《护理学导论》英文讲义第十章护理程序

Introductiontonursing

Chapter10Nursingprocess

Section1Nursingprocessandassessing

Contentsoutline

Historicalperspective

DescriptionofnursingprocessCharacteristicsofnursingprocessAssessment

DefinitionPurpose

TypesandcharacteristicsofdataSourcesofdata

Methodsofdatacollection

Objectives

Afterstudyingthissession,thestudentsshouldbeableto:

Stateconceptofnursingprocess

Statefivesteps(phases)ofnursingprocess

Definethemajorcharacteristicsofnursingprocess

Stateconceptofassessing

Differentiateobjectivedataandsubjectivedata

Identifysourcesofdata

Applythemethodscorrectlyindatacollection

KeyPoints

Conceptofnursingprocess

Steps(phases)ofnursingprocess3.Characteristicsofnursingprocess

4.Conceptofassessing

DifficultPoints

Typesofdata

Sourcesofdata

Applythemethodscorrectlyindatacollection

Contents

Historicalperspective

In1955,LydiaHallintroducednursingprocess

1960-1973,nursingtheoristshadbeenverifyingstepsofnursingprocess

1973,ANApublishedthe“StandardsofNursingPractice”,thefivenursingprocessmodelisdescribedinstandardsofnursingpractice.

1980,furthercommitmentbytheANAtothefive-stepnursingprocessmodelwasdocumentedinthe1980“NursingandSocialPolicyStatement”,thismadethismodelthestandardforprofessionalnursingpracticein1991,RevisionoftheANA“StandardsofclinicalNursingPractice”continuestousethefive-stepmodel.

Descriptionofnursingprocess

Asystematicmethodthatdirectsthenursingandclienttogether

Determinetheneedfornursingcare

Planandimplementthecare

Evaluatetheresults

Five-stepnursingprocessmodel

Assessing

establishesthedatabasecontinuouslyupdatesthedatabasevalidatesdata

communicatesdata

Diagnosing

interpretsandanalyzesclientdataidentifiesclientstrengths,healthproblemformulates,validatesnursingdiagnosesdevelopsaprioritizedlistnursingdiagnose

Planning

establishesprioritieswritesexpectedoutcomes

develops,selectsnursinginterventionscommunicatestheplanofcare

Implementing

carriesouttheplanofcare

continuescollectingdataandmodifiestheplandocumentscare

Evaluating

measuresdesiredoutcomes

identifiesfactorscontributingtofailuremodifiestheplanofcare

Thefivestepsinnursingprocessareinterrelated,eachofthefivestepsdependsontheaccuracyofthestepsprecedingit.Theprocessprovidesaframeworkthatenablethenursetoprovideeffectivecaretotheclients.

Characteristicsofnursingprocess

Systematic

Eachstepdependsontheaccuracyofthepreviousstepandinfluencesthenextstep.Thenursingprocessdirectseachstepofnursingcareinasequentialmanner.

Interpersonal

Ensurethatnursesareclient-centeredratherthantasked-centered

Goal-oriented

Offerameansfornursesandclientstoworktogethertoidentifyspecifichealthgoalswhicharemostimportanttotheclient:improvingtheiroralhygiene,livewithpain,recoverfromanacutemedicalillness,preventionrecurrence,orpreparefordeath

Assessing

Definition

Aprocessofgathering,verifying,andcommunicatingdataaboutaclient

Purpose

toobtainrelevantinformationaboutthestrengthsandneedsofclients

toestablishadatabaseaboutclients:pt,familypatternsofhealthandillness,deviationfromnormal,strengths,copingabilitiesandriskfactorsforhealthproblem

toestablishadatabaseforplanningcare

Typesofdata

Subjectivedata

Client’sperceptionsabouttheirhealthproblems

Objectivedata

Observationsormeasurementsmadebythedatacollectorbasedonanacceptedstandard

Characteristicsofdata

Complete

Alltheclientdataneeded

Factualandaccurate

Recordingtheclient’sbehaviors,factually

Relevant

Whatandhow:whattypeofdataandhowmuchdatatocollectforeachclient.

