6ce3Nursing process .ppt.ppt

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Nursing process

Foundation of nsg profession.Serves as a guide for professional nursing practiceIdentifies, discovers health care needs of the patient/family/community.Helps in the clinical application of theory**ARUN PIRAVOM

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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 1960s.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 **ARUN PIRAVOM

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NURSE LEADERSCONTRIBUTION

Florence Nightingalehelped to establish nursing as a separate body of knowledge from medicine.1952 --Hildegard PeplauIdentified stages of nurse client Relationship- orientation,identification,exploitationand resolution.1955 -- Lydia Hall First person who introduced the term nursing process (not used in nursing publications until 1960s)**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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).**ARUN PIRAVOM

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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. **ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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How does the nursing process work?The nursing process uses the problem solving approach.**ARUN PIRAVOM

STEPSNURSING PROCESSPROBLEM SOLVING METHODASSESSMENTCollecting and examining the dataEncountering the problem and collecting dataDIAGNOSISAnalyzing data to identify health problems and strengths.Analysing the data to identify exactly what the problem is. PLANNINGDeveloping the planMaking a plan of actionIMPLEMENTATIONPutting the plan into actionPutting the plan into actionEVALUATIONDetermining how well the plan has workedEvaluation of the results

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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.**ARUN PIRAVOM

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RELATIONSHIP AMONG THE STEPS OF THE NURSING PROCESSThe 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?)**ARUN PIRAVOM

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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.

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NURSING ASSESSMENTCollecting the dataValidating the dataOrganising the dataIdentifying the patternsCommunicating or recording the data

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Collecting the data: gathering information about the patientResources used:Patient primary source of informationSecondary 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)

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TYPES OF NURSING ASSESSMENTINITIAL ASSESSMENTFOCUS ASSESSMENTTIME LAPSED ASSESSMENTEMERGENCY ASSESSMENT -- BRENDA, fundamental of nursing.DATA BASE ASSESSMENTFOCUS ASSESSMENT-- ROSALINDO ALFARO**ARUN PIRAVOM

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TYPEAIMTIME FRAMEINITIAL ASSESSMENTInitial identification of normal function, functional status and collection of data concerning actual or potential dysfunction.Provides a baseline for reference and future comparisonShould be done within the specific timeframe after admission into a hospital, nursing home, ambulatory health care centre or home health care settings. FOCUS ASSESSMENTDetermine the status of a specific problem identified during previous assessment.-ongoing process-integrated with nursing care-done a few minuites to a few hours between assessments.TIME LAPSED ASSESSMENTComparison of clients current status to baseline obtained previously.Detection of changes in all functional health patterns (after an extended period of time has passed)Several months (3, 6 or 9 months or more) between assessments.EMERGENCY ASSESSMENTIdentification of life threatening situationAnytime a physiological, psychological or emotional crisis occurs.

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DATA BASE NURSING ASSESSMENT:Performed on initial contactGather information about all aspects of clients health statusIdentifies clients strengths and problemsIt 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 modelTo 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).

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WAYS OF ORGANIZING THE NURSING DATA BASEFew examples of data base tools organized according to Gordons functional health patternOrems theory of self careRoys adaptation modelkings system modelRogers unitary human being modelAll these tools are well organized, comprehensive and holistic in focus.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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CLINICAL SKILLS USED IN ASSESSMENTTYPEDEFINITIONOBSERVATION - the act of noticing client cuesINTERVIEWING - 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.**ARUN PIRAVOM

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PROMOTING A SUCCESSFUL INTERVIEW GUIDELINESAmount of pertinent data collected depends on interviewing skills.Establishing rapportEnsure privacyUse the persons nameExplain your purposeUse good eye contactDont hurryHow to observeUse your sensesNotice general appearanceNotice body languageNotice interaction pattern**ARUN PIRAVOM

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How to ask questionsAsk about main problems firstUse terminology which is understandableUse open ended questionsUse reflectionDont start with personal or delicate questionsDefer questions that are not pertinentUse an orgainised assessment tool to prevent omissions.How to listenBe an active listenerAllow the person to finish sentencesBe patient if the person has memory blockGive your full attentionFor clarification summarise or restate what has been said**ARUN PIRAVOM

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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.Dont rely on memory.Choose a method of organizing your assessment and use it consistently.**ARUN PIRAVOM

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Identifying subjective/objective dataSubjective 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.**ARUN PIRAVOM

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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 toavoid missing pertinent informationmisunderstanding situationsjumping to conclusions or focusing in wrong direction**ARUN PIRAVOM

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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.

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VALIDATING THE DATA: Making sure that you know which data are actually fact and which data are questionableDATA VALIDATION

Identification of cues

Make inferences about cues

Validate cues and references

Methods

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Compare cues to knowledge base of normal functionReferral to textbooks, journals, researchReportsCheck consistency of cues (recheck)Clarification of clients statementSeek consensus with peers and colleagues about inferences

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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 togetherCan 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.**ARUN PIRAVOM

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COMPONENTS OF GORDANS 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 beused for clients of all ages and in all speciality areas, and is relevant for the assessment of the person, family or community.**ARUN PIRAVOM

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The advantage of a functional health framework areclient strengths or assets not merely the deficits, problems or limitations can be identified.The focus is on nursing diagnosis not medical diagnosis **ARUN PIRAVOM

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Demographic dataVital signs, orientation to unitHealth perception and health managementNutrition and metabolismEliminationActivity and exercise cardiovascular status, respiratory status, ADL, mobility status, level of consciousness.Cognition and perception reflexes, sensorium, cognition and pain.Sleep and restSelf perception and self conceptRole and relationshipsSexuality and reproduction Coping and stress toleranceValues and beliefs.**ARUN PIRAVOM

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COMPONENTS OF DATABASE ASSESSMENT FORM ORGANISED ACCORDING TO OREMS 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

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I. CLIENT PROFILEII. UNIVERSAL SELF CARE REQUISITES III. DEVELOP MENTAL SCRIV. HEALTH DEVIATION SCRPersonal characteristics

Current health orientation

Family characteristics

Environmental characteristicsAir

Water

Food

Elimination

Activity or rest

Solitude and social interaction

Hazards

NormalcyLife cycle stage

Psychosexual

Psychosocial

Intellectual

Moral

Conditions that promote or prevent normal developmentPresent history of health deviation

Past history of health deviation

Family health history

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ROYS 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.,**ARUN PIRAVOM

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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. **ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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.

