Alayna Alfred
Chrischeal Charles
Jamahl Guillaume
Jemima Philippe
Objective 6:
Describe the development of patient-centered outcomes
 A well written patient- centered outcome does the following
 Uses the word patient or part of the patient as the subject of the statement
 Uses measurable verb( define, describe, list, walk, demonstrate, and verbalize)
 Is specific for the patient and the patients problem
 Does not interfere with the medical plan of care
 Is realistic for the patient and the patient's problem
 Includes a time frame for patient reevaluation
 Because the subject of the patient outcome statement is meant to be the patient or a
part of the patient, the outcome statement should begin with the words, “ the patient
will” or “The patient's… will.””
 The properly written patient outcome statement is specific to the patient and the
patient's medical problem
Two ways to approach writing patient outcome statements
 List the desired behavior in broader terms and then list exact criteria or standards
 Indicate a reversal of the problem identified by the NANDA-I nursing diagnosis
label
Objective 6: Continued
 Example of both methods:
 The patient will improve mobility as evidenced by the
ability to ambulate 200 feet by the third day following
surgery
Objective 7:
Discuss the creation of nursing orders.
 For care planning purposes, its necessary for you to be able to change the guiding
general statement about the nursing intervention to a more specific statement. That
detailed statement is now a nursing order
 Nursing order= general statement about the nursing interventions to a more specific
statement
 A nursing order is necessary since the nurse who's writing the care plan is providing
instructions for all caregivers
 Nursing orders include the following:
 Date
 Signature of the nurse responsible for the care plan
 Subject( who will be carrying out the activity)
 Action verb
 Qualifying details
 A proper nursing order is specific for the problem, realistic for the patient,
compatible with the medical plan of care, and based on scientific principles
 The correct nursing order includes an action or command verb
 Examples of action or command verbs: ambulate, offer, encourage, demonstrate,
turn, teach, and monitor
Diagnosis:
 To diagnose is to identify the type and cause of a health
condition
 The ANA ( American Nurses Association) defines diagnoses as
“ a clinical judgments about the clients response to actual or
potential health conditions or needs
 Provides the basis for determining a care plan to achieve
expected outcomes
Cues that have significance for nursing are:
 Deviations in the patients usual health status
 Changes in the patients usual health status
 Developmental delays
 Dysfunctional behavior
 Changes in usual behavior
Nursing Diagnosis:
 Defined as the type of health problem that can be identified
 In 1990 the NANDA( North American Nursing Diagnosis Association) now
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known as NANDA international approved an official definition for nursing
diagnosis that remains in current use
When nurses submit nursing diagnoses, the following four components are
addressed
Nursing diagnoses title or label
Definition of the title or label
Contributing, etiologic, or related factors
Defining characteristics
Lists of nursing diagnoses are often presented in alphabetical order for
example: constipation, fatigue, hopelessness, powerlessness, and pain
Adjectives also add meaning to the nursing diagnosis label by describing or
modifying the label.
Examples of adjectives are imbalanced, ineffective, perceived, impaired,
and excess
4 Types of Nursing Diagnosis:
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Actual nursing diagnosis:
defined as the human responses to health conditions and life processes that exist in an individual,
family, or community
• Risk nursing diagnosis:
supported by risk factors that contribute to increased vulnerability
Written as two part statements (1) the nursing diagnosis label and (2) the risk factors
Example of risk nursing diagnosis: risk for impaired skin integrity related to physical immobilization
• Syndrome nursing diagnosis:
written as one part statements
Used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain
circumstances
Post trauma syndrome, risk for disease syndrome, impaired environmental interpretation syndrome,
and relocation stress syndrome are the current syndrome diagnoses
• Wellness Nursing Diagnosis:
“human responses to levels of wellness in an individual, family, or community( NANDA-I,2009)
Written as one part statement as well
Words “readiness for enhanced” are used in a wellness nursing diagnosis
Standardized Languages:
 Defined as one in which the terms are carefully defined and mean the same
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thing to all who use them
Helps accomplish the following:
Improve communication by providing consistent terminology to describe
clinical problems and treatments
Support computerized patient records
Improve testing of nursing interventions for effectiveness
Define and expand nursing knowledge
Facilitate research to improve patient care
Demonstrate nursing's contribution to patient care
Influence health policy decisions
NANADA-1, Nursing Interventions Classification( NIC), and Nursing
Outcomes Classification( NOC) are examples of standardized languages
describing diagnoses, interventions, and outcomes, created by the ANA
organization
The system is useful to computer- based systems and describes nursing
practice
Standardized Languages:
Continued
 The standardized languages, developed at the
University of Iowa, encourages enhanced
communication between nurses about nursing
interventions.
Credits:
• Alayna Alfred
 Chrischeal Charles
 Jamahl Guillaume
 Jemima Philippe