Alayna Alfred Chrischeal Charles Jamahl Guillaume Jemima Philippe

Objective 6: Describe the development of patient-centered outcomes A well written patient- centered outcome does the following Uses the word patient or part of the patient as the subject of the statement Uses measurable verb( define, describe, list, walk, demonstrate, and verbalize) Is specific for the patient and the patients problem Does not interfere with the medical plan of care Is realistic for the patient and the patient's problem Includes a time frame for patient reevaluation Because the subject of the patient outcome statement is meant to be the patient or a part of the patient, the outcome statement should begin with the words, “ the patient will” or “The patient's… will.”” The properly written patient outcome statement is specific to the patient and the patient's medical problem Two ways to approach writing patient outcome statements List the desired behavior in broader terms and then list exact criteria or standards Indicate a reversal of the problem identified by the NANDA-I nursing diagnosis label

Objective 6: Continued Example of both methods: The patient will improve mobility as evidenced by the ability to ambulate 200 feet by the third day following surgery

Objective 7: Discuss the creation of nursing orders. For care planning purposes, its necessary for you to be able to change the guiding general statement about the nursing intervention to a more specific statement. That detailed statement is now a nursing order Nursing order= general statement about the nursing interventions to a more specific statement A nursing order is necessary since the nurse who's writing the care plan is providing instructions for all caregivers Nursing orders include the following: Date Signature of the nurse responsible for the care plan Subject( who will be carrying out the activity) Action verb Qualifying details A proper nursing order is specific for the problem, realistic for the patient, compatible with the medical plan of care, and based on scientific principles The correct nursing order includes an action or command verb Examples of action or command verbs: ambulate, offer, encourage, demonstrate, turn, teach, and monitor

Diagnosis: To diagnose is to identify the type and cause of a health condition The ANA ( American Nurses Association) defines diagnoses as “ a clinical judgments about the clients response to actual or potential health conditions or needs Provides the basis for determining a care plan to achieve expected outcomes Cues that have significance for nursing are: Deviations in the patients usual health status Changes in the patients usual health status Developmental delays Dysfunctional behavior Changes in usual behavior

Nursing Diagnosis: Defined as the type of health problem that can be identified In 1990 the NANDA( North American Nursing Diagnosis Association) now known as NANDA international approved an official definition for nursing diagnosis that remains in current use When nurses submit nursing diagnoses, the following four components are addressed Nursing diagnoses title or label Definition of the title or label Contributing, etiologic, or related factors Defining characteristics Lists of nursing diagnoses are often presented in alphabetical order for example: constipation, fatigue, hopelessness, powerlessness, and pain Adjectives also add meaning to the nursing diagnosis label by describing or modifying the label. Examples of adjectives are imbalanced, ineffective, perceived, impaired, and excess

4 Types of Nursing Diagnosis: Actual nursing diagnosis: defined as the human responses to health conditions and life processes that exist in an individual, family, or community Risk nursing diagnosis: supported by risk factors that contribute to increased vulnerability Written as two part statements (1) the nursing diagnosis label and (2) the risk factors Example of risk nursing diagnosis: risk for impaired skin integrity related to physical immobilization Syndrome nursing diagnosis: written as one part statements Used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances Post trauma syndrome, risk for disease syndrome, impaired environmental interpretation syndrome, and relocation stress syndrome are the current syndrome diagnoses Wellness Nursing Diagnosis: “human responses to levels of wellness in an individual, family, or community( NANDA-I,2009) Written as one part statement as well Words “readiness for enhanced” are used in a wellness nursing diagnosis

Standardized Languages: Defined as one in which the terms are carefully defined and mean the same thing to all who use them Helps accomplish the following: Improve communication by providing consistent terminology to describe clinical problems and treatments Support computerized patient records Improve testing of nursing interventions for effectiveness Define and expand nursing knowledge Facilitate research to improve patient care Demonstrate nursing's contribution to patient care Influence health policy decisions NANADA-1, Nursing Interventions Classification( NIC), and Nursing Outcomes Classification( NOC) are examples of standardized languages describing diagnoses, interventions, and outcomes, created by the ANA organization The system is useful to computer- based systems and describes nursing practice

Standardized Languages: Continued The standardized languages, developed at the University of Iowa, encourages enhanced communication between nurses about nursing interventions.

Credits: Alayna Alfred Chrischeal Charles Jamahl Guillaume Jemima Philippe