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  1. 1. 2011 IDA JEAN ORLANDO THE NURSING PROCESS The Collaboration of the Nursing Process in properly assessing an Elderly Client and how it affects the old person in performance of Activities of Daily Living Maeah Stephanie Macapaz- Abadejos1 IDA JEAN ORLANDO- PHILO THEO 3/18/2011
  2. 2. TABLE OF CONTENTSTitle Page Page………………………………………………1Table of Contents Page……………………………………………..2Ida Jean Photos Page……………………………………………..3Conceptual Framework Page……………………………………………..4Schematic Diagram Page……………………………………………..5Discussion of Different Concepts of Page………………………………………………6the TheoryAssumptions and Assertions Page……………………………………………7-8Nursing Paradigm Page……………………………………………..9Limitations Page…………………………………………….10Assessment Tool Page………………………………………..11-17Statement of the Problem Page……………………………………………..18Nursing Care Plan Page…………………………………………19-23Bibliography Page…………………………………………….24 Maeah Stephanie Macapaz- Abadejos2 | P a g e
  3. 3. IDA JEAN ORLANDO Maeah Stephanie Macapaz- Abadejos3 | P a g e
  4. 4. Conceptual Framework Distinguish the Theory NEED PRESENTING BEHAVIOUR OF PATIENT NURSING PROCESS DISCIPLINEANA DNA PATIENTS NEED FOR HELP RESOLVED Maeah Stephanie Macapaz- Abadejos4 | P a g e
  5. 5. Analyze the Theory •PATIENTS VERBAL OR NON-VERBAL LANGUAGE Sense of Helplessness •NURSES RESPONSE Exploration ofpatients behavior •NURSES ACTION Deliberative approach(Dynamic •PATIENTS REACTIONApproach) •PATIENTS NEED FOR HELP RESOLVEDWell Being Maeah Stephanie Macapaz- Abadejos5 | P a g e
  6. 6.  In the late 1950s, Orlando developed her theory inductively through an empirical study of nursing practice.  For 3 years, she recorded 2000 observations between a nurse and patient interactions.  She was only able to categorize the records as "good" or "bad" nursing.According to records:  Good Nursing nurses focus was on the patients immediate verbal and non verbal behavior from the beginning through the end of the contact  Bad Nursing nurses focus was on a prescribed activity or something that had nothing to do with the patients behaviorFrom these observations, she formulated the Deliberative Nursing Processwhich was published in 1961.Conducted research at McLean Hospital through continuous tape recording ofnurses with patients and other health care membersBased on this research, her formulations were validated, thus she extendedher theory to include the entire nursing practice system which then evolvedas Nursing Process Discipline.Orlandos theory remains one the of the most effective practice theoriesavailable. Many theory scholars utilized her concept as basis for their further studies.Her work has been translated into six languages and was contained in theinternational section.A web page about her theory, developed by Schmieding in 1999, is updatedperiodically and contains extensive references. Maeah Stephanie Macapaz- Abadejos6 | P a g e
  7. 7. Assumptions about Nurses: The nurses reaction to each patient is unique Nurses should not add to the patients distress The nurses mind is the major tool for helping patients The nurses use of automatic responses prevents the responsibility of nursing from being fulfilled Nurses practice is improved through self-reflectionAssumptions about Patients: Patients needs for help are unique Patients have an initial ability to communicate their needs for help When patients cannot meet their own needs they become distressed The patients’ behavior is meaningful Patients are able and willing to communicate verbally (and non- verbally when unable to communicate verbally)Assumptions about the nurse-patient situation: The nurse-patient situation is a dynamic whole The phenomenon of the nurse-patient encounter represents a major source of nursing knowledgeAssumptions about Nursing: Maeah Stephanie Macapaz- Abadejos7 | P a g e
  8. 8. Nursing is a distinct profession separate from other disciplinesProfessional nursing has a distinct function and product (outcome)There is a difference between lay and professional nursingNursing is aligned with medicine Maeah Stephanie Macapaz- Abadejos8 | P a g e
  9. 9. HEALTH is not well-defined but assumed as ³freedom from mental or physical discomfort and feelings of adequacy and well-being NURSING providing direct assistance to individuals in whatever setting for ENVIRONMENT the purpose of avoiding, relieving, dimi is not clearly defined as nishing, or curing the well but assumed as a persons sense of nursing situation when helplessness there is a nurse-patient contact and that both nurse and patientperceive, think, feel, and act in the immediate situation PERSON unique and developmental beings with needs, individuals have their own subjective perceptions and feelings that may not be observable directly Maeah Stephanie Macapaz- Abadejos9 | P a g e
