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  1. 1. Nursing Process
  2. 2. “ To you, O Lord, I lift up my soul. In you, I trust , Oh my God.” Psalm 25:1
  3. 3. NURSING PROCESS <ul><li>systematic, rational method of planning and providing individualized nursing care </li></ul><ul><li>Is a problem-solving framework for planning and delivering nursing care to patients and their families </li></ul>
  5. 5. NURSING PROCESS <ul><li>A way of thinking as a nurse. </li></ul><ul><li>A framework of interrelated activities resulting in competent nursing care. </li></ul><ul><li>Dynamic and cyclical in nature. </li></ul><ul><li>A scientific, problem-oriented approach to patient care. </li></ul>
  6. 6. Assessing – collecting, organizing and communicating / recording client data <ul><li>Purpose: to establish data base about the client’s response to health concerns or illness and the ability to manage health care needs </li></ul>
  7. 7. Assessment <ul><li>Activities: </li></ul><ul><li>Obtain health hx </li></ul><ul><li>Perform P.A. </li></ul><ul><li>Review records, e.g. lab records, other health care records </li></ul><ul><li>Interview support persons </li></ul><ul><li>Review literature </li></ul><ul><li>Validate assessment data </li></ul>
  8. 8. Nursing Process
  9. 9. Assessment <ul><li>Assessment (Data Collection) </li></ul><ul><li>= Observation + Interview + Examination </li></ul>
  10. 10. Observation
  11. 11. Interview
  12. 12. Examination
  13. 14. Data Collection – process of gathering information about the client’s health status <ul><li>TYPES OF DATA : </li></ul><ul><li>Subjective – symptoms or covert data </li></ul><ul><li>e.g. – itching pain, feelings of worry </li></ul><ul><li>includes client’s sensations, feelings, values, beliefs, attitudes and perception of personal health status and life situations. </li></ul><ul><li>Problem : Fever  subjective cue: “Mainit ang pakiramdam ko.” </li></ul>
  14. 15. Assessment <ul><li>“ Let me look at that.” </li></ul><ul><li>“ Tell me about it.” </li></ul>
  15. 16. Types of Data <ul><li>Objective data – signs or overt data; detectable by an observer or can be tested against an accepted standard </li></ul><ul><li>e . g. – discoloration of the skin </li></ul><ul><li>Problem: fever -objective cue : skin is warm to touch; temp. is 38.9 C/ax </li></ul>
  16. 17. Objective data <ul><li>Caput medusae </li></ul><ul><li>BP reading </li></ul>
  17. 18. SOURCES OF DATA : <ul><li>Primary source - client (best source of data) </li></ul>
  18. 19. SOURCES OF DATA: <ul><li>Secondary sources – indirect sources </li></ul><ul><li>e.g. – family members, </li></ul><ul><li>-support people, </li></ul><ul><li>-client records (medical records, records of therapies by other health professionals and laboratory records), </li></ul><ul><li>-health care professionals, </li></ul><ul><li>- literature </li></ul>
  19. 20. METHODS OF DATA COLLECTION: <ul><li>Observing  using the five senses; a conscious deliberate skill that is developed only through effort and with an organized approach </li></ul>
  20. 21. METHODS OF DATA COLLECTION <ul><li>Interview  a planned communication or conversation with a purpose </li></ul>
  21. 22. <ul><li>2 approaches: </li></ul><ul><li>a. direct interview  highly structured and elicit specific information by asking closed questions that call for a specific amount of data. </li></ul><ul><li>Interview </li></ul><ul><li>b. nondirective  the nurse allows the client to control the purpose, subject matter and pacing </li></ul><ul><li>Requirement: </li></ul><ul><li>RAPPORT - the understanding between two or more people. </li></ul><ul><li>Interview </li></ul>
  22. 23. Kinds of interview questions: <ul><li>Closed questions  restrictive and generally require only short answers giving specific information; often begin with when, where, who, what, do, does, did </li></ul><ul><li>Open-ended questions  lead or invite clients to explore their thoughts or feelings </li></ul>
