Nursing Process Module PDF

B. NURSING PROCESS Introduction The nursing process is a systematic, rational method of planning and providing individualized nursing care. Its purposes are to identify a client’s health status and actual or potential health care problems or needs, to establish plans to meet the identif...

B. NURSING PROCESS Introduction The nursing process is a systematic, rational method of planning and providing individualized nursing care. Its purposes are to identify a client’s health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions those needs. The client may be an individual, a family, a community or a group. Hall originated the term nursing process in 1955, and Johnson (1959), Orlando (196), and Weidenbach (1963) were among the first to use it to refer to a series of phases describing the practice of nursing. Since then, various nurses have described the process of nursing and organized the phases in different ways. The use of nursing process in clinical practice gained additional legitimacy in 1973 when the phases were included in the American Nurses Association (ANA) Standards of Nursing Practice. Learning Objectives At the end of discussion, you will be able to: 1. Describe the phases of nursing process. 2. Identify the major characteristics of the nursing process. 3. Identify the activities of each phase of nursing process 4. Identify the components of a nursing diagnosis. 5. Identify essential guidelines for writing nursing care plans. 6. Identify guidelines for writing goals/ desired outcomes. 7. Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning. 8. Describe three categories of skills used to implement nursing interventions. 9. Identify guidelines for implementing nursing interventions 10. Explain how evaluating relates to other phases of nursing process 11. Describe the 5 components of the evaluation process Learning Contents NURSING PROCESS - is a systematic, rational method of planning and providing individualized nursing care. - Cyclical; its components follow a logical sequence, but more than one component may be involved at one time. PURPOSES: 1. To identify a client’s health status and actual or potential health care problems or needs. 2. To establish plans to meet the identified needs. 3. To deliver specific nursing interventions to meet those needs. -the client may be INDIVIDUAL, FAMILY, COMMUNITY OR A GROUP FIVE PHASES OF NURSING PROCESS - The phases are not separate entities but overlapping, continuing sub processes. - Each phase affects the others; they are closely interrelated. - It is cyclical; at the end of first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified. Characteristics of Nursing Process 1. Cyclic and dynamic 2. Client-centeredness 3. Focus on problem solving and decision-making 4. Interpersonal and collaborative style 5. Universal applicability 6. Use of critical thinking and clinical reasoning ASSESSING - The systematic and continuous collection, organization, validation, and documentation of data (information).  - A continuous process carried out during all phases of the nursing process. - All phases of nursing process depend on the accurate and complete collection of data. - Assessments vary according to their purpose, timing, time available, and client status. - Nursing assessments should include the client’s perceived needs, health problems, related experience, health practices, values and lifestyles. -data collected should be relevant to particular health problem; therefore, nurses should think critically about what to assess. - nurses collects comprehensive data : physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/trans-personal, and economic assessment (2010 revision of ANA Standard 1: Assessment) - also involves elicitation of client’s own perspectives on their condition; identifying barriers of communication; recognizing the impact of the nurse’s own attitudes, values, and beliefs on the assessment process; and increase emphasis on protection of the privacy of data Types of Assessment TYPE TIME PERFORMED PURPOSE 1. INITIAL Performed within To establish a complete ASSESSMENT specified time after database for problem admission to a health care identification, agency reference, and future comparison 2. PROBLEM- Ongoing process To determine the status FOCUSED integrated with nursing of specific problem ASSESSMENT care identified in earlier assessment 3. EMERGENCY During any physiological To identify life- ASSESSMENT or psychological crisis of threatening problems the client and identify new or overlooked problems 4. TIME-LAPSED Several months after To compare the client’s REASSESSMENT initial assessment status to baseline data previously obtained. COLLECTION OF DATA -the process of gathering information about a client’s health status. - must be both systematic and continuous to prevent the omission of significant data and reflect a client’s changing health status.  - To collect data accurately, both the client and nurse must actively participate. DATA BASE - contains all the information about a client; includes nursing history, physical assessment, primary care provider’s history and physical examination, results of lab and diagnostic tests and material contributed by other HCP. - Also includes past history and current problems Components of Nursing Health History 1. Biographic data 2. Chief complaint or reason for visit 3. History of present illness 4. Past History 5. Family History of illness 6. Lifestyle 7. Psychological data 8. Social data 9. Patterns of health care Types of Data ❑ SUBJECTIVE DATA -Also referred as ‘SYMPTOMS’ OR COVERT DATA - Apparently only to the person affected - can be described or verified only by the client Example: itching, pain, feeling of worry ❑ OBJECTIVE DATA - Also referred to as SIGNS OR OVERT DATA -Detectable by an observer or can be measured or tested against an accepted standard - obtain by observation or physical examination Example: discoloration of skin, blood pressure reading Other Types of Data ❑ CONSTANT DATA – Information that does not change overtime Example: blood type, race ❑ VARIABLE DATA  – Information that change quickly, frequently or rarely Example: blood pressure, level of pain SOURCES OF DATA ❑ PRIMARY SOURCES OF DATA ❖ consist of statements made by the client but also include those objective data that can be directly obtained by the nurse from the client ✓ CLIENT - best source of data unless the client is too ill, young or confused to communicate clearly - can provide subjective data that no one else can offer ❑ SECONDARY SOURCES OF DATA ❑ data aside from the client 1. SUPPORT PEOPLE -family members, friends, and caregivers who know the client well -often can supplement or verify information provided by the client 2. CLIENT RECORDS -Information documented by various HCP -Types of records: medical record, records of therapies and laboratory records 3. HEALTH CARE PROFESSIONALS -Because assessment is an ongoing process, verbal reports from other HCP serve as other potential sources of information about the client’s health 4. LITERATURE - Professional journals and reference texts, can provided additional information for the data base DATA COLLECTION METHOD 1. OBSERVING – gather data by using the senses - A conscious, deliberate skill that is develop through effort and with an organized approach  2 ASPECTS OF OBSERVING 1. Noticing the data 2. Selecting, organizing, and interpreting the data 2. INTERVIEWING – a planned communication or conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counselling or therapy. ❖ FOCUSED INTERVIEW- the nurse asks the client specific questions to collect information related to the client’s problem 2 Approaches to Interviewing 1. DIRECTIVE INTERVIEW ✓ Highly structured and elicits specific information ✓ The nurse establishes the purpose of interview and controls the interview, at least at the outset ✓ The client responds to questions but may have limited opportunity to ask questions or discuss concerns ✓ Example: in an emergency situation 2. NONDIRECTIVE INTERVIEW ✓ Rapport building interview ✓ The nurse allows the client to control the purpose, subject matter and pacing ✓ Rapport: is an understanding between two people ✓ A combination of directive and nondirective approach is usually appropriate during the information- gathering interview TYPES OF INTERVIEW QUESTIONS 1. CLOSED- ENDED QUESTIONS - used in directive interview, are restrictive and generally require only “yes or no” or short factual answers that provide specific information 2. OPEN-ENDED QUESTIONS - Associated with nondirective interview, invites clients to discover or explore, elaborate, clarify , or illustrate their thoughts or feelings -Specifies only the broad topic to be discussed and invites answer longer than  1 or 2 words 3. NEUTRAL QUESTIONS - A question that client can answer without direction or