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Role In Planning Care
- Eliminate gaps in the patient’s care to insure quality of care
- Provides a means of professional communication
- Provides legal protection for the nurse
- Regulatory agencies require documentation of the planning of care
- Multi – Source Data Collection
- Direct Observation
- Patient Interview
- Review of records: look for trends in vitals, special considerations, baselines, etc. Look for H&P (hx and physical) = goldmine of information.
- Critical thinking and observation skills are essential: In clinicals, always review pt chart night before and begin formulating nursing diagnosis, care plan, intervensions, etc. Also look at literature review related to pt's condition.
- Communication skills & knowledgeable assessment skills are necessities
- PATIENT IS ALWAYS THE PRIMARY DATA SOURCE: Rely on hearsay and pt's friend's family as a secondary or tertiary source.
- Other data sources?
- Special attention should be paid to clients own words or expressions of their problem
- Remember subjective/objective
- PQRSTU: Paliative, Quality, Region, Severity, Timing, Understanding (pick a good time/place to educate.)
- Privacy and remove distractions
- Nurse has to critically think about what to assess / determined by clinical knowledge, clinical specialty and experience
- Use of all the senses for assessment
- Comprehensive approach moves from general to specific
- Allows for use of key assessment data to respond to priorities (ABCs)
- Organizing the information into sets or categories to identify emerging patterns & potential problems
- Clustering of descriptive, concise, and complete data
- The goal of data grouping is to arrive at a nursing diagnosis
What are Gordon’s Functional Health Patterns?
- Organizes individual nursing diagnoses into categories to assist in organization of data collection
- Are interrelated and represent the basic needs that must be met for all life’s functions within developmental considerations.
- Assists the nurse in differentiating between areas for independent nursing intervention and areas requiring collaboration or referral
- Can offer a BIG clue as to the priority of care for the patient at any given point in time.
Health Perception/Health Management
- Problems in this health pattern are a result of lack of perception and management
- Assists individuals families or groups who may have
- limited knowledge/understanding of their current health status and/or how to achieve/maintain good health
Activity and Exercise
- Focuses on ADL’s and the amount of energy available to the individual to support these activities
- Includes all aspects of maintaining self and leisure activities
- Will include dysfunctions of cardiac, respiratory and neuromuscular function because energy and mobility are dependent upon them
- May be the primary reason that the pt. is admitted to the health care system
- Must be aware that any admission to the hospital can promote the development of problems within this health pattern
- Potential problems may develop as a result of a medical diagnosis (bedrest) or agency rules and regulations (limited visiting hours)
- Focuses on food and fluid intake and the body’s use of that intake
- Looks at the whole relationship between food and function
- Problems may arise from a physiologic illness or psychological illness, ie. stress-->under/over eating.
- Sociologic - income, inadequate storage, cultural food preferences
- Focuses on bowel and bladder functioning
- May be primary reason for seeking healthcare or may be a secondary problem to impaired mobility
- Includes habits of excretory irregularity, aids for regularity, or devices for incontinence
- Includes relaxation sleep and rest
- Looks specifically on how a pt. rates / judges the adequacy in terms of quantity or quality
- Looks at energy level in response to adequacy and use of sleep aids
- Initial step in assessment paramount in maintaining and returning to health
- How a pt thinks, perceives, and incorporates those processes in their life to best adapt and function
- Deals with how a pt thinks, their thought processes, and knowledge (both acquisition and application
- Perception – interpretation of sensory stimuli
- Composed of beliefs attitudes and values about the self, body image, self esteem and information about abilitiesClient contributes self-knowledge through interactions with the nurse or other members of the healthcare team
- Determinant of pts. interaction with others
- Affected by experiences prior to and during the course of Illness
- Concerned with how a person feels they are performing an expected behavior delineated by the self and others
- Can include family and work roles/responsibilities roles, work and social/cultural roles
- Can also be important in patient teaching as a source of strength
- Focuses on the sexual/reproductive aspects of an individual over the entire life span.