  23. 24. PLANNING THE INTERVIEW AND SETTING: <ul><li>Time  need to be scheduled when the client is comfortable and free of pain </li></ul><ul><li>Place  must have adequate privacy to promote communication </li></ul><ul><li>Seating arrangement </li></ul><ul><li>Distance  most people feel comfortable 3 to 4 ft apart during an interview </li></ul>
  24. 25. STAGES OF AN INTERVIEW: <ul><li>Opening  sets the tone of the remainder of the interview. </li></ul><ul><li>a.1. Establish rapport  process of creating good will and trust </li></ul><ul><li>a.2 Orientation  explaining the purpose and nature of the interview </li></ul><ul><li>Body  client communicates what he or she thinks, feels, knows and perceives in response to questions from the nurse </li></ul><ul><li>Closing  important in facilitating future interactions. </li></ul>
  25. 26. ASSESSMENT TOOLS: GORDON’S FUNCTIONAL HEALTH PATTERN FRAMEWORK <ul><li>pattern - signifies a sequence of recurring behavior </li></ul><ul><li>dysfunctional as well as functional behavior </li></ul><ul><li>to discern emerging patterns . </li></ul>
  26. 27. <ul><li>TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: </li></ul><ul><li>1.Health – perception – health – management – pattern: </li></ul><ul><li>describes client’s perceived pattern of health and well-being and how health is managed </li></ul><ul><li>How does the person describe her/ </li></ul><ul><li>his current health? </li></ul><ul><li>What does the person do to improve or maintain her/ his health? </li></ul>
  27. 28. 1.Health – perception – health – management – pattern: <ul><li>What does the person know about links between lifestyle choices and health? </li></ul><ul><li>How big a problem is financing health care for this person? </li></ul><ul><li>Can this person report the names of current medications she/he is taking and their purpose? </li></ul>
  28. 29. 1.Health – perception – health – management – pattern: <ul><li>If this person has allergies, what does s/he do to prevent problems? </li></ul><ul><li>What does this person know about medical problems in the family? </li></ul><ul><li>Have there been any important illnesses or injuries in this person's life? </li></ul>
  29. 30. 1.Health – perception – health – management – pattern: Nsg. Dx <ul><li>Ineffective health maintenance </li></ul><ul><li>Ineffective therapeutic regimen management </li></ul><ul><li>Ineffective family therapeutic regimen management </li></ul><ul><li>Ineffective community therapeutic regimen management </li></ul>
  30. 31. 1.Health – perception – health – management – pattern: Nsg. Dx <ul><li>Risk for infection </li></ul><ul><li>Risk for injury (trauma) </li></ul><ul><li>Risk for falls </li></ul>
  31. 32. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>2.Nutritional – metabolic pattern: </li></ul><ul><li>pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply </li></ul><ul><li>Is the person well nourished? </li></ul><ul><li>How do the person's food choices compare with recommended food intake? </li></ul>
  32. 33. 2.Nutritional – metabolic pattern: Nsg. Dx <ul><li>Imbalanced nutrition: more than body requirements </li></ul><ul><li>Risk for imbalanced nutrition: more than body requirements </li></ul><ul><li>Imbalanced nutrition: less than body requirements </li></ul>
  33. 34. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>3. Elimination – pattern: </li></ul><ul><li>describes pattern of excretory function ( bowel, bladder and skin) </li></ul><ul><li>Are the person's excretory functions within the normal range? </li></ul><ul><li>Does the person have any disease of the digestive system , urinary system or skin ? </li></ul>
  34. 35. 3.Elimination – pattern: Nsg. Dx <ul><li>Constipation </li></ul><ul><li>Diarrhea </li></ul><ul><li>Risk for constipation </li></ul><ul><li>Bowel incontinence </li></ul><ul><li>Impaired urinary elimination </li></ul><ul><li>Functional urinary incontinence </li></ul>
