11 Steps of the Nursing Process new 26 11 2018 (2).pptx

FUNDA

1. Nursing Process

2. 1. Conduct the health history. 2. Perform the physical assessment. 3. Interview the patient’s family or significant others. 4. Study the health record. 5. Organize, analyze, synthesize, and summarize the collected data. Assessment

3. Data collection Data verification Data organization Data interpretation Data documentation Assessment Elements Of The Assessment Process

4. Obtain baseline data and track changes. Early recognition of the critically ill or deteriorating patient. Risk assessment. Screening for health problems. Identify actual and potential problems and prioritise care. Care planning, tailored to individual patient needs. Discharge planning. PURPOSE OF ASSESSMENT

5. TYPES OF ASSESSMENT Comprehensive Focused Ongoing

6. Completed upon admission Includes a complete health history Provides a baseline data Should include: Assessment of physical and psychosocial aspects of the client’s health, The client’s perception of health He presence of health risk factors The client’s coping patterns Assessment Comprehensive Assessment

7. Limited in scope Focus on a particular need or health problem Often used in health care agencies with short stays (e.g., OPD surgery centers and emergency departments, labor & delivery & in mental health settings). Focused Assessment

8. Systematic follow-up of identified problem Includes systematic monitoring & observation Allows to broaden or to confirm the validity of the initial assessment data Determine response to nursing interventions Identify any emerging problems. Ongoing Assessment

9. The nurse must possess strong cognitive, interpersonal, and technical skills in order to elicit appropriate information and make relevant observations during the data collection process. Assessment DATA COLLECTION

10. Subjective data ( symptoms ) are data from the client’s point of view and include feelings, perceptions, and concerns Objective data (signs) are observable and measurable (quantitative) data, obtained through observation, physical examination, laboratory and diagnostic testing. The data can be seen, heard, or felt by someone other than the patient. Types of Data

11. Client Family/significant other Other health care professionals Medical records Interdisciplinary conferences, rounds, and consultations Results of diagnostic tests Relevant literature Sources Of Data

12. Observation Interview Health history Symptom analysis Physical examination Laboratory and diagnostic data Methods of Data Collection

13. Observation Observations include factors as client mood, interactions with others, physical and emotional responses , and any safety considerations . By observation, the nurse can detect nonverbal cues that indicate a variety of feelings as presence of pain, anxiety, and anger.

14. Interview is a therapeutic interaction used to collect data about client’s health history and current health needs . Observation of nonverbal behavior is also essential to effective data collection. Phases of Interview Introduction Working and Closure.

15. Introduction Establishes the goals for the interaction Collection of data about the client Allow adequate time and privacy Inform about interview duration. Nurse should sit, establish eye contact, and listen attentively Note nonverbal messages (indicate uncomfortable, tired, or preoccupied with other matters

16. Working Focuses on the details of data collection Interview may be structured and formal or unstructured and informal Interview begins with biographical data. Client’s reason for seeking health care Gather information from general-specific Use of Nursing Checklist A comprehensive interview by open-ended questions, while focused interview by direct, closed questions.

17. Closure Indicate Interview Closure by stating that almost all information needed has been obtained or time is over. During closure phase, the nurse summarizes what was covered or accomplished during interview and requests validation of perceptions with the client.

18. Preparing the Interview Environment Assure adequate lighting. Maintain comfortable room temperature Select an environment that is as free of noise and distractions as possible. Maintain client privacy. Make sure that the interview is timed appropriately. Promote client comfort.

