BACHELOR OF SCIENCE IN NURSING NCMA 113 (Fundamentals of Nursing) COURSE MODULE COURSE UNIT WEEK 2 6 7 PLANNING PHASE: TOWARDS GOALS AND OUTCOMES • • • • • • Read course and unit objectives Read study guide prior to class attendance Read required learning resources; refer to unit terminologies for jargons Proactively participate in classroom discussions Participate in weekly discussion board (Canvas) Answer and submit course unit tasks. Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts, process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition At the end of the course unit (CM), learners will be able to: Cognitive • Identify factors that the nurse must consider when setting priorities. • State the purposes of establishing client goals/desired outcomes. Affective • Distinguish between goals and expected outcomes. Psychomotor • Develop a patient centered goal on a given scenario. Nursing Diagnosis - This is a clinical judgment concerning human response to health condition/s, life processes or vulnerability for that response by an individual , family, or community that a nurse is licensed and competent to treat. Priority setting – This is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions. Nursing intervention - This is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. PLANNING • The nurse collaborates with the patient and the family and the rest of the health care team to determine the urgency of identifies problems and prioritizes patient needs. • A deliberative, systematic phase of nursing process that involves decision making and problem solving. Types of Planning 1. INITIAL PLANNING • admission assessment • initial comprehensive plan of care 2. ONGOING PLANNING • done by all nurses who work with the client, occurs at the beginning of the shift as the nurse plans the care to be given that day. • PURPOSES: - To determine whether the client’s health status has changed - To set priorities for the client’s care during the shift - To decide which problems to focus on during the shift - To coordinate the nurse’s activities so that more than one problem can be addressed at each client contact 3. DISCHARGE PLANNING • the process of anticipating and planning for the needs after discharge PLANNING PROCESS Setting Priorities Establishing client's goals Selecting nursing intervention Individualized Nursing Care Plan Writing The Planning Process A. SETTING PRIORITIES Priority setting is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions. This may use models such as: Maslow’s Hierarchy of Human Needs and the ABC’s of emergency care (AirwayBreathing-Circulation) Factors to consider: • Client’s Values and Beliefs- values concerning health may be more important to the nurse than to the client. • Client’s Priorities- involving client in prioritizing and care planning enhances cooperation. • Resources Available • Urgency of Health problem § HIGH - If untreated, result in harm to patient or others § INTERMEDIATE - Non-emergent, non-life threatening needs of the patients. § LOW - May not always related to a specific illness but affect the patient’s future well-being B. ESTABLISHING CLIENT’S GOAL GOAL – ultimate outcome OUTCOMES – measurable changes that must be achieved to reach a goal Patient-Centered Goal reflects a patient’s highest possible level of wellness and independence in function. It is realistic and based on patient needs, abilities, and resources. It is focused on PATIENT’s specific behavior NOT the nurse’s goal or interventions. Nursing-sensitive patient outcome is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions, such as: Reduction in pain frequency and severity Incidence of pressure ulcers Incidence of falls COMPONENTS OF GOAL/ DESIRED OUTCOME STATEMENT 1. Subject- a noun ( client, any part of client) 2. Verb- specifies an action the client is to perform 3. Conditions/ Modifiers- added to verb to explain –what, where, when, how? 4. Criterion of Desired Outcome- level at which client will perform specified behavior (time, speed, accuracy, distance, quality) GOALS MUST BE SMART! • Specific - Address only one behavior perception or physiological response. • Measurable - Quantify the expected change in physiologic findings, patient’s knowledge perceptions and behavior. • Attainable - Consider the patient’s desire to recover and their physical and psychological conditions. • Realistic - Set goals and outcomes within the patient’s limitations and abilities • Timed - Provide time frame (short term goal and long term goal) Patient ambulates in the hall 3 times a day by Friday SUBJECT Patient Specific? Yes, it states exactly what is expected of the client after the interventions. VERB ambulates Measurable? Yes, the goal stated that the patient must ambulate 3 times a day by Friday. CONDITION in the hall 3 times a day Attainable? Realistic? Yes, this goal Yes, the nurse can be attained considers the by the patient. current ability of the client and his condition. CRITERION by Friday. Timed? Yes, it must be achieved by Friday. C. SELECTING NURSING INTERVENTION NURSING INTERVENTION is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Must be evidenced-based. This includes direct and indirect care measures aimed at individuals, families and/or community. CATEGORIES OF NURSING