Nursing Diagnosis - Assessment & Types of Assessment PDF

- ASSESSMENT - NURSING DIAGNOSIS D R S E R P İ L TO P Ç U 1  ASSESSMENT The nurse makes ongoing assessments During the assessment step of the nursing process, the nurse establishes the database The nursing history identifies the patient’s health status, strengths, health problems,...

- ASSESSMENT - NURSING DIAGNOSIS D R S E R P İ L TO P Ç U 1  ASSESSMENT The nurse makes ongoing assessments During the assessment step of the nursing process, the nurse establishes the database The nursing history identifies the patient’s health status, strengths, health problems, health risks, and need for nursing care. The nurse may also perform a nursing physical examination to collect data. 2 3  TYPES OF NURSING ASSESSMENTS 1- First Assessment The first assessment is start after the patient is admitted to a healthcare agency or service. The purpose of this assessment is to establish a complete database for problem identification and care planning. The nurse collects data; patient’s health, priorities for ongoing focused assessments and future comparison. 4  TYPES OF NURSING ASSESSMENTS 2- Focused Assessment The nurse gathers data about a specific problem that has already been identified. Helpful questions include: What are your symptoms? When did they start? Were you doing anything different than usual when they started? What makes your symptoms better? Worse? Are you taking any remedies (medical or natural) for your symptoms? A focused assessment is routinely part of ongoing data collection. Focused assessment identify new or overlooked problems. 5  TYPES OF NURSING ASSESSMENTS 3- Emergency Assessment When a physiologic or psychological crisis presents, the nurse performs an emergency assessment to identify life threatening problems A nursing home resident who begins choking in the dining room, a bleeding patient brought to the emergency room with a stab wound An unresponsive patient in the rehabilitation unit 6  TYPES OF NURSING ASSESSMENTS 4- Time-Lapsed Assessment The time-lapsed assessment is scheduled to compare a patient’s current status to baseline data obtained earlier. «Taking vital sign every 4 hours» 7  DATA COLLECTION Because many different types of data are collected about patients, there is a need to structure data collection systematically. When the nurse internalizes such assessment guidelines, it is easier to focus on the patient during the assessment Gordon’s framework identifies 11 functional health patterns and organizes patient data Maslow uses a hierarchy of five sets of human needs 8 DATA COLLECTION- TYPES OF DATA: SUBJECTIVE AND OBJECTIVE Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person Examples of subjective data are feeling nervous, nauseated, or chilly and experiencing pain Subjective data also are called symptoms or covert data 9  DATA COLLECTION- TYPES OF DATA: SUBJECTIVE AND OBJECTIVE Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them Examples of objective data are an elevated temperature reading (39.2 °C), skin that is moist, and refusal to look at or eat food. Objective data also are called signs or overt data 10 11 DATA COLLECTION- CHARACTERISTICS OF DATA I- Purposeful When preparing for data collection, the nurse identifies the purpose of the nursing assessment (comprehensive, focused, emergency, time-lapsed) and then gathers the appropriate data. 12 DATA COLLECTION- CHARACTERISTICS OF DATA II- Complete As much as possible, all the patient data needed to understand a patient health problem and develop a plan of care to maximize health and well-being should be identified For example, a patient has lost weight;  The weight loss was intentional or unintentional?  It was related to a change in eating or exercise patterns or to some underlying pathologic condition?  13 DATA COLLECTION- CHARACTERISTICS OF DATA III- Factual and Accurate It is best to describe observed behavior; - √ Patient frequently is observed lying with his face to the wall - √ He refused lunch today and ate only soup for dinner - X Patient is depressed 14  DATA COLLECTION Sources of Data Patient; The patient is the primary and usually the best source of information Family and Significant Others; Family members, friends, and caregivers are especially helpful sources of data when the patient is a child or has limited capacity to share information with the nurse Patient Record; Records prepared by different members of the healthcare team provide information essential to comprehensive nursing care. 15  PATIENT RECORD; Medical history, physical examination, and progress notes; These sources record the findings of physicians as they assess and treat the patient; they focus on identifying pathologic conditions and their causes and on determining the medical regimen for treatment Consultations; The patient’s physicians may invite specialists to assess and to work with the patient. Their focus is on identifying findings that help to establish a medical diagnosis or on planning and executing the treatment regimen. 