T5 Plan the Nursing Intervention

8/11/2019 T5 Plan the Nursing Intervention

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PLANNING THE NURSING

INTERVENTION

Ninuk Dian

k

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EXCELLENCE WITH MORALITY

NURSINGPROCESS

Process uses to identify, diagnose, and treathuman responses to health and illness (ANA,2003)


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FIVE-STEPSNURSINGPROCESS

Assess-Gatherinformation

about the clientsconditions

Diagnose. Identifythe clientsproblems

Plan. Set goals of

care and desiredoutcomes and

identify appropriatenursing actions

Implement.Perform thenursing actionsidentified in the

planning

Evaluate. Determineif goals met and

outcome achieved

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NURSINGCAREPLANS

The nursing care plan consists of a nursing diagnosiswith defining characteristics (subjective and objectivedata that support the diagnosis), related factors or riskfactors, expected outcomes/goals, and nursinginterventions.


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NCP

In agreement with the client, the nurse addresses each ofthe problems identified in the diagnosing phase. Whenthere are multiple nursing diagnoses to be addressed, thenurse prioritizes which diagnoses will receive the mostattention first according to their severity and potentialfor causing more serious harm. For each problem ameasurable goal/outcome is set. For each goal/outcome,the nurse selects nursing interventions that will helpachieve the goal/outcome.

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NCP

A common method of formulating the expectedoutcomes is to use the evidence-based Nursing OutcomesClassification to allow for the use of standardizedlanguage which improves consistency of terminology,definition and outcome measures. The interventionsused in the Nursing Interventions Classification againallow for the use of standardized language which

improves consistency of terminology, definition andability to identify nursing activities, which can also belinked to nursing workload and staffing indices


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CHARACTERISTICSOFNURSINGCAREPLANS

Its focus is holistic, and is based on the clinical judgment of the

nurse, using assessment data collected from a nursingframework.

It is based upon identifiable nursing diagnoses (actual, risk orhealth promotion) - clinical judgments about individual, family,or community experiences/responses to actual or potentialhealth problems/life processes.

It focuses on client-specific nursing outcomes that are realisticfor the care recipient

It includes nursing interventions which are focused on the

etiologic or risk factors of the identified nursing diagnoses. It is a product of a deliberate systematic process.

It relates to the future.

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PLANNING Planning is a category of nursing behaviours in which client-

centered-goals and expected outcome are specifically chosen toresolve the clients problem and achieve the goals andoutcomes.

Is dynamic, will change as the clients need are met or as newneeds are identified

It requires a nurse to use deliberate decision making and

problem solving skills to design care for each client. Priorities are set during planning because a client often has

more than one nursing diagnosis and variety of proposedinterventions.

To establish a plan: collaborate with client and family, consultwith other member of health care team, review pertinentliterature


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CRITICALTHINKINGANDASSESSMENTPROCESS

Assessment

Diagnosis

Planning

Implementation

Evaluation

KnowledgeUnderlying disease process

Normal growth anddevelopmentNormal psychologyNormal assessment findingsHealth promotion

Assessment skillsCommunication skills

AttitudesPerseverance

FairnessIntegrityConfidenceCreativity

StandardScope of nursing practiceSpecialty standards of practiceIntellectual standard ofmeasurement

ExperiencePrevious client careexperience

Validation of assessmentfindingsObservation of assessmenttechniques

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NURSINGDIAGNOSIS

A nursing diagnosisis part of the nursing process andis a clinical judgment about individual, family, orcommunity experiences/responses to actual or potentialhealth problems/life processes. Nursing diagnoses aredeveloped based on data obtained during the nursingassessment.


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CONT..

Actual diagnosis- "A clinical judgment about humanexperience/responses to health conditions/life processesthat exist in an individual, family, or community". Anexample of an actual nursing diagnosis is: Sleepdeprivation.

Risk diagnosis- "Describes human responses to healthconditions/life processes that may develop in avulnerable individual/family/community. It is supportedby risk factors that contribute to increased vulnerability."An example of a risk diagnosis is:Risk for shock.

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CONT..

Health promotion diagnosis- "A clinical judgmentabout a persons, familys or communitys motivation anddesire to increase wellbeing and actualize human healthpotential as expressed in the readiness to enhancespecific health behaviors, and can be used in any healthstate." An example of a health promotion diagnosis is:Readiness for enhanced nutrition.

Syndrome diagnosis- "A clinical judgment describinga specific cluster of nursing diagnoses that occurtogether, and are best addressed together and throughsimilar interventions." An example of a syndromediagnosis is:Relocation stress syndrome


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PROCESSOFDIAGNOSIS

Conduct a nursing assessment- collection ofsubjective and objective data relevant to the carerecipient's (person, family, group, community) humanresponses to actual or potential health problems / lifeprocesses.

Cluster and interpret cues/patterns- Assessmentdata must be clustered and interpreted before the nursecan plan, implement or evaluate a plan to supportpatient care

Generate Hypotheses- possible alternatives thatcould represent the observed cues/patterns.

