NUR 323 - Week 2 (Patient Centered Care & Nursing Process)

What does patient centered care include?

• the patient (INCLUDE them in their care)

• the nurse

• reflective practice → patient & nurse learning

• clinical reasoning & judgement (best interventions)

• nurse’s action and response to clinical need

Nursing Process

1. Assess the patient to determine the need for care

2. Determine Nursing Diagnoses for actual and potential health problems

3. Identify expected Outcomes and Plan Care

4. Implement the care

5. Evaluate the results of care

Clinical Judgment Model

1. Identify and recognize relevant clinical data cues

2. Assess data cues from existing knowledge and identify patterns

3. Prioritize hypotheses to determine most pressing problem

4. Generate solutions and expected outcomes to establish plan of care

5. Take action and implement nursing intervention

6. Evaluate outcomes

True or false: the second step in providing patient-centered care is conducting a comprehensive assessment to gather both subjective & objective information about the patient

FALSE → this is the first step

What is the assessing step?

Systematic and continuous collection, analysis, validation, and communication of patient data

• VITAL!

What does the data collected during the assessment phase reflect?

It reflects how the patient’s health functioning can be enhanced by health promotion or how it is compromised by illness or injury

• forms a database of important information that allows us to form an effective plan of care

True or false: every step of the nursing process is dependent on the initial data gathered in the assessment phase

TRUE → it must be complete and accurate

What are assessment priorities for data collection?

• health orientation → are there health problems?

• culture → ethnicity, religion, socioeconomic

• developmental stage

• need for nursing

What types of data are needed to develop a plan of care?

• Maslow’s hierarchy of needs

• Gordons functional health patterns

• HELP

Who is the primary source of information?

the PATIENT

Where else can we gather information from?

• family & significant others

• patient record

• assessment technology

• other healthcare professionals

• nursing literature

Why isn’t the patient record or family of the patient the primary source?

It is secondary, information could be outdated, and errors as a result of translations in chart

When is an initial assessment performed?

shortly after admission

What is the purpose of an initial assessment?

to establish a complete database for problem identification & care planning

What does an initial assessment allow the nurse to do?

• establish priorities for focused care

• baseline for comparison

• judgment on patient’s ability to self-manage care

• plan & deliver person-centered care

• make referrals to other providers if needed

What is the purpose of a focused assessment?

ongoing data collection regarding an identified problem & identified new or overlooked problems

What are the components of a focused assessment?

• health history (subjective data)

• physical assessment (objective data)

Subjective data

Information perceived only by the affected person

• obtained through patient interview (what the patient says)

• symptoms

What is an example of subjective data?

Feeling anxious, feeling dizzy, feeling pain

Objective data

observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

• obtained through physical assessment

• signs

What is an example of objective data?

elevated temperature, skin moisture, vomiting

What are some problems related to data collection?

• bad organization of database

• omission of important data (not asking subjective questions)

• inclusion of duplicate or incorrect data

• failure to establish trust with patient

• writing interpretation of data rather than observed behavior (not “seemed anxious” → elevated HR & shaking indicated anxiety)

• failure to update database

The nurse uses ____ and ____ for early data analysis

cues & inferences

Cues

subjective & objective data to help identify that something may be wrong

Inferences

judgments reached about cues that MUST be validated

How do we use clinical reasoning during assessment?

• assess systematically & comprehensively

• detect bias & determine credibility of source

• identify abnormal findings & risks

• judgment about data significance

• check accuracy & notice missing info

What does assessment set the stage for?

diagnosis

Nursing Diagnosis Definition

the interpretation and analysis of patient data to identify actual or potential patient strengths, health problems or issues that nursing intervention can prevent or resolve

True or false: a nursing diagnosis may change from day to day as the patient’s responses to health and illness change

TRUE

What does a nursing diagnosis provide the basis for selecting and facilitating the achievement of patient-forward ______?

interventions & outcomes

What are 3 purposes of the diagnosing step?

• identifying how a person responds to actual or potential health processes

• identifying factors that contribute to or cause health problems

• identifying resources or strengths that the person can draw on to prevent or resolve problems

Medical Diagnosis

describes problems for which the physician directs the primary treatment

• goal: identify disease

• remains the same throughout disease presence

Collaborative Problems

Managed by using physician-prescribed, nursing-prescribed and other discipline prescribed interventions

• physician’s direct treatment and nurses monitor onset or changes in status

True or false: physicians are primarily responsible for collaborative problems

FALSE → nurses are primarily responsible for collaborative problems

What are the 3 types of nursing diagnoses?

