Nursing Process Online

Alia Andriany S.Kep, Ns Bagian KDK Prodi S1 Ners STIKES Graha Edukasi MKS

Problem Solving Nursing Process Encounter problem Assessment Collect data Identify exact Diagnosis nature of problem Determine plan of Planning action Carry out plan Implementation Evaluate plan in

Scientific Method Recognize problem Collect data Formulate hypothesis

Select plan for testing hypothesis Test hypothesis Interpret results Evaluate hypothesis

Nursing

A.

Characteristics 1. Open, flexible 2. Humanistic and individualized 3. Cyclical 4. Outcome focused ( results oriented) 5. Emphasizes feedback and validation

B. 

Nursing Process vs. Medical Process

1. Medical-identification of a disease and tx.

2. Nursing -identification of actual / potential responses to illness C.

Why do we learn about the Nursing Process ? • Practice Standards in the U.S. • Basis for State Boards NCLEX • Critical thinking skills

Data collection….data base Types of Assessment Types of Data Sources

Methods interview & physical assessment techniques

Cues = signs and symptoms

Cues

Inference = what you think, a judgement about the cues

Inference

Swollen finger Misshapen Reddened Painful

Broken finger

Air Requisite Lungs clear RR 18 labored O2, Chest X-ray shows pneumonia nonproductive cough

Respiratory Problem  Ineffective Airway

Activity & Rest Requisite Bed rest, full passive ROM P.T.daily, Reddened skin on ankle & elbow, 40 degree contracture on left leg, atrophy of muscles

Possible Skin Problem  Risk for Impaired Tissue Integrity

1953 term first used 1973 --- First national conference of nursing diagnosis .(theorists, educators,

administrators and practioners) 1985 named NANDA 1990 ANA endorsed it as official diagnosis taxonomy ….Is incorporated in ANA standards of practice Meets every two years Local chapters

148 diagnoses + 16 Carpenito

1. Benefits of a Nursing Diagnosis a. Communication between Nurses b. Identification of patient goals 2. Types of Diagnostic Statements • actual • risk • possible • wellness • syndrome.

Three Part Statement

P E S

P= Problem ( Precise qualifier / modifiers ) Altered High Risk Ineffective Decreased Deficit Excess Dysfunctional Disturbance Chronic Less than More than Diagnostic Label = Problem + modifier Anticipatory = Chronic Pain

E

=

Related Factors Related factors are etiological or other contributing

factors that have influenced the health status change. Etiology sometimes = Causes or factors of risk

Chronic pain r/t Altered Tissue perfusion ………. secondaryAlteration to Diabetes in skin Integrity

Pathophysiologic r/t ( caused by) Compromised immune system Inadequate peripheral circulation Treatment-related Medications Diagnostic studies lack of knowledge Surgery Treatments

Inadequate circulation

Anxiety r/t (caused by) of how to dress his wound

Situational Environmental Home unsteady gait Community Institution Personal Life experiences Roles Maturational Requirements r/t Age related

Risk for Injury r/t

Nutrition Imbalance : Less than Body to inadequate sucking

S   =    Defining characteristics S= signs / symptoms Clinical cues--subjective and objective signs or symptoms that point to the nursing diagnosis

• Are separated into major and minor designations. • Major defined as critical indicators present 80-100 of the time. • Minor are supporting and present 50-79%

Major defining characteristics must be present for a  diagnosis to be valid

P

E

Diagnostic Label I impaired Skin Integrity immobility

Related factor related to prolonged

S Defining characteristics as evidenced by a 2 cm sacral lesion A real problem exists !!!!!!!!

.

Is a clinical judgment that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation. Two part statement.---------P ( problem) E ( related risk factors) No defining characteristics No signs or symptoms because No problem yet

Risk nursing diagnoses P

Diagnostic label Risk for Injury

E

Etiological risk factors related to lack of awareness of hazards

Factors present which present a risk situation for a problem to occur

POSSIBLE NURSING DIAGNOSIS

Statements describing a suspected problem for which additional data is needed. Two part statement P

nursing diagnostic label Possible Self Concept Disturbance E

etiological factors related to recent loss of roll responsibilities secondary to exacerbation of MS.

