Handout Nursing Process

Nursing Process, Nursing Skills, and Clinical Reasoning

Characteristics of the Nursing Process • Systematic Systematic — part of an an ordered ordered sequence sequence of activities activities • Dynamic Dynamic — great interactio interaction n and overlapping overlapping among among the five steps • Interpersona Interpersonall — human being being is always always at at the heart heart of nursing • Outcome Outcome oriented oriented — nurses and and patients patients work work together together to identify outcomes • Universally Universally applicabl applicable e — a framework framework for for all nursing nursing activities

JoannesPaulus T. Hernandez, BS (Human) Biology, BS Nursing, R.N.

The Nursing Process • One of the major guidelines guidelines for nursing nursing practice practice • Helps nurses nurses implement implement their their roles • Integrates Integrates art and and science science of nursing • Allows Allows nurses to use critical critical thinking thinking • Defines the areas areas of care that are within within the domain domain of nursing • It is a systematic method that that directs the the nurse and client as they together determine the need for nursing care, plan and implement the care, and evaluate the result.

Characteristics of the Nursing Process (Continued) It is a GOSH approach for efficient and effective provision of nursing care.

G – oal-oriented oal-oriented O – rganize rganized d S – ystema ystematic tic H – umani umanist stic ic care care

Historical Development of the Nursing Process • 1955 — nursing nursing process process term was first first used by Lydia Hall

• 1960’s 1960’s — specifi specific c steps delinea delineated ted • 1967 — Yura and Walsh published published first first comprehensive comprehensive book on nursing process • 1973 — ANA Congress Congress for Nursing Nursing Practice Practice develope developed d Standard of Practice

Problem solving and the Nursing Process • Trial-and-e Trial-and-error rror problem problem solving • Scientific Scientific problem problem solving solving • Intuitive Intuitive thinking thinking • Critical Critical thinking thinking

• 1982 — state state board board examinati examinations ons for professi professional onal nursing uses nursing process as organizing concept

Joannes Paulus T. Hernandez, B.S.H.B., BSN RN

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Overview of the Five Steps of the Nursing Process: ASSESSING

Benefits of the Nursing Process • Patient – Scientifically Scientifically based, based, holistic holistic individuali individualized zed patient patient care – Cont Contin inui uity ty of of care care – Clear, Clear, efficient, efficient, cost-effec cost-effective tive plan plan of action action • Nurse – Opportunity Opportunity to work collabo collaborativ ratively ely with other healthcare workers – Satisfactio Satisfaction n of making making a difference difference in lives lives of patient patients s – Opportunity Opportunity to grow professionally professionally

Five Steps of the Nursing Process

Overview of the Five Steps of the Nursing Process: ASSESSING It is the systematic and continuous collection, validation, and communication of client data as compared to standard.

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Activities:

1. 2. 3. 4.

Col lection of data Validation of data – data confirmation/comparing confirmation/comparing to standards Organizing data data Analyzing data

5. Recording/documentation of of data • Types of data: 1. Subjective data (symptoms) –described by person experiencing it 2. Objective data (signs) – can be observed and measured • Sources of data: 1. Primary Data – data directly gathered gathered from the client 2. Secondary data – data gathered from client’s significant others, client’s medical records, patient’s chart, other members of the health team, and related health care literature • Methods of collecting data: 1. Interview –a planned communication communication with the client 2. Observation –the use of five senses and instruments 3. Physical Assessment –assessment for objective data and is focused primarily on the client’s functional abilities

Assessing is primarily focused on the client’s response to health problem.

Five Steps of the Nursing Process • Assessing Assessing — collecting, collecting, validatin validating g and communicatin communicating g of patient data

Four Types of Nursing Assessments

• Diagnosing Diagnosing — analyzing analyzing patient patient data to identify identify patient patient strengths and problems

• Comprehensiv Comprehensive e initial initial

• Planning Planning — specifying specifying patient patient outcomes outcomes and related related nursing interventions

• Emerg Emergen ency cy

• Implementin Implementing g — carrying out the the plan of care

• Focu Focuse sed d • Time-la Time-lapsed psed

• Evaluating Evaluating — measuring measuring extent to to which patient patient achieved achieved outcomes


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Comprehensive Initial Assessment

Time-Lapsed Assessment

• Performed Performed shortly after admittance admittance to hospital hospital

• Performed to compare compare a patient’s patient’s current status to baseline data obtained earlier

• Performed Performed to establish a complete complete database database for problem identification and care planning • Performed by the nurse to collect data on all aspects of patient’s health

• Performed to reassess health status and make necessary revisions in plan of care. • Performed by the the nurse to collect data about current health status of patient

Focused Assessment

Establishing Assessment Priorities

• May be performed during initial assessment or as routine ongoing data collection

• Health Health orientation orientation

• Performed Performed to gather data about about a specific problem already identified, or to identify new or overlooked problems

