ASN 180 Transition
to Professional
Nursing
III Overview of Patient Care
Objectives 1 & 2
Objectives
1. Discuss the nursing process to include:
a. Assessment
b. Nursing Diagnosis
c. Outcome Identification and Planning
d. Implementation
e. Evaluation
2. Apply the nursing process to common clients
concerns and issues.
Assessment
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Data collection step
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Thorough health and medical history
Physical Assessment
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Gordon’s Functional Health Patterns
Head-to-toe approach
Body System Approach
Hints for getting the most information
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Ask open-ended questions, i. e. can’t be
answered in one word
Listen and watch for cues: gasps, wincing
If the patient is unable to give information,
as significant other.
Use a standardized form.
DO NOT VIOLATE HIPPA
Nursing Diagnosis
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A three part statement that consists of:
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Problem (Nursing Diagnosis)
Etiology (“related to” statement)
Symptoms (“as manifested by” statement)
Use information from defining
characteristics and critical thinking skills to
develop Nursing Diagnosis
Steps to develop ND statement
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Cluster like characteristics together
Analyze/interpret the characteristics
Select a ND that fits with the appropriate
related factor and defining characteristics.
Writing the ND statement
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Write the ND label from the ND Handbook.
Write a phrase that describe the cause of
the “problem” (ND). Begin that statement
with “related to”.
The last phrase is the list of defining
characteristics that lead you to that
diagnosis. Begin that statement with “as
evidenced by – AEB”.
Planning
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Consists of:
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Measurable client outcomes
Nursing interventions
Rationales for interventions
Nursing-sensitive Outcomes (NOC)
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Select appropriate outcomes for the patient
from the list.
Make sure they are patient-specific and
measurable.
If you cannot find an outcome that fits your
patient, you may have selected an
inaccurate ND
Planning and Intervention
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Write the selected outcome/s in the Outcome
Criteria column.
Complete this statement below by finishing the
“as evidenced by (AEB)” phrase with a list of the
expected behaviors. Here is where you can be
specific on your measurements
AEB should basically be the opposite of AMB.
Planning and Intervention, cont.
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Select nursing interventions (NIC) that are
appropriate to your patient and write at
least three in the Nursing Interventions
column.
Make sure to include a date, day or
frequency in the statement. This helps the
next nurse know when to do or repeat
interventions.
Planning and Intervention, cont.
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For each intervention, you should have a rationale
(reason that it is appropriate) and cite the source
of that rationale.
You may use the NDH or any other relevant and
legitimate source, such as textbooks or EBP
studies.
If you use a source other than the NDH, or a
textbook you should provide a copy for the
instructor.
Intervention
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Writing the interventions on the care plan is
part of the Planning step of the Nursing
Process.
You don’t enact the Intervention step until
you implement the interventions.
Evaluation
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Did your patient meet the outcome?
Since your outcome was stated in a
measurable way, it is now easy to
determine if it has been met
.
Evaluation Column
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List the # of the outcome and write the word/s
“Met”, “Not Met”, or “Ongoing” as appropriate.
Then describe how it was “met” or “not met”
If it is “met”, congratulations, you succeeded
If “not met”, consider changing the interventions.
Use “ongoing” only if the NIC worked but there
was not enough time.
Important points
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The more your patient is involved in the
planning, the more likely it will succeed.
Write your plan clearly enough that any
caregiver that follows you knows the goals
and what to do.
Case Study
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History
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Mrs. Hogan, a 38-yo woman is admitted in
obvious respiratory distress. She is having
difficulty breathing with audible high-pitched
wheezing and has difficulty speaking. Gasping,
she states, “I am having a bad asthma attack., I
took my Albuterol and Vanceril, but they aren’t
helping. Her husband just started working at an
asbestos removal company.
More information
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Assessment:
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Expiratory wheezes and scattered rhonchi
throughout
Afebrile, 142/96, 88, 34, 86% O2 sat
Treatment
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2L O2 via NC
IV fluids
Albuterol nebulizer
Now let’s try a care plan
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Assess
Diagnose
Plan
Interventions
Evaluation
Objectives
1. Discuss the nursing process to include:
a. Assessment
b. Nursing Diagnosis
c. Outcome Identification and Planning
d. Implementation
e. Evaluation
2. Apply the nursing process to common clients
concerns and issues.