The Nursing Process

Evaluative measures are skills and techniques used to assess if the patient's known problems have improved, worsened, or otherwise changed.

Assessment measures are performed at the point of care when problems are being identified. Evaluative measures are performed at the point of care when changes to the problem are identified.

Planning.

Interventions may be across disciplines, and are used to attain goals specific to the nursing diagnosis.

• Focus on the client
• Address only one goal or outcome
• Develop outcomes that are observable
• Write outcomes that can be measured
• Clearly state time frame
• Consult with the client
• Be realistic

1. Independent nursing interventions (aka nurse-initiated interventions) - actions that a nurse initiates without direction from a physician or other healthcare professional.

2. Dependent nursing interventions (aka physician-initiated interventions) - actions that require an order from a physician or another healthcare professional

3. Collaborative interventions - therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

Implementation

• Reassessing the client
• Organizing resources and care delivery
• Anticipating/preventing complications
• Communicating nursing interventions

• Cognitive skills - involve application of critical thinking
• Interpersonal skills - involves devloping a trusting relationship with the pt, expressing a level of caring, and communicating clearly with the pt & their family
• Psychomotor skills - involves the integration of cognitive and motor activities. (ex: you must understand anatomy (cognitive) and practice good coordination & precision (motor) when giving an injection.)

Evaluation (final step) - measures the pt's response to nursing actions and the client's progress toward achieving goals.

the specific, step-by-step objective that leads to attainment of the goal and the resolution of the etiology for the nursing diagnosis.

Short term goal - objective behavior or response that is expected to be achieved in a short period of time, usually less than a week. (ex: Client's level of comfort will improve before surgery)

Long term goal - objective behavior or response that is expected to be achieved over a longer period of time, usually over weeks or months. (ex: Patient will be tobacco-free within 60 days)

A specific and measurable behavior or response that reflects the client's highest possible level of wellness and independence in function

• Set priorities
• Determine goals
• Develop expected outcomes
• Formulate a plan of care

• Avoid legally in advisable statements
• Identify the problem and etiology
• Identify only one client problem in the diagnostic statement

During data collection, data clustering, data interpretation, and statement of the nurs. diag.

• Actual nursing diagnosis
• Risk nursing diagnosis
• Health Promotion nursing diagnosis
• Wellness nursing diagnosis

• Nursing diagnosis - the nurse can legally order the primary interventions to achieve the goal for the pt
• Collaborative problem - nursing interventions AND medical interventions are needed to achieve the goal for the pt

the indentification of a disease condition based on a specific evaluation of physical signs, symptoms, patient's medical history, and the results of diagnostic tests and procedures.

Standard nursing diagnostic statements endorsed by the North American Nursing Diagnosis Association

Actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status

• Identification of specific client responses to health care problems
• Clinical judgment about individual, family, or community responses to actual and potential health problems or life processes.

Compare it to other records to determine data accuracy

• Subjective - what the pt tells you/ what you cannot physically see or assess yourself
• Objective - an assessment you can make during a physical exam

• Primary source - the patient
• Secondary source - the pt's family, records, physician, etc.

Determining if goals were met and outcomes achieved

Performing the nursing actions identified in "Planning"

• Set goals of care and desired outcomes
• Identify appropriate nursing actions

Identifying the client's problems

Gathering information about the client's condition

• Assess
• Diagnose
• Plan
• Implement
• Evaluate

to diagnose, and to treat human responses to actual or potential health problems

Incomplete, incorrect, or inaccurate care

A written guideline for client care used by all members of the nursing team. It coordinates nursing care, promotes continuity of care, and lists outcome criteria to be used in the evaluation of nursing care.

A nursing care plan

• A gathering of data that is diagramed out to show all they all relate.
• A visual representation of client problems that show relationships to one another.
• Groups and categorizes nursing concepts for a holistic view of healthcare needs.

A treatment plan that outlines the interventions of each health care discipline, including hour-to-hour care (or daily) of certain procedures, consults, and other activites. It ensures better continuity of care by clearly mapping out the responsibilities of different staff.

The nurse who writes the care plan leaves it for the next shift nurse. She will then work on whatever interventions or tasks are appropriate for that shift.

• A care plan is modified if a goal has not been met or if a new problem has arisen. Reassessment of the patient is appropriate and critical thinking must be used to develop new interventions according to the new care plan.
• A care plan is discontinued if all expected outcomes and goals are met. You must confirm this evaluation with the patient and come to an agreement.
• Documentation is very important when changing or discontinuing a care plan. Any reassessment data should be recorded. A care plan must be very accurate and current to ensure appropriate continuity of care.