The assessment is a critical steps of the nursing process and is essential to provide best practice care. The four activities of the assessment phase is collecting data, organizing data, validating data, documenting data. The steps enable the nurse to gather information about the patient and family that can be implemented in diagnosis, planning, goals, and evaluation. SOAP notes are usually related to primary health issues.
S-stand for subjective data and symptoms,
O- objective finding the nurses are using their senses and relevant laboratory data, vital signs, and diagnostic procedures
A- stands for assessment, condition change
P-stands for plan, nursing intervention that deal with the specific problem
P-stand for problem
I-stand for interventions
PIE notes include nursing progress note, goals and reviewed daily to prevent less redundary
Focus DAR notes
Dar focus notes are used on broader scale. The nurse can focus on the patient’s strengths as well as problem areas.
Second step of the Nursing Process
Interpret & analyze collected data
Clinical judgment concerning a patient’s actual or potential health problem
Nursing Diagnosis is formulate according to (NANDA : North American Nursing Diagnosis Association)- Statement of how the patient is RESPONDING to an actual or potential problem that requires nursing intervention
Nursing Diagnosis is a tool used by nurse educators, nursing colleges, and health care organization. Nursing diagnosis is not a medical diagnosis, it a problem present during the nursing assessment which is caused by the disease. NANDA enables the nurses to use a common language to describe the patients health relate to illness. A total of 206 nursing diagnosis labels are currently approved by NANDA. Nursing diagnosis is the foundation for establishing a patient’s nursing care plan.
The nurses use the nursing diagnoses as a way to communicate nursing requirements for patient care to other nurses and medical care team. It is important for the patients to have a have accurate nursing diagnosis to ensure patient receive quality nursing care.
Actual Nursing Diagnosis
3 part statement
Related to (R/T)
(signs & symptoms)
Risk Nursing Diagnosis
Two-part statements because they do not include defining charactertics.
Ex: Risk for Aspiration related to loss of consciousness
Ex: Readiness for to enhance well-being
One part statements without risk factors or defining character tics
Nursing Diagnosis Case Study
Mrs. Lorraine is a 36 –year-old house wife, mother of three –year-old triple girls, who was admitted to the hospital yesterday with bilateral pneumonia.
Vital signs:T-101.2 P-104 R-29 BP-116/66.
IV D51/2 NS infusing at 125cc/hr.
Appetite is poor; drinking only small amount of fluids.
Auscultation of chest reveals bilateral crackles and wheeze.
Frequent productive cough of thick green-yellow mucous.
States she get “short of breath “ with any activity.
Her husband is home with the triple, and she is worried about him having to take care of the girls.
Third step of Nursing Process
Four critical elements of planning include:
Decision making/Establishing priorities
Formulating goals and developing outcomes using the SMART
Individualized nursing interventions
Third step of the nursing process includes the construction of guidelines that establish the proposed direction of nursing practices in the resolution of nursing diagnoses and the development of the patient’s plan of care. Prior to this step is the collection of assessment data and the development the of nursing diagnoses. A plan of action is formulated with specific goals to resolve the nursing diagnoses or health issues of the patient . S- specific to the patient, M-measurable, A-action oriented, R-realistic, and T- time specific.
Types of Planning
Individualize care plan Base on initial assessment Prioritized problem, identifying appropriate patient goals. Implement nursing care to increase resolution of the patient’s problems. Patient is the primary source of information.
Nurses continue to update patient’s plan of care Nurses who care for the patient are all involve in the patient care. Plan of care is revise as new information is collected and evaluated.
Includes critical anticipation and planning for the patient’s needs after discharge. Involves patient and family in discharge planning. Anticipate date of discharge.
Patient will experience adequate respiratory function within 48 hours as evidenced by:
Respiratory rate 12-18, decrease dyspnea
Goals should be:
Measurable and observable
Reasonable and realistic
Goals derived from the nursing diagnosis are broad statement about what the patient will be after the nursing interventions has been implemented.
A goal or expected outcome statement describes patient behaviors that would demonstrate a reduction, resolution, or prevention of a particular problem identified in the nursing diagnosis. Short term goals- is an objective behavior or response that expects the patient to achieve in a short period of time, usually less than a week, a few hours or days.
Long-term-goals-Is an objective behavior or response that expects the patient to achieve over a longer period of time, several hours, weeks and or months.
Expected outcomes: is an objective behavior that expects the patient to achieve.
Goals/expected outcomes must be congruent with the response component of the nursing diagnosis statement.