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CONT..

Validation & Prioritization of Nursing Diagnoses- taking necessary steps to rule out other hypotheses, toconfirm with the patient(s) the validity of thehypotheses, and to prioritize the list of diagnoses. Afocused assessment may be needed to obtain data for oneor more diagnoses

Planning- Determining appropriate (realistic) patientoutcomes and interventions most likely to supportattainment of those outcomes through evidence-basedpractice


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CONT..

Implementation- Putting the plan of care (nursingdiagnoses - outcomes - interventions) into place,preferably in collaboration with the care recipient(s)

Evaluation- Movement toward identified outcomes iscontinually evaluated, with changes made tointerventions as necessary. When no positive movementis occurring, reassessment to reevaluate appropriatenessof diagnoses and/or achievability of outcomes mustoccur.

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NURSINGDIAGNOSIS

Activity intolerance

Anxiety

Risk for respiration

Bowel incontinence

Etc

Nomenclature:

PE

PES


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NURSINGINTERVENTION

Are not selcted haphazardly, when choosing anintervention, a nurse deliberates abut six importantfactors:

Characteristic of the nursing intervention

Expected outcome

Research base

Feasibility

Acceptability to the client

Capability of the nurse

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NURSINGINTERVENTION

Interventions must be directed toward altering theetiological factors associated with the dx

When the etiological factor cannot change, theinterventions must be directed toward treating the signsand symptoms

For risk, interventions must be aimed at

altering/eliminating the risk factors


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GOAL

The goalas established in a nursing care plan in termsof observable client responses is what the nurse hopesto achieve by implementing nursing orders. It is adesired outcome or change in the client's condition. Theterms goal and outcome are often used interchangeably,but in some nursing literature, a goal is thought of as amore general statement while the outcome is morespecific. For example, a goal might be that a patient'snutritional status will improve overall, while the outcomewould be that the patient will gain five pounds by a

certain date

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EXPECTEDOUTCOMES

Must be specified before selecting an intervention

The language can assist the intervention due to it isstated in term used to evaluate the effectiveness ofintervention

Nursing intervention classification is designed to showthe link to nursing outcomes classification


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GOAL

Has to be written clearly so that all members of thenursing team understand a clients plan of care and areable to collaborate in achieving the sane goals andoutcomes.

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GOALSANDEXPECTEDOUTCOMES Client centered: reflect the client behaviour and responses

expected as a result of nursing intervention.

Singular goal/outcome: each goal/expected outcome shouldonly address one behaviour or response

Observable: the nurse must be able to determine throughobservation if the change has taken place

Measurable: goal and expected outcome are written to give the

nurse a standard against to measure the clients response tonursing care

Time limited: the time frame indicates when the expectedresponse should occur

Mutual factors: ensure both nurse and client agree on thedirection and time limits of care

Realistic: can be achieved


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NURSINGINTERVENTION-RESEARCHBASE

Research in support of a nursing intervention willindicate the effectiveness of using the intervention withcertain types of clients

Refer to research articles or EBP protocols the describethe utilisation of research findings in similar clinicalsituations and settings

When research is not available, use scientific principles(e.g. Infection control) or consult a clinical expert aboutyour client population

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FEASIBILITY

A specific intervention may have the potential forintracting with other interventions chosen by the nurseor other health care providers

The nurse must be knowledgeable of the total plan ofcare

Consider cost: is the intervention clinically effective and

cost effective? Consider time: are time and personnnel resources

available?


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ACCEPTABILITYOFCLIENT

The intervention must be acceptable to the client andfamily and congruent with the clients goals, health carevalues, and culture

To faciliatte informed choice, a client must know howhe/sge is expected to participate and the anticipatedeffect of the intervention

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CAPABILITYOFTHENURSE

Nurse must be able to carry out the intervention

Nurse must be knowledgeable of the scientific rationaleof the intervention

Nurse must possess the necessary psychosocial andpsychomotor skills to complete the intervention

Nurse must be able to function within the particular

setting to effectively use health care resources


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TYPESOFNURSINGINTERVENTION

Nurse-initiated intervention

Independent response of the nursee to the clients healthcare needs and nursing diagnoses

Nurse is able to act within his/her own scope of practiceto intervene on a clients behalf

Autonomous actions based on scientific rationale that isexpected to benefit client

Do not require a physicians or NP or other healthprofessional orders

e.g. Instructing clients to manage their activities of dailyliving

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PHYSICIAN-INITIATED

INTERVENTION

Based on physician response to treat medical diagnoses

E.g. Dressing care, administer medication, invasiveprocedures, prepare client for dx tests


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COLLABORATIVEINTERVENTION

Therapies that require the knowledge, skill, and expertiseof multiple health care professionals

E.g. Care of client with multiple fracture and dementia

Client require interventions from multiple health careprofessionals that all directed toward the long term goalof maintaining the client present level of health

Client will require nursing intervention to preventpressure ulcers

Physical therapy to prevent musculoskeletal changes

from immobility Occupational interventions for eating and hygiene needs

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NURSINGORDER Nursing ordersare instructions for the specific

activities that will perform to help the patient achieve thehealth care goal. How detailed the order is depends onthe health personnel who will carry out the order.Nursing orders will all contain:

The date

An action verb like "monitor," "instruct," "palpate," orsomething equally descriptive

A content area that is the where and the what of theorder, for example, placing a "spiral bandage on the leftleg from ankle to just below the knee"

A time element will define how long or how often thenursing action will occur

The signature of the prescribing nurse, since orders arelegal documents.