19. Demographic information Reason for seeking health care Perception of health status Previous illnesses Client/family medical history Immunizations/exposure to communicable disease Allergies Current medications Developmental level Psychosocial history Socio-cultural history Activities of daily living Review of systems Assessment 3- Health History

20. The purpose of the physical examination is to make direct observations of any deviations from normal and to validate subjective data gathered through the interview. Baseline measurements are obtained, and physical examination techniques are used to gather objective data. Assessment Physical Examination

21. Baseline Data Data forms the basis for comparison and evaluation of a client at a given time. Measurement of height, weight, and vital signs (temperature, pulse, respirations, and blood pressure) is important for comparison with future measurements in order to judge the significance of any changes (progress or regression) over time. Assessment

22. Physical examination: use of visual, auditory, tactile, and olfactory senses & systematic assessment techniques. The four assessment techniques used in physical examination are Inspection Palpation Percussion auscultation . Assessment Techniques

23. Inspection I nvolves careful visual observation . Observed first from a general point of view and then with specific attention to detail. Requires adequate lighting and exposure of the body parts being observed. Be sensitive to the client’s feelings of embarrassment with the use of inspection and respond to this situation by discussing the technique with the client and using measures such as draping in order to increase client’s comfort.

24. Palpation Palpation uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations & pulsations, swelling, masses, tenderness. It requires a calm, gentle approach and is used systematically, light palpation preceding deep palpation & palpation of tender performed last. In palpation uses the hands and fingers in different ways for assessment of: • Temperature: dorsal (back) surface of the hand • Texture, pulses, and swelling: using fingertips • Vibration: base of the fingers • Shape and consistency of organs or masses: grasping organ or mass between fingertips

25. Percussion Percussion uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs . Used for assessing density of structures or determining the location and size of organs. Structures with relatively more air (such as the lungs) produce louder, deeper, and longer sounds with percussion than more dense, solid structures (such as the liver), which produce softer, higher, and shorter sounds.

26. Auscultation Auscultation involves listening to sounds in the body that are created by movement of air or fluid. Areas most often auscultator include the lungs, heart, abdomen , and blood vessels . Although direct auscultation is sometimes possible, a stethoscope is usually employed in order to channel the sound.

27. Laboratory and Diagnostic Data Results of laboratory and diagnostic tests can be useful objective data serve as defining characteristics & helpful in ruling out certain suspected problems. In addition, the effectiveness of nursing and medical interventions and progress toward health restoration are often monitored through laboratory and diagnostic test data.

28. It is the process through which data are validated as being complete and accurate. Data are reviewed for inconsistencies or omissions. It is done by examining the congruence between subjective and objective data. Findings should also be compared with norms. Any grossly abnormal findings should be rechecked and confirmed. DATA VERIFICATION

29. After data collection is completed and information is validated, the nurse organizes, or c lusters, the information together in order to identify areas of strengths and weaknesses . This process is known as data clustering . DATA ORGANIZATION

30. Data clustering facilitates recognition of patterns, and determination of further data that are needed. Data interpretation is necessary for identification of nursing diagnoses. DATA INTERPRETATION

31. Accurate and complete recording of assessment data are essential for communicating information to other health care team members. In addition, documentation is the basis for determining quality of care and should include appropriate data to support identified problems. DATA DOCUMENTATION

32. Open-Ended Formats Allows the nurse to write a narrative description of observations. This format is more time-consuming for the nurse, but allows flexibility in recording findings. Checklist Formats Formats that include checklists facilitate documentation by summarizing findings in an abbreviated form. They also provide more consistency in the recording of information and reduce the likelihood of omitting relevant information. Combination Formats Allow the convenience of a checklist together with space to document a complete narrative description of any significant or abnormal findings. Specialty Formats Specialty areas such as outpatient surgery, labor and delivery, and psychiatric facilities may use abbreviated formats focused directly on assessment needs for the particular service provided. Documentation of assessment data is essential as a means of communication among health care team members to assure accurate problem identification, determination of appropriate client outcomes, and continuity of care. Assessment Types of Assessment Formats

33. Nursing diagnosis

34. Statement describes the human response (health state or actual/potential altered interaction pattern) of individual or group which nurse order definitive interventions to maintain health state or to reduce , eliminate, or prevent alterations”. Judgment process resulting in a statement conveying the person’s adaptation status ”. Nursing diagnosis