• Developmenta Developmentall stage • Need Need for nursi nursing ng

• Performed by the nurse to collect data about about the specific problem

Emergency Assessment

Medical vs. Nursing Assessments

• Performed Performed when a physiologic or psychological psychological crisis crisis presents

• Medical Medical assessments assessments

• Performed Performed to identify identify life-threatening life-threatening problems problems • Performed by the nurse to gather gather data about about the lifelifethreatening problem


– Target Target data pointing pointing to pathologi pathologic c conditions conditions • Nursing assessments assessments – Focus on on the patient’ patient’s s response response to health health problems problems

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The Skill of Nursing Observation

Successful Interview Techniques

• Determines Determines the patient’s patient’s current responses (physical (physical and emotional)

• Focus on the patient patient during during the interview interview

• Determines Determines the patient’s patient’s current ability ability to manage care • Determines Determines the immediate immediate environment environment and its safety • Determines Determines the larger environment environment (hospital (hospital or community

• Listen to to the patient attentiv attentively ely • Ask about about patient’s patient’s main problem problem first • Pose questions questions and comments comments in appropriate appropriate manner • Avoid comments comments and question question that that impede communication • Use silence silence and touch approp appropriately riately

Four Phases of a Nursing Interview

Five Parts of Communication Process (Berlo)

• Preparatory Preparatory phase

• The stimulus stimulus or referent referent

• Introd Introduct uction ion

• The sender sender or source of message message (encoder) (encoder)

• Workin Working g phase phase

• The message message itself itself

• Termina Terminatio tion n

• The medium medium or channel channel of communication communication • The receive receiverr

Purpose of a Nursing Physical Assessment

Four Levels of Communication

• Appraisal Appraisal of health health status status

• Intrap Intrapers ersona onall

• Identificatio Identification n of health problems problems

• Interp Interpers ersona onall

• Establishment Establishment of a database for nursing interventio intervention n

• SmallSmall-gro group up • Organi Organizat zationa ionall


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Roles of Group Members

The Helping Relationship

• Task-oriente Task-oriented d — focus on work to be done

• Does not occur spontan spontaneously eously

• Maintenance Maintenance — focus on well-bei well-being ng of people people doing work work

• Characterize Characterized d by an unequal sharing of information information

• Self-serving Self-serving — advance advance the needs needs of individual individual members members at group’s expense

• Built on on the patient’ patient’s s needs

Forms of Communication

Characteristics of the Helping Relationship

• Verbal (language) (language)

• Dyna Dynami mic c

• Nonverbal Nonverbal (body (body language) language)

• Purposeful Purposeful and and time limited limited

– Facia Faciall expres expressio sions ns – Post Postur ure, e, gai gaitt

• Person providing assistance is professionally accountable for the outcomes

– Gest Gestur ures es – General General physi physical cal appea appearan rance ce – Mode Mode of dress dress and groomin grooming g – Sounds – Silenc e

Factors Influencing Communication

Phases of the Helping Relationship

• Developmental Developmental level

• Orientation Orientation phase

• Gend Gender er

• Working Working phase phase

• Sociocul Sociocultura turall differe differences nces

• Termina Terminatio tion n phase phase

• Roles and responsibi responsibilities lities • Space and territori territoriality ality • Physical, Physical, mental, mental, and emotional emotional state • Environ Environmen mentt


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Goals of the Orientation Phase

Factors that Promote Effective Communication

• Establish Establish tone and guidelines guidelines for the relationship relationship

• Dispositional Dispositional traits traits

• Identify Identify each other other by name name

• Rappo Rapport rt builders builders

• Clarify Clarify roles of both both people people • Establish Establish an agreement agreement about the relationship relationship • Provide the patient with orientation orientation to the the healthcare system

Goals of the Working Phase

Dispositional Traits

• Work together together to meet the the patient’s patient’s needs

• Warmth Warmth and friendliness friendliness

• Provide Provide whatever assistance assistance is needed to achieve achieve each goal

• Openness Openness and and respect

• Provide Provide teaching teaching and counseling counseling

• Empa Empath thy y • Honesty, Honesty, authenticit authenticity, y, trust • Cari Caring ng • Compet Competence ence • Genuine Genuineness ness

Rapport Builders Goals of the Termination Phase • Specific Specific objectives objectives • Examine Examine goals of helping relationship relationship for attainment attainment • Make suggestion suggestions s for future efforts if necessary necessary • Encourage Encourage patient to express express his or her emotions emotions about the termination

• Comfortable Comfortable environment environment • Priv Privac acy y • Confid Confidenti entiali ality ty • Patient Patient versus versus task focus • Utilization Utilization of nursing nursing observations observations • Optima Optimall pacing pacing • Providing Providing personal personal space


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Developing Conversation Skills

Basic Components of Assertiveness

• Control Control the tone tone of your your voice

• Having Having empat empathy hy

• Be knowledgeable knowledgeable about the the topic of conversation conversation

• Describing Describing one’s feelings feelings or the situation situation

• Be flexi flexibl ble e

• Clarifying Clarifying one’s one’s expectations expectations

• Be clear clear and concise concise

• Anticipatin Anticipating g consequences consequences

• Avoid words that might have different interpretations interpretations • Be trut truthf hful ul • Keep Keep an open open mind mind • Take advantage advantage of available available opportunities opportunities

Developing Listening Skills • Sit when communicat communicating ing with a patient. patient.

