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Alia Andriany S.Kep, Ns Bagian KDK Prodi S1 Ners
STIKES Graha Edukasi MKS
Problem Solving Scientific Method Nursing Process
Encounter problem Recognize problem AssessmentCollect data Collect dataIdentify exact Formulate hypothesis Nursing
Diagnosisnature of problemDetermine plan of Select plan for testing Planning action hypothesisCarry out plan Test hypothesis
Interpret results ImplementationEvaluate plan in Evaluate hypothesis Evaluationnew situation
A. Characteristics1. Open, flexible
2. Humanistic and individualized
3. Cyclical
4. Outcome focused ( results oriented)
5. Emphasizes feedback and validation
B. Nursing Process vs. Medical Process
1. Medical-identification of a disease and tx.
2. Nursing -identification of actual / potential responses to illness
C. Why do we learn about the Nursing Process ?
• Practice Standards in the U.S.
• Basis for State Boards NCLEX
• Critical thinking skills
Data collection….data base
Types of Assessment
Types of Data
Sources
Methods
interview & physical assessment techniques
Swollen finger
Misshapen
Reddened
Painful
Cues Inference
Broken finger
Cues = signs and symptoms
Inference = what you think,a judgement about the cues
Air Requisite
Lungs clearRR 18 laboredO2, Chest X-ray shows pneumonianonproductive cough
Lungs clearRR 18 laboredO2, Chest X-ray shows pneumonianonproductive cough
Activity & Rest Requisite
Bed rest, full passive ROMP.T.daily, Reddened skinon ankle & elbow, 40 degreecontracture on left leg, atrophyof muscles
Bed rest, full passive ROMP.T.daily, Reddened skinon ankle & elbow, 40 degreecontracture on left leg, atrophyof muscles
Respiratory Problem
Possible Skin Problem
Ineffective AirwayRisk for Impaired TissueIntegrity
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
1. Benefits of a Nursing Diagnosis
a. Communication between Nurses
b. Identification of patient goals
2. Types of Diagnostic Statements• actual• risk• possible• wellness• syndrome.
Three Part Statement P E SP = Problem
( Precise qualifier / modifiers )Altered High Risk Ineffective Decreased Deficit Excess Dysfunctional DisturbanceChronic Less than More than Anticipatory Diagnostic Label = Problem + modifier
= Chronic Pain
E = Related FactorsRelated factors are etiological or other contributing
factors that have influenced the health status change.
Etiology sometimes = Causes or factors of riskChronic pain r/t Altered Tissue
perfusion
………. secondary to DiabetesPathophysiologic Alteration in skin Integrity r/t ( caused by)Compromised immune system Inadequate circulationInadequate peripheral circulation
Treatment-relatedMedicationsDiagnostic studies Anxiety r/t (caused by) lack of knowledgeSurgery of how to dress his woundTreatments
SituationalEnvironmental Home Risk for Injury r/t unsteady gaitCommunityInstitutionPersonalLife experiencesRoles
Maturational Nutrition Imbalance : Less than Body Requirements r/t
Age related to inadequate sucking
S = Defining characteristicsS= signs / symptoms
Clinical cues--subjective and objective signs or symptoms that point to the nursing diagnosis
• Are separated into major and minor designations.• Major defined as critical indicators present 80-100 of the time.• Minor are supporting and present 50-79%
Major defining characteristics must be present for a diagnosis to be valid
P E
Diagnostic Label Related factorI impaired Skin Integrity related to prolonged immobility
SDefining characteristics
as evidenced by a 2 cm sacral lesion
A real problem exists !!!!!!!!A real problem exists !!!!!!!!
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)
No defining characteristics
No signs or symptoms because
No problem yetNo problem yet
Risk nursing diagnoses
P EDiagnostic 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
POSSIBLE NURSING DIAGNOSISStatements describing a suspected problem for which additional data is needed. Two part statement
Pnursing diagnostic label
Possible Self Concept Disturbance E
etiological factorsrelated to recent loss of roll responsibilities secondary to exacerbation of MS.
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
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 wellness2. effective present status or function.