Sourcesofdata

Primary

Client

.Healthcareneeds

·Lifestyle

·Presentandpastillness

·Perceptionofsymptoms

·Changesinactivities

Secondary

.Nurse’sownObservations

.Family,members,friends,Supportpeople

TertiaryClientrecord·

.healthrecord:age,sex,occupation,religiouspreference,financialstatus

·medicalhistory

·physicalexamination

·progressnotes

·consultations

.diagnosticstudy:bloodanalysis,urineanalysis,radiologicalexamination,stoolanalysis,sputumanalysis,andothers:electrocardiogramECG,stresstest,tuberculosisTBskintest

Otherhealthcareprofessionals

.Literature:consultthenursingandrelatedliteratureonspecifichealthproblems.

Methodsofdatacollection

Observation

useofthefivephysicalsenses(hearing,seeing,tactile触觉,smell嗅觉,taste,味觉)togatherdata

client’scurrentresponsetosituation.

client’scurrentabilitytomanagehiscare,needforadditional

informationornursingassistance?theimmediateenvironmentthelargerenvironment

Interview

Apattern ofplannedcommunicationforaspecificpurposeandfocusedonaspecificcontentarea

Nursinghealthhistory

reasonforseekinghealthcare:goalsofcare,expectationoftheservicesandcaredelivered,andexpectationofthehealthcaresystem

presentillnessorhealthconcern:onset,symptoms,natureofsymptoms,duration,precipitatingfactors,reliefmeasures,andweightlossorgain

pasthealthhistory，habits,prescribedandself-prescribedmedications,workhabits,relaxationactivities,andsleep,exercise,andeatingornutritionalpatterns.

familyhistory:healthstatusoftheimmediatefamilyandlivingrelatives.

environmentalhistory:hazards,pollutants,andphysicalsafety.psychosocialandculturalhistory:

reviewofsystem:head-totoereviewofallmajorbodysystems,as

wellastheclient’sknowledgeofandcompliancewithhealthcare.

expectationsofcare

abilityandwillingnesstoparticipateinthecarepersonalresourcesanddeficits

Initiatingofaninterview

Thenurseinitiatestheinterviewbystatinghisorhernameandstatus,identifyingthepurposeoftheinterview,andclarifyingtherolesofnurseandclient.

4.5.3Physicalassessment

Takingofvitalsignsandothermeasurementsandtheexaminationofallbodypartsusingthetechniquesofinspection,palpation,percussion,andauscultation.

Generalsurvey

measuringheight,weight,andvitalsignshead-to-toeexaminationofthebodysystems

Sorting,validatingdata

OrganizestheinformationintomeaningfulclustersbyusingSystem-orientedformat

Functionalhealthpatternformat

focuses attention on functions needing support and assistance forrecovery

confirmingorverifyingsoastokeepdataasfreefromerror,bias,andmisinterpretationaspossible

Datadocumentation

Essentialfortworeasons

alldatapertinenttoclientstatusareincluded

legalandprofessionalresponsibility

Datashouldbesummarizedandenteredintocomputerorrecordedinink

usingthedesignatedagencyforms

Datashouldbewrittenlegibly,goodgrammarUsestandardmedicalabbreviations

Criticalthinkingexercise

Workingwithanotherstudent,togetherinterviewclientsinbothhomeandinstitutionalsettings.Makealistoftheobjectiveandsubjectivedatayougatheroneachclientinterviewedandcompareyourdatalists.Explorethereasonsforthedifferencesyoudiscoveramongclients,betweenhomeandresidentialsettings,andbetweenwhatyouandyourpartnerdecidetorecord.

Section2 NursingDiagnosis

Objectives:

Afterstudyingthissession,thestudentsshouldbeableto

Definetheconceptofnursingdiagnosis.