Blocks to Communication

• Be alert and and relaxed and and take your your time.

• Failure Failure to perceive the patient patient as a human being being

• Keep the conversatio conversation n as natural as possible. possible. • Maintain Maintain eye contact if appropria appropriate. te. • Use appropriate appropriate facial expressions expressions and body body gestures. • Think before before responding responding to the patient. patient. • Do not pretend to listen. listen. • Listen for themes themes in the patient’s patient’s comments. comments. • Use silence, therapeutic touch, and humor appropriately. appropriately.

• Failur Failure e to listen listen • Inappropria Inappropriate te comments comments and questions • Using Using clichés clichés • Using closed questions questions • Using question questions s containing containing the words words “why” “why” and “how” “how” • Using questions questions that that probe for information information

Interviewing Techniques

Blocks to Communication (continued)

• Open-ended Open-ended questions questions or comments comments

• Using leading leading questions questions

• Closed questions questions or comments comments

• Using comments comments that that give advice advice

• Validating Validating questions questions or comments comments

• Using judgment judgmental al comments comments

• Clarifying Clarifying questions questions or comments comments

• Changing Changing the subject

• Reflective Reflective questions questions or comments comments

• Giving Giving false false assurance assurance

• Sequencing Sequencing questions questions or comments comments

• Using gossip and rumors

• Directing Directing questions questions or comments comments


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Type of Questions Used in Interviews

When to Verify Data

• Closed questions questions — elicit specific specific information information

• When there is a discrepancy between what the person is saying and what the nurse is observing

• Open-ended Open-ended questions questions — allow the the patient patient to verbalize verbalize freely

• When the data data lack lack objectivity objectivity

• Reflective Reflective questions questions — encourage encourage patient patient to elaborate elaborate on thoughts and feelings • Direct question questions s — validate validate or clarify clarify information information

Sources of Data • Pati Patien entt • Family and significant significant others • Patien Patientt record record • Other healthca healthcare re professionals professionals • Nursing and and other healthcare healthcare literature literature

Problems Related to Data Collection

Validating Inferences

• Inappropria Inappropriate te organization organization of the database

• Performing Performing a physical examinati examination on using proper equipment and procedure

• Omission Omission of pertinent pertinent data • Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data • Failure Failure to establish rapport rapport and partnership partnership

• Using clarifying clarifying statem statements ents • Sharing Sharing inferences inferences with other team members members • Checking Checking findings findings with research reports reports

• Recording an interpretation interpretation of data rather than observed behavior • Failure Failure to update update the database database


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Overview of the Five Steps of the Nursing Process: DIAGNOSING

Documentation of Data • Enter initial database database into computer or record in ink on designated forms the same day patient is admitted. • Summarize Summarize objective objective and subjective subjective data in concise, comprehensive, and easily retrievable manner. • Use good grammar and standard medical abbreviations. • Whenever Whenever possible, use use patient’s patient’s own words. • Avoid non-specifi non-specific c terms subject to individual individual interpretation or definition.

Overview of the Five Steps of the Nursing Process: DIAGNOSING

Objective Data vs. Subjective Data

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It is a process which results to Nursing D iagnosis.

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Nursing Diagnosis is a statement of a client’s potential or actual health resulting from analysis of data.

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Nursing Diagnosis uses PES format:

It is used to identify health care n eeds and prepare a Nursing Di agnosis. problem

P –roblem E – tiology tiology

• Objecti Objective ve data data – Observable Observable and measura measurable ble data data that can can be seen, seen, heard, or felt by someone other than the person experiencing them

S – ignsand Symptoms Symptoms

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1. D ata Clustering 2. 3. 4. 5. 6.

– E.g., elevate elevated d temperature, temperature, skin moisture, moisture, vomitin vomiting g • Subject Subjective ive data data

Activities:

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Comparing data against against standards Data analysis ysis Identify gaps and inconsistencies Determine health problems problems Formulation of Nursing Diagnosis Diagnosis

Types of Nursing Diagnosis:

1. Actual Nursing Diagnosis –pr oblem is present

– Information Information perceived perceived only only by the the affected affected person

2. Potential Nursing Diagnosis – problem may arise 3. Possible Nursing Diagnosis Diagnosis – problem may be present

– E.g., pain pain experience, experience, feeling dizzy, dizzy, feeling feeling anxious anxious

4. Wellness Nursing Diagnosis – transition from a specific level of of wellness to a higher level of wellness

Prioritizing nursing diagnosis diagnosis is based on what problem endagers person’s life.