35. Nursing diagnosis allows for: Empowerment of the profession of nursing Facilitates effective communication Provides a means to individualize nursing care Essential to clinical practice and education & pivotal for theory development & research Nursing diagnosis PURPOSES OF NURSING DIAGNOSIS

36. 1- The Two-Part Statement First component is a problem statement or diagnostic label . Second component is the etiology linked by term related to (RT). Nursing diagnosis COMPONENTS OF A NURSING DIAGNOSIS

37. Examples: Disturbed Body Image RT loss of left lower extremity Activity Intolerance RT decreased oxygen-carrying capacity of cells . Descriptive words ( qualifier s) include: Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, Ris k. These terms placed before problem statement. Nursing diagnosis

38. 2- The Three-Part Statement 1 st component is diagnostic label . 2 nd component is etiology linked by RT . 3 rd componen t is defining characteristics (known as S & S , subjective and objective data, or clinical manifestations). 3 rd part is joined to first 2 components with the connecting phrase “ as evidenced by ”. Defining characteristics may assist the nurse in identify client goals, measurable client outcome criteria, & relevant nursing interventions. Nursing diagnosis

39. Nursing diagnosis Comparison of 1, 2 & 3 Part Nursing Diagnosis Statements One-Part Statement Two-Part Statement Three-Part Statement Part 1: Wellness condition/state to be enhanced (no Related to, no etiology, and no defining characteristics) Part 1: Problem Related to Part 2: Etiology (no defining characteristics) Part 1: Problem Related to Part 2: Etiology Part 3: Defining characteristics

40. Nursing diagnosis CATEGORIES OF NURSING DIAGNOSES

41. A) Actual diagnoses:  problems that are already in existence . Example : Excess Fluid Volume (RT) IV infusion overload Anxiety RT unknown results of breast biopsy. B) Risk diagnoses :  problems might occur but not currently in existence . Examples : Risk for Poisoning RT increased mobility of infant & failure to have house childproofed Risk for Deficient Fluid Volume RT excessive number of stools. Nursing diagnosis

42. C) Wellness diagnoses  identify the individual or state that may be enhanced by health promoting activities . Consist of a one-part statement (no “related to”) that uses label “Potential for Enhanced” followed by state nurse desires to enhance. Examples: Readiness for Enhanced Community Coping and Readiness for Enhanced Spiritual Well-Being . Nursing diagnosis

43. Is the type of classification under which the diagnostic label is grouped based on which human response the client is demonstrating to the actual or perceived stressor. The NANDA nursing diagnosis taxonomy is composed of 9 patterns of human response: • Exchanging • Valuing • Perceiving • Communicating • Choosing • Knowing • Relating • Moving • Feeling Nursing diagnosis TAXONOMY OF NURSING DIAGNOSIS

44. Assessing Database C ollects data cues from the client . Examples of cues: poor skin turgor , parched lips, dry skin , decreased urine output, and complaint of thirst . Processes these cues and determines a nursing diagnosis , plans client outcomes & implement therapeutic nursing interventions Validating Cues After reviewing data cues, validates that information and examines it carefully. Example: determines if information is accurate and complete . Interpreting Cues Through interpretation of data cues and use of critical-thinking strategies, the nurse assigns a meaning to the data cues. Nursing diagnosis DEVELOPING A NURSING DIAGNOSIS

45. Once cues collected, validated, and interpreted , the data are then grouped into clusters . Related information about client grouped together . Conclusions are drawn from the data cues. Example : data cues that can be clustered include: Subjective : “I always seem to be hungry and I eat 5 or 6 times a day” and “I’ve gained 12 pounds in the past year.” Objective : weight 204 pounds, protruding abdomen, double chin, fleshy loose upper arms, and dimpling of buttocks. Nursing diagnosis Clustering Cues