  35. 36. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>4. Activity – exercise pattern : </li></ul><ul><li>describes pattern of exercise, activity, leisure and recreation </li></ul><ul><li>How does the person describe her/ his weekly pattern of activity and leisure, exercise and recreation? </li></ul><ul><li>Does the person have any disease that affects her/ his cardio-respiratory system or musculo-skeletal system </li></ul>
  36. 37. 4. Activity – exercise pattern : Nsg. Dx <ul><li>Activity intolerance </li></ul><ul><li>Risk for activity intolerance </li></ul><ul><li>Fatigue </li></ul><ul><li>Deficient diversonal activity </li></ul><ul><li>Impaired physical mobility </li></ul>
  37. 38. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>5.Cognitive – perceptual pattern : </li></ul><ul><li>describes sensory perceptual and cognitive pattern </li></ul><ul><li>-make a quick neurological assessment </li></ul>
  38. 39. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>6.Sleep – rest pattern: </li></ul><ul><li>describes patterns of sleep, rest and relaxation </li></ul><ul><li>Describes person's sleep-wake cycle. </li></ul><ul><li>Does this person appear physically rested and relaxed? </li></ul>
  39. 40. 6.Sleep – rest pattern: Nsg. Dx <ul><li>Disturbed sleep pattern </li></ul>
  40. 41. <ul><li>7.Self – perception – self – concept – pattern : </li></ul><ul><li>describes self-concept pattern and perceptions of self (body comfort, body image, feeling state) </li></ul><ul><li>Is there anything unusual about this person's appearance? </li></ul><ul><li>Does this person seem comfortable with her/ his appearance? </li></ul><ul><li>Describe person's feeling state </li></ul>
  41. 42. 7.Self – perception – self – concept – pattern : Nsg. Dx <ul><li>Fear </li></ul><ul><li>Anxiety </li></ul><ul><li>Risk for loneliness </li></ul><ul><li>Hopelessness </li></ul><ul><li>Powerlessness </li></ul><ul><li>Risk for powerlessness </li></ul><ul><li>Situational low self-esteem </li></ul><ul><li>Risk for situational low self-esteem </li></ul><ul><li>Chronic low self-esteem </li></ul><ul><li>Body image disturbed </li></ul><ul><li>Disturbed personal identity </li></ul><ul><li>Risk for violence, self-directed </li></ul>
  42. 43. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>8.Role – relationship pattern : </li></ul><ul><li>describes patterns of role engagements and relationships </li></ul><ul><li>How does this person describe her/ his various roles in life? </li></ul><ul><li>Has, or does this person now have positive role models for these roles? </li></ul>
  43. 44. 8.Role – relationship pattern : <ul><li>Which relationships are most important to this person at present? </li></ul><ul><li>Is this person currently going though any big changes in role or relationship? What are they? </li></ul>
  44. 45. 8.Role – relationship pattern : Nsg. Dx <ul><li>Anticipatory grieving </li></ul><ul><li>Dysfunctional grieving </li></ul><ul><li>Risk for dysfunctional grieving </li></ul><ul><li>Ineffective role performance </li></ul><ul><li>Social isolation </li></ul><ul><li>Impaired social interaction </li></ul><ul><li>Relocation stress syndrome </li></ul>
  45. 46. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>9.Sexuality – reproductive pattern : </li></ul><ul><li>describes client’s patterns of satisfaction and dissatisfaction with sexuality; describes reproductive pattern </li></ul><ul><li>Do you have regular menstruation? </li></ul><ul><li>When was the last sexual intercourse? </li></ul><ul><li>Sexual activities? </li></ul>
  46. 47. 9.Sexuality – reproductive pattern : Nsg. Dx <ul><li>Sexual dysfunction </li></ul><ul><li>Rape-trauma syndrome </li></ul>
  47. 48. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>10.Coping – stress – tolerance – pattern : </li></ul><ul><li>describes general coping pattern and effectiveness of the pattern in terms of stress tolerance </li></ul><ul><li>How does this person usually cope with problems? </li></ul><ul><li>Do these actions help or make things worse? </li></ul><ul><li>Has this person had any treatment for emotional distress? </li></ul>
