NURSING PROCESS Nursing Outcome Classification (NOC) – a system that can be used to select outcome

measure related to nursing diagnosis.

“Outcomes need to be identifies before nursing interventions are determined.”

Analogy: Planning a road trip

ASSESSMENT “Simply getting in a car and driving will get a person somewhere, but that may not be
the place a person really wanted to go. It is better to have a clear location (outcome)
in mind and then choose a route (intervention) to get to the desired location.”
EVALUATION DIAGNOSIS
Activities of Outcome Identification

1. Establish priorities
Priority
o is a choice that comes first over other possible options
OUTCOME o often based on urgency or importance
IDENTIFICATION
Establish priorities
IMPLEMENTATION
Establish client
• Maslow’s hierarchy of basic needs can guide the selection of high-priority
goals and outcome problems
identification • Focus on the problem the client feels is most important if this priority does
PLANNING not interfere with medical treatment.
• Consider the effect on potential problems when setting priorities.
o Easy to prevent than cure
o More effective, less costly
o Less time consuming
• Consider costs, resources available, personnel, and time needed to plan for
OUTCOME IDENTIFICATION and treat each of the client’s identified problem.

• The formulation of goals and measurable outcomes that provides the basis 2 purposes of involving client in priority setting:
for evaluating nursing diagnosis. • This approach involves clients in planning their own care.
• The most recent addition of the nursing process. • Cooperation between the nurse and the client is enhanced when priority
Purposes: setting is done together.

• Providing individualized care Priority setting – is a decision making process that rans the order of nursing
diagnoses in terms of importance to the patient.
• Promoting patient participation
• Planning realistic and measurable care “Priorities constantly change as the patient situation and condition change.”
• Allowing for involvement of support people
• Nurses uses assessment skills and data collection, clinical experience and
Nursing Outcome – refers to a measurable behavior and perception demonstrated evidence-based practice to determine priorities.
by an individual, family, group or a community that is responsive to nursing
intervention.
High priority patients involves… Nursing Outcome versus Nursing Intervention
• Life threatening situation
• Nursing outcome provides a point of reference for determining whether the
o example: difficulty of breathing, hemorrhage
intervention is appropriate and effective.
• Something that needs immediate attention
• Nursing intervention states what the nurse will do.
o example: preparation for a test, discharge from the facility that will
occur shortly Patient Outcome
• Something that is very important to the patient
o Example: pain, anxiety • Must be behavioral
• Written to indicate a desired state
High priority nursing diagnoses • Contain an action verb and a qualifier that indicate level of performance
• Potentially life threatening and require immediate actions. that needs to be achieved
• Examples: impaired gas exchange, self-directed risk for violence o Qualifier – a description of the parameter for the outcome
Medium priority nursing diagnoses • Short-term outcome can be met in a relatively short period
o Within days or less than 1 week
• Involve problems that could result in unhealthy consequences such as
o E.g. the client will turn himself from side to side q 2 hours
physical and emotional impairment but not likely to threaten life.
• Long-term outcome requires more time
• Examples: fatigue, stress incontinence
o Several weeks or months
Low priority nursing diagnoses o Usually describe expected benefits or results that are seen after
• Problem will be easily resolved with minimal interventions and have little the plan of care has been implemented.
potential to cause significant dysfunction o E.g. re-establishment of client’s usual bowel elimination pattern in
2 months.
Nurses use priorities to plan care and determine the order in which interventions are
• The nurse needs to revise outcomes if the patient’s situation or medical
carried out.
condition changes.”
2. Establish patient outcomes and outcome criteria
Example of Behavioral Verbs used in patient goals
Outcome
Calculate Distinguish Practice
• A measurable, expected, client-focused goal to be achieved at some Classify Draw Recall
specified time in the future Communicate Explain Recite
Compare Express Record
• A measuring stick of the plan of care
Construct Identify Stand
Patient outcome Contrast List State
Define Maintain Use
• An educated guess, made as a broad statement about what that patient’s Demonstrate Name Verbalize
state will be after the nursing intervention is completed; the desired result Describe Participate Walk
of nursing care. Discuss Perform
• It directly addresses the problem stated in the nursing diagnosis; that which
you hope to achieve with your client and which is designed to prevent, Specific Components
remedy or lessen the problem identifies in the nursing diagnosis. Outcome = Client behavior + Criterion of performance + Conditions + Time frame

