Nursing Problem Solving & Processes

Problem-Solving Approach

• Problem-solving is a systematic process and part of decision-making
• Focuses on analyzing difficult situations

Traditional Problem-Solving Process

• Identify the problem
• Gather data to analyze the problem's causes and consequences
• Explore alternative solutions
• Evaluate the alternatives
• Select the best solution
• Implement the solution
• Evaluate the results

Nursing Process

• It is a theoretical system for solving problems and making decisions
• Ida Jean Orlando developed it in the late 1950s
• Consists of a strong critical thinking component

Phases of the Nursing Process

• Assessment
• Diagnosing
• Planning
• Implementing
• Evaluation

Assessment Phase

• Involves collecting, organizing, validating, and documenting data

Data Collection

• Utilize patient information to adapt data collection
• Gather thorough data
• Support subjective findings with objective information

General Assessment

• Consists of patient interviews/conversations
• Physical assessments
• Includes examination of diagnostic and lab test results

Subjective Data

• Comes from the patient, caregiver, and close friends/family members
• Includes feelings, thoughts, and beliefs
• Information from patients and family is not automatically considered subjective

Objective Data

• Your findings, including what you saw, smelled, felt, and heard
• Diagnostic and Lab test results
• Be specific with observations
• Instead of saying “Patient appears to be in discomfort,” say “Patient is grimacing.”

Steps for Collecting Assessment Data

• Ask the patient about their feelings, thoughts, and beliefs related to the nursing diagnosis
• Ensure patient statements cannot be proven or validated, if it can be validated, it’s probably not subjective.
• Ask if the data is related to the diagnosis or problem identified

Collecting Subjective Data Example

• Notice a patient has a wound
• Collect data by noting the patient's beliefs, concerns, and thoughts about the wound

Asking Questions

If a patient does not volunteer data, ask general questions such as:

• How do you think the wound is healing?
• Are you having any discomfort at the site of the wound?
• Do you have knowledge about what can help to improve wound healing?
• Responses to these questions provide subjective data

Organizing Data

• Differentiate important data
• Determine whether there are any abnormal findings
• Identify signs and symptoms
• Cluster/Group data
• Determine if more data is needed

Validating Data

• Clarify vague or unclear data
• Compare data with another source to determine data accuracy
• Check the information collected to avoid making incorrect inferences
• Ask patients to validate unclear information from the interview and history
• Compare data in the medical record with other nurses or healthcare team members

Collecting Data

• If you see someone crying, what are the reasons that can be inferred?

Documenting Data

• Varies based on institution policies
• Includes nurses' notes and relevant charts

Diagnosis

• Involves nurses identifying diagnoses based on standardized language (NANDA-I)

Nursing vs. Medical Diagnoses

• Nurses can diagnose
• Applicable nursing diagnoses are chosen from NANDA-I
• The diagnostic label is read to choose the most applicable one
• Formulate the diagnosis properly

Types of Nursing Diagnoses

• Problem-focused/actual diagnoses

  • Three-part statements: Label, related factor, defining characteristics

• Potential diagnoses

  • Risk diagnoses
    • Two-part statements: Label + (related to) risk factors
  • Health Promotion Diagnoses
    • Two/Three part statement

• Syndrome Diagnoses

  • Three-part statements: Label, related factor, defining characteristics

Nursing Diagnosis Examples

• Risk for infection related to break in skin continuity and low white blood cell count (3000 cells per microliter) and history of frequent viral infections
• Impaired tissue integrity related to insufficient oxygen delivery to tissues due to chronic hyperglycemia as evidenced by a pressure ulcer to the right heel, blood glucose levels elevated at 300-450mg/dl over the past 2/52
• Readiness for enhanced health literacy related to the patient's expression of wanting to learn more about managing her critical illness

Problem-Focused/Actual Diagnoses

• Related factor is the CAUSE
• Other labels are just a connector

Identifying Part 2

• Related factors are used in diagnostic statements as of 2024
• Challenges include Identifying the cause
• and how it is phrased
• NANDA-I guidelines state it cannot be related to a medical procedure or medical diagnosis
• It must be modifiable by the nurse

Planning Phase

• Involves formulating goals and expected outcomes
• Planned interventions
• Writing out the care plan

Elements of a Nursing Care Plan

• Assessment (subjective and objective data that support nursing diagnosis)
• Nursing Diagnosis
• Goals and Expected Outcomes
• Interventions
• Evaluation

Steps in Planning Nursing Care

• Prioritize problems/nursing diagnoses
• Formulate goals/desired outcomes
• Select nursing interventions
• Write nursing care plan

Prioritization

• Look at the signs and symptoms
• Diagnostic findings
• Medical diagnosis
• Life-threatening problems should be given high priority (airway, breathing, circulation)
• Ask, which nursing diagnosis requires attention first?
• Utilize Maslow's Hierarchy of Needs

