1. How to Write Nursing (Client) Outcomes How to Write Nursing (Client) Outcomes Gail Ladwig, RN, MSN, CHTP Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Definition: Outcomes  An individual, family, or community state, behavior, or perception  Measured along a continuum  Uses a measurement scale  Uses a five-point Likert-type scale (Nursing Outcomes Classification system: NOC)  Can be compared with a baseline over time (Moorhead et al., 2008)

3. 3 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Process  Writing outcomes is part of the planning phase of the nursing process.  Measurable outcomes are based on the nursing diagnosis identified in the assessment.  The client is involved.

4. 4 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Process: How to Write Measurable Outcomes  Writing outcomes  Step one Assessment Assessment  Step two Analyze assessment information Analyze assessment information Formulate nursing diagnosis Formulate nursing diagnosis  Step three Planning phase Planning phase Write measurable outcomes based on nursing diagnosis identified in the assessment Write measurable outcomes based on nursing diagnosis identified in the assessment

5. 5 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step One Assessment

6. 6 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment and Nursing Outcomes  Comprehensive assessment leads to an appropriate client outcome  Collection of information about the client:  Holistic and detailed  Supports critical thinking  Determines problems and strengths  Beginning and ongoing during all phases of the nursing process

7. 7 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment  Assess the client  Perform a thorough holistic nursing assessment  Use the format adopted by the facility or educational institution  Nursing assessments based on conceptual models:  Gordon's functional health patterns  Orem’s self-care model  Roy’s adaptation model

8. 8 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking  Look for normal and abnormal findings  Validate the data with the client  “This is what I have noticed.”  “Does this describe how you feel?”  “Tell me more.”  “What can I do to help?”

9. 9 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Immediate Reporting  Report, record, and ACT on information that requires immediate attention  Some examples: Sharp, unrelenting pain Sharp, unrelenting pain Vital signs greatly deviated from normal Vital signs greatly deviated from normal Change in level of consciousness Change in level of consciousness  When in doubt, report and ACT

10. 10 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Documentation  Record all information obtained from the health history and physical assessment.  In some institutions, enter this information into a computer.

11. 11 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Confidentiality  Share only information that is of benefit to the nursing and medical team for planning care.  Keep notes safe.  Do not leave them at site of interview.

12. 12 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Confidentiality (continued)  The client’s name should appear only on agency documents.  Do not put client's name on any notes used for classroom work.  Follow Health Insurance Portability and Accountability Act (HIPAA) guidelines regarding client confidentiality.

13. 13 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Two Nursing Diagnosis

14. 14 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Analyze Assessment Information Formulate Nursing Diagnosis  Identify diagnosis  Identify related factors  List defining characteristics

15. 15 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis Critical Thinking  Analyze information  Based on client assessment information, ask:  Can a change occur with a nursing intervention?  Does it fit the NANDA definition?  Are the defining characteristics in the assessment?

16. 16 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Use of Assessment Information  Organize the information  Identify patterns in the assessment Highlight problems Highlight problems  Make a list of all problems and potential problems  Group like problems together  Make initial inferences or impressions  Prioritize the problems Use Maslow’s hierarchy Use Maslow’s hierarchyMaslow’s hierarchyMaslow’s hierarchy  Record and report the information

17. 17 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis List  Select the appropriate nursing diagnosis for the client from the NANDA-I approved list.  Nursing Diagnoses: Definitions and Classification 2007-2008  Ackley/Ladwig, Nursing Diagnosis; Evidence- Based Guide to Planning Care; or online at Evolve Care Plan Constructor.  List of 203 “approved nursing diagnoses”

18. 18 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking Check  The three-part diagnostic statement may be referred to as the PES system:  (P)roblem: nursing diagnosis label  (E)tiology: “related to” phrase  (S)ymptoms: defining characteristics

19. 19 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Document Selected Nursing Diagnoses on the Nursing Plan of Care

20. 20 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Three Planning: Nursing (Client) Outcomes

21. 21 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Select Appropriate Outcomes  Use NOC (Nursing Outcomes Classification) -OR-  Write outcome statement (Both methods are included in Ackley/Ladwig, 2010, and on the EVOLVE Care Plan Constructor site.)

