FUNDA LEC 11

ESTABLISH PRIORITIES CRITERIA

III. OUTCOME
IDENTIFICATION o PRIORITY

– is a choice that comes first over

OUTCOME IDENTIFICATION other possible options
Ü The formulation of goals and measurable – often based on urgency or
outcomes that provides the basis for importance
evaluating nursing diagnoses.
o PRIORITY SETTING
Ü The most recent addition of the nursing
process. – is a decision making process that
ranks the order of nursing
Ü PURPOSES: diagnoses in terms of importance
o Providing individualized care to the patient
o Promoting patient participation
o Planning realistic and “Priorities constantly change as
measurable care the patient situation and condition
o Allowing for involvement of change."
support people
A. HIGH PRIORITY
NURSING OUTCOME
– potentially life threatening and
Ü refers to a measurable behavior and require immediate actions
perception demonstrated by an
individual, family, group or a community – High priority patients involves:
that is responsive to nursing intervention.
§ Life threatening situation
NSG OUTCOME CLASSIFICATION (NOC) (example: difficulty
breathing, hemorrhage)
Ü a system that can be used to select
outcome measure related to nursing § Something that needs
diagnosis immediate attention
(example: preparation for a
"OUTCOMES NEED TO BE IDENTIFIED test, discharge from the
BEFORE NURSING INTERVENTIONS ARE facility that will occur
DETERMINED" shortly)
ANALOGY: PLANNING A ROAD TRIP § Something that is very
important to the patient
"Simply getting in a car and driving will get a (example: pain, anxiety)
person somewhere, but that may not be the
place the person really wanted to go. It Is B. MEDIUM PRIORITY
better to have a clear location (outcome ) in
mind and then choose a route (intervention) to – involve problems that could
get to the desired location" result in unhealthy
consequences such as
physical and emotional
ACTIVITIES OF OUTCOME IDENTIFICATION impairment but not likely to
threaten life
1. Establish Priorities
2. Establish Patient Outcomes And C. LOW PRIORITY
Outcome
– problem will be easily resolved
 FUNDA LEC 12

ESTABLISH PATIENT OUTCOMES AND § Demonstrate

OUTCOME CRITERIA § Describe
§ Discuss
o PATIENT OUTCOME § Distinguish
§ Draw
– an educated guess, made as a § Explain
broad statement about what that § Express
patient's state will be after the § Identity
nursing intervention is completed § List
§ Maintain
– it directly addresses the problem § Name
stated in the nursing diagnosis § Participate
§ Perform
– must be behavioral § Practice
§ Recall
– written to indicate a desired state § Recite
§ Record
– contain an action verb and a § Stand
qualifier: § State
§ Use
that indicate level of § Verbalize
performance § Walk

that needs to be achieved

NSG OUTCOME VS. NSG INTERVENTION
• Qualifier — a description of the
parameter for the outcome o Nursing outcomes

A. SHORT TERM OUTCOME – provides a point of reference for

determining whether the intervention
– can be met in a relatively short is appropriate and effeetlve
period ( within days or less than 1
week) o The Nursing intervention

B. LONG TERM OUTCOME – states what the nurse will do

– requires more time (perhaps

several weeks or months) OUTCOME CRITERIA

– usually describe expected Ü Specific, measurable, realistic

benefits or results that are seen
after the plan of care has been
implemented
“The nurse needs to revise outcomes if
the patient's situation or medical
condition changes."
statements of goal attainment
Ü Present information that will guide the
evaluation phase of the nursing process
Ü Answers the questions who, what
actions, under what circumstances, how
well and when

EXAMPLES OF BEHAVIORAL VERBS USED Ü Alfaro-Lefevre (2014) an outcome criteria

IN PATIENT GOALS requires the following:

§ Calculate § Subject: Who is the person expected

§ Classify to achieve the goal?
§ Communicate
§ Compare § Verb: What actions must the person
§ Construct do to achieve the goal?
§ Contrast
§ Define
 FUNDA LEC 13

§ Condition: Under what

circumstances is the person to
perform the action?

§ Criteria: How well is the person to

perform the action?

§ Specific Time: When is the person

expected to perform the action?

