Ch 10: Nursing Dianosis, Outcome, Identification, Planning, Implementation, and Evaluation

Nursing Process: 6 step-problem solving approach
1. Assessment
2. Nursing Diagnoses
3. Outcome Identification
4. Planning (formulation of a nursing plan of care)
5. Implementation of nursing actions or interventions
6. Evaluation of the client’s response to interventions
Nursing Process
Ongoing, systematic series of actions, interactions, and transactions of interrelated, interdependent, and recurrent steps.
Nursing Diagnoses
-Statement of existing problem or potential health problem that a nurse is both competent and licensed to treat.
(NANDA): A cynical judgment about individual, family, or community responses to actual or potential health problems or life processes.
-Provides basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable and communicates that information to nursing staff.
Analysis of assessment data involves differentiating cues from inferences, assuring validity, and determining how much data is needed
-Cues: facts collected through interviewing, observing, examining, and reviewing client medical record (VS, feelings, lab results).
-Inferences: judgments nurse makes about cues (Decreased blood volume, rapid pulse, moist skin, pallor), only as valid as data used.
Validation of Data
Rechecking data collected, asking someone to analyze data, comparing subjective and objective data, asking client to verify data.
Nursing Diagnoses
Consult list of defining characteristics for diagnoses suspected to determine if enough valid cues are present to confirm the diagnoses.
Medical / Psychiatric Diagnoses
Categorize and describe specific medical or mental disorders.
Nursing Diagnoses
Address clients response to specific problem, or how that problem affects the client’s daily functions.
Actual Nursing Diagnoses
Clinical judgment on review of validated data, including presence of defining characteristics.
1. Acute pain r/t surgery aeb…
2. Anxiety r/t chemotherapy aeb…
3. Sleep deprivation r/t acute pain aeb…
Risk of Nursing Diagnoses
Clinical judgment of client’s degree of vulnerability to development of specific problem.
1. Risk for impaired parenting r/t divorce
2. Risk for suicide r/t depression
3. Risk for post-trauma syndrome r/t auto accident
Wellness Nursing Diagnoses
Clinical judgment about an individual, group, or community transitioning from a specific level to a higher level of wellness.
1. Readiness for enhanced community coping r/t identified support groups and role responsibilities
2. Readiness for enhanced spiritual well-being r/t inner peace and identified purpose to one’s life
3. Readiness for enhanced family coping r/t common identified goals and open communication
Syndrome Nursing Diagnoses
Cluster of actual or high-risk diagnoses that are predicted to be present because of a certain event or situation.
1. Impaired environmental interpretation syndrome r/t disorientation and confusion
2. Rape-trauma syndrome r/t sexual assault aeb…
3. Relocation stress syndrome r/t high degree of environmental change secondary to frequent moves
Possible Nursing Diagnoses
Not a type of diagnoses, but a suspected problem that requires additional data to confirm.
1. Possible activity intolerance r/t obesity
2. Possible loneliness r/t hospitalization
3. Possible noncompliance r/t illiteracy
-North American Nursing Diagnosis Association, purpose is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses
-Current domains: Health Promotion, Nutrition, Elimination, Activity /Rest, Perception/Cognition, Self-Perception, Role Relationships, Sexuality, Coping/Stress Tolerance, Life Principles, Comfort, Growth and Development
Psychiatric Mental Health Nursing (PMHN)
-A specialized area of nursing practice committed to promoting mental health through assessment, diagnosis, and treatment of human responses to mental health problems and psychiatric disorders.
-System organized around 8 human response processes: Activity, Cognition, Ecological, Emotional, Interpersonal, Perception, Physiologic and Valuation
Examples of Nursing Diagnoses in PMHN
Activity intolerance, Acute confusion, Anticipatory grieving, Anxiety, Bathing/hygiene self-care deficit, Caregiver role strain, Risk for caregiver role strain, Chronic pain, Decisional conflict, Deficient diversional activity, Deficient knowledge, Delayed growth and development, Disturbed body image, Disturbed sleep pattern, Dressing/grooming self-care deficit, Dysfunctional grieving, Fear, Feeding self-care deficit, Hopelessness, Imbalance nutrition: less than body requirements, Impaired adjustment, Impaired memory, Impaired parenting, Impaired social interaction, Impaired verbal communication, Ineffective coping, Ineffective health maintenance, Ineffective role performance, Ineffective sexuality patterns, Interrupted family processes, Noncompliance, Parental role conflict, Post-trauma syndrome, Powerlessness, Relocation stress syndrome, Risk for injury, Risk for loneliness, Risk for other-directed violence, Risk for self-directed violence, Social isolation, Spiritual distress, Toileting self-care deficit
People responsible for making a psychiatric diagnoses when a psychiatric problem exists…
Clinical Nurse Specialists
Nurse Practitioners
Licensed Clinical Social Workers
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
-American Psychiatric Association (APA) published DSM-IV-TR which is a 5 axial system of psychiatric disorders and is the accepted standard for identifying psychiatric disorders.
