PRIORITIZING

WITHIN THE NURSING PROCESS

Objectives
Formulate priorities for managing and delivering nursing care
Apply the specific priority-setting model appropriate to presenting circumstances in various clinical situations

Topic Outline

Assessment Analysis Outcome Identification

ASSESSMENT

ANALYSIS

OUTCOME IDENTIFICATION

Health
History Observation Physical Exam

Clinical Eye

Assessment

Interview

Laboratory results Radiology

Results

Clustering
Health

History
Observation Clinical Eye Physical

CLUSTERED DATA
Exam

Subjective data Objective data

Assessment

Interview

Laboratory

results Radiology
Results

Supporting data

What are the defining characteristics?

These are the observable cues/inferences that cluster as manifestations of an actual or wellness diagnosis For actual nursing diagnosis- the DC are the clients signs and symptoms For risk nursing diagnosis- no subjective and objective signs are present

Example of Clustered Data

The Patient is 73 years old, has a fifthgrade education, and lives with her 55year-old developmentally disabled son.
The patient has recently been diagnosed with Heart failure The patient will probably need a digitalis preparation and ongoing diuretic therapy

NOTE:
The Nurse should never implement before assessing
However, in situations involving an urgent problem, performing only a partial assessment may be necessary, after implementation of interventions, a complete assessment can be performed

Drill
Here is the situation
Patient D
Severe Dehydration Needs a central line for fluid replacement Vital signs: Temp: 37.2 C, PR= 108, RR=24, BP= 90/60 mmHg Assessment done at 3:30 pm The Physician will be on the unit at 4:00 pm to place the central line

Given the scenario, which nursing activity has the highest priority?
Assess urine output
Ensure that central line equipment is on the unit

Ensure that consent form is signed

Perform a body system assessment Take the vital signs

ANSWER
Ensure that consent form is signed Take the vital signs Perform a body system assessment Ensure that central line equipment is on the unit Assess urine output

Rationale:
Assessing includes collecting, verifying, and organizing. Ensuring that the consent form is signed is verification. Without a consent form, the procedure cannot be done. It is included with the assessment and therefore is the first priority

ASSESSMENT

ANALYSIS

OUTCOME IDENTIFICATION

ANALYSIS
The Nurse prepares a list of patient needs and a list of nursing diagnosis for the cluster of the previously discussed 73-year-old patient is: Deficient knowledge related disease process, precautions, and side effects of diuretic and digitalis therapy.

Go back to the situation.

CLUSTERED DATA The Patient is 73 years old, has a fifthgrade education, and lives with her 55year-old developmentally disabled son.

The patient has recently been diagnosed with Heart failure

The patient will probably need a digitalis preparation and ongoing diuretic therapy

Nursing Diagnosis

Deficient knowledge related to disease process, precautions, and side effects of diuretic and digitalis therapy

NURSING DIAGNOSIS
3 STEPS Analyze Data

Identify Health Problems, risks, strengths

Formulate diagnostic statement

1. Analyze Data

Compare data against the standards Clustering cues Identify gaps and inconsistencies

2. Identifying Health Problems, Risks, and Strengths

After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses. In addition the nurse must determine whether the clients problem is a nursing diagnosis, medical diagnosis, or collaborative problem.

3. Formulating Diagnostic statements

Basic two-part statement (P-E) Basic three-part nursing diagnosis (P-E-S)

Basic Two-part statement

Problem-Etiology (P-E) Ineffective Breastfeeding related to Breast engorgement

Basic Three-part Statement

Problem-Etiology-Signs and Symptoms (P-E-S) Ineffective airway clearance related to increased mucus production as manifested by bilateral crackles upon auscultation

MASLOWS HIERARCHY OF NEEDS

Self Actualization Self-Esteem

Love and Belongingness

Safety and Security

Physiologic needs

Nursing Diagnoses Categorized using Maslows H.O.N.

Physiologic needs Activity Intolerance Diarrhea Gas exchange, impaired

Incontinence, bowel/urinary
Sleep deprivation Swallowing, impaired Sexual dysfunction

Nursing Diagnoses Categorized using Maslows H.O.N.

SAFETY AND SECURITY

Injury, risk for

Poisoning, risk for Trauma, risk for Disuse syndrome, risk for Falls, risk for Fear

Nursing Diagnoses Categorized using Maslows H.O.N.

LOVE AND BELONGINGNESS Anxiety

Loneliness, risk for

Parenting, impaired Social Isolation

Nursing Diagnoses Categorized using Maslows H.O.N.

SELF-ESTEEM Coping, ineffective Denial, ineffective Powerlessness Rape trauma syndrome Post-trauma response Disturbed body image Self-esteem, disturbance or chronic low Suicide, risk for Self-mutilation Violence, risk for self directed or other directed

Nursing Diagnoses Categorized using Maslows H.O.N.

SELF-ACTUALIZATION
Development, risk for delayed Growth and development, delayed Health-seeking behaviors Spiritual distress Therapeutic regimen management, effective

OUTCOME IDENTIFICATION
Goals and measurable outcomes provide a means to determine whether the nursing diagnoses are appropriate for situation. Priorities are established to help the nurse achieve the nursing desired outcome After the nursing diagnosis are prioritized, the nurse can identify patient goals and outcomes based on Nursing Outcomes Classification (NOC)

Thank you!
TO GOD BE THE GLORY