Ü Example outcome criterion:

“The patient (who) verbalizes (what

action) three dietary modifications of a
low salt diet to his wife (under what
circumstances) accurately (how well)
after the teaching session (when)."
 FUNDA LEC 14

COMPONENTS OF GOAL/DESIRED OUTCOME STATEMENTS

Goal/desired outcome statements should have the following four components:

1. SUBJECT

Ü a noun, is the client, any part of the client, or some attribute of the client, such as the
client's pulse or urinary output

Ü the subject is often omitted in goals

Ü it is assumed that the subject is the client unless indicated otherwise

2. VERB

Ü specifies an action the client is to perform, for example, what the client is to do, learn, or
experience

Ü verbs that denote directly observable behaviors, such as administer, show, or walk, must
be used

3. CONDITIONS OR MODIFIERS

Ü may be added to the verb to explain the circumstances under which the behavior is to be
performed

Ü they explain what, where, whene or how

Ü For example:

Walks with the help of a cane (how). After attending two group diabetes classes,
lists signs and symptoms of diabetes (when). When at home, maintains weight at
existing level (where). Discusses food pyramid and recommended daily servings
(what). Conditions need not be included if the criterion of performance clearly
indicates what is expected.

4. CRITERION OF DESIRED PERFORMANCE

Ü indicates the standard by which a performance is evaluated or the level at which the client
will perform the specified behavior

Ü these criteria may specify time or speed, accuracy, distance, and quality

Ü to establish a time-achievement criterion, the nurse needs to ask "How long?"

Ü to establish an accuracy criterion, the nurse asks "How well?"

Ü Similarly, the nurse asks "How far?" and "What is"

 FUNDA LEC 15

GUIDELINES FOR WRITING GOALS/DESIRED OUTCOMES

The following guidelines can help nurses write useful goals and desired outcomes:

1. Write goals and outcomes in terms of client responses, not nursing activities. Beginning each
goal statement with The client will may help focus the goal on client behaviors and responses.
Avoid statements that start with enable, facilitate, allow, let, permit, or similar verbs followed by
the word client. These verbs indicate what the nurse hopes to accomplish, not what the client
will do.

Correct: The client will drink 100 mL of water per hour (client behavior).

Incorrect: Maintain client hydration (nursing action).

2. Be sure that desired outcomes are realistic for the client's capabilities, limitations, and
designated time span, if it is indicated. Limitations refers to finances, equipment, family support,
social services, physical and mental condition, and time.

For example, the outcome "Measures insulin accurately" may be unrealistic for a client
who has poor vision due to cataracts.

3. Ensure that the goals and desired outcomes are compatible with the therapies of other
professionals.

For example, the outcome "The client will increase the time spent out of bed by IS minutes
each day" is not compatible with a primary care provider's prescribed therapy of bed rest.

4. Make sure that each goal is derived from only one nursing diagnosis.

For example, the goal "The client will increase the amount of nutrients ingested and show
progress in the ability to feed self" is derived from two nursing diagnoses: Imbalanced
Nutrition: Less Than Body Requirements and Feeding Self-Care Deficit.

Keeping the goal statement related to only one diagnosis facilitates evaluation of care by
ensuring that planned nursing interventions are clearly related to the diagnosis.

5. Use observable, measurable terms for outcomes. Avoid words that are vague and require
interpretation or judgment by the observer.

For example, phrases such as increase daily exercise and improve knowledge of nutrition
can mean different things to different people.

If used in outcomes, these phrases can lead to disagreements about whether the
outcome was met. These phrases may be suitable for a broad client goal but are not
sufficiently clear and specific to guide the nurse when evaluating client responses.

6. Make sure the client considers the goals/desired outcomes important and values them.

Some outcomes, such as those for problems related to self-esteem, parenting, and
communication, involve choices that are best made by the client or in collaboration with
the client.
 FUNDA LEC 16

–
IV. PLANNING it is a critical element in focusing
nursing activities

PLANNING – it serves as evaluation criteria

Ü development of nursing strategies – it must reflect the standard of care

designed to ameliorate patient problems established by the institution and
the profession
Ü a written plan of care is developed to
direct nursing care activities – IMPORTANT CONCEPTS:

Ü a deliberative, systematic phase that 1. Patient-centered

involves decision making and problem 2. Step by Step process
solving
Step by step process as
Ü the process of designing nursing evidenced by the following:
activities required to prevent, reduce, or
eliminate a client’s health problem Ø Sufficient data are
collected to substantiate
Ü the nurse develops a plan to assist the nursing diagnosis
client to an optimum or improved level of
functioning in the problem areas Ø At least one goal must be
identified in the nursing diagnosis stated for each nursing
diagnosis
Ü this is the time wherein the nurse can
determine how to give nursing care in Ø Outcome criteria must be
an organized, and goal-directed manner identified for each goal