Purposes of the Diagnosing Step Characteristics of Data • Comp Comple lete te • Factual Factual and and accurate accurate • Rele Releva vant nt

• Identify Identify how an individual, group, group, or community community responds to actual or potential health and life processes. • Identify factors that that contribute to or cause health problems (etiologies). • Identify Identify resources or strengths strengths the individual, individual, group or community can draw on to prevent or resolve problems.


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Purposes of the Diagnosing Step

Purposes of the Diagnosing Step Types of Diagnoses • Nursing Nursing diagno diagnosis sis – Describes Describes patient patient problems problems nurses nurses can treat independently • Medical Medical diagnosis diagnosis – Describes Describes problems problems for for which the the physician physician directs directs the primary treatment • Collaborati Collaborative ve problems problems – Managed Managed by using using physician-p physician-prescribe rescribed d and nursingnursingprescribed interventions

Nursing Concerns and Responsibilities (Alfaro, 2004) • Monitoring Monitoring for changes changes in health status status • Promoting Promoting safety safety and preventing preventing harm • Identifying Identifying and meeting meeting learning learning needs • Promoting Promoting comfort comfort and managing managing pain • Promoting Promoting health health and well-being well-being • Addressing Addressing problems problems that limit independence independence • Determining Determining human human responses responses


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Four Steps of Data Interpretation and Analysis • Recognizing Recognizing significa significant nt data – Compar Comparing ing data data to stand standard ards s • Recognizing Recognizing patterns patterns or clusters clusters • Identifying Identifying strengths strengths and problems problems • Reaching Reaching conclusions conclusions

Overview of the Five Steps of the Nursing Process: PLANNING

Reaching Conclusions • No pro probl blem em • Possibl Possible e problem problem • Actual or potentia potentiall nursing diagnosis diagnosis • Clinical Clinical problem other than than nursing diagnosis diagnosis

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Identifying beforehand the specific actions to be done before implementation of nursing interventions.

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It is used to determine the goals of care and the course of actions to be undertaken during the implementation phase.

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Activities:

1. Priority setting 2. Setting goals and objectives: Goals may be short-term or long term; the characteristics of a well-started behavioral objectives are as follows: S – mart mart M – easurable easurable A – ttainable ttainable R –ealistic T – ime-framed ime-framed

3. Identify alternative nursing nursing care 4. Select nursing measure 5. Formulation of Nursing Care Care Plan (NCP) The Nursing Care Plan is made mainly as guide to individualize individualize care.

Formulation of Nursing Diagnoses

Goal of Outcome Identification and Planning Step

• Problem Problem — identifies identifies what is is unhealthy unhealthy about patient patient

• Establish Establish priorities. priorities.

• Etiology Etiology — identifies identifies factors factors maintaining maintaining the unhealth unhealthy y state

• Identify Identify and write expecte expected d patient outcomes. outcomes.

• Defining Defining characteristics characteristics — identifies identifies the subjective subjective and and objective data that signal the existence of a problem


• Select evidence-bas evidence-based ed nursing interventions. interventions. • Communicate Communicate the the plan of of care.

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A Formal Plan of Care Allows the Nurse To:

Three Elements of Comprehensive Planning

• Individualiz Individualize e care that maximizes maximizes outcome achievement achievement

• Init Initia iall

• Set prior prioriti ities es

• Ongoi Ongoing ng

• Facilitate communication among nursing personnel and colleagues

• Disch Dischar arge ge

• Promote continuity of high-quality, cost effective care • Coordi Coordinat nate e care • Evaluate Evaluate patient patient response response • Create Create a record used for evaluation, evaluation, research, research, reimbursement and legal reasons • Promote Promote nurse’s professional professional development development

Initial Planning • Developed Developed by the nurse who performs performs the nursing nursing history and physical assessment • Addresses each problem listed in the prioritized nursing diagnoses • Identifies appropriate patient goals and related nursing care

Ongoing Planning • Carried out by any nurse who interacts with with patient • Keeps the the plan up to date • States States nursing diagnoses diagnoses more clearly clearly • Develops Develops new diagnoses, diagnoses, • Makes outcomes outcomes more realistic realistic and develops develops new outcomes as needed • Identifies Identifies nursing interventions interventions to accomplish accomplish patient goals


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Discharge Planning

Long-Term vs. Short-Term Outcomes

• Carried Carried out by the nurse who worked worked most closely closely with patient

• Long-term Long-term — requires a longer period to to be achieved achieved and may be used as discharge goals

• Begins when the patient patient is admitted for treatment treatment

• Short-term Short-term — may be accompli accomplished shed in a specified specified period of time

• Uses teaching teaching and counseling skills skills effectively effectively to ensure home-care behaviors are performed competently

Prioritizing Nursing Diagnoses

Categories of Outcomes

• High priority priority — greatest greatest threat threat to patient patient well-being well-being

• Cognitive Cognitive — describes describes increases increases in patient patient knowledge knowledge or intellectual behaviors

