6/9/2015NRS320 Collings20121 The Nursing Process Craven Unit 2 – Ch. 10-14 Cathi Collings MSN &...

04/18/2304/18/23 NRS320 Collings2012NRS320 Collings2012 11

The Nursing ProcessThe Nursing ProcessCraven Unit 2 – Ch. 10-14Craven Unit 2 – Ch. 10-14

Cathi Collings MSN Cathi Collings MSN & Peggy Korman CNM& Peggy Korman CNM

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Chapter 11: Chapter 11: Nursing AssessmentNursing Assessment


Nursing ProcessNursing Process

Nursing Assessment Nursing Assessment ActivitiesActivities

–Collection of dataCollection of data–Validation of dataValidation of data–Organization of dataOrganization of data


Preparing for AssessmentPreparing for Assessment

•Types of assessmentTypes of assessment–Admission assessmentAdmission assessment–Focused assessmentFocused assessment–Time-lapse assessmentTime-lapse assessment–Emergency assessmentEmergency assessment


NCLEX Question ?????NCLEX Question ?????

Which of the following is done to Which of the following is done to evaluate any changes in the patient’s evaluate any changes in the patient’s functional health from baseline?functional health from baseline?

a. Focus assessmenta. Focus assessmentb. Time-lapse assessmentb. Time-lapse assessmentc. Emergency assessmentc. Emergency assessmentd. Initial assessmentd. Initial assessment


Preparing for AssessmentPreparing for Assessment

• Setting and environmentSetting and environment– Quiet, private settingQuiet, private setting– Restricted or secludedRestricted or secluded– Minimal distractionsMinimal distractions


Assessment SkillsAssessment Skills

• ObservationObservation– VisionVision– SmellSmell– HearingHearing– TouchTouch

• InterviewingInterviewing– Preparatory Preparatory

phasephase– Introductory Introductory

phasephase– Maintenance Maintenance

phasephase– Concluding Concluding

phasephase



Assessment During an Assessment During an InterviewInterview

Assessment Skills Assessment Skills

• Physical examination techniquesPhysical examination techniques– InspectionInspection– PalpationPalpation– PercussionPercussion– AuscultationAuscultation


Data CollectionData Collection

• Types of dataTypes of data– SubjectiveSubjective– ObjectiveObjective

• Sources of dataSources of data– PrimaryPrimary– SecondarySecondary


QuestionQuestion

Tell whether the following statement is Tell whether the following statement is true or false:true or false:

Bowel sound is an example of Bowel sound is an example of objective data.objective data.


Validate DataValidate Data

• Comparing cues to normal functionComparing cues to normal function

• Referring to textbooks, journals, and Referring to textbooks, journals, and research reportsresearch reports

• Checking consistency for cuesChecking consistency for cues

• Clarifying the patient’s statementsClarifying the patient’s statements

• Seeking consensus with colleagues Seeking consensus with colleagues about inferencesabout inferences


Organize DataOrganize Data

• Functional health approachFunctional health approach

• Head-to-toe modelHead-to-toe model

• Body systems modelBody systems model


Case StudyCase Study• P.J. is an 81 year old widowed male.P.J. is an 81 year old widowed male.

• c/o sore right foot, trouble walking for “few years”, worse in the last c/o sore right foot, trouble walking for “few years”, worse in the last month.month.

• Hx: Type 2 DM, HTN, diabetic neuropathy, former smokerHx: Type 2 DM, HTN, diabetic neuropathy, former smoker

• 3 children, all live out of state.3 children, all live out of state.

• c/o recent poor appetite.c/o recent poor appetite.

• 2 dime sized ulcers on right foot, yellow, black toes. 2 dime sized ulcers on right foot, yellow, black toes.

+ sensation to bilateral feet.+ sensation to bilateral feet.


AssessmentAssessment

• Denies severe pain, 2/10 at toes.Denies severe pain, 2/10 at toes.

• BP 180/92, HR 88 and regular, RR 20 and BP 180/92, HR 88 and regular, RR 20 and unlabored, T 36.7unlabored, T 36.7

• S1, S2. S1, S2.

• DP/PT pulse 1+ left, not able to doppler or DP/PT pulse 1+ left, not able to doppler or palpate on right.palpate on right.


