FUNDAMENTALS OF NURSING MODULE 4-6

MODULE 4-6
 result oriented
Test Coverage:  designed to help you stay focused on getting the best
results in the most efficient way .
M4 – Overview of nursing process
 Nursing process PRO-ACTIVE
M5-Diagnosis
Lesson 1: Key terms related to diagnosis  emphasizes the need to not only treat problems, but
Lesson 2: How to make definitive diagnoses also
Lesson 3: Types of nursing diagnosis  maximize health by managing risk factors & by
Lesson 4: Comparison of nursing diagnosis to medical Diagnosis. encouraging healthy behaviors
M6- PLANNING
EVIDENCE-BASED
 it mandates that judgments, decisions, & actions be
MODULE 4: NURSING ASSEMENT AND PROCESS based on the best evidence than guesswork
OVERVIEW OF NURSING PROCESS  strict documentation requirements ensure that we
have the data we need to manage care & help
 a deliberate activity whereby the practice of nursing is researchers study care practices & improve them
performed in a systematic manner
 the foundation, the essential, enduring skill that has INTUITIVE & LOGICAL
characterized nursing from the beginning of the
 principles of nursing process push you to
profession
acknowledge patterns & intuitive hunches, then to
 A SYSTEMATIC & OUTCOME ORIENTED method
look for evidence that supports your intuition
that nurses use to expedite diagnosis and treatment of
actual and potential health problems
consists of 5 INTERRELATED STEPS ;
REFLECTIVE, CREATIVE & IMPROVEMENT-
 Assessment, Diagnosis, Planning, Implementation & ORIENTED
Evaluation which serves as CRITICAL THINKING  stresses the need for on-going evaluation, requiring
MODEL FOR NURSING. to continually reflect on both patient responses
(outcomes) &practice (how we give care) so that
PURPOSE OF NURSING PROCESS corrections can be immediately done
 requires to work continually to improve nursing care,
 ☺ to provide a systematic methodology for nursing encouraging one to think creatively about how to get
practice: better results in easier, more efficient, less costly
 ☺ it unifies, standardizes, and directs nursing practice ways.
 ☺ help the nurse continually assess & reassess the
patient’s response to illness & then plan appropriate NURSING PROCESS
care in any setting for illness care or health promotion

CHARACTERISTIC OF THE NURSING PROCESS

THAT PROMOTE CRITICAL THINGKING

PURPOSEFUL & DELIBERATE

 each step has specific principles and rules designed
to achieve a specific purpose

HUMANISTIC
 must consider unique interests, values, desires and
culture
 guides you to focus holistically on the body, mind & PRINCIPLES OF NURSING PROCESS (ACODE)
spirit
 pushes you to consider health problems in context of  A cognitive process
how they impact on sense of well-being and ability to  Client centered
do desired activities  Outcome-directed;
 Systematic problem-solving approach
SYSTEMATIC  Dynamic and cyclic
 Encourages medical diagnosis.
 five steps guide you to think systematically about
what’s STEPS OF THE NURSING PROCESS
 most important & to take deliberate steps to maximize
efficiency 1. ASSESSMENT
 Collect & Record all information needed to
STEP - BY – STEP, YET DYNAMIC be able to:
 to ensure that nothing important is missed  Predict, detect, prevent, manage, or eliminate health
problems
OUTCOME- FOCUSED & COST EFFECTIVE  Clarify expected outcomes (results?)

LOREY MANALO 1
  Develop a comprehensive plan  collecting, organizing and communicating / recording
client data

Purpose:
2. DIAGNOSIS  to establish data base about the client’s response to
 Analyze assessment data, draw conclusions, health concerns or illness and the ability to manage
and determine: health care needs
 Actual and potential health problems and their
cause(s) CHARACTERISTICS OF AN ASSESSMENT THAT
 Presence of risk factors PROMOTES CRITICAL THINKING
 Resources, strengths, use of healthy behaviors
 Health states that are satisfactory but could be improved PURPOSEFUL
 your aim is to gain all the information needed to
3. PLANNING ensure that your patients have “individualized
 Clarify expected outcomes, set priorities, and plans”
determine interventions. The interventions
aredesigned to: FOCUSED & RELEVANT
 detect, prevent, and manage health problems and risk  Must be focused to gain relevant information,
factors depending on purpose and context
 promote optimum function, independence, and
sense of well-being SYSTEMATIC
 achieve the expected outcomes safely and efficiently.  Helps pay attention to what’s important, learn
how to prioritize,be comprehensive, and avoid
omission errors.
4. IMPLEMENTATION
 Put the plan into action by: COMPREHENSIVE & ACCURATE
 Assessing appropriateness of (and readiness for)  factual & complete
interventions
 Performing interventions, then reassessing to RECORDED IN A STANDARDIZED WAY
determine initial responses  value the importance of completing a
 Making immediate changes as needed standardized tool designed to promote an
 Charting to monitor progress assessment that’s purposeful, relevant,
systematic and complete.
5. EVALUATION
 Assess the patient to decide whether expected outcomes 2 MAIN TYPES OF ASSESMENT
have been met
 Then decide whether to discharge the patient or modify the
 Data Base Assessment
plan as appropriate, and you plan for ongoing continuous
 “start of care” assessment
assessment and improvement.
 Comprehensive information gathered on
initial contact with the person to assess all
aspects of health status
NURSING PROCESS  Focus Assessment
ASSESMENT  Data gathered to determine the status of a
specific condition

ASSEMENT ACTIVITIES.

