Nursing process .ppt

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1 : Mr.Arun II year M.Sc nursing PCON,Bengaluru. Mail- id : Mobile: 9886505608 Nursing process 5/18/2011 1 ARUN PIRAVOM
2 : Nursing process Foundation of nsg profession. Serves as a guide for professional nursing practice Identifies, discovers health care needs of the patient/family/community. Helps in the clinical application of theory 5/18/2011 2 ARUN PIRAVOM
3 : EVOLUTION: The term nursing process is synonymous to problem solving approach(for discovering the health care needs of the client or familiy). Widespread use of the term nursing process in late 1960’s. Before that nurses cared for people based on a medical model (loosely structure framework). Since then several nursing leaders were instrumental in developing a model of nursing process 5/18/2011 3 ARUN PIRAVOM
4 : NURSE LEADERS CONTRIBUTION Florence Nightingale helped to establish nursing as a separate body of knowledge from medicine. 1952 --Hildegard Peplau Identified stages of nurse client Relationship- orientation, identification,exploitation and resolution. 1955 -- Lydia Hall First person who introduced the term nursing process (not used in nursing publications until 1960’s) 5/18/2011 4 ARUN PIRAVOM
5 : 1959 -- Dorothea Orlando theorised that nurses must be intrinsically involved not passively in the nursing process. (specifies the unique role of nurses) 1967-- Yura And Walsh devised 4 steps of nursing process (assessment, planning, implementation and evaluation) which is the basis for widely accepted 5 step nursing process. 5/18/2011 5 ARUN PIRAVOM
6 : 1971 -- Dorothea Orem identified 3 levels of client involvement in nursing care. (supportive educative, partly compensatory and wholly compensatory) -helps in establishing focus for decision making. 1973 -- ANA introduced diagnosis as a separate step of nursing process in standards of nursing practice. (standards are formulated based on the 5 steps of nursing process). 5/18/2011 6 ARUN PIRAVOM
7 : 1980 -- ANA identified diagnosis of actual and potential health problems as an integral part of nursing practice. 1991 -- newest development in nursing process is 6 step nursing process introduced by ANA in standards of clinical nursing practice. In this model “outcome identification” was distinguished as 3rd step of nursing process. 5/18/2011 7 ARUN PIRAVOM
8 : Definition: Nursing process is orderly, systematic manner of determining the clients health status,/ specifies the problems defined as “alterations in human need fulfillment”,/ making plans to solve them, /initiating and implementing the plans, /and evaluating the extent to which plan was effective in promoting the optimum wellness and resolving the problems identified. - Yura And Walsh, 1988. Nursing process is the organized and systematic method of giving individualized care focuses upon treating unique responses of individual to actual or potential problems. 5/18/2011 8 ARUN PIRAVOM
9 : Nursing process has the following characteristics: It is the framework for providing nursing care to client/family/community. It is orderly and systematic. It is interdependent (nursing care depends on decisions made by other health care professional). It provides individualized care, client centered, uses the client strengths (make use of positive aspects / strengths). For eg., exercise in improving the health status of the client, client cooperation. It is appropriate for use throughout the life span. It can be used in all settings. (hospital, community, ambulatory and home health care settings) Complements current role of customers in health care. 5/18/2011 9 ARUN PIRAVOM
10 : Goals : Promotes, maintains, restores health or to assist patient to achieve peaceful death. (when the condition is terminal) To enable individual or groups to manage their own health care to the best of their ability. To provide nursing care of best quality or efficiency as possible. 5/18/2011 10 ARUN PIRAVOM
11 : How does the nursing process work? The nursing process uses the problem solving approach. 5/18/2011 11 ARUN PIRAVOM
12 : Why should we use nursing process? (Benefits) delivers nursing care in a systematic or organized manner. nursing process is holistic in focus (ensures that clients unique needs are met) encourages identification and utilization of client strengths. promotes flexibity, independent thinking for nurses. documentation enhances communication, continuity of care, reduces omissions and duplication of care. helps the nurses to have the satisfaction of getting the results. 5/18/2011 12 ARUN PIRAVOM
13 : RELATIONSHIP AMONG THE STEPS OF THE NURSING PROCESS The diagram shows the 5 steps of nursing process and their relationship. Each step is overlapping the other step. Each step of nursing process is dependent upon the accuracy of the proceding step (interdependent). Steps are overlapping which means that you may have to move quicker for some problems than for others. Evaluation involves examining all the previous steps especially focuses upon the goal achievement. (is the diagnosis accurate? Goal appropriate?) 5/18/2011 13 ARUN PIRAVOM