16  PATIENT RECORD; Reports of laboratory and other diagnostic studies; Reports of laboratory studies and other diagnostic tests, such as radiographs, Reports of therapies by other healthcare professionals; Other healthcare professionals who interact with the patient also record their findings and note any progress the patient is making in their specific areas—for example, nutrition, physical therapy, or speech therapy. 17  DATA COLLECTION Nursing and Other Healthcare Literature To obtain a comprehensive patient database, it may be necessary to consult the nursing and related literature on specific health problems For example, if a nurse has not cared for a patient with Paget’s disease before, it is important for him or her to read about the clinical manifestations of the disease and its usual progression to know what to look for when assessing the patient. 18 METHODS OF DATA COLLECTION Components of data collection include the nursing history and the nursing physical assessment Observation is a key nursing skill, whether gathering the nursing history or performing the physical examination Observation is the conscious and deliberate use of the five senses to gather data 19  METHODS OF DATA COLLECTION Nursing History The nursing history should be obtained as soon as possible after a patient presents for care and should be followed by the nursing physical assessment. The nursing history should clearly identify the patient’s strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems 20 METHODS OF DATA COLLECTION - NURSING HISTORY PATIENT INTERVIEW The nurse obtains a nursing history by interviewing the patient. An interview is a planned communication. Strong interviewing skills are needed to establish a successful working partnership with the patient. 21 METHODS OF DATA COLLECTION Nursing Physical Assessment Physical assessment is the examination of the patient for objective data that may better define the patient’s condition and help the nurse in planning care. The physical assessment normally follows the nursing history and interview, and may verify data gathered during the history or yield new data. 22  METHODS OF DATA COLLECTION DATA REPORTING AND RECORDING The patient data collected by the nurse should be share with other healtcare prefessionals Timing Critical change in the patient’s health status should reporting to other nurses or healthcare professionals ( body temperature before surgery). Documentation The initial database should be entered into the computer or recorded in ink, using the designated agency forms, the same day the patient is admitted to the agency. 23 DIAGNOSING 24 25  HISTORY OF NURSING DIAGNOSES The term nursing diagnosis first appeared in the literature in the 1950s. The Model Nurse Practice Act of the American Nurses Association (ANA) (1955) excluded diagnosis or prescriptive therapies. In 1973, The first conference on nursing diagnosis identified and defined 80 nursing diagnoses -North American Nursing Diagnosis Association International (NANDA-I) Research in the field of nursing diagnosis continues to grow 26 NURSING DIAGNOSIS VS MEDICAL DIAGNOSIS Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness Nursing diagnoses are written to describe patient problems that nurses can treat independently 27 NURSING DIAGNOSIS VS MEDICAL DIAGNOSIS «Myocardial infarction (heart attack) is a medical diagnosis. Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Deficient Knowledge, Pain, and Altered Tissue Perfusion» «A medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient’s pathology. The complimentary nursing diagnoses of Impaired verbal communication, Risk for falls, Interrupted family processes and Powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family» 28 DATA INTERPRETATION AND ANALYSIS Most experienced nurses begin the work of interpreting and analyzing data while they are still collecting (assessing) it. The term cue is often used to denote significant data or data that influence this analysis. Significant data should “raise a red flag” for the nurse 29 DATA INTERPRETATION AND ANALYSIS 1- Recognizing Significant Data Sorting out healthy patient responses from those that are not healthy is not as clear-cut A heart rate of 60-100 beats per minute is generally considered normal. However, an athletic individual may have a resting heart rate below 50, which can be interpreted as a physiological norm rather than an abnormality. Similarly, oxygen saturation is typically considered normal within the range of 95-100%. However, in a patient with chronic obstructive pulmonary disease (COPD), an oxygen saturation level of 88-92% might be considered normal. 