Ø Nursing interventions must

[PURPOSES OF PLANNING] be specifically designed to
meet the identified goal
PURPOSES OF PLANNING
o Direct patient care activities Ø Each nursing intervention
o Promote continuity of care must be supported by
o Focus charting requirements scientific rationale
o Allow for delegation of specific activities
Ø Evaluation must address
whether each goal was
completely met, partially
[ACTIVITIES OF PLANNING] met or completely unmet

ACTIVITIES OF THE PLANNING PHASE

[TYPES OF CARE PLANS]
1. Planning Nursing Interventions
TYPES OF PLANNING
– determining appropriate nursing 1. Instructional plan of care or student care
interventions for a specific patient plan
2. Clinical plans of care
– Nursing interventions: are any
treatment, based upon clinical CLINICAL PLANS OF CARE
judgment and knowledge, that a » multidisciplinary
nurse performs to enhance client » nurses often take the primary
outcomes responsibility in developing and updating
the plan
2. Writing the Client Plan of Care » all members of the team are encouraged
to read and add to the plan
– it documents the problem solving » TYPES:
process o Individual Plan of Care
– for each patient
 FUNDA LEC 17

– are all activities, verbal and nonverbal,

o Standardized Plan of Care
– written by group of nurses
experts in given areas for a
patient population with
specific medical diagnosis
o Generic Plan of Care
– written for a specific
nursing diagnosis
o Computerized Plan of Care
– generated from the
assessment data entered
into a computer about a
specific patient
people use when interacting directly with
one another
The effectiveness of a nursing
action often depends largely on
the nurse’s ability to communicate
with others.
The nurses uses therapeutic
communication to understand the
client and in turn be understood.
– are necessary for all nursing activities:
caring, comforting, advocating, referring,
counseling, and supporting are just a few

– interpersonal skills include conveying

knowledge, attitudes, feelings, interest,
V. IMPLEMENTATION and appreaciation of the client’s cultural
values and lifestyle
IMPLEMENTATION
TECHNICAL SKILLS
Ü putting planned nursing interventtions
into action where reassessment occurs – are purposeful “hands-on” skills such as
simultaneously manipulating equipment, giving
injections, bandaging, moving, lifting, and
Ü actual initiation of the plan repositioning clients

Ü is the phase in which the nurse performs – these skills are also called tasks,
or delegates activities necessary for procedures, or psychomotor skills
achieving the client’s health goals

Ü described broadly, the activities in this

steo include doing, delegating, and [TYPES OF NURSING
recording INTERVENTIONS]
Ü activities: reassessment NURSING INTERVENTION
setting priorities
perform nursing interventions Ü are any treatment based upon clinical
recording of nursing actions judgment and knowledge that a nurse
performs to enhance patient/client
outcomes
[IMPLEMENTATION SKILLS]
Ü purpose:
IMPLEMENTATION SKILLS NEEDED: o to monitor health status
1. Intellectual skills o prevent, resolve, or control a
2. Interpersonal skills problem
3. Technical skills o assist with activities of daily living
(ADL)
INTELLECTUAL SKILLS o promote optimum health and
independence
– include problem-solving, decision-
making, critical thinking, clinical Ü TYPES:
reasoning, and creativity (they are crucial o Independent
to safe, intelligent nursing care) o Dependent
o Collaborative
INTERPERSONAL SKILLS
Ü CARE:
 FUNDA LEC 18

o Direct 3. Behavioral
o Indirect 4. Safety
5. Family
INDEPENDENT INTERVENTIONS 6. Health System
7. Community
– are those activities that nurses are
licensed to initiate on the basis of their Ü All NIC interventions have been linked to
knowledge and skills NANDA nursing diagnostic labels. The
nurse can look up a client’s nursing
– they include physical care, ongoing diagnosis to see which nursing
assessment, emotional support and interventions are suggested.
comfort, teaching, counseling,
environmental management, and making Ü However, each nursing diagnosis
referrals to other health care contains suggections for several
professionals interventions, so nurses need to select
the appropriate interventions based on
DEPENDENT INTERVENTIONS their judgment and knowledge of the
client.
– are activities carried out under the orders
or supervision of a licensed physician or
other healthcare provider authorized to
write orders to nurses
[MAJOR CATEGORY OF NSG
INTERVENTION]
– primary care providers’ orders commonly
direct the nurse to provide medications, MAJOR CATEGORIES OF NURSING
intravenous therapy, diagnostic tests, INTERVENTION CLASSIFICATION (NIC):
treatmentsm diet, and activity
I. Cognitive Intervention
With the client, the nurse is a. Educational
responsible for assessing the b. Delegation and Supervisory
need for, explaining, and II. Interpersonal Intervention
administering the medical orders a. Coordinating
b. Supportive
COLLABORATIVE INTERVENTIONS c. Psychosocial
III. Technical Interventions
– are actions the nurse carries out in a. Maintenance
collaboration with other health team b. Surveillance or Monitoring
members, such as physical therapists, c. Psychomotor
social workers, dietitians, and primary
care providers COGNITIVE INTERVENTIONS

