Nursing Process Online


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Nursing Process Online

  1. 1. Alia Andriany S.Kep, Ns Bagian KDK Prodi S1 Ners STIKES Graha Edukasi MKS
  2. 2. Problem Solving Scientific Method Nursing Process Encounter problem Recognize problem Assessment Collect data Collect data Identify exact Formulate hypothesis Nursing Diagnosis nature of problem Determine plan of Select plan for testing Planning action hypothesis Carry out plan Test hypothesis Interpret results Implementation Evaluate plan in Evaluate hypothesis Evaluation new situation
  3. 3. <ul><ul><ul><li>A . Characteristics </li></ul></ul></ul><ul><li>1. Open, flexible </li></ul><ul><li>2. Humanistic and individualized </li></ul><ul><li>3. Cyclical </li></ul><ul><li>4. Outcome focused ( results oriented) </li></ul><ul><li>5. Emphasizes feedback and validation </li></ul>
  4. 4. <ul><ul><ul><li>B. Nursing Process vs. Medical Process </li></ul></ul></ul><ul><li>1. Medical-identification of a disease and tx. </li></ul>2. Nursing -identification of actual / potential r esponses to illness C. Why do we learn about the Nursing Process ? <ul><li>Practice Standards in the U.S. </li></ul><ul><li>Basis for State Boards NCLEX </li></ul><ul><li>Critical thinking skills </li></ul>
  5. 5. Data collection….data base Types of Assessment Types of Data Sources Methods interview & physical assessment techniques
  6. 6. Swollen finger Misshapen Reddened Painful Cues Inference Broken finger Cues = signs and symptoms Inference = what you think, a judgement about the cues
  7. 7. Air Requisite Lungs clear RR 18 labored O 2, Chest X-ray shows pneumonia nonproductive cough 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 Respiratory Problem  Possible Skin Problem  Ineffective Airway Risk for Impaired Tissue Integrity
  8. 8. 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 1953 term first used
  9. 9. 1. Benefits of a Nursing Diagnosis a. Communication between Nurses b. Identification of patient goals <ul><li>2. Types of Diagnostic Statements </li></ul><ul><li>• actual </li></ul><ul><ul><ul><li>• risk </li></ul></ul></ul><ul><ul><ul><li>• possible </li></ul></ul></ul><ul><ul><ul><li>• wellness </li></ul></ul></ul><ul><ul><ul><li>• syndrome. </li></ul></ul></ul>
  10. 10. Three Part Statement P E S P = Problem <ul><li>( Precise qualifier / modifiers ) </li></ul><ul><ul><ul><li>Altered High Risk Ineffective Decreased </li></ul></ul></ul><ul><ul><ul><li>Deficit Excess Dysfunctional Disturbance </li></ul></ul></ul><ul><ul><ul><li>Chronic Less than More than Anticipatory </li></ul></ul></ul>Diagnostic Label = Problem + modifier = Chronic Pain
  11. 11. 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 ……… . secondary to Diabetes Pathophysiologic Alteration in skin Integrity r/t ( caused by ) Compromised immune system Inadequate circulation Inadequate peripheral circulation Treatment-related Medications Diagnostic studies Anxiety r/t ( caused by ) lack of knowledge Surgery of how to dress his wound Treatments
  12. 12. Situational Environmental Home Risk for Injury r/t unsteady gait Community Institution Personal Life experiences Roles <ul><li>Maturational Nutrition Imbalance : Less than Body Requirements r/t </li></ul><ul><li>Age related to inadequate sucking </li></ul>
  13. 13. <ul><li>S = Defining characteristics </li></ul><ul><li>S = signs / symptoms </li></ul><ul><li>Clinical cues-- subjective and objective signs or symptoms that point to the nursing diagnosis </li></ul><ul><ul><ul><li>• Are separated into major and minor designations. </li></ul></ul></ul><ul><ul><ul><li>• Major defined as critical indicators present 80-100 of the time. </li></ul></ul></ul><ul><ul><ul><li>• Minor are supporting and present 50-79% </li></ul></ul></ul><ul><ul><ul><li>Major defining characteristics must be present for a </li></ul></ul></ul><ul><ul><ul><li>diagnosis to be valid </li></ul></ul></ul>
  14. 14. P E Diagnostic Label Related factor I impaired Skin Integrity related to prolonged immobility S Defining characteristics as evidenced by a 2 cm sacral lesion A real problem exists !!!!!!!!
  15. 15. 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 ) S No defining characteristics No signs or symptoms because No problem yet
  16. 16. Risk nursing diagnoses P E Diagnostic label Etiological risk factors Risk for Injury related to lack of awareness of hazards Factors present which present a risk situation for a problem to occur
  17. 17. 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.