30  DATA INTERPRETATION AND ANALYSIS 2- Recognizing Patterns Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue; Diagnosing a woman recovering from any kind surgery with «Ineffective Coping» solely on the basis of tears may misinterpret the patient’s crying, which may be a healthy release of emotion. 31  DATA INTERPRETATION AND ANALYSIS 3- Identifying Strengths and Problems Determining the Patient’s Strengths If a patient appears to meet a standard, the nurse concludes that this strength contributes to the patient’s level of wellness. For example, a person with a history of maintaining a well balanced diet is usually better able to cope with illness than a person who has a history of eating poorly 32  DATA INTERPRETATION AND ANALYSIS 3- Identifying Strengths and Problems Determining Problems the Patient Is Likely to Experience It is important for nurses to identify potential health problems. For example, a nurse notes that a patient has signs of a wound infection, Tries to find is it normal body defense or not 33  DATA INTERPRETATION AND ANALYSIS 4- Identifying Potential Complications Patients may experience many complications related to their diagnoses, medications or treatment regimens, or invasive diagnostic studies. You are most likely to prevent potential complications For example, slurred speech, changes in skin color or moistness, inability to move an extremity or abnormal movement, and changes in levels of consciousness may all be indications of serious and life-threatening complications 34 DATA INTERPRETATION AND ANALYSIS 5- Reaching Conclusions The nurse reaches one of four basic conclusions after interpreting and analyzing the patient data; No Problem Possible Problem Actual or Potential Nursing Diagnosis Clinical Problem Other Than Nursing Diagnosis 35 FORMULATING AND VALIDATING NURSING DIAGNOSES NANDA describes five types of nursing diagnoses: Actual, risk, possible, wellness, and syndrome. Actual Nursing Diagnoses Actual nursing diagnoses represent a problem that has been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor Risk Nursing Diagnoses Risk nursing diagnoses are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. 36  FORMULATING AND VALIDATING NURSING DIAGNOSES Possible Nursing Diagnoses Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed. Syndrome Nursing Diagnoses Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation (Self care deficiency syndrome or Post-Trauma Syndrome) 37 38  FORMULATING AND VALIDATING NURSING DIAGNOSES Parts of Nursing Diagnosis Statements Problem The purpose of the problem statement is to describe the health state or health problem of the patient as clearly and concisely as possible. NANDA recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. 39  FORMULATING AND VALIDATING NURSING DIAGNOSES Parts of Nursing Diagnosis Statements Etiology The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. Unless the etiology is correctly identified, nursing actions might be inefficient and ineffective. For example, a diabetic patient who is frequently admitted to the hospital with hyperglycemia and who has a poor history of dietary and pharmacologic management is diagnosed to be noncompliant. 40  FORMULATING AND VALIDATING NURSING DIAGNOSES Parts of Nursing Diagnosis Statements Defining Characteristics The subjective and objective data that signal the existence of the actual or potential health problem are the third component of the nursing diagnosis. NANDA has identified defining characteristics for each accepted nursing diagnosis 41 NURSING DIAGNOSIS: A CRITIQUE Nurses might be caring simultaneously for three women who have had a modified radical mastectomy because of breast cancer Patient A Disturbed Body Image Ineffective Coping Patient B Pain Bathing/Hygiene Self-Care Deficit Patient C Sexual Dysfunction Powerlessness 42 PLANNING NURSING CARE 43  OUTCOME IDENTIFICATION AND PLANNING After you identify a patient’s nursing diagnoses and collaborative problems, you begin planning, the third step of the nursing process. Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions. Planning requires critical thinking applied through deliberate decision making and problem solving. It also involves working closely with patients, their families, and the health care team through communication and ongoing consultation. A plan of care is dynamic and changes as the patient’s needs change. 