Transcript Application of Nursing Process and Nursing Diagnosis: An

Chapter 4
The Planning Step:
Creating the Plan of Care
The Planning Step
Planning: Third step of the nursing process,
during which goals/outcomes are determined
and interventions chosen
The Planning Step
 Plan of Care: Written evidence of the
second and third steps of the nursing
process that identifies the client’s needs,
goals/outcomes of care, and interventions
to treat the needs and achieve the
outcomes
Setting Priorities for Patient Care
 Starts with ranking the client’s needs
 Maslow’s hierarchy of needs is a useful
framework for this process
Maslow’s Hierarchy of Needs
Establishing Client Goals
 Once you have prioritized client needs, establish
the goals for treatment/discharge.
 Goals (used broadly):
Guidelines indicating the overall direction for
movement as a result of the interventions of the
healthcare team
Establishing Client Goals
 Long-Term Goals: Those
goals that may not be
achieved before
discharge from care but
may require continued
attention by the client
and/or others
 Short-Term Goals:
Those goals that usually
must be met before
discharge or movement to
a less acute level of care
Identifying Desired Outcomes(Goals)
The next step is to determine specific outcomes—
 Defined as client responses that are achievable and
desired by the client
 Can be attained within a defined period given the present
situation and resources
 Are the desired results of actions undertaken
 Are measurable steps toward achieving the
treatment/discharge criteria established earlier
Identifying Desired Outcomes
Outcome statements need to:
 Be specific
 Be realistic
 Consider the client’s circumstances and
desires
 Indicate a definite time frame
 Provide measurable evaluation criteria for
determining success or failure
Identifying Desired Outcomes
 Desired outcomes are written by listing
items/behaviors that can be observed and
monitored to determine whether a
positive/acceptable outcome has been
achieved within the indicated time frame
 This itemized listing of outcomes serves as the
evaluation tool
Identifying Desired Outcomes
 When outcomes are written properly, they
provide direction for planning and validating the
choice of appropriate nursing interventions
 All outcomes should tell the reader specifically
what the client is working on or doing
PLANNING
 Clarifying expected outcomes/goals
 Always start with “the patient…”
 Measuring sticks for success of plan
 Direct interventions
 Provide time frame to motivate those involved
 USE INDICATORS – THESE HELP MAKE
OUTCOMES SPECIFIC!
PLANNING
 Outcome statements:
 Specific to patient!
 Subject (ex. Patient)
 Verb (measurable verb)
 Condition (if necessary)
 Criteria (ex. 50% of meal, for ½ hour, etc.)
 Target time (by when!!!!)
PLANNING
 The patient will report a reduction in frequency of
stools to <3/day by 11/2/07.
 Patient will exhibit balance of fluid volume by
intake equal to output within 1 week.
 Patient will demonstrate ability to transfer from
bed to wheelchair without assistance in 3 days.
Selecting Appropriate Nursing
Interventions
 Nursing interventions:
Any direct care treatment that a nurse performs
on behalf of a patient, including nurse- and
physician-initiated treatments, and provision of
essential daily functions for the patient who
cannot do them
YOUR NURSING CARE
Selecting Appropriate Nursing
Interventions
 Nursing interventions are prescriptions for
behaviors, treatments, activities, or actions that
assist the client in achieving the expected
outcomes
Selecting Appropriate Nursing
Interventions
Nursing interventions need to be based on:
 The nursing diagnosis
 The desired outcomes
 The ability of the nurse to implement the
intervention
 The ability and willingness of the client to
undergo the intervention
 The appropriateness of the intervention
Selecting Appropriate Nursing
Interventions
Interventions must:
 Be age-/situation-appropriate
 Promote identified client strengths, when
possible
Selecting Appropriate Nursing
Interventions
 Nurses are accountable for being current and
accurate in identifying interventions
 Nursing standards and agency policy must also
be considered when choosing specific
interventions
Sample Interventions (Nursing Orders)
 Obtain weight each day before breakfast
 Keep HOB elevated >30 degrees at all times
 Refer patient to social service to ensure
continued care.
Sample Interventions
 Keep all necessary objects on patient’s right
side.
 Administer O2 @ 2L/min via NC to maintain
pulse ox >93%
 Instruct patient not to strain for bowel movement.