  18. 18. 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
  19. 19. 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
  20. 20. Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation. One part statement Diagnostic label Disuse syndrome. 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
  21. 21. 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
  22. 22. Diagnosis Ineffective Breathing Patterns Related to r/t (E) Immobility and chest pain Secondary to abdominal surgery As evidenced by ( P ) (S)  in respiratory rate from 12 to 22 pulse rate  88 to 104 and irregular
  23. 23. Two practice situations Nurse is primary provider Nurse works in collaboration with others COLLABORATIVE PROBLEMS PC Physiological problems nurses monitor Watching for complications …….. P otential C omplications
  24. 24. All collaborative problems begin with the label POTENTIAL COMPLICATION (PC) Potential complication : Sepsis PC: Sepsis Usually occur in association with a specific pathology treatment
  25. 25. Situation : Man admitted post gastric ulcer Problem /complication : PC : G I bleeding Nursing focus : Monitor for onset and manage episodes of gastric bleeding <ul><ul><ul><li>review exercise: </li></ul></ul></ul><ul><ul><ul><li>1. Intravenous Therapy PC : _____________ PC :_______________ </li></ul></ul></ul><ul><ul><ul><li>2. Head Concussion PC : ____________ PC :________________ </li></ul></ul></ul><ul><ul><ul><li>3. Nasogastric Suction PC :_____________ PC :________________ </li></ul></ul></ul>
  26. 26. 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
  27. 27. 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
  28. 28. 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”
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 6 .__ C __Impaired Tissue Integrity ( 2&quot; 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 related to being NPO aeb inability to take food in mouth 10._____Impaired Physical Mobility related to pain in leg joints aeb patient reports pain in leg joints
  33. 33. 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
  34. 34. G . PLANNING PHASE &quot; Determination of nursing care in an organized, individualized and goal directed manner&quot; 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
  35. 35. 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 <ul><ul><ul><li>Diagnosis --------------- Ineffective Airway Clearance </li></ul></ul></ul><ul><li>r/t Etiology -----------------------Weakness secondary to Stroke </li></ul><ul><li>aeb Maj. Defining Characteristic ( Symptoms) - Nonproductive Ineffective cough </li></ul><ul><li>Broad Outcome ----------------Effective Airway by 10/4/04 Time frame </li></ul><ul><li>aeb Outcome Criteria --------- ( symptoms ) Productive cough </li></ul>
  36. 36. planning Purpose of Outcomes and Criteria Indicators of achievement was the airway effective? Measuring sticks Did problem ( cough ) stay the same, get  or  , disappear ? Direct Interventions Interventions will be directed toward facilitating a productive cough Motivating factors Goal motivates, something to aim for
  37. 37. Planning Guidelines Relate to a human 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
  38. 38. 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
  39. 39. Planning realistic Considers strengths/weaknesses of staff and patient and resources time limited - long/short term ex. within 4 hrs Before d/c ongoing should be determined by patient and nurse Ex. Nurse Pain free patient addicted
  40. 40. Planning Goals Cognitive = Knowledge of Hyper and Hypoglycemia Psychomoto r = Will Effectively Breast Feed Affective = Will be less Anxious Functioning of Body = Have Effective Airway Clearance
  41. 41. Planning Diagnosis 1. Imbalanced Nutrition Broad Outcome Pt will experience Balanced Nutrition 2. Acute Pain Pt will experience minimal or no pain Pt will not experience an injury 3. Risk for Injury 4. Activity Intolerance Pt will experience improved tolerance to activity
  42. 42. Planning 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
  43. 43. Planning <ul><li>3. Self Care Deficit: Bathing /Hygiene R/T lack of motivation secondary to depression AEB Unwilling to wash body parts </li></ul><ul><li>goal = Will experience no self care hygiene deficit by 11/05/05 AEB </li></ul>Outcome Criteria: Patient washing arms and legs
  44. 44. Diagnosis Ineffective Breathing Patterns Related to r/t (E) Immobility and chest pain Secondary to abdominal surgery As evidenced by ( P ) (S)  in respiratory rate from 12 to 22 pulse rate  88 to 104 and irregular Outcome /goal Effective Breathing Date: by 10/22/04 aeb  respiratory rate to 12 to 16  pulse rate to 80 and regular
  45. 45. Interventions ( actions, orders ) &quot; Specific nursing activities /actions that a nurse must perform to prevent complications , provide comfort(physical, psychological and spiritual) and promote, maintain and restore health.&quot; 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
  46. 46. interventions Diagnosis Altered Skin Integrity Broad Outcome Pt. will experience wound healing Etiolog y R/t immobility secondary to fracture INTERVENTIONS Defining Characteristics aeb 3cm diameter ankle wound Outcome Criteria    aeb  diameter to 2cm   
  47. 47. interventions Characteristics a. consistent b. scientific basis c. law, professional standards, agency accrediting bodies <ul><li>Intervention Rationale </li></ul><ul><li>Teach client to rotate Repeated use of the same insulin injection sites site may cause fibrosis, and decreased insulin </li></ul><ul><ul><ul><li>absorption </li></ul></ul></ul>
  48. 48. 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 ........................... Donna Betsy Bed trapeze specialized, air mattress Position cue to turn turn q. 2 hours Nutrition  protein, zinc etc. tube feeding,  fluids
  49. 49. interventions <ul><li>strengths / weaknesses </li></ul><ul><ul><li>*power components </li></ul></ul><ul><ul><li>*resources </li></ul></ul><ul><ul><li>*family/others </li></ul></ul><ul><li>safe environment </li></ul><ul><li>assessment as an intervention </li></ul><ul><li>teaching as an intervention </li></ul><ul><li>consulting/referring as an intervention </li></ul>
  50. 50. interventions 4. Guidelines for Writing a. date and sign b. list specific activities Incorrect Correct Teach colostomy care 1. demonstrate steps us applying colostomy pouch 2. identify equipment needed with colostomy care 3. provide printed instructions and discuss content 4. Have client do return demonstration
  51. 51. 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
  52. 52. 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
  53. 53. . IMPLEMENTATION– &quot; 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 4. Consider combining interventions 5. Should not be mechanical 6. Include the family 7. Know institutional procedures
  54. 54. EVALUATION Outcome and outcome criteria comparison &quot; To determine how well the plan worked&quot; 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
  55. 55. THE END!!!!!!