Nursing process

Mr.Arun II year M.Sc nursing PCON,Bengaluru. Mail- id : arunpiravom1986@yahoo.in

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Mobile: 9886505608

Nur sing pr ocess

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

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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
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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 1960s)
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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.
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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 04/28/12 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.
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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.
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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.
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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.
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STEPS

How does the nursing process work? The nursing process uses the problem solving approach.
NURSING PROCESS

PROBLEM SOLVING METHOD

ASSESSMENT

Collecting and examining the data

Encountering the problem and collecting data

DIAGNOSIS

Analyzing data to identify health problems and strengths.

Analysing the data to identify exactly what the problem is.

PLANNING IMPLEMENTATION EVALUATION 04/28/12

Developing the plan Putting the plan into action Determining how well the plan has worked ARUN PIRAVOM

Making a plan of action Putting the plan into action Evaluation of the results 11

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.
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RELATIONSHIP AMONG THE STEPS OF THE NURSING PROCESS the 5 steps of nursing process The diagram shows

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?) 04/28/12 ARUN PIRAVOM 13

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 ASSESSMENT Collecting the data Validating the data Organising the data Identifying the patterns Communicating or recording the data
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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)
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TYPES OF NURSING ASSESSMENT INITIAL ASSESSMENT FOCUS ASSESSMENT TIME LAPSED ASSESSMENT EMERGENCY ASSESSMENT -- BRENDA, fundamental of nursing. DATA BASE ASSESSMENT FOCUS ASSESSMENT -- ROSALINDO ALFARO
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TYPE INITIAL ASSESSMENT

AIM

TIME FRAME

Initial identification of normal function, Should be done within the specific functional status and collection of data timeframe after admission into concerning actual or potential a hospital, nursing home, dysfunction. ambulatory health care centre Provides a baseline for reference and future or home health care settings. comparison

FOCUS ASSESSMENT

Determine the status of a specific problem -ongoing process identified during previous assessment. -integrated with nursing care -done a few minuites to a few hours between assessments.

TIME LAPSED ASSESSMENT

Comparison of clients current status to Several months (3, 6 or 9 months or baseline obtained previously. more) between assessments. Detection of changes in all functional health patterns (after an extended period of time has passed)

EMERGENCY ASSESSMENT

Identification of life threatening situation

Anytime a physiological, psychological or emotional crisis occurs. 18

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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).
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WAYS OF ORGANIZING THE NURSING DATA BASE Few examples of data base tools organized according to Gordons 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.
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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 movementpoor diet, reduced fluids, medications, immobility prevention or management.
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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.
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PROMOTING A SUCCESSFUL INTERVIEW GUIDELINES Amount of pertinent data collected depends on interviewing skills. Establishing rapport Ensure privacy Use the persons name Explain your purpose Use good eye contact Dont hurry How to observe Use your senses Notice general appearance Notice body language Notice interaction pattern
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How to ask questions Ask about main problems first Use terminology which is understandable Use open ended questions Use reflection Dont 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
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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.
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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.
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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 to avoid missing pertinent information misunderstanding situations jumping to conclusions or focusing in wrong direction
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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 questionable
DATA VALIDATION Identification of cues Make inferences about cues Validate cues and references

Methods

Referral to textbooks, Check consistency Clarification of Compare cues journals, research of cues (recheck) clients statement to knowledge base Reports of normal function

Seek 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 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. 04/28/12 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 be used for clients of all ages and in all speciality areas, and is relevant for the assessment of the person, family or community.
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 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

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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.
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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 self and others.
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I.

CLIENT PROFILE

II. UNIVERSAL SELF III. DEVELOP CARE MENTAL REQUISITES SCR

IV. HEALTH DEVIATION SCR

Personal characteristics Current health orientation Family characteristics Environmental characteristics

Air Water Food Elimination Activity or rest

Life cycle stage Psychosexual Psychosocial Intellectual Moral Conditions that promote or prevent normal development

Present history of health deviation Past history of health deviation Family health history

Solitude and social interaction Hazards Normalcy

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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 ARUN PIRAVOM etc., 04/28/12 36

 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.
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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.
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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.
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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 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.

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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 04/28/12 ARUN PIRAVOM nursing practice.

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Evolution of nursing diagnosis:historical development Before 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.

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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.
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ANALYSIS OF DATA/ DIAGNOSTIC REASONING A 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 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

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STEPS

NURSING DIAGNOSIS

COLLABORATIVE PROBLEM AND MEDICAL DIAGNOSIS

Focus of assessment activities Main focus is upon monitoring Main focus is on monitoring for human responses to actual pathophysiological response of and potential health problems body organs or systems.

Problem identification

Nurse identifies and validates that Nurse may identify problem but is problem exists independently 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.

treatment

Nurse initiates interventions for treatment independently

Nurse 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.
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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.
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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

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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. PIRAVOM 04/28/12 ARUN

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Nursing diagnosis

Signs and Etiology/ sympto contributing ms factors present

Nsg care plan

actual nursingpresent diagnosis

- 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 - 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. Gather more data to clarify vague cues ARUN PIRAVOM to determine if the s/s or 52 and contributing factors are actually present.

Potential nursing diagnosis

absent

present

Possible 04/28/12 nursing problem

unsure

unsure

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.
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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 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)
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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?
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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 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 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.
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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 pneumonia Dont state 2 problems at the same time eg, pain and fear related diagnostic procedure Dont 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.

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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 physicians order for diagnosis/ monitoring/ treatment.
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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 ptknowledge 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 04/28/12 ARUN PIRAVOM 59 first to improve mobility)

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)
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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
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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 goal The second part of the statement is the outcome.
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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.

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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).
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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 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.
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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.
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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.
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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.
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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

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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).
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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.
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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.

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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.
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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.
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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 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)
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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.
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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 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 physicians order. Omitting documentation order 04/28/12 ARUN PIRAVOM 77

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.
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