14 : Assessment: Gathering information and examining information to obtain facts necessary to determine health status or strengths or problems. It is the collection of subjective or objective data from client or others for describing the health problems. First step of nursing process and is the first stage of problem identification. It includes the following activities. 5/18/2011 14 ARUN PIRAVOM
15 : NURSING ASSESSMENT Collecting the data Validating the data Organising the data Identifying the patterns Communicating or recording the data 5/18/2011 15 ARUN PIRAVOM
16 : Collecting the data: gathering information about the patient Resources used: Patient – primary source of information Secondary sources are the medical records, nurses records, patient family, professors and literatures. 3 phases of data collection: gather information before you actually see the patient. Interviewing, examining or observing the patient. (physical examination) Reviewing the resources (records and literatures) 5/18/2011 16 ARUN PIRAVOM
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19 : DATA BASE NURSING ASSESSMENT: Performed on initial contact Gather information about all aspects of clients health status Identifies clients strengths and problems It is planned, systematic, comprehensive to ensure that all pertinent information is obtained. This method of data collection uses an assessment tool which is not disease oriented, but holistic or human response oriented. Developed according to nursing model To know how the person functions as a biopsychosocial human being(holistc nursing focus) Tells how patient lives his or her daily life (crucial when identifying the nursing diagnosis). 5/18/2011 19 ARUN PIRAVOM
20 : WAYS OF ORGANIZING THE NURSING DATA BASE Few examples of data base tools organized according to Gordon’s functional health pattern Orems theory of self care Roys adaptation model kings system model Rogers unitary human being model All these tools are well organized, comprehensive and holistic in focus. 5/18/2011 20 ARUN PIRAVOM
21 : FOCUS ASSESSMENT: used to gather information specific to determining the status of actual or potential problem. -ongoing assessment -ask yourself the following questions-any observable s/s? any factors contributing to the problem? how patient feels about managing /preventing a problem? Eg, constipation – cramping pain, no bowel movement- poor diet, reduced fluids, medications, immobility prevention or management. 5/18/2011 21 ARUN PIRAVOM
22 : CLINICAL SKILLS USED IN ASSESSMENT TYPE DEFINITION OBSERVATION - the act of noticing client cues INTERVIEWING - interaction and communication process for gathering data by questioning and information exchange. PHYSICAL EXAMINATION - analysis of bodily functioning using the techniques of inspection, palpation, percussion and auscultation. INTUITION - use of insights, instincts or clinical experience to make judgement about client care. 5/18/2011 22 ARUN PIRAVOM
23 : PROMOTING A SUCCESSFUL INTERVIEW – GUIDELINES Amount of pertinent data collected depends on interviewing skills. Establishing rapport Ensure privacy Use the person’s name Explain your purpose Use good eye contact Don’t hurry How to observe Use your senses Notice general appearance Notice body language Notice interaction pattern 5/18/2011 23 ARUN PIRAVOM
24 : How to ask questions Ask about main problems first Use terminology which is understandable Use open ended questions Use reflection Don’t start with personal or delicate questions Defer questions that are not pertinent Use an orgainised assessment tool to prevent omissions. How to listen Be an active listener Allow the person to finish sentences Be patient if the person has memory block Give your full attention For clarification summarise or restate what has been said 5/18/2011 24 ARUN PIRAVOM
25 : Physical assessment is performed in conjunction with interview, through systematic examination of the client. It involves 4 steps. Methods of physical examination – own preference or depends on condition of the client. Head to toe approach for clients who are well and systems approach for an ill client. Guidelines (physical examination) always promote communication between yourself and client during the physical examination. Don’t rely on memory. Choose a method of organizing your assessment and use it consistently. 5/18/2011 25 ARUN PIRAVOM
26 : Identifying subjective/objective data Subjective data: what patient actually states (feelings, perception) Objective data: concrete observable information (vital signs, lab studies, changes in physical appearance or behaviour). Identifying cues and making inferences: Subjective objective data that you identify in a client as cues. Cues are hints that prompt you to make judgment or inference. Eg, subj data: penicillin for tooth abscess , obj data: rashes over the face and abdomen. 5/18/2011 26 ARUN PIRAVOM