Definetheconceptofcollaborativeproblems

DescribeimportanceandpurposesofND

DescribeandidentifycategoriesofND

Stateformatforwritingdiagnosticstatements

Keypoints

Conceptofnursingdiagnosis

Conceptofcollaborativeproblems

PurposesofND

DifficultpointsContents

Revision

Thediscussionofnursingasascienceandaprofessiondescribednursingashavingindependent,interdependent,anddependentfunctions.Asnursesinterpretandanalyzeclientdata,nurseidentifieswhatitisabouttheclientthatisnurse’suniqueconcern,nursingdiagnosesarethereforewrittentodescribeclientproblemsthatnursescantreatindependently;theymayidentifyhealthproblemsthatarebettertreatedbyphysicians(medicaldiagnoses)orbynursesworkingwithotherhealthcareprofessionals(collaborativeproblems).

Thediscussionofnursingdiagnosishasfocusedprimarilyonthoseproblemsthatarewithinthedomainofnurse’sindependentfunction.Theseareproblemsforwhichnursescanlegallydeterminetheactionstoprevent,solve,orrelievetheproblems.

Manyofclientshavediagnosedmedicalproblems(disease).Thesesameclientshavealikehoodofdevelopingdifficultiesorpotentialcomplicationsrelatedtoadiseaseortomedicalorsurgicalinterventionsusedtotreatthedisease.Otherclientsareatriskfordevelopingmedicalcomplicationsfromdiagnostictests,whetherornottheyhaveactualdisease.Theseactualorpotentialproblemsareoutsidethenurse’sindependentfunction,,aredesignatedas“collaborativeproblems”.

Diagnosing:isphase2ofthenursingprocess.Thisphaseincludesanalyzingdata,formulatingnursingdiagnoses,andidentifyingstrengthsandproblems/needsofclients.

Analyzingdata:focalpointsareboththeclients’strengthsandneeds

Nursingdiagnoses:summarizetheclients’

Analyzing:isanimportantmentalactivitythatfollowscollectingdatainwhichnurseandclientformconclusiononwhichtobasenursingcare.Analyzingisthebridgeconnectingrotenursingresponsibilitieswithindividualizedclientconsiderations.whenanalyzingdata,thenursecomparesfactsgatheredfromtheclientwithanumberofacceptedforms:anatomic,physiologic,psychological,anddevelopmental.Atthesametime,thenursedrawsonacceptednursingknowledgeandpersonalnursingexperiencestorecognizepatternsin,orrelationshipsamongthedata.

Historyofnursingdiagnosis

Inthe1950sand1960s,nursingleadersrecognizedtheneedtodescribenursingworkandnursingknowledge.Severalstudiesweredonetoidentifypatientproblemsrequiringnursingintervention.Thetermnursingdiagnosisbegantoappearinthenursingliteratureinthe1950stodescribethefunctionsofaprofessionalnurse(McManus,1951).Fry(1953statedthatnursingdiagnosisisbasedontheclient’sneedsfornursingratherthanmedicalcare.Beforethattime,nursinghadbeenseen

asasetoftasks,nursesassistedphysiciansintreatingdiseases.Theygathereddataaboutpatientstoensurethatdoctorscouldmakemedicaldiagnoses,nottoplannursingcare.Inthe1960s,diagnosiswasbecominganimportantpartofthenursingprocess.In1973,theAmericanNursesAssociation(ANA)StandardsofNursingPracticeincludednursingdiagnosisasanimportantnursingactivity,makingitalegitimatefunctionofprofessionalnursesduringthe1070sand1980s,thetermnursingdiagnosiswasincorporatedintonearlyallstatenursepracticeacts,anddiagnosisbecameanursingobligationaswellasalegalright.Diagnosisisnowtaughtinmostschoolsofnursing.

DefinitionofND

Anursingdiagnosisisaclinicaljudgmentaboutindividual,family,orcommunityresponsetoactualorpotentialhealthproblems/lifeprocesses.Nursingdiagnosesprovidethebasisforselectionofnursinginterventionstoachieveoutcomesforwhichthenurseisaccountable.(approvedatthe9thconferenceofNANDA,1990)

Strengths:alsocalledinternalresources,arebiologic,psychological,social,orspiritualqualitiesthatcontributetoaperson’scharacter,integrity,anduniqueness.Strengthsareimportantconsiderationswhenplanningnursingcare.