Nurse may take one of three actions *confirm the presence of major signs and symptoms, thus labeling an actual diagnosis * confirm the presence of potential risk factors, thus risk diagnosis *rule out the diagnosis at this time.

Some texts say one part statement

Is a clinical judgment about an individual, family or community in transition from a specific level of wellness to a higher level of wellness. Two cues must be present:

1. desire for a higher level of wellness 2. effective present status or function. One part statement beginning with Readiness for Enhanced Diagnostic Label Readiness for Enhanced Parenting

One part statement Diagnostic label Disuse syndrome.

Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation Nursing Diagnoses Associated with Disuse Syndrome Risk for Constipation Risk for Altered Respiratory Function Risk for Infection Risk for Thrombosis Risk for Activity Intolerance Risk for Injury Risk for Altered Thought Processes

INEFFECTIVE BREATHING PATTERNS DEFINITION Ineffective Breathing Patterns: State in which a person experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern DEFINING CHARACTERISTICS Major (Must Be Present, One or More) Changes in respiratory rate or pattern (from baseline) Changes in pulse (rate, rhythm, quality) Minor (May Be Present) Orthopnea Tachypnea, hyperpnea, hyperventilation Dysrhythmic respirations. Splinted/guarded respirations

Diagnosis

Related to r/t

( P) (E)

Ineffective Breathing Patterns

Immobility and chest pain Secondary to abdominal surgery

As evidenced by

(S)

↑ in respiratory rate from 12 to 22 pulse rate ↑ 88 to 104 and irregular

Two practice situations Nurse is primary provider Nurse works in collaboration with others

COLLABORATIVE PROBLEMS

PC

Physiological problems nurses monitor Watching for complications ……..Potential Complications

All collaborative problems begin with the label POTENTIAL COMPLICATION (PC) Potential complication: Sepsis PC: Sepsis

Usually occur in association with a specific pathology treatment

Situation:

Man admitted post gastric ulcer

Problem /complication:

PC: G I bleeding

Nursing focus: Monitor for onset and manage episodes of gastric bleeding review exercise: 1. Intravenous Therapy PC: _____________ PC:_______________ 2. Head Concussion PC: ____________ PC:________________ 3. Nasogastric Suction PC:________________

PC:_____________

1. Don’t use medical terms when writing a diagnosis I‑ Self‑Care Deficit Hygiene r/t Stroke C- Self-care Deficit: Hygiene r/t weakness secondary to Stroke

2. Don’t write a diagnosis for an unchangeable situation I‑ Anxiety r/t impending death aeb stating” I am afraid to die” C- Anxiety r/t fear of dying

Common errors

3. Use of procedure / treatment instead of a human response I- Catherization r/t urinary retention C- Risk for Infection Transmission r/t device with contaminated drainage:urinary

4. Don’t write diagnoses that are too general I- Constipation r/t nutritional intake aeb small hard stools C- Constipation r/t  dietary roughage and  fluid intake

Common errors

5. Don’t combine two problems at the same time I- Pain and Fear r/t to upcoming abdominal surgery

C- Pain r/t tissue trauma secondary to abdominal surgery aeb “ Pain ranked 4/5”

6. Don’t use judgmental/value laden language or make assumptions

. I- Spiritual Distress r/t atheism aeb statement “ I don’t believe in God anymore” C- Spiritual Distress r/t to feelings of abandonment aeb “ I don’t think God cares about me”

Common errors

7. Don’t make statements that are legally inadvisable I- Tissue Integrity Impaired r/t to infrequent turning aeb 3 cm diameter ankle ulcer C- Tissue Integrity Impaired r/t immobility secondary to fracture

8. Both parts of a diagnostic statement are the same I- Self care deficit : feeding r/t feeding problem aeb unable to

bring food to mouth C- Self Care Deficit: feeding r/t neurological impairment of rt. hand aeb unable to bring food to mouth

