Nursing ProcessNursing Process

PlanningPlanning

DefinedDefined

• Establishing client centered goalsEstablishing client centered goals• Identifying expected client outcomesIdentifying expected client outcomes• Establishing nursing interventionsEstablishing nursing interventions

PrioritizingPrioritizing

• Put the Nursing Diagnoses in order of Put the Nursing Diagnoses in order of importanceimportance– HighHigh – life-threatening if not treated – life-threatening if not treated – IntermediateIntermediate – non-emergent or non-life – non-emergent or non-life

threateningthreatening– LowLow – may affect future well-being – may affect future well-being

• May need to be re-evaluated and re-May need to be re-evaluated and re-ordered as time progresses ordered as time progresses

• Involve the patient when possibleInvolve the patient when possible

Goals & OutcomesGoals & Outcomes

• Specific statements of behavior or Specific statements of behavior or responsesresponses

• Serve as focal point for interventionsServe as focal point for interventions– Selection of appropriate onesSelection of appropriate ones– Evaluation of effectivenessEvaluation of effectiveness

GoalsGoals

• MustMust be: be:– SpecificSpecific– ObservableObservable– SingularSingular– MeasurableMeasurable– Time-limitedTime-limited

Also . . .Also . . .

• Client-centeredClient-centered– Focused on optimum level of wellness & Focused on optimum level of wellness &

independenceindependence– Agreeable with patient (and family)Agreeable with patient (and family)– Realistically based on patient needs & Realistically based on patient needs &

resourcesresources– Preventative as well as restorativePreventative as well as restorative

More . . .More . . .

• Short-termShort-term– Usually expected to be Usually expected to be

accomplished in about 1 weekaccomplished in about 1 week

• Long-termLong-term– Achieved over a period of weeks or Achieved over a period of weeks or

monthsmonths

Expected OutcomesExpected Outcomes

• Desired response of client’s Desired response of client’s condition in any areacondition in any area– PhysiologicalPhysiological– SocialSocial– EmotionalEmotional– DevelopmentalDevelopmental– spiritualspiritual

E. O.s are . . .E. O.s are . . .

• MeasurableMeasurable• SpecificSpecific• Proof of the effectiveness and Proof of the effectiveness and

efficiency of interventionsefficiency of interventions

Writing E. O.sWriting E. O.s

• Several for EACH diagnosis and goalSeveral for EACH diagnosis and goal• Written sequentiallyWritten sequentially

– Often one builds on another, like taking Often one builds on another, like taking stepssteps

• Given time framesGiven time frames– When should this be accomplished?When should this be accomplished?

• In terms that allow measurementIn terms that allow measurement– Not “less” pain, but “pain rating Not “less” pain, but “pain rating

decreased to 3 on 1-10 scale”decreased to 3 on 1-10 scale”

The Plan of CareThe Plan of Care

• Focuses on the patientFocuses on the patient• Utilizes research-based knowledge Utilizes research-based knowledge

and practiceand practice• Involves other health care Involves other health care

disciplinesdisciplines• Includes the patient’s familyIncludes the patient’s family• Draws on community resourcesDraws on community resources

scenarioscenario

• 74 yom, s/p R humerus fx. DC’d to 74 yom, s/p R humerus fx. DC’d to home tomorrow. Widowed; only home tomorrow. Widowed; only child lives 3 hr away.child lives 3 hr away.

• Goals?Goals?• Outcomes?Outcomes?• Resources?Resources?

Which Interventions?Which Interventions?