46. 1. Collect data cues from the assessment phase. 2. Data cues are validated and examined. 3. Data cues are interpreted and assigned a meaning through the use of critical thinking. 4. Data are grouped into clusters. 5. The NANDA list is consulted. 6. The first part of nursing diagnosis statement is written. 7. Related to (RT) factors are identified. 8. Phrases from steps 6 and 7 are combined to form a two-part nursing diagnosis. Nursing diagnosis STEPS IN DEVELOPING A NURSING DIAGNOSIS

47. N ursing diagnosis from NANDA list becomes the diagnostic label, first part of diagnosis statement . Etiologies are also identified from NANDA list. Appropriate etiology is selected and joined to the first part of the statement with the “related to” phrase. In a two-part statement , would be Imbalanced Nutrition: More Than Body Requirements RT excessive food intake. The three part statement would be Imbalanced Nutrition: More Than Body Requirements RT excessive food intake AEB weight gain, increased appetite, excess adipose tissue, and increased abdominal girth. Nursing diagnosis Writing the Nursing Diagnosis Statement

48. Mr. Lowder is a 62-year-old, male, admitted last night through the E R because of Difficulty breathing . Difficulty voiding. His lower extremities are very swollen. History: smokes 1 pack of cigarettes a day for 45 years. His vital signs are P 112; R 30; BP 172/96; T 101.1°F. Education: eighth-grade, Attends church every week , He is estranged from his daughter, and says, “ I hate hospitals because my mother died in one .” APPLICATION: WRITING NURSING DIAGNOSIS

49. From the data cues in this case study, group data into clusters. Look at the NANDA list of diagnoses and see which diagnoses “fit” best with your data clusters. Write the first part of the NANDA diagnosis for each cluster. Attempt to identify etiological (related to) factors for the list you started in step 3. Write two-part nursing diagnosis statements by combining steps 3 and 4. Identify whether the nursing diagnoses on your list are actual , possible , risk , or wellness-oriented nursing diagnosis statements. Prioritize the nursing diagnoses.

50. Outcome Identification & Planning

51. Establishing priorities Setting goals and developing expected outcomes Planning nursing interventions (with collaboration and consultation) Documenting Planning The 4 critical elements of planning include:

52. Maintain or improve health at an optimal level Framework to base scientific nursing practice. Provide adequate direction to ensure quality nursing care for individual clients Present a vehicle to improve staff communication , and to provide continuity in the delivery of individualized, quality nursing care to all clients. Planning Purposes of Outcome Identification and Planning

53. Establishing Priorities Establishing Goals & Expected Outcomes Writing Goals Planning Process Of Outcome Identification And Planning

54. Examines client’s nursing diagnoses and ranks them; physiological or psychological importance . Nursing diagnoses is ranked by nurse , client or family In selecting priorities: First physiological needs (e.g., respiration, nutrition, hydration, elimination) Next ( safe environment , stable living condition ) Determine its level of need , and Rank the need in order of priority . Another consideration is client preferences . Involve client in establishing priorities. Anticipation of future diagnos es. Planning 1- Establishing Priorities

55. Prioritizing Nursing Diagnoses with Accompanying Nursing Implications Priority Diagnosis Nursing Implications High Ineffective Breathing Pattern • Assess breath sounds. • Auscultate lungs. • Monitor vital signs. • Reposition client. Moderate Risk for Impaired Skin Integrity • Perform comprehensive skin assessment. • Keep skin clean and dry. • Provide turning schedule. Low Ineffective Coping • Assist to identify problem. • Encourage keeping daily journal. • Teach expressing feelings strategies .

