A= assessment data
D= nursing diagnosis -using PES Problem,etiology,symptoms.
P= plan - formulate and write outcomes,interventions based on EBN
I= implementation of care - giving care
E= evaluation of care- revise care make sure it is working
EBN evidence based nursing
systematic process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences
Barriers to EBN
lack of understanding of the process and limited knowledge of the research process
3 problem solving methods used by Nurses
1. Nursing Process
Nursing process uses
nursing interventions for individual patients to attain individual client outcomes.
EBN and quality control initiatives use nursing interventions to
improve the quality of care for large numbers of patients to help them achieve positive outcomes
giving appropriate care and not causing harm .
Evidence-based practice (EBP) is an approach to using the best quality evidence from clinical research, integrated with patient values and clinical experience as an ongoing process in the provision of high-quality hand therapy to individual patients.
▪ There are five sequential steps to the process.
1 Defining a specific clinical question
2 Finding the best evidence that relates to the question
3 Determining if the study results are true and applicable to the patient
4 Integrating patient values and clinical experience with the evidence to make conclusions
5 Evaluating the impact of decisions through determination of patient outcomes
The Joint Commission
formerly known as the Joint Commissioin on the Accreditation of Healthcare Organizations (JACHO), voluntary but necessary for Medicaid certification, holding certain licenses, obtaining reimbursements from insurance companies, and receive malpractice insurance
Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.
This is a clinical judgment about individual, family, or community responses to actual or potential health problem/life processes. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
North American Nursing Diagnosis Association International. Provides a standardization of language concerning patient status and nursing activities that enables nurses to work in the managed care environment, improve quality of care, reduce costs, promote research, and facilitate the development of a reimbursement system for nursing services rendered.
Nursing diagnosis labels 5 choices
1. Actual Nursing Diagnosis -
2.Risk Nursing Diagnosis
3.Health-Promotion Nursing diagnosis
5.Syndrome Nursing Diagnosis
Actual Nursing diagnosis
describes human responses to health condition or life processes. It is supported by defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences
Risk Nursing Diagnosis
a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
Health-Promotion Nursing diagnosis
clinical judgment of a person's, family's, or community;s motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific behaviors such as nutrition and exercise
human responses to levels of wellness in an ind, family or community that have a readiness for enhancement; written as a one part statement. Words "readiness for enhanced" are used ex. readiness for enhanced nutrition to eat better
A diagnosis related to a cluster or group of signs and symptoms that almost always occur together. Together, these clusters represent a distinct clinical picture.
Making a Nursing Diagnosis
After the Assessment is finished-
identify common patterns/symptoms of response to actual or potential health problems from the assessment -
then select appropriate nursing diagnosis label
Highlight symptoms ask what is normal ?
Is this a problem for patient?
Ask patient more questions to validate your findings
List all symptoms
cluster similar symptoms
What do these symptoms mean when the are combined?
Select a nursing diagnosis label from the NANDA-I
Nursing diagnostic statement is written in this format:
Insomnia r/t anxiety and stress aeb (as evidence by) difficulty falling asleep
writing measurable patient outcomesand nursing interventions to accomplish the outcomes . Before this can be done if the patient has more then one diagnosis, the priority of the nursing diagnosis must be determined.
This is determined by immediate needs based on ABC airway,breathing,and circulation and using Maslow's hierarchy of needs, like physiological before lets say Anxiety.
NOC important for the nurse to include the Patient in determining outcomes The use of outcomes information creates a continuous feedback loop to be use in EBN care and the best possible outcomes for the patient.
Nursing Outcomes Classifications. Standardizes the terminology and criteria for measurable or desirable outcomes as a result of nursing interventions.
Writing patient outcomes use SMART
-Write mesaurable client outcomes; not nursing outcomes
-Identify nursing interventions to accomplish the outcomes
interventions are id as independent (autonomous actions taken by a nurse in response to a nursing diagnosis)or collaborative with other health care workers may require a physician order. NIC interventions in text.
- More than 542 interventions developed
- Each intervention includes:
* a label (name)
* a definition
* a list of activities that outline key actions
- Linked to NANDA diagnostic labels
- Select appropriate intervention and customize
Evidence based interventions
those based on theory and shown to be effective through empirical study should be individualized and patient should have input
Documenting the Care Plan
essential, if it was not documented it was not done, they become part of the patients permanent record.
Implementation nursing process
Step 4 - carrying out the plan of care, implements medical orders as well as nursing orders, which should complement each other
evaluation nursing process
Step 5 (final) - way nurses determine wheather a client has reached a goal, entire process is ongoing if outcomes are not met then the nurse begins again with the assessment to figure out why the outcome was not met a ongoing process using EBN to achieve the best possible outcomes. Use NOC outcomes and NIC interventions assures a common language is being used for the next shift nurse to follow. ADPIE