• Apply critical thinking to determine Apply critical thinking to determine which willwhich will– Assist patient to achieve goalsAssist patient to achieve goals– Are pertinent to the patient’s situationAre pertinent to the patient’s situation– Meet the standards of careMeet the standards of care– Fulfill the objectives stated in goal and Fulfill the objectives stated in goal and

expected outcomesexpected outcomes

Intervention TypesIntervention Types

• Nurse-initiatedNurse-initiated– Does not require physician orderDoes not require physician order

• Physician-initiatedPhysician-initiated– Does Does require physician (or NP) orderrequire physician (or NP) order

• Collaborative Collaborative – May require physician orderMay require physician order

Nurse-initiatedNurse-initiated

Autonomous actions Autonomous actions • Based on scientific rationaleBased on scientific rationale• Within the Within the nurse’s ownnurse’s own scope of practice scope of practice• Predictable benefit to patient-centered Predictable benefit to patient-centered

goalgoal– ADLsADLs– Health educationHealth education– Health promotionHealth promotion– Counseling Counseling

Physician-initiatedPhysician-initiated

• Requires order by physician or nurse Requires order by physician or nurse practitioner working in collaboration practitioner working in collaboration with physicianwith physician

• Allows nurse to fit the order into the Allows nurse to fit the order into the patient-centered planpatient-centered plan

• Nurse must still act within the Nurse must still act within the appropriate scope of practiceappropriate scope of practice

Collaborative Collaborative

• Acting as coordinator between Acting as coordinator between various health care teamsvarious health care teams

• Ensure appropriate, timely Ensure appropriate, timely interventionsinterventions

Nursing responsibilityNursing responsibility

• ALWAYS stay within the scope of ALWAYS stay within the scope of practicepractice

• ALWAYS be a patient advocateALWAYS be a patient advocate• ALWAYS check orders for ALWAYS check orders for

correctnesscorrectness• Select interventions that are Select interventions that are

appropriate for each patient’s appropriate for each patient’s individual plan of careindividual plan of care

Nursing Care PlanNursing Care Plan

• A written planA written plan• Focuses on clinical careFocuses on clinical care• Aids in thorough, accurate delivery Aids in thorough, accurate delivery

of careof care• Identify and coordinate resourcesIdentify and coordinate resources• Organizes nursing informationOrganizes nursing information

Student Care PlansStudent Care Plans

• Divided into columns to facilitate Divided into columns to facilitate understanding of the various aspects understanding of the various aspects of the planof the plan

• Scientific rationale is required to Scientific rationale is required to assist students to understand the assist students to understand the “why” of what is planned “why” of what is planned

Institutional Care PlansInstitutional Care Plans

• Often utilize Kardex systemOften utilize Kardex system– Brief synopsis of care planBrief synopsis of care plan– Usually kept at nurses’ stationUsually kept at nurses’ station– Updated dailyUpdated daily

• Computerized Computerized – Standard formStandard form– Easy to followEasy to follow– Prompts attention to each systemPrompts attention to each system

Institutional Care PlansInstitutional Care Plans

• Community-based toolsCommunity-based tools– Includes family and outside resources in Includes family and outside resources in

the assessmentthe assessment– Focus on family education to provide Focus on family education to provide

many of the implementationsmany of the implementations

• Critical pathwaysCritical pathways– All disciplines of health care team work All disciplines of health care team work

together to develop a generic tool that together to develop a generic tool that can be applied to most patients with a can be applied to most patients with a similar diagnosis (example hip fx)similar diagnosis (example hip fx)

Concept MapConcept Map

• Flowchart styleFlowchart style• Uses diagrams to show relationship Uses diagrams to show relationship

between client problems and between client problems and interventionsinterventions

• Can be used throughout the day to Can be used throughout the day to assist students in noting how various assist students in noting how various problems, treatments, nursing problems, treatments, nursing diagnoses and plans interrealatediagnoses and plans interrealate

ConsultationConsultation

• When an identified problem cannot be When an identified problem cannot be solved with available knowledge and solved with available knowledge and resourcesresources

• 11stst- identify the problem- identify the problem• 22ndnd– find the appropriate consultant– find the appropriate consultant• 33rdrd- share pertinent data with consultant- share pertinent data with consultant• 44thth- stick to the facts, no opinions- stick to the facts, no opinions• 55thth- discuss consultant’s - discuss consultant’s

recommendations recommendations • 66thth- incorporate 5 into plan of care- incorporate 5 into plan of care