April 21, 2005

NURSING PROCESS
ASSESSMENT: Purposes 1. Establishes a database about the clients perceived needs/ health problems & responses to these problems 2. Database serves as a basis for the Nursing Diagnosis & for planning individualized Nursing Care that is modified prn. 3. Utilized in the nurses collaborative roles. Definition: Purposeful systematic collection, verification, analysis, & communication of data about a clients health statue including strengths and weakness. It is both the 1st & an ongoing component of the wrong process Primary focus: clients response to Health Care concerns

Assessment Tips: 1. Nurses need to develop assessment skills so as not to miss recognizing relevant problems or dismissing relevant cues. 2. Data collected should be descriptive, concise & complete EXCLUDE interpretative statements. Two (2) Steps / Key Activities: 1. Collection & Verification of data a. Comprehensive database format Using a health history form & Gordons functional patterns b. Problem-oriented approach starts with problem area then spreads out to relevant areas 2. Analysis of the data as a basis for the Nursing Diagnosis & Planning individualized care which is modified prn. Types of DATA 2. Subjective Data also referred to as symptoms / covert data include: clients sensations, feelings, values, beliefs, attitudes and perceptions of personal health status / life situation e.g. presence of pain, meaning of an illness 2. Objective Data also referred to as signs / overt data observations or measurements made by the data collector e.g. v/s, abdominal girth, wound condition

Sources of DATA I. Primary Source: Client II. 1. 2. Secondary Source: Family & Significant Others - can be primary source of information about infants (children, critically ill, mentally handicapped, disoriented or unconscious clients) Also important secondary source of information (literature books) a. supply information about the clients current health status b. indicate when changes occurred and how the clients functioning was affected c. makes pertinent observations about the client
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3. 4. -

Health Care Team Members physicians, nurses, PT, social workers, CHW, spiritual advisers sharing of information ensures continuity of care & verification of information e.g. how the client interacts within the health care environment reaction to info. Client Records reviewing these BEFORE interviewing the client minimizes possible stress & annoyance

MEDICAL RECORDS enables the nurses to identify past & present patterns of health & illness. Other Records: - e.g. laboratory, educational, military & employment records - many contain important data such as immunizations, prior illnesses - health center records may be accessed if the client gives written permission 5. Nurses Experience

Three (3) Phases in Data Collection - Before going to the client - When you see the client interview & PE - After seeing the client obtain additional information from other sources April 22, 2005 Methods of Data Collection 1. Interview A pattern of communication initiated for a specific purpose & focused on a specific content area Purpose/Objectives: a. Establish a therapeutic relationship with the client b. Establish the nurses sense of caring for the client as an individual c. Introduce the client to the facility in a non-threatening manner d. Gain insight about the clients concerns e. Determine the clients expectations of the health care providers & the Health Care Delivery System f. Branching go to other areas Major Purposes: a. Obtain a comprehensive nursing history b. Identify health needs and risks factors c. Determine specific changes in level of wellness & patterns of living d. Help clients relate their own interpretation & understanding of their condition allow them to express their needs Preparation for the interview: a. Consider the purposes for the interview b. Collect data from all available sources c. Create a conducive environment Considerations: a. May be focused or comprehensive b. Use therapeutic communication c. Use observation skills

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d. Techniques will depend on the clients personality, health care needs, the health care setting, the nurses skill & experience Types of Interview Techniques: a. Open-ended Questions requires time, useful if you want to have descriptive data b. Back channeling start with Open-ended but back tracks to prior events c. Problem-seeking interview start of with the patients problems d. Close-ended Questions used for interviewing weak patients, less time to conduct the interview Preparation for the Interview a. Consider the purposes of the interview b. Connect data for all available sources c. Create a conducive environment Phases of the Interview: a. Orientation Phase Before beginning, review the purpose for the interview types of data needed most appropriate methods for conducting the interview expectations; duration of the interview; objectives; purpose; types of data needed; before beginning, review appropriate methods of interviewing The interview helps establish the nurse-client relationship Goal of initial interview; lay the groundwork for the nurse to understand the clients needs & begin relationship that allows the client to be an ACTIVE partner in decision making. It is important to communicate a sense of TRUST & CONFIDENTIALITY & convey PROFESSIONALISM & COMPETENCE