Externalresources:theyprovideimportantsourcesofsupportincopingwithhealthproblems.

supportsystems:family,friends,healthcareprofessionals

financialresources:income,insurances

environmentalresources:healthcare,recreation,shopping,transportation,education

education:level,training,andoccupationalexperience

humanresponses:reactionstoaneventorstressorsuchasdiseaseorinjury.Humanresponsesoccurinseveraldimensions.Theycanbebiological(physical),psychological,interpersonal/social,orspiritual.

Ahealthproblem(maladaptive/harmfulresponse)

isahumanresponsetoalifeprocess,event,orstressor

isahealth-relatedconditionthatboththepatientandthenursewishtochange

requiresinterventioninordertopreventorresolveillnessorto

facilitatecoping

resultsinineffectivecoping,adaptation,ordailylivingthatisunsatisfyingtothepatientisanundesirablestate

actualproblem/needs:arethosethatcanbeidentifiedfromthe

currentdata.

potentialproblem/needs:arethosethatthepersonisathighrisktodevelop,givenhisorherparticularsituation.

possibleproblems/needs:arethoseforwhichthenursehasobtainedenoughdatatosuggestaidea,butnotenoughtoidentifyanactual

problem.

NDemphasizestheuniquecontributionnursescanmaketothehealthofindividualsandcommunity.

Theconditioncanberesolvedprimarilybynursinginterventions.

Nursesassumeresponsibilityforpt/clientoutcomesrelatedtothecondition.

ImportanceandpurposesofND

toidentify(1)actualandpotentialproblemsinthewaytheclientrespondstohealthorillness,(2)factorsthatcontributetoorcausetheproblems(etiologies),and(3)strengthstheclientcandrawontopreventorresolvetheproblems.

facilitateindividualizedcare.

Promoteprofessionalaccountabilityandautonomybydefininganddescribingtheindependentareaofnursingpractice.

Provideaneffectivevehicleforcommunicationamongnursesandotherhealthcareprofessionals.

TheNANDAClassificationsystems(taxonomy):identifiesandclassifiesideasorobjectsonthebasisoftheirsimilarities.

BackgroundknowledgeofNANDA

Before1973,therewasnolanguagetodescribetheconclusionsthatnursesreachedthroughassessment.In1973,agroupofnursesfromtheUnitedStatesandCanadamettoidentifynursingfunctionsandto

establishaclassificationsystemofnursingdiagnoses.NursingfacultyatSt.LouisUniversity,ledbyKristineGebbieandMaryAnnLavin,calledthefirstconferenceonclassification.Anationaltaskforcewasformedand100nursesattendedtheFirstConferenceonND.Thisgroupcontinuedtomeeteverytwoyearsand,attheFifthConferencein1982,formallybecametheNorthAmericanNursingDiagnosisAssociation(NANDA).NANDAmembershipconsistsofnursesfromeducation,practice,research,andadministration,aswellasfromallnursingspecialtyareas(intensivecare,maternal-child,homehealth).Thisdiversityassuresinputfromavarietyofperspectives.Themajorfunctionoftheearlygroupsweretogenerate,name,andimplementdiagnosticcategories.

ThefirstNANDAtaxonomywasalphabeticalandnonhierarchical.

In1987,TaxonomyIwasorganizedaccordingtheninehumanresponsepatterns:

Choosing

Communicating

Exchanging

Feeling

Knowing

Moving

Perceiving

Relating

Valuing

Anewframework(TaxonomyII)wasacceptedatthe2000conferenceandwillbeusedtoorganizethemorethan150NANDAdiagnosticlabels.(14domains)

Healthpromotion

Nutrition

Elimination

Activity/rest

Perception/cognition

Self-perception

Role relationships

Sexuality

Coping/stress tolerance

Lifeprinciple

Safety/protection

Comfort

Growth/development

other

CategoriesofND

Actualnursingdiagnoses:isaproblemthatisactuallypresentatthetimeyoumaketheassessment.Youwouldrecognizeitbythepresenceof

associatedsignsandsymptoms(definingcharacteristics).Nursingcareisdirectedtowardrelieving,resolving,orcopingwithactualproblems.