The Client Plan of Care
The client plan of care is written to:
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Provide continuity of care
Enhance communication
Assist with determining agency or unit staffing needs
Document the nursing process
Serve as a teaching tool
Coordinate care among disciplines
Discharge Planning
 Begins when the client enters the healthcare
setting
 Nurse is responsible for planning continuity of
care
 between nursing personnel
 between services within the care setting
 between the care setting and the community
Documenting the Plan of Care
 The format for documenting the plan of care is
determined by agency policy
 Whatever the format, the plan of care must
reflect basic nursing standards of care
 Personal client data, nonroutine care, and
qualifiers such as time or amount are added as
appropriate
Documenting the Plan of Care
 Clinical pathways: A type of abbreviated plan
of care providing outcome-based guidelines for
goal achievement within a designated length of
stay
 Mind mapping: A care-planning technique
using a graphic representation to visualize the
interconnections among all the components of
client care
Validating the Plan of Care
Review the plan of care to ensure that:
 It is based on accepted nursing practice
 It provides for the safety of the client
 Nursing diagnostic statements are supported by
patient data
Validating the Plan of Care (cont.)
 Review the plan of care to ensure that:
 Goals and outcomes are measurable
 The interventions can benefit the client and are
logically sequenced
 It demonstrates individualized client care
Chapter 5
The Implementation Step:
Putting the Plan of Care into Action
The Implementation Step
 Implementation: Fourth step of the
nursing process, in which the plan of care
is put into action; performing identified
interventions/activities
Identifying Caregiving Priorities
 No plan of care can predict everything that
will happen with a client.
 Your individual knowledge base, expertise,
and recognition of agency routines allow
you to adapt to the changing needs of the
client/situation.
IMPLEMENTATION
 Getting Report
 Prep – look up info, read chart, arrive early, etc.
 Use worksheets to organize info.
 Taped reports can be reviewed as needed.
Setting Daily Priorities
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Make initial rounds
Verify critical information
Identify urgent problems
Determine which problems to handle
Determine interventions
What can the patient do? What can be
delegated?
 Make (and follow) a worksheet
Assessing appropriateness of delegated
interventions
 Delegation does NOT change responsibility.
 Appropriate tasks
 Patient condition
 Always remember your practice standards
Ethical and Legal Concerns
 The wishes of the client and
family/significant others about what is
being done need to be discussed and
respected.
Delivering Nursing Care
 Interventions may be composed of many
activities ranging from simple tasks to
complex procedures.
Performing Interventions/ Reassessing
 Always assess before and after interventions
 Use each encounter as an opportunity
 Preparation!
 Know what you need to do
 Know policies/procedures
 Dealing with problems
 KNOW THE RATIONALE BEHIND THE ACTION!
Ongoing Data Collection
 Monitor the client to collect additional data.
 This information will be used to make
decisions about the need for new
outcomes, and interventions and to reprioritize the plan of care.
Documentation
 It is legally required that all healthcare settings
document nursing observations, the care
provided, and the client’s response.
 Many agencies use flow sheets to document
routine activities, monitoring, and ongoing client
care.
Charting
 Assessment-Interventions-Responses
 Purpose of charting:
 Communicate care
 Help identify patterns
 Provide basis for evaluation (quality)
 Create a legal document
 Supply validation for insurance
Charting
 Principles:
 INITIAL and ongoing assessments
 Interventions and nursing care performed
 Patient RESPONSE
 All charting should reflect nursing process.
Charting
 Guidelines
 Chart as soon as possible
 Follow facility policy
 Reflect
 Record important action immediately
 Record ALL variations from norm
 Precise
 Focus on significant events
 Stick to facts
 Sign
Verbal Communication with the
Healthcare Team
 The way information is conveyed can affect the
way the information is heard and the quality of
the healthcare provided.
 Avoid judgmental language.
 Be conscious of your tone of voice and body
language.
 Present information in an objective and accurate
way.
Verbal Communication with the
Healthcare Team
Change of shift report includes:
 Basic client data
 Abnormalities/changes in assessment findings
 Diagnostic procedures and results
 Variations from usual routine
 Activities not completed on your shift
 Status of invasive treatments
 Additions or changes to the plan of care
Verbal Communication with the
Healthcare Team
 Client confidentiality is an ethical/moral concern
that must be respected by each professional at
all times.