1. Collecting Data
2. Identifying Cues & Making Inferences
3. Validating / Verifying Data
4. Organizing / Clustering Data
5. Identifying Patterns / Testing First Impressions
6. Reporting and Recording Data

DATA GATHERING PROCEDURE

PRIMARY SOURCE
ASSESMENT  Client / patient

SECONDARYSOURCES
 systematic, deliberate process
 Significant others
 continuous data collection  Nursing & Medical Records
 analyzes data about the patient, client’s human  Verbal & Written Consultations
response, health status, strengths and concerns
 Diagnostic / Laboratory Studies
 finding all the “necessary puzzle pieces” to get a
picture of your patient’s health status

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The most up-to-date information comes from your direct  Opening → sets the tone of the remainder of the
assessment of the patient. interview.
ASSEMENT ACTIVITY 1.Establish rapport → process of creating good will and trust
2. Orientation → explaining the purpose and nature of the
COLLECTING DATA interview
 Data Collection Skills
 Body → client communicates what he or she thinks, feels,
A. Observation of patient knows and perceives in response to questions from the
B. Interview of patient, family & nurse
other nurses  Closing → important in facilitating future interactions.
C. Examination of Patient
D. Medical Record Review
DATA COLLECTION SKILL
A. OBSERVATION
• noting pieces of information or cues through the use of senses C. EXAMINATION OF THE PATIENT (PHYSICAL
(sight, touch, hearing, smell and taste). ASSESSMENT)
It has to be:
➢ THOROUGH
B. INTERVIEW ➢ SYSTEMATIC
• a structured form of communication that the nurse uses to ➢ SKILLED
collect data face to face
EXAMINATION OF THE PATIENT APPROACHES:
KEYPOINT FOR INTERVIEW
> Head-to-toe Assessment/Cephalocaudal
> Body System Approach
 ability to establish rapport
 ability to ask questions
EXAMINATION OF THE PATIENT
 ability to listen is essential to successful interviews
 ability to observe SKILLS USED IN PHYSICAL EXAM:
 Inspection / Visualization
INTERVIEW  Palpation
 Percussion
DIRECT INTERVIEW
 Auscultation
 Highly structured and elicit specific information by
D. MEDICAL RECORD/S REVIEW
asking closed questions that call for a specific amount
PURPOSES:
of data.
 To relate the past health care history of the patient to
INDIRECT INTERVIEW
the present episode
 The nurse allows the client to control the purpose,
subject matter and pacing  to identify what medication the patient is taking so that
the assessment can include the effectiveness of the
medication & the occurrence of any side effects
KINDS OF INTERVIEW QUESTION COLLECTING DATA
CLOSE ENDED Data Collection Format
 restrictive and generally require only short answers
giving specific information; often begin with when,
 Maslow’s Basic Need Frameworks
where, who, what, do, does, did.
 Henderson’s Components of Nursing Care
 Gordon’s Functional Health Patterns
OPEN-ENDED
 lead or invite clients to explore their thoughts or  Nanda’s Human Response Patterns
feelings.  Nursing Theories
 Human Growth & Development.
PLANNING THE INTERVIEW AND SETTING
IDENTIFYING SUBJECTIVE & OBJECTIVE DATA
 Time → need to be scheduled when the client is
comfortable and free of pain Subjective Data
 Place → must have adequate privacy to promote  information given verbally by the patient
 communication
 Seating arrangement Objective Data
 Distance → most people feel comfortable 3 to 4 ft.  factual data that are observed by the nurse & could
apart during an interview be noted by any other skilled observer

STAGES OF AN INTERVIEW

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  Double check that your equipment is working
TYPES OF DATA correctly.
SUBJECTIVE DATA  Recheck own data
- symptoms or covert data  Look for factors that may alter accuracy
e.g. – itching pain, feelings of worry include  Ask someone else, preferably an expert, to collect
client’s sensations, feelings, values, beliefs, attitudes and the same data
perception of personal health status and life situations.  Compare subjective & objective data to see if what
the person is stating is congruent with what you
Problem: Fever → subjective cue: “Mainit ang observe
pakiramdam ko.”  Clarify statements and very your inferences with
the patient
OBJECTIVE DATA  Compare your impressions with those of other key
 signs or overt data members of the health care team.
•detectable by an observer or can be tested against
an accepted standard 4. ORGANIZING /CLUSTERING DATA
e.g. – discoloration of the skin RULE:
Problem: FEVER
Objective cues: skin is warm to touch Cluster your data according to your purpose
temperature is 38.9 C
 to identify nursing diagnoses and problems
 to identify signs and symptoms of possible medical
problems
 to set priorities
 clustering data one way, then clustering it another
way helps you think critically

