Nursing Process & SBAR
Nursing Interventions Should Be.... - -Appropriate to the diagnosis and outcomes
-Consistent with research findings and standards of care
-Realistic in terms of abilities, time, and resources available to the nurse and patient
-Compatible with patient's values, beliefs, and psychosocial background
-Compatible with other planned therapies
Objective Data - CAN be verified
-BP 170/110, diaphoresis, equal pupillary reaction, slurred speech
Outcomes & Patient Goals - -Goals relate directly to nursing diagnoses
-Realistic, Patient Centered, and Measurable
-Written as behavioral statements
Parts of Outcome Criteria - Patient centered, specific, measurable, and realistic
-Who: starts with pt as subject
-What Action: contains action verb
-How Well: contains performance criteria
-When: have time frame
E.g.: Patient will heal without complications to circulation, sensation or mobility by the time the
cast is taken off
Primary Source of Data - What patient says or guardian says
Purpose of Assessment - -Establish Baseline
-Determine normal function
, -Determine presence of dysfunction (things you can fix vs. can't)
-Appraisal of total patient situation (physical, psychological, emotional, sociocultural, spiritual)
-Synthesize data to determine nursing diagnoses
Actual Diagnoses - 3 Parts: Diagnostic Label, Related Factors (etiology), Defining Characteristics
(signs/symptoms, validates diagnoses)
-E.g. Impaired physical mobility r/t right tibial fracture AEB RLE cast and need to use crutches to
ambulate
Assessment - Use your best judgement
-What do you think is wrong (problem seems to be cardiac, respiratory, infection .... etc)
Background - Deliver concise history
-What led to current situation
-Include pertinent background information (admitting diagnoses and date of admission, current
meds, allergies, IV fluids, most recent vitals, current labs, code status, other)
Characteristics of the Nursing Process - Assessment, diagnosing, outcome identification,
implentating, evaluation
1. Framework for providing nursing care to patients, families, and communities
2. Based on relationships
3. Orderly and systematic
4. Interdependent
5. Provides individualized care
Nursing Interventions Should Be.... - -Appropriate to the diagnosis and outcomes
-Consistent with research findings and standards of care
-Realistic in terms of abilities, time, and resources available to the nurse and patient
-Compatible with patient's values, beliefs, and psychosocial background
-Compatible with other planned therapies
Objective Data - CAN be verified
-BP 170/110, diaphoresis, equal pupillary reaction, slurred speech
Outcomes & Patient Goals - -Goals relate directly to nursing diagnoses
-Realistic, Patient Centered, and Measurable
-Written as behavioral statements
Parts of Outcome Criteria - Patient centered, specific, measurable, and realistic
-Who: starts with pt as subject
-What Action: contains action verb
-How Well: contains performance criteria
-When: have time frame
E.g.: Patient will heal without complications to circulation, sensation or mobility by the time the
cast is taken off
Primary Source of Data - What patient says or guardian says
Purpose of Assessment - -Establish Baseline
-Determine normal function
, -Determine presence of dysfunction (things you can fix vs. can't)
-Appraisal of total patient situation (physical, psychological, emotional, sociocultural, spiritual)
-Synthesize data to determine nursing diagnoses
Actual Diagnoses - 3 Parts: Diagnostic Label, Related Factors (etiology), Defining Characteristics
(signs/symptoms, validates diagnoses)
-E.g. Impaired physical mobility r/t right tibial fracture AEB RLE cast and need to use crutches to
ambulate
Assessment - Use your best judgement
-What do you think is wrong (problem seems to be cardiac, respiratory, infection .... etc)
Background - Deliver concise history
-What led to current situation
-Include pertinent background information (admitting diagnoses and date of admission, current
meds, allergies, IV fluids, most recent vitals, current labs, code status, other)
Characteristics of the Nursing Process - Assessment, diagnosing, outcome identification,
implentating, evaluation
1. Framework for providing nursing care to patients, families, and communities
2. Based on relationships
3. Orderly and systematic
4. Interdependent
5. Provides individualized care