• problem-focused

• risk for

• health promotion

Problem-focused nursing diagnosis

• undesirable human response to a health condition/life process

• ALREADY exists in patient

What are the components of problem-focused nursing diagnoses?

• label

• related to factor

• defining characteristics

Risk nursing diagnosis

vulnerability of an individual for developing an undesirable human response to health conditions/life processes

What are the components of risk nursing diagnoses?

ONLY label & related to factors

• no defining characteristics bc the problem does not currently exist for the patient

Health promotion nursing diagnosis

clinical judgment concerning patient’s motivation & desire to increase their well-being

• responses expressed by the patient are used to determine their readiness to enhance health behaviors

What are the components of health promotion diagnosis?

one-part statement: nursing diagnosis label

What are the four steps of data interpretation?

1. recognize significant data

2. recognize patterns or clusters

3. identify strengths, problems, and potential complications

4. reach conclusions

How do we recognize significant data?

nurses must be aware of “norms” to recognize if data is significant

• changes in usual health patterns that are unexplained

• not population norm

• unproductive behavior

• behavior indicating developmental lag

What is a data cluster?

a grouping of patient data or cues that point to a health problem

True or false: you can make a nursing diagnosis based on 1 piece of concerning data

FALSE - you CANNOT make a nursing diagnosis based on 1 piece of data

What is the issue with using a single cue for diagnosis?

making errors in diagnosing that leads to unsafe care

True or false: nursing diagnoses are always derived from clusters of data

True

What does Maslow’s Hierarchy look at?

• physiologic

• safety & security

• love & belonging

• self esteem

• self-actualization

What does Gordon’s functional health patterns look at?

• health perception/management

• nutrition

• elimination

• activity

• cognition

• sleep

• self-perception

• role

• sexuality

• coping

• value belief

What does human response patterns look at?

• exchanging

• communicating

• relating

• valuing

• choosing

• moving

• perceiving

• knowing

• feeling

What are the different body systems in the medically-focused model?

• neurologic

• cardiovascular

• respiratory

• gastrointestinal

• musculoskeletal

• genitourinary

• psychosocial

Which model is easiest to begin with?

the medically-focused model → body systems

What is a strength?

when a patient meets a norm, this is considered a strength contributing to the level of wellness

• includes patient & family

• ex: adequate finances, support system, coping

True or false: many people take their strengths for granted and may not know how to utilize them when responding to illness

TRUE

What is a patient problem area?

when the patient doesn’t meet the health norm they likely have a limitation

• also determining problems the patient is likely to experience → implications for future nursing intervention

What is a patient complication?

they relate to diagnoses, medications, invasive diagnostic studies, or treatment regimens

• be familiar with potential complications

What is the role of the nurse in regard to complications?

early detection & prevention through identification of abnormal data sets

What are the four basic conclusion categories?

• no problem

• possible problem (need more data)

• actual or potential problem

• clinical problem other than nursing diagnosis (pass off to another healthcare member)

True or false: it is important to partner with patients, as they want to play a leading role in treating their health problems

TRUE

What do we do once a cluster of patient data indicates there is a health problem that nursing can address?

write a nursing diagnosis

What is the problem component (label) of a nursing diagnosis statement?

• identifies what is unhealthy about patient; alteration to health status

• INFORMS patient outcomes

What is the cause/etiology component (r/t) of a nursing diagnosis statement?

• identifies factors that keep patient unhealthy (contributing cause)

• INFORMS nursing interventions

What is the defining characteristics (AEB) of a nursing diagnosis statement?

• identifies subjective & objective data that signal existence of problem

• INFORMS evaluative criteria

True or false: although defining characteristics are written last in a formal diagnosis, they are considered first and are part of the assessment.