pressure form the nurse, is an open ended, and is used in nondirective interview Try to avoid asking “why” question. These questions can be perceived as a form of interrogation by the client. PLANNING THE INTERVIEW AND SETTING ❑ The nurse reviews available information before beginning an interview. ❑ Both the nurse and the client must be made comfortable in order to encourage an effective interview ❑ Each interview is influenced by : ❑ TIME ✓ The nurse need to plan the interview with clients when the client: ✓ physically comfortable and free of pain ✓ when interruptions from friends, family or other HCP are minimal ❑ PLACE ✓ well lighted, well ventilated room that is relatively free of noise, movements, and distractions encourages communication ✓ the place should not allow others to overhear or see the interview. ❑ SEATING ARRANGEMENT ✓ The nurse can sit at a 45-degree angle to the bed when the client is in bed (less formal) ✓ Seating with no table in between, a few feet apart, creates a less formal atmosphere. ❑ DISTANCE ✓ The distance should neither too small nor too great because some feel uncomfortable when talking to someone who is too close or too far away. ✓ PROXEMICS – THE STUDY OF USE OF SPACE  ❑ LANGUAGE ✓ Failure to communicate in language the client can understand is a form of discrimination ✓ The nurse must use words that the client can understand. ✓ The nurse must avoid using medical terms ✓ If giving written documents to client, the nurse must determine that the client can read in his or her own native language ✓ Ensure confidentiality of information is observed STAGES OF INTERVIEW 1. OPENING –sets the tone of the interview PURPOSE: ✓ Establish rapport –creating goodwill and trust ✓ Orient the interviewee- explains the purpose and nature of interview 2. BODY - The client communicates what he/she thinks, feels, knows, and perceives in response to questions from the nurse 3. CLOSING - The nurse terminates the interview when the needed information has been obtained. 3. EXAMINING ✓ Physical examination or physical assessment is a systematic data collection method that uses observation to detect health problems. ✓ To conduct the examination, the nurses uses techniques of inspection, auscultation, palpation, and percussion ✓ Must be carried out systematically o Organized according to examiner’s preference o Cephalocaudal (head-to-toe approach) o body systems approach – screening examination /review of systems ORGANIZING DATA - the nurse uses a written or electronic format that organizes the assessment data systematically - referred as NURSING HEALTH HISTORY, NURSING ASSESSMENT, OR NURSING DATABASE FORM 1. CONCEPTUAL MODELS/ FRAMEWORKS  Most schools and health care agencies developed their own STRUCTURED ASSESSMENT FORMAT based on selected nursing models/ frameworks ❑ Gordon’s Functional Health Patterns ❑ Orem’s Self-care Model ❑ Roy’s Adaptation Model 2. WELLNESS MODELS - Nurses use wellness models to assist clients to identify health risks and to explore lifestyle, habits and health behaviours, beliefs, values, and attitudes that influence level of wellness. 3. NONNURSING MODELS -Frameworks and models from other disciplines like BODY SYSTEM MODEL, MASLOW’S HIERARCHY OF NEEDS. DEVELOPMENTAL THEORIES VALIDATING DATA -is an act of double checking or verifying data to confirm that it is accurate and factual. -validating data helps the nurse complete these tasks: 1. Ensure that assessment information is complete. 2. Ensure that objective data and related subjective data agree 3. Obtain additional info that may have been overlooked. 4. Differentiate cues and inferences ❖ CUES- subjective or objective data that can be directly observed by the nurse ❖ INFERENCES- nurses interpretation or conclusion made based on the cues 5. Avoid jumping to conclusions and focusing on the wrong direction to identify problems DOCUMENTING DATA - To complete the assessment phase, the nurse records the client data. - accurate documentation is essential and should include all the data collected about the client’s health status -data are recorded in factual manner and not interpreted by the nurse - to increase accuracy, the nurse records subjective data in the client’s own words, using quotation marks. Rechanging on other words what someone says increases the chance of changing original meaning Subjective data: “masakit ang ulo ko” as verbalized by the patient DIAGNOSING ✓ The second phase of