Nursing Diagnosis and Planning

1. Nursing Diagnosis and Planning Med/Surg I Lisa Osborne/Rhonda Keen

2. Intro to Problem solving • Difference in how to do a task and why we do it and what does it mean if it is abnormal • Trial and error • Rogaine – antidepressant with some hair growth going on ? • Can we use this on patient’s if so to what extent…

3. Scientific Method • Scientific method vs the nursing process • Nursing process uses evidence based implementation not trial and error or a hypothesis • Critical Thinking • The ability to use critical thinking is essential in the nursing process

4. The Nursing Process • Data Collection • Data gathered to determine what the problem is. • Nursing Diagnosis • Statement about the actual or potential health concern of the client • Clear, concise, client-centered, and client-specific • You cannot make a client do what they do not want to do—plan together • Not the same as medical diagnosis—which identifies the disease the patient is believed to have—Doctors study the physiologic findings to give diagnosis—will give a basis for prognosis • Planning • Implementation • Will discuss in the next chapters • Evaluation • Will discuss in the next chapters

5. The Nursing Diagnosis • Identifies nursing priorities • Directs nursing interventions to meet the client’s high-priority needs • Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team • Guides the formulation of expected outcomes for quality assurance requirements of third-party payers • Provides a basis of evaluation to determine if nursing care was beneficial to the client and cost effective • Is of help when making staff assignments

6. NANDA • North American Nursing Diagnosis Association • Determine appropriate and acceptable nursing diagnoses • NANDA is the standard for nursing care plans • They do change

7. The Diagnostic Statement • Has two to three parts • Problem • Clear and concise explanation of the health problem the patient is having • Etiology • What is the cause of the problem? • Signs and Symptoms • What signs and symptoms cause this to be a problem?

8. Writing the Diagnostic Statement • The problem and etiology separated by the abbreviation R/T which means related to • Etiology and S/S are separated by evidenced by statement • Examples: • Ineffective coping R/T prognosis of terminal illness as evidenced by hands trembling, verbalization of nervousness, excitability • Impaired gas exchange R/T diagnosis of emphysema as evidenced by chest x-ray and ABG results of PAO2 of 60. • Collaborative problem simply means you will work with the healthcare team to devise treatments

9. Planning Care • Planning is the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals • Setting priorities, establishing expected outcomes and nursing interventions result in the planning of nursing care

10. Setting Priorities • The most life-threatening or damaging problems are priority one. Remember Maslow’s Hierarchy of Needs • Needs for water, food, air are primary • Airway is usually priority one—if applicable • This is also dependant on the client’s view of their problems—what they see as the most important • Lower level priorities are mostly psycho-social or spiritual—this doesn’t mean that it is ignored—and it may be the priority for the patient

11. Maslow’s

12. Establishing Expected Outcomes • An expected outcome is a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care • It may be referred to as a goal or objective • Should have the following characteristics • Client-oriented—the client is expected to meet the outcome • Specific—everyone including the client will know what is to occur • Reasonable—the outcome should be within the client’s capacity and abilities—taking into consideration their limits • Measurable—the behavior can be observed and measured

13. STG and LTG • Short-Term Goals • Should reflect a more rapid type of outcome—for example the patient who has oxygen applied will have a pulse ox of 88% or above within the next hour • Long-Term Goals • Outcome that requires a longer period to achieve—for example same patient after implementing your plan for pulmonary rehab exercises—within two weeks the client will be able to dress his self without assistance using effort saving methods taught in pulmonary rehab

14. Selecting Nursing Interventions • AKA nursing orders—written and assigned by the plan of care for nursing to follow—could be physician ordered but is usually a nursing measure—without a physician order • Usually selected based on scientific research that has demonstrated the action is effective—Care Plan Book—or nursing text • Consider how will you help the patient to reach the STG and LTG—for example same patient as before—we need to improve their air exchange for the hypoxia—intervention number one—apply oxygen at 2l/min per physician order • How do we know that we have helped—intervention number two—monitor continuous pulse ox or monitor ABG results 1 hour after oxygen applied per MD order • What else can we do to improve the problem—intervention number three—keep head of bed in high fowler’s position • What can help us to our long term goal as well—intervention number four—attend pulmonary rehab 2 days per week starting when the patient SPO2 is 88 or above and the patient is less dyspneic

15. Other Stuff • Kardex—plan of care used to be written on for everyone to see—now more often written out either hand-written or printed from the computer and placed on the chart in order of priority • We give this information either in report or upon reviewing the plan of care • You should change the plan of care to suit the changes in the client as needed each time you care for the patient • JCAHO—now known as joint commission requires nursing care plan to endorse the facilities for Medicare reimbursement—noncompliance can be dealt with severely—even shutting the facility down

16. Leadership • Knowledge, self-awareness, communication, energy, goals and action • Types of leaders • Therapeutic communication-effective • Sbar • Power vs Influence • Continuity of Care- performance improvement

17. MISC….. • What if it goes wrong: variance/incident and sentinel event • Delegation/ Assignment: Do not delegate nursing process, education, judgement task or unstable client task • Delegation game / Prioritization