Nursing Care Planning and Decision-Making

Assessment - Nursing Diagnosis

• Nurses perform ongoing assessments throughout the nursing process to establish a database.
• The nursing history gathers data on the patient's health status, strengths, problems, risks, and need for nursing care.
• Nurses may also conduct a physical examination to collect objective data.

Types of Nursing Assessments

• First Assessment: Conducted after admission to a healthcare agency, it creates a comprehensive database for problem identification and care planning. Data collection includes patient's health, priorities for ongoing assessments, and future comparison.
• Focused Assessment: Gathers data about a specific identified problem. Helpful questions include those about symptoms, when they started, factors making symptoms better or worse, use of remedies. It's a routine part of ongoing data collection.
• Emergency Assessment: Performed during a physiologic or psychological crisis to identify life-threatening problems. Examples include a patient choking or experiencing a bleeding episode, or an unresponsive patient.
• Time-Lapsed Assessment: Scheduled to compare a patient's current status against earlier baseline data, often used for vital signs every 4 hours.

Data Collection

• Data collection involves structured methods to gather patient information systematically.
• Gordon's functional health patterns framework organizes patient data using a five-part framework.
• Data types include subjective (e.g., symptoms, feelings) and objective (e.g., measurable signs, physical observations).

Data Collection - Subjective Data

• Subjective data are personal perceptions only understood by the affected individual.
• Examples include feeling nervous, nauseous, or chilly, experiencing pain.
• Subjective data can also be referred to as symptoms or covert data.

Data Collection - Objective Data

• Objective data are observable and measurable.
• Examples include elevated body temperature, skin condition (e.g., moist), and refusal of food or fluids.
• Objective data can also be referred to as signs or overt data.

Data Collection - Sources of Data

• Patient is the primary source.
• Family and significant others can provide crucial information, especially for children or those with limited capacity.
• Patient Records are essential to care planning.
• Medical history, physical exams, progress notes, reports of lab tests, and therapies from other professionals (nutritional, speech, physical therapy) are recorded within the patient's record.
• Consultations with specialists help in establishing medical diagnosis or planning/executing treatment.
• Healthcare literature on specific health problems can be consulted.

Data Collection - Characteristics of Data

• Purposeful: The nurse identifies the reason for the assessment and gathers appropriate data.
• Complete: Data to understand the patient's health problems and needs are collected.
• Factual and accurate: Observed behavior is described objectively. Data should be reported accurately and factual.
• Nurse should be aware that they need to carefully and precisely note what they observe. This is crucial for the record and to be able to explain what they are seeing.

Methods of Data Collection

• Patient Interview: Gathering nursing history through planned communication with the patient.
• Nursing Physical Assessment: Examining the patient, using senses to collect objective data, and verify data from history or yield new data.
• Nursing History: Typically completed first, focusing on patient's strengths, weaknesses, health risks/problems (environmental and hereditary), past and present conditions. Should be carried out as soon as possible after patient presents for care.

Data Reporting and Recording

• The nurse should share patient data with other healthcare professionals.
• Critical changes in a patient's health status (e.g., change in body temperature, vital signs) should be reported promptly.
• Initial data should be recorded in the designated agency format on the day of admission.

Diagnosing

• Summarize data from the assessment phase.
• Determine potential problems.
• Identify actual or potential problems.
• Identify risk factors.
• Determine if a problem exists.
• Provide resources/strengths/weaknesses for health promotion.

History of Nursing Diagnoses

• Nursing diagnoses emerged in the 1950s.
• Initial definitions/classifications evolved over the years.
• The number of identified diagnoses continues to grow.

Nursing vs. Medical Diagnosis

• Medial diagnoses identify diseases.
• Nursing diagnoses focus on unhealthy responses to health and illness.
• Nursing diagnoses are used to describe issues that nurses can independently treat.
• Medical diagnoses often remain steady until the end of the disease process, but nursing diagnoses can change from day-to-day.

Data Interpretation and Analysis

• Experienced nurses analyze data while collecting it.
• Significant data (cues) are noted to denote important or influential data for analysis.
• Significant data should raise a red flag to the nurse for potentially problematic situations.
• Significant data is usually a collection of observed phenomena and should be analyzed through comparisons.
• The analysis should highlight patient strength(s) and problem(s).
• Identify potential complications early.
• Reach conclusion from analysis.

Formulating and Validating Nursing Diagnoses

• NANDA defines five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome.
• Actual diagnoses describe existing problems with major defining characteristics, such as anxiety.
• Risk diagnoses describe vulnerability to potential problems, such as risk for falls.
• Possible diagnoses represent suspected problems requiring further data collection, such as a suspected infection.
• Syndromes are clusters of actual or risk diagnoses related to a specific event or situation, such as self-care deficiency syndrome.
• A nursing diagnosis should clearly identify the problem and related factors (etiology).

Parts of Nursing Diagnosis Statements

• The Purpose of a problem statement is used to accurately describe the health state (or health problem) of the patient.
• NANDA recommends using quantifiers or descriptors to specify the meaning of the problem statement.

Outcome Identification and Planning

• Identifying patient-centered goals and outcomes.
• Set priorities.
• Prescribe individualized nursing interventions.
• Collaborative approach with patients, families, and the care team through communication and ongoing consultation.
• The care plan can be dynamic as patient needs change.

Types of Nursing Interventions

• Nurse-initiated: Actions a nurse performs independently, such as patient education, monitoring, and supporting self-care abilities.
• Physician-initiated: Actions based on a physician's order to treat, such as administering medications or ordering tests.
• Collaborative: Actions performed by multiple health care team members in collaboration, such as nursing, therapy, and other medical professionals.

Implementing the Plan of Care

• Carrying out nurse-initiated, physician-initiated, and collaborative interventions.
• Evaluate patient response to nursing interventions during implementation.
• Nurses need to organize resources to ensure an effective plan of care.
• Factors impacting the successful implementation of care can include patient and/or nurse limitations (developmental stage, resources). Nurse should check with the patient before performing procedures.

Evaluating

• Determining whether the patient has reached established outcomes.
• Based on the patient's responses, decide to terminate, modify, or continue the plan of care if necessary.
• Document the evaluation and modify the plan as needed.

Types of Outcomes

• Cognitive Outcomes: Focus on increased knowledge, evaluated by asking patients to recall or repeat information.
• Psychomotor Outcomes: Involve the achievement of physical skills evaluated through demonstrating those skills
• Affective Outcomes: Focus on changes in feelings or attitudes, evaluated by checking the patient's attitudes and feelings.
• Physiologic Outcomes: Involve measurements of body processes, evaluated using physical assessment skills and comparing them to earlier data.

Time Criteria for Outcomes

• Follow the designated time frames and evaluate the patient's attainment of the outcome.

Documentation of Outcomes

• Summarize findings and results of the evaluation. Nurses have three options: met, partially met, or not met.
  • Explain why outcomes were not met if not met to adjust/modify the plan of care.

Modifying the Plan of Care

• If outcomes were not met, modify the plan of care.
• Options include: adjusting diagnosis, refining the desired outcomes, altering time criteria, or changing the intervention methods.