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2. Briefly describe one of your patients/clients who had a
medical prognosis that was “negative,” but a nursing prognosis that
was “positive.” Why?
Describe one of your patients/clients who had a medical prognosis
that was “positive” but a nursing prognosis that was “negative.”
OF THE NURSING PROCESS
A systematic, rational method of planning and providing individualized nursing care.
CHARACTERISTICS OF THE NURSING PROCESS
The nursing process:
Is open and flexible to meet the unique needs of client, family, group, or community.
Is cyclic and dynamic; there is no absolute beginning and end.
Is client-centered; it individualizes the approach to a client’s particular needs.
Is interpersonal and collaborative; it requires direct and consistent communication.
Permits creativity for both nurse and client in devising solutions to problems.
universally applicable to all clients and health care settings
OF THE NURSING PROCESS
The nursing process has evolved as various nurse theorists and organizations wrote about the
1952, Peplau (a psychiatric/MH nurse) identified four sequential
phases related to personal therapeutic interactions: (1) orientation,
(2) exploitation, (3) resolution.
1955, Hall originated the term nursing
1959, Johnson described the steps as (1) assessing situations, (2)
decision making, (3) implementation of actions to resolve problems,
1961, Orlando (a psychiatric/MH nurse) described three phases: (1)
client’s behavior, (2) reaction of the nurse, (3) nursing actions.
1963, Wiedenbach described the steps as (1) identify help needed, (2)
minister help, (3) validate help given.
1967, Knowles described the “five Ds”: (1) discover, (2) delve,
(3) decide, (4) do, (5) discriminate.
1967, Western Interstate Commission on Higher Education (WICHE)
described the steps as (1) perception and communication, (2)
interpretation, (3) intervention, (4) discrimination.
1967, Catholic University of America described four components: (1)
assessing, (2) planning, (3) interventions, (4) evaluation.
1971, Orem described three steps: (1) initial and continuing
determination of need for nursing care, (2) designing nursing actions
that will contribute to client’s achievement of health goals, (3)
initiating, conducting and control of assisting actions.
1973, the ANA Standards of Nursing Practice identified five steps: (1)
assessing, (2) diagnosing, (3) planning, (4) intervention, and (5)
In 1975, Gebbie and Lavin instituted the first national conference on classification of nursing diagnoses, which led to the use of the five step nursing model: (1) assessment, (2) nursing diagnosis, (3) planning, (4) intervention (5) evaluation.
The collection, organization, validation, and recording of data.
ELEMENTS OF ASSESSMENT
Collecting data—the process of gathering information about a client’s condition.
Organizing data—the process of organizing data using an assessment framework that allows the establishment of patterns and priorities for care.
Non-nurse models: EX: Maslow’s hierarchy of needs.
Nurse models: EX: Gordon’s functional health pattern framework.
theorist models: EX:
Orem’s Self-Care model or Roy’s Adaptation model.
Validating data—the process of verifying data for accuracy:
Compare subjective and objective data for consistency.
Clarify ambiguous or vague statements.
Use cues (direct observations) not inferences (conclusions).
Re-check data that is extremely abnormal.
Determine factors that may interfer with accurate measurement.
references (texts, journal reports) to explain phenomena.
process of accurately documenting the data.
OF NURSING DIAGNOSES
Nursing Diagnosis--A clinical judgement about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide for the selection of nursing interventions to achieve outcomes for which the nurse is accountable.
Wellness Diagnosis--A clinical judgement about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness (NANDA, 1990).
HISTORY OF NURSING DIAGNOSES
1973, the First Task Force to Name and Classify Nursing Diagnoses met
and the Clearinghouse for Nursing Diagnosis was established at St. Louis University.
1977, a nurse theorist group (Callista Roy, Margaret Newman, Martha
Orem, Imogene King) presented an organizing framework for nursing diagnoses called Patterns of Unitary Man (Humans) to the nursing diagnosis organization.
1982, the North American Nursing Diagnosis Association (NANDA) was
1987, Taxonomy I (list of
nursing diagnoses) was published.
