Nursing Process

NURSING CARE PLAN / NURSING PROCESS NURSING PROCESS 1. Assessment 2. Nursing Diagnosis (What’s the problem? What are the patient’s needs?) 3. Planning (What needs to be done?) 4. Implementation (Do what needs to be done to meet the patient’s needs.) 5. Evaluate / Reassess (Have the patient’s needs been met?) 6. Documentation (If you don’t write it, you didn’t do it!!) - documentation allows for thorough assessments to be passed to others and followed up STEP I

ASSESSMENT subjective data (covert) – information that the patient gives to the care provider objective data (overt) – information that you gather from assessing (looking, touching, hearing) the patient - may better define patient’s condition and help in planning care - gather data that is individualized to the patient - continuous collection, validation, and communication of patient data - includes all pertinent patient information collected by the nurse and other healthcare professionals - enables a com0prehensive and effective plan of care to be designed and implemented for the patient - collection of patient data is a vital step in the nursing process because the remaining steps depend on complete, accurate, factual and relevant data - initial comprehensive nursing assessment results in baseline data that enable the nurse to: • make a judgement about patient’s health status, ability to manage his/her healthcare, and need for nursing • refer the patient to physician or other healthcare professional • plan and deliver individualized, holistic nursing care - sources for data include patient, patient’s family and significant others, patient record, patient’s healthcare professional, and literature - medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus primarily on the patient’s responses to health problems and functional abilities - purpose for which an assessment is being performed offers the best guideline about what type and how much data to collect - priorities are influenced by patient’s health orientation, developmental stage, and need for nursing

- include appraisal of health status, identification of health problems, and establishment of data for nursing intervention - methods used to collect data are inspection, palpation, percussion, and auscultation - data needs to be: • complete – as much as possible • factual and accurate – allows other healthcare professionals to explore causes of the behavior • relevant – only experience teaches nurses what data is needed in specific cases - observation is key – observation of the conscious and deliberate, use the five senses • what are the patient’s current responses – be alert to signs of distress and things out of the ordinary • what is the patient’s current ability to manage his/her care • what is the immediate environment – safety, people, temperature, etc. • what is the larger environment – hospital or community STEP 2 ANALYSIS - begin the work of interpreting and analyzing data while still collecting (assessing) - group data or cues that point to the existence of a patient health problem (separating into “like piles”) - nursing diagnoses should always be derived from clusters of significant data rather than from a single cue - when the nurse recognizes a cluster of significant patient data indicating a health problem that can be treated by independent nursing interventions, a nursing diagnosis should be written - nursing diagnosis is written either as two-part statements listing the patient’s problem and its cause or as three-part statements that also include the problem’s defining characteristics STEP 3 DIAGNOSIS - classifying - purpose is to identify how an individual responds to actual or potential health and life processes, identify factors that contribute to or cause health problems (etiologies), and identify resources or strengths that can be drawn on to prevent of resolve problems nursing diagnoses – actual or potential health problems that can be prevented or resolved by independent nursing intervention - clinical judgment about individual responses to actual or potential health problems/life processes

- provides the basis for selection of nursing interventions to achieve outcomes - NEVER a medical diagnosis - medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness - medical diagnoses remains the same for as long as the disease is present, whereas nursing diagnosis may change from day to day as the patient’s responses change - nurses monitor certain physiologic complications to detect onset or changes in status - involves potential complications that must be identified early so that preventive nursing care can be instituted early Documentation Format: P – problem = what is it related to *** - identifies what is unhealthy about the patient, indicating the need for change - clear, concise statement of patient’s health problem - suggests patient outcomes E – etiology = what is causing it as manifested by *** - identifies factors (physiologic, psychological, sociologic, spiritual, environmental) that are maintaining the unhealthy state or response - contributing or causative factor - directs nursing intervention S – signs and symptoms gathered from objective and subjective assessment - identify the subjective and objective data that signal the existence of the problem ***Linking words that must be used in care plan to link potential complications and problem*** Guidelines for Writing Nursing Diagnoses 1. Phrase nursing diagnosis as patient problem or alteration in health state rather than as patient need 2. Check to ensure patient problem precedes etiology and the two are linked by the phrase “related to” 3. Defining characteristics in nursing diagnosis should follow etiology and linked by the phrase “as manifested by” or “as evidenced by” 4. Use nonjudgmental language 5. Be sure problem state indicates what is unhealthy about patient or what needs to be changed