ORGANIZING / CLUSTERING DATA

ASSEMENT ACTIVITY

2. IDENTIFYING CUES & MAKING INFERENCES

CUES
 the subjective & objective data identified MASLOW’S HIERARCHY OF NEEDS
INFERENCE  Used to set priorities
 how one interprets or perceive a cue  Physiologic- vital signs, nutrition, sex, pain
 Safety and security-energy level, presence of risk
factors
3.VALIDATING /VERIFYING DATA  Love and belongingness- Family and relationship
Advantages  Self-esteem- honors, awards, recognitions
It helps one to avoid:  Self-actualization- self-fulfillment, selfless service
 Making assumptions ABC (AIRWAY BREATHING CIRCULATION)
 Missing key information  Used to set priorities
 Misunderstanding situations  I.E. Bleeding-circulation, Difficulty of Breathing-
 Jumping to conclusions or focusing in the wrong Airway and Breathing
direction
 Making errors in problem identification BODY SYSTEM
 Used to identify signs and symptoms of possible
GUIDELINES IN VALIDATING/VERIFYING DATA medical problems
 I.E. Body systems- cardiovascular, respiratory,
 Data that can be measured accurately can be lymphatic systems
accepted as factual.
 Data that someone else observes (indirect data) may GORDON’S FUNCTIONAL HEALTH PROBLEMS
or may not be true.  Used to identify nursing diagnosis and problems
 Psychological, Elimination, Rest and Sleep,
Validate questionable information by using the ff. Oxygenation, Nutrition… etc.
techniques, as appropriate:
 Double check information that’s extremely
abnormal or inconsistent with patient cues

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5.IDENTIFYING PATTERNS / TESTING FIRST
IMPRESSIONS NURSING DIAGNOSIS

 involves deciding what’s relevant & irrelevant,  it refers to a problem statement that nurse makes
making tentative decision about what the data regarding a patient’s condition
suggests  a clinical judgment about the patient’s response to
 focusing assessment to gain more information to actual or potential health conditions or needs
better understand the situations at hand  provides the basis for prescriptions (interventions) for
 remember cause & effect; find out why or how the definitive therapy for which the nurse is accountable
pattern came to be  expressed concisely and includes the etiology of the
condition when known.
6. REPORTING & RECORDING
MODULE 5: DIAGNOSIS
Report abnormal findings as soon as possible LESSON 1: KEY TERMS RELATED TO
DIAGNOSIS
 Before reporting, take a moment to be sure you have
all the necessary information readilyat hand COMPETENCY
 jot down the facts in order of importance
 give precise information, state the facts rather than
how you interpret the facts  having the knowledge and skills to identify problems
and risks and to perform action safely & efficiently in
various situations.
TO SUMMARIZE……….
Nursing Assessment includes: QUALIFIED
1. Collecting Data
2. Identifying Cues & Making Inferences  being competent and having the authority to perform
3. Validating / Verifying Data an action of give a professional option.
4. Organizing / Clustering Data
5. Identifying Patterns / Testing First Impressions NURSING DOMAIN
6. Reporting and Recording Data
 actions a nurse is legally qualified to perform
MODULE 5: DIAGNOSIS
NURSING PROCESS: DIAGNOSIS MEDICAL DOMAIN

 activities and actions a physician is legally qualified to

perform depending on state regulations, APN are also
legally qualified to perform some things in the medical
domain.

ACCOUNTABLE

 being responsible and answerable for something

DEFINITIVE INTERVENTIONS

 most specific actions or treatments required to prevent,

resolve, or manage a health problem.

OUTCOME
‘’The nurse analyzes the assessment data in determining
health problems’’  the result of prescribed interventions, usually referred
to as desired result of interventions, includes a specific
time frame when the outcome is expected to be
DIAGNOSING
achieved.
 a form of decision making that the nurse uses to
SIGNS
arrive at judgments and conclusions about patients’
responses to actual or potential health problems
 objective (observable data) known to suggest a health
DIAGNOSE problem.

 To make judgment and specifically name actual and SYMPTOMS

potential health problems or risk factors present,
based on evidence from assessment data.

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  subjective (reported) data known to suggest a health  the conclusions you make during this phase affect
problem. the entire plan of care.
 To identify client strengths and health problems that
CUES can be prevented or resolved by collaborative and
independent nursing interventions
 signs and symptoms that prompt you to suspect the  To develop a list of nursing and collaborative
presence of a health problem or desire to improve problems
health.
NURSING PROCESS-DIAGNOSIS

