the observer.

6. Make sure the client considers the goals/desired outcomes important and values them.

3. Deciding problems that must be recordedDECIDING WHICH PROBLEMS MUST BE RECORDED..is influenced by your understanding of:

The whole picture of all the problems present

The person’s overall health status and expected discharge outcomes

The expected length of contact with the patient. Focus on what must be achieved before what’s nice to do

DECIDING WHICH PROBLEMS MUST BE RECORDED

The patient’s perception of priorities. If the patient doesn’t agree with your priorities, it’s unlikely the plan will succeed.

Whether there are standard plans that apply. For example, are there critical pathways, guidelines, protocols, procedures, or standard plans that address daily priorities for this particular patient’s situation?

THREE BASIC STEPS TO DETERMINE WHICH PROBLEMS MUST BE RECORDED

• Create a problem list

• Decide which problems must be managed in order to achieve the overall outcomes of care

• Determine what documentation will guide how each problem will be managed eg, Nurse-developed individualized plan? Patient self-manages?

4. Determine InterventionsInterventions are actions performed by the nurse to monitor health status, reduce risks, resolved, prevent, manage a problem, facilitate independence or assist with activities of daily living, promote optimum sense of physical, psychological and spiritual wellbeing.

CLASSIFICATION OF INTERVENTIONSInterventions can be classified into:

• direct interventions which are performed through interactions with patients

• indirect care interventions are those done away from the patient, such as monitoring results of laboratories.

Interventions should:

direct, prevent and manage health problems and risks

promote optimum function and sense of well being

achieve the desired outcomes safely and efficiently

INDIVIDUALIZED CAREQuestions to ask for individualized care

• What can be done to minimize or prevent risk?

• What can be done to manage problems?

• How can I tailor interventions to meet the expected outcomes?

• How likely are we able to get desired versus adverse responses to the intervention?

TEACHINGTEACHING: THE KEY TO EMPOWERMENTTeaching patients about their health and treatment plan and motivating them to become involved in managing their care is the key to empowering them to become their best advocate and caregiver.

GUIDELINES IN PLANNING FOR TEACHING:– Assess readiness to learn and previous knowledge before developing a teaching plan.– Ask about preferred learning styles– Plan for environment that is conducive to learning– Identify active learning experiences (with client involvement)– Use simple words– Determine learning outcomes mutually – Encourage asking questions– Plan to pace learning – Allow time to discuss progress– Find ways to include significant others in the teaching session.

Standardized Plans

Guides that generally, but not completely apply to individual situations

Nurses can help individualized these plans accordingly

5. Ensuring plan is adequately recorded

Remember the E.A.S.E. mnemonic?E= expected outcomeA= actual and potential problemsS= specific interventionsE= evaluation/progress notes

WHEN RECORDING THE PLAN OF CARE REMEMBER THAT YOU MUST USE STANDARDIZED OR RECOGNIZED TERMS

GUIDELINES FOR WRITING NURSING CARE PLAN

1. Date and sign the plan2. Use category headings3. Use standardized/approved medical or

English symbols and key words rather than complete sentences to communicate your ideas unless the agency policy dictates otherwise.

4. Be specific5. Refer to procedures books or other

sources of information rather than including all the steps on a written plan

6. Tailor the plan to the unique characteristics of the client by ensuring that the client’s choice, such as preferences about the times of care and the methods used, are included.

7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones

8. Ensure that the plan contains interventions for ongoing assessment of the client.

9. Include collaborative and coordination activities in the plan.

10. Include plans for the client discharge and home care needs.

IMPLEMENTATION

ACTIVITIES IN IMPLEMENTATION1. Preparing for report and getting report2. Setting daily priorities3. Assessing and re-assessing4. Performing interventions and making

necessary changes5. Charting6. Giving report

1. Preparing for report and getting report

• Learning about patient’s problems

• Reading chart

• Getting to the unit early

• Receiving inter-shift report

• Using your worksheet

2. Setting daily priorities

• Make initial quick rounds

• Immediately after shift report, verify critical information

• Identify urgent problems

• List your patient’s major problems in relation to expected outcomes for the day