In 2000, Taxonomy II (updated list of nursing diagnoses) was published.
nurse can submit a possible new diagnosis or revision of a current
diagnoses undergo a systematic review to determine consistency with
established criteria for a nursing diagnosis.
must include the label, definition, and an integrative review of the
literature describing the defining characteristics.
diagnostic label approved by NANDA includes a definition,
etiology/related factors, and defining characteristics.
OF A NURSING DIAGNOSTIC LABEL
state in which an individual has insufficient psychological or
psychological energy to endure or complete required or desired
Major (must be present)
Minor (may be present)
OF NURSING DIAGNOSES
nursing diagnosis is a judgment made after thorough, systematic data
diagnoses relate to independent nursing functions (areas of health
care that are unique to nursing and separate and distinct from medical
management). Nurses are
also obligated to carry out physician-prescribed therapies and
treatments (dependent nursing functions).
Nurses carry out some dependent functions, such as using
analgesics for pain, but will also use independent nursing interventions for alleviating pain.
nurses are responsible for making nursing diagnoses, even though other
nursing personnel may contribute data to the process and may implement
diagnoses describe a continuum of health states (a) actual health
problems, or deviations from health; (b) potential health problems
(presence of risk factors that predispose persons and families to
health problems; and (c) healthy responses (areas of enriched personal growth).
domain of nursing diagnoses includes only those health states that
nurses are able and licensed to treat.
diagnoses involve human responses that vary greatly from one person to
the next, and a single nursing diagnosis may occur as a response to
any number of diseases.
diagnoses are oriented toward the individual (in contrast to a medical
diagnosis which is oriented to the pathology).
diagnoses change as the client’s responses change (in contrast to
the medical diagnosis which remains constant throughout the duration
of the illness).
diagnoses have no universally accepted classification system although
this systemis being developed. Medicine,
on the other hand, has a well developed classification (code) system
accepted by the profession and by third party payers.
JCAHO currently requires evidence of nursing diagnoses in client records.
TYPES OF NURSING DIAGNOSES
Actual diagnosis—a clinical judgment about a client’s response to a health problem that is present at the time of the nursing diagnosis.
clinical judgment that a client is more vulnerable to develop
than others in the same or similar situation.
type of potential risk/problem.
NOTE: The PES format (see below) is not used for collaborative problems because they are potential problems.
problems tend to be present any time a particular disease or treatment
is present, that is, each disease or treatment has specific
complications that are always associated with it.
problems require both medical and nursing interventions.
nursing interventions focus on monitoring the client’s condition and
prevention of potential complications.
clinical judgment about a health problem that is unclear or the
causative factors are unknown.
clinical judgment indicating a healthy response of a client who
desires a higher level of wellness.
OF A NURSING DIAGNOSIS
Problem Statement (P) (also known as the Diagnostic Label)
Describes the client’s health problem or the response for which therapy is given.
Directs the formation of client goals and outcome criteria.
include qualifiers to give additional meaning to the diagnostic
label—altered, impaired, decreased, ineffective, acute, chronic.
Etiology (E) /Related Factors
one or more probable causes of the health problem--“related to…”
include client behaviors, environmental factors, or interactions
between the two.
direction to the nursing interventions; different etiologies require
the nurse to individualize care.
factors—describe the etiology or likely cause of actual nursing
factors—describes the etiology of potential nursing diagnoses; there
are no subjective and objective signs present.
Defining Characteristics (also known as Signs/Symptoms (S)
of signs and symptoms that indicate a particular diagnostic
Major—those signs/symptoms that must be present for
Minor—those signs/symptoms that may or may not be present for a valid diagnosis.
Actual nursing diagnoses—the defining characteristics are the client’s signs and symptoms.
Risk nursing diagnoses—the defining characteristics are the same as the etiology, indicating the client is more than “normally” vulnerable to the problem.
THE DIAGNOSTIC PROCESS
data against standards (identifying significant cues).
data either inductively or deductively
(generating tentative hypotheses).
gaps and inconsistencies.
Part Statements (P)—used for wellness
“Potential for enhanced” followed by desired higher level wellness
for enhanced parenting…”
Part Statements (PE)—used for risk
nursing diagnoses that are NOT “usual”.