b. Working Phase - Use of questions & interview techniques are used to form a database - Communication strategies include: (See HC1 Resource Material) a. Silence f. stating observation b. Paraphrasing g. attentive listening c. Clarifying h. related questions d. Summarizing i. focusing e. Conveying acceptance j. offering information c. Termination Phase 2. The client is given a clue that the interview is coming to an end and in a friendly manner Allow Client to ask final questions Allow the Client to clarify anything End in a friendly manner & indicate when there will be additional contact

Physical Examination It is a systematic data collection method that uses observational skills Purposes verify information & collect more data Characteristics a. b. c. d. Systematic Skillful Thorough Minimizes client discomfort / embarrassment / anxiety

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Techniques: a. Inspection b. Palpation c. Auscultation d. Percussion 3. Results of Laboratory & Diagnostics Tests These are compared with established norms in order to: a. verify alterations identified in the nursing health history & physical examination b. Identify actual / potential health care problems not previously noted by the client or the nurse c. Evaluate the effectiveness of nursing & medical interventions Nursing Health History Definition Data collected about the clients level of wellness (past & present), family history, changes in life patterns, sociocultural history, spiritual health & mental / emotional reactions to illness Objective to identify patterns of health & illness, risk factors for physical & behavioral health problems, deviations from normal, & available resources for adaptation 1. Biographical Information demographic data that includes: Age address Occupation working status Marital status Insurance coverage 2. Reason for Seeking Health Care clients perception might differ from information contained in the admission form Identifies potential areas for education, counseling, & community resources required throughout all phases of diagnosis and recovery

3. Client Expectation a. b. c. d. e. f. client satisfaction is becoming a standard measure of quality for all hospitals; areas where clients usually have expectations: information needed to independency care for their health problems caring & compassion of Health Care Providers Timeliness of caregivers response to requests Relief of pain & symptoms Involvement in decision making Cleanliness of environment

4. Present Illness a. b. c. d. Onset when gradual / sudden Duration of Symptoms Location, Intensity, & Quality (Piercing, Stubbing, Radiating) of Symptoms Precipitating / Aggravating / Relieving Factors

5. Past Health History (asked first to address the present condition) data on clients previous health care experiences: a. Previous hospitalizations / surgery b. Allergies food, drugs, latex, pollutants (note specific reactions & treatment)

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c. Habits & Lifestyles patterns use of alcohol, tobacco, caffeine, OTC drugs, maintenance medication (type, frequency, duration of use) d. Sleep, exercise & nutrition 6. Family History to determine risk for genetic / familial disease; to identify areas of health promotion & illness It also includes information on: a. Family Structure b. Family interaction c. Family function To know the emotional and cognitive environment of the family

7. Environmental History a. b. c. d. e. f. data on home environment & support systems May include the following: Function of utilities Layout of rooms in the house Barriers / risks to client safety Exposure to pollutants Existence of crime (e.g. prevents client from walking around the neighborhood) Available resources

8. Psychosocial History includes information about ways that the client & his / her family cope with stress, & experience of recent losses (create a sense of grief)

9. Spiritual Health represents totality of ones being difficult to assess quickly This includes information on the following: a. Beliefs about life b. source for guidance in acting on beliefs c. relationship with family in exercising faith, rituals, beliefs & practices

10. Review of Systems a systematic method for collecting data on all Body Systems Gordons FUNCTIONAL HEALTH PATTERNS serve as one way to focus or organize data collection

Functional Health Patterns a. Health Perception Health Management Clients awareness of personal health & well-being; health practices; understanding of how health practices contribute to health status To assess this pattern, focus on a general survey of the clients health status and their usual health behaviors b. Nutritional Metabolic Pattern