 This requirement extends to conversations
 at the nursing station
 on the telephone
 wherever client information is discussed
Chapter 6
The Evaluation Step:
Determining Whether Desired
Outcomes Have Been Met
The Evaluation Step
Evaluation: Final step of the nursing process
 An interactive process
 Essential to ensuring quality care
 Done by reviewing client responses
The Evaluation Step
Focus is on:
 Appropriateness of the care provided
 Client’s progress (or) lack of progress toward
desired goals
The Evaluation Step
Three components:
 Reassessment
 Modification of the plan of care
 Termination of services
Reassessment
 An ongoing “measuring and monitoring”
of the client’s status and response to nursing
interventions
Reassessment
Determines:
 Appropriateness of nursing actions
 Need to revise interventions
 Development of new client needs
 Required referrals
 Need to rearrange priorities
Reassessment
Outcomes/Goals may be evaluated by:
 Direct observation
 Client interview
 Review of records
Reassessment
When an outcome is not met completely, ask:
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Were the outcomes realistic and appropriate?
Was the client involved in setting the outcomes?
Does the client believe the outcomes were important?
Does the client know why the outcomes have not been
met?
 Have all the identified interventions been carried out?
 What variables may have affected achievement of the
outcomes?
 Were new needs/adverse client responses detected
early enough to make appropriate changes?
Modification of the Plan of Care
When the client’s condition has changed in an
anticipated or unanticipated direction:
 A change in treatment approach is indicated
 The plan of care must be modified to reflect these
changes
Modification of the Plan of Care
 When revising outcomes, remember that they
may simply need to be restated or have their
time frames lengthened.
Modification of the Plan of Care
Patient care conference—
 Often “multi-disciplinary”
 Chance to address the changing needs of the
client/significant others
 Opportunity to gain additional insights and problem-solve
solutions
Termination of Services
 Focus is on how the client will manage on his or her own
 It is possible that not all goals/outcomes will be met
before discharge
Termination of Services
 Unmet goals/outcomes are reviewed and the reasons
documented
 The discharge plans are finalized and put into action
Termination of Services
Discharge summary
 Documents findings and client
instructions/recommendations
 Client is given a copy
 May be shared with the home health nurse/primary
healthcare provider
Enhancing Delivery of Quality Care
 This is the key to:
 Refining standards of care
 Determining agency protocols, policies, and
procedures
 The provision of evidence-based nursing care
Chapter 7
Documenting the Nursing Process
Role of Documentation
 A requirement for accreditation
 A legal requirement
 A record of the use of the nursing process for the delivery
of individualized client care
Progress Notes
Progress notes should:
 Include all significant events
 Be clear and objective
 Reflect progress toward outcomes
Progress Notes
7 Functions
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Staff documentation
Evaluation
Relationship monitoring
Reimbursement
Legal documentation
Accreditation
Training and supervision
Progress Notes
Staff Communication
 Colleague-to-colleague
 Among nurses
 Between the nursing staff and other healthcare
providers
Progress Notes
Evaluation
For the purposes of review, the medical record
should:
 Be written to facilitate an assessment of the care
provided
 Serve as a method of tracking the client’s response to
treatment
 Be a means for evaluating the quality of care
Progress Notes
Relationship Monitoring
 Nurse/client relationship is a therapeutic relationship built
on a series of interactions.
 Notes detailing observations and monitoring of the
client’s interactions are an important component of
nursing care.
Progress Notes
Reimbursement
 The medical record provides proof of services.
 Absence of such documentation may result in termination
of funding or treatment.
 Ex: MDS (Minimum Data Set) – required in long term care.
Info must be reflected throughout notes.
Progress Notes
Legal Documentation
 All aspects of the medical record may be important for
legal documentation
 Notations need to be—
 written in permanent ink/computer-entered
 specific about date and time
 signed by the person making the entry
Progress Notes
Legal Documentation
 An error must be—
 crossed out with one line
 still legible
 identified as an “error”
 initialed by the author
 White-outs are not acceptable
Progress Notes (Legal Documentation)
 If reported, record it!
 Follow policies/procedures of your facility
 Written: ink, legible, on-time, ONE LINE THROUGH
MISTAKES! –
 ….even better: GET IT RIGHT THE FIRST TIME.
 Computer: Must know procedure for documentation
(and correction of error!)
 Chart objectively, quotes for subjective data.
 Coherent, defensible
Guidelines: How to chart
 Stick to the facts – see, hear, smell, feel, measure,
and count.