• Medium priority priority — non-threate non-threatening ning diagnose diagnoses s • Low priority priority — diagnoses diagnoses not specifica specifically lly related related to current health problem

• Psychomoto Psychomotorr — describes describes patient’s patient’s achievement achievement of new new skills • Affective Affective — describes change changes s in patient patient values, values, beliefs, beliefs, and attitudes

Maslow’s Hierarchy of Human Needs

Parts of a Measurable Outcome

• Physio Physiologi logic c needs needs

• Subj Subject ect

• Safety Safety needs needs

• Verb

• Love and and belonging belonging needs needs

• Condit Condition ions s

• Self-e Self-estee steem m needs

• Performance Performance criteria

• Self-actualiz Self-actualization ation needs

• Target Target time time


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Common Errors in Writing Patient Outcomes

Structured Care Methodologies

• Expressing Expressing patient outcome outcome as nursing intervention intervention

• Procedure Procedure — set of of how to action action steps steps

• Using verbs that that are not observable observable or measurable measurable

• Standard Standard of care care — description description of accepta acceptable ble level of patient care

• Including Including more than one patient patient behavior behavior or manifestation in short-term outcomes

• Algorithm Algorithm — set of steps steps used to to make a decision decision

• Writing Writing vague vague outcomes outcomes

• Clinical Clinical practice practice guideline guideline — statement statement outlining outlining appropriate practice for clinical condition or procedure

Types of Nursing Interventions

Types of Institutional Plans of Care

• Nurse-initia Nurse-initiated ted — actions actions performed performed by a nurse nurse without without a physician’s order

• Kardex Kardex plans plans of care care • Computeriz Computerized ed plans plans of care

• Physician-ini Physician-initiated tiated — actions actions initiated initiated by a physician physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

• Case manageme management nt plans plans of care

• Collaborati Collaborative ve — treatments treatments carried carried out out by a nurse nurse initiated by other providers

• Student Student plans plans of of care

– Clinica Clinicall pathwa pathways, ys, care care maps maps • Concept Concept map map care care plan

Actions Performed in Nurse-Initiated Interventions (Alfaro, 2002)

Problems Related to Outcome Identification and Planning

• Monitor Monitor health health status status

• Failure Failure to involve involve patient patient

• Reduce Reduce risks risks

• Insufficient Insufficient data data collection collection

• Resolve, Resolve, prevent, prevent, or manage a problem problem

• Nursing diagnose diagnoses s developed from inaccurate inaccurate or insufficient data

• Facilitate Facilitate independence independence or assist assist with ADLs

• Outcomes Outcomes stated too too broadly broadly

• Promote Promote optimum sense of physical, psychological, psychological, and spiritual well-being

• Outcomes Outcomes derived from poorly developed developed nursing diagnoses • Failure Failure to write nursing nursing order order clearly • Nursing orders orders that do not not solve problems problems • Failure Failure to update update the plan of care care


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Overview of the Five Steps of the Nursing Process: IMPLEMENTING

Outcomes for “Caregiver Home Readiness” • Willing Willing to assume assume caregiver caregiver role • Knowledge Knowledge about about caregiver caregiver role • Demonstration of positive regard for care recipient • Participati Participation on in home care decision decision On-going data collection directs revision of plan of care and interventions.

• Confidence Confidence in ability ability to manage care at home home • Knowledge Knowledge of where to obtain obtain needed equipment equipment

Overview of the Five Steps of the Nursing Process: IMPLEMENTING •

Putting the Nursing Care Plan into action.

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It is used to carry out the NCP and meet client’s health goals.

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Requirements for implementation:

1. Therapeutic use of self (TUOS) 2. Knowledge 3. Technical skills 4. Communication skills •

Nurses implement independent (nurse-prescribed), interdependent (collaborative), and dependent (physician’s-prescribed) nursing actions.

On-going data collection directs revision of plan of care and interventions.

Types of Nursing Interventions • Independent Independent nursing nursing actions actions – Nurse-i Nurse-init nitiat iated ed interve interventi ntions ons • Protocols Protocols • Standing Standing orders orders • Dependent Dependent and collaborative collaborative nursing actions actions – Physician-in Physician-initiat itiated ed intervention interventions s – Collab Collabora orativ tive e interve interventi ntions ons

Advantages of Nursing Interventions Classifications

Implementing the Care Plan

• Standardizin Standardizing g nomenclature nomenclature

• Organize Organize resources resources

• Expanding Expanding nursing nursing knowledge knowledge

• Anticipate Anticipate unexpected outcomes/situa outcomes/situations tions

• Developing Developing information information systems systems

• Promote Promote self-care: teaching, teaching, counseling, advocacy advocacy

• Teaching Teaching decision decision making making

• Assist patient patients s to meet health outcomes outcomes

• Ensuring Ensuring appropriate appropriate reimbursement reimbursement • Allocating Allocating nursing nursing resources resources • Communicati Communicating ng nursing to non-nurses non-nurses • Linking Linking nursing nursing content content