27 : Validating the data: Making sure that you know which data are actually fact and which data are questionable. This means making sure that your cues and inferences (interpretations) are correct. If you are not sure of the validity of your information obtain more data to verify and examine the facts. Validation helps you to avoid missing pertinent information misunderstanding situations jumping to conclusions or focusing in wrong direction 5/18/2011 27 ARUN PIRAVOM
28 : Teqniques of validating data: Recheck your own data( checking BP). look for temporary factors that may alter the accuracy of your data. (temp) ask someone else. (recheck with another person (an experienced)) always double check the data that are extreamly abnormal.(infant weighing scale). compare your subjective and objective data.(racing heart) clarify patient or family statements and verify your inferences. 5/18/2011 28 ARUN PIRAVOM
29 : VALIDATING THE DATA: Making sure that you know which data are actually fact and which data are questionable DATA VALIDATION Identification of cues Make inferences about cues Validate cues and references Methods 5/18/2011 29 ARUN PIRAVOM
30 : Organizing or clustering the data: Clustering the data into categories of information which helps to identify the patient strengths, actual and potential problems. Many institutions recommend a tool for organizing data. Eg) maslows, gordans gives methods of organizing the data. Organizing brings the data together Can observe a pattern of human behaviour. Cluster data according to nursing model- helps to identify the nursing diagnosis. Clustering the data according to systems model helps to identify data to be referred to the physician. 5/18/2011 30 ARUN PIRAVOM
31 : COMPONENTS OF GORDAN’S FUNCTIONAL HEALTH PATTERNS The clients strengths, talents and functional health patterns are an integral part of the assessment data. An assessment of functional health focuses not only on the clients normal function but on his / her altered function or risk for altered function. Because the information gathered using the 11 functional health patterns is basic to nsg, it is applicable for all conceptual models of nursing practice. Functional health assessment can be used for clients of all ages and in all speciality areas, and is relevant for the assessment of the person, family or community. 5/18/2011 31 ARUN PIRAVOM
32 : The advantage of a functional health framework are client strengths or assets not merely the deficits, problems or limitations can be identified. The focus is on nursing diagnosis not medical diagnosis 5/18/2011 32 ARUN PIRAVOM
33 : Demographic data Vital signs, orientation to unit Health perception and health management Nutrition and metabolism Elimination Activity and exercise – cardiovascular status, respiratory status, ADL, mobility status, level of consciousness. Cognition and perception – reflexes, sensorium, cognition and pain. Sleep and rest Self perception and self concept Role and relationships Sexuality and reproduction Coping and stress tolerance Values and beliefs. 5/18/2011 33 ARUN PIRAVOM
34 : COMPONENTS OF DATABASE ASSESSMENT FORM ORGANISED ACCORDING TO OREM’S THEORY OF SELF CARE. Person is an individual who can learn to meet self care requisites( actions or measures used to provide self care), if for some reason, the person cannot learn self care measures, others must provide care. Nursing is viewed by orem as a service geared toward helping the self and others. 5/18/2011 34 ARUN PIRAVOM
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36 : ROY’S ADAPTATION MODEL: Goal is to promote patient adaptation in all 4 adaptive modes – physiologic, self concept, role function and interdependence during health and illness. person encounters adaptation problems in changing environment, especially in situations of health and illness. A . PHYSIOLOGICAL MODE: encompasses the physiological needs- basic needs are identified. Activity, rest, nutrition, elimination, oxygenation, fluid and electrolyte, endocrine, skin integrity, senses, neurological function. B. SELF CONCEPT MODE: Perception of Physical self – patient appraisal of his physical functioning, wellness, illness and appearance. Personal self- how he/she perceives himself or herself in relation to others. Individual perception of his worth. Eg low self esteem, observer, dreamer, comparer etc., 5/18/2011 36 ARUN PIRAVOM