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NURSINGINTERVENTION

Ax: fever (t=40C), diaphoresis, poor skin turgor, no skinbreakdown noted, unconscious, bed rest.

Dx: risk for impaired skin integrity r.t. physicalimmobility

Goal: skin remains intact through discharge

Expected outcomes:

Client is afebrile in 24hr, skin colour returns to normalinn 48hr, skin turgor returns to normal in 48 hr

Intervention: turn client every 1 as follow: 8 amsupine, 9.30 am 30 degree left lateral position, 11 am 30

degree right lateral position, 12.30 supine. Continue asaforementioned cycle; keep HOB < 30 elevation,administer IV fluid as ordered, apply air fluidized beduntil body fluids are contained.

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NCP

Activity Intolerance

Alteration in Bowel Elimination: Constipation

Alteration in Bowel Elimination: Diarrhea

Alteration in Comfort: Pain

Alteration in Patterns of Urinary Elimination:Incontinence

Alteration in Patterns of Urinary Elimination: Retention Alterations in Cardiac Output: Decreased


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NCP

Disuse Syndrome

Fluid Volume Deficit Fluid Volume Excess

Impaired Gas Exchange

Impaired Physical Mobility

Impaired Skin Integrity

Impaired Social Interaction

Impaired Verbal Communication

Ineffective Airway Clearance

Ineffective Breathing Patterns Self Care Deficit: Bathing

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EXERCISE

Formulate goal, expected outcomes and nursingintervention for the following case studies


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CASEI

Mr Andrew 42 years old, trauma patient is brought to theED in an ambulance. He was the driver in a motorvehicle collision and was not wearing seat belt. Thepassenger in the car was dead at the scene. Theparamedics stated that there was significant damage tothe car on the passenger side.

Subjective data: Is awake, Complains of shortness ofbreath and abdominal pain

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CONT

Objective data: Physical Examination:

4 cm head laceration

Badly deformed right lower leg without pulses

Unequal pupils

Decreased breath sounds on left side of chest

Asymmetric chest movement

Vital signs: BP 90/40, HR 130 beats/min, RR 36breaths/min.

O2 saturation 82%


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CASEII

John, 34 years old man, was admitted to the emergencydepartment after his wife found him comatose in hisapartment.

Subjective Data

Was diagnosed with diabetes mellitus 12 months ago

Was taking 48 U of insulin daily: 12 U of regular insulinplus 20 U of NPH before breakfast, 8 U of regular insulinbefore dinner, and 8 U of NPH at bedtime.

Has history of flu for 1 week with vomiting and anorexia.

Stopped taking insulin 2 days ago when he was unable toeat.

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CONT..

Objective Data

Physical Examination

Breathing is deep and rapid

Acetone smell on breath

Skin flushed and dry

Diagnostic studies

Blood glucose level of 730 mg/dl (40.5 mmol/L)

Blood pH of 7.26


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CASEIII

Susan is a 16-year-old high school student who sustained aC7 spinal cord injury when she dove into a lake while

swimming with her friends. Susan is admitted directly tothe ICU.

Subjective Data: Has patchy sensation in her upperextremities

Objective Data

Very weak bicep and triceps strength bilaterally

Bowel and bladder control present

Moderate strength in both of lower extremities

X-rays show no fracture dislocation of the spine Placed on bed rest with a hard cervical collar

Methylprednisolone administered per protocol

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CASEIVMs. Patricia was bought to the first aid tent provided for

participants in a charity marathon. She is a diabetic wellmaintained on regimen of self-monitoring of blood glucose,insulin and diet.

Subjective Data

States she feels cold, has a headache and her fingers feel numb

Took her usual insulin dose this morning but was unable to eat

her entire breakfast due to lack of time Completed the entire marathon in a personal-best time

Objective Data

Has slurred speech and unsteady gait, Pulse 120 beats/min,Appears confused

Capillary blood glucose level 48 mg/dl (2.7 mmol/L)


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HOWTOADDRESSTHECASSESTUDIES

Write down the diagnoses and the evidence (subjective

and objective data) Write the goal

Write the expected outcomes

Write the interventions

e.g. Case II: fluid volume deficit r.t. ......

As evidence by:

Subjective data.....

Objective data.....

Goal:Expected outcome

Interventions:

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T5 Plan the Nursing Intervention

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