  48. 49. 10.Coping – stress – tolerance – pattern : Nsg. Dx. <ul><li>Ineffective coping </li></ul><ul><li>Disabled family coping </li></ul><ul><li>Ineffective community coping </li></ul><ul><li>Post-trauma syndrome </li></ul><ul><li>Risk for post-trauma syndrome </li></ul><ul><li>Risk for suicide </li></ul>
  49. 50. TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: <ul><li>11. Value – belief pattern : </li></ul><ul><li>describes patterns of values, beliefs or goals that guide choices or decisions </li></ul><ul><li>E.g reads bible everyday </li></ul>
  50. 52. REVIEW OF SYSTEMS <ul><li>goal : to gather data from the client in each of the major body systems. </li></ul><ul><li>General Health . Weight loss, weakness, feelings of fatigue, mood changes, night sweats, or bleeding tendencies? </li></ul>
  51. 53. REVIEW OF SYSTEMS <ul><li>Skin . </li></ul><ul><li>Skin diseases such as eczema, psoriasis, </li></ul><ul><li>acne; change in pigmentation; </li></ul><ul><li>tendency toward bruising; </li></ul><ul><li>excessive dryness or moisture; jaundice; </li></ul><ul><li>itching, rashes, hives; </li></ul><ul><li>change in color or size of moles; </li></ul><ul><li>or open sores that are slow to heal? </li></ul><ul><li>Hair . Itchy scalp, loss of hair, excessive body hair? Does the client wear a wig? </li></ul><ul><li>Nails . color changes, biting, clubbing, splitting? </li></ul>
  52. 54. REVIEW OF SYSTEMS <ul><li>Head </li></ul><ul><li>Frequent or severe headaches, </li></ul><ul><li>fainting, </li></ul><ul><li>dizziness, </li></ul><ul><li>accident resulting in unconsciousness </li></ul>
  53. 55. REVIEW OF SYSTEMS <ul><li>Eyes . </li></ul><ul><li>Difficulty seeing, </li></ul><ul><li>eye infection, eye pain, excessive tearing, double vision, blurring, sensitivity to light, cataracts, itching, spots in front of eyes? </li></ul><ul><li>Does the client wear glasses (for near or far vision) or contact lenses? </li></ul><ul><li>When was the client’s last eye examination? </li></ul>
  54. 56. REVIEW OF SYSTEMS <ul><li>Ears </li></ul><ul><li>Any infection, </li></ul><ul><li>loss of hearing, pain, discharge, ringing in the ears? </li></ul><ul><li>Does the client wear a hearing aid? </li></ul><ul><li>Nose . </li></ul><ul><li>Frequent colds, </li></ul><ul><li>nosebleeds, </li></ul><ul><li>allergies, pain, </li></ul><ul><li>tenderness, </li></ul><ul><li>postnasal drip? </li></ul>
  55. 57. REVIEW OF SYSTEMS <ul><li>Mouth and throat . </li></ul><ul><li>Sore gums; bleeding gums; sores, lumps or white spots on the mouth, lips or tongue; </li></ul><ul><li>toothaches, cavities, </li></ul><ul><li>difficulty swallowing; </li></ul><ul><li>voice change or hoarseness? </li></ul><ul><li>Does the client wear dentures (upper, lower, partial)? </li></ul><ul><li>When was the client’s last dental appointment? </li></ul>
  56. 58. REVIEW OF SYSTEMS <ul><li>Neck . </li></ul><ul><li>Pain, swelling, stiffness, limited movements, swollen glands? </li></ul><ul><li>Breasts . </li></ul><ul><li>Nipple discharge, Scaling or cracks around nipples, dimples, lumps, </li></ul><ul><li>pattern of self breast examination? </li></ul><ul><li>Last mammogram? </li></ul>
  57. 59. REVIEW OF SYSTEMS <ul><li>Respiratory system . </li></ul><ul><li>Chest pain; cough; shortness of breath; wheezing; coughing up blood; </li></ul><ul><li>lung disease such as tuberculosis, emphysema, asthma, bronchitis? </li></ul><ul><li>Has the client ever had a chest x-ray? When? Results? </li></ul>
  58. 60. REVIEW OF SYSTEMS <ul><li>Cardiovascular system . </li></ul><ul><li>Heart disease, </li></ul><ul><li>palpitations, heart murmur, </li></ul><ul><li>high blood pressure, </li></ul><ul><li>anemia, </li></ul><ul><li>varicose veins, </li></ul><ul><li>leg swelling or ulcer? </li></ul>
  59. 61. REVIEW OF SYSTEMS <ul><li>Gastrointestinal system . </li></ul><ul><li>Nausea, vomiting, loss of appetite, indigestion, </li></ul><ul><li>heartburn, </li></ul><ul><li>bright blood in stools, </li></ul><ul><li>diarrhea, constipation, </li></ul><ul><li>abdominal pain; excessive gas, </li></ul><ul><li>hemorrhoids, rectal pain, </li></ul><ul><li>colostomy, ileostomy? </li></ul>
