Disuses the fundamentals concepts of nursing. it discusses the nursing process, prioritization using the airway, breathing and circulation. it covers a case study and uses it to explain the nursing assessment and diagnosis.

1. Clinical Reasoning in
Nursing
Week #5 – Foundational Concepts of
Professional Nursing

2. Outcomes Identification

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.

11. Planning

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:

14. Planning
 Establish priorities
 Select Interventions

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)

16. Pneumonia Critical Pathway

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

20. Guidelines for Setting Priorities
 Life threatening issues
 ABC’s
 Safety issues
 “High” priorities
 Protect clients’ basic needs of
safety, adequate oxygenation &
comfort
 Physiological + Psychological

21. Nursing Interventions

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

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

33. Identify Nursing interventions for
the remaining Nursing Diagnoses
for Mrs. Payne

34. Mrs. Payne’s Diagnoses
 Impaired Physical Mobility
 Risk for Falls
 Functional Urinary Incontinence

35. Implementation

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

45. Implementation Methods
Delegating, supervising, and evaluating
others
Communicating nursing interventions
Providing written documentation
Oral communication

46. Evaluation

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?