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Aims of Teaching and Counseling

Teaching Acronym

• Maintaining Maintaining and promotin promoting g health

• T – une into into the the pati patient ent

• Preventing Preventing illness

• E – dit patien patientt informati information on

• Restor Restoring ing health health

• A – ct on every teaching teaching moment moment

• Facilitatin Facilitating g coping

• C – lari larify fy often often • H – onor the patient patient as partners partners in the the education education process

Teaching Outcomes

Factors Affecting Patient Learning

• High-level High-level wellness and related related self-care practices practices

• Age and and developmenta developmentall level

• Disease preventi prevention on or early detection detection

• Family Family support networks networks and financial resources resources

• Quick recovery recovery from trauma trauma or illness illness

• Language Language deficits deficits

• Enhanced ability to adjust to developmental life changes

• Litera Literacy cy level level

Focus of Patient Education

Critical Developmental Areas

• Preparation Preparation for receiving receiving care

• Physical Physical maturation maturation and abilities abilities

• Preparation Preparation before before discharge from health care facility facility

• Psychosocial Psychosocial development development

• Documentatio Documentation n of patient patient education activity activity

• Cognitive Cognitive capacity capacity • Emotional Emotional maturity maturity • Moral and and spiritual spiritual development development


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Teaching Plans for Older Adults

Three Learning Domains

• Allow Allow extra extra time time

• Cognitive Cognitive — storing storing and recalling recalling of new new knowledge knowledge in the brain

• Plan short short teaching teaching sessions sessions • Accommodate Accommodate for for sensory deficits deficits • Reduce Reduce environmental environmental distractions distractions

• Psychomoto Psychomotorr — learning learning a physical skill • Affective Affective — changing changing attitudes, attitudes, values, values, and feelings feelings

Cope Model

Key Points to Effective Communication

• C – reativ reativity ity

• Be sincere sincere and and honest. honest.

• O – ptimi ptimism sm

• Avoid too too much detail and and stick to the basics. basics.

• P – lanni lanning ng

• Ask for for questio questions. ns.

• E – xpert xpert informa informatio tion n

• Be a cheerleader cheerleader for the patient patient.. • Use simple simple vocabulary. vocabulary. • Vary the the tone tone of voice. voice. • Keep content content clear. clear. • Listen and and do not interrupt. interrupt.

Providing Culturally Competent Patient Education

Sources of Information

• Develop an understand understanding ing of the patient’s patient’s culture.

• Prim Primar ary y — pati patien entt

• Work with with multicultural multicultural team. team.

• Secondary Secondary — medical medical records, records, patient patient family family

• Be aware of personal personal assumptions, assumptions, biases, biases, and prejudices. • Understand Understand the core cultural cultural values of the patient patient or group. • Develop written material in native language language of the the patient. • Use testimonials testimonials of persons persons with same cultural cultural background as the patient.


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Teaching Strategies Assessment Parameters • Readiness Readiness to learn learn • Abilit Ability y to learn learn • Learning Learning strengths strengths

• Lect Lectur ure e • Discu Discussi ssion on • Panel Panel discussi discussion on • Demonstr Demonstrati ation on • Disco Discover very y • Role Role playi playing ng • Audiovisual Audiovisual materials materials • Printed Printed materials materials • Programmed Programmed instruction instruction • Web-based Web-based instruction instruction

Promoting Compliance • Be certain that instructi instructions ons are understandable understandable and support patient goals. • Include Include the patient and and family as partners partners in process. • Utilize Utilize interactive interactive teaching strategies. strategies. • Develop interpersona interpersonall relationships relationships with patients patients and their families.

Considerations for Successful Patient Teaching • Forming Forming contractual contractual agreements agreements • Considering Considering time time constraints constraints • Schedul Scheduling ing • Group versus versus individual individual teaching teaching • Formal versus versus informal informal teaching teaching • Manipulatin Manipulating g the physical environment environment

Sample Teaching Strategies

Obtaining Feedback About Learning

• Cognitive Cognitive domain domain — lecture, lecture, panel, discove discovery, ry, written written materials

• Reinforcing Reinforcing and celebrati celebrating ng learning

• Affective Affective domain domain — role modeling, modeling, discussion, discussion, audiovisual materials

• Evaluating Evaluating teaching teaching • Revisi Revising ng the plan plan

• Psychomotor Psychomotor domain domain — demonstrati demonstration, on, discovery, discovery, printed materials


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Documentation of the Teaching-Learning Process

Variables Influencing Outcome Achievement

• Summary Summary of the learning learning need

• Patient Patient variables variables

• The The plan plan

– Dev Develo elopme pmenta ntall stage stage

• The implementa implementation tion of of the plan

– Psycho Psychosoc social ial back backgrou ground nd

• Evaluation Evaluation results

• Nurse Nurse variab variables les – Resou esourc rces es – Curren Currentt standa standards rds of of care care – Resea Research rch findi finding ngs s – Ethical Ethical and and legal legal guides guides to to practice practice

Guidelines to Patient Counseling

Common Reasons for Noncompliance

• Make everyone feel comfortable in the situation and surroundings.