  60. 62. REVIEW OF SYSTEMS <ul><li>Genitourinary system . </li></ul><ul><li>Frequency, dribbling, urgency, </li></ul><ul><li>urination at night, </li></ul><ul><li>difficulty starting stream, </li></ul><ul><li>blood in urine, </li></ul><ul><li>incontinence, </li></ul><ul><li>pain or burning upon urination, urinary tract infection, </li></ul><ul><li>sexually transmitted disease such as gonorrhea or syphilis? </li></ul>
  61. 63. REVIEW OF SYSTEMS <ul><li>Females : </li></ul><ul><li>Age of menarche, last menstrual period (LMP), </li></ul><ul><li>duration, amount of flow, regulatory of cycle? </li></ul><ul><li>Any problems with painful menstruation, bleeding within periods, </li></ul><ul><li>pain during intercourse, </li></ul><ul><li>vaginal discharge, vaginal itching, vaginal infection? </li></ul>
  62. 64. REVIEW OF SYSTEMS <ul><li>Males : </li></ul><ul><li>Penile discharge, </li></ul><ul><li>swelling, masses or lesions, </li></ul><ul><li>difficulty in sexual functioning? </li></ul>
  63. 65. REVIEW OF SYSTEMS <ul><li>Musculoskeletal system : </li></ul><ul><li>Muscular pain, </li></ul><ul><li>swelling or weakness; </li></ul><ul><li>joint swelling, </li></ul><ul><li>soreness, or stiffness; </li></ul><ul><li>leg cramps; </li></ul><ul><li>bone defects? </li></ul>
  64. 66. REVIEW OF SYSTEMS <ul><li>Neurologic system : </li></ul><ul><li>Difficulty of walking; </li></ul><ul><li>unconsciousness; </li></ul><ul><li>seizures; </li></ul><ul><li>tremors; </li></ul><ul><li>paralysis; numbness, tingling; or burning sensations in any body part; </li></ul><ul><li>weakness on one side of body; speech problems; unclear thinking; changes in emotional state? </li></ul>
  65. 67. REVIEW OF SYSTEMS <ul><li>Endocrine system : </li></ul><ul><li>History of goiter; </li></ul><ul><li>heat or cold; </li></ul><ul><li>intolerance; </li></ul><ul><li>diabetes; </li></ul><ul><li>excessive thirst; </li></ul><ul><li>excessive eating? </li></ul>
  66. 69. NURSING DIAGNOSIS : <ul><li>statement of the client’s health status </li></ul><ul><li>clinical judgment about individual, family or community responses to actual and potential health problems / life processes. </li></ul><ul><li>Purpose: Provides the basis for selections of nursing interventions to achieve outcomes for w/c the nurse is accountable </li></ul>
  67. 70. NURSING DIAGNOSIS : <ul><li>Eg. </li></ul><ul><li>Problem : Fever  nursing diagnosis : Alteration in thermoregulatory function : or </li></ul><ul><li>hyperthermia related to inflammatory process </li></ul>
  68. 72. TYPES OF NURSING DIAGNOSES: <ul><li>Actual Nursing Diagnosis  a judgment about the client’s response to a health problem w/c is present at the time of nursing assessment </li></ul><ul><li>Potential Nursing Diagnosis  a judgment that a client is more vulnerable to develop the problem in the same / similar situation </li></ul>
  69. 73. <ul><li>Problem Statement  describes the client’s health problem or response for which nursing therapy is given </li></ul><ul><li>Qualifiers  added words to give additional meaning to the diagnostic statement </li></ul><ul><li>Altered  change from baseline </li></ul><ul><li>Impaired  made worse, weakened, damaged </li></ul><ul><li>Decreased  smaller in size, amount or degree </li></ul><ul><li>Ineffective  not producing the desired effect </li></ul><ul><li>Acute  severe or of short duration </li></ul><ul><li>Chronic  lasting a long time </li></ul>
  70. 74. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><ul><li>Using medical diagnosis </li></ul></ul><ul><ul><ul><li>INCORRECT: Self-care deficit related to stroke </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Self-care deficit related to neuromuscular impairment </li></ul></ul></ul><ul><ul><li>Relating the problem to an unchangeable situation </li></ul></ul>
