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8/11/2019 Nursing Implementation Des 2013
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Nursing Process
Implementation
Moh. Afandi, SKep.,Ns.,MAN.,HNC
E-mail: mohafandi2003@yahoo.com.
+6281-908-134-304
mailto:mohafandi2003@yahoo.commailto:mohafandi2003@yahoo.com8/11/2019 Nursing Implementation Des 2013
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Nursing Process
Specific to the nursing profession
A framework for critical thinking
Its purpose is to:
Diagnose and treat human responses to
actual or potential health problems
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Nursing Process
Organized framework to guide practice
Problem solving method - client focused
Systematic- sequential steps Goal oriented- outcome criteria
Dynamic-always changing, flexible
Utilizes critical thinking processes
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Scientific Method of problemsolving
ID problem
Collect data
Form hypothesis Plan of action
Hypothesis testing
Interpret results
Evaluate findings
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Advantages of NursingProcess
Provides individualizedcare
Client is an active
participant Promotes continuity of
care
Provides more effective
communication amongnurses and healthcareprofessionals
Develops a clear andefficient plan of care
Provides personal
satisfaction as yousee client achievegoals
Professional growth
as you evaluateeffectiveness of yourinterventions
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5Steps in the Nursing Process
Assessment
NursingDiagnosis
Planning
Implementing Evaluating
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Assessment
First step of the Nursing Process Gather Information/Collect Data
Primary Source- Client / Family
Secondary Source- physical exam, nursing history,team members, lab reports, diagnostic tests..
Subjective-from the client (symptom)
I have a headache
Objective- observable data (sign) Blood Pressure 130/80
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Assessment-collecting data
Nursing Interview (history)
Health Assessment -Review of Systems
Physical Exam Inspection
Palpation
Percussion
Auscultation
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Assessment-collecting data
Make sure information is complete &accurate
Validate prn Interpret and analyze data
Compare to standard norms
Organize and cluster data
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Example of Assessment
Obtain info from nursing assessment,history and physical (H&P) etc...
Client diagnosed with hypertension
B/P 160/90
2 Gm Na diet and antihypertensivemedications were prescribed
Client statement I really dont watch mysalt Its hard to do and I ust dont et
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Nursing Diagnosis
Secondstep of the Nursing Process
Interpret & analyze clustered data
Identify clients problems and strengths
Formulate Nursing Diagnosis (NANDA :North American Nursing Diagnosis
Association)-Statement of how the client is
RESPONDING to an actual or potential
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Nsg Dx vs MD Dx
Within the scope ofnursing practice
Identify responses
to health and illness
Can changefromday to day
Within the scope ofmedical practice
Focuses on curing
pathology
Stays the sameaslong as the disease
is present
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Formulating a NursingDiagnosis
Composed of 3 parts:
Problem statement- the clientsresponse to a problem
Etiology- whats causing/contributing tothe clients problem
Defining Characteristics- whats theevidence of the problem
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Nursing Diagnosis
Problem( Diagnostic Label)-based onyour assessment of client(gathered
information), pick a problem from theNANDA list...
Etiology- determine what the problem is
caused by or related to (R/T)... Defining characteristics- then state as
evidenced by (AEB) the specific facts theproblem is based on...
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Example of Nursing Dx
Ineffective therapeutic regimenmanagement
R/Tdifficulty maintaining lifestyle changesand lack of knowledge
AEBB/P= 160/90, dietary sodiumrestrictions not being observed, and client
statements of I dont watch my salt Itshard to do and I just dont get it.
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Types of Nursing Diagnoses
ActualImbalanced nutrition; less than bodyrequirements RT chronic diarrhea, nausea,and pain AEB height 55 weight 105 lbs.
RiskRisk for falls RT altered gait and generalizedweakness
WellnessFamily coping: potential for growth RTunexpected birth of twins.
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Collaborative Problems
Require both nursing interventions andmedical interventions
EXAMPLE: Client admitted with medical dxof pneumonia
Collaborative problem = respiratory
insufficiencyNsg interventions: Raise HOB, Encourage
C&DB
MD interventions: Antibiotics IV, O2 therapy
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Planning
Thirdstep of the Nursing Process This is when the nurse organizes a nursing
care plan based on the nursing diagnoses.
Nurse and client formulate goals to help theclient with their problems
Expected outcomes are identified
Interventions (nursing orders) are selected toaid the client reach these goals.
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PlanningBegin by prioritizingclient problems
Prioritize list of clientsnursing diagnosesusing Maslow
Rank as high,intermediate or low
Client specific
Priorities can change
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PlanningDeveloping a goal and outcome statement
Goal and outcomestatements are clientfocused.