• Lack of family family support support

• Counseling Counseling may be formal formal or informal. informal. • Use interpersonal interpersonal skills skills of warmth warmth friendliness, friendliness, openness, and empathy.

• Lack of understandi understanding ng about the the benefits • Low value value attached attached to outcomes outcomes • Adverse Adverse physical or emotional emotional effects of treatment treatment

• Caring Caring is fundamental fundamental in the counseling counseling role.

• Inability Inability to afford afford treatment treatment

Types of Counseling

Factors to Consider When Delegating Nursing Care

• ShortShort-term term

• Patient Patient condition condition

• Situationa Situationall crisis

• Complexity Complexity of the action

• Long Long-t -term erm

• Potential Potential for harm

• Developmental Developmental crisis

• Degree of problem-solving problem-solving and innovation innovation necessary necessary

• Motiva Motivatio tional nal

• Level of interaction interaction required required with patient patient • Capabiliti Capabilities es of UAP • Availabilit Availability y of professional professional staff to accomplish workload workload


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Overview of the Five Steps of the Nursing Process: EVALUATING

Nursing Care That Should Not Be Delegated to a UAP • Initial Initial and ongoing ongoing nursing assessment assessment • Determination of nursing diagnoses, plans, evaluations evaluations • Supervision Supervision and education education of nursing personnel personnel • A nursing intervention intervention requiring requiring professional nursing nursing knowledge, judgment and/or skill

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Measuring the client’s health achievements based on the goals specified.

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It is used to determine the extent of which goals of nursing care have been achieved.

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Activities:

1. Data collection about about the client’s response 2. Compare data to outcome outcome criteria 3. Analyze the the result 4. Modify the Nursing Care Plan as necessary To encourage further goal achievement, it is important for the nurse to evaluate client’s goal achievment as early as possible.

Five Rights of Delegation

Evaluating Step

• Right Right task task

• Allows Allows achievement achievement of outcomes outcomes

• Right circumstances circumstances

• Directs Directs nurse-patient nurse-patient interactions interactions

• Right Right person person

• Measures Measures patient outcome outcome achievement achievement

• Right direction/ direction/communi communication cation

• Identifies Identifies factors factors to achieve outcomes outcomes

• Right Right supervisi supervision on

• Modifies Modifies the plan of care, care, if necessary necessary

Overview of the Five Steps of the Nursing Process: EVALUATING

Action Based on Outcome Achievement • Terminate Terminate plan plan of care • Modify Modify plan plan of care • Continue Continue plan plan of care


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Four Types of Outcomes • Cognitive Cognitive — increase increase in patient patient knowledge knowledge • Psychomoto Psychomotorr — patient’s patient’s achievement achievement of of new skills skills • Affective Affective — changes in patient patient values values belief, and and attitudes • Physiologic Physiologic — physical physical changes changes in the the patient patient

Five Classic Elements of Evaluation

Evaluating Outcomes

• Identifying Identifying evaluative evaluative criteria and standards standards

• Cognitive Cognitive — asking asking patient patient to repeat repeat information information or apply apply new knowledge

• Collec Collectin ting g data • Interpreting Interpreting and summarizin summarizing g findings • Documenting Documenting judgment judgment

• Psychomoto Psychomotorr — asking patient patient to to demonstrate demonstrate new skill skill • Affective Affective — observing observing patient patient behavior behavior and conversati conversation on

• Terminating, Terminating, continuing, continuing, or modifying modifying the plan

• Physiologic Physiologic — using physical physical assessment assessment skill to to collect and compare data

Evaluative Criteria vs. Standards

Variables Affecting Outcome Achievement

• Criteria Criteria — measurable measurable qualities, qualities, attributes, attributes, or characteristics that specify skills, knowledge, or health status

• Pati Patient ent

– Describe accepta acceptable ble levels levels of performance performance by stating stating expected behaviors of nurse or patient • Standards Standards — levels of performance performance accepted accepted and and expected by the nursing staff – Established Established by authority authority,, custom, custom, or consent consent


– E.g., a patient patient gives gives up and and refuses refuses treatment treatment • Nurs Nurse e – E.g., a nurse nurse is suffering suffering from burn-out burn-out • Health Healthcare care system system – E.g., E.g., inadeq inadequat uate e staffin staffing g

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Evaluative Statements • Decide how well outcome was met (met, partially met, or not met) • List patient data or behaviors that support this decision decision

Four Steps Crucial to Improving Performance • Discover Discover a problem. problem. • Plan a strateg strategy y using indicators. indicators. • Implement Implement a change. • Assess the change and/or plan a new strategy if outcomes are not met.

