NURSING AS A SCIENCE 4

• 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.
• BASIC THREE-PART STATEMENTS/ PES FORMAT

   

  a.        PROBLEM (P): statement of the client’s response (NANDA LABEL)

  b.      ETIOLOGY (E): factors contributing to or probable causes of the responses

  c.     SIGNS AND SYMPTOMS (S): defining characteristics manifested by the client. Cannot be used for risk diagnoses
• 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

   

  -          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.

  -          end product of the planning phase à 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

  2. ONGOING PLANNING

  3. DISCHARGE 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 OF ONGOING PLANNING

   

  a.        To determine whether the client’s health status has changed.

  b.        To set principles for the client’s care during the shift.

  c.        To decide which problem to focus on during the shift.

  d.        To coordinate the nurse’s 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
  • INFORMAL NURSING CARE PLAN
  • FORMAL NURSING CARE PLAN
  • STANDARDIZED CARE PLAN
  • INDIVIDUALIZED CARE 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
• GUIDELINES FOR WRITING NURSING CARE PLANS

  1. 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
  2. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative plans
  3. Ensure that the plan contains ongoing assessment of the client
  4. Include collaborative and coordination activities in the plan
  5. Include plans for the client’s discharge and home care needs
• THE PLANNING PROCESS

  1. SETTING PRIORITIES
  2. ESTABLISHING CLIENT GOALS/ DESIRED OUTCOMES
  3. SELECTING NURSING INTERVENTIONS AND ACTIVITIES
  4. WRITING INDIVIDUALIZED NURSING INTERVENTIONS ON CARE PLAN
• 1. SETTING PRIORITIES

  • The process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
• 1. ESTABLISHING CLIENT GOALS/ DESIRED OUTCOMES

  • After establishing priorities, the nurse and client set goals for each nursing diagnosis.
  • GOAL - broad
  • DESIRED OUTCOME - specific
• THE NURSING OUTCOME CLASSIFICATION

  
  

  • a taxonomy developed to describe client outcomes that respond to nursing interventions.
  • 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).
• THE NURSING OUTCOME CLASSIFICATION

  • each NOC outcome is assigned a four-digit identifier, indicated in this text by square brackets, and a definition
  • NOC outcomes are broadly stated and conceptual
  • 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
• PURPOSE OF GOALS/ DESIRED OUTCOME

  
  

  1. Provide direction for planning nursing interventions.
  2. Serve as a criterion for evaluating client progress
  3. Enable the client and nurse to determine when the problem has been resolved
  4. Help motivate the client and nurse by providing a sense of achievement
• COMPONENTS OF GOAL / DESIRED OUTCOME STATEMENTS

  
  

  1. SUBJECT
  2. VERB
  3. CONDITIONS OR MODIFIERS
  4. CRITERION OF DESIRED PERFORMANCE
• NURSING INTERVENTION

  
  

  • include both direct and indirect care, as well as nurse initiated, physician initiated or other health provider initiated.
• TYPES OF NURSING INTERVENTION

  
  

  1. INDEPENDENT INTERVENTIONS

  2. DEPENDENT INTERVENTIONS

  3. COLLABORATIVE INTERVENTIONS
• NURSING INTERVENTION CLASSIFICATION (NIC)

  
  

  - AKA a taxonomy of nursing intervention.

  - a set of standardized language to describe the interventions the nurses perform

  - consists of 3 levels:

     Level I- DOMAINS

     LEVEL II- CLASSES

     LEVEL III- INTERVENTIONS
• INDEPENDENT INTERVENTIONS – are those activities that nurses are licensed to initiated on the basis of their knowledge and skills
• 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
• 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
• 1. SUBJECT – the client, any part of the client or some attribute of the client
• 2. VERB - specifies an action the client is to perform
• 3. CONDITIONS OR MODIFIERS – may be added to the verb to explain the circumstances under which the behavior is to perform.
• 4. CRITERION OF DESIRED PERFORMANCE – Indicates the standard by which a performance is evaluated or the level at which the client will perform the specific behavior.
• • 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