Worded positively Measurable, specific
observable, time-limited,and realistic
Goal = broad statement
Expected outcome =objective criterion formeasurement of goal
Utilize NOC as standard
EXAMPLE
Goal:
Client will achievetherapeutic managementof disease process.
Outcome Statement:
AEB B/P readings of
110-120 / 70-80 andclient statement ofunderstandingimportance of dietarysodium restrictions by
day of discharge.
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Planning- Types of goals
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals
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Goals are patient-centered andSMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR
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Planning-select interventions
Interventions are selected and written.
The nurse uses clinical judgment andprofessional knowledge to selectappropriate interventions that will aid theclient in reaching their goal.
Interventions should be examined for
feasibility and acceptability to the client
Interventions should be written clearlyand specifically.
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Interventions3 types
Independent ( Nurse initiated )- anyaction the nurse can initiate without
direct supervision Dependent ( Physician initiated )-
nursing actions requiring MD orders
Collaborative- nursing actionsperformed jointly with other health careteam members
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Implemention
The fourthstep in the Nursing Process
This is the Doing step
Carrying out nursing interventions(orders) selected during the planningstep
This includes monitoring, teaching,
further assessing, reviewing NCP,incorporating physicians orders andmonitoring cost effectiveness ofinterventions
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Implementing- Doing
Monitor VS q4h
Maintain prescribed diet
(2 Gm Na) Teach client amount of
sodium restriction,foods high in sodium,
use of nutrition labels,food preparation andsodium substitutes
Teach potentialcomplications ofhypertension to instill
importance ofmaintaining Narestrictions
Assess for cultural
factors affectingdietary regime
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ImplementingDoing
Teach the client-hypertension cant becured but it can becontrolled.
Remind the client tocontinue medicationeven though no S/Sare present.
Teach clientimportance of life stylechanges: (weight
reduction, smokingcessation, increasingactivity)
Stress the importanceof ongoing follow-upcare even though thepatient feels well.
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Evaluation- To determineeffectiveness of NCP
Final stepof the Nursing Process butalso done concurrently throughout client care
A comparison of client behavior and/or
response to the established outcome criteria Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help clientreach stated goals.
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FOCUS
Types of interventions: Direct/Indirect
Protocols and Standing Orders
Collaborating with the Client
What is a personalized plan of care?
Implementation process
reassessing.
reviewing and revising existing care plans.
organizing and care delivery.
anticipating and preventing problems.
knowledge, skills, and qualifications.
requiring support and assistance.
Provision of care
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IMPLEMENTATION
The step in the nursing processwhere the nurse provides care to
the clients. The nurse initiates orcompletes interventionsnecessary for achieving goals and
expected outcomes.
Begins after the care plan has
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Implementation
Implementation includes nursinginterventions(any treatment
based upon clinical judgment andknowledge that the nurseperforms to enhance client
outcomes).
May involveassisting and
directing client ADLs, providing
ypes o urs ng
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ypes o urs ngInterventionsDirect Care Interventions:
Treatments performedthrough interaction withthe client i.e. medicationadministration, IVinfusion, grief counseling.
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Indirect Intervention
Treatments performed
away from the client buton behalf of the client orgroup of clients (i.e.documentation,interdisciplinarycollaboration).
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CYCLICAL PROCESS
The nursing process is cyclical.
Implement, evaluate and thenyou may have to review and
adjust your assessment, plan andimplementation based on new
information/data.
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Nursing Intervention: PROTOCOLS
Nursing interventions can bedeveloped, communicated, and
organized on the basis ofprotocols or standing orders.
Protocol:Provides a standard ofcare or clinical guideline that canbe individualized for each client
depending on how an institution
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Standing Order
Pre-printed document containingorders for the conduct of routine
therapies, monitoring guidelines,and/or diagnostic procedures forspecific clients with identified
clinical problems. Must be signedby a licensed
prescribing physician or HCP in
charge of care.
SIX FACTORS TO CONSIDER WHEN
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SIX FACTORS TO CONSIDER WHENSELECTING INTERVENTIONS
Desired or expected outcome:Each outcome should have an
intervention.
Characteristics of the nursingdiagnosis: Intervention will alterthe related factor or treat thesigns and symptoms (defining
characteristics).
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SIX FACTORS TO CONSIDER WHENSELECTING INTERVENTIONS
Feasibility for performing the intervention:cost/time and how it affects other interventions.
Acceptability to the client: Explain how the client
is to participate, what the intervention involves,and how the client might be affected. Importantto collaborate with the client, as they need tomake informeddecisions Consider values,beliefs and culture leads to a personalized plan
of care Capability of the nurse: knowledge of the
scientific rationale, necessary skills, functionwithin the setting, consultation is critical.
