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Nursing Process
Nursing diagnosis, NOC, NIC, Intervention, and Evaluation
| Question | Answer |
|---|---|
| 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 |
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