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Patterns of food and fluid intake, relationship of intake of metabolic needs; skin assessment (inadequate intake of nutrients result to poor wound healing, inadequate fluid intake result to dry skin), fluid volume, Thermo-regulation To assess this pattern, focus on eating habits, appraisal of appetite, weight loss or gain, changes in skin, hair or nails Blood pressure, pulse rate c. Elimination Pattern Patterns of excretory function (Bowel, Bladder and Skin) and client perception of same Assess usual bowel and bladder elimination habits, laxative use, and excretory function of skin (e.g. excessive perspiration) Bowel - 24 hrs - digestion and peristaltic movement; pain, appearance, time Urine dribbling, color, odor, frequency Sweat smell, volume Consider causative factors for any elimination patterns d. Activity Exercise Patter Patterns of exercise, activity, leisure, recreations, and ADLs; factors that interfere with desired or expected individual pattern Assess mobility status, exercise routine, leisure activities, cardiovascular status Cardiovascular status pulse rate, blood pressure Breathing respiratory rate Range of Motion mobility, movement e. Sleep Rest Pattern Patterns of sleep and rest-relaxation periods during 24 hour day, as well as quality and quantity are included in this category. Assess regular sleep habits and routine. Consider how the patient looks if looks rested or not f. Cognitive Perceptual Pattern Adequacy of sensory modes, such as vision, hearing taste, touch, smell, pain perception, cognitive functional activities Assess changes in cognitive function, ability to hear, see and speak, presence of pain, numbness, or other sensations Write down the words of the patient verbatim. Subjective data Pain Quality, Scale Awareness of body parts (diabetic patients on movement of extremities) g. Self-Perception and Self-Concept Pattern

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Individual attitudes about self, perception of abilities, body image, identity, general sense of worth and emotional patterns Assess descriptions of self, physical appearance, effects of illness, major life accomplishments and changes Male diabetic patients might experience erectile dysfunction, which affects self-image or ego. Sense of worth, Lack of body parts, Functional disability affects self-perception Write down the words of the patient verbatim. Subjective data h. Role Relationship Pattern Clients perception of major roles and responsibilities in current life situation Assess clients perceptions of key relationships, observation of interaction with others Role reversal, relationships, roles i. Sexuality Reproductive Pattern Clients perceived satisfaction or dissatisfaction with sexuality Reproductive stage and pattern Assess clients appraisal of his or her sexual role and sexual health Sexual activities, sexual patterns, number of births, any problems encountered related to sexual activities j. Coping Stress Tolerance Pattern General coping pattern, stress tolerance & management, support systems, & perceived ability to control and manage situations Assess current stress level, coping ability, ability to endure life stressors, physiologic responses to stress Factors affecting stress (stressors) k. Value Belief Pattern Values, goals, or beliefs that guide choices or decisions Assess identification of valued people and possessions, source of support, religious practices Religion, faith Formulating Nursing Judgment DATA INTERPRETATION inferential reasoning attaches new meaning to known clinical data 1. After collecting data, one must judge the VALUE & SIGNIFICANCE 2. Analyzing data leads to ACCURATIVE & MEANINGFUL interpretations of the clients problems 3. The extent of the problem & relationships between problems must be traced

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4. Verification of Data is a MUST DATA CLUSTERING Nurse ORGANIZES the data into meaningful clusters & focuses attention on client functions needing support & assistance for recovery This leads to the formulation of Nursing Diagnosis

DATA DOCUMENTATION This is the last part of a complete assessment Thoroughness & accuracy are a MUST because seemingly unimportant data maybe needed later; & observation & recording of client status is a LEGAL & PROFESSIONAL responsibility

April 23, 2005 NURSING DIAGNOSIS: Definition: it is a clinical judgment about individual, family or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 1990) NANDA North American Nursing Diagnosis Association Purposes: To identify health problems involving the client & the family Provides the basis for selection of nursing interventions to achieve the outcomes for which the nurse is accountable (provides direction for nursing care)

Advantages: Among Nurses: Promotes professional accountability & autonomy by defining & describing the independent area of nursing practice Facilitate communication among nurses about a clients level of wellness & assist in discharge planning Prioritizes the clients needs Serves as a focus for quality improvement