37 : C. ROLE FUNCTION MODE: emphasizes the need for social integrity. Position held in the society, interactions based on that position and how he/she performs daily functions based on that position. D. INTERDEPENDENCE MODE: how patient balances between dependent and independent behaviour in relationship to others. Identify dependent behaviour- help seeking/attention seeking/ affection seeking. Independent behaviour- initiative taking, obstacle mastering, satisfaction from work. 5/18/2011 37 ARUN PIRAVOM
38 : Identifying pattens and filling in the gaps of missing data. Those questions or thoughts that come to your mind (when you are clustering the data together) will guide you to gather additional information to describe problems more clearly. Eg) using probing questions ask how? Why? Initial impressions about the pattern of information that guides you to identify gaps in the data collection. Eg) a 72 year old blind, hurts himself frequently, bruises Needs extra time to fill gaps in data collection. But by identifying the gaps you are less likely to miss any problems. 5/18/2011 38 ARUN PIRAVOM
39 : Communicating or recording the data: Verbal communication of significant findings for eg., abnormal vital signs , pain, problems with breathing or circulation should be given priority over completing nursing data base records. Reporting significant data alerts the key people involved in their patient care. If problem requires the attention of a more qualified professional you should report the information as soon as possible. Having communicated significant data to the appropriate individuals, complete the nursing data base record. 5/18/2011 39 ARUN PIRAVOM
40 : Guidelines For Recording The Nursing Data Base: Use ink and write or print legibly. Follow precisely hospital or facility policies and procedures for recording the data base. Follow an organized method of recording the data. Document the name of any person contributing to the history other than the patient. Be clear when you record what you observed. Eg, Right: breath sounds diminished at left lower base and he complains of piercing pain. Wrong: seems to be having breathing difficulty. Write patient statements using the patient own words. Eg. It feels like knife cutting me in two when I move my left side. Chart whom you notified if you have reported significant data. Chart the most critical data first. Eg vital signs, medications, allergies so that if you leave the unit for some reason, they will be readily available. 5/18/2011 40 ARUN PIRAVOM
41 : NURSING DIAGNOSIS Definition: An actual or potential health problem that focuses upon the holistic or human response of an individual or group and that the nurses are responsible and accountable for identifying and treating independently. Purpose of the nursing diagnosis: analyse the collected data identify the client strengths identify the clients normal functional level and indicators of actual or potential dysfunction formulate a diagnostic statement in relation to this synthesis. 5/18/2011 41 ARUN PIRAVOM
42 : Significance of nursing diagnosis: Provides a means of communicating nursing requirements of clients to other nurses, the health care team and the public. Facilitates the development of nursing autonomy and accountability. Nursing diagnostic labels can serve as shorthand for specific client problems. Ensures that clients receive quality nursing care. Increases the specificity of nursing interventions for each client. Coding of nursing diagnosis in computerized systems allows direct reimbursement of nurses. The nursing diagnosis taxonomy will help to bridge the gap between knowledge and practice and will articulate the scope of nursing practice. 5/18/2011 42 ARUN PIRAVOM
43 : Evolution of nursing diagnosis:historical development Before the 1970’s nurses were responsible for assessing patients, but were not allowed to make judgements about their observations. ANA recognized a need to publish new standards for nsg practice that included the role of nurse as a diagnostician.(ANA standards of nursing practice, 1973). These standards were followed by the publication of the ANA social policy statement(1980), which stated that “nursing is the diagnosis and treatment of human responses to actual and potential problems. 5/18/2011 43 ARUN PIRAVOM
44 : With these publications and with subsequent changes in nurse practice acts, nurses became responsible and accountable for making nursing diagnosis and their focus became one of treating the whole person, not just the disease. To meet this challenge and to identify categories of problems that should be considered to be nsg diagnosis, a group of nurses (made up of theorists, administrators and practitioners) met in 1973 to form the national conference group for the classification of nursing diagnosis. As a result of their work, a list of diagnosis that were accepted to study and clinical testing was developed(1973). This group has since become the North American Nursing Diagnosis Association(NANDA) and has held national meeting every 2 years. 5/18/2011 44 ARUN PIRAVOM