Don’t use due to or caused

Review exercise:   Put a “ C “ in front of the correct nursing diagnosis: 1._____Risk for Constipation related to being on strict bedrest 2._____Risk for Injury related to lack of side rails on bed 3._____Fear and Anger related to lack of knowledge of Hypertension 4._____Hopelessness related to progressive disease process 5._____ Risk for Spiritual Distress due to inability to attend church services

Review exercise: Put a “ C “ in front of the correct nursing diagnosis: 1.__C___Risk for Constipation related to being on strict bedrest 2._____Risk for Injury related to lack of side rails on bed 3._____Fear and Anger related to lack of knowledge of Hypertension 4._____Hopelessness related to progressive disease process 5.__C___ Risk for Spiritual Distress related to inability to attend church services

6.__C__Impaired Tissue Integrity ( 2" stage 2 ulcer on ankle) related to ankle pressure and rubbing on sheets 7._____Impaired Walking related to Stroke 8._____Mastectomy related to cancer 9______Imbalanced Nutrition : Less than Body Requirements being NPO aeb inability to take food in mouth 10._____Impaired Physical Mobility related to pain in leg joints patient reports pain in leg joints                 

related to aeb

Risks of Diagnostic Errors 1. may aggravate problems 2. omit essential interventions 3. allow problems to exist 4. wasteful interventions 5. influence others 6. danger of legal liability

G. PLANNING PHASE " Determination of nursing care in an organized,

individualized and goal directed manner" 1. Determine priorities and list problems Which do you think need immediate attention? What does the patient think?

Maslow hierarchy + severity of problem + patient input

Review question: Which of the following problems would you treat first ? Severe breathing Diarrhea Itching

planning

2. Establishment of ( goals) OUTCOME and OUTCOME CRITERIA ( What will the patient be able to do? and in what time frame ? = OUTCOME And how will I know it was successful? = OUTCOME CRITERIA Diagnosis --------------- Ineffective Airway Clearance r/t Etiology -----------------------Weakness

secondary to

Stroke aeb Maj. Defining Characteristic (Symptoms)- Nonproductive Ineffective cough Broad Outcome ----------------Effective Airway by 10/4/04 Time frame aeb Outcome Criteria--------- (symptoms) Productive cough

plannin g

Purpose of Outcomes and Criteria

Indicators of achievement

Measuring sticks

Direct Interventions

Motivating factors

was the airway effective?

Did problem ( cough) stay the same, get  or  , disappear ? Interventions will be directed toward facilitating a productive cough

Goal motivates, something to aim for

Planning Guidelines Relate to a human response….. response Dx. Altered Elimination: Constipation r/t immobility aeb hard stools, no bowel movement for 5 days Outcome: Normal elimination aeb Outcome criteria: soft stools at least q. 2-3 days Be patient centered Dx. Risk for impaired skin integrity r/t decreased mobility Incorrect= Prevent skin breakdown

Correct Outcome: Pt. will not experience any skin breakdown

Planning outcomes clear and concise Incorrect = CDBPD indep q2

Correct = cough, deep breath, postural drainage

outcome criteria describes behavior that is measurable and observable Incorrect = drinks enough amounts of fluid

Drinks 2000 ml. Fluid in 24 hours

Planning realistic Considers strengths/weaknesses of staff and patient and resources   time limited - long/short term ex. within 4 hrs           ongoing

Before d/c

should be determined by patient and nurse

Ex. Nurse Pain free

patient addicted

Planning Goals Cognitive=     Knowledge of Hyper and Hypoglycemia Psychomotor =   Will Effectively Breast Feed Affective =     Will be less Anxious Functioning of Body  =   Have Effective Airway Clearance

Planning Diagnosis 1. Imbalanced Nutrition  

2.   Acute Pain

Broad Outcome Pt will experience Balanced Nutrition

Pt will experience minimal or no pain

3. Risk for Injury

Pt will not experience an injury

4. Activity Intolerance

Pt will experience improved tolerance to activity

Plannin g  Write the outcome criteria for the following diagnostic statements  1. Ineffective Health Maintenance R/T lack of motivation AEB reports eating high fat diet goal= Will have effective health maintenance by 4/23/ 05 Aeb