44 UNIQUE FOCUS OF NURSING OUTCOME IDENTIFICATION AND PLANNING The primary purpose of the nursing process is to design a plan of care for and with the patient that, once implemented, results in the; Prevention, reduction, or resolution of patient health problems and identified in the patient outcomes 45 NANDA - Nursing Diagnoses NIC- The nurse will... NOC- The patient will... 46 47  OUTCOME IDENTIFICATION, PLANNING, AND CRITICAL THINKING Successful implementation of each step of the nursing process requires high-level skills in critical thinking. To plan healthcare correctly, the nurse must: Be familiar with standards , identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care Remember the goal of patient-centered care 48 OUTCOME IDENTIFICATION, PLANNING, AND CRITICAL THINKING To plan healthcare correctly, the nurse must: Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions? Trust clinical experience and judgment Respect your clinical intuitions Recognize personal biases and keep an open mind 49  OUTCOME IDENTIFICATION, PLANNING, AND CRITICAL THINKING Questions to facilitate critical thinking during planning and outcome identification include: Setting priorities: Which problems require my immediate attention or that of the team? Which problems are my responsibility, and which should I refer to someone else? Which problems are most important to the patient? 50  OUTCOME IDENTIFICATION, PLANNING, AND CRITICAL THINKING Questions to facilitate critical thinking during planning and outcome identification include: Identifying outcomes: What must I observe in the patient to identified by the nursing diagnoses and general problem list? What is the time frame for accomplishing these outcomes? Do the outcomes need to be modified in light of the patient’s response (or lack of response) to the planned interventions? 51  OUTCOME IDENTIFICATION, PLANNING, AND CRITICAL THINKING Questions to facilitate critical thinking during planning and outcome identification include: Selecting evidence-based nursing interventions: How can I tailor my interventions to increase the likelihood of patient benefit? What can I do to minimize the possibility of this harm? 52  COMPREHENSIVE PLANNING In acute care settings, three basic stages of planning are critical to comprehensive nursing care: initial, ongoing, and discharge. If a nurse develops a comprehensive plan of care on the patient’s first day but fails to update the plan, the plan will not be effective or efficient. 53 COMPREHENSIVE PLANNING Initial Planning Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Assessment: Patient reports shortness of breath and has leg swelling. BP: 150/95 mmHg, HR: 110 bpm. Plan: Monitor fluid balance, administer diuretics, and educate on a low-sodium diet. Goal: Reduce swelling and improve breathing within 24-48 hours. 54  COMPREHENSIVE PLANNING Ongoing Planning Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function. Ongoing Planning Adjustments: New Diagnosis: Risk for Impaired Skin Integrity due to delayed wound healing observed during care. Revised Goal: Wound will show signs of healing (e.g., reduced redness and swelling) within one week. New Intervention: Apply prescribed wound dressings, monitor for infection, and educate the patient on proper foot care. 55  COMPREHENSIVE PLANNING Discharge Planning Client education regarding the patient, their problems and needs, and description of what to do, how to do it, and what not to do. History of the hospitalization and an explanation of test data and in-hospital procedures. 56 57  ESTABLISHING PRIORITIES To develop a prioritized list of nursing diagnoses, the nurse needs guidelines for ranking diagnoses as high, medium, or low priority High-priority diagnoses pose the greatest threat to the patient’s well-being Non–life-threatening diagnoses are ranked as medium priorities, and diagnoses that are not specifically related to the current health problem are of low priority. 58 59  ESTABLISHING PRIORITIES Three helpful guides to facilitate critical thinking when prioritizing patient problems include Maslow’s Hierarchy of Human Needs Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following hierarchy: 1. Physiologic needs 2. Safety needs 3. Love and belonging needs 4. Self-esteem needs 5. Self-actualization needs 60  ESTABLISHING PRIORITIES Patient Preference It is best to first meet the needs the patient thinks are most important, if this order does not interfere with other vital therapies Anticipation of Future Problems Assigning low priority to a diagnosis that the patient wants to ignore but that can result in harmful future consequences for the patient might be nursing negligence. 