  71. 75. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><ul><li>Confusing the etiology or signs/symptoms for the problem </li></ul></ul><ul><ul><ul><li>INCORRECT: Post-operative lung congestion related to bed rest </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Ineffective airway clearance related to general weakness and immobility </li></ul></ul></ul>
  72. 76. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><ul><li>Use of a procedure instead of a human response </li></ul></ul><ul><ul><ul><li>INCORRECT: Catheterization related to urinary retention </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Urinary retention related to perineal swelling </li></ul></ul></ul>
  73. 77. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><li>Lack of specificity </li></ul><ul><ul><ul><li>INCORRECT: Constipation related to nutritional intake </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Constipation related to inadequate dietary bulk and fluid intake </li></ul></ul></ul>
  74. 78. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><li>Combining two nursing diagnosis </li></ul><ul><ul><ul><li>INCORRECT: Anxiety and fear related to separation from parents </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Anxiety related to change in environment and unmet needs </li></ul></ul></ul>
  75. 79. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><li>Relating one nursing diagnosis to another </li></ul><ul><ul><ul><li>INCORRECT: Coping, individual ineffective related to anxiety </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Anxiety, severe related to change in role functioning and socio-economic status </li></ul></ul></ul>
  76. 80. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><li>Use of judgmental/value-laden language </li></ul><ul><li>Ineffective airway clearance related to bad habit </li></ul>
  77. 81. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES <ul><li>Making assumptions </li></ul><ul><ul><ul><li>INCORRECT: Risk for altered parenting related to inexperience </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Deficient knowledge regarding child care issues related to lack of previous experience, unfamiliarity with resources </li></ul></ul></ul>
  78. 82. <ul><li>Writing a Legally Inadvisable Statement </li></ul><ul><ul><ul><li>INCORRECT: Skin integrity related to not being turned every 2 hours </li></ul></ul></ul><ul><ul><ul><li>CORRECT: Impaired skin integrity related to pressure and altered circulation </li></ul></ul></ul>
  79. 83. A Nursing Diagnosis <ul><li>Is </li></ul><ul><ul><li>A statement of a patient problem </li></ul></ul><ul><ul><li>Actual or potential </li></ul></ul><ul><ul><li>Within the scope of nursing practice </li></ul></ul><ul><ul><li>Directive of nursing intervention </li></ul></ul><ul><li>Is Not </li></ul><ul><ul><li>A medical diagnosis </li></ul></ul><ul><ul><li>A nursing action </li></ul></ul><ul><ul><li>A physician order </li></ul></ul><ul><ul><li>A therapeutic treatment </li></ul></ul>
  80. 84. Medical Dx vs.Nursing Diagnosis <ul><li>Myocardial infarction </li></ul><ul><li>Chronic ulcerative colitis </li></ul><ul><li>Chronic ulcerative colitis </li></ul><ul><li>Cancer of the breast </li></ul><ul><li>Cerebral vascular accident </li></ul><ul><li>Fear r/t possible recurrence of uncertain outcome </li></ul><ul><li>Diarrhea r/t dis. process </li></ul><ul><li>Alteration in nutrition: less than body requirements r/t altered GI absorptions </li></ul><ul><li>Risk for(Potential) body image disturbance if mastectomy is required </li></ul><ul><li>Self-care deficit: dressing & grooming r/t right sided flaccidity </li></ul>
  81. 85. <ul><li>Etiology (Related/ Risk Factors)  the probable cause of the health problem ; may include client’s behavior, environmental factors or the interaction of the two; </li></ul><ul><li>NANDA-“ related to” to describe the etiology or likely cause </li></ul><ul><li>Example: </li></ul><ul><li>Activity intolerance related to decreased cardiac output. </li></ul><ul><li>Ineffective breast-feeding related to first-time experience </li></ul><ul><li>Altered bowel elimination; constipation related to insufficient fluid intake. </li></ul>