Safe for the patient
Based on scientific rationale
Stated clearly and concisely
Realistic for the patient, nurse, and resources available
Congruent with other therapies the patient is receiving.
Nursing intervention are based on the nursing diagnoses and identified goals/expected outcomes. interventions are prioritized according to the order in which they will be implemented. Interventions should be individualized to meet biopsychosocial needs of the patient.
All phases of the nursing process, it is important to include the patient and family or significant others in the process of planning and implementing appropriate nursing actions. Nursing interventions assist patient to maximize her capabilities. Nurse must understand the rational, technique, and possible effects of each intervention action.
Finally the nurse must document care given to patient. “the old saying, “if it is not charted it has not been done”
Accurate and completed documentation of patient care is a legal requirement in all health care settings.
Patients with multifaceted it takes a team of nurses and other health professionals to provide the best quality care. The patient is the most important part of the team, and through a collaborative team based approach, patients can receive the highest quality of care. Independent- nurse initiates intervention and act independently without doctor orders. Dependent- Nurse requires a doctor to implement intervention. Collaborative-requires a multiple team of nurses and health care professional with skills and knowledge. Implementation this phase is the “doing and documenting of the process. Intervention that was identified in the original planning is implemented.
Example of Nursing Care Plan
What the expected behavior?
Was the patient able to perform the expected behavior in the time
specified in the goal?
Was the patient able to perform the behavior as well as described in the expected outcomes statement?
The patient’s role in the nursing process is never more important than in the evaluation process.
The nurse can assess through objective data whether or not the nursing actions were effective.
The patient provides necessary subjective data regarding the effectiveness of the plan of care.
Goals should be sign by RN and indicate whether the goal was resolved, partially resolved, or not resolved at all.
Scientific Knowledge Base
Nursing students need for critical thinking in nursing has been accentuated in response to the rapidly changing health care organization. Nurses must think critically to provide effective evidence based practice care whilst coping with the expansion in role associated with the complexities of current health care systems.” According to Simpson & Courtney (2008) It is important that nurse educator assist nursing students in gaining competences in critical thinking skills by using a varies of teaching strategies that include case studies, role play small group discussion and questioning. Critical thinking and the nursing process are connected by the problem solving method.
Describe Implementation Learning Agreement
Clear written Objectives
Methods of Achievement
Methods to Evaluate
The learning agreement is a process used to transfer the responsibility of learning from the instructor to the nursing student (Barrington & Street,2009). This process enables the student to move from passive learning to active learning process. This higher level of thinking enables the nursing students to grow and achieve their career goals. The objectives are clearly stated and by the end of the program the students will be able to define, and implement the nurse process and critical thinking skills.
Reflection Value Professional Career
Accomplishing the outcomes that the novice nursing students gain a understanding of the nursing process and critical thinking skill will provide a solid foundation to provide holistic patient centered care. My goals for the future include becoming a nursing professor at the university I graduate from. As nurse educator I will be able to prepare novice nursing students to face challenges of life –threatening situations. Nursing students will be provide hand on experience that helps to develop personal philosophies and values that will inevitably follow them into their own practice.
Highlight Professional Relationships
Dean of program
Faculty Fulltime & part-time
First semester students
New Class of Spring 2014
To implement this program required the support of the Dean of the Nursing Department, Program Director current nursing instructors, and mentor. The effects of the program focus will be immediately, seen pass taking the course. The students will be given a questionnaire evaluation upon completing the course. The Dean of the Nursing allowed me to attend faculty meetings to observe the interactions between the different faculty of the department. Meeting new students each semester and welcoming them to the school was highlight of relationship.
Student Support Services
Center for the Global learner
Center for Academic Excellence
Nurse educators should provide students with information on available resources to help deal with potential problems. Novice nursing students explore their support systems and begin to formulate a record of available sources to help them to be successful. The school’s web page will be opened and the students were shown how they could access the information needed to contact the different resources for students. Faculty information was provided for each students and office hours.
Summary Overview Program Objectives Project Agenda Introduce/Icebreaker Content Outline Teaching Strategies, Flipping Class, Traditional Method PowerPoint’s with strategies with speaker’s notes Resources Handouts
Fast pace changes in the health care system have put a large demands on nurse educators to educate novice nursing students on the nursing process and critical thinking skills. Nurses must be able to make quit accurate decision in the time of emergency situation. The nursing process will enables nurses to identify health care needs, determine priorities, establish goals, outcomes, implement intervention, and evaluate provide evidence based practice care.
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