Answers the questions who, what actions, under what circumstances, how well and
when
Client Behavior
• An observable activity the patient will demonstrate at some time in the
future showing improvement in the problem area
• E.g. (Client) will drink – problem with dehydration
• What actions must the person do to achieve the goal?
Note: At times when writing an outcome statement, the word “client or patient”
or the actual name of the person may be omitted since the outcome always
refers to the client.
Criterion of Performance
• Is a stated level or standard for the patient’s behavior stated in the outcome
• Criterion of acceptable performance – the level at which the patient will
perform the behavior
• How well is the person to perform the action?
• E.g. At least 500 ml of fluids
Will lose 5 lbs during the first week
Will draw up correct amount of insulin
Will inject insulin using sterile technique
Will walk to the end of the hall three times per day
Conditions
• Specific aids that will help the patient perform a behavior at the level
specified in the criteria portion of the outcome statement.
• Not all outcomes will have a condition.
• Under what circumstances is the person to perform the action
• E.g. with the use of a straw
Time Frame
• Time or date that clarify how long it would realistically take for the client to
reach the level of functioning in the criteria part of the outcome
• It may be stated in minutes, hours, days, weeks and months
• E.g. q 4 hours
• When is the person expected to perform the action?
Goal: (Client) will drink at least 500 ml of fluids with the use of a straw q 4 hours.
Example:
Nursing Diagnosis:
• Ineffective airway clearance r/t thoracic incision pain as evidence by weak
coughing effort.
Outcome Criteria:
• Client will demonstrate (CB) effective coughing and deep breathing (CP) q 2
hours (TF) on the first day of surgery.
Reminders in writing outcome based on nursing diagnosis
• For an Actual (focused problem) Nursing Diagnosis – the outcome is a client
behavior that demonstrates reduction or alleviation of the problem.
• For Risk Nursing Diagnosis – the outcome is a client behavior that
demonstrates maintenance of the current status of health or functioning.
Criteria for Client Outcome
Goals and objectives should be SMART
• Specific – Derive each outcome from only one diagnosis.
• Measurable – The outcome is an observable or measurable client behavior
• Attainable – the outcome can be achieved within the given standard and
time frame
• Realistic – The outcome is realistic for the nurse’s level of skill and
experience. It should be realistic for the client’s capabilities in the time span
you designate in your outcome.
• Time bound – Designate a specific time for achievement of each outcome.
Note:
• Whenever possible the outcome is important and valued by the client, the
nurses and the physician.
• Write outcomes in terms of client behavior, not nursing actions.
• Keep outcomes short.
• Present information that will guide the evaluation phase of the nursing
process.
Writing an Outcome Statement
• After determining the pt’s present health status (nursing diagnosis), next
step is to set goals for changing or maintaining health status
Goal: desired outcome; expected outcome; predicted outcome
 • Describes the client responses that you expect to achieve as a result of Note:
interventions
• Nursing interventions must be specifically designed to meet the identified
• Broad statement
goal
Objectives – more specific, observable criteria used to evaluate whether the broad • Each nursing intervention must be supported by scientific rationale
goal has been met • Evaluation must address whether each goal was completely met, partially
met or completely unmet
Example:
Types of Plans of Care
Goal Specific Objective
Improve nutritional status Will gain 5 lb by December 25 1. Instructional plan of care of student care plan
Decrease pain Will rate pain as less than 3 on a 1-10 scale 2. Clinical plans of care
Increase self-care abilities Will be able to feed self by end of the week • Multidisciplinary
• Nurses often take the primary responsibility in developing and
updating the plan
PLANNING
• Development of nursing strategies designed to ameliorate patient • All members of the team are encouraged to read and add to the
plan.
problems.
Types of Clinical Plan of Care
• A written plan of care is developed to direct nursing care activities
1. Individual Plan of Care – for each patient
Purposes: 2. Standardized Plan of Care – written by group of nurse experts in
given areas for a patient population with specific medical diagnosis
• Direct patient care activities 3. Generic Plan of Care – written for a specific nursing diagnosis
• Promote continuity of care 4. Computerized Plan of Care – generated from assessment data
• Focus charting requirements entered into a computer about a specific agent
• Allow for delegation of specific activities
IMPLEMENTATION
Activities of the Planning Phase
• Action phase
1. Planning nursing interventions
• Actual initiation of the plan
• Determining appropriate nursing interventions for specific patient
• Activities:
2. Writing a patient plan of care
o Reassessment
• It documents the problem solving process
o Setting priorities
• It is a critical element in focusing nursing activities
o Perform nursing interventions
• It serves as evaluation criteria o Recording of nursing actions
• It must reflect the standard of care
Relationship of implementation to other phases of the nursing process
Important concepts in writing a plan of care
• Implementation depends on the first three phases: assessment, diagnosis,
1. Patient centered planning. These steps provide for autonomous nursing actions.
2. Step by step process as evidence by the ff:
• Implementation overlaps with other phases.
• Sufficient data are collected to substantiate nursing diagnosis
• At least one goal must be stated for each nursing diagnosis
• Outcome criteria must be identified for each goal
Process of Implementing Nursing Interventions – are any treatment based upon clinical judgement and
knowledge that a nurse performs to enhance patient/client outcomes
1. Reassess the client
• Ongoing assessment is not the same as assessment. It occurs during Nursing Interventions