  82. 86. <ul><li>Medical Diagnosis  made by a physician refers to a pathophysiologic responses that are fairly uniform from one client to another. </li></ul><ul><li>Nursing Diagnosis  describes the clients’ physical, sociocultural, psychologic and spiritual responses to an illness or potential health problems; vary among individuals. </li></ul>
  83. 89. Nursing diagnosis <ul><li>Actual nursing diagnoses PES approach </li></ul><ul><li>= Problem + Etiology + S/S </li></ul><ul><li>Impaired verbal communication r/t cultural differences as manifested by inability to speak English </li></ul>
  84. 90. Nursing diagnosis <ul><li>Potential nursing diagnosis PRF approach (risk factor) </li></ul><ul><li>Potential skin breakdown r/t physical immobilization in total body cast </li></ul><ul><li>Potential fluid volume deficit r/t diarrhea, age 3 yrs., low oral intake, elevated temperature </li></ul>
  85. 91. PLANNING <ul><li>involves decision making and problem solving </li></ul><ul><li>Planning process includes: </li></ul><ul><li>A.Setting priorities  establishing a preferential order for nursing strategies ; the nurse must consider a variety of factors : </li></ul><ul><li>1.Client’s health values and beliefs  a client may believe that being home with children is more urgent than a health problem. </li></ul><ul><li>2.Client’s priorities  involving the client enhances cooperation between nurse and client </li></ul><ul><li>3.Urgency of health problems  ABC’s of life (airway, breathing, circulation ) </li></ul><ul><li>4.Medical treatment plan  must be congruent with treatment of other health care professionals </li></ul>
  86. 92. PLANNING <ul><li>should be S-M-A-R-T (specific, measurable, attainable, realistic and time-bound) </li></ul><ul><li>Example: </li></ul><ul><li>Problem : Fever  subjective cues : “Mainit ang pakiramdam ko.” </li></ul><ul><li>objective cues : skin is warm to touch; temp. is 38.9 C </li></ul><ul><li> nursing diagnosis : Alteration in thermoregulatory function: hyperthermia related to inflammatory process </li></ul><ul><li> plan : After 4 hours of continuous nursing intervention, patient’s temperature will decrease from 38.9 C to 37.5C/ ax. </li></ul>
  87. 94. PLANNING <ul><ul><li>Planning </li></ul></ul><ul><ul><li>= setting priorities + establishing goals + planning interventions </li></ul></ul>
  88. 95. PLANNING <ul><li>B. Establish Goals </li></ul><ul><li>Components of a goal statement </li></ul><ul><li>Goal statement </li></ul><ul><li>= pt behavior + criteria of performance + Time + conditions (if needed) </li></ul>
  89. 96. Components of a goal statement <ul><li>PATIENT BEHAVIOR - an observable activity that the patient will demonstrate </li></ul><ul><ul><li>(the patient) will void </li></ul></ul><ul><ul><li>Decrease in ( the patient’s) BP </li></ul></ul><ul><ul><li>(the patient) will ambulate </li></ul></ul><ul><ul><li>(the patient) will report </li></ul></ul><ul><ul><li>(the patient) will drink </li></ul></ul>
  90. 97. Components of a goal statement <ul><li>TIME FRAME - a designated time or date when the patient should be able to achieve the behavior </li></ul><ul><ul><li>Within the next hour </li></ul></ul><ul><ul><li>By discharge </li></ul></ul><ul><ul><li>At the end of this shift </li></ul></ul><ul><ul><li>By Dec. 25 </li></ul></ul><ul><ul><li>In 2 months </li></ul></ul>
  91. 98. Components of a goal statement <ul><li>CONDITIONS - specific aides which will facilitate the patient performing a behavior at the level in the criteria and within the specified time frame </li></ul><ul><ul><li>With the help of a walker </li></ul></ul><ul><ul><li>With the use of a wheelchair </li></ul></ul><ul><ul><li>With the help of the family </li></ul></ul><ul><ul><li>With the use of medication </li></ul></ul><ul><ul><li>Using oral analgesics q3-4 hrs </li></ul></ul><ul><ul><li>Using IM Demerol q3-4 hrs </li></ul></ul>
