Processes in Nursing Care

1. Processes in Nursing Care The Nursing Diagnostic Process Planning Implementation Evaluation Dr. BelalHijji, RN, PhD February 11, 2012

2. Objectives • After this lecture, students will be able to • Identify the steps of the nursing diagnostic process • Discuss how to avoid common errors in nursing diagnostic statements • Identify and describe the steps of planning phase of the nursing process • Identify and discuss the steps of the implementation phase of the nursing process • Describe the evaluation of nursing care

3. The NANDA (North American Nursing Diagnosis Association) Diagnoses and Nursing Diagnostic Process • The following types of nursing diagnoses identified by the NANDA are described: • Actual nursing diagnosis: An example, “urinary retention related to swelling of the perineum following normal delivery”. This diagnosis is supported by the defining characteristics of distended bladder, voiding small amounts, and feels the urge to void. • Risk nursing diagnoses: An example, “an overweight client with spinal cord injury is at risk for impaired skin integrity”. For this diagnosis to be made, data to support client’s vulnerability is needed. Such data may include physiological, psychosocial, familial, and lifestyle factors that increase the client’s vulnerability to develop the condition

4. The diagnostic process is composed of: • Data validation and clustering (described earlier) • Analysis and interpretation of data • Identification of client needs • Formulation of nursing diagnoses

5. Analysis And Interpretation of Data • Consider that a health problem, such as stomach cancer, does not automatically indicate a certain nursing diagnosis exists. Data analysis must be performed to formulate the client’s response.

6. Individual signs or symptoms cannot support a diagnostic label. However, when multiple signs or symptoms are clustered together as a group, one can think about the relationship between and among these findings. • For example, gray hair does not necessarily indicate that a person is an older adult. However, clustering together gray hair, wrinkled skin, and age spots increases the probability that the person is an old adult. • Defining characteristics are not within healthy norms and form the basis for problem identification.

7. Identification of Client Needs • To individualise nursing diagnoses, a client’s needs should be identified. This is accomplished by considering all assessment data and focusing on the more relevant data. • The identification phase is composed of the general health care need, then formulating the nursing diagnosis by recognising the specific health care need. An example is problems with elimination and the specific problem of constipation.

8. Formulation of Nursing Diagnoses • The nursing diagnosis is stated in a two-part format: the diagnostic label followed by a statement of a related factor. • The related factors are etiological or contributing conditions that have influenced the client’s response to the health problem. • The aetiology of the nursing diagnosis must be within the domain of nursing practice and a condition that responds to nursing interventions. A medical diagnosis cannot be recorded as the aetiology of a nursing diagnosis. • For example, acute pain related to breast cancer is incorrect. However, acute pain related to impaired skin integrity secondary to mastectomy incision results is nursing interventions to reduce stress on the suture line and improving client’s comfort.

9. Avoiding Common Errors in Nursing Diagnostic Statements • Nursing diagnoses are easy to write! However, you need to remember that: • The problem portion of the statement is the client’s response to illness. • Avoidance of most common errors in writing nursing diagnoses is possible through: • Identifying the client’s response not the medical diagnosis • Identifying the NANDA diagnostic statement rather than a symptom which is not sufficient for problem identification. For example, SOB, pain on inspiration, and productive cough should be written as ineffective breathing pattern R/T increased airway secretions.

10. Identifying a treatable aetiology rather than a clinical sign or chronic problem • Identifying a problem caused by the treatment or diagnostic study rather than the treatment or study itself. For example, say anxiety r/t lack of knowledge about cardiac catheterisation but NOT anxiety r/t cardiac catheterisation. • Identifying a client’s problem rather than the nursing intervention. For example, say diarrhoea r/t food intolerance but not offer bedpan frequently because of altered elimination pattern

11. Identifying a client’s problem rather than the goal. For example, say imbalanced nutrition: less than body requirements r/t inadequate protein intake, but not client needs high protein diet related to potential alteration in nutrition. • Avoiding legally inadvisable statements. You can say chronic pain r/t improper use of medication, but not recurrent angina related to insufficient medication. • Identifying only one problem in the diagnostic statement.