TRUE

True or false: the nursing diagnosis label considers the patient’s needs

FALSE - only problems or alterations to health state

True or false: when writing a nursing diagnosis statement, we need to write in legally advisable terms and use nonjudgmental language

TRUE

True or false: we can cite medical diagnoses in the problem statement

FALSE → never

What is the primary purpose of the outcome identification and planning step?

to design a plan of care with and for the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems

• also aids in attainment of patient’s health expectations

What are the four steps used to identify outcomes and plan care?

1. establish priorities

2. identify and write expected patient outcomes

3. select evidence-based nursing interventions

4. communicate nursing care plan

Step 1 - Establishing priorities

Ask -

• which problems require my immediate attention vs which can i wait?

• what problem is most important to patient?

Rank -

• high (greatest threat)

• medium (not life threatening)

• low (not specifically related to current health)

Anticipate future problems!

Expected outcome definition

a conclusion to a patient health problem or expectation with specific measurable criteria (SMART); results achieved

• Ex: if label is about pain then outcome should be related to pain

Step 2 - Identify & write expected patient outcomes

They describe the conclusion expected for the patient (results)

• should be time-limited (short or long → >1 week)

• categories: cognitive, psychomotor, affective, clinical, functional, quality of life

• goals should be SMART (specific, measurable, attainable, relevant, time-oriented)

What verbs should we AVOID when writing an expected patient outcome?

• know

• understand

• learn

These are very hard to observe!

Nursing Intervention Definition

Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes

Step 3 - Selecting Nursing Interventions

• nurses perform interventions on behalf of patients

• developed on information that relates to the cause of the problem

What is the greatest challenge of the nursing intervention stage?

to identify the interventions that most likely lead to the achievement of outcomes

What should each nursing intervention include?

• action to be performed

• by who

• how, when, where, how much, how long

• date

• signature

Must specify what intervention and by when + what teaching needs to patients have

What do well-written nursing interventions accomplish?

• assist patient in meeting an outcome

• describe action nurse will perform

• refer nurse to procedure for routine steps

• dated & signed

True or false: nursing interventions should mention any vital signs being checked and at what frequency

FALSE - these are expectations of nurses

What are the 3 types of nursing interventions?

• nurse-initiated → performed without physician order

• physician/provider-initiated → action initiated by physician but carried out by nurse under doctor’s orders

• collaborative → treatment initiated by other provider & carried out by nurse

Nursing care plan definition

a written guide for nursing care

Step 4 - Communicating the nursing plan of care

directs the efforts of nursing team to meet patient’s needs or health goals & ensures that the team delivers efficient, holistic, goal-oriented, person-centered care

True or false: a well-written care plan must be updated to reflect changes in patient needs and should address discharge needs

TRUE

What is the purpose of implementing the nursing care plan?

to help the patient achieve health outcomes

How does the nurse carry out planned evidence-based actions/interventions?

• determining patient’s need for nursing assistance

• promoting self-care

• assisting patient to achieve health outcomes

True or false: upon implementing the nursing care plan, there must be a continuation of data collected to evaluate and make alterations to the plan

TRUE

Protocol

written plans that detail the nursing activities & responsibilities to be executed in specific situations

• signed by the provider

• ex: specific nursing responsibilities are prescribed in advance and ready for implementation when a patient is admitted to or discharged from the institution.

Standing orders

written in advance by a prescribing provider empowering the nurse to initiate actions that ordinarily require the order or supervision of a health care provider

• ex: standard orders for narcotic overdoses that specify the agents the nurse is to administer to reverse respiratory depression in an emergency.

What is the purpose of evaluating the nursing care plan?

to allow the patient’s achievement of the expected outcomes to direct future nurse-patient interactions

• involves interpreting & analyzing data

• when factors are not contributing to achievement of expected outcomes, the care plan is modified

What are the 3 types of decisions nurses may make during the evaluating step of nursing care plan?

1. Terminate - when expected outcome is achieved

2. Modify - alter care plan when outcomes are not met

3. Continue - maintain care plan if more time is needed to achieve outcomes (intervention is working and outcome is partially met)

Cognitive outcome

describes increases in patient knowledge or intellectual behaviors

Psychomotor outcome

describes the patient’s achievement of new skills

Affective outcome

describes changes in the patient’s values, beliefs, and attitudes

Physiological outcome

describes changes in patient physiologic (physical) parameter

What are the two parts of the evaluative statement?

1. decision about how well outcome was met

2. patient data or behaviors that support the decision