Keypoint:

problempresent

signsandsymptomspresent

Potential(risk)nursingdiagnosis:isonethatislikelytodevelopifthenursedoesnotintervene.Youwilldiagnosethembythepresenceofriskfactorsthatpredisposeapatienttodevelopingaproblem.Nursingcareisdirectedtowardpreventingtheproblembyreducingtheriskfactors,ortowardearlydetectionoftheproblemtolessenitsconsequences.Keypoint

problemmaydevelop

riskfactorspresent

Possiblenursingdiagnoses:similartoaphysician’s“rule-outdiagnosis,isonethatyoutentativelybelievetoexist.Youhaveenoughdatatosuspectaproblem,butnotenoughtobesure.Apossibleproblemdirectsnursingcaretowardgatheringfocusdatatoconfirmoreliminatethediagnosis.Usingpossibleproblemscanhelpyouavoid:omittinganimportantdiagnosisandmakinganincorrectdiagnosisbecauseofinsufficientdata.

Keypoint:

unsureifproblemispresent

somesigns/symptomspresent,butnotdefinitive

dataincomplete

Wellnessdiagnosis

Apersistentcritiqueofnursingdiagnosisthatfocusexclusivelyonclienthealthproblemsistheirlimitedapplicabilityinnursingsettingsthatprimarilydealwithhealthyclients.Toremedythisconcern,WNwereproposedandarenowreadilyaccepted.

Wellnessdiagnosisisaclinicaljudgmentaboutanindividual,family,orcommunityintransitionfromaspecificlevelofwellnesstoahigherlevelofwellness.

Establishingprioritiesamongnursingdiagnoses

Whenestablishingpriorities,thenurseconsidersthefollowingquestions:

whatstrengthsdoesthepersonhave,andhowcantheybestbeused?

Arethereacuteorlife-threateningproblems?

Whatistheclient’smostpressingstatedconcern?

Whichproblemscantheclientworkonbyhimselforherself,andwithwhichoneswilltheclientneednursingassistance?

Formatforwritingdiagnosticstatements

Actualnursingdiagnoses

Three-partstatement(P.E.S.format):theproblemandtheetiology,definingcharacteristics.

Problem:describestheclient’shealthstatusclearlyandconcisely,thissectionidentifieswhatisunhealthyabouttheclientsandwhattheclientwouldliketochangeinhisorherhealthstatus,itsuggestsclientgoals.NANDArecommendsuseofthefollowingquantifierswhenwritingtheproblemstatement:

Acute:severebutshortofdurationAltered:achangefrombaseline

Chronic:lastingalongtime,recurring,habitual,constantDecreased:lessened,lesserinsize,amount,ordegree

Deficient:inadequateinamount,quality,or degree,defective,notsufficient,incomplete

Disturbed:agitated,interrupted,interferedwithDysfunctional:abnormal,incompletefunctioning

Excessive:characterizedbyanamountorquantitythatisgreaterthanisnecessary,desirable,ordegree

Increased:greaterinsize,amount,ordegree

Impaired:madeworse,weakened,damaged,reduced,deterioratedIneffective:notproducingthedesiredeffect

Intermittent:stoppingorstartingagainatintervals,periodic,cyclicEtiology:theetiologydescribesfactorscausingorcontributingtoactualproblems,forpotentialproblems,itdescribestheriskfactorsthatarepresent

Definingcharacteristics:thesubjectiveandobjectivedatathatsignaltheexistenceoftheactualorpotentialhealthproblem.

Problem [relatedto(r/t)]Etiology [asevidenced(manifested)by(A.M.B)]Symptomsandsigns

Potential(risk)nursingdiagnoses,andpossiblenursingdiagnoses

NANDArecommendsuseofthe“risk”quantifierwhenwritingthePotential(risk)nursingdiagnosesproblemstatement,andpossiblequantifierwhenwritingthePossiblenursingdiagnosesproblemstatement:

Two-partstatement(P.E.Format):theproblemandtheetiology(riskfactors).

Wellnessdiagnosis

Thediagnosticstatementforwellnessdiagnosisisone-partstatementthatcontainsthelabel“potentialforenhanced”followedbythedesiredhigher-levelwellness.

Collaborativeproblems

Manyofclientshavediagnosedmedicalproblems(disease).Thesesameclientshavealikehoodofdevelopingdifficultiesorpotentialcomplicationsrelatedtoadiseaseortomedicalorsurgicalinterventionsusedtotreatthedisease.Otherclientsareatriskfordevelopingmedicalcomplicationsfromdiagnostictests,whetherornottheyhaveactualdisease.Theseactualorpotentialproblemsareoutsidethenurse’s

independentfunction,aredesignatedas“collaborativeproblems”.

Collaborativeproblemas“certainphysiologiccomplicationsthatnursesmonitortodetectonsetorchangesinstatus.Nursesmanagecollaborativeproblemsusingphysician-prescribedandnursing-prescribedinterventionstominimizethecomplicationsoftheevent”(Carpenito,1995).Nursesfocusmainlyonmonitoringandpreventingsuchproblemswhicharecomplicationofadisease,test,ortreatmentthatnursescannottreatindependently.Writingadiagnosticstatementofacollaborativeproblem,focusonthepotentialcomplicationsoftheproblem,use“PC”(forpotentialcomplication),followedbyacolon,andlistthecomplicationsthatmightoccur.Forclarity,linkthepotentialcomplicationsandthecollaborativeproblembyusing“relatedto”.

Processofdiagnosticreasoning

Diagnosticreasoningcanbedividedintofourbroadstages.

interpretthedata

compareindividualdatatostandardsandnormstoidentifysignificantcues.

Clustersignificantcues,lookforpatternsandrelationships

Identifywellnessdiagnoses,actual,potential,andpossiblenursingdiagnoses,collaborativeproblems,anmedicalproblems

Identifypatientandfamilystrengths

Determinetheetiologiesoftheproblems

Categorizeproblems

Verifythediagnoses

verifydiagnosesandstrengthswithpatient,family,otherprofessionalsandreference.

Labelthediagnoses

Choosestandardizedproblemlabel.Writetheformalhealthstatusstatements:nursingandwellnessdiagnoses,collaborativeproblems,andstrengths.

Prioritizetheproblems

11.1Recordtheproblemstatementsontheappropriatedocuments:patientcareplan,chart.

12.Differencebetweennursingdiagnosis,medicaldiagnosis,collaborativeproblem

Nursingdiagnosis:

-identifyhumanresponsestohealthandillness

-describe problems treated by nurses within the scope ofindependentnursingpractice

-maychangefromdaytodayastheclient’sresponseschange.

Medicaldiagnosis:

-identifydiseases

-Describe problems for which the physician directs the primary

treatment

-Remainsthesameforaslongasthediseaseispresent

Session4 Planning

Objectives:

Afterstudyingthissession,thestudentsshouldbeableto

Meaningofplanning

Purposeofplanning

Importanceofplanning

Statestepsthatoccurintheplanningphase.

State the difference between Initial and ongoing planning, anddischargeplanning

Keypoints

Purposeofplanning

Stepsthatoccurintheplanningphase

Difficultpoints

Stepsthatoccurintheplanningphase

difference between Initial and ongoing planning, and dischargeplanning

Contents

Concept(Meaning)ofplanning:

Phase3inthenursingprocessisplanning.

Iyeretal.(1986)stated,“Planninginvolvesthedevelopmentofstrategiesdesignedtoprevent,minimize,orcorrecttheproblemsidentifiedinthenursingdiagnosis”.