the nursing process ✓ The nurses uses critical thinking skills to interpret assessment data and identify client strength and problems. ✓ Identification and development of nursing diagnoses began formally in 1973, when 2 faculty members of SLU, Kristine Gebbie and Mary Ann Lavin, perceived a need to identify nurse’s roles in an ambulatory care setting. ✓ In 1982, the conference group accepted the name NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION (NANDA), recognizing the participation and contributions of nurses in the USA and Canada. ✓ In 2002, the organization changed its name to NANDA INTERNATIONAL to further reflect the worldwide interest in nursing diagnosis ✓ The purpose of NANDA International is to define, refine and promote TAXONOMY of nursing diagnostic terminology of general use to professional nurses. ✓ TAXONOMY – classification system or set of categories arranged based on a single principle or set of principles. DEFINITIONS: ❖ DIAGNOSING-refers to the reasoning process ❖ DIAGNOSIS- a statement or conclusion regarding the nature of a phenomenon ❖ DIAGNOSTIC LABELS- The standardized NANDA names for the diagnoses ❖ ETIOLOGY – causal relationship between a problem and its related or risk factors ❖ NURSING DIAGNOSIS- The client’s problem statement, consisting of the diagnostic label plus etiology. NURSING DIAGNOSIS NANDA DEFINITION: A clinical judgment concerning a human response to health conditions/ life processes, or a vulnerability for that response, by an individual, family, group or community NANDA-1 THINK TANK, 2009: A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. STATUS OF NURSING DIAGNOSES Refers to the actuality and potentiality of the problem/syndrome or the categorization of the diagnosis as a health promotion diagnosis.  The kinds of nursing diagnoses according to status are actual, health promotion, risk, and syndrome. 1. ACTUAL DIAGNOSIS is a client problem that is present at the time of the nursing assessment. Example: Ineffective breathing pattern 2. HEALTH PROMOTION DIAGNOSIS relates to client’s preparedness to implement behaviors to improve their health condition. Example : Readiness for enhanced coping 3. RISK NURSING DIAGNOSIS is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. Example: Risk for infection 4. SYNDROME DIAGNOSIS is assigned by a nurse’s clinical judgment to describe a cluster of nursing diagnoses that have similar interventions COMPONENTS OF A NANDA NURSING DIAGNOSIS 1. PROBLEM (DIAGNOSTIC LABEL) AND DEFINITION ✓ Describes the client’s health problem or response for which nursing therapy is given. ✓ Describes the client’s health status clearly and concisely in a few words. ✓ To be clinically useful, diagnostic labels need to be specific, when the word SPECIFY follows a NANDA label, the nurse states the area in which the problem occurs. EXAMPLE: deficient knowledge (medication) or deficient knowledge (dietary adjustments) Activity intolerance QUALIFIERS -words that have been added to some NANDA labels to give additional meaning to the diagnostic statement, for example: DEFICIENT (inadequate in amount, quality, or degree; not sufficient; incomplete) IMPAIRED (made worse, weakened, damaged, reduced, deteriorated) DECREASED (lesser in size, amount, or degree) INEFFECTIVE (not producing the desired effect) COMPROMISED (to make vulnerable to threat) 2. ETIOLOGY (RELATED FACTORS AND RISK FACTORS) ✓ Identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care. ✓ Differentiating among possible causes in the nursing diagnosis is essential because each may require different nursing interventions. Example: Bed rest or immobility Generalized weakness 3. DEFINING CHARACTERISTICS ✓ The cluster of signs and symptoms that indicate the presence of a particular diagnostic label. ✓ For actual diagnoses: the defining characteristics are the client’s signs and symptoms ✓ For risk nursing diagnoses: no subjective and objective signs, are present ✓ EXAMPLE: Verbal report of fatigue or weakness DIFFERENTIATING NURSING DIAGNOSES FROM MEDICAL DIAGNOSES NURSING DIAGNOSIS - A statement of nursing judgment and refers to a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat. - Describe the human response, a client’s physical, sociocultural, psychological, and spiritual responses to an illness or a health problem. MEDICAL DIAGNOSIS -made by a physician and refers to a condition that only a physician can treat. -refer to disease processes—specific pathophysiologic responses that are fairly uniform from one client to another. THE DIAGNOSTIC PROCESS 1. ANALYZING DATA THREE STEPS: 1. Comparing data with standards (identify significant cues). - Nurses draw knowledge and experience to compare client data to standards and norms and identify significant and relevant cues.  -STANDARD OR NORM- generally accepted measure, rule, model, or pattern 2. Cluster the cues (generate tentative hypothesis). -data clustering is a process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant -the beginning of synthesis 3. Identify gaps and inconsistencies. - Skillful assessment minimizes gaps and inconsistencies in data. However data analysis should include a final check 2. IDENTIFYING HEALTH PROBLEMS, RISKS, AND STRENGTHS ✓ After data are analysed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process. ✓ DETERMINING PROBLEMS AND RISKS o The nurse and client together identify problems that support tentative actual, risk, and possible diagnoses o The nurse must determine whether the client’s problem is a nursing diagnosis, medical diagnosis or collaborative problem 1. DETERMINING STRENGTHS o The nurse and client establish the client’s strengths, resources and abilities to cope. o By taking an inventory of strengths, the client can develop a more well-rounded self-concept and self-image. 3. FORMULATING DIAGNOSTIC STATEMENTS ❖ Most nursing diagnoses are written as TWO-PART OR THREE-PART STATEMENTS ❖ BASIC TWO-PART STATEMENTS 1. PROBLEM (P): statement of the client’s response (NANDA LABEL) 2. ETIOLOGY (E): factors contributing to or probable causes of the responses ❑ The two parts are joined by the words RELATED TO rather than DUE TO. PROBLEM RELATED TO ETIOLOGY CONSTIPATION RELATED TO PROLONGED LAXATIVE USE  ❖ BASIC THREE-PART STATEMENTS/ PES FORMAT 1. PROBLEM (P): statement of the client’s response (NANDA LABBEL) 2. ETIOLOGY (E): factors contributing to or probable causes of the responses 3. SIGNS AND SYMPTOMS (S): defining characteristics manifested by the client. ❑ Cannot be used for risk diagnoses PROBLEM RELATED ETIOLOGY AS SIGNS AND TO MANIFESTED SYMPTOMS BY Situational Related to Feelings of a.m.b Hypersensitivity Low Self- (r/t) rejection by to criticism Esteem husband ❖ ONE-PART STATEMENTS -Any health promotion diagnoses and syndrome nursing diagnoses, consist a NANDA label only. - NANDA has specified that any health diagnoses will be developed as one-part statements beginning with the words READINESS FOR ENHANCED followed by the desired higher level of wellness ❑ Example: Readiness for enhanced parenting PLANNING PLANNING ❖ Is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. ❖ NURSING INTERVENTION- any treatment, based upon clinical judgement and knowledge that a nurse performs to enhance patient or client outcomes. ❖ the end product of the planning phase → CLIENT CARE PLAN ❖ Nurses do not plan for the client, but encourage the client to participate actively to the extent possible. ❖ Begins with the first client contact and continues until the nurse-client relationship ends. Types of Planning 1. INITIAL PLANNING  - The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. -planning should be initiated as soon as possible after the initial assessment 2. ONGOING PLANNING - The nurses who work with the client do ongoing planning. - occurs at the beginning of the shift as the nurse plans the care to be given that day PURPOSES: 1. To determine whether the client’s health status has changed. 2. To set principles for the client’s care during the shift. 3. To decide which problem to focus on during the shift. 4. To coordinate the nurses activities so that more than one problem can be addressed each client contact. 3. DISCHARGE PLANNING - The process of anticipating and planning for needs after discharge is a crucial part of a comprehensive health care plan Characteristics of a Plan Specific Measurable Attainable Realistic Time Bounded DEVELOPING NURSING CARE PLAN ❖ FORMAL OR INFORMAL PLAN OF CARE- the end product of planning phase ❖ INFORMAL NURSING CARE PLAN – a strategy for action that exist in the nurses mind ❖ FORMAL NURSING CARE PLAN – a written or computerized guide that organizes information about the client’s care ❖ STANDARDIZED CARE PLAN – a formal plan that specifies the nursing care for groups of clients with common needs. ❖ INDIVIDUALIZED CARE PLAN – is tailored to meet the unique needs of a specific client – needs that are not addressed by the standardize plan Guidelines for Writing Nursing Care Plans 1. Date and sign the plan 2. Use category headings  3. Use standardized/approved medical or English symbols and key words rather than complete sentences to communicate your ideas unless agency policy dictates otherwise 4. Be specific 5. Refer to procedure books or other source of information rather than including all the steps on a written plan 6. Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices, such as preferences about the times of care and the methods used, are included 7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative plans 8. ensure that the plan contains ongoing assessment of the client 9. include collaborative and coordination activities in the plan 10. include plans for the client’s discharge and home care needs THE PLANNING PROCESS ACTIVITIES: 1. Setting priorities ❖ -The process of establishing a preferential sequence for addressing nursing diagnoses and interventions. ❖ FACTORS TO CONSIDER: 1. Client’s health values and beliefs 2. Client’s priorities 3. Resources available to the nurse and client 4. Urgency of the health problem 5. Medical treatment plan 2. Establishing client goals/ desired outcomes ❖ After establishing priorities, the nurse and client set goals for each nursing diagnosis. ❖ GOAL- broad Example: IMPROVED NUTRITIONAL STATUS ❖ DESIRED OUTCOME- specific Example: gain 5lb by April 25 Improved nutritional status as evidenced by weight gain of 5lbs by April 25 ❖ THE NURSING OUTCOME CLASSIFICATION  o A taxonomy developed to describe client outcomes that respond to nursing interventions. o Standardized common nursing language is required in the taxonomy, over 385 outcomes belong to one of seven domains (physiological health) and a class within the domain (nutrition under psychological). o Each NOC outcome is assigned a four-digit identifier, indicated in this text by square brackets, and a definition o NOC outcomes are broadly stated and conceptual o INDICATORS: are stated in neutral terms, and each outcome includes a five- point scale that is used to rate the client’s status on each indicator ▪ Example : mobility level ▪ Indicator: walking ( independent with assistive device ), move with ease ▪ NOC rating at initiation: 2 ( substantially compromised) ▪ Outcome target rating : 4 ( mildly compromised) o THE CLIENT WILL HAVE IMPROVED MOBILITY, AS EVIDENCED BY ABILITY TO WALK WITH ASSISTANCE DEVICE AND MOVE EASILY Guidelines for Writing the Desired Outcomes 1. Write goals and outcomes in terms of client responses, not nursing activities. Beginning each goal statement with “the client will” –focus on client behaviour and responses Correct: The client will drink 100ml of water per hour (client behaviour) Incorrect: Maintain client hydration (nursing action) 2. Be sure that desired outcomes are realistic for client’s capabilities, limitations, and designated time span, if it is indicated. Measures insulin accurately (unrealistic for client with poor vision) 3. Ensure that the desired outcomes are compatible with the therapies of other professional. The client will increase the time spent out of bed by 15 minutes each day incompatible with patients prescribed for bed rest) 4. Make sure that each goal is derived from only one nursing diagnosis. The client will increase the amount of nutrients ingested and show progress in the ability to feed self is derived from 2 nursing diagnoses -imbalanced nutrition and feeding self-care deficit 5. Use observable, measurable terms for outcomes Increase daily exercise is not measurable 6. Make sure the client considers the goals / desired outcomes important and values them. 3. Selecting nursing interventions and activities NURSING INTERVENTION - include both direct and indirect care, as well as nurse initiated, physician initiated and other health provider initiated. TYPES OF NURSING INTERVENTION 1. INDEPENDENT INTERVENTIONS –are those activities that nurses are licensed to initiated on the basis of their knowledge and skills Ex: physical care, ongoing assessment, emotional support, health teaching 2. DEPENDENT INTERVENTIONS –are those activities carried out under the orders or supervision of a licensed physician or other HCP authorized to write orders to nurses Ex: dangle for 5mins, 12 hours post op, medication administration 3. COLLABORATIVE INTERVENTIONS –are actions the nurses carries out in collaboration with the other HC team members, such as PT, social worker, dietitian, and primary care provider Criteria in Choosing Nursing Interventions 1. Safe and appropriate for individuals age, health, and condition. 