[NSG INTERVENTION – applying general principles of teaching

and learning process
CLASSIFICATION]
a. Educational Interventions
NIC INTERVENTIONS – develop teaching plan
– health education
Ü are organized into 7 domains, classes, – assess readiness to learn
and interventions (by Research team
from Iowa College of Nursing) b. Delegation and Supervisory Intervention

Ü provides 554 interventions – Delegation

– transfer of responsibility for
Ü provides label and definition for each the performance of the task
intervention to another individual while
retaining accountability for
Ü DOMAINS: the outcome
1. Physiologic: Basic
2. Physiologic: Complex Principles: Observe RIGHTS:
 FUNDA LEC
person, task,
circumstancesm
communication,
evaluation
– Supervisory
– applied in the context of
overseeing overall care of
patient
– include ensuring that other
members of the team and
those involved with patient
and family show return
demonstartion of care
INTERPERSONAL INTERVENTIONS
a. Coordinating Interventions
– with other members of the health
team (example: referral to other
healthcare, self-help group, home
heath agencies)
b. Supportive Interventions
– emphasize the use of
communication skills, relief of
spiritual distress, and caring
behvior and comfort
c. Psychosocial Interventions
– exploring feelings; focus on
resolving emotional,
psychological or social problems
TECHNICAL INTERVENTIONS
a. Maintenance Interventions
– retains certain state of health,
preventing complication of
deterioration of ohysical and
psychological functioning and
preserving independence
– include: basic hygiene, skin care,
other routine nursing activities
VI. EVALUATION
EVALUATION
Ü the judgment of the effectiveness of
nursing care to meet patient goals based
on patient’s responses
Ü an important aspect of the nursing
process because conclusion drawn from
19
the evaluation determines whether the
nursing interventions should be
terminated, continued, or changed
Ü on going all throughout the nursing
process
Ü the plan of care is the foundation of
evaluation
PURPOSES OF EVALUATION
Ü To determine whether to continue,
modify, or terminate the plan of care
o To examine patient’s responses to
nursing interventions
o To compare patient’s behavioral
responses to outcome criteria
o To appraise goal attainment or problem
resolution
o To provide basis for revision of plan of
care
o To appraise the nursing care delivered
o To monitor the quality of nursing care
EVALUATION SKILLS
1. Knowledge of standard of care
2. Knowledge of normal patient responses
3. Conceptual models and theories of
nursing
4. Ability to monitor the effectiveness of
nursing intervention
5. Awareness of clinical research
TYPES OF EVALUATION
1. Structure Evaluation
– focuses on the attributes of the
setting or surroundings
– it deals with environmental
aspects that influence the quality
of care
– example: availability of
equipment, layout of physical
facilities
2. Process Evaluation
– focuses on the nurse’s
performance and whether the
 FUNDA LEC
nursing care provided was
appropriate and competent
3. Outcome Evaluation
– focuses on the patient and
patient’s function
– determines the extent to which the
patient;s behavioral response to
nursing intervention reflects the
desired patient goal and outcome
criteria
– example: To establish standards
of care for a specific diagnosis and
then compare actual patient
outcomes with that standard
EVALUATION ACTIVITIES
1. Review patient goals and outcome
criteria
§ Observing patient behavior
§ Using documentation of patient’s
responses
§ Receiving feedback (patient,
family, other members of the
health team)
2. Collect data
§ Collect objective and subjective
data
§ Example: The patient will state
that pain is relieved within 10
minutes after positioning
The subjective statement of
the patient would be
needed to judge whether
this goal has been
achieved
3. Measure goal/outcome achievement
§ Making judgment about the goal
attainment by comparing the
patient’s actual behavior
responses to the predicted
responses and predetermined
outcome criteria developed in the
planning phase
§ Judgment that may be made are
as follows:
o The goal was completely
met
20
o The goal was partially met
o The goal was completely
unmet
4. Record judgment or measurement of
goal attainment
§ Write subjective and objective
data gathered
§ Document the judgment made
about the goal attainment
§ Avoid ambiguous terminology
(inadequatem good, extremly well,
normal)
5. Revise or modify the plan of care
reassessment
§ If there is a new diagnosis, write a
new plan of care
PROCESS OF IMPLEMENTING
• Reassessing the client
• Determining the nurse's need for
assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
REASSESSING THE CLIENT
» Just before implementing an intervention,
the nurse must reassess the client to
make sure the intervention is still needed.
Even though an order is written on the
care plan, the client's condition may have
changed.
» For example, a client has a nursing
diagnosis of Disturbed Sleep Pattern
related to anxiety and unfamiliar
surroundings. During rounds, the nurse