Among Clients: Better communications among health workers ELIMINATES potential problems in giving care; also MAINTAINS focus on meeting clients health care goals Individualized, high-quality, continuous care

Diagnostic Process Includes decision-making steps the nurse uses to develop a diagnostic statement Dynamic process where the nurse uses critical thinking as the client needs/clinical situation change

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a. -

Analysis & interpretation of Data Recognize pattern (cluster or defining characteristic) defining characteristics are assessment findings that SUPPORT the presence of a diagnostic category Compare cues with normal standards Compare with Normal Standards Soft, formed stool daily Soft, formed Soft, non-distended No discomforts during each BM

Recognize Pattern Diarrhea x 3 wks. Stools; ribbon-shaped, water Abdomen: distended, Cramping before & during each BM a. b.

Make a reasoned conclusion about the clients response to a health problem Identification of client needs after identifying the clients needs, the nurse should determine whether these are actual or potential

Formulation of the Nursing Diagnosis I. 5 Types 1. Actual clinically validated by major defining characteristics a. Pain R/T impaired skin integrity 2. Risk clinical judgment that the client is vulnerable/likely to develop a problem a. Risk for Impaired Skin Integrity R/T immobility 3. Possible is unclear/ the causative factors are unknown a. Fluid Volume Deficit R/T Imbalance Between Intake and Output 4. Syndrome diagnostic label given to distinct cluster of a nursing diagnoses that frequently go together & present a clinical picture a. Risk for Disuse Syndrome; i. Risk for Activity Intolerance ii. Body image Disturbance iii. Risk for infection iv. Altered Thought Processes integrity v. Impaired Physical Mobility vi. Constipation vii. Risk of injury viii. Powerlessness ix. Impaired Tissue 5. Wellness clinical judgment about a client in transition from a specific level of wellness a. Family Coping: Potential for Growth R/T Unexpected Birth of Twins

Format (NANDA) Nursing Diagnostic Statement 2 Part Format: Diagnostic Label + (from approved NANDA taxonomy) Related Factor (etiology, condition that causes/ is associated with clients actual or Potential response to health problem; should be within the domain of nursing practice

e.g. Constipation R/T Poor Intake of Fluid & Fiber 3 Part Format:

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Diagnostic Label

Related Factor +

Defining Characteristics

e.g. Constipation R/T Poor Intake of Fluid & Fiber A/E (As Evidenced) by Hard, Dry stools The modification of the Nursing Diagnosis is ONGOING as the level of wellness & the needed nursing care change RELATED FACTOR Inadequate dietary fiber effects of medications Inadequate fluid intake Discomfort Excessive role demands Increased energy requirements

DIAGNOSTIC STATEMENT Constipation Fatigue

Sources of Diagnostic ERRORS A. a. b. c. d. a. b. c. d. B. Errors in Data Collection Occurs during the assessment process Causes: lack of knowledge/skill inaccurate data missing data incomplete data disorganization How to Avoid Errors: Critical review of nurses level of comfort & competence with interview & P.A. skills Determine the accuracy of data collected Check completeness of data Be organized prepare equipment & forms needed, ensure that the environment is private, quiet and comfortable for the client

Errors in interpretation & Analysis of Data After verifying accuracy & completeness of data, seek supportive literature to ensure an adequate knowledge base to form a correct nursing diagnoses Begin to identify & organize relevant assessment patterns to support the presence of client problems Causes: a. inaccurate interpretation of cues b. failure to consider conflicting cues c. using an insufficient number of cues d. using unreliable or invalid data e. failure to consider cultural influences or developmental stage Errors in Data Clustering The nursing diagnosis should be derived from the data, NOT the reverse Causes: a. insufficient cluster of cues b. premature or early closure when the nurse makes a nursing diagnosis BEFORE all data have been grouped c. incorrect clustering when the nurse tries to make the nursing diagnosis fit the s/s obtained Errors in Diagnostic Statement Can occur in the manner in which the nursing diagnosis is stated