56. After assessing the client , formulating nursing diagnoses , and establishing priorities , the nurse sets goals and identifies and establishes expected outcomes for each nursing diagnosis. The purposes are to Provide guidelines for individualized nursing interventions Establish evaluation criteria to measure effectiveness of NCP A goal is an aim , intent , or an end . A goal is a broad statement describing the intended or desired change in the client’s behavior, response, or outcome . An expected outcome is a detailed, specific statement that describes the methods through which goal will be achieved . Planning Establishing Goals and Expected Outcomes

57. Written goals need to be constructed clearly . Goals establish appropriate evaluation criteria to measure the effectiveness of planned nursing interventions Goals should meet immediate , long-term prevention and rehabilitation needs of the client. A short-term goal: an expectation to achieve the nursing diagnosis in a short period of time, in a few hours or days . L ong-term goal: expected to achieve over weeks or months Long-term goals is important in discharge planning , assists in coordinating all health care team to accomplish the same purpose, promotes continuity of care Consider the accuracy in identifying the etiology Planning Writing Goals

58. Used in the evaluation process by providing a standard for comparison . Expected outcomes are constructed to be: Realistic Mutually desired by the client and nurse Attainable within a defined time period Desired outcomes are the measurable steps toward achieving the previously established goals. E.O. may be written in spiritual, emotional, physiological, developmental & social dimensions. Each ND has one global goal & several expected outcomes. Expected Outcomes (E.O.)

59. Subject Task Statement Criteria Time Frame . Planning Components of goals & expected outcome include

60. Subject The subject identifies person who will perform desired behavior or meet the goal. The client is the person who needs to achieve a desired change in behavior. Task Statement the task statement or action verb . It enables the evaluator to determine achievement of observable behavior. Only one task statement should be used for each goal

61. Criteria Criteria are standards used to evaluate goal accomplishment. Criteria may include : 1. A time limit; 2. Amount of activity 3. Accurate performance 4. Description of the performance Conditions It is the conditions under which the client should perform or demonstrate mastery of the task. Time Frame It is the time in which the client should perform or demonstrate mastery of the task.

62. APPLICATION: RESTORATIVE CARE SETTING Fatima is recovering from orthopedic back surgery in a restorative care facility. A nursing diagnosis of Risk for Disuse Syndrome related to immobilization due to skeletal traction has been identified. The following factors need to be considered in writing the short-term and long-term goals for this client: Immediate needs: Maintenance of elimination patterns, promotion of skin integrity, preservation of effective breathing patterns, and minimization of long-term immobility Rehabilitative needs: Resumption of normal musculoskeletal function, ability to use assistive devices correctly, increase in activity tolerance, and enhancement of self-esteem and well-being The short-term goals should focus on maintenance of physiological patterns involving elimination, skin integrity, respiration, and mobility. The long-term goals should concentrate on the client’s return to maximal functional capability and independence Planning

63. Use a decision-making process to select appropriate nursing interventions. It is an action performed by a nurse to helps client achieve results specified by goals & expected outcome. Several nursing interventions are developed for each goals Interventions are prioritized according to order in which they will be implemented. Delivery of quality, individualized care is enhanced. Interventions can be developed from ND etiology . Example , for a client with angina with nursing diagnosis of Pain related to MI , an appropriate nursing intervention would be to help client conserve energy (bed rest). Planning Planning Nursing Interventions

64. The nurse may use various guidelines in selecting appropriate nursing interventions. These guidelines include The individual nurse practice acts, state boards of nursing standards, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for nursing care. In determining nursing interventions to use, the nurse should critically consider the consequences and the risks of each intervention . Select the most effective interventions with the minimum risk . After setting goals and planning the appropriate nursing interventions, the nurse writes nursing orders to communicate the exact nursing interventions that are to be implemented for the client. A nursing order is a statement within the realm of nursing practice. For example , a health care practitioner’s order to force fluids must be specified in nursing order as the number of milliliters/hour or per shift (e.g., 100 ml/h or Day shift = 800 ml; Evening shift = 800 ml; Night shift = 400 ml). Ensuring that nursing orders are well written requires several essential elements include: the 1. nursing order date , 2. action verb , 3. detailed description , 4. time frame , and 5. signature . TAXONOMY OF NURSING DIAGNOSIS

65. Nursing Interventions: Selection Guidelines ND: Acute Pain related to myocardial ischemia Goal: Client will resume normal activities of daily living. Expected Outcome: Client will verbalize relief of pain . Etiology : Myocardial ischemia Nursing Interventions : • Assess pain (location, quality, severity, duration, onset, relief. • At first signs of pain, instruct to relax and rest. • Instruct client to take sublingual nitroglycerin. • If pain continues after repeating doses every 5 minutes for three pills, notify practitioner. • Administer oxygen as prescribed. • Note time interval between episodes of pain. • Maintain bed rest and quiet environment. • Give analgesic medications as prescribed. • Offer assurance and emotional support Expe Outcome : pt will verbalize relief of pain.

