Nursing process part seventh generation disinfectant

Nursing process

1. The Nursing Process
Part II
10/08/24 RMG 1

2. Planning & Outcome
Identification
Third step of the Nursing Process
This is when the nurse organizes a nursing care
plan based on the nursing diagnoses.
Nurse and client formulate goals to help the
client with their problems
Expected outcomes are identified
Interventions (nursing orders) are selected to aid
the client reach these goals.
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3. Planning
Involves setting priorities, stating client
goals/outcomes and selecting nursing
interventions
A care plan is developed, which acts as a
guide for patient/client care
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4. Prioritizing Problems
Place in order of importance or urgency
Maslow’s Hierarchy of Human Needs

Physiological

Safety and security

Love and belonging

Self-esteem

Self-actualization
A,B,C’s
Nursing Process
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5. Prioritize
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6. Planning – Begin by
prioritizing client problems
Prioritize list of client’s
nursing diagnoses using
Maslow’s hierarchy of
needs
Rank as high,
intermediate or low
Client specific
Priorities can change
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7. Planning
Developing a goal and outcome statement
Goal and outcome
statements are client
focused.
Worded positively
Measurable, specific
observable, time-limited,
and realistic
Goal = broad statement
Expected outcome =
objective criterion for
measurement of goal
Utilize NOC as standard
EXAMPLE
Goal:
Client will achieve
therapeutic management
of disease process….
Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of
understanding importance
of dietary sodium
restrictions by day of
discharge.
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8. Planning- Types of goals
Short term goals
Long term goals
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9. Short and Long Term Goals
Short term goals can be achieved in a reasonable
amount of time ( few hours to few days)
Long term goals may take weeks/months to be
achieved
Client will ambulate down the hall within 2
days.
Client will walk the length of the hallway
independently by the end of 2 weeks
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10. Achieving Goals/Outcomes
Be realistic in setting goals. (look at overall
health state, growth & development level,
prognosis)
Set goals mutually with client
Goals should be measurable, use measurable,
observable verbs
Identify one behavior per outcome
When indicated use short-term vs. long tern goals
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11. Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)
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12. Determining Interventions
Nursing interventions are actions performed by
nurse to reach goal or outcome
Monitor health status
Minimize client risks
Direct Care Intervention: Direct action
performed to client (inserting foley catheter)
Indirect Care Intervention: actions performed
away from client ( looking at lab results)
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13. Determining Interventions
Interventions will be collaborative, combining
nursing actions and physician orders.
Ineffective Airway Clearance related to
incisional pain
Nursing Actions: Ascultate breath sounds every
four hours, Assist with coughing and deep
breathing every hour etc.
Physician orders: pain medication, activity
orders
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14. Planning-select interventions
Interventions are selected and written.
The nurse uses clinical judgment and
professional knowledge to select
appropriate interventions that will aid the
client in reaching their goal.
Interventions should be examined for
feasibility and acceptability to the client
Interventions should be written clearly and
specifically.
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15. Interventions – 3 types
Independent ( Nurse initiated )- any
action the nurse can initiate without direct
supervision
Dependent ( Physician initiated )-nursing
actions requiring MD orders
Collaborative- nursing actions performed
jointly with other health care team members
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16. Nursing Rational
This is the scientific reason you did this for
your patient. Reason for choosing a
particular intervention. Tell us (cite) where
you got your information. This could be
yours, from your books or a reliable
internet source
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17. Nursing Care Plans
Written guidelines for client care
Communicates care and enhances continuity
Organizes information – promotes efficiency
Involves client and family
Meets requirements of accrediting agencies
Care plans help students learn problem solving,
skills of written communication, organizational
skills, and application of theory
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18. 10/08/24 RMG 18

19. 10/08/24 RMG 19

20. Implemention
The fourth step in the Nursing Process
This is the “Doing” step
Carrying out nursing interventions (orders)
selected during the planning step
This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating
physicians orders and monitoring cost
effectiveness of interventions
Utilize NIC as standard
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21. Implementing- “Doing”
Monitor VS q4h
Maintain prescribed diet
(2 Gm Na)
Teach client amount of
sodium restriction, foods
high in sodium, use of
nutrition labels, food
preparation and sodium
substitutes
Teach potential
complications of
hypertension to instill
importance of
maintaining Na
restrictions
Assess for cultural
factors affecting
dietary regime
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22. Implementing – “Doing”
Teach the client-
hypertension can’t be
cured but it can be
controlled.
Remind the client to
continue medication
even though no S/S
are present.
Teach client importance
of life style changes:
(weight reduction,
smoking cessation,
increasing activity)
Stress the importance of
ongoing follow-up care
even though the patient
feels well.
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23. Evaluation- To determine
effectiveness of NCP
Final step of the Nursing Process but
also done concurrently throughout client care
A comparison of client behavior and/or response
to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help client reach
stated goals.
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24. Evaluation
Outcome criteria met? Problem resolved!
Outcome criteria not fully met? Continue
plan of care- ongoing.
Outcome criteria unobtainable- review each
previous step of NCP and determine if
modification of the NCP is needed.
Were the nsg interventions
appropriate/effective?
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25. Evaluation
Factors that impede goal attainment:
Incomplete database
Unrealistic client outcomes
Nonspecific nsg interventions
Inadequate time for clients to achieve
outcomes.
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26. Checkpoint!
Identify which stage of the nursing process
is being described below:
The nurse writes nursing interventions
A goal is agreed upon
The nurse performs a physical assessment
A revision is made to the NCP
The nurse administers antibiotic medication
A statement is written that outlines the clients
response to a potential health problem
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