Chapter 10 — Nursing Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 10—Nursing Diagnosis, Outcome Identification,

Planning, Implementation, and Evaluation


Making accurate nursing diagnoses takes knowledge and practice. If the nurse uses a systematic approach to nursing diagnosis validation, then accuracy will increase. The process of making nursing diagnoses is difficult because nurses are attempting to diagnose human responses. Humans are unique, complex, and ever-changing; thus, attempts to classify these responses have been difficult.

Carpenito-Moyet, 2008


Learning ObjectivesAfter studying this chapter, you should be able to

• Articulate the purpose of using a nursing diagnosis in the psychiatric–mental health setting

• Distinguish among the four types of nursing diagnoses

• Explain the use of the phrase possible nursing diagnosis

• Understand the rationale for using the Diagnostic and Statistical Manual, 4th edition, Text Revision (DSM-IV-TR) or the Psychodynamic Diagnostic Manual (PDM) in the psychiatric–mental health setting

• Describe the purpose of using mnemonics when developing a plan of care

• Discuss the rationale for using outcome identification as part of the nursing process


Learning Objectives (cont.)• Compare and contrast the use of the following

when developing a plan of care: concept mapping, clinical pathways, concept mapping, critical pathways, and evidence-based nursing practice

• Construct a nursing care plan in the psychiatric setting

• Interpret the nurse’s role when implementing nursing interventions

• Explain the rationale for the evaluation phase of the nursing process


Six Steps of the Nursing Process

Assessment

Nursing diagnosis

Outcome identification

Planning (formulation of a plan of nursing care)

Implementation of nursing actions or interventions

Evaluation of the client’s response to interventions


Nursing Diagnosis

The North American Nursing Diagnosis Association (NANDA) defines a nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.

• Cues

• Inferences

• Data

• List of defining characteristics


Diagnostic Systems

• North American Nursing Diagnosis Association (NANDA) diagnostic system

• Psychiatric–Mental Health Nursing (PMHN) diagnostic system


Classification of Nursing Diagnosis Carpenito-Moyet (2008)

• Actual nursing diagnosis

• Risk nursing diagnosis

• Wellness nursing diagnosis

• Syndrome nursing diagnosis


DSM-IV-TR

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision

• Published by the American Psychiatric Association (APA) to ensure consistency and commonality of language

• Required by insurance companies for reimbursement

• Also used to identify and communicate accurate public health statistics

• Presents decision trees for differential diagnoses


Outcome Identification

When possible, the nurse, client, significant others, and multidisciplinary team members work together to formulate the outcomes.

• Measurable

• Client oriented

• Realistic

• Directly related to the nursing diagnosis


Planning

The planning phase involves developing a plan of care to guide therapeutic intervention and achieve expected outcomes.

• Standardized care plans

• Concept mapping

• Clinical pathways

• Critical pathways


General Principles for Plans of Care

• Individualize or personalize the plan

• Use simple, understandable language

• Be specific when stating nursing interventions

• Prioritize nursing care

• State expected outcomes

• Indicate the responsible party or discipline for each nursing intervention


Implementation

• Evidence-based nursing practice is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and client preferences.


Interventions for the Psychiatric–Mental Health Clinical Setting

• Counseling interventions to help the 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 biological interventions to restore the client’s health and prevent future disability

• Health education

• Case management

• Interventions to promote mental health and prevent mental illness


Advanced Practice PMHN Interventions

• Individual, group, family, and child therapy

• Pharmacologic agent prescription

• Consultation with other health care providers


Evaluation

Four possible outcomes:

• The client may respond favorably or as expected to nursing interventions.

• Short-term outcomes (goals) may be met, but long-term goals may remain unmet.

• The client may be unable to meet or achieve any outcomes (goals).

• New problems or needs may be identified requiring the nurse to modify or revise the plan of care.


Key Terms

• Actual nursing diagnosis

• Clinical pathways

• Critical pathways

• Cues

• Decision trees

• DSM-IV-TR

• Expected outcomes

• Inferences

• Mnemonics

• Nursing diagnosis

• Risk nursing diagnosis

• Standardized nursing care plans

• Syndrome nursing diagnosis

• Wellness nursing diagnosis


Reflection

Making accurate nursing diagnoses takes knowledge and practice.

??

• What difficulties have you experienced arriving at a nursing diagnosis as you developed a care plan for a client?

• How did you validate data?• How did you classify your

nursing diagnoses (eg, actual, risk, wellness, or syndrome diagnosis)?

Documents

Chapter 10 — Nursing Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation