1. ASN 180 Transition to Professional Nursing III Overview of Patient Care Objectives 1 & 2

2. Objectives 1.Discuss the nursing process to include: a.Assessment b.Nursing Diagnosis c.Outcome Identification and Planning d.Implementation e.Evaluation 2.Apply the nursing process to common clients concerns and issues.

3. Assessment Data collection step Thorough health and medical history Physical Assessment Gordon’s Functional Health Patterns Head-to-toe approach Body System Approach

4. Hints for getting the most information Ask open-ended questions, i. e. can’t be answered in one word Listen and watch for cues: gasps, wincing If the patient is unable to give information, as significant other. Use a standardized form. DO NOT VIOLATE HIPPA

5. Nursing Diagnosis A three part statement that consists of: Problem (Nursing Diagnosis) Etiology (“related to” statement) Symptoms (“as manifested by” statement) Use information from defining characteristics and critical thinking skills to develop Nursing Diagnosis

6. Steps to develop ND statement Cluster like characteristics together Analyze/interpret the characteristics Select a ND that fits with the appropriate related factor and defining characteristics.

7. Writing the ND statement Write the ND label from the ND Handbook. Write a phrase that describe the cause of the “problem” (ND). Begin that statement with “related to”. The last phrase is the list of defining characteristics that lead you to that diagnosis. Begin that statement with “as evidenced by – AEB”.

8. Planning Consists of: Measurable client outcomes Nursing interventions Rationales for interventions

9. Nursing-sensitive Outcomes (NOC) Select appropriate outcomes for the patient from the list. Make sure they are patient-specific and measurable. If you cannot find an outcome that fits your patient, you may have selected an inaccurate ND

10. Planning and Intervention Write the selected outcome/s in the Outcome Criteria column. Complete this statement below by finishing the “as evidenced by (AEB)” phrase with a list of the expected behaviors. Here is where you can be specific on your measurements AEB should basically be the opposite of AMB.

11. Planning and Intervention, cont. Select nursing interventions (NIC) that are appropriate to your patient and write at least three in the Nursing Interventions column. Make sure to include a date, day or frequency in the statement. This helps the next nurse know when to do or repeat interventions.

12. Planning and Intervention, cont. For each intervention, you should have a rationale (reason that it is appropriate) and cite the source of that rationale. You may use the NDH or any other relevant and legitimate source, such as textbooks or EBP studies. If you use a source other than the NDH, or a textbook you should provide a copy for the instructor.

13. Intervention Writing the interventions on the care plan is part of the Planning step of the Nursing Process. You don’t enact the Intervention step until you implement the interventions.

14. Evaluation Did your patient meet the outcome? Since your outcome was stated in a measurable way, it is now easy to determine if it has been met.

15. Evaluation Column List the # of the outcome and write the word/s “Met”, “Not Met”, or “Ongoing” as appropriate. Then describe how it was “met” or “not met” If it is “met”, congratulations, you succeeded If “not met”, consider changing the interventions. Use “ongoing” only if the NIC worked but there was not enough time.

16. Important points The more your patient is involved in the planning, the more likely it will succeed. Write your plan clearly enough that any caregiver that follows you knows the goals and what to do.

17. Case Study History Mrs. Hogan, a 38-yo woman is admitted in obvious respiratory distress. She is having difficulty breathing with audible high-pitched wheezing and has difficulty speaking. Gasping, she states, “I am having a bad asthma attack., I took my Albuterol and Vanceril, but they aren’t helping. Her husband just started working at an asbestos removal company.

18. More information Assessment: Expiratory wheezes and scattered rhonchi throughout Afebrile, 142/96, 88, 34, 86% O2 sat Treatment 2L O2 via NC IV fluids Albuterol nebulizer

19. Now let’s try a care plan Assess Diagnose Plan Interventions Evaluation

20. Objectives 1.Discuss the nursing process to include: a.Assessment b.Nursing Diagnosis c.Outcome Identification and Planning d.Implementation e.Evaluation 2.Apply the nursing process to common clients concerns and issues.