AssessmentAssessment

• Bilateral feet cool, R>LBilateral feet cool, R>L• Cap refill R > 3 sec., L = 3 sec.Cap refill R > 3 sec., L = 3 sec.• Scattered expiratory wheezes RUL, RA, Scattered expiratory wheezes RUL, RA,

SpO2 = 95%.SpO2 = 95%.• AAOX3, pleasant, conversant.AAOX3, pleasant, conversant.• c/o hunger, “haven’t eaten yet today” (time c/o hunger, “haven’t eaten yet today” (time

is now 6:10pm)is now 6:10pm)• Denies bowel/bladder problems.Denies bowel/bladder problems.


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NURSING PROCESSNURSING PROCESS

• DEFINITIONDEFINITION

– THE ACT OF THE ACT OF REVIEWINGREVIEWING THE THE PATIENT’SPATIENT’S SITUATIONSITUATION IN ORDER TO IN ORDER TO OBTAINOBTAIN INFORMATIONINFORMATION OF PAST HISTORY, OF PAST HISTORY, PRESENT STATUS AND TO PRESENT STATUS AND TO IDENTIFYIDENTIFY PATIENTPATIENT CURRENT CURRENT PROBLEMSPROBLEMS AND AND NEEDSNEEDS

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NURSING PROCESSNURSING PROCESS(ADPIE)(ADPIE)

• AASSESSMENTSSESSMENT

• NURSING NURSING DDIAGNOSISIAGNOSIS

• PPLANNINGLANNING

• IIMPLEMENTATION OF NURSING ACTIONSMPLEMENTATION OF NURSING ACTIONS

• EEVALUATIONVALUATIONNRS320 Collings2012NRS320 Collings2012

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ASSESSMENTASSESSMENT

• ASSESSMENT IS THE DELIBERATE AND SYSTEMATIC ASSESSMENT IS THE DELIBERATE AND SYSTEMATIC

COLLECTION OF DATA COLLECTION OF DATA TO DETERMINE A CLIENT’S TO DETERMINE A CLIENT’S

CURRENT AND PAST CURRENT AND PAST HEALTHHEALTH STATUS AND STATUS AND

FUNCTIONALFUNCTIONAL STATUS AND TO DETERMINE THE STATUS AND TO DETERMINE THE

CLIENTS CLIENTS PRESENT AND PAST COPING PATTERNSPRESENT AND PAST COPING PATTERNS

• (Carpenito-Moyet, 2005)(Carpenito-Moyet, 2005)

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DATA COLLECTIONDATA COLLECTION• SUBJECTIVE DATASUBJECTIVE DATA

– ““THE PATIENT STATES”THE PATIENT STATES”– ““I feel …”I feel …”

• OBJECTIVE DATAOBJECTIVE DATA– MEASURABLE DATA MEASURABLE DATA

•TEMPERATURETEMPERATURE

•PULSEPULSE

•RESPIRATIONSRESPIRATIONS

– What you seeWhat you see


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ASSESSMENT DATAASSESSMENT DATA

• WHERE DOES THE NURSE OBTAIN WHERE DOES THE NURSE OBTAIN ALL OF THE INFORMATION NEEDED ALL OF THE INFORMATION NEEDED TO DEVELOP A CARE PLAN FOR THE TO DEVELOP A CARE PLAN FOR THE PATIENT?PATIENT?– PATIENTPATIENT– FAMILYFAMILY– INFORMATION SYSTEMS (PT. CHART)INFORMATION SYSTEMS (PT. CHART)– REPORT (NURSE TO NURSE)REPORT (NURSE TO NURSE)– Physical AssessmentPhysical Assessment


What next?What next?• Organize data - by system, problem, etc.Organize data - by system, problem, etc.

• Identify Subjective & Objective dataIdentify Subjective & Objective data

• Identify abnormal findings, links between Identify abnormal findings, links between informationinformation– E.g. c/o pain, hx of injury, current condition of E.g. c/o pain, hx of injury, current condition of

wound, treatments used, pain scale ratingwound, treatments used, pain scale rating– Nursing student, mother of 2 toddlers, PT work Nursing student, mother of 2 toddlers, PT work

all fit in “roles” or ‘stressors’ w/ coping all fit in “roles” or ‘stressors’ w/ coping strategies, statements [“I am too busy to be strategies, statements [“I am too busy to be sick”]sick”]


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ASSESSMENT DATAASSESSMENT DATA

• SUBJECTIVESUBJECTIVE– Nurses report Nurses report

(second hand (second hand assessment assessment information)information)