22. 22 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. NOC Outcome Definition  An individual, family, or community state, behavior, or perception  Measured along a continuum  Response to a nursing intervention  Group of indicators used to determine patient status in relation to the outcome (Moorhead et al., 2008)

23. 23 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. NOC Rating Scale  Five-point Likert-type rating scale  Used to evaluate progress toward achieving the outcome

24. 24 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Example: NOC Rating Scale (Nursing Outcomes Classification, 2000)

25. 25 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Writing Outcomes Criteria if you are not using the NOC list Outcomes must be:  Measurable  Related to a time frame  Client-centered  Attainable  Realistic

26. 26 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Case Scenario  Identify  Nursing diagnosis  Identify outcomes

27. 27 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Sample Case Study  A 73-year-old man has been admitted to the unit with an admitting medical diagnosis of COPD (chronic obstructive pulmonary disease). He states that he has “difficulty breathing when walking short distances” (RR = 26). He also states that his “heart feels like it is racing” at the same time (HR = 120). He states that he is “tired all the time,” and while talking to you, he is continually wringing his hands and looking out the window.

28. 28 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Select Appropriate Nursing Diagnosis Write Nursing Diagnostic Statement

29. 29 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnostic Statement  (P) Activity Intolerance  (E) Related to imbalance between oxygen supply and demand  (S) Verbal report of fatigue  Abnormal heart rate in response to activity “Heart feels like it is racing” “Heart feels like it is racing”  Exertional dyspnea “Difficulty breathing when walking short distances” “Difficulty breathing when walking short distances”

30. 30 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Select Appropriate Outcomes Write Appropriate Outcomes

31. 31 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking: Writing Outcomes  What will the client change?  How will you know?  What information will be needed to demonstrate the change?  What statement will the client make that demonstrates change?

32. 32 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Areas for Client Change (Improvement)  Activity intolerance  Verbal report of fatigue  Abnormal heart rate in response to activity “Heart feels like it is racing” “Heart feels like it is racing”  Exertional dyspnea “Difficulty breathing when walking short distances” “Difficulty breathing when walking short distances”

33. 33 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Client Outcomes for Activity Intolerance  Client will:  Participate in prescribed physical activity with appropriate increases in heart rate (HR), blood pressure, and respiratory rate (RR).  Demonstrate increased activity tolerance.

34. 34 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking: Measurable Outcomes  What will be measured after the physical activity?  How will it be measured?  How will activity tolerance be demonstrated?

35. 35 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Demonstrate Measurable Outcomes  Use the term “as evidenced by” -OR- -OR-  Use the acronym “AEB”

36. 36 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Measurable Outcomes: AEB  HR (>100 beats/min) and RR (>20 breaths/min) after activity  Client will state subjective feelings after activity

37. 37 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Time Frame  How often will nursing activity be done with the client?  How long will the nursing activity be done with the client?

38. 38 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Time Frame: Examples of outcomes associated with nursing intervention of assisting the client with increasing activity  Assist the client to walk in the hall for 5 minutes.  Have the client perform this activity three times a day.

39. 39 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Individualized Outcomes  How will the activity be individualized?

40. 40 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Individualized Outcomes: Example  Client will walk in the hall for 5 minutes three times a day.

41. 41 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Attainable Outcomes  What is reasonable and attainable for this client?

42. 42 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Attainable Outcomes: Example  Client will be able to walk in the hall three times a day for 5 minutes.

43. 43 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Realistic Outcomes  What was client able to do before?  What changes would be possible for this client?

44. 44 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Realistic Outcomes: Examples  Client-reported fatigue  “Heart racing after activity”  “Difficulty breathing when walking short distances”  Outcomes selected  Walk for 5 minutes in the hall  Do this three times a day

45. 45 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Individualized Outcome  Activity tolerance improved  AEB  Client will walk in the hall for 5 minutes three times a day.  Client’s HR will be >100 beats/min and RR will be >20 breaths/min after activity.  Client will state positive subjective feelings after activity.

46. 46 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Document Outcomes  Document appropriate outcomes on the nursing plan of care.

47. 47 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking: Evaluation of Outcomes  Activity intolerance improved  AEB  Client states, “I do not feel tired all the time anymore.”  HR is 90 beats/min after walking in the hall for 5 minutes.  Client states, “My heart isn’t racing anymore.”  RR is 18 breaths/min after walking in hall for 5 minutes.  Client states, “My breathing is easier.”

48. 48 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Summary: Writing Outcomes  Perform assessment  Formulate nursing diagnosis  Begin planning  Write measurable, realistic, attainable, client- focused outcomes with a time frame based on the nursing diagnosis identified in the assessment.  Involve the client.

49. 49 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Complete the Nursing Process  You can write outcomes  Great job!  What's next:  Finish the plan  Deliver care  Don’t forget to document each step

50. 50 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. References  Moorhead S, Johnson M, Maas M et al: Nursing Outcomes Classification, ed. 4, St. Louis, Mosby, 2008.