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Nurse Caring Concepts 1A
Week 7: September 27, 2004
• Priority nursing diagnoses: those that will, if not managed, will:
- Negatively affect client functional status
- Deter progress toward outcomes
• Nursing diagnoses should be:
- Appropriate for the individual client
- Realistic; amenable to nursing intervention
- Relevant to the setting and length of stay
• Reevaluate your list of selected priority nursing diagnoses to be sure that all needs are accounted for
• Care plan with 3 – 5 nursing diagnoses are manageable
• Prioritize nursing diagnoses based on:
- Maslow’s hierarchy
- Client’s condition & needs
1

• NANDA label describes human responses that are problems. Usually, the healthy alternative is goal that patient wants to achieve
• To identify a goal, ask yourself:
- If problem were solved, reduced (actual nsg dx) or prevented (risk nsg dx), how will patient look or behave?
- What will you see, hear, palpate or observe?
• Establish goals with patient (if possible)
• Long term goal: expected to be achieved over weeks or months
• Short-term goal:
- Expected to be achieved in shorter time period (hour, day, week)
- Often stepping stone on way to reaching long-term goal
2

• Statement that reflects client’s:
- Resolution of a problem
- Progress towards resolution of a problem
- Prevention of a problem
• Should be attainable, realistic & represent a greater level of achievement for client
• Should not conflict with MD orders
• Describes a measurable behavior that
- Nurse can validate by seeing or hearing, or
- Client can measure subjectively & describe
• Only one action verb per goal
• Describe something that the client (or any part of client) will do, not something nurse will do
• Attainable & realistic in time frame specified
• Specify content - what is to occur (will lose 5 lbs)
• Specify time - when it is to have occurred ( during my shift, in 24 hours, by discharge, prior to surgery, at all times, by end of discussion)
• Impaired Tissue Integrity r/t destruction of tissue 2° pressure and friction AMB stage II pressure ulcer on coccyx
• Long term goal: (Client’s) Pressure ulcer will heal within two months
• Short term goal: (Client will) Demonstrate 3 measures that she can do to prevent pressure ulcers during my shift
3

• Fear r/t anticipated dependence 2° nursing home rehab admit AMB statement “I am afraid that I will never go home”
• Long term goal: (Client will) Report an increase in psychological comfort before discharge to LTC
• Short term goals:
- (Client will) Discuss fears with RN today (9/27)
- (Client’s) Pulse & respiratory rate will be WNL following discussion with RN today (9/27)
• Goal Includes two action verbs
- Incorrect: Describe the four basic food groups and choose a balanced diet for lunch
- Correct: Describe the four basic food groups
• Goal lacks specificity:
- Incorrect: Client will walk 5 ft by 1100 on 9/29
- Correct: Client will walk 5 ft with walker by
1100 on 9/29
• Goal is not time targeted:
- Incorrect: Client will walk independently from her room to the nurses’ station and back again
- Correct: Client will walk independently from her room to nurses’ station & back by 1430 today
• Outcome is not specific or concrete:
- Incorrect : Client’s BP will be WNL today
- Correct : Client’s BP will be <130/80 today
4