C. -

D. -

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This can be avoided by using appropriate, concise, & precise language & the appropriate terminology Causes: a. wrong diagnostic label selected b. condition is a collaborative problem c. failure to validate nursing diagnosis with client d. failure to seek guidance Examples CORRECT Diarrhea R/T Unknown Cause STATED AS MEDICAL Dx Diarrhea STATED IN MEDICAL TERMINOLOGY alteration in bowel elimination R/T lesion in descending colon STATED AS NURSING INTERVENTION offer bedpan frequently because of diarrhea (wrong, this is intervention not a diagnosis) Other ways to avoid & correct Errors: Identify clients response to illness State a NANDA diagnostic statement Identify an etiology treatable by nursing Identify a client need associated with a treatment or test Identify clients response to equipment Identify clients (not the nurses) problem Identify the clients problem NOT intervention Identify clients problems not goals Avoid prejudicial statements Avoid words that can put down your client j. State the etiology legibly k. Identify a problem AND or etiology l. Identify only one client problem in a diagnostic statements a. b. c. d. e. f. g. h. i.

April 28, 2005 PLANNING: Definition: It is a category of nursing behavior in which client-oriented goals & expected outcomes are established & nursing interventions are selected to achieve the goals & outcomes of care. If Client still refuses & hard headed, the next step should be to insist the intervention on the client especially if it is life threatening; the nurse can assume responsibility for the situation. But if he really refuses, let the client sign a waver. Establishing Priorities: uses critical thinking skills to establish priorities for the clients diagnosis by ranking them in order of importance established to help nurse anticipate & sequence nursing intervention when a client has multiple problems / alterations Maslows hierarchy of needs can be a basis for the ranking

Problems Alteration: Priority selection is the method the nurse & client use to make mutually ranks the diagnosis in order of importance based on the Clients desires, needs, & safety.

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Example: MASLOWS Hierarchy of Needs can be used for ranking Physiological Needs water, air, food Safety & Security Needs assurance of care according to environmental hazard, fear of certain procedure Love & Belonging Needs Relationships Self-Esteem Needs Self-perception: amputees, Body image: disturbance, loss of hope Self-Actualization highest level Priorities are classified as: High if untreated, result harm in clients Intermediate Non-emergent, non-life threatening needs of the clients Low clients needs that may not be directly R/T a specific illness/prognosis Priorities depend on: Urgency of the problem Nature of the treatment indicated Interactions among the nursing diagnosis Client should be involved in priority setting

Formulating Goals of Care & Expected Outcomes: Definition: are specific statements used to indicate anticipated client behavior or responses for nursing care within a given frame Purposes - To provide direction for individualized nursing intervention - To set standards of determining the effectiveness of the intervention - you can evaluate if interventions are met or not Goals & Expected Outcome: Goals: stated in a general manner; guidepost to the selection of nursing interventions & criteria in the evaluation of these Client Centered Goal: specific, measurable objective designed to reflect the clients active involvement; should be realistic & based in the clients needs & resources Categories: Short-term Goal expected to be achieved in less than a week (1 week) Long-term Goal expected to be achieved over weeks or months suggested (weeks or months) Steps: 1. 2. 3. 4. Ask yourself what problems needs immediate action / attention Identify problems with a simple solution Come up with a problem list study a problem that leads another problem Study the list & decide what problems needs nursing intervention / will be managed by intervention

Outcome: more specific statements, a measurable change in the clients status in response to nursing care Expected Outcome: specific, step-by-step objective that leads to attainment of goal & the resolution of the etiology for the nursing diagnosis Functions of Expected Outcomes: They provide: 1. a direction for nursing activities