 The accuracy & relevancy of the entire plan depends

DEFINITVE DIAGNOSIS on your ability to clarify the problems and what factors
are causing or contributing to them if you make errors
in this phase, your whole plan may be USELESS,
 most specific, most correct diagnosis that clearly
even DANGEROUS.
identifies both the problem and the cause.
MODULE 5: DIAGNOSIS
DEFINING CHARACTERISTICS LESSON 2: HOW TO MAKE DEFINITIVE DIAGNOSIS
 a cluster of signs and symptoms, and related factors  Diagnostic process involves critical thinking skills of
usually seen with a specific nursing diagnosis. analysis and synthesis
 In critical thinking, a person reviews data and
RULE OUT considers explanations before forming an opinion.
 Analysis is the separation into components, that is,
 to decide that a certain problem is NOT present. the breaking down of the whole into its parts
(deductive reasoning) Synthesis the putting together
RELATED FACTOR of parts into the whole (inductive reasoning)

 something known to be associated with specific health

problem (history of frequent falls is a related factor to STEPS HOW TO MAKE DEFINITIVE DIAGNOSIS
RISK FOR INJURY)
1. Analyzing data
2. Identifying health problems, risks, and strengths
RISK FACTOR ETIOLOGY
3. Formulating diagnostic statements

 something known to cause, or contribute to a diagnosis

(decreased vision is a related factor for RSK FOR ANALYZING DATA
INJURY)

DIAGNOSIS 1. Compare data against standards (identify significant cues).

2. Cluster the cues (generate tentative hypotheses).
3. Identify gaps and inconsistencies
Becoming a competent DIAGNOSTICIAN
 Act in your patient’s best interest, and protect yourself
1. Compare data against standards (identify significant
from legal problems, you must understand the key
cues). A cue is considered significant if it does any of the
terms to DIAGNOSIS
following:
LEGAL IMPLICATION OF THE WORD DIAGNOSIS a. Points to negative or positive change in a client’s health status
or pattern.
 The word DIAGNOSIS implies that there’s a situation b. Varies from norms of the client population.
or problem requiring appropriate, qualified treatment. c. Indicates a developmental delay.
 This means if you identify a problem, you must decide
whether you’re qualified to treat it or willing to accept 2. Cluster the cues
responsibility for treating it.  determine the relatedness of facts and
 If you’re not, you’re responsible for getting qualified  determining whether any patterns are present, whether
help. the data represent isolated incidents, whether the data
are significant.
PURPOSES OF NURSING DIAGNOSIS  it involves making inferences
 Interpret the possible meaning of the cues, labels the
 To provide the basis for determination of a plan of cue clusters with tentative diagnostic hypotheses
care to achieve expected outcomes for a patient’s
health status. (ANA, 1998) 3. Identify gaps and inconsistencies
 to clarify the exact nature of the problems and risk  skillful assessments minimize gaps and
factors to achieve the overall expected outcomes of inconsistencies in data
care  sources of conflicting data include measurement error,
expectations and inconsistent or unreliable reports

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 Knowledge Deficit (Pregnancy)

9.State the diagnosis CLEARLY & CONCISELY.

IDENTIFYING HEALTH PROBLEMS, RISKS, AND High Risk for trauma related to dizziness.
STRENGTHS Fatigue related to dizziness.

MODULE 5: DIAGNOSIS
 Determining problems and risks After grouping and
clustering the data, the nurse and client together
LESSON 3: TYPES OF NURSING DIAGNOSIS
identify problems that support tentative actual, risk, and
possible diagnoses.  Actual nursing diagnosis
 Determining strengths establish the client’s strengths,  Health promotion diagnosis
resources, and abilities to cope.  Risk diagnosis
 Syndrome diagnosis
FORMULATING DIAGNOSTIC STATEMENTS
ACTUAL NURSING DIAGNOSIS
Guidelines in Writing a Nursing Diagnosis
 present or existing problem that may or may not
1.Write the diagnosis in terms of the person’s response rather necessitate immediate concern
than nursing need.  a client problem that is present at the time of the
Needs suctioning because she has many secretions. nursing assessment
High Risk for Aspiration related to excessive oral
secretions. Actual Nursing Diagnosis = Patient problem + Causes if known

2. Use “RELATED TO” rather than “DUE TO” or “CAUSED BY” PES APPROACH
to connect the two parts of the statement.

Altered Sexuality Patterns related to change in body

image.
Altered Sexuality Patterns caused by change in body
image

3. Write the diagnosis in LEGALLY advisable terms.

High Risk for trauma related to inadequately

HEALTH PROMOTION DIAGNOSIS
maintained skin traction.
High Risk for trauma related to hazards of skin traction.
 relates to clients’ preparedness to implement
4.Write the diagnosis WITHOUT value judgments. behaviors to improve their health condition

Altered Parenting related to poor bonding with child. Readiness for ……

Altered Parenting related to prolonged separation from
child.
RISK DIAGNOSIS
5. Avoid reversing the parts.
 a clinical judgment that a problem does not exist, but
Impaired social interaction related to confinement to the presence of risk factors indicates that a problem is
home. likely to develop unless nurses intervene.
Confinement to home related to impaired social
interaction. PRS APPROACH

6.Avoid including signs & symptoms of illness in the first part of

the statement.
Withdrawn behavior related to inability to engage in
satisfying personal relationships.
Social isolation related to inability to engage in
satisfying personal relationships

7.Be sure that the two parts of the diagnosis do not mean the
same thing.
Stress Incontinence related to impaired muscle tone of
the urinary bladder.
Stress incontinence related to inability to control urine. SYNDROME DIAGNOSIS

8.Express the problems and related factors in terms that can be  is assigned by a nurse’s clinical judgment to describe
changed. a cluster of nursing diagnoses that have similar
Knowledge Deficit (Prenatal Diet) interventions