• Determine the interventions that must be done to prevent, resolve or manage the problem

• Decide what things the patient and/or significant others can do on their own and things you must do by yourself

• Make personal worksheet for getting things done for the day and refer

ALWAYS REMEMBER TO PARTNER WITH PATIENTS IN SETTING PRIORITIES

DELEGATING Transferring to a competent individual the authority to perform selected tasks in a situation while retaining accountability for results

Five Rights of Delegation

• RIGHT Task

• RIGHT Person

• RIGHT Situation

• RIGHT Communication

• RIGHT Evaluation

Delegate with full knowledge of: standardsof care, specific job descriptions, knowledgeof competencies of delegatees

Delegate when…

• The patient is stable

• The task is within the worker’s job description and capabilities

• The amount of RN time with the patient isn’t significantly reduced

What not to delegate?

Complex assignments

Unpredictable outcomes

Increased risk of harm

Problem-solving and creativity

3. Assessing and re-assessing

• Assess with and open mind

• It is fine to use critical paths, but nurses should be able to identify and manage care variances

4. Performing interventions and making necessary changesInterventions may be:

• Independent

• Dependent

• Collaborative

Interventions may be:

• Physical

• Psychological

• Spiritual

• Social

• Interventions may be:

• Promotive

• Preventive

• Curative

• Rehabilitative

GUIDELINES IN IMPLEMENTING INTERVENTIONS1. Base nursing interventions on scientific

knowledge, nursing research and professional standards of care

2. Clearly understand the interventions to be implemented and question any that are not understood

3. Adapt activities to the individual client4. Implement safe care5. Provide teaching, support and comfort6. Be holistic7. Respect the dignity of the client and enhance the client’s esteem8. Encourage clients to participate actively in implementing nursing interventions

5. Charting Purposes:

• Communicate care

• Help identify patterns

• Provide basis for evaluation

• Create legal document

• Supply validation for insurance purposesTypes of Charting• Source-Oriented – caregivers of different disciplines’ charting• Focus charting – specifies concerns of patients (Ex. DAR-data, Action, Response)• Multidisciplinary – different disciplines write on the same form• Flow sheet – monitoring (if none specify so)• Charting by exception (CBE)• Addendum Sheets (Patients education plan, Discharge Instructions)• Computerized Patient Records (CPR) / Electronic Medical Records (EMR)

Memory Jogs Used for Charting

• AIR-A (Assessment, Intervention, Response, Action)

• DIE (Data, Intervention, Evaluation)

• PIE (Problem, Intervention, Evaluation)

• SOAP, SOAPIE (Subjective/Objecctie data, Assessment, Plan, Intervention, Evaluation)

• Keep your data up-to-date and constantly evaluate

GENERAL GUIDELINES FOR RECORDING• DATE AND TIME - Essential for client safety.- Record in conventional manner (eg, 9:00 am or 3:15 pm) or in military clock (24 hour clock) which avoids confusion about whether a time was am or pm.• TIMING- Done as soon as possible after an assessment or intervention. - No recording should be done before providing nursing care.• LEGIBILITY- All entries must be legible and easy to read to prevent interpretation errors.• PERMANENCE- All entries on the client’s record are made in dark ink so that the record is permanent and changes are identified.