45 : ANALYSIS OF DATA/ DIAGNOSTIC REASONING A method of thinking that uses logic to come to conclusions about an individual’s health status is called diagnostic reasoning. Nursing diagnosis VS collaborative problem: nurses are involved in identifying 2 type of problem- nursing diagnosis (involves independent role) and collobarative problem(dep role). Collobarative problem: an actual or potential health problem(complication) that focuses upon the pathophysiologic response of the body(to trauma, disease, diagnostic studies or treatment modalities) and that nurses are responsible and accountable to identify and treat in collaboration with the physician. Medical diagnosis: a traumatic or disease condition that is validated by the medical diagnostic studies and for which treatment focuses upon correcting or preventing pathophysiology of specific organs or body systems. (required by a licensed physicians) 5/18/2011 45 ARUN PIRAVOM
46 : Diagram to identify whether you have identified a nursing diagnosis/ collaborative problem Identification of actual or potential health problem Can the nurse validate the problem and initiate treatment independently? Yes No Nursing diagnosis collaborative problem 5/18/2011 46 ARUN PIRAVOM
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48 : Using NANDA list of nursing diagnosis Is helpful in identifying nursing diagnosis. publishes accepted list every 2 years. - NANDA publishes diagnostic labels that have been accepted for clinical testing to validate whether it is indeed a problem that can be identified or treated by nurses. Each diagnostic label has 3 components: Title (label): offers a concise description of the health problem. Defining characteristics: cluster of signs and symptoms that are often seen with that particular diagnosis. Etiological and contributive factors: identifies those situational, pathophysiological and maturational factors that can cause or contribute to the problem. 5/18/2011 48 ARUN PIRAVOM
49 : Writing diagnostic statements for actual nursing diagnosis: 3 part statement that includes problem, cause or etiology and signs and symptoms (defining characteristics) Rule: link the problem and its etiology using “related to” add “ as manifested by” or “ as evidenced by” and state major signs and symptoms.(that validate that diagnosis exist). Eg) Fluid volume excess related to inability of kidney to excrete waste products as manifested by edema, wt gain, decreased urine output, SOB, abnormal breath sounds,JVD. 5/18/2011 49 ARUN PIRAVOM
50 : Writing diagnostic statement for potential nursing diagnosis - 2 part statement, high risk factors present but there is no signs and symptoms. Eg, potential for impaired skin integrity related to prolong immobility Rule: state potential problem adding ‘related to’ to link problem with contributing factors 5/18/2011 50 ARUN PIRAVOM
51 : Writing diagnostic statement for possible nursing diagnosis 2 part statement You suspect a nursing diagnosis but there is no adequate information Label it as a possible nursing diagnosis. Rule: state possible problem adding ‘related to’ to link it with possible contributive factors. Eg, possible spiritual distress related to terminal/ chronic illness(cancer). Plan of care: gather more data to determine whether diagnosis is actually present. 5/18/2011 51 ARUN PIRAVOM
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53 : How to identify nursing diagnosis: Identify usual lifestyles and coping patterns: to understand how the problem is affecting individual’s sense of wellbeing, to identify factors contributing to the problem and how he/she can attain or maintain an optimum health status in his/her own way. Eg, chronic constipation- leads a sedentary life, reduced fibre intake, hates to do exercise. To identify how individual usually copes with changes in lifestyle helps to detect how he might be able to deal with present health problem. Eg, client when he is depressed – performs some ex’s/ works/ reads books to get his mind off his problem. The first person may find confinement to bed more difficult than 2nd person. 5/18/2011 53 ARUN PIRAVOM
54 : How to determine etiology of the nursing diagnosis: Just as the problem identification, identifying etiology depends on the nurses knowledge, experience and skills. Questions to ask to identify the etiology factors that client identifies as causing problem factors r/t developmental age, presence of disease condition or situational changes in life styles factors from other resources (medical records, health care professionals, literatures) 5/18/2011 54 ARUN PIRAVOM
55 : Writing diagnostic statements for the collaborative problem Rule: describe the collaborative problem using the term potential complication. Link the problem and its cause using ‘secondary to’ or ‘ related to’ . Eg, potential complication: paralytic ileus secondary to spinal surgery. Potential complication: arrhythmias secondary to decreased serum potassium. Helps to determine what complications you are looking for? And how it might be prevented? 5/18/2011 55 ARUN PIRAVOM
