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Nursing Process

Nursing diagnosis, NOC, NIC, Intervention, and Evaluation

What do you do when creating a ND? Identidy pt's strengths and health problems
Patients will have.... more than one diagnosis
Diagnosis "To distinguish" "To know"
What is a Nursing Diagnoses? Pt's, family or community actual or potential health problem that can be prevented or resolved
Standard Nursing Diagnostis statements ANA and NANDA
Identifies diseases, physician directs primary treatment Medical Diagnosis
To write a ND you should Analyze data Identify pt's strengths and weakness Validate info Identify actual and potential problems
Nursing diagnoses describes... problems withing the scope of independent nursing practice
Relationship ND and Accountability NS -> Clear identification of the body of nursing knowledge -> Greater accountability -> Greater professional autonomy
Legal implications with ND If you identify the problem, YOU must decide if you are qualify to treat it and will accept responsability. If not you are still responsible for getting help
Actual ND A problem that has been validated (Evidence)
Potential ND Risk. Diagnosis pt is vulnerable to or for
Possible ND Need Additional information
Wellness ND Critical judgement that validate a desired level of wellness. Needs two cues to be validated
Sundrome ND Comprise a cluster of diagnoses that may be present or potential for because of a certain event or situation EX. Rape trauma syndrome
What should each ND contain? Definition, Defining characteristics and related factors
No problem No nursing response indicated BUT reinforce good habits and patterns. Promote health
Possible problem Collect more date
Actual or potential problem Begin planning, implementing, and evaluating care to reduce, prevent or resolve problem
What are strenghts? Functions like cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths
Resources for strength support people, adequate finances, healthy environment, mdecent health
Health Problem Person does not meet a standard of health or has limitation in an aspect of health status
Example of ND Acute Pain r/t tissue damange of right ankle and evidenced by crying, elevated VS, c/o pain 8/10, statements of "it hurts"
Why do we use NANDA ND?? to simplify and make diagnosis similar across the field.
Planning Establish pt's goals Identify priority ND Evidence based nursing intervention Document n communicate plan of care
Why do nurses plan care? Prevent, reduce or resolution of the problem and attainment of pts health expectations
Outcome should demonstrate progress or regression in improvement or resolution of pt's problem
Outcome/Goals Necessary part of planning phase
Initial Planning Developed by the nurse who performs the initial health history n physical assessment. Critical pathways used to plan care and individualized it to each individual
Ongoing Planning Carried out by any nurse. Adjusted and updated w/ pt's responses to intervention to keep plan current
Discharge Planning Best carried out by primary nurse or specialized nurse. Assure continuum of care
How should you prioritize ND? High - Greatest threat Medium - Not life threatning Low - Not related to problem
Maslow's Law 1. Physiologic needs 2. Safety Needs 3. Love n belonging 4. Self-esteem 5. Self-actualization
Short term goals Less than a week
Long term goals More than a week
NOC Opposite of problem. After finding diagnosis, make a statement and choose appropriate goals
Short term should support long term outcomes
NOC should be written in verbs describe, perform, verbalize, identify, reduce to, increase to, lose, gain, demonstrate
Parts of NOC Subject Verb Condition Criteria (how well will pt do) Time
NOC Example Pt will list a variety of five techniques that will avoid pain rising above a 4/10 within one week or by discharge
Intervention Actions that will help achieve goal
Physician initiated intervention Carrying out physicians prescribed orders
Collaborative intervention performed jointly by nurses n other healthcare team members EX. OT or PT
Nurse initiated intervention carried out by nurses w/o supervision or directing another healthcare member. EX. Turn pt q 2 h
Structure care methodologies intervention Nursing care is standarized (Critical pathways)
Consultation Intervention Nurses expand their nursing knowledge n discuss effective strategies
NIC What will nurse do to achieve goal.
Always Always include Teaching, learning opportunities
Implementation RN carries out plan of care by performing intervention and documentint, communicationg, collaborating, giving care.
Delegate Nursing Care Ethically and legally responsible for care when other help. Take frequent mini reports from unlicensed assistive personnel
Evaluation Evaluation of pt's achieved planned outcome (goal)
Cognitive evaluation Ask pt to repeat information or apply new knowledge
Psychomotor evaluation Ask pt to emonstrate new skill
Affective evaluation Observe pt's behaviors
Physiologic evaluation Perform physical assessment to evaluate physical changes in the pt
Created by: 635630362