(P)—“Risk for infection…
(E)—related to recent radiation therapy” (but patient was
admitted for GI bleeding).
Three Part Statements (PES)--used for actual nursing diagnoses
(E)—related to prolonged bedrest...
Signs/Symptoms (S)—manifested by weakness and fatigue.”
Collaborative Problem Statements—used for potential problems that are “usual”.
NOTE: The PES format is not used for collaborative problems because they are potential problems.
disease or treatment plus the possible complication the nurse is
“Potential complication of head injury: Increased intracranial pressure.”
diagnoses are grouped according to high, medium, or low priority.
threatening conditions (EX: loss of respiratory function).
threatening conditions (EX: acute illness).
developmental needs or minimal nursing support.
a nursing theoretical framework (Orem, Roy) makes priority setting
CORRECT VS. INCORRECT DIAGNOSTIC STATEMENTS
(need) related to fever.
(problem) related to fever.
related to improper positioning (implies liability).
related to immobility (legally acceptable).
related to strict rules necessitating church attendance
related to inability to attend church services (nonjudgmental).
ineffective airway clearance
related to emphysema (medical terminology).
ineffective airway clearance
related to accumulation of secretions in lungs (nursing
related to laryngectomy (nurse can do nothing about the laryngectomy).
related to loss of speech (loss of speech provides the nurse with
direction for planning alternative communication methods).
authors add an additional step (prognostic phase) between the diagnostic
and planning phase.
OF NURSING PROGNOSIS
Prognosis—A prediction of the possible or probable course of events and outcomes associated with a particular health status or situation under various treatment options or lack of treatment.
OF A NURSING PROGNOSIS
A nursing prognosis is similar to a medical prognosis in that it precedes treatment decisions, but it differs from a medical prognosis in that prognostic data relate to the client’s functioning capacities.
Nursing prognoses deal with the likelihood that the client and his/her support system will be able to respond in such a way that:
well-being, and effective functioning are promoted.
Daily living is as effectively managed as capacities, external
resources, and daily living permit.
resulting quality of life is satisfying.
Prognostic terms include resolution, stabilization, progression, continuation, good, poor, etc.
If nursing prognoses are contingent on a variety of uncertain variables—if, then are used.
COMPONENTS OF A NURSING PROGNOSIS
Examples of variables are the client age, general health, effects of health problem and treatment, functional capacity for ADL, demands placed on support system, health care resources, etc.
predict success, failure, or some improvement.
or avoidance of a problem.
of the problem or dysfunction.
of the diagnosed problem.
of a problem that will continue.
requiring palliative treatments.
with the course of events as well as the outcomes.
Consideration of what is expected to happen, direction of the change, and the pattern or rate of change.
Used as a basis for setting
realistic goals and evaluating responses to nursing interventions.
The phase of the nursing process that involves decision-making and problem solving.
Setting Priorities—the process of establishing a preferential order for nursing strategies.
may be partially and concurrently addressed by nursing strategies.
Priorities do not remain fixed; they
change as the client’s responses change.
Also known as outcome criterion, objective, predicted outcome or outcome identification. Well-stated goals/expected outcomes are:
Derived from the first clause of the nursing diagnosis.
Possible to achieve.
Stated in terms of client responses, not nursing activities.
Statements of one specific response or behavior.
Specific and concrete.
Measurable, that is, the outcome can be seen, heard, or felt--even by another nurse.
Valued by the client and family.
Compatible with other therapies.
Goals—a broad statement. EX: “The client’s nutritional status will improve.”
Goals are derived from the nursing diagnosis. If the nursing diagnoses is “Fluid volume deficit…”, then the goal statement is “The client’s fluid volume will be restored…”
Goals can be long term (chronic conditions) or short term (acute conditions).
Specific expected outcome MUST follow a goal.
The phrase that points to the expected outcome is “as evidenced by…”
EX: “as evidenced by
moist mucous membranes by 11/05/01.”