56 : How to identify a collaborative problem: Ability to identify collaborative problem depends on knowledge on disease condition, trauma, surgery, anaesthesia and treatment modalities. Guidelines: Consider your patients medical diagnosis Determine s/s of most frequent and dangerous complications associated with specific medical diagnosis. Be aware of recent diagnostic/ treatment modalities (to det asso comp’s). If situation is complex, check with reference.(ask qualified person) Consult policy, procedures, protocols, standards regarding a diagnostic or treatment situation because it often lists asso/ potential comp’s. eg, ICD. 5/18/2011 56 ARUN PIRAVOM
57 : Using nursing diagnosis terminology correctly Or how to avoid errors while writing diagnostic statements Guidelines: Don’t state nursing diagnosis in medical terminology. E g, related to laparotomy. Don’t state nursing diagnosis as medical diagnosis. E g, potential for pneumonia Don’t state 2 problems at the same time eg, pain and fear related diagnostic procedure Don’t write nsg diagnosis which is legally incriminating. E g, potential for injury rlt lack of siderails on the bed. Don’t write nsg diagnosis based on value judgements. Eg, spiritual distress r/t atheism as manifested by statements(no belief), as individual may at peace with his own belief. 5/18/2011 57 ARUN PIRAVOM
58 : PLANNING Activities: setting priorities establishing client goals or outcomes determining nursing interventions documenting the plan of nursing care. Setting priorities: Determine problems that need immediate attention (life threatening problems) and taking immediate appropriate action. Determine nsg diagnosis that will be addressed on the NCP (unusual and complex) . Determine collaborative problem that requires physician’s order for diagnosis/ monitoring/ treatment. 5/18/2011 58 ARUN PIRAVOM
59 : Principles of setting priorities: Priority ratings will be influenced by the following Clients own perception of priorities Overall treatment plan(if a person goes for physio therapy- to eat earlier than usual) Overall health status of the client(newly diagnosed diabetic pt- knowledge deficit is given high priority where as the same is given low priority for critically ill) Presence of the potential pbm. Eg, Assisting the patient to mobilize during the imm postop day to p/v comp’s takes priority over patient’s desire to mobilize on his own. Nursing students should choose a method of assigning priority rating and use it consistently to become systematic and comprehensive.( according to gordan’s / maslow’s) Problems that are contributing factors to other problems should be treated first.( Joint pain – reduced mobility, resolve the problem of pain first to improve mobility) 5/18/2011 59 ARUN PIRAVOM
60 : Establishing goals: Reason for setting realistic goals: Measuring sticks of plan of care( to measure the success of plan by determining achievement of goals set forth) Directs interventions Motivating factor (within the timeframe- person will do better if a time frame is given). Types: Short term goals- goals that can be met relatively quickly Long term goals- goals that can be achieved over a long period of time.(wks/months) 5/18/2011 60 ARUN PIRAVOM
61 : We may set several STG in order to reach LTG. E g, STG- Mr. X will turn / reposition herself from side to side every 2 hours. LTG- Mr. X will maintain good skin integrity. LTG are goals that are ongoing to be accomplished everyday. E g, Mr. X will demonstrate How to change colostomy bag with in 2 days. how to give complete colostomy care according to hospital standards by discharge 5/18/2011 61 ARUN PIRAVOM
62 : Client centered goals: recognized as efficient or effective method of writing goal statement because this focuses upon end result of plan of care( that client benefits from nursing care). Rule: the subject of client centered goal must be patient or part of patient. E g, Patient will ambulate 3 times a day, Skin will remain intact free from signs of irritation. Goals Vs outcomes : goals, objectives, outcomes are terms used interchangeably with outcomes usually being more specific. Rule: state the broad goal and add ‘as evidenced by’ and list the data that will tell you that patient has achieved the goal. E g, Client will demonstrate effective airway clearance as evidenced by clear lung, ability to cough out sputum, absence of fever. The first part of statement is the broad goal The second part of the statement is the outcome. 5/18/2011 62 ARUN PIRAVOM