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 NAME THE PROBLEMS BY USING THE LABELS THAT
MOST CLOSELY MATCH ASSESMENT CUES

COMPONENTS OF A NANDA NURSING DIAGNOSIS Diagnosis is based on recognizing when patient cues match the
North American Nursing Diagnosis Association signs and symptoms or defining characteristics of a specific
diagnosis.
A nursing diagnosis has three components:
(1) the problem and its definition, WHEN YOU SUSPECT A SPECIFIC PROBLEM, LOOK FOR
(2) the etiology, OTHER SIGNS, SYMPTOMS, AND RISK FACTORS
(3) the defining characteristics Each component serves a COMMONLY ASSOCIATED WITH THE PROBLEM.
specific purpose
“More than one cue, more likely it’s TRUE. More than one
PROBLEM (DIAGNOSTIC LABEL) AND DEFINITION source, more likely of course.’’

WHEN YOU MAKE DIAGNOSIS, BACK IT UP WITH

 The standardized NANDA names for the diagnoses are
EVIDENCES.
called diagnostic labels the client’s problem statement,
consisting of the diagnostic label plus etiology (causal
 Cues are like “key puzzle pieces”, if you don’t have
relationship) between a problem and its related or risk
them, you can’t complete the puzzle and label the
factors is called a nursing diagnosis.
problem.
Qualifiers are words that have been added to some NANDA
INCLUDE PROBLEMS FROM PATIENT’S PERSPECTIVE
labels to give additional meaning to the diagnostic
statement,
 Patients know themselves best, and must be included
DEFICIENT in the diagnostic process.
 Inadequate in amount, quality, or degree; not sufficient.  Things that the patient sees as problems should be
given a high priority.
IMPAIRED
 Made worse, weakened, damaged, reduced, PATIENTS OFTEN PRESENT COMPLAINING OF TWO OR MORE
deteriorated RELATED PROBLEMS

DECREASED  Often one problem creates another.

 Lesser in size, amount, or degree.
MODULE 5: DIAGNOSIS
LESSON 4: COMPARISON OF NURSING DIAGNOSIS
FUNDAMENTAL PRINCIPLES AND RULES OF VS MEDICAL DIAGNOSIS
DIAGNOSTIC REASONING
MEDICAL DIAGNOSIS
KNOW YOUR QUALIFICATION AND LIMITATION
→ made by a physician refers to a pathophysiologic response
that are fairly uniform from one client to another. ▪
 People have the right to be assessed by a qualified
health care professional.
 Although you may feel that you have the knowledge to
NURSING DIAGNOSIS
do an assessment and diagnose the problems, you
must determine (for your patient and your own legal
protection) whether you have the authority to do so → describes the clients’ physical, sociocultural, psychologic and
spiritual responses to an illness or potential health problems;
KEEP AN OPEN MIND vary among individuals.

 Prevents you from seeing problems from a narrow

perspective, a common critical thinking error. A NURSING DIAGNOSIS

IS
MAKING A DIAGNOSES INVOLVES COMPARING YOUR ▪ A statement of a patient problem
PATIENT’S CUES (Sign and symptoms) WITH ‘’TEXTBOOK ▪ Actual or potential
PICTURE’’ OF DIAGNOSES YOU SUSPECT ▪ Within the scope of nursing practice
▪ Directive of nursing intervention
 You make a definitive diagnosis, when your patient’s
data closely match the “textbook picture” of the IS NOT
diagnosis you suspect. A medical diagnosis
▪ A nursing actions
▪ A physician orders
▪ A therapeutic treatment

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 MAIN FOCUS MEDICAL DIAGNOSIS NURSING DIAGNOSIS
identifies pathologic basis for identifies response to illness
NURSING DIAGNOSIS illness
Focuses on the physical Focuses on the physical,
 The impact of disease, trauma or life changes upon condition of the client psychosocial & spiritual
patient and families (human responses) needs of the client
 Problems with functioning independently (ADL) Addresses actual existing Addresses actual & potential
 Quality of life issues (pain, ability to do desired problems problems
activities) Not validated with the client Validated with the client, if
possible
MEDICAL DIAGNOSIS Uses standardized goals & Uses INDIVIDUALIZED
treatments goals & interventions
 Disease, trauma and pathophysiology May not be resolvable usually resolvable
 Quality of life tissues (pain, ability to do desired
activities, but to a lesser extent than nursing – they MEDICAL DIAGNOSIS
often refer this problem to other disciplines.
 Allows opportunity to ramble and get off track.  Myocardial infarction
 Chronic ulcerative colitis
 Chronic ulcerative colitis
PRIMARY MANAGER OF THE PROBLEM  Cancer of the breast
 Cerebral vascular accident
NURSING DIAGNOSIS
NURSING DIAGNOSIS
 Nurse (may use other resources such as physical
therapy or physician expertise, but the nurse accepts  Fear r/t possible recurrence of uncertain outcome
primary responsibility for monitoring status and  Diarrhea r/t dis. Process
allocating resources.  Alteration in nutrition: less than body requirements r/t
 Definitive Diagnosis altered GI absorptions
 Authority to diagnose is within the nursing domain  Risk for (Potential) body image disturbance if
mastectomy is required
 Self-care deficit: dressing & grooming r/t right sided
MEDICAL DIAGNOSIS flaccidity