Insurance companies require a diagnosis using DSM-IV-TR for reimbursement.
-Student/staff nurses do not use the DSM-IV-TR to diagnoses clients, but more as a reference of characteristics of a specific psychiatric disorder.
-Structured decision trees help clinician understand the organization and hierarchical structure of the DSM-IV-TR classification. Each tree has questions to rule in or out various disorders. Decision tree categories: disorders due to general medical condition, substance-induced disorders, psychotic disorders, mood disorders, anxiety disorders, somatoform disorders.
Axis I: Clinical disorders and other that may be a focus of clinical attention.
293.0: Delirium Due to a General Medical Condition
300.02: Generalized Anxiety Disorder
295.30: Schizophrenia, Paranoid Type
V15.81: Noncompliance with Treatment
V65.2: Malingering
313.82: Identity Problem
Axis II: Personality disorders and mental retardation.
301.83: Borderline Personality Disorder
301.0: Paranoid Personality Disorder
317: Mild Mental Retardation
318.2: Profound Mental Retardation
Axis III: General medical conditions.
850.9 (ICD-9-CM code): Concussion
333.1: Medication-Induced Postural Tremor
428.0 (ICD-9-CM code): Congestive Heart Failure
Axis IV: Psychosocial and Environmental Problems: This axis is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. The problems are grouped into the following categories: primary support group, social environment, educational, occupational, housing, economic, access to health care services, interaction with the legal system/crime, and other psychosocial and environmental problems.
Include a negative life event, an environmental difficulty or deficiency, inadequate social support, or interpersonal stress.
Axis V: Global assessment of functioning (GAF):
This axis is for reporting the clinician’s judgment of the individual’s overall level of functioning. it is useful in planning interventions and measuring outcomes. The clinician is to consider the client’s psychological, social, and occupational functioning on impairment in functioning due to physical or environmental limitations is not to be considered.
91-100: Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. The client’s functioning score should be rated between 91 and100.
41-50: Serious symptoms (suicidal ideation, sever obsession rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (no friends, unable to keep a job). The clients score should be rated between 41 and 50
Psychodynamic Diagnostic Manual (PMD)
-Developed by a Task force comprised of five major psychoanalytic organizations, covers adults, children, adolescents, and infants, emphasizing individual variations as well as commonalities.
-Premise: clinically useful classification of mental health disorders must begin with an understanding of healthy mental functioning.
-Focuses on full range of mental functioning and complements DSM-IV-TR.
-It systemically describes healthy and disordered personality functioning, individual profiles of mental functioning (patterns of relating, coping, and forming moral judgments), and symptom patterns, including differences in each client’s personal/subjective experience of his or her symptoms.
-Involves full range of human cognitive, emotional, and behavioral capacities and uses the multidimensional approach:
Dim I: Personality Patterns and Disorders
Dim II: Mental Functioning
Dim III: Manifest Symptoms and Concerns
-Promotes improvement in diagnosis and treatment of mental health disorders
Mental Disorders
Past 2 decades defined on the basis of presenting symptoms and their patterns, with overall personality functioning and levels of adaptation playing a minor role.
Mnemonics (memory aids such as abbreviations, rhymes, or visual cues that help individuals recall important lists)
Used frequently to impart pertinent information during the development of psychiatric diagnosis and treatment
FEVER: used as aid to diagnoses presence of neuroleptic malignant syndrome (adverse effect of med)
F- fever
E- encephalopathy
V- vital sign instability
E- elevated WBC/CPK
R- rigidity
Expected outcomes (outcome criteria)
-Measurable client-oriented goals that are realistic in relation to client’s present and potential capabilities.
-Contain specific information or modifiers and time factors or deadlines so that they can be evaluated and revised as the client progresses.
-Expected outcomes can be difficult to formulate. clients with psychiatric-mental health disorders may engage in power struggles or focus on issues seemingly unrelated to identified needs or existing problems (noncompliance, manipulation, demonstration of lack of trust, verbalization of multiple complaints, increased dependency on caregivers)
-Outcomes or measurable goals are short/or long term and clearly stated by nurse and describes the expected end result of care.
-Are the consequences of a treatment or intervention and should be directly related to the nursing diagnoses.