assessment. • To monitor health status
Example: • Prevent, resolve, or control a problem
• Assist with activities of daily living (ADL)
Implementation Assessment
• Promote optimum health and independence
While bathing an elderly patient The nurse observes a reddened
area on the patient’s sacrum Interventions can be:
When emptying the catheter bag The nurse measures 200ml and 1. Direct or indirect
notices a strong odor 2. Independent, dependent, interdependent
3. Multidisciplinary
2. Determining the nurse’s need for assistance
3. Implementing the nursing interventions 1. Nurse Initiated and Order Interventions (Independent Nursing Actions)
4. Supervising delegated care • These interventions are solely in range of practice of nursing.
5. Documenting nursing activities • E.g. physical care, ongoing assessment, emotional support, hx teaching
• Implementation ends when nursing actions resulting in client responses
Categories of Independent Nursing Interventions
have been recorded in the client’s chart
• Health teachings and health counseling
Implementation skills needed: • Referrals to other health care professionals
1. Intellectual (cognitive) skills • Specific nursing treatments to lessen current difficulties
2. Interpersonal skills • Provides support, comfort and encouragement
3. Psychomotor/Technical skills • Assessment of client status and response to treatment
• Discharge planning related to lifestyle changes
1. Cognitive skills
• Assistance with meeting basic needs
• When helping a client walk, the nurse notices that the IV flow rate is too
slow. He quickly checks to see that the tubing is not kinked and the IV has • Environmental management – the aspect of nursing care that is involved in
not infiltrated. When no mechanical problems are noted, he opens the the establishment and maintenance of a safe and therapeutic environment
roller clamp to increase the flow. When it is too slow, he raises the bag 2. Physician Initiated and Ordered Interventions (Dependent Nursing Intervention)
higher to make use of gravity. • These are orders to assess the client’s status, scheduled test and treatment
2. Interpersonal skills plans written on the chart
• Interpersonal skills are used with patients, families and other health team • E.g. medications, IV therapy, diagnostic tests
members. 3. Nurse Initiated and Physician Ordered Interventions
• The nurse listens actively; conveys interest; gives clear explanations; • These are actions based on the nurse’s assessment of the client and
comforts; makes referrals; delegated activities; and shares attitudes, identification of the problem and needs legal written order from the doctor
feelings, and knowledge. to alleviate the problem because the nurse is not licensed to do and order
3. Psychomotor/Technical skills such treatment.
• Performing hands-on skills, such as changing dressings, giving injections, 4. Collaborative Interventions
turning and positioning patients, attaching a monitor to a patient, and • Done with other health team members (PT, social worker, dietician,
suctioning a tracheostomy. physician)
Nursing Intervention Classification (NIC) b. Supportive Interventions – emphasize the use of communication skills,
relief of spiritual distress, and caring behavior and comfort.
• Nursing interventions are organized into 7 domains, classes and c. Psychosocial Interventions – exploring feelings; focus on resolving
interventions (by Research team from Iowa College of Nursing) emotional, psychological or social problems
• The NIC provides 554 interventions 3. Technical Interventions
• It provides label and definition for each intervention a. Maintenance Interventions – retains certain state of health, preventing
• Directs our focus to the content and process of nursing care by identifying complication or deterioration of physical and psychological functioning
and standardizing the care activities and preserving independence.
Domains • Include: basic hygiene, skin care, other routine nursing
1. Physiologic: Basic activities
2. Physiologic: Complex b. Surveillance or Monitoring Interventions – include detecting changes
3. Behavioral from baseline data and recognizing abnormal responses.
4. Safety • Example: frequent checking of VS, temperature
5. Family c. Psychomotor Interventions
6. Health system • Those requiring technical expertise
7. Community • Example: insertion of catheter suctioning, care of equipment
changing, removing, cleansing
Major Categories of Nursing Intervention (NIC)
EVALUATION
1. Cognitive Intervention – Applying general principles of teaching and learning
process • The sixth phase
a. Educational Interventions • The judgement of the effectiveness of nursing care to meet patient goals
• Develop teaching plan based on patient’s responses.
• Health education • Ongoing all throughout the nursing process
• Assess readiness to learn • The plan of care is the foundation of evaluation
b. Delegation and Supervisory Interventions • It is a planned, ongoing, purposeful activity in which client, nurse, significant
• Delegation – transfer of responsibility for the performance of others and health care professionals determine the client’s progress
the task to another individual while retaining accountability towards:
for the outcome. o Achievement of the goal/outcomes
• Principles of delegation – observe RIGHTS: person, task, o The effectiveness of the nursing care plan
circumstances, communication, evaluation.
Purpose of Evaluation
• Assignment – transfer of responsibility and accountability
• Supervisory interventions – is applied in the context of • To examine patient’s responses to nursing interventions.
overseeing overall care of patient • To compare patient’s behavioral responses to outcome criteria.
o It includes ensuring that other members of the team • To appraise goal attainment or problem resolution.
and those involved with patient and family show • To provide basis for revision of plan of care.
return demonstration of care. • To appraise the nursing care delivered.
2. Interpersonal Interventions • To monitor the quality of nursing care.
a. Coordinating Interventions – with other members of the health team
• Example: referral to other health care, self-help group, home
health agencies
Evaluation Skills