 Physician or Advanced Practice Nurse MODULE 6: PLANNING

 Definitive Diagnosis LESSON 1: TYPES OF PLANNING
 Nursing is required to seek physician or APN
diagnosis. PLANNING

NURSING RESPONSIBILITIES - Planning is a category of nursing behavior in which

client centered goals and expected outcomes are
NURSING DIAGNOSIS established and nursing intervention are selected to
achieve the goals and outcomes of care
1. Identification of risk factors, anticipating potential
complications. TYPES OF PLANNING
2. Monitoring to detect and report early signs and
symptoms or potential complications or change in - Planning begins with the first client contact and continues
status. until the nurse–client relationship ends, usually when the client
3. Initiating actions within the nursing domain to prevent is discharged from the health care agency. All planning is
or minimize the problems and their potential multidisciplinary (involves all health care providers interacting
complications. with the client) and includes the client and family to the fullest
4. Implementing medical orders (physician or APN is extent possible in every step.
primary manager of the problem.
INITIAL PLANNING
- The nurse who performs the admission assessment
MEDICAL DIAGNOSIS
usually develops the initial comprehensive plan of
care. This nurse has the benefit of seeing the client’s
1. Identification of signs, symptoms and risk factors
body language and can also gather some intuitive
2. Early detection of actual or potential problem.
kinds of information that are not available solely from
3. Initiation of a comprehensive plan to prevent, correct,
the written database. Planning should be initiated as
or control the problems (nurse is the primary manager
soon as possible after the initial assessment.
of the problems)
ONGOING PLANNING
- All nurses who work with the client do ongoing
planning. As nurses obtain new information and
evaluate the client’s responses to care, they can

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 individualize the initial care plan further. Ongoing It is not necessary to resolve all high-priority diagnoses
planning also occurs at the beginning of a shift as the before addressing others. The nurse may partially
nurse plans the care to be given that day. Using address a high-priority diagnosis and then deal with a
ongoing assessment data, the nurse carries out daily diagnosis of lesser priority. Furthermore, because the
planning for the following purposes: client may have several problems, the nurse often
deals with more than one diagnosis at a time.
1. To determine whether the client’s health status has
changed Priorities change as the client’s responses, problems, and
2. To set priorities for the client’s care during the shift therapies change. The nurse must consider a variety of factors
3. To decide which problems to focus on during the when assigning priorities, including the following:
shift
4. To coordinate the nurse’s activities so that more 1. Client’s health values and beliefs: Values concerning health
than one problem can be addressed at each client may be more important to the nurse than to the client.
contact. 2. Client’s priorities: Involving the client in prioritizing and care
planning enhances cooperation. Sometimes, however, the
DISCHARGE PLANNING client’s perception of what is important conflicts with the
- Discharge planning, the process of anticipating and nurse’s knowledge of potential problems or complications.
planning for needs after discharge, is a crucial part of 3. Resources available to the nurse and client. If finances,
a comprehensive health care plan and should be equipment, or personnel are scarce in a health care agency,
addressed in each client’s care plan. Because then a problem may be given a lower priority than usual.
the average stay of clients in acute care hospitals has 4. Urgency of the health problem. Regardless of the framework
become shorter,people are sometimes discharged still used, life-threatening situations require that the nurse assign
needing care. Although many clients are discharged them a high priority.
to other agencies (e.g., long-term care facilities), such 5. Medical treatment plan. The priorities for treating health
care is increasingly being delivered in the home. problems must be congruent with treatment by other health
Effective discharge planning begins at first client professionals.
contact and involves comprehensive and ongoing
assessment to obtain information about the client’s 2.Establishing Client Goals/ Desired Outcomes
ongoing needs.
- After establishing priorities, the nurse and client set
THE PLANNING PROCESS goals for each nursing diagnosis. On a care plan,
the goals/ desired outcomes describe, in terms of
In the process of developing client care plans, the nurse
observable client responses, what the nurse hopes to
engages in the following activities:
achieve by implementing the nursing interventions.
• Setting priorities
• Establishing client goals/desired outcomes
ESTABLISHING GOALS AND EXPECTED OUTCOMES
• Selecting nursing interventions and activities
• Writing individualized nursing interventions on care plans.
GOALS:
1.Setting Priorities
Is and educated guess
Addresses directly the problem started in nursing diagnosis
- Priority setting is the process of establishing a
preferential sequence for addressing nursing
EXPECTED OUTCOMES:
diagnoses and interventions. The nurse and client
begin planning by deciding which nursing diagnosis
Is a measurable client behavior that indicated whether the
requires attention first, which second, and so on.
person has achieved the expected benefit of nursing care.
Instead of rank-ordering diagnoses, nurses can group
them as having high, medium, or low priority. Life-
Example for goal and expected outcome
threatening problems, such as impaired respiratory or
cardiac function, are designated as high priority.
Goal: Mr. X will ambulance independently in 3 days
Health-threatening problems, such as acute illness and
decreased coping ability, are assigned medium priority
Expected outcome:
because they may result in delayed development or
cause destructive physical or emotional changes. A
Mr. X will turn in bed independently in 24 hours
low-priority problem is one that arises from normal
Mr. X will get up to chair 3 times daily for next 2 days
developmental needs or that requires only minimal
Mr. X will walk with assistance to hallway in 48 hours
nursing support A low-priority problem is one that
arises from normal developmental needs or that
3.Selection of intervention
requires only minimal nursing support.