Goal Setting

• A goal broadly describes a desired change in a patient's condition, perceptions, or behavior
• A short-term goal is an expected objective behavior or response within a short time (usually less than a week)
• A long-term goal is an expected objective behavior or response over several days, weeks, or months

Outcomes

• An expected outcome is the measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal
• Think of a goal as an ultimate outcome
• Expected outcomes are measurable changes that a patient achieves to reach a goal

Outcome Requirements

• Outcome statements must have a subject
  • This is the Patient
• Must have a verb
  • What do you want the patient to do?
• Conditions
  • Under what conditions do you want the patient to dot this? Could also be a timeline.
• Criteria
  • How will you measure that the patient did this? How will you know?
• Outcome statements must be SMART
  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Time-bound

Examples of Goal Setting w/ Expected Outcomes for Mr. Lawson

• Nursing Diagnosis: Acute Pain related to trauma of surgical incision
  • Goal: Mr. Lawson will achieve pain relief by day of discharge
    • Expected Outcomes: Mr. Lawson reports pain at a level of 3 or below by discharge, Mr. Lawson walks to chair with no increase in pain in 24 hours, Mr. Lawson's incisional area shows signs of wound healing by discharge
• Nursing Diagnosis: Lack of Knowledge regarding postoperative care
  • Goal: Mr. Lawson will express understanding of how to minimize postoperative risks by discharge
    • Expected Outcomes: Mr. Lawson describes activity restrictions to follow by discharge in 48 hours, Mr. Lawson demonstrates how to cleanse surgical wound by discharge day, Mr. Lawson describes three risks for infection in 24 hours
• Nursing Diagnosis: Risk for Infection
  • Goal: Mr. Lawson will remain infection free by discharge
    • Expected Outcomes: Mr. Lawson remains afebrile by discharge, Mr. Lawson's wound shows no purulent drainage by discharge, Mr. Lawson's wound closes at site of incision separation by discharge

Example of Goal & Outcome Statements

• Within 30 minutes of nursing interventions, the patient will experience a reduction in pain as evidenced by patient rating pain 3 or less out of 10 on the pain scale
• By discharge, the patient will demonstrate understanding of insulin administration and glucose monitoring as evidenced by patient choosing appropriate locations and technique for self-administration of insulin and correctly performing the finger prick glucose test

Goal/Outcome Don'ts

• The nurse can not be the subject of the outcome
• Do not try to fix all the problems/signs and symptoms in a short space of time
• Do not use these terms: "will know" (will demonstrate knowledge), "will understand" (will display/express understanding), "should have"
• "At least” needs more criteria

Formulating Goals

• Be clear about the type of interventions
• Will you be collaborating?
• Will you use dependent interventions (e.g., medication administration)?
• Are the interventions independent nursing interventions?
• State which types of interventions will be utilized to achieve the desired outcome

Action Verbs

• Achieve
• Verbalize
• Participate
• Demonstrate
• Remain
• Display
• Maintain

Interventions

• Must be congruent with the goal and expected outcome
• No redundancies
• Begin with a verb
• Do not use word "Assess"
• Scepticism with verbs such as "ensure" and "encourage"
• Scientific rationales
• Provide the underlying reasons for which the nursing intervention was chosen
• Choose interventions to alter the etiological (related to) factor or causes of the diagnosis
• When an etiological factor cannot change, direct the interventions toward treating the signs and symptoms
• For risk diagnoses, direct interventions to alter /eliminate risk diagnosis

Implementation Phase

• Implementation process involves doing planned interventions
• Reassessing the patient at each interaction
• Delegating
• Supervising
• Documenting
• Requires cognitive, interpersonal, and psychomotor skills

Types of Interventions

• Direct care interventions: Activities of daily living, Physical care techniques, Life saving measures, Counseling, Teaching, and Preventative
• Indirect care interventions: Performed away from but on behalf of patient, Not usually included on care plans, Hand-off reports, Delegation, Documentation, and Infection control and environmental safety measures

Evaluation

• Determines whether a patient's condition or well-being improved after nursing interventions were delivered
• Provides valuable information about the efficacy of interventions
• Tells whether goals/expected outcomes were achieved of whether clinical practices/nursing care standards are effective
• The outcomes are the criteria for judging the success in delivering nursing care
• Evaluation is critical to knowing a patient's health status
• It is part of every health-care organization’s quality assessment

Evaluative Measures

• These are used to determine the success of goals and expected outcomes
• I.e. inspect color, condition, and location of pressure injury

Evaluation Summary

• Planned, ongoing, purposeful activity
• Client's progress towards goals/desired outcomes and the effectiveness of the nursing care plan (NCP)
• Determines whether interventions should be terminated, continued, or changed
• Determines if the desired outcome was achieved and to what extent
• Written in past tense