• Is stated in negative, rather than positive terms:
- Incorrect: Client’s skin will not become ulcerated
- Correct: Client’s skin will remain intact
• Is stated in terms of nurse activities, rather than patient goals
- Incorrect: Prevent infection of incision
Correct: Incision will remain free of infection as evidenced by well approximated edges & absence of redness & drainage
• Outcome is not observable or measurable:
- Incorrect : Client will know which high sodium foods to avoid after teaching session today
- Correct : Client will name six high sodium foods to avoid after teaching session today
- Incorrect : After discussion, client will be less anxious
- Correct : After discussion, client will report that she feels less anxious
• Planning
- Selecting nursing interventions to assist patient in achieving goals
• Implementation
- Performing the interventions identified in the planning step
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• Development of nursing strategies to prevent, reduce or eliminate identified problems
• Purpose is to provide:
- Consistent, individualized approach to care
- Direction to health care team
- Focus charting requirements
• Activities of planning step
- Planning nursing interventions
- Writing holistic nursing care plan
• Initial planning: RN who performs admission assessment should develop initial comprehensive care plan
• Ongoing planning: Done each shift by any nurse who works with client
• Discharge planning: Begins with admission & continues until discharge
Action nurse performs on behalf of patient
Major focus:
• Actual diagnoses
- Reduce or eliminate related factors
- Promote higher level of wellness
- Monitor status
• Risk diagnoses
- Reduce or eliminate risk factors
- Prevent reoccurrence of the problem
- Monitor for onset
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• Independent: RN prescribes & performs or delegates
(includes physical care, emotional support & comfort, teaching, counseling)
• Dependent: MD prescribes & RN is responsible for performing (includes medications, IVs, diagnostic tests, treatments, diet & activity)
• Interdependent: Nurse carries out in collaboration with other health team members (PT, RT, etc)
• Textbooks: Carpenito, Craven & Hirnle; Lewis,
Heitkemper & Dirksen
• Standardized care plans: Carpenito, Craven &
Hirnle, Lewis, Heitkemper & Dirksen, hospitalspecific care plans
• Hospital-specific policy/procedure manuals
• Nursing literature (peer-reviewed journals; online sources)
• Other healthcare professionals
• Your own ingenious, individualized idea
• Consistent with standards of care
• Based on scientific research
• Realistic in terms of client abilities & resources
• Congruent with patient’s values & beliefs
• Realistic in terms of nursing/facility abilities & resources
• Compatible with medical orders
7

• Begin with verb
- All interventions are performed by RN
- Is understood (but not written) that each begins with words “RN will”
- Incorrect: Needs to be suctioned
- Correct: (RN will) Suction oropharynx PRN
• Individualize for patient needs
- Generic: Encourage PO fluid intake
- Individualized: Encourage PO fluids intake; patient prefers room temperature water
• Are specific enough to be interpreted easily
- Incorrect: Restrict fluids
- Correct: Restrict oral fluids to 1000 cc/24 hrs
• Do interventions provide patient with means to achieve goals?
- If long term goal is:
Client will gain five pounds by 0600 on 9/28
- Must be an intervention that stipulates:
Weigh patient daily at 0600
• Do interventions address all aspects of the etiology?
- Constipation r/t habitual laxative use, inadequate fluid intake & decreased peristalsis 2 °lack of exercise
• Written guideline; blueprint for action
- Directs care
- Documents the client’s health care needs
- Communication between nurses and other health care professionals
- Designed to decrease the risk of incomplete, incorrect or inaccurate care
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• More elaborate than those used in hospitals or other healthcare agencies
• Essential for learning:
- Nursing process
- Skills of written communication
- Organizational skills needed for nursing care
- Application of theory to clinical practice
• Scientific rationale (with reference citation) is required to support each intervention selected and should be able to “stand alone.”
• Intervention: Teach client to avoid caffeinecontaining foods & beverages after noon
• Scientific Rationale :
- Incorrect: “Can produce wakefulness”
- Correct: R: "Caffeine and nicotine are CNS stimulants that lengthen sleep latency and increase nighttime wakening" (Miller as cited in Carpenito-Moyet, 2004, p. 729).
• Nursing diagnosis listed in order of priority in
1st large column
• Goals corresponding to each nursing diagnosis in 2nd large column
• Specific nursing interventions in 3rd large column followed by scientific rationale and reference
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• Action phase of nursing process during which care plan is initiated
• Implementation Skills
- Cognitive: Problem-solving, decision-making, critical thinking
- Interpersonal: in every patient contact
- Psychomotor: performing a variety of hands-on skills
• For your primary client:
- 1 complete nursing diagnosis statement
- 1 long term and 1 short term goal
- 3 interventions with supporting scientific rationale & reference citation
P Nursing Diagnosis
R
Nursing
Diagnosis
Statement
Outcome Criteria
Long term goal
Short term goal
M Interventions
O
1. Intervention.
Scientific Rationale
(Author, year, p.#)
2. Intervention.
Scientific Rationale
(Author, year, p.#)
3. Intervention.
Scientific Rationale
(Author, year, p.#)
T
C
Evaluation
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