2. Achievable with the resources available. 3. Congruent with the clients values, beliefs and culture. 4. Congruent with other therapies 5. Based on nursing knowledge and experience or knowledge from relevant sciences 6. within established standards of care as determined by Philippine Nursing Law and Magna Carta of Health Workers Nursing Intervention Classification ( NIC)  - AKA a taxonomy of nursing intervention. - a set of standardized language to describe the interventions the nurses performs - consists of 3 levels : Level I- DOMAINS LEVEL II- CLASSESS LEVEL III- INTERVENTIONS 4. Writing individualized nursing interventions on care plan Diagnosis : Impaired airway clearance r/t viscous secretion Example Intervention: 1. Instruct in breathing and coughing techniques. Remind to perform and assist q3h 2. Auscultate lungs q4h. Vital signs q4h 3. Monitor level of consciousness 4. Administer prescribed expectorant 5. Maintain high fowler’s position 6. Administer oxygen by nasal cannula as prescribed 7. Assist with postural drainage daily at 9:30 am 8. Administer prescribed antibiotic. - used past tense if the interventions are implemented to your patient. IMPLEMENTING IMPLEMENTING - the action phase in which the nurse performs the nursing interventions -consists of doing and documenting the activities that are specific nursing actions needed to carry out the interventions. SKILLS: 1. COGNITIVE SKILLS –problem solving , decision making, critical thinking, clinical reasoning and creativity 2. INTERPERSONAL SKILLS –are all of the activities, verbal and nonverbal, people use when interacting directly with one another 3. TECHNICAL SKILLS – are purposeful (hands-on) skills such as manipulating equipment, giving injections, bandaging, and repositioning client. PROCESS OF IMPLEMENTING 1. Reassessing the client 2. Determining the nurse’s need for assistance  3. Implementing the nursing interventions 4. Supervising the delegated care 5. Documenting the nursing activities Guidelines for Implementing Nursing Interventions 1. Base nursing interventions on scientific knowledge, nursing research, and professional standards of care (evidence-based practice) when these exist. 2. Clearly understand the interventions to be implemented and question any that are not understood. 3. Adapt activities to the individual client. 4. Implement safe care. 5. Provide teaching, support and comfort. 6. Be holistic. 7. Respect the dignity of the client and enhance the client’s self-esteem 8. Encourage clients to participate actively in implementing the nursing interventions. EVALUATING EVALUATING - A PLANNED, ONGOING, PURPOSEFUL activity in which clients and HCPs determine : a. Client’s progress towards achievement of goals or outcomes b. The effectiveness of the NCP -An important aspect of nursing process because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued or changed. – continuous FIVE COMPONENTS OF EVALUATION 1. Collecting data related to the desired outcomes 2. Comparing the data with the desired outcomes Goal met: the client response is the same as the desired outcomes Goal partially met: either a short term outcome is achieved but the long term was not Goal not met Evaluation statement : consist of 2 parts→ conclusion and supporting data 3. relating nursing activities to outcomes 4. Drawing conclusions about problem status 5. Continuing, modifying, or terminating the nursing care plan LEARNING ACTIVITY Nursing Care Plan Formulation. (30 points) A patient went to the Emergency Department with chief complaints of persistent watery stool for 3 days, stomach ache, body weakness and fever. Upon assessment, the patient’s temperature is 38.5 degree celsius, warm to touch, flushy skin, with signs of moderate dehydration (skin goes back slowly when pinched, sunken eyeballs and dry lips), with guarding behaviour, facial grimace and pain scale of 8/10. Based on the following data, make at least 3 Nursing Care Plan. Use your NANDA book as your reference. Assessment Diagnosis Planning Implementation Rationale Evaluation Subjective: Objective: REFERENCES Berman A. et al. 2018. Kozier & Erb’s Fundamentals of Nursing Concepts, Process, and Practice 10th edition. Pearson Education South Asia PTE. LTD.