1. Assessment
2. diagnosis
3. planning
4. implementation
5. evaluation

• (North American Nursing Diagnosis Association)
• developed a standardized terminology for identifying client problems (nursing diagnosis)
• A group of nursing  educators, theorists and advance practice nurses form US and Canada who develop standard terminology, content & format of nursing diagnoses
• Group meets every 2 years to revise/update the list of approved nursing diagnoses; new diagnoses are tested to evaluate appropriateness and usefulness

• Created by Center for Nursing Classification and Clinical Effectiveness at University of Iowa
• NOC: standardized terminology for nursing outcomes (Nursing Outcomes Classification [NOC]); describes general expected outcomes responsive to nursing interventions
• NIC: for nursing interventions (Nursing Interventions Classification [NIC]) 

• Symptoms
• usually obtained during a nursing history
• include client's own feelings, perceptions and descriptions of their health status
• Described verified and apparent only to the client

• Signs
• usually obtained during a physical examination
• observable and measurable
• felt, seen, heard, or smelled by the nurse

Primary Sources of Data

(Subjective)

What the client tells the nurse:

"my shoulder is really, really sore"

Primary sources of Data

(objective)

Data the nurse obtains through observation and examination:

the client is observed grimacing when attempting to brush her hair w/ her left arm

Secondary sources of Data

(Subjective)

what others tell the nurse based on what the client has told them:

"she told me that her shoulder is sore every morning"

Secondary sources of Data

(objective)

Data collected from other sources (e.g. family, friends, carefibers, health care professionals, literature review, medical records):

PT note in chart indicates that the client has decreased ROM of shoulder

• Collected during initial assessmnet (baseline data), focused assessment, and ongoing assessment
• Methods: observation, interviewing, physical exam, collaboration
• subjective data
• objective data

• recognize patterns or trends
• compare the data w/ normal standards
• arrive at diagnostic conclusions

Nursing Dx

(define)

Nursing Dx

("formula")

used to construct a nursing Dx

Problem statement r/t (related to) etiology AEB (as evidenced by) defining characteristics

signifies a problem that has common signs and symptoms that almost always present together

(used when a cluster of nursing Dx are often seen together [ex.  Rape-trauma syndrome related to anxiety about potential health problems and as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.])

1. goal
2. client outcomes

1. will identify the desired client status
2. will identify the observable criterion that will determine success or failure of the goal

1. client-centered
2. singular
3. observable
4. measurable
5. time-limited
6. mutually agreed upon
7. reasonable

• any treatment or action that the nurse performs to enhance/achieve the client's oucomes

Types of interventions

(Nurse initiated/ independent interventions)

• expected to benefit the client, based on scientific rationale
• initiated by the nurse based on the client's nursing Dx, health care needs, and w/i the nurse's scope of practice
• ex. turning the client every 2 hours to prevent skin breakdown

types of nursing interventions

(physician initiated/ dependent interventions)

nuse initiates as a result of a primary care provider's order or facility/ agency protocol

(ex. blood administration procedure)

types of nursing interventions

(collaborative interventions)

interventions the nurse carries out in collaboration w/ other HC team professionals

(ex. assuring client receives and eats his evening snack)

Nursing Care Plan

end product of the planning step

allows for quick identification of pt nursing Dx, outcomes, & interventions that need to be implimented

Implementation

(skills used)

1. intellectual skills (problem solving, creative and critical thinking)

2. interpersonal skills (therapeutic communication)

3. technical skills (psychomotor performance)

nurse determines the effectiveness of the nursing care plan

the nurse will compare what actually happened to the desired client outcome

"were the desired client outcomes met?"

"were the nursing interventions appropriate/ effective?"

"do the outcomes and/or interventions need to be modified?"

incomplete database

unrealistic client outcomes

nonspecific nursing interventions

inadequate time for client to achieve outcome

Problem Statement

(Nursing Dx)

• Standardized terminology created by NANDA
• brief phrase or term describing the client's response to actual or potential health problems
• directs the development of desired client outcomes
• descriptors or modifiers limiting or definig the diagnostic label

Etiology

(Nursing Dx)

• one or more probable causes of the health problem
• factors causing or contributing to the health problem
• related or risk factors of the health problem
• biological, psychological, social, developmental, treatment-related and situational factors contributing to the cause of the problem

Defining Characteristics

(Nursing Dx)

• Subjective and objective data obtained from client assessment
• cues and inferences that point to the existence of a particular diagnostic label

Q: subjective or objective data?

R: 22 bpm that is even and unlabored

Q: subjective or objective data?

"I can only walk 3 blocks before my legs start to hurt"

Q: By the second postop day a client has not achieved satisfactory pain relief.  Based on this eval. what should the nurse do next based on the nursing process?

a. reassess the client to determine the reason satisfactory pain relief has not been achieved

b. wait to see if pain lessens over next 24 hours

c. change plan to ensure that client achieves adequate pain relief

d. teach client about the plan of care that is being implemented to manage his pain

Q: when a nurse evaluated the care he has given a client, the client's responses to care are comparred with the

A. assessment data

B. nursing Dx

C. client outcomes

D. medical Dx

Q: the cues and inferences that the nurse uses to choose a nursing Dx label are considered the 

A. probable cause

B. defining characteristics

C. nursing interventions

D. goals

Q: in evaluation, the nurs must gather info about the client to

A. judge whether or not the client outcomes have been met

B. organize resources to proceed w/ implementing interventions

C. est. client-centered outcomes that are measurable and realistic

D. determine the priority nursing Dx and appropriate interventions

Determine the correct nursing process step for the following statement:

"identify the client's health problem"

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

assessment

(subjective data)

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Determine the correct nursing process step for the following statement:

Actual Nursing Dx

(rules for writing)

PRN

P=problem from NANDA list

R=related factors (NOT a medical Dx)

S=signs & symptoms (defining characteristics)

**Incorporating a medical Dx into a nursing Dx statement: secondary to the r/t portion

ex. diarrhea r/t GI disorder secondary to UC aeb watery bowel movements 5 times per day, abdominal distension, cramping w/ defication**

Risk Nursing Dx

(rules for writing)

PR

P=problem (NANDA)

R=related risk factors

risk impaired skin integrety r/t obesity, excessive diaphoresis, confinment to bed

Step #3: Planning

(4 Key steps)

1. Establishing priorities

2.Establishing outcomes

3. Determine interventions

4. Writing plan of care (POC)

Establishing outcomes:

(3 parts to a patient outcome)

1. problem- reverse statement of the problem in the PES/PR statement

2. expected outcome- what will be observed in patient after care is done to show the benefits of nurse care

3. target time- when pt is expected to be able to meet the outcome

ex. Nsg. Dx:

  Impaired physical mobility R/T musculoskeletal impairment AEB pain on ambulation, limited ROM, postural instability.

  Goal:

  Mr. J will demonstrate an improvement in physical mobility AEB ambulating 20 feet TID by 05-05-05.

• MUST be directed at altering the cause or related factors of the problem
• MUST aide in achieving pt oucomes
• MUST be safe for the pt
• MUST be individualized and compatible w/ the patient's goals and values
• MUST be based on Scientific Rationale
• MUST be congruent w/ other therapies
• MUST be ralistic for patient, hospital staff, and available rescources ($$)
• creates opportunity for teaching by the nurse explaining the rationale for the intervention