- Involve sex role behavior (and how we relate to each other, gender ID, physiologic and biologic functioning, cultural/societal expectations of sexual behavior capability to procreate and express sexual feelings
- Problems may result from illness, lifestyle, violence, or self - concept
- Ability to respond is affected by a complex interaction of physical social and emotional reactions (physiological/psychosocial). Assessment focuses on gaining an understanding of how these factors interact.
- Stress Tolerance implies responses to the usual amount of stress
- Coping refers to the pattern of responding to non-routine threats
- Disfunction results when when the usual routine or automatic response may be not readily available
- At core of existence: judgment and interpretation of the meaning of life
- Interconnectedness with the spiritual side and the environment
- Disturbances may be mild or severe depending on health problem
- Faith retention/ability to maintain religious practices beliefs practices and spiritual life. Often will relate to end-of-life issues.
What is a Nursing Diagnosis?
- is a clinical judgment about individual, family, or community responses to actual/potential health problems/ life processes.
- provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is responsible
- changes as the patient’s situation or condition changes. As pt condition changes, diagnosis can be altered, added to, or subtracted.
- Is always individualized to the pt. Care plans do not necessarily have ALL interventions/goals, etc for every pt.
Use critical thinking to...
- Analyze and interpret data
- Draw conclusions about the client's health status
- Verify problems with the client
- Prioritize the problems
- Record the diagnostic statements
What are the 6 steps of Diagnotic Reasonsing?
- 6 Steps of Diagnostic Reasoning:
- --Problem Sensing
- --Rule - Out Process
- --Synthesize the Data
- --Evaluating/Confirming the Hypothesis
- --List the Patient’s Problems/ Needs
- --Reevaluate the Problem List
Nursing Diagnosis facts.
- Are not parallel to medical diagnoses
- Involve independent nursing activities as well as collaborative roles and actions
- A conclusion which describes a health need drawn from the data collected about a patient that is amenable to treatment by nurses
- Defining characteristics are clinical criteria that represent the presence of the diagnostic category
How are Nursing and Medical Diagnoses different?
- Holistically considers both the problem and the effect of the problem on the individual's ability to function as him/herself.
- Nursing complements the work of our medical brethren
- Focus is the patient response instead of the disease process
- Ensures meeting on needs unique to the individual
Components of a NANDA diagnosis
- Diagnostic Label: Human Response (Problem) as giving by the NANDA Definition. Distinguishes it from similar diagnoses
- Defining characteristics (Etiology) (SnSs) and root causes.
- Indication of the factors contributing to that response
- Related Factors: Phrases used to link the response to the etiologic factors which include "related to" (r/t), "secondary to", or "due to"
- Risk Factors
Writing a Diagnostic Statement
- Nursing Diagnosis (NANDA) + etiology (reason i.e. why it’s a problem or the cause of the problem) + as evidenced by (symptoms)
- --Connecting Phrase“related to (r/t)” (need at least 2 of these to make a diagnosis)
- --Actual Diagnosis use the direct relationship of symptoms and etiology to the problem is established by the phrase:“as evidenced by (aeb)”
- Example: Body image disturbance related to amputation of right lower limb as evidenced by patient not looking at the limb.
Status classification of patient problems/needs
- Describes a human response (problem or need) to health conditions/life processes that exists (currently present) and is supported by defining characteristics (manifested by signs and symptoms).
- The problem/need is written as a three part statement.
- Describes a human response (problem or need ) to health conditions/life processes that are likely to develop. It ( the problem) has not occurred, but is supported by risk factors that contribute to increased vulnerability.
- A possible diagnosis is based on partial (or incomplete) data
- The problem/need is written as a two part statement (will not have "aeb")
Common Errors in Creating and Writing a patient diagnostic statement.