discovers that the client is sleeping and
therefore defers the back massage that
had been planned as a relaxation
strategy.
DETERMINING THE NURSE'S NEED FOR
ASSISTANCE
» When implementing some nursing
interventions, the nurse may require
assistance for one or more of the
following reasons:
o The nurse is unable to implement the
nursing activity safely or efficiently
 FUNDA LEC
alone (e.g., ambulating an unsteady
obese client)
o Assistance would reduce stress on
the client (e.g., turning a person who
experiences acute pain when
moved).
o The nurse lacks the knowledge or
skills to implement a particular
nursing activity (e.g., a nurse who is
not familiar with a particular model of
traction equipment needs assistance
the first time it is appred).
IMPLEMENTING THE NURSING
INTERVENTIONS
» It is important to explain to the client what
interventions will be done, what
sensations to expect, what the client is
expected to do, and what the expected
outcome is. For many nursing activities it
is also important to ensure the client's
privacy. for example, by closing doors,
pulling curtains, or draping the client.
» When implementing interventions,
nurses should follow these guidelines:
o Base nursing interventions on
scientific knowledge, nursing
research, and professional standards
of care (evidence-based practice)
when these exist. The nurse must be
aware of the scientific rationale, as
well as possible side effects or
complications, Of all interventions.
For example, a client has been
taking an oral medication after
meals; however; this medication is
not absorbed well in the presence
of food. Therefore, the nurse will
need to explain why this practice
needs to be altered.
o Clearly understand the interventions
to be implemented and question any
that are not understood. The nurse is
responsible for intelligent
implementation of medical and
nursing plans of care. This requires
knowledge of each intervention, its
purpose in the client's plan of care,
any contraindications (e.g., allergies),
and changes in the client's condition
that may affect the order.
21
o Adapt activities to the individual client.
A client's beliefs, values, age, health
status, and environment are factors
that can affect the success of a
nursing action.
For example, the nurse
determines that a client chokes
when swallowing pills. The nurse
consults with the primary care
provider to change the order to a
liquid form Of the medication. Or,
the nurse recognizes that many
Asian people prefer to drink hot
water ratherthan ice water and,
after confirming it with a specific
client, supplies this at the bedside.
o Implement safe care.
For example, when changing a
sterile dressing, the nurse
practices sterile technique to
prevent infection; when giving a
medication, the nurse administers
the correct dosage by the ordered
route.
o Provide teaching. support. and
comfort. The nurse should always
explain the purpose of interventions,
what the client will experience, and
how the client can participate. The
client must have sufficient knowledge
to agree to the plan of care and to be
able to assume responsibility for as
much self-care as desirable. These
independent nursing activities
enhance the effectiveness of nursing
care plans.
o Be holistic. The nurse must always
view the client as a whole and
consider the client's responses in that
context.
For example* whenever possible,
the nurse honors the client's
expressed preference that
interventions be planned for times
that fit with the client's usual
schedule Of visitors, work, sleep,
or eating.
o Respect the dignity Of the client and
enhance the client's self- esteem.
Providing privacy and encouraging
clients to make their own decisions
 FUNDA LEC 22

are ways of respecting dignity and

enhancing setf-esteem.

o Encourage clients to participate

actively in implementing the nursing
interventions. Active participation
enhances the client's sense of
independence and control, However,
clients vary in the degree of
participation they desire. Some want
total involvement in their care,
whereas others prefer little
involvement. The amount of desired
involvement may be related to the
severity of the illness; the client's
culture; or the client's fear,
understanding of the illness, and
understanding of the intervention

DOCUMENTING NURSING ACTIVITIES

» After carrying out the nursing activities,

the nurse completes the implementing
phase by recording the interventions and
client responses in the nursing progress
notes. These are a part of the agency's
permanent record for the client. Nursing
care must not be recorded in advance
because the nurse may determine on
reassessment of the client that the
intervention should not or cannot be
implemented.

For example, a nurse is authorized to

inject 10 mg of morphine sulfate
subcutaneously to a client, but the
nurse finds that the client's respiratory
rate is 8 breaths per minute. This
finding contraindicates the
administration of morphine (a
respiratory depressant). The nurse
withholds the morphine and reports
the client's respiratory rate to the
nurse in charge and/or primary care
provider.