6. Avoid defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement 7. Ensure problem statement suggests patient outcomes and that etiology direct selection of nursing measures STEP 4 CLIENT GOALS goal – aim or end

AND

OUTCOMES

patient outcome – expected conclusion to patient health problem, or in the event of a wellness diagnosis, an expected conclusion to patient’s health expectation plan of nursing care (patient care plan) – written guide that directs the efforts of the nursing team as nurses work with patients to meet their health goals - specifies nursing diagnoses, outcomes, and associated nursing interventions - patient centered to keep the patient and patient’s interest and preferences central in every aspect of planning and outcome identification - goals are indicated by phrases like “The patient will _______” - measurable (something that can be counted or scaled) criteria used to evaluate the extent to which a goal has been met within the specified time limits - if outcomes specified are not valued by the patient or do not contribute to the prevention, resolution, or reduction of the patient’s problems or the achievement of the patient’s health expectations, the plan of care may be meaningless - parameters of definition are indicated by phrases like “as evidenced by” - primary purpose of outcome identification and planning is to design a plan of care for and with the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and attainment of patient’s health expectations, as identified in outcomes - broad aims are to promote wellness, prevent disease and illness, promote recovery, and facilitate coping with altered functioning - because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow’s Hierarchy of Human Needs • physiologic • safety • love and belonging

• self-esteem • self-actualization - it is best to first meet the needs the patient thinks are most important, if this order does not interfere with other vital therapies - evaluative statements (patient has met, partially met, or not met) include a statement about achievement of desired outcome and list actual patient behavior as evidence supporting the statement - if plan is not met, recommendations for revising the plan of care are included in the evaluative statement Guidelines for Writing Outcomes 1. Each set of outcomes is derived from only one nursing diagnosis 2. At least one of the outcomes shows a direct resolution of the problem statement in the nursing diagnosis 3. Both long-term and short-tem outcomes are identified as necessary 4. Cognitive, psychomotor, and affective outcomes appropriately signal the type of change needed by patient 5. Patient and family value the outcomes 6. Each outcome is brief and specific (clearly describes one observable, measurable patient behavior/manifestation) is phrases positively, and specifies a time line 7. Outcomes are supportive of total treatment plan To be measurable, outcomes should have: • subject – patient or some part of the patient • verb – indicates the action the patient will perform - helpful verbs: define, prepare, identify, design, list, verbalize, describe, choose, explain, select, apply, demonstrate • conditions – specifies particular circumstances in or by which the outcome is to be achieved • performance criteria – describe in observable, measurable term the expected patient behavior or other manifestation • target time – specifies when the patient is expected to be able to achieve outcomes Commonly Encountered Problems: failure to involve the patient in the planning process, insufficient data collection, use of inaccurate or insufficient data to develop nursing diagnoses, outcomes that are stated too broadly

STEP 5 PLANNING - give the goal (activity) and rationale for nursing interventions - educate and/or offer ways to meet outcomes / goals STEP 6 INTERVENTIONS - nursing actions planned in previous step are carried out - patient is primary in determining how nursing interventions are implemented - successful nurses modify actions according to patient’s changing ability and willingness to participate in the plan of care and previous responses to nursing interventions and progress toward goal/outcome achievement nurse-initiated interventions – carrying out nurse-prescribed interventions resulting from assessment of patient needs written on nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another healthcare professional physician-initiated interventions – carrying out physician-prescribed orders - nurses are responsible for not only nurse-prescribed interventions but also for the clarification of any questionable order collaborative interventions – actions performed jointly by nurses and other members of the healthcare team STEP 7 EVALUATION - nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care; however, the patient is always the nurse’s primary concern - functions to determine whether the outcomes have been or are being met and then identifying the appropriate nursing response * Goal Met * Goal Partially Met * Goal Not Met - based on the patient’s responses to the plan of care (feedback), the nurse decides to • terminate plan when each expected outcome is achieved • modify the plan if there are difficulties achieving the outcomes • continue the plan if more time is needed to achieve the outcomes