One part statement beginning with Readiness for Enhanced
Diagnostic Label Readiness for Enhanced Parenting
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 ConstipationRisk for Altered Respiratory FunctionRisk for InfectionRisk for ThrombosisRisk for Activity IntoleranceRisk for InjuryRisk for Altered Thought Processes
INEFFECTIVE BREATHING PATTERNS
DEFINITIONIneffective Breathing Patterns: State in which a person experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern
DEFINING CHARACTERISTICSMajor (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, hyperventilationDysrhythmic respirations. Splinted/guarded respirations
Diagnosis Ineffective Breathing Patterns
Related to r/t
(E)(E) Immobility and chest pain
Secondary to abdominal surgery
As evidenced by
((PP))
(S)(S) in respiratory rate from 12 to 22
pulse rate 88 to 104 and irregular
Two practice situations
Nurse is primary provider
Nurse works in collaboration with others
COLLABORATIVE PROBLEMS PC
Physiological problems nurses monitor
Watching for complications ……..Potential Complications
All collaborative problems begin with the label POTENTIAL COMPLICATION (PC)
Potential complication: Sepsis
PC: Sepsis
Usually occur in association with a specific pathology treatment
Situation: Man admitted post gastric ulcer
Problem /complication: PC: G I bleeding
Nursing focus: Monitor for onset and manage episodes of gastric bleeding
review exercise: 1. Intravenous Therapy PC: _____________ PC:_______________2. Head Concussion PC: ____________ PC:________________
3. Nasogastric Suction PC:_____________ PC:________________
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
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
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 Godanymore” C- Spiritual Distress r/t to feelings of abandonment
aeb “ I don’t think God cares about me”
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
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
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
6.__C__Impaired Tissue Integrity ( 2" 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
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
G. PLANNING PHASE" Determination of nursing care in an organized, individualized and goal directed manner"
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 breathingDiarrheaItching
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
Diagnosis --------------- Ineffective Airway Clearance
r/t Etiology -----------------------Weakness secondary to Stroke aeb Maj. Defining Characteristic (Symptoms)- Nonproductive Ineffective cough Broad Outcome ----------------Effective Airway by 10/4/04 Time frame
aeb Outcome Criteria--------- (symptoms) Productive cough
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 InterventionsInterventions will be directed toward facilitating a productive cough
Motivating factors Goal motivates, something to aim for
Planning
Guidelines
Relate to a human responseRelate to a human response…..Dx. Altered Elimination: Constipation r/t immobility aebhard stools, no bowel movement for 5 days
Outcome: Normal elimination aebOutcome criteria: soft stools at least q. 2-3 days
Be patient centeredBe patient centeredDx. Risk for impaired skin integrity r/t decreased mobility
Incorrect= Prevent skin breakdown
Correct Outcome: Pt. will not experience any skin breakdown
Planningoutcomes clear and conciseoutcomes clear and concise
Incorrect = CDBPD indep q2
Correct = cough, deep breath, postural drainage
outcome criteria describes behavior that isoutcome criteria describes behavior that is measurable and observablemeasurable and observable
Incorrect = drinks enough amounts of fluid
Drinks 2000 ml. Fluid in 24 hours
Planning
realisticrealisticConsiders strengths/weaknesses of staff Considers strengths/weaknesses of staff and patient and resourcesand patient and resources
time limitedtime limited - long/short term
ex. within 4 hrs Before d/c ongoing
should be determined by patient and nurseshould be determined by patient and nurse
Ex. Nurse Pain free patient addicted
Planning
Goals
Cognitive= Knowledge of Hyper and Hypoglycemia
Psychomotor = Will Effectively Breast Feed
Affective = Will be less Anxious
Functioning of Body = Have Effective Airway Clearance
Planning
Diagnosis
1. Imbalanced Nutrition
Broad Outcome
Pt will experienceBalanced Nutrition
2. Acute Pain Pt will experience minimal or no pain
Pt will not experience an injury3. Risk for Injury
4. Activity Intolerance Pt will experience improved tolerance to activity
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
Planning
3. Self Care Deficit: Bathing /Hygiene R/T lack of motivation secondary to depression AEB Unwilling to wash body parts goal = Will experience no self care hygiene deficit by 11/05/05 AEB
Outcome Criteria: Patient washing arms and legs
Diagnosis Ineffective Breathing Patterns
Related to r/t
(E)(E) Immobility and chest pain
Secondary to abdominal surgery
As evidenced by
((PP))
(S)(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
Interventions( actions, orders )
" Specific nursing activities /actions that a nurse must perform to prevent complications , provide comfort(physical, psychological and spiritual) and promote, maintain and restore health."
Categoriesa. 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
interventions
Diagnosis
Altered Skin Integrity
Broad Outcome
Pt. will experience wound healing
Etiology
R/t immobilitysecondary to fracture
INTERVENTIONS
Defining Characteristics
aeb 3cm diameterankle wound
Outcome Criteria
aeb diameter to 2cm
interventions
Characteristics a. consistentb. scientific basis c. law, professional standards, agency accrediting bodies
Intervention Rationale Teach client to rotate Repeated use of the same insulin injection sites site may cause fibrosis,
and decreased insulinabsorption
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 ...........................
DonnaDonna BetsyBetsyBed trapeze specialized, air mattress
Position cue to turn turn q. 2 hours
Nutrition protein, zinc etc. tube feeding, fluids
interventions
•strengths / weaknesses*power components*resources*family/others
•safe environment
•assessment as an intervention
•teaching as an intervention
•consulting/referring as an intervention
interventions
4. Guidelines for Writinga. date and signb. 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
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
I. Documentation‑‑Care plan1. Purpose
a. continuity of careb. permanent recordc. documentation
2. Characteristicsa. R.N. authoredb. initiated after first contactc. readily availabled. current
3. Forms( all have diagnosis, outcomes and interventions)
a. standardizedb. computerized
. IMPLEMENTATION–" Initiation of the care plan to achieve specific outcomes”
***performing the planned interventions
Guidelines1. Review the interventions2. Analyze the skills, time and equipment involved3. Know reasons, expected effect and potential hazards 4.
Consider combining interventions5. Should not be mechanical6. Include the family7. Know institutional procedures
EVALUATION Outcome and outcome criteria comparison
" To determine how well the plan worked" Process
1. Gathering data2. Compare data with outcome criteria
3. Make judgmenta. outcome achievedb. outcome not achievedc. partially achieved
If not----‑check interventionshuman responsesoutcomesrelated factors
THE END!!!!!!
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