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NURSING DIAGNOSISDefinition: 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 dataidentify the client strengthsidentify the clients normal functional level and indicators of actual or potential dysfunctionformulate a diagnostic statement in relation to this synthesis.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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Evolution of nursing diagnosis:historical developmentBefore the 1970s 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.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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ANALYSIS OF DATA/ DIAGNOSTIC REASONINGA method of thinking that uses logic to come to conclusions about an individuals 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)

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Diagram to identify whether you have identified anursing diagnosis/ collaborative problemIdentification of actual or potential health problem

Can the nurse validate the problem

and initiate treatment independently?

Yes No

Nursing diagnosis collaborative problem**ARUN PIRAVOM

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STEPSNURSING DIAGNOSIS COLLABORATIVE PROBLEM AND MEDICAL DIAGNOSISFocus of assessment activitiesMain focus is upon monitoring human responses to actual and potential health problemsMain focus is on monitoring for pathophysiological response of body organs or systems. Problem identification Nurse identifies and validates that problem exists independentlyNurse may identify problem but is required to refer to physician for validation that problem exists. Nurse may not be qualified to diagnose exact nature of problems, but refers abnormal data to the physician. treatmentNurse initiates interventions for treatment independentlyNurse collaborates with the physician to initiate intervention for treatment. Nurse may have standing orders to initiate diagnostic studies or treatment for the problem without physician order.

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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. **ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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 **ARUN PIRAVOM

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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.**ARUN PIRAVOM

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Nursing diagnosisSigns and symptomsEtiology/contributing factorsNsg care planactual nursing diagnosispresentpresent- monitor signs and symptoms( to determine improvements or deterioration in conditions).- identify interventions to reduce/ eliminate the cause of the problem. Eg, FVE r/t acute renal dysfn.Intvn: decrease protein intake, decrease fluid intake, K.F tests, wt monitoring Potential nursing diagnosisabsentpresent- perform daily focus assessment to determine if s/s have appeared to change status from potential to actual.- identify interventions to prevent, reduce or remove contributing factors.Eg, potential impaired skin integrity related to immobility. Int/v:Monitor for pressure points, freq turning positioning, massage. Possible nursing problemunsureunsureGather more data to clarify vague cues and to determine if the s/s or contributing factors are actually present.Eg, Possible spiritual distress r/t cancer.Int/v: to det whether cancer is curable, severity of illness.

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How to identify nursing diagnosis:

Identify usual lifestyles and coping patterns: to understand how the problem is affecting individuals 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 exs/ works/ reads books to get his mind off his problem. The first person may find confinement to bed more difficult than 2nd person.**ARUN PIRAVOM

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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 etiologyfactors that client identifies as causing problemfactors r/t developmental age, presence of disease condition or situational changes in life stylesfactors from other resources (medical records, health care professionals, literatures)**ARUN PIRAVOM

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Writing diagnostic statements for the collaborative problemRule: 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?**ARUN PIRAVOM

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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 diagnosisDetermine s/s of most frequent and dangerous complications associated with specific medical diagnosis.Be aware of recent diagnostic/ treatment modalities (to det asso comps).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 comps. eg, ICD.**ARUN PIRAVOM

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Using nursing diagnosis terminology correctly Or how to avoid errors while writing diagnostic statements

Guidelines:

Dont state nursing diagnosis in medical terminology. E g, related to laparotomy.Dont state nursing diagnosis as medical diagnosis. E g, potential for pneumoniaDont state 2 problems at the same time eg, pain and fear related diagnostic procedureDont write nsg diagnosis which is legally incriminating. E g, potential for injury rlt lack of siderails on the bed.Dont 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. **ARUN PIRAVOM

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PLANNING

Activities:setting prioritiesestablishing client goals or outcomesdetermining nursing interventionsdocumenting 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 physicians order for diagnosis/ monitoring/ treatment.**ARUN PIRAVOM

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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 comps takes priority over patients 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 gordans / maslows) 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)**ARUN PIRAVOM

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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 interventionsMotivating factor (within the timeframe- person will do better if a time frame is given).Types:Short term goals- goals that can be met relatively quicklyLong term goals- goals that can be achieved over a long period of time.(wks/months)**ARUN PIRAVOM

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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 **ARUN PIRAVOM

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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 goalThe second part of the statement is the outcome.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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).**ARUN PIRAVOM

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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 rulesUse 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.

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Determining the goals for collaborative problems:To detect / report early s/s of potential complication of collaborative problemTo 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.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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. **ARUN PIRAVOM

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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 manuals.eg, provide catheter care every shift, change IV lines every 48 hours **ARUN PIRAVOM

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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).**ARUN PIRAVOM

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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, Gs, 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. **ARUN PIRAVOM

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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.**ARUN PIRAVOM

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Care plan for community based setting:Eg, (clinics and community centres, clients 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.**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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 memberseach 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)**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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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 interventionsA 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 physicians order.Omitting documentation order**ARUN PIRAVOM

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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.**ARUN PIRAVOM

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