1. Knowledge of standard of care Example of data collection methods

2. Knowledge of normal patient responses
3. Conceptual models and theories of nursing Outcome Statement Data Collection Activity
By the end of the week, names foods to Using food guide pyramid, ask client to
4. Ability to monitor the effectiveness of nursing intervention
avoid on a low fat diet tell you which foods to avoid
5. Awareness of clinical research

Types of Evaluation
Outcome Statement Data Collection Activity
1. Structure Evaluation Heart rate < 100 bpm at all times Auscultate apical heart rate
• Focuses on the attributes of the setting or surroundings
• It deals with environmental aspects that influence the quality of care
3. Measure Goal/Outcome Achievement
• Example: availability of equipment, layout of physical facilities
• Making judgement about the goal attainment by comparing the
2. Process Evaluation
patient’s actual behavioral responses to the predicted responses and
• Focuses of the nurse’s performance and whether the nursing care predetermined outcome criteria developed in the planning phase
provided was appropriate and competent
• Comparing data with outcomes
3. Outcome Evaluation
Desired Outcome: Client will (Did the client drink 3000 cc
• Focuses on the patient and the patient’s function drink 3000 cc of fluid in 24 of fluid in 24 hours?)
• Determined the extent to which the patient’s behavioral response to hours
nursing intervention reflects the desired patient goal and outcome
criteria Judgements that may be made are as follows:
• Example: To establish standards of care for a specific diagnosis and • The goal was completely met.
then compare actual patient outcomes with that standard. • The goal was partially met.
Evaluation Activities • The goal was completely unmet.

1. Review patient goals and outcome criteria Drawing conclusions

• Observing patient behavior
• Using documentation of patient’s responses
• Receiving feedback (patient, family, other members of the health team)
2. Collect Data (Objective and subjective data)
• Collecting data related to the desired outcomes.
Example:
• Goal: The patient will state that pain is relieved within 10 minutes
after positioning
o The subjective statement of the patient would be needed
to judge whether this goal has been achieved.
• Desired Outcome: Client will drink 3000 cc of fluid in 24 hours
o Record of client’s intake for 24 hours
Conclusion Description
Goal met The desired client response occurred; that is, the actual
response is the same as the desired outcome
Goal partially met Some, but not all, desired behaviors were observed, or
the predicted outcome is achieved only part of the time
Goal not met The desired client response did not occur by the target
time, or the actual outcome does not match the desired
outcome
4. Record judgement or measurement of goal attainment
• Write subjective and objective data gathered
• Document the judgement made about the goal attainment
• Avoid ambiguous terminology (inadequate, good, extremely well,
normal)
 Write the EVALUATIVE statement

• A conclusion
• Supporting data
o Example:
▪ “Goal Met”: Fluid intake of 3200 cc in 24 hours;
with good skin turgor and moist mucous
membranes.
5. Revise or modify the plan of care
• Reassessment
• If there is a new diagnosis, write a new plan of care