 Avoid labeling – objective description.
 Be specific – avoid “adequate” or “good”
 Use neutral language – nothing inappropriate!
 Eliminate bias – avoid negative reference.
 Keep record intact – never discard original, even if
damaged. (Attempts to delete electronic records
usually flagged)
RED FLAGS IN CHARTING
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Improper corrections
Missing dates, times, or pages
Out of sequence
Additions added incorrectly
Additions in different handwriting/ink
 Examples of spelling errors:
 “Walk patient in hell”
 Pt. appears to be seeping quietly”
 Foley draining fowl-smelling urine”
Techniques for Descriptive Note Writing
 Notes must give the reader a clear picture of
what occurred with the client
 To ensure clarity, use descriptive (or
observational) statements
 Avoid use of judgmental language
Judgmental Language
 Statements of opinion
 Open to varying interpretation
 Lack supporting data
Judgmental Language
Types of judgmental statements include
phrases that:
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Make reference to undefined time periods
Refer to undefined quantities
Refer to qualities
Fail to specify any objective basis for the
judgment made
Descriptive Note Writing
Undefined Periods of
Time
 Statements that refer to
undefined periods of time
without clarification may leave
the statement unclear and
judgmental.
Watch for words such as:
 often
 rarely
 seldom
 almost always
 frequently
 occasionally
 most of the time
Techniques for Descriptive Note Writing
Undefined Quantities
 Statements that refer to
undefined quantities may be
open to interpretation.
Watch for words such as:
 some
 a lot
 enough
 many
 a great deal
 very little
 too much
Techniques for Descriptive Note Writing
Watch for words such
as:
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passive
nervous
Demanding
irritating
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manipulative
alcoholic
incompetent
disturbed
Descriptive Note Writing
Qualities
 Observed behaviors may call for descriptions that are
influenced by your own biases and cultural background.
 Verify the connotations of such descriptions with others,
especially the client, before using them.
Descriptive Note Writing
Watch for words such as:
 friendly
 attentive
 aloof
 unhappy
 excited
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apathetic
enthusiastic
bored
proud
Descriptive Note Writing
Qualities
Watch for words such as:
 Slang words are unclear and
should not be contained in a
professionally written note.
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hyped-up
loose
spaced-out
pushy
cool
bummed
tanked-up
crazy
Descriptive Note Writing
Objective Basis for Judgments
 Recording your observations and giving an objective
basis for your judgment reduces the possibility of
miscommunication
 The reader will not have to look elsewhere for
clarification
Descriptive Note Writing
 Avoid statements such as:
“Michelle is improving.”
 Instead, provide an objective basis for your
judgment:
“Michelle is improving; she walked the length of the
hall using her crutches unassisted.”
Descriptive Note Writing
Descriptive Language
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Contains observations only
Avoids statements that are evaluative or judgmental
Contains measurable periods of time
Contains measurable quantities
Provides a basis or rationale for qualities named in the
note
Descriptive Note Writing
Content of Note/Entry
 As specific and accurate as possible
 Correct grammar and spelling
 Legible writing
 Abbreviations used cautiously or not at all
Descriptive Note Writing
Content of Note/Entry
 Concise, short, succinct sentences or phrases
 Redundancy avoided
 Consistent in style and format
Descriptive Note Writing
Format of note entry may vary—
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Block notes, with a single entry covering an entire shift
Narrative timed notes
Problem-oriented medical record system
Focus charting—viewing the client from a positive rather
than a problem-oriented perspective
ACTUAL NOTES (EXAMPLES)
1 . The lab test indicated abnormal lover function.
2. The patient has no previous history of suicides.
3. Patient has left white blood cells at another hospital.
4. She has no rigors or shaking chills, but her husband states she was very hot in
bed last night.
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better and on the third day it disappeared.
7. The patient is tearful and crying constantly. She also appears to be depressed.
8 The skin was moist and dry.
9. Discharge status: Alive but without permission.
10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
11. Patient had waffles for breakfast and anorexia for lunch.
12. She is numb from her toes down.
13. While in ER, she was examined, x-rated and sent home.
14. Occasional, constant infrequent headaches.
15. Patient was alert and unresponsive.
16. Examination of genitalia reveals that he is circus sized.
17. Skin: somewhat pale but present.
18. The pelvic exam will be done later on the floor.
19. Patient has two teenage children, but no other abnormalities.