The Nursing Process &Nosocomial Infections in Relation to IV Therapy Nelia B. Perez RN, MSN
Definition: Nosocomial infection(NI) is every infectious process,appearing during hospital stay,despite its clinical picture, carrierstatus and time of manifestation -during hospital treatment or afterdischarge.
Infections that develop inoutpatient departments, dayclinics or other closed humangroups such as in nursinghouses or orphanages and areassociated to medical ordental procedures arenosocomial too.
NURSING PROCESS• The cornerstone of the nursing profession.• Includes: ADOPIE – Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation
NURSING PROCESS IS:• ORGANIZED & SYSTEMATIC• HUMANISTIC : The plan of care is developed and implemented with great consideration to the unique needs and concerns of the individual client It is individualized It involves aspect of human dignity
• EFFICIENT : Relevant to the needs of the client and Promotes client satisfaction and progress• EFFECTIVE :Utilizes resources wisely in terms of human, time, cost resources
THE HEART OF THE NURSING PROCESS• K – knowledge; S – skills; C - caring• Knowledge – broad, varied A. MANUAL B. INTELLECTUAL C. INTERPERSONAL TECHNICAL• SKILLS CRITICAL THINKING : careful deliberate, goal-directed – to solve problems/make decisions check forevidence. Keeping an open mind and Avoid jumpinginto conclusions• TO ESTABLISH POSITIVE INTERPERSONAL
ASSESSMENT• Collecting, validating, organizing and recording data about the client’s health status (individual, family, community)• PURPOSE: To establish a data base• ACTIVITIES: COLLECTING DATA: Gathering information.Include the physical, psychological, emotional,socio-cultural, and spiritual factors
TYPES OF DATA:• SUBJECTIVE DATA (SYMPTOMS) - experienced by the client - EX. Pain, dizziness,• OBJECTIVE DATA (SIGNS) - those that can be observed and measured - EX. Pallor, diaphoresis, blood pressure, reddish urine, body temp.• METHODS OF COLLECTING DATA: – INTERVIEW. Planned purposeful conversation – OBSERVATION. (use of senses, lab results interpretation, physical examination)
• SOURCE OF DATA: PRIMARY: Patient/ Client• SECONDARY: Family members, S.O., patient’s chart/record, health team members, related literature• VERIFYING / VALIDATING DATA. Make sure your information is accurate.• ORGANIZING DATA. Cluster facts into groups of information (subjective and objective information)
Let’s review! SUBJECTIVE OR OBJECTIVE???– Headache– Temp 37.9 C RR: 20 bpm– Redness in the IV site– Client states, “ My IV site hasn’t been changed since Friday (3 days).”– Cyanosis– Urine output: 60ml– Ate only half of the food served
DIAGNOSING• Is a process which results to a diagnostic statement or nursing diagnosis• The clinical act of identifying problems• It means to analyze assessment and derive meaning from this analysis.• PURPOSE: To identify the client’s health care needs and to prepare diagnostic statements
NURSING DIAGNOSIS• Is a statement of client’s potential or actual alteration of health status. Uses critical thinking and skills analysis• Uses PRS/PES format – P- PROBLEM – R-RELATED TO FACTORS – S- SIGNS AND SYMPTOMS – P-PROBLEM – E-ETIOLOGY – S-SIGNS AND SYMPTOMS
ACTIVITIES DURING DIAGNOSING:• Organize cluster or group data. Ex. Pallor, dyspnea, weakness, fatigue – pertain to problems with oxygenation• Compare data against standards (accepted norms). Ex. Amber, clear urine VS cloudy urine or tea colored urine.• Analyze data after comparing with standards Identify gaps and inconsistencies in data• Determine the client’s health problems, health risks, strengths• Formulate Nursing Diagnosis statements
Examples of Nursing Diagnoses:• Anxiety related to insufficient knowledge regarding IV Catheter Insertion• Ineffective airway clearance related to tracheobronchial infection as manifested by weak cough, adventitious breath sounds, and copious green sputum production.