- Using the Medical Diagnosis
- Relating the Problem to an Unchangeable Situation
- Confusing the Etiology/Signs & Symptoms for the Problem
- Use of a Procedure Instead of a Human Response
- Writing a Legally Inadvisable Statement
- Lack of Specificity
- Combining Two Nursing Diagnoses
- Relating One Nursing Diagnosis to Another
- Use of Judgmental / Value-Laden Language
- Making Assumptions
- Developing a plan of action with the patient to reduce or eliminate the problems and promote health
- Key Activities include:
- Setting Priorities
- Establishing Goals/Outcomes
- Determining Nursing Interventions
- Documenting the Nursing Care Plan
What are some considerations for setting priorities in health plan?
- Priorities may be influenced by the following:
- Overall health status of the client
- Client’s own perception of priorities.
- Overall treatment plan
- Presence of potential problems
- Rationale: Priority will be influenced by viewing the entire picture of the problems & how they affect the client’s health status
- NOC: Nursing Outcome Classification (goals)
- NIC: Nursing Intervention Classification (intervension)
- NANDA says: The problem--> goal: if you know what the symptoms are, you know when you've reached your goal (they symptoms will go away)
- Etiology--> interventions: If you know the root cause, you know which steps are needed to address that cause.
Writing a Quality Nursing Plan
- Clearly stated in terms of patient behavior and observable assessment factors
- Are realistic, achievable, safe, and acceptable to the patient
- Written in specific concrete terms depicting patient action
- Directly observable by use of one of the five senses
- Are patient-centered
Long Term vs. Short Term goasl
- Goals (giant steps!!)
- --Long Term
- --Overall broad directions to guide the plan of care
- Outcomes (baby steps!!)--Short Term
- --Measurable steps to achieve the goals of treatment/discharge criteria (etiology of the ND)
Guidlines for goas/outcomes
- Client-Centered factors
- Singular factors
- Observable factors
- Measureable factors
- Time Limited factors
- Mutual factors
- Realistic Factors
- Patient responses that are achievable.
- Can be attained within a defined time period given the present situation and resources
- Be specific, realistic. C
- onsider the patients circumstances and desires
- Provide measurable evaluation criteria for determining success or failure
What are Nursing Intervension
- Prescriptions for behaviors, treatments, activities or actions that assist the patient in achieving the expected outcomes
- Method of individualizing care
- Provide an environment conducive to carrying out the planned interventions
- Consider which interventions can be combined
Qualities of a good Intervension
- Date the intervention was written
- Action verb to describe the activity to be performed
- Qualifiers/Specificity – frequency, amount, location
- Rationale for stated interventions
- The outcome of the intervension will be good for the patient.
- Estimate the probability that each of the consequences will occur
Nursing plan implementation
- Performing nursing activities and interventions
- Continuing to collect data
- Recording and Communicating the Patient’s Health Status & Response to Interventions
Qualities of effective Intervensions
- Identify Caregiving Priorities
- Timely. Will account for Anticipatory, & Preventive care.
- Cost Effective
- Considerate of ethical and legal concerns
- Simple--> Complex Procedures
- Identify who is responsible for the implementation of an intervention
Qualities of good documentation of Intervensions
- It is legally required that all healthcare settings document nursing observations, the care provided, and the patient’s response
- Continue monitoring the patient.
- Important to continue documenting data collected throughout the implementation phase
What are some questions a Nursing Evaluation of health plan should answer?
- Have the goals been achieved?
- Have you partially achieved the goals, or not at all?
- What changes (if any) need to be made?
- Focus on appropriateness of the care provided
- Appropriate revisions of nursing interventions and/or patient outcomes may be necessary
- Evaluating the clients response to care
- The need to revise the interventions.
- The development of new patient problems or needs
- The need to rearrange priorities to meet the changing demands of care
- The need for referral to other sources
Termination of Services
- Discharge planning started at time of admission
- Verify patient/significant other/pt support has received verbal & written instructions regarding treatments, medications, & activities
- Signs and symptoms indicating the need for continued contact with healthcare providers are reviewed