INTERVENTIONS INDEPENDENT (Nurse-initiated) Actions that a nurse can perform without supervision or direction from others DEPENDENT (health care provider-initiated) Actions that require an order from the health care provider (doctor), such as: Administering medication Implementing an invasive procedure Preparing for diagnostic tests INTERDEPENDENT (Collaborative) These are therapies that require the combined knowledge, skill and expertise of multiple health care providers. Factors in choosing intervention 1. Desired patient outcome 2. Characteristics of the nursing diagnosis 3. Research base knowledge for the intervention 4. Feasibility for doing the intervention 5. Acceptability to the patient 6. Nurse’s competency Errors in writing intervention • Failure to precisely or completely indicate nursing actions wrong statement: Perform exercises on lower extremity correct statement: Perform ROM for flexion and extension of right knee; plantar flexion and dorsiflexion of right ankle, 3x a day • Failure to indicate frequency wrong statement: Administer pain medication correct statement: Administer Mefenamic acid 500 mg as ordered by the physician (3x a day or as necessary) • Failure to indicate quantity wrong statement: Irrigate wound once a shift. correct statement: Irrigate wound with 100 ml normal saline until clear; once every shift. • Failure to indicate method wrong statement: Change patient’s dressing daily correct statement: Apply transparent dressing to skin tear site daily. • Failure to precisely or completely indicate nursing actions wrong statement: correct statement: D. INDIVIDUALIZED NURSING CARE PLAN WRITING NURSING CARE PLAN § This includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient’s clinical needs and situation. § This may be subject to revision when the patient’s status changes implementation § This formally begins after the development of the plan of care. Preparations for implementation Time Management Equipment Personnel Environment Patient Implementation skills Cognitive Skills Interpersonal Skills Psychomotor skills Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts, process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition Seaback, Wanda (2007) Nursing process: concepts & application Singapore, Delmar Learning, 2nd edition Weber, Janet R. Kelley, Jane H. (2013) Health Assessment in Nursing Lippincott Williams and Wilkins, 5th edition Brooks, A. (2019, August 19). What Is a Nursing Intervention? A Beginner’s Guide. Retrieved from Rassmusen College: https://www.rasmussen.edu/degrees/nursing/blog/nursingintervention-beginners-guide/ Categorizing Care: A Guide to Nursing Interventions. (2017, July). Retrieved from Husson University: https://online.husson.edu/nursing-interventions-nic-system/ NANDA. (2020). NANDA Nursing Diagnosis List. Retrieved from NANDA Nursing Diagnosis List: http://www.nandanursingdiagnosislist.org/ Nurse Journal.org. (n.d.). The Value of Critical Thinking in Nursing + Examples. Retrieved from Nurse Journal: https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ Science Direct. (2019). Nursing Process. Retrieved from science Direct: https://www.sciencedirect.com/topics/nursing-and-health-professions/nursing-process • Write an appropriate goal and at least one intervention for each nursing diagnosis. 1. Kenneth Ramos has experienced intermittent nausea for approximately six months due to a possible gastric ulcer. He states, “I know I should eat, but when I eat, I hurt.” He has lost 28 pounds since his last annual checkup and weighs less than ideal for his height. His nurse identifies the nursing diagnosis: Imbalanced Nutrition: Less than Body Requirements; RT: inability to ingest nutrients as a result of biological factors; AEB: reported food intake less than recommended daily allowance; weight loss of 28 punds over last year. 2. Karen Ignacio, a neonate, is experiencing a fluctuation in her body temperature from normal to below normal range. Her nurse discovers that Karen’s mother does not keep her covered appropriately. The nurse identifies the nursing diagnosis: Risk for Hypothermia; risk factors: exposure to cool environment, inadequate clothing, extremes of age (newborn). 3. Mr. delos Reyes had abdominal surgery one day ago. He has a medical history of diabetes mellitus and must take morning and evening insulin subcutaneously. His nurse identifies the nursing diagnosis: Risk for Infection; RT inadequate primary defenses (surgical incision/broken skin), increased environmental exposure, chronic disease, invasive procedures. 4. Mr. Santiago states he has been travelling out of the country. Since his return last week, he has been experiencing abdominal cramping and several liquid stools. The nursing diagnosis is identified is Diarrhea RT: gastrointestinal disorder; AEB: abdominal cramping, increased frequency of defecation, liquid stools. 5. Grace was admitted to the hospital diagnosed with pneumonia. Assessment reveals bilateral wheezes in the midanterior lung fields and mild dyspnea. The nurse observes Grace coughing up copious amounts of thick, yellow sputum. The nursing diagnosis is identified as Ineffective Airway Clearance; RT; tracheobronchial infection; AEB: abnormal breath sounds (wheezes), productive cough, dyspnea.