61 62  IDENTIFYING AND WRITING OUTCOMES The Nursing Outcomes Classification (NOC) developed by the Iowa Outcomes Project presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention The current classification lists 385 outcomes with definitions, indicators, measurement scales, and supporting references. The outcomes may be used for individuals, families, or communities Explicit linkages between the NANDA diagnoses and the NOC facilitate a comprehensive approach to care planning 63 IDENTIFYING AND WRITING OUTCOMES Establishing Long-Term Versus Short-Term Outcomes Outcomes might be either long term or short term. Long term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes They also may be used as discharge goals 64 IDENTIFYING AND WRITING OUTCOMES Involving Patient and Family in Outcome Development One of the most important considerations patient and family to be as involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability that the goals will be achieved. Identifying Culturally Appropriate Outcomes 65 IDENTIFYING AND WRITING OUTCOMES Avoiding Common Errors Common errors when writing patient outcomes include the following: Expressing the patient outcome as a nursing intervention. Incorrect: “Offer Mr. Myer 60 mL fluid while awake.” Correct: “Mr. Myer will drink 60 mL fluid every 2 hours while awake, beginning 2/24/12.” Using verbs that are not observable and measurable. Incorrect: “Mrs. Gaston will know how to bathe her newborn” Correct: “After attending the infant care class, Mrs. Gaston will correctly demonstrate the procedure for bathing her newborn Verbs to be avoided when writing goals include “know,” “understand,” “learn,” and “become aware.” These verbs are too general and cannot be measured. 66  IDENTIFYING AND WRITING OUTCOMES Avoiding Common Errors Common errors when writing patient outcomes include the following: Including more than one patient behavior in short-term outcomes. Incorrect: “Patient will list dangers of smoking and stop smoking.” Correct: “By next meeting, 3/02/25, the patient will (1) identify three dangers of smoking and (2) describe a plan he is willing to try to stop smoking. By 6/05/25, the patient will report that he no longer smokes.” Writing outcomes that are so vague that other nurses are unsure of the goal of nursing care. Incorrect: “Patient will cope better.” Correct: “After teaching, 10/02/25, the patient will (1) describe two new coping strategies he is willing to try and (2) demonstrate decreased incidence of previously observed ineffective coping behaviors (chain smoking, withdrawal behavior, heavy alcohol consumption).” 67  IDENTIFYING NURSING INTERVENTIONS A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes There are nurse-initiated, physician-initiated, and collaborative interventions. 68  IDENTIFYING NURSING INTERVENTIONS Nurse-Initiated Interventions Nursing interventions are actions performed by the nurse to: 1. Monitor health status 2. Reduce risks 3. Resolve, prevent, or manage a problem 4. Facilitate independence or assist with activities of daily living 5. Promote optimal sense of physical, psychological, and spiritual well-being 69  IDENTIFYING NURSING INTERVENTIONS Nurse-Initiated Interventions- Identifying and Selecting Appropriate Nurse- Initiated Interventions After writing the patient outcomes, the nurse identifies various nursing interventions to help the patient achieve the outcomes. The Nursing Intervention Classification (NIC), the first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties, greatly facilitates the work of identifying appropriate interventions 70  IDENTIFYING NURSING INTERVENTIONS Nurse-Initiated Interventions- Identifying and Selecting Appropriate Nurse-Initiated Interventions Releted patient outcome Realistic Compatible with patient values, beliefs, culture... Compatible with other planned therapies 71 IDENTIFYING NURSING INTERVENTIONS Nurse-Initiated Interventions- Individualizing Evidence-Based Interventions You should always be prepared to explain why you are doing intervention “a” as opposed to intervention “b” or “c.” You should know how likely it is that the proposed intervention will achieve the desired outcomes and what the associated risks are. 72  IDENTIFYING NURSING INTERVENTIONS Nurse-Initiated Interventions- Writing Nurse-Initiated Interventions in the Plan of Care Following are examples of well-stated nursing interventions: Offer patient 60 mL water or juice (prefers orange or apple juice) every 2 hours while awake for a total minimum PO intake of 500 mL. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. 73  IDENTIFYING NURSING INTERVENTIONS Physician-Initiated Interventions Intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a doctor’s order. For example, a physician examining a patient brought into the emergency room after a motor vehicle accident might ask the nurse to administer a medication to relieve pain and schedule the patient for radiographs and other diagnostic tests. 74  IDENTIFYING NURSING INTERVENTIONS Collaborative Interventions Nurses also carry out treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants For example, nurses caring for a patient who was in a motor vehicle accident might eventually be implementing interventions written by a physical therapist, occupational therapist, or other member of the healthcare team. 75  STUDENT PLANS OF CARE The care plans that students are required to develop are often more detailed than those found in practice settings. The aim is to assist students to assimilate each of the five steps of the nursing process. Although care plan formats vary among different nursing programs, many use a five-column format. 