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Objectives
Formulate priorities for managing and delivering nursing care
Apply the specific priority-setting model appropriate to presenting circumstances in various clinical situations
Topic Outline
ASSESSMENT
ANALYSIS
OUTCOME IDENTIFICATION
Health
History Observation Physical Exam
Clinical Eye
Assessment
Interview
Results
Clustering
Health
History
Observation Clinical Eye Physical
CLUSTERED DATA
Exam
Assessment
Interview
Laboratory
results Radiology
Results
Supporting data
The Patient is 73 years old, has a fifthgrade education, and lives with her 55year-old developmentally disabled son.
The patient has recently been diagnosed with Heart failure The patient will probably need a digitalis preparation and ongoing diuretic therapy
NOTE:
The Nurse should never implement before assessing
However, in situations involving an urgent problem, performing only a partial assessment may be necessary, after implementation of interventions, a complete assessment can be performed
Drill
Here is the situation
Patient D
Severe Dehydration Needs a central line for fluid replacement Vital signs: Temp: 37.2 C, PR= 108, RR=24, BP= 90/60 mmHg Assessment done at 3:30 pm The Physician will be on the unit at 4:00 pm to place the central line
Given the scenario, which nursing activity has the highest priority?
Assess urine output
Ensure that central line equipment is on the unit
ANSWER
Ensure that consent form is signed Take the vital signs Perform a body system assessment Ensure that central line equipment is on the unit Assess urine output
Rationale:
Assessing includes collecting, verifying, and organizing. Ensuring that the consent form is signed is verification. Without a consent form, the procedure cannot be done. It is included with the assessment and therefore is the first priority
ASSESSMENT
ANALYSIS
OUTCOME IDENTIFICATION
ANALYSIS
The Nurse prepares a list of patient needs and a list of nursing diagnosis for the cluster of the previously discussed 73-year-old patient is: Deficient knowledge related disease process, precautions, and side effects of diuretic and digitalis therapy.
Nursing Diagnosis
Deficient knowledge related to disease process, precautions, and side effects of diuretic and digitalis therapy
NURSING DIAGNOSIS
3 STEPS Analyze Data
1. Analyze Data
Compare data against the standards Clustering cues Identify gaps and inconsistencies
Physiologic needs
Incontinence, bowel/urinary
Sleep deprivation Swallowing, impaired Sexual dysfunction
OUTCOME IDENTIFICATION
Goals and measurable outcomes provide a means to determine whether the nursing diagnoses are appropriate for situation. Priorities are established to help the nurse achieve the nursing desired outcome After the nursing diagnosis are prioritized, the nurse can identify patient goals and outcomes based on Nursing Outcomes Classification (NOC)
Thank you!
TO GOD BE THE GLORY