63 : Determining goals from nursing diagnosis For every nursing diagnosis you must identify client centered goals. Goal statement can be derived directly from nursing diagnosis. Steps for deriving goals from nursing diagnosis: look at the first clause of nursing diagnosis or problem statement (words before related to) E g, potential impaired skin integrity r/t immobility Now restate the first clause in goal statement that would describe an improvement or absence of problem. E g, client will demonstrate no signs of skin irritation. 5/18/2011 63 ARUN PIRAVOM
64 : Rules for stating client outcomes/ goals from nursing diagnosis. Client outcome statement should describe what is to be done, who is to do it, when they are to do it?, how they are to do it?, where they are to do it?, how well they are to do it?. Each goal statement must have components: Subject ( who is the person expected to achieve the goal) Verb (action), Condition (circumstances), Criteria (how well) specific time (when to perform) E g, Mr. Smith / will walk / with a cane / at least to the end of the hall and back / this afternoon. When writing client outcomes avoid using verbs that are non measurable (know, understand, appreciate, think, accept, feel). Use measurable verbs (demonstrate, exercise, list, verbalize, communicate, perform). 5/18/2011 64 ARUN PIRAVOM
65 : Guidelines for establishing client goals/outcomes from nursing diagnosis Be realistic in establishing goals(consider behaviour pattern, resources, therapy and time) Set goals mutually with client or others involved in health care(goals should be congruent with other health care professionals) Establish both STG and LTG. Goals should describe client behaviour/ action. Follow the rules Use measurable, observable verbs to describe action. Each outcome should describe only one behaviour. eg, client will discuss the role of insulin and give his own insulin-wrong statement. The subject of outcome should be client or part of the client. Outcome should reflect accepted standards of ANA/ institution. 5/18/2011 65 ARUN PIRAVOM
66 : Determining the goals for collaborative problems: To detect / report early s/s of potential complication of collaborative problem To implement preventive or corrective nsg treatment ordered by the physician. (standards, protocols, procedure or policies) DETERMINING NURSING INTERVENTIONS: Nursing interventions: Specific nursing actions performed to prevent complications, provide for comfort, promote/maintain/restore health. 5/18/2011 66 ARUN PIRAVOM
67 : Interventions to identify when planning for comprehensive patient care Performing nsg assessment to determine the status of existing problem or to identify a new problem. Performing client education or teaching for the client to gain knowledge. Counselling the client to make decisions Consulting / referring to other health care professional to obtain appropriate directions. Performing specific interventions to reduce / resolve problem Assisting client to perform activities by themselves. Nurses role: assessing, teaching, counseling, consulting when providing patient care. 5/18/2011 67 ARUN PIRAVOM
68 : Guidelines for planning nursing interventions for nursing diagnosis Do focus assessment of the problem before determining interventions. Choose interventions that will reduce/eliminate the cause. Consider goal before choosing interventions(specific for the client) Identify the client strengths of the client/family to make them participate in the interventions. Individualise the nursing interventions.(interventions should be specific to an individual). Be realistic when choosing interventions- consider limitations/preferences of the client, developmental age of the client, within the capability of the nurse, congruent with other therapies, provide under safe therapeutic environment, utilize appropriate resources. Know the rationale for actions(utilize scientific rationale). Create opportunity for teaching and learning whenever possible(eg, teach reason for intervention) Consult other professionals (eg,dietician) when indicated. 5/18/2011 68 ARUN PIRAVOM
69 : Determining nursing interventions for collaborative problem Perform frequent assessment to determine early s/s of pathophysiological complications. Eg,CHF-assess lung sounds 2 hourly. Alerting physician when early s/s of potential complications are suspected. Eg, contact physician when urine output is less than 30ml/hr. Perform preventive or corrective nursing actions as per order eg, irrigate NG tube every 2 hourly. Perform nsg acitons as described in standard policy and procedure, provide catheter care every shift, change IV lines every 48 hours 5/18/2011 69 ARUN PIRAVOM
70 : Types of care plans: Institutional care plans: Many institutions maintain standardized care plans on each unit. These care plans incorporate client outcomes and nursing interventions according to unique standards of institution. They are concise document becomes part of medical record. Many hospitals use kardex NCP (trade name for card filling system) allows quick reference to particular needs of client for certain aspects of nursing care. Information about medications, activity levels, level of self care, diet, treatment and procedures are included on outside of the card and NCP is placed inside the card. Each institution has its own format eg, 3 column NCP(plg,goal,intvn)/ 4 column NCP(plg,goal,intvn,evn). 5/18/2011 70 ARUN PIRAVOM