66. PC: ABDOMINAL SURGERY PB: TD:____/____Ineffective breathing pattern r/t: op site/incision pain. EO: Respiratory rate & effort WNL with good chest expansion. 1: Ausculate breath sounds Q4H & PRN. Note diminished/absent sounds, rales wheezing, crackles, rhonchi . DOCUMENT IN NURSES' NOTES. 2: Assist pt to TCDB Q2H while awake. Support incision. DOCUMENT RESPONSE & EFFORT. PB: TD:____/____Potential for infection r/t surgical incision/indwelling cath. EO: Surgical incision healing w/out s/s of infection. 1: Assess for s/s of infection Q4H: (fever, chills, swelling, redness, pain, drainage, increased WBC, etc) PLAN OF CARE

67. PDOCUMENT IN NURSE'S NOTES. PB: TD:____/____Pain r/t_______________ surgical incision/operative site. EO: Pt reports pain relieved/ controlled. 1: Implement Patient Controlled Analgesia (PCA) Protocol and PCA Teaching Protocol. PB: TD:____/____Altered bowel elimination r/ t____________________surgery . EO: Pt' bowel elimination is normal within limits of surgical procedure. 1: Restart oral fluids gradually. Offer clear liquids frequently. 2: Observe for abdominal distention & evaluate tolerance when Pt begins taking fluid/foods post-op. DOCUMENT IN NURSES' NOTES. INT SIGNATURE PLAN OF CARE

68. Independent nursing interventions: Are nursing actions initiated by the nurse that do not require direction or an order from another health care professional. It include: activities of daily living, health education, health promotion, and counseling. Example : elevate a client’s edematous extremity. Categories of Nursing Interventions

69. Interdependent nursing interventions: Are those actions that are implemented in a collaborative manner by the nurse with other health care professionals. It allow nursing diagnoses to be resolved on basis of recommendations of an interdisciplinary health team approach. Example , a client care conference . Categories of Nursing Interventions

70. Dependent nursing interventions Those actions that require an order from another health care professional . Example: administration of a medication . Rationales should accompany nursing intervention. A rationale is an explanation based on theories & scientific principles of natural and behavioral sciences and the humanities. Categories of Nursing Interventions

71. Evaluating care involves determining the client’s progress toward achievement of expected outcomes . Effective planning is essential if evaluation is to be effective . In other words, the planned outcomes are the yardsticks by which effectiveness of therapies are evaluated. If there is no stated expectation of care (i.e., client outcome), how can progress be measured? Planning Evaluating Care

72. The plan of care is a written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health. Nursing care plans (NCP) usually include components such as assessment , nursing diagnoses , goals and expected outcomes , nursing interventions , and evaluations . NCP begins on day of admission and continually updates and individualizes the client’s plan of care until discharge. The plan of care directs the efforts of the entire health care team regarding each client. PLAN OF CARE

73. Assumes responsibility for the coordination of total nursing care. Use critical thinking in establishing collaborative relationships with members of health care team. Clear communication of the client’s plan of care to other health care personnel. Communicate care plan in clear , precise terms . Avoid using vague terminology such as improved, adequate, and normal.   Establish a realistic nursing plan of care to avoid setting a goal that is too difficult or impossible to achieve. Planning STRATEGIES FOR EFFECTIVE CARE PLANNING