Improving Professional Performance • Peer Peer revie review w • Quality Quality assurance assurance programs programs • Structure Structure evaluations evaluations • Process Process evaluations evaluations • Outcome Outcome evaluat evaluations ions • Quality Quality improvement improvement • Nursing Nursing audit audit • Concurrent Concurrent and retrospective retrospective evaluations evaluations

Revisions in the Plan of Care

Determining Adequacy of Evaluation Step

• Delete or modify modify the nursing nursing diagnosis. diagnosis.

• Evaluate Evaluate patient achievemen achievementt of desired outcomes. outcomes.

• Make the outcome outcome statement statement more realistic. realistic.

• Review how the the process is used. used.

• Adjust time time criteria in outcome statement statement..

• Revise Revise the plan of care care if necessary. necessary.

• Change Change nursing intervent interventions. ions.

• Participate Participate in quality-assurance quality-assurance programs. programs.


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• Evaluate Evaluate patient achievement achievement of desired outcomes. outcomes.

• Evaluate Evaluate patient achievemen achievementt of desired outcomes. outcomes.

• Review how the process process is used. used.

• Review how the the process is used. used.

• Revise the the plan of care if necessary. necessary.

• Revise Revise the plan of care care if necessary. necessary.

• Participate Participate in quality-assuranc quality-assurance e programs.

• Participate Participate in quality-assurance quality-assurance programs. programs.

Major Premises of Quality Improvement (Schroeder, 1994) • Focus on organiza organizational tional mission mission • Continuous Continuous improvement improvement • Customer Customer orientation orientation • Leadership Leadership commitment commitment

Nursing Skills

• Empowe Empowermen rmentt • Collaborati Collaboration/crossi on/crossing ng boundaries boundaries • Focus Focus on proces process s • Focus on data data and statistical statistical thinking thinking

Questions to Insure a Firm Commitment to Evaluation

Four Blended Skills

• What are are the patient’s patient’s outcomes? outcomes?

• Cognitive Cognitive skills skills — make sense sense of the situati situation on and grasp grasp what is necessary to achieve goals

• What are are nursing nursing values? values? • How can these values values be formalized formalized in standards standards and evaluative criteria?

• Technical Technical skills — manipulate manipulate equipment equipment skillfully skillfully to produce desired outcome

• What data exist to determine determine whether criteria are met?

• Interpersonal Interpersonal skills — establish establish and maintain maintain caring caring relationships that facilitate achievement of goals

• How can these these data best be collected, analyzed, and interpreted?

• Ethical/lega Ethical/legall skills — personal moral code and and professional role responsibilities

• To what courses courses of actions do the findings findings lead? lead?


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Cognitively Skilled Nurses Ethically and Legally Skilled Nurses • Offer scientific scientific rationale rationale for patient plan plan of care • Select nursing interventions interventions most likely likely to yield desired outcomes • Use critical thinking thinking to solve problems problems creatively creatively

• Are trusted to act act in ways that that advance interests of patients • Are accountabl accountable e for the practice practice • Act as effective effective patient advocat advocates es • Mediate ethical conflict among patient, significant others, and healthcare team

Technically Skilled Nurses • Use technical equipment equipment with competence competence and ease to achieve goals with minimal distress to patients • Creatively adapt equipment and technical procedures to needs of patients in diverse circumstances

Considerations When Posed with a Thinking Challenge • Purpose Purpose of of thinking thinking • Adequacy Adequacy of of knowledge knowledge • Potential Potential problems problems • Helpful Helpful resour resources ces • Critique Critique of judgment/d judgment/decision ecision

Interpersonally Skilled Nurses • Use interactions with with patients and significant others and colleagues to affirm their worth • Elicit personal personal strengths strengths and abilities abilities of patients to achieve health goals

Characteristics of Interpersonal Caring • Promotion Promotion of dignity dignity and respect of patients patients • Centrality Centrality of the caring caring relationship relationship • Mutual enrichment enrichment of both participan participants ts in the nursepatient relationship

• Provide the healthcare team with knowledge about patient goals and expectations • Work collaborati collaborative ve with healthcare team as respected respected and credible colleagues


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Developing Ethical/Legal Skills • Developing Developing accounta accountability bility • Reporting incompetent, incompetent, unethical, or illegal practice

Steps in Concept Map Care Planning • Develop Develop a basic skeleton skeleton diagram. diagram. • Analyze Analyze and categoriz categorize e data. • Analyze Analyze nursing diagnoses diagnoses relationships. relationships. • Identify Identify goals, outcomes, outcomes, and intervention interventions. s. • Evaluate Evaluate patient’s patient’s responses. responses.

Clinical Reasoning

Critical Thinking and Clinical Reasoning • Is purposeful, purposeful, informed, outcome-focuse outcome-focused d thinking • Is driven by patient, patient, family, and community community needs • Is based on principles principles of nursing process process and scientific scientific method • Uses both intuition and logic, based based on knowledge, skills, experience • Requires Requires strategies strategies that make make the most of human potential • Is constantly reevaluating, self-correcting, and and striving to improve


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Handout Nursing Process

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