  92. 102. Planning Process <ul><li>C. Planning Interventions </li></ul><ul><li>render continuous tepid sponge bath </li></ul><ul><li>loosen tight and thick clothing </li></ul><ul><li>increase fluid intake </li></ul><ul><li>keep room well ventilated </li></ul><ul><li>administer antipyretics as indicated/ordered </li></ul>
  93. 104. IMPLEMENTATION / INTERVENTION <ul><li> implement the interventions identified in the plan of care . </li></ul><ul><li>Cognitive/Intellectual Skills  include problem solving, decision making, critical thinking and creative thinking </li></ul>
  94. 105. IMPLEMENTATION / INTERVENTION <ul><li>Interpersonal skills  activities use when communicating directly with one another; include verbal and nonverbal activities ; necessary for caring, comforting, referring, counseling and supporting clients; </li></ul>
  95. 106. IMPLEMENTATION / INTERVENTION <ul><li>Technical / psychomoto r skills  ‘hands-on’ skills </li></ul><ul><li>such as manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients; require knowledge and frequently manual dexterity. </li></ul>
  96. 108. <ul><li>The process of implementing: </li></ul><ul><li>1.Reassessing the client  reassess whether the intervention is still needed </li></ul><ul><li>Note: </li></ul><ul><li>even though an order is written on the care plan, the situation or the client’s condition may have changed. </li></ul>
  97. 109. The process of implementing: <ul><li>2.Determining the need for nursing assistance  the nurse maybe unable to implement the nursing strategies safely alone </li></ul>
  98. 110. The process of implementing: <ul><li>3.Implementing nursing strategies  nursing activities include caring , communicating , helping , teaching , counseling , acting as a client advocate and change agent , l eading and managing . </li></ul>
  99. 111. The process of implementing <ul><li>4.Communicating nursing actions  recording the interventions along with the client responses in the nursing progress notes. </li></ul>
  100. 112. TYPES OF NURSING ACTIONS: <ul><li>Independent Nursing Actions  an activity that the nurse initiates as a result of the nurse’s own knowledge and skills </li></ul><ul><li>Dependent nursing actions  activities carried out on the order of the physician, under the physician’s supervision or according to specified routines </li></ul><ul><li>Collaborative nursing actions  activities performed either jointly with another member of the health care team or as a result of a joint decision by the nurse and another health care team member </li></ul>
  101. 113. <ul><li>Problem : Fever  subjective cues : “Mainit ang pakiramdam ko.” </li></ul><ul><li>objective cues : skin is warm to touch; temp. is 38.9 C </li></ul><ul><li> nursing diagnosis : Alteration in thermoregulatory function: hyperthermia related to inflammatory process </li></ul><ul><li> plan : After 4 hours of continuous nursing intervention, patient’s temperature will decrease from 38.9 C to 37.5C. </li></ul>
  102. 114. Intervention <ul><li>continuous tepid sponge bath rendered </li></ul><ul><li>tight and thick clothing loosened </li></ul><ul><li>fluid intake increased </li></ul><ul><li>room kept well ventilated </li></ul><ul><li>antipyretics as indicated/ordered administered </li></ul>
  103. 115. EVALUATION <ul><li>The evaluation process has 6 components : </li></ul><ul><li>Identifying the expected outcomes that the nurse will use to measure client goal achievement </li></ul><ul><li>Collecting data related to the expected outcomes </li></ul><ul><li>Comparing the data with the expected outcomes and judging whether the goals have been achieved </li></ul><ul><li>Relating nursing actions to client outcomes </li></ul><ul><li>Drawing conclusions about problem status </li></ul><ul><li>Reviewing and modifying the client’s care plan </li></ul><ul><li>determine client’s progress toward goal achievement and the effectiveness of NCP </li></ul>
  104. 118. <ul><li>EVALUATION STATEMENT consist of 2 parts : a conclusion and a supporting data </li></ul><ul><li>Example : Goal met : After 4 hours of continuous nursing intervention, temperature decreased from 38.9 to 37.4 C/ax </li></ul>