74. P lanning includes: the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. Planning TAXONOMY OF NURSING DIAGNOSIS

75. Implementation

76. I mplementation , involves the execution of the nursing plan of care derived during the planning phase of the nursing process. It involves completion of nursing activities to accomplish predetermined goals and to make progress toward achievement of outcomes . Implementation phase begins with assessment and continually interacts with the other steps in the process

77. Implementation is a fulfillment of client needs that results in health promotion, prevention of illness, illness management, or health restoration . It involves delegation of tasks to staff members and assistive personnel and documentation of specific activities executed by the nurse and the client ’ s response to these activities. PURPOSES OF IMPLEMENTATION

78. REQUIREMENTS FOR EFFECTIVE IMPLEMENTATION Implementation phase requires cognitive (intellectual), psychomotor (technical), and interpersonal skills. Cognitive skills enable nurses to make appropriate observations , understand rationale for activities performed, and appreciate differences among individuals and how they influence nursing care . Psychomotor skills is necessary to safely and effectively perform nursing activities. Interpersonal skills involves communication with clients and families as well as with other health care professionals.

79. IMPLEMENTATION ACTIVITIES Establishment of priorities Ongoing assessment Allocation of resources Initiation of nursing interventions Documentation of interventions and client response

80. Implementation Continuous observations allow for adaptations to be made to better individualize care. Ongoing assessment demands attention to verbal and nonverbal cues from client and requires knowledge of expected responses to specific interventions. If nurses observe that responses are different from those expected, this can lead to a change in expected outcomes and accompanying interventions. Ongoing Assessment

81. Establishment of Priorities Following ongoing assessment and review of problem list , priorities are determined. Priorities are based on: Which problems are deemed most important by nurse, client , and family or significant others Activities previously scheduled by other departments (surgery, diagnostic testing) Available resources

82. Before implementing the nursing plan, nurse reviews proposed interventions to determine the level of knowledge and the types of skills required for safe and effective implementation . Assessment provides data for determining if an activity can be performed independently by client, can be completed with assistance from family, or requires assistance of health care personnel . Allocation of Resources

83. Delegation is process of transferring a selected nursing task to competent individual . Some interventions are complex and require the knowledge and skills of a RN , other interventions are simple &can be delegated to assistive personnel . RN authorized by law to provide care to clients and supervise & instruct others to deliver this care . RN is empowered to delegate tasks to others. Delegation of Tasks

84. Sample Worksheet of Nursing Activities Time Activity 6:45 am 7:00 7:10 7:30 8:00 8:30 8:40 9:15 10:00 10:15 10:30 11:45 Listen to change-of-shift report. Perform head-to-toe assessment, including vital signs. Check routine medication times. Chart assessment findings. Serve breakfast. While client eats breakfast, review chart for new laboratory test data, Record I&O after breakfast; remove breakfast tray. Gather supplies for hygiene. Assist with AM care. Assist up to chair. Show films about diabetic skin care. Document interventions and observations on chart. Review care plan for any needed revisions. Report status of client to charge nurse. Take and record vital signs.

85. Nursing Interventions A nursing intervention is an action performed by nurse that help client to achieve expected outcomes. All interventions must conform to standards of care Nurses should understand reason for intervention , expected effect , and potential problems may result. Nursing interventions are a blend of science (rational acts) and art (intuitive actions).

86. Types of Nursing Interventions Nursing interventions are written as orders in the care plan and may be: Nurse-initiated, Health care practitioner-initiated, or Derived from collaboration with other health care professionals. Interventions can also be categorized as: Independent Dependent, or Interdependent, depending on the authority required. Interventions can be implemented on the basis of standing orders or protocols.