76 77 IMPLEMENTING 78  During the implementing step of the nursing process, nursing actions planned in the previous step are carried out The purpose of implementation is to assist the patient in achieving: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning 79 80  CRITICAL THINKING AND IMPLEMENTING As you implement the plan of care, you are constantly thinking critically Since patient conditions can change dramatically in minutes, you must reassess different solution of interventions. As a student, you will always need to ask if you are competent to implement the plan of care. If you doubt that your cognitive, interpersonal, or technical skills are adequate to successfully implement the plan of care, it is your responsibility to ask for help. 81  TYPES OF NURSING INTERVENTIONS Nursing interventions fall into three main categories that determine which medical professionals are responsible for carrying out a patient intervention: 1- Independent: A nurse can carry out these interventions on their own, without input or assistance from others. An example of an independent intervention includes educating a patient on the importance of their medication so they can administer it as prescribed. Teaching or encouraging the patient deep breathing for relaxation or oxygen saturation 82  TYPES OF NURSING INTERVENTIONS 2- Dependent: These nursing interventions require an order from a physician, such as ordering the prescription for a new medication 3- Interdependent: Nurses work alongside multiple members of a care team to perform these interventions An example of an interdependent intervention could include a patient recovering from knee surgery who is prescribed pain medication by a physician, administered medication by a nurse and given physical therapy exercises by a specialist. 83 IMPLEMENTING THE PLAN OF CARE When carrying out the plan of care, nurses use specialized abilities to; (1) determine the patient’s new or continuing need for nursing assistance (2) promote self-care, and (3) assist the patient to achieve valued health outcomes. 84  IMPLEMENTING THE PLAN OF CARE- DETERMINE THE PATIENT’S NEED Reassessing the Patient and Reviewing the Plan of Care A patient’s condition can change dramatically in a matter of minutes Therefore, it is critical to assess the patient carefully before initiating any nursing intervention to make sure that the plan of care Organizing Resources Successful implementation of the plan of care requires a high degree of organization and efficiency in today’s chaotic healthcare environments. 85 IMPLEMENTING THE PLAN OF CARE- DETERMINE THE PATIENT’S NEED Organizing Resources - Patient and Patient Visitors Make sure the patient is physically and psychologically prepared for what you are going to do If visitors are in the room, check with the patient to see if she or he wants the visitor(s) to stay during the procedure. - Personnel Identify if you are able to carry out the planned intervention independently or if you are likely to need assistance. 86 IMPLEMENTING THE PLAN OF CARE- DETERMINE THE PATIENT’S NEED Organizing Resources - Equipment Anticipate all the equipment you will need to successfully carry out the intervention and arrange it so that it is easily accessible - Environment Think through the proper environment for each intervention. Pay special attention to respecting the patient’s dignity, privacy, and safety needs. Remember routine measures as simple as closing a door 87 IMPLEMENTING THE PLAN OF CARE- PROMOTING SELF-CARE: TEACHING, COUNSELING, AND ADVOCACY Although most people can independently meet their basic human needs, illness and the stress of diagnostic and therapeutic measures may interfere with a person’s usual practice of self-care. The plan of nursing care should include promote greater independence – for patients 88 IMPLEMENTING THE PLAN OF CARE- ASSISTING PATIENTS TO MEET HEALTH OUTCOMES A-Variables That Influence Outcome Achievement Some of the most important variables that influence how the plan of care is implemented follow; 1- Patient Developmental Stage - Addressing the developmental needs of a patient involves identifying the patient’s developmental stage; premature, todler, child, teenage, elder........ - To implement a comprehensive and holistic plan of care, nurses must find creative ways to meet developmental needs 89 IMPLEMENTING THE PLAN OF CARE- ASSISTING PATIENTS TO MEET HEALTH OUTCOMES Variables That Influence Outcome Achievement 2- Psychosocial Background When choosing nursing interventions, the nurse should consider and respect the patient’s socioeconomic background and culture. The nurse needs to assess whether the patient values this intervention and is willing to make the necessary changes. 