Types of Nsg. Diagnoses:• ACTUAL NURSING DIAGNOSIS• A judgment about the client’s response to a health problem that is present at the time of nursing assessment• Based on the presence of signs and symptoms• Ex. - ALTERED COMFORT: PAIN – PAIN
RISK NURSING DIAGNOSIS• A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop• Ex. RISK FOR INFECTION , RISK FOR CONSTIPATION
POSSIBLE NURSING DIAGNOSIS• Is one in which evidence about a health problem is unclear or the causative factors are unknown.• Requires more data either to support or to refute it.• Ex. Possible Vein Thrombosis related to prolonged IV Therapy
COMPONENTS of a NANDA NURSING DIAGNOSIS• PROBLEM (diagnostic label) and DEFINITION• Describes the client’s health status clearly and concisely in a few words• Qualifiers: Deficient – inadequate in amount, quality, or degree; not sufficient Impaired – made worse, weakened, damaged
• Ineffective – not producing the desired effect• ETIOLOGY (related factors & risk factors) Identifies one or more probable causes of health problem• Gives direction to what health needs to attend to.
DEFINING CHARACTERISTICS• A cluster of signs and symptoms that indicate the presence of a particular diagnostic label• ACTUAL DX: signs and symptoms• HIGH RISK/ RISK: factors that cause the client to be more vulnerable to the problem
• Ex. ACTIVITY INTOLERANCE RELATED TO IMMOBILITY as manifested by verbal reports of fatigue or weakness during leg exercises• Formulating statements: Problem – Etiology format Problem – etiology – signs and symptoms format
OUTCOME IDENTIFICATION• Refers to formulating and documenting measurable, realistic, client – focused goals.• Provides the basis for evaluating nursing diagnosis and interventions.
ACTIVITIES INCLUDE:• ESTABLISH PRIORITIES.• Life-threatening should be given highest priority ABC’s (airway, breathing, circulation)• Maslow’s hierarchy of needs (physiologic needs over psychosocial)• Unstable clients vs. clients with stable conditions• Actual problems vs. potential concerns
• Ex. GOAL: The client will be able to improve mobility.• DESIRED OUTCOMES: By the end of the week, client will be able to ambulate with crutches. By end of the month, client will be able to stand without assistance.
PLANNING• Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. Involve the client and his family• Begins with the first client contact until client is discharged from the facilityActivities:• Plan nursing interventions (also called nursing orders); may be dependent, independent, interdependent.
TYPES OF PLANNING• Initial planning - starts upon initial assessment/admission• Ongoing planning - Done by all nurses who work with the client to: Determine change in the health status. Set priorities for the client’s care during theshift. Decide which problems to focus on during theshift. Plan nursing activities during the shift.
Discharge planning• The process of anticipating and planning for needs after discharge. Includes: ff. up care, referrals, medications, diet modifications, significant other/care provider, health teachings, which signs and symptoms to watch for.
IMPLEMENTATION• Putting the nursing care plan into action Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal level of health Activities: – Set priorities. – To determine the order in which nsg interventions are carried out. – Perform nsg. Interventions Record actions. SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT DONE!!!
EVALUATION• Is assessing the client’s response to nsg intervention and then comparing the response to predetermined standards or outcome criteria.• Purpose: To appraise the extent to which goals and outcome criteria of nsg care have been achieved
Activities:• Collect data about the client’s response• Compare response to goals and outcome criteria• Assess whether goals are met (partially/completely) or unmet Analyze reasons for outcomes• Modify care plan as needed
BENEFITS OF THE NURSING PROCESS FOR THE CLIENT• Quality client care.• It meets standards of care.• Continuity of care.• Participation by the clients in their health care.
BENEFITS OF THE NURSING PROCESS FOR THE NURSE• Consistent and systematic nursing education• Job satisfaction• Professional growth• Avoidance of legal action• Meeting professional nsg standards• Meeting standards of accredited hospitals