71 : Computerized care plans: Are forms created for a specific nursing diagnosis/for specific clinical area. Eg, coronary care, abdominal surgery, post partum and same day surgery unit. Nurse selects ND then individualises standard care plan by making selections from the format(eg CP list). Each list generates ND, G’s, O/c, and intvn for specific clients. Nurse finishes with assessment determines whether SCP should be used for specific clients. Even if it is appropriate, she adds or deletes information on SCP to individualise it for client needs. Failure to do so may result in incomplete/inaccurate care. Adv: -is a method to streamline care plans. -provides documentation for 3rd party reimbursement -incorporates current practical guidelines to achieve outcome for specific clients. 5/18/2011 71 ARUN PIRAVOM
72 : Student care plans: More elaborate than care plan used in the hospital because the purpose is to teach the process of planning care. Progresses step by step beginning with the assessment to evaluation. It varies from one institution to another institution, between beginners and advanced students. Similar to model used in hospital but only modification is it includes scientific rationale for nsg intervention. 5/18/2011 72 ARUN PIRAVOM
73 : Care plan for community based setting: Eg, (clinics and community centres, client’s homes). In these settings, nurse completes a comprehensive, home or family assessment and nurse designs a plan to 1) educate the client/ family about necessary care techniques. teach them how to integrate care within family activities. In this setting, client / family unit is in equal partnership with health care professionals, ultimately client / family must be able to independently provide majority of health care. 5/18/2011 73 ARUN PIRAVOM
74 : Critical pathways: All staffs from all disciplines(medicine, nsg, pharmacy, social worker) develop integrated care plan for a projected length of stay( no of visits for client with specific condition). Eg, for lung transplantation evaluation, care plan is recommended on day to day basis. Clients activities, consultations, procedures, discharge planning activities and educational topics expected for client progress throughout the transplantation process. The nurse or other health care members use the pathway to maintain client progress and use pathway as documentation tool. 5/18/2011 74 ARUN PIRAVOM
75 : POMR (problem oriented medical record): Method of charting patients plan of care All health care members document patient problems in same place on the chart.(called problem list). Problems identified by the physician, nurses, doctors, physiotherapists are listed in order of when they are identified(not necessarily in the order of priority). Adv- improves communication among members each member is aware of all problems of particular patient. SOAP charting: all members of health care team use this method of charting includes documentation of following informations-(subjective data, objective data, analysis (problem statement), plan (goals/interventions) 5/18/2011 75 ARUN PIRAVOM
76 : SOAPIE charting: expanded form of SOAP charting, similar to nsg process includes implementation and evaluation. SOAP-At present used for initial assessment of patient. SOAPIE- used after implementation of care. DOCUMENTATION OF NURSING CARE PLAN: Why should we document? 3 purposes: To direct nsg care. Serves as legal documentation. Serves as only written record which can be later used as tool for evaluation. 5/18/2011 76 ARUN PIRAVOM
77 : Components: brief client profile (name, age, height, weight, reason, other information) Long term overall discharge goal- Eg, Mr. X will become more involved in activities by ------(date). Nursing diagnosis and expected outcome. Specific nursing order for each interventions A space for evaluative comments. (progress reports). Common errors in nursing care plan Listing a problem that is already covered by hospital policy. Calling a collaborative problem a nursing diagnosis. Writing a nursing order which is already covered by physician’s order. Omitting documentation order 5/18/2011 77 ARUN PIRAVOM
78 : Guidelines for documentation Be sure that the diagnosis, outcome, nursing order, evaluation are addressed on the nursing care plan. List only nursing diagnosis/ collaborative problem that vary from routine / standard care. Be brief but be clear(use accepted abbreviations(NPO) List LTG/STG set target date for goal achievement. 5/18/2011 78 ARUN PIRAVOM


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