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