  10. 10. Highly interactive nature Orlandos theory makes it hard to include thehighly technical and physical care that nurses give in certain settings.Her theory struggles with the authority derived from the function ofprofession and that of the employing institutions commitment to the public. Maeah Stephanie Macapaz- Abadejos10 | P a g e
  11. 11. Nursing process •Subjective Data Assessment •Objective Data •Nursing Diganosis Diagnosis •Validation of Patients Need •Short Term Goals Planning •Long Term Goals •Strategies to Achieve Goals Implementation •Intervention •Patient Outcome Evaluation •Success on Care Plan The patient must be the central character Nursing care needs to be directed at improving outcomes for the patient; not about nursing goals The nursing process is an essential part of the nursing care planAssessment Involves taking vital signs, performing a head to toe assessment, listeningto the patients comments and questions about his health status, observinghis reactions and interactions with others. It involves asking pertinentquestions about his signs and symptoms, and listening carefully to theanswers. Maeah Stephanie Macapaz- Abadejos11 | P a g e
  12. 12.  the most critical stepAnswers the questions: “What is happening?” (Actual problem), or“What could happen?” (Potential problem) Involves collecting, organizing, and analyzing information/data about the patientResults in Nursing Diagnoses Two parts: Data collection & Data analysis1. Data Collection: A Holistic ApproachTypes of data Subjective: “symptoms” that the patient describes; e.g. “I can’t doanything for myself” Objective: signs that can be observed, measured, and verified; e.g.swollen joints Sources of data Primary: the patient; is always the best source Secondary: everything/everybody elseMethods of Data CollectionObservation Requires practice and skill Systematic, head-to-toe (cephalocaudal)Results in objective, factual informationDocument exactly what you observe e.g. “Yawned frequently, had dark circles under eyes” NOT “Patient seems tired”Observation results in a General SurveyThe General Survey: a brief description of patient’s appearance andbehavior. Maeah Stephanie Macapaz- Abadejos12 | P a g e
  13. 13. A 64 year old, well groomed African-American male in acutedistress. Awake, alert, and oriented. Approximately 6’, 1 170lbs. Hairsparse and gray, eyes brown. Sitting on side of bed, holding side rail forsupport. Verbal responses coherent but halting.Methods of data collectionInterviewStructured form of communicationPurpose: to provide care specific to this individual’s needs and problemsFocus: patient’s perceptionsNurse must: explain purpose of interview, provide comfort and privacy,ensure confidentialityResult: A comprehensive Health HistoryComponents of the Health History Demographic data CC: chief complaint HPI: history of present illness PMH: past medical history FMH: family medical history (genogram) ROS: review of systems Psychosocial historyMethods of Data CollectionExamination Inspect Palpate Percuss AuscultateNurse must: explain what you are doing, provide privacy, and askpermission before you touch the patient2. Data Analysis Maeah Stephanie Macapaz- Abadejos13 | P a g e
  14. 14. Data review Are data accurate and complete? Data interpretation What are the patient’s actual and/or potential problems? Develop a problem list based on the data Prioritize the patient’s problems DiagnosisNurses only make nursing diagnoses, except in the case of NursePractitioners who have been trained and licensed to make medicaldiagnoses. Once you have identified the patients problems related to hishealth status, you formulate a nursing diagnosis for each of them. You willalso prioritize the problems in formulating your plan and goals.Step Two of the Nursing ProcessNursing Diagnosis: a statement that describes a specific human responseto an actual or potential health problem that requires nursing interventionWritten in P E formatP = Problem: use North American Nursing Diagnosis Association (NANDA)category [due to or related to]E = Etiology: cause of the problemRheumatoid Arthritis Self-care deficit: bathing, related to joint stiffness PlanningSetting goals to improve the outcomes for the patient is a primary focus ofthe nursing process. Based on the nursing diagnoses, what are theexpectations for this patient? This not about nursing goals. They are patientgoals. This is about improving the health status and quality of life for yourpatient. This is about what your patient needs to do to improve his healthstatus and/or better cope with his illness.Plan: to provide consistent, continuous care that will meet the patient’sunique needs. Maeah Stephanie Macapaz- Abadejos14 | P a g e