- Dark ink reproduces well on microfilm and in duplication processes.• ACCEPTED TERMINOLOGY- Use only commonly accepted abbreviations, symbols, and terms that are specified by the agency. - When in doubt about whether to use an abbreviation, write the term in full until certain about the abbreviation.• CORRECT SPELLING- Essential for accuracy in recording. - If unsure how to spell a word, look it up in a dictionary or other resource book.• SIGNATURE- Includes the name and title; for example, “Lorivi May C. Cruz, RN” or “LMC Cruz, RN.” - The following title abbreviations are often used but nurses need to follow agency policy about how to sign their names.examplesRN registered nurseLVN licensed vocational nurseLPN licensed practical nurseNA nursing assistantNS nursing studentPCA patient care associateSN student nurse• ACCURACY- Notations on records must be accurate and correct. Accurate notations consists of facts or observations rather than opinions or interpretations. Example: Fact: “refused medication” opinion: “uncooperativeobservation: “was crying” interpretation: “was depressed”- Similarly, when a client expresses worry about the diagnosis or problem, this should be quoted directly on the record: “Stated: ‘I’m worried about my leg.’ ” - When describing something, avoid general words, such as large, good or normal, which can be interpreted differently.Example: chart specific date such as “2cm x 3 cm bruise” rather than “ large bruise.”- When recording mistake is made, draw a line through it and write the words mistaken entry above or next to the original entry, with your initials or name (depending on agency policy)- Do not erase, blot out, or use correction fluid.- The original entry must remain visible.- Write on every line but never between lines.

- If a blank appears in a notation, draw a line through the blank space and sign the notation

• SEQUENCE- Document events in the order in which they occur; for example, record assessments, then nursing interventions, and then the client’s responses.

• APPROPRIATENESS- Record only information that pertains to the client’s health problems and care.- Recording irrelevant information may be considered an invasion of the client’s privacy and/or libelous.

• COMPLETENESS- Nurses’ notes need to reflect the nursing process.- Record all assessments, dependent and independent nursing interventions, client problems, client comments and responses to interventions and tests, progress towards goals, and communication with other members of the health team.- Care that is omitted because of the client’s condition or refusal of treatment must also be recorded. Document what was omitted, why it is omitted, and who was notified.• CONCISENESS- Recording need to be brief as well as complete to save time in communication. Client’s name and the word client are omitted.Example ”Perspiring profusely. Respirations shallow, 28/min.”End each thought or sentence with a period.• LEGAL PRUDENCE- For the best legal protection, the nurse should nit only adhere to professional standards of nursing care but also follow agency policy and procedures for intervention and documentation in all situations – especially high risk situations.

6. Giving reportChange of shifts report should be accurate, factual and organizedEndorsements

• Inter-shift reports

• Intra-shift reports

GUIDELINES: CHANGE OF SHIFT REPORT

• Use a written printed guide

• Begin by giving a general background information

• Be specific

• If you make an inference back it up with evidence

• Describe the status of all invasive lines

• Stress abnormal findings

EVALUATION

Evaluation

• A critical, careful and deliberate appraisal of various aspects of patient care

• Involves examining all of the steps of the nursing process

PURPOSES OF EVALUATION

• Determining outcome achievement

• Identifying variables affecting outcome achievement

• Deciding whether to discharge patient or to continue care

STEPS IN EVALUATION1. Determine current health status and

readiness to test for outcome achievement 2. List the outcomes set forth in planning3. Compare what the patient is able to do in

relation to the outcome. 4. Decide the extent of outcome achievement

by asking the following questions Have the outcomes been completely met ? Have the outcomes been partially met Have the outcomes not at all been met ?5. Record your findings on the patient’s record.

TYPES OF EVALUATION

• Outcome studies the results or outcomes of care

• Process studies how the care had been given

• Structure studies the setting where carre had been rendered

OUTCOME EVALUATIONFocuses on demonstrable changesEXAMPLES:“How many clients undergoing hip repairs develop pneumonia?”

“How many clients who have a colostomy experience an infection that delays discharge?

PROCESS EVALUATION Focuses on how the care was givenEXAMPLES“Is the care relevant to the client’s needs?“Is the care appropriate, complete and timely?

STRUCTURE EVALUATIONFocuses on the setting in which the care was givenEXAMPLESWhat effect does the setting have on the quality care?

Nurses’ Role in Preventing Mistakes

• Think analytically

• Remember that how you document is important

• Work on your own personal improvement

MISTAKES

• SENTINEL EVENTS an unexpected incident which cause the death or serious physical or psychological injury to the client

• NEAR MISS anything that happened during the process of care that didn’t affect the outcome, but for which a reoccurrence carries a significant chance of a serious adverse outcome

• HAZARDOUS CONDITION any set of circumstances which significantly increases the likelihood of a serious adverse outcome