- Nurses frequently use Maslow’s hierarchy of needs  Characteristic of nursing diagnosis

when setting priorities. In Maslow’s hierarchy,  Goals and expected outcome
physiological needs such as air, food, and water are  Feasibility of the intervention
basic to life and receive higher priority than the need  Acceptability of the patient
for security or activity. Growth needs, such as self-  Own competency
esteem, are not perceived as “basic” in this framework.  Evidence base for the intervention.

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 BASIC PRINCIPLES: ATTENDING TO URGENT
4.Selecting nursing intervention strategy PRIORITIES

1. Choose a method of assigning priorities and use it

consistently.
 example: some nurses use the ABC method
 make sure that the patient has NO
THREATS to his
 A  AIRWAY
 B  BREATHING
 C  CIRCULATION

2. Maslow’s Hierarchy of Needs

Priority 1 Physiologic Needs – problems with

breathing, circulation, nutrition, hydration, elimination,
temperature regulation, physical comfort

PLANNING Priority 2  Safety and Security -- environmental hazards,

- “The nurse develops a plan of care that fear
prescribes interventions to attain expected
outcomes” Priority 3  Love & Belonging -- isolation, loss of loved one

Priority 4  Self Esteem -- inability to perform normal

activities

Priority 5  Personal Goals -- Threat to the ability to achieve

personal goals.

3. Problems usually present in a cluster – study the

relationships among the problems to determine major
priorities.
- Assign high priority to problems that contribute to
other problems.

example: if someone has chest pain and difficulty of

breathing, pain management is a high priority because pain
causes increased stress and oxygen demand.

GUIDELINES FOR SETTING PRIORITIES

4 MAIN PURPOSES OF THE PLAN FOR CARE
1. Maslow’s hierarchy of basic needs can guide the selection of
1. Promotes communication among caregivers to high-priority problems.
promote continuity of care. 2. Focus on the problems the patient feels are most important
2. Directs care and documentation. if this priority does not interfere with medical treatment
3. Creates a record that can later be used for evaluation, 3.Consider the patient’s culture, values and beliefs when setting
research & legal reasons. priorities.
4. Provides documentation of health care needs for 4.Consider the effect of potential problems when setting
insurance reimbursement purposes. priorities
5.Consider costs, resources available, personnel and time
ACTIVITIES OF PLANNING PHASE needed to plan & treat each of the patient’s identified problems
6.Consider state laws, hospital policy statements, and outcome
 Attending to urgent priorities criteria established for the particular setting.
 Clarifying expected outcomes
 Deciding which problems must be prescribed CLARIFYING OR ESTABLISHING
 Determining Individualized Nursing interventions OUTCOME(RESULT)
 Making sure the plan is adequately recorded
Patient Outcome
SETTING PRIORITIES  the desired result of nursing care;
 that which one hopes to achieve with the patient and
- it serves the purpose of ordering the delivery of which is designed to prevent, remedy or lessen the
nursing care so that the more important or life- problem identified in the nursing diagnosis
threatening problems are treated before less critical
problems are treated