  15. 15. Includes Patient Goals & Nursing Orders Patient Goals: describe the desired result of nursing careWhat will the patient (or part of the patient) do to resolve or lessen theproblem identified in the nursing diagnosis? By when will this be accomplished?Patient Goals are directly related to the patient’s problem as stated in thenursing diagnosis: One goal should describe resolution of the problem Additional goals should describe steps that contribute to problemresolution Patient Goals can be long term or short termPatient Goals are: Focused on the patient Clear and Concise Observable, Measurable, Realistic: how much? how far? how long? howwell? Written with a specific time frame: by when should the goal beaccomplished? Determined by the nurse and the patient Mr. H. will perform entire bath unassisted by 4-4-11Nursing Orders Describe what the nurse will do to help the patient achieve the goals. Nursing Orders must: Focus on nursing actions Describe when and how the nurse will perform nursing actions Include the date & be signed by the nurse 3/30/11 The nurse will assist Mr. H. with bathing until he is able to batheindependently. M.S.Macapaz, RN Maeah Stephanie Macapaz- Abadejos15 | P a g e
  16. 16. Planning also involves making plans to carry out the necessary interventionsto achieve those goals. The use of formal care plans or care maps andprotocols is highly advised.For example: "after instruction insulin therapy, the patient will successfullyreturn demonstrate the ability to accurately draw up the insulin by Mondayand safely self inject by Tuesday."ImplementationImplementation is setting your plans in motion and delegatingresponsibilities for each step. Communication is essential to the nursingprocess. All members of the health care team should be informed of thepatients status and nursing diagnosis, the goals and the plans. They arealso responsible to report back to the RN all significant findings and todocument their observations and interventions as well as the patientsresponse and outcomes.Implement: Carry out the care plan Reassess the patient Validate that the care plan is accurate Carry out nurses’ orders Document on patient’s chartEvaluationThe nursing process is an ongoing process. Evaluation involves not onlyanalyzing the success (or failure) of the current goals and interventions, butexamining the need for adjustments and changes as well. The evaluationprocess incorporates all input from the entire health care team, including thepatient. Evaluation leads back to Assessment and the whole process beginsagain.Evaluate: Compare the patient’s current status with the stated PatientGoals Were the goals achieved? Why not? Review the nursing processProblem: “I can’t do anything for myself” Maeah Stephanie Macapaz- Abadejos16 | P a g e
  17. 17. Nursing Diagnosis: Self care deficit: bathing, related to joint stiffnessPatient Goal (resolution): Mr. H. will perform entire bath unassisted by 4-4-11Patient Goal (contributory): Mr. H. will bathe his upper body unassisted by4-1-00.Nursing order: 3/30/11 The nurse will assist Mr. H. with bathing until he isable to bathe independently. M.S.Macapaz RNEvaluation: Was Mr. H. able to bathe unassisted by 4-4-00? Maeah Stephanie Macapaz- Abadejos17 | P a g e
  18. 18. The Collaboration of the Nursing Process in properly assessing an ElderlyClient and how it affects the old person in performance of Activities of Daily Living Maeah Stephanie Macapaz- Abadejos18 | P a g e
  19. 19. Nursing Diagnosis: Impaired Physical MobilityRelated Factors:  Activity intolerance  Perceptual or cognitive impairment  Musculoskeletal impairment  Neuromuscular impairment  Medical restrictions  Prolonged bed rest  Limited strength  Pain or discomfort  Depression or severe anxietyNOC Outcomes (Nursing Outcomes Classification)Suggested NOC Labels  Ambulation: WalkingNIC Interventions (Nursing Interventions Classification)Suggested NIC Labels  Exercise Therapy: Ambulation  Fall PrecautionsOngoing Assessment Assess for impediments to mobility (see Related Factors in this care plan).--Identifying the specific cause (e.g., chronic arthritis versus Maeah Stephanie Macapaz- Abadejos19 | P a g e
  20. 20. stroke versus chronic neurological disease) guides design of optimaltreatment plan.Assess patient’s ability to perform ADLs effectively and safely on adaily basis.Suggested Code for Functional Level Classification0 Completely independent1 Requires use of equipment or device2 Requires help from another person for assistance, supervision, orteaching3 Requires help from another person and equipment or device4 Is dependent, does not participate in activity--Restricted movementaffects the ability to perform most ADLs. Safety with ambulation is animportant concern.Assess patient or caregiver’s knowledge of immobility and itsimplications.--Even patients who are temporarily immobile are at riskfor effects of immobility such as skin breakdown, muscle weakness,thrombophlebitis, constipation, pneumonia, and depression.Assess for developing thrombophlebitis (e.g., calf pain, Homans’ sign,redness, localized swelling, and rise in temperature).