87. The format for each intervention is as follows: label, name, definition, a list of activities that a nurse performs to carry out the intervention, and a list of background readings Nursing Interventions Classification

88. Nursing Intervention Activities Nursing interventions include: • Assisting with ADL • Delivering skilled therapeutic interventions • Monitoring and surveillance of response to care • Teaching • Discharge planning • Supervising and coordinating nursing personnel

89. Determining the efficacy of interventions is by evaluating clients ’ achievement of expected outcomes. The Nursing Intervention Classification (NIC), previously described, provides a systematic method for linking nursing activities to client outcomes. Evaluating Interventions

90. Communication through written documentation Nurse record all interventions &observations Documentation provides a legal record & allows communication with health care team members. Documentation is indicators for quality improvement. Form of documentation ( checklists, flow sheets, or narrative summaries). A complete description must be provided if there are any deviations from the norm or if any changes have occurred. Documentation of Interventions

91. Evaluation

92. E valuation is the fifth step in the nursing process and involves determining whether the client goals have been met, have been partially met, or have not been met. Evaluation is not only a part of the nursing process, but it is also an integral process in determining the quality of health care delivered.

93. EVALUATION OF CLIENT CARE Evaluation is the measurement of the degree to which objectives are achieved. Therefore, evaluating the care provided to clients is an essential part of professional nursing. “ Evaluation is a planned, systematic process . . . [that] compares the client’s health status with the desired expected outcomes”

94. The purposes of evaluation include: To determine the client ’ s progress or lack of progress toward achievement of expected outcomes To determine the effectiveness of nursing care in helping clients achieve the expected outcomes To determine the overall quality of care provided To promote nursing accountability

95. COMPONENTS OF EVALUATION Evaluation is a fluid process that is dependent on all the other components of the nursing process. Evaluation affects, and is affected by, assessment, diagnosis, outcome identification and planning, and implementation of nursing care.

96. Nursing Process Phase Evaluation Focus Assessment Data collection was thorough and complete. Data were collected from multiple, varied sources. Data were relevant to client needs. Appropriate methods were used to obtain data. A systematic, organized method was used in collecting data. Diagnosis Nursing diagnoses were client-centered, accurate, and relevant. Each nursing diagnosis was complete. Nursing diagnoses were comprehensive. Diagnoses were based on the collected data. Nursing diagnoses guided planning and implementation of care. Outcome identification and planning Expected outcomes were relevant to nursing diagnoses. Objectives were prioritized. Outcomes were realistic and achievable. Resources (including team members) were used efficiently. Nursing plans were documented.. Implementation Team members followed the plan of care. Necessary resources were available. Nursing actions assisted client in meeting expected outcomes. Client achieved expected outcomes

97. Techniques Effective evaluation results primarily from the nurse ’ s accurate use of communication and observation skills Both verbal and nonverbal communication between nurse and client can yield important information about accuracy of goals and expected planned outcomes and nursing interventions that have been executed for resolution of the client ’ s problems. The nurse needs to be sensitive to clients ’ willingness or hesitation to discuss their responses to nursing actions and must use the techniques of therapeutic communication to collect all necessary data.

98. Nursing audits examine data related to: • Safety measures • Treatment interventions & responses to interventions • Pre-established outcomes used as basis for interventions • Discharge planning • Client teaching • Adequacy of staffing patterns Nursing Audit A nursing audit is the process of collecting and analyzing data to evaluate the effectiveness of nursing interventions.

99. The aspects that need to be evaluated to determine the quality of health care are: • Appropriateness (the care provided adhered to standards and resulted in achievement of goals) • Clinical outcomes • Client satisfaction • Cost-effectiveness • Access to care • Availability of resources

100. Peer Evaluation Another method of evaluating quality of care is peer evaluation (also referred to as peer review ), the process by which professionals provide to their peers critical performance appraisal and feedback that are geared toward corrective action. According to the ANA (1988): Peer review in nursing is the process by which practicing Registered Nurses systematically assess, monitor, and make judgments about the quality of nursing care provided by peers, as measured against professional standards of practice.

101. MULTIDISCIPLINARY COLLABORATION IN EVALUATION Evaluating the quality of care provided is a responsibility shared among members of the health care team. In addition to those directly involved (the health care providers, clients, and families), others interested in the outcomes of evaluation include the community and third-party payers (both public and private reimbursement organizations).