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 OUTCOME IDENTIFICATION  CONDITION: Under what circumstances is the
person to perform the actions?
“The nurse identifies expected outcomes individualized  PERFORMANCE CRITERIA: How well is the
to the patient” person to perform the actions?
 TARGET TIME: By when is the person expected
 the nurse develops outcomes for the patient to to be able to perform the actions?
achieve showing an optimum or improved level of
functioning in the problem areas identified in the PATIENT BEHAVIOR
nursing diagnoses - An observable activity the patient will demonstrate at
some time in the future showing improvement in the
A SHIFT FROM GOALS & OBJECTIVES TO problem area
OUTCOMES
Examples:
GOALS & OBJECTIVES - (The patient) will void
 refers to the INTENT - Decrease in (the patient’s) BP
- (The patient) will ambulate
 What you intend to do
- (The patient) will report
- (The patient) will drink
OUTCOMES
 refers to RESULTS
CONDITIONS
 what you expect the patient to be able to do - specific aids that will help the patient perform a
behavior at the level specified in the criteria portion of
Expected Outcomes  describes what will be observed in the outcome statement
the patient after care is done to show the benefits of nursing NOTE: “not all outcomes will have conditions”
care.
3 MAIN PURPOSES
CONDITIONS
1. They are the “measuring sticks” specific aides which will facilitate the patient performing a
for the plan of care. behavior at the level in the criteria and within the specified
2. They direct interventions. time frame
3. They are motivating factors  With the help of a walker
 With the use of a wheelchair
PRINCIPLE OF PATIENT- CENTERED OUTCOMES  With the help of the family
 With the use of medication
1. Outcome describe the specific benefits you  Using oral analgesics q3-4 hrs
expect to see in the patient after care has been  Using IM Demerol q3-4 hrs
given.
PERFORMANCE CRITERIA
SHORT TERM OUTCOME – describe early expected benefits - a stated level or standard for the patient behavior
of nursing interventions stated in the outcome
- it specifies a realistic improvement in functioning in
LONG TERM OUTCOME – describe the benefits expected to the problem area by a stated time and will be used to
be seen at a certain point in time after the plan has been determine whether the outcome was satisfactorily
implemented achieved
- It clarifies and individualizes the outcome based on
2. Outcome may relate to problems or interventions. the patient’s ability and a realistic expectation for the
level of functioning in the future
PROBLEM OUTCOMES -- state what you expect to observe in
the patient when the problems are resolved or controlled TIME FRAME
INTERVENTION OUTCOMES -- state the benefit you expect - a time or date to clarify how long it would realistically
to observe in the patient after an intervention is performed take for the patient to reach the level of functioning
stated in the criteria part of the outcome
3. To create explicit (very specific outcomes, include
the following components. a. INTERMEDIATE OUTCOMES
> subject it identifies behavior a patient can achieve fairly quickly
> verb e.g.: in an 8-hr shift, daily basis
> condition
> performance criteria b. LONG TERM OR FINAL OUTCOMES
> target time - it gives direction for the nursing care over time
- it tries to identify the maximum level of functioning
COMPONENTS OF OUTCOME STATEMENTS possible for a patient with a particular nursing diagnosis
e.g.: breastfeeding 10 to 15mins/ breast every 2 to 5 hrs,
 SUBJECT: Who is the person expected to within 2 wks of delivery
achieve the outcome (e.g. Patient or parent)
 VERB: What actions must the person take to
achieve the outcome?

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  TIME FRAME to observe in the patient after you perform an
- a designated time or date when the patient should intervention.
be able to achieve the behavior
 Within the next hour DERIVING DESIRED OUTCOME NURSING
 By discharge DIAGNOSES
 At the end of this shift
 By Dec. 25
 In 2 months

c.DISCHARGE OUTCOMES

-it appears at the end of the critical pathways used with the
hospitalized patients
-it identifies the behavior the patient is
expected to achieve to be safely discharged from the institution

e.g.: Return of the swallow-gag reflex vital signs in the normal

range for this patient

d.HEALTH PROMOTION / WELLNESS OUTCOMES

4. Use measurable verbs (verbs that describe things you

can see, feel, smell or hear).

COMPONENTS OF GOALS/DESIRED OUTCOMES

5. Consider affective, cognitive and psychomotor

outcomes.

 Affective domain -- changes in attitude, feelings, or

values GUIDELINES FOR WRITING OUTCOME
 Cognitive domain – dealing with acquired knowledge STATEMENTS OR OBJECTIVES
or intellectual skills
 Psychomotor domain – dealing with developing motor 1. For an actual nursing diagnosis, the outcome is a
skills patient behavior that demonstrates reduction or
alleviation of the problem.
EXAMPLES OF VERBS REPRESENTING THE 3 DOMAINS 2. For at risk nursing diagnosis, the outcome is a
patient behavior that demonstrates maintenance of
COGNITIVE AFFECTIVE PSYCHOMOTOR the current status of health or functioning.
Teach Express Demonstrate 3. The outcome is realistic for the patient’s capabilities in
Discuss share Practice the time span you designate in your outcome
Identify Listen Perform 4. The outcome is realistic for the nurse’s level of skill,
Describe Communicate Walk experience and time/ workload.
5. The outcome is congruent with and supportive of
List Relate Administer
other therapies.
Explore Give 6. Whenever possible, the outcome is important and
valued by the patient, family, the nurse and the
At a basic level, determining outcomes requires you to physician.
simple “reverse the problem”, or state what you expect

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 7. The outcome is an observable or measurable patient
behavior
8. Write outcomes in terms of patient behavior, not
nursing actions.
9. Keep the outcome short.
10. Make the outcome specific.
11. Derive each outcome from only one nursing
diagnosis.
12. Designate a specific time for the achievement of each
outcome.

DECIDING WHICH PROBLEM MUST BE RECORDED

- is influenced by your understanding of:

 the whole picture of all the problems present

 the person’s overall health status and expected
discharge outcomes
 the expected length of contact with the patient.
Focus on what MUST be achieved before what’s
NICE to do.
 the patient’s perception of priorities
 whether there are standard plans that apply, are there
critical pathways? Guidelines? Protocols?

- Always check policies and procedures for

recording the plan, as they are designed to help
your patients and protect you from legal liability.

3 BASIC STEPS TO DETERMINING WHICH

PROBLEMS MUST BE RECORDED

1. Create a problem list.

2. Decide which problem must be managed in order to
achieve the overall outcomes of care.
3. Determine what documentation will guide how each
problem will be managed.

- It’s your responsibility to make sure that any

problems, diagnoses, risk factors that are likely to
impede progress toward outcome achievement
are addressed somewhere on the patient record.

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