--Bed rest orimmobility promote clot formation.Assess skin integrity. Check for signs of redness, tissue ischemia(especially over ears, shoulders, elbows, sacrum, hips, heels, ankles,and toes).Monitor input and output record and nutritional pattern. Assessnutritional needs as they relate to immobility (e.g., possiblehypocalcemia, negative nitrogen balance).--Pressure sores developmore quickly in patients with a nutritional deficit. Proper nutrition alsoprovides needed energy for participating in an exercise orrehabilitative program.Assess elimination status (e.g., usual pattern, present patterns, signsof constipation).--Immobility promotes constipation.Assess emotional response to disability or limitation. Maeah Stephanie Macapaz- Abadejos20 | P a g e
  21. 21. Evaluate need for home assistance (e.g., physical therapy, visiting nurse). Evaluate need for assistive devices.--Proper use of wheelchairs, canes, transfer bars, and other assistance can promote activity and reduce danger of falls. Evaluate the safety of the immediate environment.--Obstacles such as throw rugs, children’s toys, and pets can further impede one’s ability to ambulate safely.Therapeutic Interventions Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation.--The longer the patient remains immobile the greater the level of debilitation that will occur. Facilitate transfer training by using appropriate assistance of persons or devices when transferring patients to bed, chair, or stretcher. Encourage appropriate use of assistive devices in the home setting.-- Mobility aids can increase level of mobility. Provide positive reinforcement during activity.--Patients may be reluctant to move or initiate new activity due to a fear of falling. Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe.--Hospital workers and family caregivers are often in a hurry and do more for patients than needed, thereby slowing the patient’s recovery and reducing his or her self-esteem. Keep side rails up and bed in low position.--This promotes a safe environment. Turn and position every 2 hours or as needed.--This optimizes circulation to all tissues and relieves pressure. Maintain limbs in functional alignment (e.g., with pillows, sandbags, wedges, or prefabricated splints). This prevents footdrop and/or excessive plantar flexion or tightness. Support feet in dorsiflexed position. Maeah Stephanie Macapaz- Abadejos21 | P a g e
  22. 22. Use bed cradle. This keeps heavy bed linens off feet. Perform passive or active assistive ROM exercises to all extremities.-- Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength and endurance. Promote resistance training services.--Research supports that strength training and other forms of exercise in older adults can preserve the ability to maintain independent living status and reduce risk of falling. Turn patient to prone or semiprone position once daily unless contraindicated.--This drains bronchial tree. Use prophylactic antipressure devices as appropriate.--This prevents tissue breakdown. Clean, dry, and moisturize skin as needed. Encourage coughing and deep-breathing exercises. These prevent buildup of secretions. Use suction as needed. Use incentive spirometer. This increases lung expansion. Decreased chest excursions and stasis of secretions are associated with immobility. Encourage liquid intake of 2000 to 3000 ml/day unless contraindicated.--Liquids optimize hydration status and prevent hardening of stool. Teach energy-saving techniques.--These optimize patient’s limited reserves. Assist patient in accepting limitations. Emphasize abilities.Education/Continuity of Care Explain progressive activity to patient. Help patient or caregivers to establish reasonable and obtainable goals. Maeah Stephanie Macapaz- Abadejos22 | P a g e
  23. 23. Instruct patient or caregivers regarding hazards of immobility.Emphasize importance of measures such as position change, ROM,coughing, and exercises. Maeah Stephanie Macapaz- Abadejos23 | P a g e
  24. 24. 1. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.4. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.5. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing – Concepts Process & Practice 3rd ed. London Mosby Year Book.6. Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-157. Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225.8. Faust C. .Orlandos deliberative nursing process theory: a practice application in an extended care facility. J Gerontol Nurs. 2002 Jul;28(7):14-89. Nursing Crib.com, Student Nurses Community; http://nursingcrib.com/nursing-notes-reviewer/assessment-first-step-in-the-nursing- process10. Nursing Care Plans; Nursing Diagnosis and Intervention by Gulanick, Mayers, Klopp, Galanes, Gradishar , Puzas http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/Constructor.cfm Maeah Stephanie Macapaz- Abadejos24 | P a g e