90 IMPLEMENTING THE PLAN OF CARE- ASSISTING PATIENTS TO MEET HEALTH OUTCOMES B-Nurse Variables Nurse variables that influence the implementation of the plan of care include levels of expertise, creativity (ability to match patient needs with specific nursing strategies), willingness to provide care, and available time C- Resources The well designed plan of care cannot be fully effective without adequate staff, equipment, and supplies 91  IMPLEMENTING THE PLAN OF CARE- ASSISTING PATIENTS TO MEET HEALTH OUTCOMES D- Research Findings Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice. Always read professional nursing journals and attend continuing education workshops and conferences 92  IMPLEMENTING THE PLAN OF CARE- ASSISTING PATIENTS TO MEET HEALTH OUTCOMES F- Ethical And Legal Guides To Practice To practice good nursing, it is important to be knowledgeable about the laws and regulations that affect healthcare and the ethical dimensions of clinical practice Each nurse is responsible for becoming sensitive to the ethical and legal dimensions of practice, and moral and legal accountability are inherent in the practice of professional nursing. 93  CONTINUING DATA COLLECTION AND RISK MANAGEMENT An important nursing intervention is ongoing data collection. Skilled nurses monitor the patient’s responses to planned interventions to determine if the plan of care is working. These assessment findings are used to update and revise the plan of care. Another vital nursing intervention is ongoing risk management. While monitoring the patient’s responses to the plan of care, nurses are also alert to the development of new problems that may result in the identification of new diagnoses or collaborative problems. 94 WHEN A PATIENT DOES NOT COOPERATE WITH THE PLAN OF CARE Common reasons for noncompliance include: Lack of family support Lack of understanding about the benefits of compliance Low value attached to outcomes or related interventions Adverse physical or emotional effects of treatment (such as pain and fatigue) Inability to afford treatment Limited access to treatment. 95 EVALUATING 96  EVALUATING In the fifth step of the nursing process, evaluating, the nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care. The purpose of evaluation is to allow the patient’s achievement of expected outcomes Based on the patient’s responses to the plan of care, the nurse decides to: Terminate the plan of care when each expected outcome is achieved Modify the plan of care if there are difficulties achieving the outcomes Continue the plan of care if more time is needed to achieve the outcomes 97 98  TYPES OF OUTCOMES Collecting Evaluative Data The nurse collects evaluative data to determine whether or not the patient has met the desired outcomes. 1- Cognitive Outcomes Cognitive outcomes involve increases in patient knowledge. These outcomes may be evaluated simply by asking patients to repeat information 99  TYPES OF OUTCOMES 2- Psychomotor Outcomes Psychomotor outcomes describe the patient’s achievement of new skills; they are evaluated by asking the patient to demonstrate the new skill. 3- Affective Outcomes Observation of patient behavior and conversation can determine whether affective outcomes have been achieved. 4- Physiologic Outcomes To evaluate achievement of this type of outcome, the nurse uses physical assessment skills to collect relevant data and compares these with previous patient data. 100  TIME CRITERIA In addition to knowing what type of data to collect to determine outcome achievement, it is important to know when to collect the data. At the designated time, the nurse, in collaboration with the patient, the family, and other members of the nursing team, evaluates the patient’s attainment of the outcome. Examples of three types of time criteria follow: By 02/02/25, the patient walk the length of the hallway with support of a walker. Beginning 03/03/25, the patient demonstrate a weight loss of 3 kg per month until target weight (135 kg) is achieved (6/8/12, weight: 151 kg). 101  DOCUMENTING JUDGMENT After the data have been collected and interpreted to determine patient outcome achievement, the nurse makes and documents a judgment summarizing the findings. The nurse has three decision options for how outcomes have been met: - Met - Partially met, or - Not met. Partialy and not met needs to revision, find the problem step and start over 102 MODIFYING THE PLAN OF CARE When the nurse has identified the factors contributing to the outcomes not being achieved, the evaluative statement can be used to suggest the necessary revision in the plan of care: (1) delete or modify the nursing diagnosis, (2) make the outcome statement more realistic, (3) increase the complexity of the outcome statement, (4) adjust time criteria in outcome statement, or (5) change the nursing intervention. 103