Outcome Criteria: Reports eating RDA of fat in diet 2.       Impaired Urinary Elimination R/T related to diagnostic instrumentation AEB reports urgency, frequency goal= Will have improved or normal elimination by 3/12/05 AEB Outcome Criteria: Reports absence of urgency and frequency

Planning    3. Self Care Deficit: Bathing /Hygiene R/T lack of motivation secondary to depression AEB Unwilling to wash body parts goal = Will experience no self care hygiene deficit by 11/05/05 AEB Outcome Criteria: Patient washing arms and legs

Diagnosis

Related to r/t

( P)

Ineffective Breathing Patterns

(E)

Immobility and chest pain Secondary to abdominal surgery

As evidenced by

↑ in respiratory rate from 12 to 22

(S)

pulse rate ↑ 88 to 104 and irregular Outcome /goal Date: by 10/22/04

Effective Breathing aeb

↓ respiratory rate to 12 to 16 ↓ pulse rate to 80 and regular

Intervention s ( actions, orders ) " Specific nursing activities /actions that a nurse must perform to prevent complications , provide comfort(physical, psychological and spiritual) and promote, maintain and restore health."

Categories a. Dependent‑implementing M.D. orders-- give Vioxx medication per order

b. Interdependent‑in cooperation with other health team members----follow P.T. plan for exercise c. Independent‑ performed without M.D. order----turn patient q.2. hrs

interventions

→

Diagnosis

→

Broad Outcome Pt. will experience wound healing

Altered Skin Integrity

Etiology R/t immobility secondary to fracture Defining Characteristics aeb 3cm diameter ankle wound

→

→

→

→

INTERVENTIONS

Outcome Criteria

aeb ↓ diameter to 2cm

interventions Characteristics a. consistent b. scientific basis c. law, professional standards, agency accrediting bodies

    Intervention                     Rationale   Teach client to rotate              Repeated use of the same      insulin  injection sites                      site may cause fibrosis,         and decreased insulin absorption

interventions INDIVIDUALIZED  Donna‑‑17 year old, immobilized by skeletal traction for a

FX. Lt. leg due to a motorcycle accident Betsy‑‑84 year old nursing home resident, slightly dehydrated , confused and confined to bed from a hip fracture Dx Risk for skin breakdown r/t immobility secondary to ........................... Bed

  Donna trapeze

Position

cue to turn

Nutrition

↑ protein, zinc etc.

Betsy specialized, air mattress turn q. 2 hours tube feeding, ↑ fluids

interventions

•strengths / weaknesses *power components *resources *family/others •safe environment •assessment as an intervention •teaching as an intervention •consulting/referring as an intervention

interventions

4. Guidelines for Writing a. date and sign b. list specific activities Incorrect Teach colostomy care

Correct 1. demonstrate steps us applying colostomy

pouch

and

2. identify equipment needed with colostomy care 3. provide printed instructions discuss content 4. Have client do return demonstration

interventions  define Who, What, Where, When, How and How Often ex. Irrigation of a wound ? ? ? ? ?

which one who will irrigate when How How long

d. individualized

I. Documentation‑‑Care plan 1. Purpose a. continuity of care b. permanent record c. documentation 2. Characteristics a. R.N. authored b. initiated after first contact c. readily available d. current 3. Forms ( all have diagnosis, outcomes and interventions) a. standardized b. computerized

. IMPLEMENTATION– " Initiation of the care plan to achieve specific outcomes” ***performing the planned interventions Guidelines 1. Review the interventions 2. Analyze the skills, time and equipment involved 3. Know reasons, expected effect and potential hazards Consider combining interventions 5. Should not be mechanical 6. Include the family 7. Know institutional procedures

4.

EVALUATION  

Outcome and outcome criteria comparison " To determine how well the plan worked" Process 1. Gathering data 2. Compare data with outcome criteria 3. Make judgment a. outcome achieved b. outcome not achieved c. partially achieved If not----‑check interventions human responses outcomes related factors

THE END!!!!!!