Agoalisanaimoranend.Aclientgoaldescribesanexpectedclientoutcome,anexpectedconclusiontoaclienthealthproblem.

Thetermoutcomeisusedtodescribetheresultsachieved.Innursingthetermexpectedoutcomesisusedtorefertothemorespecific,measurablecriteriausedtoevaluatewhetherthegoalhasbeenmet.Inthesession,wewillusegoal/outcometorefertoexpectedclientoutcome.

Purpose:Duringtheplanningstepofthenursingprocess,thenurseworkswiththeclientandfamilyto(1)identifyclientgoals/expectedoutcomesthatifachieved,prevent,reduce,oreliminatetheproblemsspecifiedinthenursingdiagnoses,and(2)identifythenursinginterventionsthataremostlikelytoassisttheclientinachievingthesegoals/outcomes.

Importanceofplanning:provideaformalplanofcare

allowsthenursetoindividualizecare.Example:chronicconstipation

setpriorities

tomaintainandpromotestrengthsandmovetowardproblemsolving

facilitatecommunicationamongnursingpersonnel

promotecontinuityofhighquality

cost-effectivecare

coordinatecare

evaluatetheclient’sresponsestonursingcare

promotethenurse’sprofessionaldevelopment

Stepsofplanning

reviewtheprioritizedlistofnursingdiagnoses

Beforedevelopingormodifyingtheplanofcare,itishelpfultoreviewtheprioritizedlistofnursingdiagnosestodetermineiftheyarecorrectlyrankedashighpriority(greatestthreattoclient’swell-being),mediumpriority,andlowpriority(notspecificallyrelatedtocurrentillnessandprognosis.

developinggoals/outcomesthedeterminetheevaluativestrategy

Guidelineforconstructinggoal:

Goalsarederivedfromtheproblemstatementofthenursingdiagnosis.ForeachNDintheplanofcare,atleastonegoalmustbewrittenthat,ifachieved,demonstratedadirectresolutionoftheproblemstatement.

Goalsareconstructedtoreflecttheperson’sratherthanthenurse’s

behavior.Subjectofthegoalstatementistheclientorclient’condition.Theclientwillmaintain… .,ortheclientwilldemonstrate… ...

Goalsarewritteninbehavioraltermswhichcanareobservable,andmeasurable.Examplesincludestate,verbalize,demonstrate,recite,gain,

lose,smile,orexercise.

Subject+verb+criteria(arewritteninbehavioraltermswhichcanareobservable,andmeasurable.)

Short-termgoals/outcomes

Short-termgoalsreflectsmallerstepsthatcanbepursuedoneatatime.

Long-termgoals/outcomes

Long-termgoals/outcomesrequirealongerperiod(usuallymorethanaweek)tobeachieved.

Goalforactual,risk,andpossiblenursingdiagnoses

goalforactualnursingdiagnosisfocusonrestoringhealthyresponsesandpreventingfurthercomplications.

goalforrisknursingdiagnosesfocusonpreventingtheproblem.

goalforpossiblenursingdiagnosesfocusonthepresenceofthediagnosiswillbeconfirmedorruledout.

Goalforcollaborativeproblems

Nursingcarefocusesonpreventionandearlydetectionofthecomplication.

Outcomesforcollaborativeproblemsshoulddescribethepatientresponsesyouwillobserveaslongastheproblemhasnotdeveloped.Thegoalmaydescribenormalfunctioningorproblemsymptomsthatyoudonotwanttooccur.

Developingnursingorders(measuresorinterventions)

Principlesforplanning

nursinginterventionsarederivedfromtheetiologyoftheND.Theeffectivenursechoosesfromvariouspossiblenursinginterventionsthosethatspecificallyaddressfactorsthatcauseorcontributetotheclient’sproblems.

effectivenursinginterventionsareconsistentwithstandardsofcare;realisticintermsoftheabilities,time,andresourcesavailabletothenurseandclient,compatiblewiththeclient’svalues,beliefs,andpsychosocialbackground,valuedbytheclient,andcompatiblewithotherplannedtherapies.

compr