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2. a projected span for a goal attainment 3. an opportunity to state additional resources that may be required to achieved the goal 4. criteria to evaluate the effectiveness of nursing activities Guidelines for Writing These: 1. 2. 3. 4. Client centered Factors Singular Factors should add only one behavioral response Observable Factors Measurable Factors give the nurse a Standard against which to measure the clients response to nursing care 5. Time-limited Factors time frame for each goal 6. Mutual Factors mutual setting goals 7. Realistic Factors short-term realistic goals Examples of Expected Outcome 1. Nursing Diagnosis: Impaired mobility R/T incisional pain Diagnostic Label: Impaired mobility Expected Outcomes: At the end of the shift, client will improve / increase mobility as evidenced by turning from side to side 2. Diagnostic Label: altered bowel elimination Expected Outcomes: At the end of the shift, client will resume usual elimination pattern as evidenced by hard formed stools & BM once a day. NURSING INTERVENTION: Definition: Actions designed to assist the clients in moving from the present level of health to that which is described in the goal, and measured with the expected outcomes 3 Competencies Needed to Initiate Intervention 1. Know the scientific rationale for the intervention 2. Possess needed psychomotor & interpersonal skills 3. Be able to function within a particular setting to use the available health care resources effectively Types 1. Nurse-Initiated Intervention are the independent response of the nurse to the clients health care needs & nursing diagnoses; based on scientific rationale; within the scope of nursing practice (requires NO supervision or direction from others) 2. Physician-Initiated Intervention based on the physicians response to a medical diagnosis; the nurse intervenes by carrying out the doctors order; requires specific nursing responsibilities & technical nursing knowledge CRITICAL THINKING is needed! 3. Collaborative Intervention Therapies that requires the knowledge, skills & expertise of multiple health care professionals Factors in Selection of Interventions (p.335)

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1. Characteristics of the nursing diagnosis interventions must be directed toward altering the etiological / risk factors associated with the diagnostic label 2. Expected Outcomes stated in measurable terms & used to evaluate the effectiveness of interventions 3. Research Base review the literature R/T diagnostic label & client findings 4. Feasibility consider interaction of nursing intervention with treatments being provided by other health professionals, clinical effectiveness & cost-efficiency, management of time & resources 5. Acceptability to the Client congruence with clients goals, and HC values self-care abilities 6. Competency of the Nurse knows scientific rationale, has psychosocial & psychomotor skills, functions effectively & efficiently uses HC resources. Planning Nursing Care Methods for Communicating a Clients Nursing Care 1. Nursing Care Plan written guidelines for clients care that is the blueprint for nursing actions & a framework for evaluation 2. Critical Pathways multidisciplinary treatment plans that prescribed intervention & the timeframe for achieving expected outcomes; a standard care plan; for high risk, high volume types of cases Purpose of Care Plans 1. Document the clients health care needs decrease the risks of incomplete, incorrect, inaccurate care 2. Make possible the coordination of the nursing care, subspecialty consultations & scheduling of diagnostic test 3. Identify & coordinate resources needed to deliver nursing care 4. Enhance the continuity of nursing care 5. Organize information exchanged by nurses in endorsement reports 6. Involve the family & client individualized Care Plan Kinds of Care Plans 1. 2. 3. 4. 5. Institutional e.g. kardex; concise documents Computerized / Standardized Care Plans it does away with the individualized care plans Student Care Plans much better; more elaborate Care Plans for Community Based Settings Critical Pathway multidisciplinary: a lot of people are involved in making the Plan Planning Care Plans Writing the NCP Cues Nursing Diagnosis Prioritize all nursing diagnosis Objective of Care Intervention should answer the question: What When How Who Rationale Evaluation

IMPLEMENTATION:

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Definitions: Implementation a category of nursing behaviors which the actions needed for achieving the goals & expected outcomes of nursing care are initiated & completed Nursing Intervention any actions taken by the nurse to help the client move from a present health state to the health state described in the expected outcomes Types of Nursing Intervention: 1. Independent autonomous actions & these are base on scientific rationale, standards of nursing practice (anything you do is within its scope, like prescribing medications that is not our practice) & within the scope of nursing law Protocols & Standing Orders written plans specifying the procedures to be followed during care of a client with certain clinical conditions a way of doing things (lay mens term) Delineate conditions that nurses are allowed to treat Example Controlled hypertension States types of treatment that nurses are allowed to give Example allowed to give immunization Protocol Example initiating CPR & Pain Management Standing Orders refers to documents containing orders for the conduct of routine therapies Monitoring Guidelines & or diagnostic procedures for specific clients with identical clinical problems Purpose: It gives the nurses legal protection Collaborative Physician Initiative / Defendant Nursing Intervention

2. 3. 4.

