Identifying Measurable Patient Outcomes

Guidelines:

• Refresher on the nursing process:
  • Assessment
  • Nursing Diagnosis
  • Outcome Identification
  • Planning
  • Implementation
  • Evaluation
• Outcome identification describes the desired/favorable patient condition that can be achieved through nursing intervention
  • Nursing-sensitive = influenced by nursing
  • Measurable/Quantified
  • Derived from nursing diagnoses
  • Direct interventions that resolve the nursing diagnosis

Considerations:

• Identification of expected/desired outcomes unique to the surgical patient
  • Provides opportunity to prioritize care
  • Go back to your S-A-B-Cs
  • Life/limb
  • Urgent/Emergent

Nurse’s role:

• Step 1: Assessment
• Step 2: Nursing Diagnosis
• Step 3: Outcome Identification
• Because of (x) data, the nursing diagnosis is (y) and the desired outcome associated with (y) is (z)

Pitfalls:

• Outcomes:
  • Should be measurable
  • Should be associated with a nursing diagnosis
  • Should be nursing-sensitive
  • Should drive the nursing interventions

Examples:

• 12 y/o female presenting with u/s confirmed ruptured appendicitis and is scheduled for a laparoscopic appendectomy. She is awake and anxious, rates pain 5/10, received antibiotics in the ED prior to transfer to the OR.
• Assessment data: Age, gender, medical diagnosis, procedure, pain rating, antibiotic status
• Nursing Diagnoses:
  • Acute pain
  • Risk for infection
  • Anxiety
• Outcome Identification:
  • Patient will report pain controlled post-op
  • Maintain safe, aseptic environment
  • Patient will appear relaxed, able to rest
• Measurable
• Related to the nursing diagnosis
• Nursing sensitive
• Drive interventions

Linchpins (Key Points):

• Quality perioperative nursing care requires purposeful, outcome-driven critical thinking skills
  • Gather the data (assessment)
  • Classify the data (nursing diagnosis)
  • Identify desired outcomes