Developing a plan of care to guide therapeutic intervention and achieve expected outcomes, use of resources, alternatives/options, referrals, groups, and consultations may ne included to assist in treatment and recovery.
Plan of Care
-Individualized and identifies priorities of care and proposed effective interventions.
-Includes client education.
-States rationale for planning and implementation of each nursing intervention is an effective learning tool for students.
-Responsibilities of team members are indicated and they are allowed access to modify and updated the plan as necessary.
-Key is priority setting, consider the urgency or seriousness of the problem or need and its impact on client, use Maslow’s hierarchy as a guide for problem solving during formulation.
– If client is psychotic and unable to participate in development of plan, mental health team formulates a plan for the client.
-Managed care companied use standardized nursing plans of care and clinical pathways to balance quality of care and cost containment.
-Intent is to avoid or limit what is perceived to be unnecessary treatment, use of trade name drugs instead of generic drugs, request repetitive laboratory work, use of various therapies when the prognosis is limited or poor.
General Principles in Writing Plans of Care
-Individualize or personalize according to nursing diagnoses and problem list. “If a person who knew nothing about the client reads the plan, what would the person learn about the client’s needs?”.
-Use simple, understandable language to communicate info about care.
-Be specific when stating nursing interventions, include rational for each.
-Prioritize nursing care (list nursing interventions for risk for injury, risk of self harm, before bathing/hygiene self care deficit).
-State expected outcomes for each nursing diagnoses for short and long term goals.
-Indicate responsible party or discipline (nursing, activity therapy).
Standardized Nursing Plan of Care
Used in the clinical setting for specific nursing diagnoses.
Concept Mapping
-Alternative to nursing plan of care, method to represent assessment data visually and enhances critical thinking.
-Enables nurse to synthesize assessment data, develop comprehensive plans of care focusing on multiple problems, effectively applying nursing care.
Clinical Pathways
Map the sequence of the standards of care necessary to achieve desired outcomes for specific disorder or condition within a particular period of time.
-Treats medical and surgical disorders or conditions.
-Used to plan care for clients with comorbid medical and psychiatric diagnoses.
-Flow charts track client’s clinical symptoms, nursing diagnoses, nursing interventions, and expected outcomes.
Critical Pathways
-Plans of care that contain interdisciplinary practice guidelines with predetermined standards of care.
-Treats medical and surgical disorders or conditions.
-Used to plan care for clients with comorbid medical and psychiatric diagnoses.
-Flow charts track client’s clinical symptoms, nursing diagnoses, nursing interventions, and expected outcomes.
-Interventions categorized based on nurse’s level of education and certification (actions, approaches, nursing orders, nursing prescriptions), interventions address specific problems and suggest possible solutions or alternatives that nurses use to meet client needs or assist client toward expected outcomes.
-Nurse implements care based on nursing theory, coordinated activities of other health care team members and delegates specific interventions to other members of the nursing team as appropriate.
-Significant changes can occur in clients mood, affect, behavior, cognition, often unexpectedly, vigilance needed to establish trust with client, promote the client’s strengths, and set mutual goals with client to promote wellness.
Evidence-Based Nursing Practice
Describes the process by which nurse make clinical decisions using the best available research evidence, clinical expertise, and client preferences.
Interventions Used by All Nurses in Psychiatric-Mental Health Clinical Setting
-Counseling interventions to help client improve or regain coping abilities.
-Maintenance of a therapeutic environment or milieu.
-Structured interventions to foster self-care and mental and physical well-being.
-Psychological and biologic interventions to restore the client’s health and prevent future disability.
-Health education.
-Case management.
-Interventions to promote mental health and prevent mental illness.
Interventions by Advanced Practice Psychiatric- Mental Health Nurse
-Individual, group, family, marital or couple, and child psychotherapy.
-Psychopharmacological interventions.
-Consultation and liaison to enhance abilities of other clinicians to provide services for clients and effect change in the system.
-Focuses on the client’s status, progress toward goal achievement, and ongoing reevaluation of the care plan.
-Four possible outcomes:
1. Client may respond favorable or as expected to nursing interventions.
2. Short-term outcomes may be met but long-term goals remain unmet.
3. Client may be unable to meet or achieve any outcomes.
4. New problems or needs may need to be identified, requiring the nurse to modify or revise plan of care.
-Continuous evaluation maintains the viability of the entire nursing process and for demonstrating accountability for the quality of nursing care rendered.
-All members of the team are encouraged to provide feedback regarding the effectiveness of the plan of care.
-Result is care plan is maintained, modified, or totally revised.
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