Determinants in Choosing Nursing Intervention 1. Set of all possible nursing intervention - consider all possible nursing intervention 2. Possible consequences associated with either nursing action - What could happen if I choose this intervention? 3. Probability that each of the consequences will occur 4. Judgment based on the value of that consequence to the client Steps in the Implementation Process 1. Reassessing the client 2. Reviewing & revising the existing NCP 3. Organizing resources equipment & personnel; check for its availability - Functional order, arrangement, location - Consider nursing care delivery system (Team nursing, functional nursing) - Functional nursing leads to fragmentation 4. Anticipating & preventing complications - identify the consequences & weigh the risks & prevent them from occurring 5. Identifying areas of assistance assistance for additional personnel, knowledge, nursing skills 6. Actual implementation of nursing intervention / Implementing nursing intervention

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a. Cognitive Skills whats normal & all normal for clients b. Interpersonal be able to communicate clearly, trust & caring sensitivity c. Psychomotor skills, aura of self-confidence

Implementation Methods: 1. Assisting with ADL Example: Minimal activities due to fracture in the arm - do counseling if ADL is not done due to knowledge deficit depends if it is permanent or temporary always determine the clients own preferences in relation to timing 2. Counseling support client in all aspects of health Example: lifestyle change, smoking cessation; clients who have been told that they have a life-threatening disease equip client with knowledge & skills, but if you cant handle, do referral 3. Teaching to increase knowledge; supposed to do right procedures & techniques Example: Client wants to know more about hypertension assess ability to understand What is the easiest way to learn things? return demonstration, visual aids 4. Providing direct Nursing Care Compensate for adverse ranks Example: HWB Application & Cold Application Preventive measures Example: stress prevention Correct techniques in giving care & preparing a client for procedure Study the procedure youll perform to the client, knowing its rationale Life saving measures Example: CPR Achieving goals of Care providing a conducive environment 5. Delegating, Supervising, evaluating work of other staff members Nurse, youll make sure the person you delegate the work is doing the procedure correctly & the person who does it is responsible & able to do the procedure 6. Communicating Nursing intervention so that youll avoid errors communicating & writing nursing intervention is important Oral Communication: - endorsement report changing shifts - transfer client from one unit to another Communication in Words - Conferences

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EVALUTION: Definition: measures the clients response to nursing actions & the clients progress toward achieving goals Purpose: allows the nurse to continually redirect nursing care to best meet clients needs after critically evaluating & revising intervention until problems are appropriately resolved Importance of Evaluation 1. Supports the basis of the usefulness & effectiveness of nursing practice which is Client-Centered 2. Provides a measurement of the quality of nursing care provided in a health care setting What to Measure? (evaluation basis) 1. Goal summary statement of what is to be accomplished when all outcomes have been met 2. Expected Outcomes step-by-step responses / behaviors that the client needs to accomplish to achieve the goals of care Steps in Evaluating Goal Achievement 1. 2. 3. 4. 5. Examine the goal statement to identify the desired client behavior / response Assess the client for the presence of that behavior / response Compare the established outcome criteria with the behavior or response Judge the degree of agreement between outcome criteria & the behavior or response If theres no agreement (or only partial agreement) identify the barriers or the causes

Evaluation Measures These are simply the assessment skills & techniques used to collect data for evaluation They are the same as assessment measures but are performed at the point of care when decisions are made about the clients status & progress Intent of assessment identify what, if any, problems exist Intent of Evaluation to determine if the known problems have improved, worsened, or otherwise changed

Care Plan Revision 1. Discontinuing the care plan a. Achievement of Expected Outcome b. If theres no new problems / risk factors c. Client can care for himself 2. Modifying the Care Plan a. Expected Outcome has not been achieved b. There are still existing problems

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c. Client cannot care for himself 3. Reassessment 4. Continue Care Plan a. Need more time to implement intervention

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