Nursing Process. Outcome Identification, Planning and Implementation. What is a Priority Nursing Diagnosis? Prioritizing Nursing Diagnosis

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1 Nursing Process Outcome Identification, Planning and Implementation Nurse Caring Concepts 1A Week 7: September 27, 2004 What is a Priority Nursing Diagnosis? Priority nursing diagnoses: those that will, if not managed, will: - Negatively affect client functional status - Deter progress toward outcomes Nursing diagnoses should be: - Appropriate for the individual client - Realistic; amenable to nursing intervention - Relevant to the setting and length of stay Prioritizing Nursing Diagnosis Reevaluate your list of selected priority nursing diagnoses to be sure that all needs are accounted for Care plan with 3 5 nursing diagnoses are manageable Prioritize nursing diagnoses based on: - Maslow s hierarchy - Client s condition & needs

2 Step 3: Outcome Identification NANDA label describes human responses that are problems. Usually, the healthy alternative is goal that patient wants to achieve To identify a goal, ask yourself: - If problem were solved, reduced (actual nsg dx) or prevented (risk nsg dx), how will patient look or behave? - What will you see, hear, palpate or observe? Establish goals with patient (if possible) Types of Goals Long term goal: expected to be achieved over weeks or months Short-term goal: - Expected to be achieved in shorter time period (hour, day, week) - Often stepping stone on way to reaching long-term goal

3 Goal Characteristics Statement that reflects client s: - Resolution of a problem - Progress towards resolution of a problem - Prevention of a problem Should be attainable, realistic & represent a greater level of achievement for client Should not conflict with MD orders Describes a measurable behavior that - Nurse can validate by seeing or hearing, or - Client can measure subjectively & describe Goal Characteristics Only one action verb per goal Describe something that the client (or any part of client) will do, not something nurse will do Attainable & realistic in time frame specified Specify content - what is to occur (will lose 5 lbs) Specify time - when it is to have occurred ( during my shift, in 24 hours, by discharge, prior to surgery, at all times, by end of discussion) Example of Long & Short Term Goals Impaired Tissue Integrity r/t destruction of tissue 2 pressure and friction AMB stage II pressure ulcer on coccyx Long term goal: (Client s) Pressure ulcer will heal within two months Short term goal: (Client will) Demonstrate 3 measures that she can do to prevent pressure ulcers during my shift

4 Example of Long & Short Term Goals Fear r/t anticipated dependence 2 nursing home rehab admit AMB statement I am afraid that I will never go home Long term goal: (Client will) Report an increase in psychological comfort before discharge to LTC Short term goals: - (Client will) Discuss fears with RN today (9/27) - (Client s) Pulse & respiratory rate will be WNL following discussion with RN today (9/27) Patient Goals: Common Errors Goal Includes two action verbs - Incorrect: Describe the four basic food groups and choose a balanced diet for lunch - Correct: Describe the four basic food groups Goal lacks specificity: - Incorrect: Client will walk 5 ft by 1100 on 9/29 - Correct: Client will walk 5 ft with walker by 1100 on 9/29 Patient Goals: Common Errors Goal is not time targeted: - Incorrect: Client will walk independently from her room to the nurses station and back again - Correct: Client will walk independently from her room to nurses station & back by 1430 today Outcome is not specific or concrete: -Incorrect : Client s BP will be WNL today - Correct : Client s BP will be <130/80 today

5 Patient Goals: Common Errors Is stated in negative, rather than positive terms: - Incorrect: Client s skin will not become ulcerated - Correct: Client s skin will remain intact Is stated in terms of nurse activities, rather than patient goals - Incorrect: Prevent infection of incision - Correct: Incision will remain free of infection as evidenced by well approximated edges & absence of redness & drainage Patient Outcomes: Common Errors Outcome is not observable or measurable: -Incorrect: Client will know which high sodium foods to avoid after teaching session today - Correct : Client will name six high sodium foods to avoid after teaching session today -Incorrect: After discussion, client will be less anxious - Correct : After discussion, client will report that she feels less anxious Nursing Process: Steps Four and Five Planning - Selecting nursing interventions to assist patient in achieving goals Implementation - Performing the interventions identified in the planning step

6 Step 4: Planning Development of nursing strategies to prevent, reduce or eliminate identified problems Purpose is to provide: - Consistent, individualized approach to care - Direction to health care team - Focus charting requirements Activities of planning step - Planning nursing interventions - Writing holistic nursing care plan Types of Planning Initial planning: RN who performs admission assessment should develop initial comprehensive care plan Ongoing planning: Done each shift by any nurse who works with client Discharge planning: Begins with admission & continues until discharge What is a Nursing Intervention? Action nurse performs on behalf of patient Major focus: Actual diagnoses - Reduce or eliminate related factors - Promote higher level of wellness - Monitor status Risk diagnoses - Reduce or eliminate risk factors - Prevent reoccurrence of the problem - Monitor for onset