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CRITICAL THINKING andIMPLEMENTATION
Consider:
Interventions that have worked in the past.
Review professional and standards of practice.Consider all possible nursing actions.
List the consequences associated with each action.
Determine the probability of consequencesassociated with each action.
Judge the value of the consequence to the client.
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Implementation ProcessSteps in the implementation process
include:
1. Reassess-determine whether the plannednursing action is still appropriate.
2. Review and revision of the presentnursing care plan-may need to revise
assessment data, diagnoses, specificinterventions, and methods ofevaluation.
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Implementation Process
3.Organize resources and care delivery-Determine equipment, personnel and environmentrequired to carry out the interventions. (privacy,reduce distractions, adequate space and lighting,physically and psychologically comfortable,administering comfort measures)
4.Anticipate and prevent complications-Weigh thebenefit of the treatment with the possible risks
and initiate risk preventing measures.
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Implementation Methods:Direct Care
Assist with activities of daily living (ADLs)-activities done through out a day. Ex. Help theclient get dressed, brush teeth, comb hair etc.
Instrumental Activities of Daily Living: skills suchas shopping, preparing meals, taking medicationsect.
Physical Care Techniques: turning and positioning
clients, administering meds, providing comfortmeasures.
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Direct Care
Counseling-Help the individual to use a problemsolving process to manage stress and help withinterpersonal interaction among the client, family
and the HCP. Focus on the development of newattitudes and feelings.
Teaching- Illustrate appropriate techniques andprocedures to clients. Ex. How to use an aerosol.
Focus is on intellectual growth. Observing for adverse reactions: Anticipate and
know potential adverse reactions, nurse actionsreduce or counteract the reaction.
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Indirect Care
Actions that support theeffectiveness of direct care
Communicating nursinginterventions-orally betweennurses and other HCPs.
Unless communication is timelyand accurate, caregivers may
become uninformed,
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APPLICATION TO THE CARE PLAN
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Nursing Interventions
The nursing care plan includes two types ofinterventions nursing interventions (5interventions), and when applicable, client
interventions (4 interventions). Interventions can be implemented by the nurse,
client, family member, depending on the level ofskill and knowledge needed. Maintaining a
partnershipis essential. Interventions must be specific andaddress the
need or desire for a changein client responsewith in the context of a particular situation.
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While there are severalinterventions derived for each
diagnosis, some interventionscan only be implemented by theclient. For example it is the client
that uses the incentivespirometer q1h while awake, it isthe client who attends the fitnessprogram, it is the client who does
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NOTE
Client interventions do NOT mirror nursinginterventions.Forexample, if the nurse administers an oral medication, onecan assume the client will swallow it. If not then it wouldnot be appropriate for the nurse to make a diagnosis that
reflects the situation, for example, impairedswallowingand derive the appropriate care plan. If thenurse is going to assist the client with something (e.g.,assist with dressing), there is no need for a correspondingclient action.
There are times however when a nursing action mustprecede a client actionsuch as when the nurse must teachthe client how to do something, and then the client canproceed unassisted. In this case the nursing intervention isto teach, and following the successful implementation ofthis intervention, the client intervention is to do.
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WRITING/FORMATTINGINTERVENTIONS
VERB-NOUN-MODIFIER
Where applicable the action verbshould be accompanied by what(noun) as well as by how much,how often, and/or under whatconditions/circumstances(modifiers).
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Intervention may include , but are not limited to those listedin the categories below:
Act for/do for: adjust, aspirate, decrease, empty, give,assess, auscultate, examine, measure, monitor, note,
observe, palpate.
Guide: guide, inform, discuss, show, counsel, assist, etc.
Support:share, suggest, talk, promote, encourage, assist,maintain, explain, ask, reinforce, etc.
Teach:demonstrate, discuss, explain, inform, instruct, list,review, show, etc.
Provide and environment that promotes physical,psychosocial and spiritual development and or positive lifestyle change: provide, promote, encourage, suggest, give,etc.
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The literature based rationale forinterventions
The literature based rationale forinterventions describes the basis
or reason for the interventions.Rationale is based on scientificresearched-based, and or
theoretical information fromcurrent nursing and or healthrelated texts and journals.
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Summary
Types of interventions: Direct/Indirect
Protocols and Standing Orders
Collaborating with the Client
What is a personalized plan of care?
Implementation process
reassessing.
reviewing and revising existing care plans.organizing and care delivery.
anticipating and preventing problems.
knowledge, skills, and qualifications.
requiring support and assistance.
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ALHAMDULILLAH
Terimakasih
53
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