12. Planning • In this phase, client-centred goals and interventions to achieve them are designed. • Planning requires decision-making and problem-solving skills to design nursing care. • In this phase, the nurse should: • establish priorities • determine goals and expected outcomes • formulate a plan of nursing care

13. Establishing Priorities • Means mutually ranking nursing diagnoses in order of importance based on the client’s safety, desires, and needs. • Priorities are classified as: • High: If untreated, harm could result, or progress to achieve outcomes will be deterred. They can be both psychological and physiological. • Intermediate: Non-emergent, non-life-threatening needs • Low: May not be directly related to a specific illness or prognosis but may affect the client’s future well-being.

14. Priority Setting Nursing DiagnosisRationale High Priority Ineffective coping r/t anxiety about Prompt intervention will help client unknown medical diagnosis prepare for and cope with a diagnostic test, treatment, or Dx. Ineffective airway clearance after Due to the risk of postop. surgery r/ t abdominal incision pain pulmonary complications, preventive pt. education will begin early. Intermediate Priority Imbalanced nutrition: less than body This nursing diagnosis does not requirements r/ t chronic diarrhea affect the client’s immediate phys- iological or emotional status. Low Priority Deficient knowledge regarding This diagnosis reflects client’s smoking cessation programmes long-term needs.

15. Goals and Expected Outcomes • Refer to specific statements of client behaviour or responses a nurse aims to achieve as a result of nursing care. • Are formulated after establishing priorities. • A goal is specific and measureable behaviour or response that reflects the client’s highest possible level of wellness and independence in function. • An expected outcome is the measureable, specific, step-by-step objective that leads to attainment of the goal and the resolution of the aetiology for the nursing diagnosis.

17. Formulating a Plan of Nursing Care • This means selecting appropriate nursing interventions. • This selection is a decision-making process; interventions should successfully meet the established goals and expected outcomes. • Interventions selection requires the nurse to have knowledge of the scientific rationale for the intervention, to possess psychomotor and interpersonal skills, and to be able to function within a particular setting and use available resources.

18. Nursing Care Plan • Is composed of nursing diagnostic statement, goals, expected outcomes, and specific nursing activities and interventions. • Coordinates nursing care, promotes continuity of care, and lists outcome criteria to be used in the evaluation of nursing care. • Decreases the risk of incomplete, incorrect, or inaccurate care.

19. Implementation • Refers to the initiation and completion of nursing actions necessary for achieving the goals and expected outcomes of nursing care. • Implementation includes interventions for performing, assisting, or directing the performance of ADL; counselling and teaching; providing direct care; delegating, supervising, and evaluating the work of other nurses; and recording and exchanging information relevant to client care.

20. Implementation Skills • Cognitive skills: involve application of nursing knowledge. • Interpersonal skills: these are essential for nursing practice. They are built on trusting relationship and clear communication. • Psychomotor skills: require the integration of cognitive and motor activities, such as learning to give an injection. In this regard, the nurse must understand anatomy and pharmacology (cognitive) and the mechanics of preparing and giving an injection (motor).

21. Types of Nursing Interventions

22. Evaluation • Is concerned with two aspects of nursing care: • Evaluate the client’s response to nursing care. Questions to consider are: “Was the intervention effective in improving the client’s level of health or functional status?”, “Did the client benefit?”. • Evaluate if the client’s expectations of care were met. Questions to ask include: “Did you receive the type of pain management you expected?”, “Did you get enough information to help you manage your asthma at home?”. • Could be positive when the desired results are met, indicating that the nursing intervention effectively met the client’s goal of improved comfort. • Could be negative indicating that the intervention was not effective was not effective in minimising or resolving the actual problem or avoiding a potential problem.