7 Type of Interventions Independent: RN prescribes & performs or delegates (includes physical care, emotional support & comfort, teaching, counseling) Dependent: MD prescribes & RN is responsible for performing (includes medications, IVs, diagnostic tests, treatments, diet & activity) Interdependent: Nurse carries out in collaboration with other health team members (PT, RT, etc) Locating Interventions Textbooks: Carpenito, Craven & Hirnle; Lewis, Heitkemper & Dirksen Standardized care plans: Carpenito, Craven & Hirnle, Lewis, Heitkemper & Dirksen, hospitalspecific care plans Hospital-specific policy/procedure manuals Nursing literature (peer-reviewed journals; online sources) Other healthcare professionals Your own ingenious, individualized idea Nursing Interventions Must Be... Consistent with standards of care Based on scientific research Realistic in terms of client abilities & resources Congruent with patient s values & beliefs Realistic in terms of nursing/facility abilities & resources Compatible with medical orders

8 Guidelines for Writing Interventions Begin with verb - All interventions are performed by RN - Is understood (but not written) that each begins with words RN will - Incorrect: Needs to be suctioned - Correct: (RN will) Suction oropharynx PRN Individualize for patient needs - Generic: Encourage PO fluid intake - Individualized: Encourage PO fluids intake; patient prefers room temperature water Are specific enough to be interpreted easily - Incorrect: Restrict fluids - Correct: Restrict oral fluids to 1000 cc/24 hrs Interventions: Overriding Considerations Do interventions provide patient with means to achieve goals? - If long term goal is: Client will gain five pounds by 0600 on 9/28 - Must be an intervention that stipulates: Weigh patient daily at 0600 Do interventions address all aspects of the etiology? - Constipation r/t habitual laxative use, inadequate fluid intake & decreased peristalsis 2 lack of exercise Nursing Care Plan Written guideline; blueprint for action - Directs care - Documents the client s health care needs - Communication between nurses and other health care professionals - Designed to decrease the risk of incomplete, incorrect or inaccurate care

9 Student Care Plans More elaborate than those used in hospitals or other healthcare agencies Essential for learning: - Nursing process - Skills of written communication - Organizational skills needed for nursing care - Application of theory to clinical practice Scientific rationale (with reference citation) is required to support each intervention selected and should be able to stand alone. Stand-Alone Scientific Rationale Intervention: Teach client to avoid caffeinecontaining foods & beverages after noon Scientific Rationale: - Incorrect: Can produce wakefulness - Correct: R: "Caffeine and nicotine are CNS stimulants that lengthen sleep latency and increase nighttime wakening" (Miller as cited in Carpenito-Moyet, 2004, p. 729). Writing the Nursing Care Plan Nursing diagnosis listed in order of priority in 1st large column Goals corresponding to each nursing diagnosis in 2nd large column Specific nursing interventions in 3rd large column followed by scientific rationale and reference

10 Step 5: Implementation Action phase of nursing process during which care plan is initiated Implementation Skills - Cognitive: Problem-solving, decision-making, critical thinking - Interpersonal: in every patient contact - Psychomotor: performing a variety of hands-on skills Due in Clinical 9/28 or 9/29 For your primary client: - 1 complete nursing diagnosis statement - 1 long term and 1 short term goal - 3 interventions with supporting scientific rationale & reference citation Cuesta Nursing Care Plan Due 9/28 or 9/29 P R Nursing Diagnosis Outcome Criteria M O Nursing Diagnosis Statement Long term goal Short term goal Interventions 1. Intervention. Scientific Rationale (Author, year, p.#) T C Evaluation 2. Intervention. Scientific Rationale (Author, year, p.#) 3. Intervention. Scientific Rationale (Author, year, p.#)

Nursing Process. What Is Nursing Diagnosis (Dx)? Step 2: Nursing Diagnosis Step 3: Outcome Identification. Nursing Diagnosis.

Nursing Process. What Is Nursing Diagnosis (Dx)? Step 2: Nursing Diagnosis Step 3: Outcome Identification. Nursing Diagnosis. Nurse Caring Concepts 1A Nursing Process Step 2: Nursing Diagnosis Step 3: Outcome Identification Week 6 September 22, 2003 What Is Nursing Diagnosis (Dx)? Has two related meanings: Nursing diagnosis is