This discusses the fundamental concepts of nursing. It convers the nursing process and goes through a case study to explain prioritization. it explains nursing diagnosis using the nursing process and the NOC outcome. it discusses assessment and the nursing diagnosis making reference the the NANDA nursing diagnosis and how all this are used to access patients on a case by case basis in order to create an effective care plan for patients.
3. NOC Outcomes (Goals) and Client (Expected) Outcomes
Broad versus Specific
NOC Outcome (Goal): Client’s lungs will remain clear
throughout postoperative period
Client Outcomes (Expected Outcomes):
Client will turn, cough & deep breath every hour
Client achieves 90% of incentive spirometer goal every 2 hours
Client’s lungs clear to auscultation on every 4 hour exam
Client daily chest x-ray shows no atelectasis
4. Assessment & Nursing Diagnosis
(Present State)
Assessment
Risk factors present that increase the vulnerability of developing pneumonia
Nursing Diagnosis
Risk for Infection related to reduced chest ventilation, environmental
microbiome change, reduced mobility, and intubation secondary to surgical
procedure
5. NOC Outcome
(Outcome State)
NOC Outcome (Goal):
Risk Control: Infectious Process
Client will remain infection-free (Ongoing outcome)
6. Mrs. Payne’s ND’s & NOC’s
Deficient Fluid Volume Fluid Balance
Client will achieve fluid balance
Imbalanced Nutrition: Less than
Body Requirements
Nutritional Status: Normal range or mild
deviation from normal range
Client will achieve balanced nutritional status
Impaired Physical Mobility Ambulation
Client will ambulate without impairment
Functional Urinary Incontinence Urinary Continence
Client will be continent of urine
Risk for Falls Fall Prevention Behavior
Client will not incur a fall
Risk for Impaired Skin Integrity Tissue Integrity: Skin and Mucous
Membranes
Client will be free of skin breakdown
Nursing Diagnosis - current state NOC Outcome - desired state
7. Client Outcomes
Short-term
To be achieved within a short time frame (often within a
week)
Long-term
To be achieved over a longer time frame (usually over weeks
or months)
8. Client Outcomes - SMART
Specific
Measurable
Attainable
Realistic
Time oriented
9. NOC (Broad) Client Outcome/Expected Outcome (Specific)
Tissue
integrity
Mrs. Payne will report any altered sensation or pain at coccyx at
least every 4 hours during waking hours.
Mrs. Payne’s NOC & Client Outcome
10. NOC Outcome & Client Outcomes
(Outcome State)
NOC Outcome (Goals):
Risk Control: Infectious Process
Client will remain infection-free
Client Outcomes (Expected Outcomes):
Client will independently turn, cough, and deep breathe every hour.
Client will return-demonstrate correct technique for incentive
spirometry after the initial instruction by the nurse.
Client will achieve 90% of incentive spirometer goal every 2 hours.
Client’s lungs will be clear to auscultation on every 4 hour exam.
Client’s daily chest x-ray will show no atelectasis.
13. ANA Practice Standard
The registered nurse develops a plan that prescribes
strategies to attain expected, measurable outcomes.
(ANA Nursing Scope and Standards of Practice, 2015)
Planning:
15. Establishing Priorities
Which problem needs immediate attention and which
can wait?
Which problems are your responsibility and which do
you need to refer to someone else?
Which problems will be addressed with standard plans?
(e.g. critical pathways & enhanced recovery after
surgery (ERAS) protocols)
18. Risk for Infection Ineffective Airway Clearance
Maintain respiratory function
Prevent occurrence
Improve respiratory function
Prevent complications
Support Recovery
Teaching
Disease process
Prognosis
Treatment
Nursing Priorities
19. Priorities
Which of the following client problems would you
need to address immediately & why?
Diarrhea
Severe dyspnea
Risk for deficient fluid volume
22. Types of Interventions
Independent Nursing Interventions
Actions that the nurse initiates; do not require an order from an other
health care professional
Autonomous actions based on scientific rationale
Dependent Nursing Interventions
Actions that require an order from another health care professional
The nurse intervenes by carrying out the providers order (s)
Collaborative/Interdependent interventions
Require combined knowledge/skill/expertise of multiple health care
professionals
23.