Components of Goal/Expected Outcome Statements
Subject (noun)—is the client. (EX: “The client will…”)
Verb—an action the client will do, learn, experience. (EX: “demonstrate…”)
Condition/Modifier—explains the circumstances under which the behavior is to be performed (what, where, when, how). (EX: “correct crutch walking…”)
Criterion of desired performance—the standard or level (evidence) by which the performance is evaluated (time, speed, accuracy, distance quality) (EX: “as evidenced by accurate positioning of hands and legs while crutch walking in the hallway.”
Selecting Nursing Strategies
For “actual” nursing diagnosis, the focus is on interventions to eliminate or reduce the etiology found in the nursing diagnostic statement.
For “potential” nursing diagnosis, the focus is on interventions to reduce the client’s risk factors (also found in the etiology of the nursing diagnostic statement).
Developing Nursing Care Plans
May be pre-planned and pre-printed (standardized), computerized, or completely handwritten. Standardized plans of care:
Ensure that minimally accepted standards of care are provided.
Promote efficient use of nurses time by eliminating repetition in writing.
Must be individualized to the patient.
BETWEEN NURSING DIAGNOSIS,
CLIENT GOALS AND OUTCOME CRITERIA
peripheral tissue perfusion (left leg) related to impaired
arterial circulation manifested by cool skin temperature,
decreased left popliteal and pedal pulses, capillary refill < 3
client will have improved peripheral tissue perfusion in left leg
and foot as evidenced by…
related to outcome of cardiac catheterization manifested
by sleeplessness, repeating same questions about procedure.
client will have decreased fear as evidenced by…
Consists of doing, delegating, and recording.
Reassessing the Client
Determining the Need for Nursing Assistance (to carry out the plan)
Implementing Nursing Strategies
Most be specific as to what, where when, and how so that subsequent nurses can carry out the plan.
Subject (noun)—is the nurse. (EX: “The nurse will…”)
Verb—an action the nurse will do.
(EX: “encourage 300cc/fluid q 8 hours…”
Communicating Nursing Actions
data—must be up to date, accurate, and available to other nurses.
data—used with rapid changes in the client’s condition, change of
shift, transfers, and discharges.
INTERVENTION CLASSIFICATION (NIC)
classification system consisting of 6 domains and 27 classes (433
intervention label includes a definition and list of all the specific
activities nurses perform to carry out interventions.
nurse chooses from the list of activities and individualizes them to the
and analysis of client data to ensure airway patency and adequate
of Nursing Intervention Classification (NIC)
in demonstrating the impact nurses have on the health care delivery
and defines the knowledge base for nursing curriculi/practice.
the appropriate selection of a nursing intervention.
communication of nursing interventions to other health care providers.
researchers to examine the effectiveness and cost of nursing care.
educators to develop curricula that articulates with clinical practice.
teaching of clinical decision making to novice nurses.
administrators in planning more effectively for staff and equipment
the development of a reimbursement system for nursing services.
the development and use of nursing information systems.
the nature of nursing to the public.
DEFINITION OF EVALUATION
Process of making judgments on goals/expected outcomes.
TYPES OF CLIENT EVALUATION
while or immediately after doing an intervention.
at specific intervals and shows extent of progress toward goal.
the client’s condition at the time of discharge.
OF CLIENT EVALUATION
in planning phase.
subjective and objective data, so that conclusions can be drawn.
outcome was completely, partially, or not met.
Nursing Actions to Outcome—nursing
interventions may need to be modified.
Conclusions about Problem Status—
EVALUATING QUALITY OF NURSING CARE
Quality assessment—examination of services only.
Quality assurance—implies evaluation of and assurance of quality health care.
of Evaluation for Nursing Care
of objective criteria to evaluate a client’s record after discharge.
review of patients’ charts to evaluate nursing competency or performance (required for JCAHO).
review organization (PRO)—develop
standards and monitoring the quality of, cost of, and access to care
(required for Medicare/Medicaid).
person equal in education, abilities, and qualifications who critically reviews the practices that the other has documented in a client’s
to Evaluating Nursing Care
on the organization/administration of the patient care system.
on the activities of the nurse or the nurse performance.
on the outcomes related to a client’s health status, welfare, and
satisfaction in terms of changes for the client.