24. Nursing Interventions Classification (NIC)
Classification system (taxonomy) of nursing
interventions
Comprehensive list
Standardized language enhances communication
across clinical settings
Domains, classes, interventions
25. Selection of Nursing Interventions
Consider:
Characteristics of the nursing diagnosis
Goals and expected outcomes
Evidence base (research/existing practice guidelines)
Feasibility of intervention
Acceptability to the patient
Your own competency
26. Back to Mrs. Payne
Nursing Diagnoses
NOC and Client Outcomes
NIC and Nursing Interventions
27. NANDA-I NOC (Broad) NIC (Broad)
Deficient fluid volume Fluid balance Fluid management
Imbalanced nutrition: Less than body
requirements
Nutritional status: Normal range or mild
deviation from normal range
Nutrition management
Impaired physical mobility Ambulation Exercise therapy
Functional urinary incontinence Urinary continence Urinary incontinence care
Risk for falls Fall prevention behavior Fall prevention
Impaired tissue integrity Tissue integrity Pressure ulcer care
Mrs. Payne’s ND’s, NOC’s, & NIC’s
28. Mrs. Payne’s NIC & Nursing Intervention
NIC (Broad) Nursing Intervention
(Specific)
Rationale
(Reference)
Pressure ulcer care Inspect and monitor the coccyx at least
once every 8-hour shift for color
changes, redness, swelling, warmth,
pain or other signs of infection.
Systematic inspection can identify
impending problems early (National
Pressure Ulcer Advisory Panel, 2014).
29. Deficient Fluid Volume
NOC:
Fluid Balance
Client/Expected Outcomes:
Mrs. Payne’s urinary output will be 1200-1500 ml/day within 2
days
Mrs. Payne’s hematocrit will decrease to normal levels within 2
days
Mrs. Payne’s body temperature will return to normal levels
within 2 days
30. Deficient Fluid Volume
NIC:
Fluid Management
Nursing Interventions
Provide fresh water and oral fluids preferred
by client
Monitor intake and output every 4 hours
31. Nutrition imbalanced, less than body requirements
NOC:
Nutritional Status: Normal range or mild deviation
from normal range
Client/Expected Outcomes:
Mrs. Payne will eat at least 75% of each meal
while in the hospital
Mrs. Payne will gain 1 pound per week
32. Nutrition imbalanced, less than body requirements
NIC
Nutrition Management
Nursing Interventions
Offer nutritional supplements throughout the day and
encourage oral intake
Avoid interruptions during mealtimes and offer companionship
Weigh patient daily
Encourage high protein foods
37. Standards of Practice: Implementation
Implementation:
The registered nurse implements the identified plan.
5A: Coordination of Care
The registered nurse coordinates care delivery
5B: Health Teaching and Health Promotion
The registered nurse employs strategies to
promote health and a safe practice environment
(ANA Nursing Scope and Standards of Practice, 2015)
38. Implementation Components
Reassessing the client
Reviewing and revising the nursing care plan
Organizing resources and care delivery
Anticipating and preventing complications
Implementing nursing interventions
39. Reassessing the Client
During initial phase of implementation
Determine whether the proposed nursing action is still
appropriate
Changes in client status can necessitate modification of
plan of care
40. Reviewing and Revising Existing Care Plan
Review care plan and compare with assessment data
Modification includes
Revise assessment data
Revise diagnoses
Revise implementation methods
Determine methods of evaluation
41. Organizing Resources and Care Delivery
Equipment – ensure availability of needed items
Identify needed personnel
Optimize the environment
Prepare the client
Anticipate and prevent complications
Identify areas of assistance
42. Implementing Nursing Interventions
Cognitive skills
Application of nursing knowledge
Interpersonal skills
Communication with client, family and colleagues
Psychomotor skills
Skills used when providing direct nursing care
43. Implementation Methods
Assisting with activities of daily living
Feeding, bathing, dressing, grooming
Adjust assistance to changes in client condition
Counseling
Emotional, intellectual, spiritual, and psychological support
Teaching
Present principles, procedures, and techniques of health care to clients
44. Implementation Methods
Providing direct nursing care
Compensation for adverse reactions
Preventive measures
Correct technique in administering care
Lifesaving measures
48. ANA Practice Standard
ANA Practice Standard
Evaluation:
The registered nurse evaluates progress toward
attainment of goals and outcomes.
(ANA Nursing Scope and Standards of Practice, 2015)
49. Evaluation
Process of continually revising nursing care to meet
client’s changing needs
Utilize the same sources that you used to collect data
during the initial assessment phase
Compare newly collected data with expected outcomes to
determine if plan of care should be changed
50. Care Plan Modification
Reassessment
Evaluate nursing diagnoses
Evaluate goals and expected outcomes
Evaluate interventions
Appropriateness
Correct application
Modify care plan based on this evaluation
51. Think about Mrs. Payne
When her more immediate fluid status and nutrition issues
have been resolved, what are the remaining issues?
What about discharge planning?
What can we do to promote optimal care for Mrs. Payne
in the long term?