– Patient statementsPatient statements• ““In quotes”In quotes”

– Family statementsFamily statements• ““In quotes”In quotes”

• OBJECTIVEOBJECTIVE– X-Ray shows …….X-Ray shows …….– Lab results are ……Lab results are ……– What you seeWhat you see– History from chartHistory from chart


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NURSING DIAGNOSISNURSING DIAGNOSIS• NURSING DIAGNOSIS CLASSIFIES NURSING DIAGNOSIS CLASSIFIES

HEALTH PROBLEMS WITHIN THE HEALTH PROBLEMS WITHIN THE DOMAIN OF NURSINGDOMAIN OF NURSING

– DOMAINDOMAIN•A REALM OR RANGE OF PERSONAL A REALM OR RANGE OF PERSONAL

KNOWLEDGE AND RESPONSIBILITYKNOWLEDGE AND RESPONSIBILITY


NURSING DIAGNOSISNURSING DIAGNOSIS

• A A NURSING DIAGNOSISNURSING DIAGNOSIS IS A IS A CLINICAL CLINICAL JUDGMENTJUDGMENT ABOUT INDIVIDUALS, ABOUT INDIVIDUALS, FAMILIES, OR COMMUNITIES AND FAMILIES, OR COMMUNITIES AND THEIR THEIR RESPONSERESPONSE TO ACTUAL TO ACTUAL AND/OR POTENTIAL HEALTH AND/OR POTENTIAL HEALTH PROBLEMS OR LIFE PROCESSES PROBLEMS OR LIFE PROCESSES

• (NANDA International, 2007)(NANDA International, 2007)


Nursing DiagnosisNursing Diagnosis

• Provides the basis for selecting Provides the basis for selecting nursing interventions to achieve nursing interventions to achieve outcomes for which the nurse is outcomes for which the nurse is accountableaccountable

• Both a label for the description and Both a label for the description and the action of describing the patient’s the action of describing the patient’s problemsproblems


Purpose of the Nursing Purpose of the Nursing DiagnosisDiagnosis

• Purpose: ID problems, synthesize info Purpose: ID problems, synthesize info from assessment by:from assessment by:– Analyzing dataAnalyzing data– ID patient strengthsID patient strengths– ID normal [baseline] functional level andID normal [baseline] functional level and– Indicators of actual or potential Indicators of actual or potential

dysfunctiondysfunction

Formulate a diagnostic statementFormulate a diagnostic statement


Your judgmentYour judgment

• The Nursing Diagnosis is where you The Nursing Diagnosis is where you share your decisions about what the share your decisions about what the patient’s PRIORITY patient’s PRIORITY ProblemsProblems are; are; what are the causes [what are the causes [Etiology- R/TEtiology- R/T]; ]; and what are the and what are the Symptoms Symptoms [AEB][AEB]– When you begin, use plain EnglishWhen you begin, use plain English– Then find the NANDA diagnosis and Then find the NANDA diagnosis and

languagelanguage


How to Choose a Nsg. DxHow to Choose a Nsg. Dx

• Identify patterns [in data]Identify patterns [in data]

• Validate the diagnosisValidate the diagnosis

• Formulate the statement using Formulate the statement using nursing language, within domain of nursing language, within domain of nursingnursing


Nursing DiagnosisNursing Diagnosis

• LanguageLanguage provides means of provides means of communication between nursescommunication between nurses

• Taxonomy: classification system Taxonomy: classification system [NANDA][NANDA]

• Problem, etiologyProblem, etiology

• Leads naturally to planning, goal Leads naturally to planning, goal setting and evaluationsetting and evaluation


The RulesThe Rules• N.D. is different than medical N.D. is different than medical

diagnosisdiagnosis– Medical DX describes disease/pathologyMedical DX describes disease/pathology– Nursing DX describes patient responseNursing DX describes patient response

•Actual, risk, or wellnessActual, risk, or wellness

•Areas that nurses treat Areas that nurses treat independentlyindependently

• Collaborative Problems: Collaborative Problems: M.D. and RN M.D. and RN involved – not in independent nursinginvolved – not in independent nursing– RN can ID problem, communicate, Treat w/ M.DRN can ID problem, communicate, Treat w/ M.D


Sample data collectionSample data collection– HR 80 B/P 140/78, sPO2 95% on RA, temp 103F HR 80 B/P 140/78, sPO2 95% on RA, temp 103F

[oral][oral]– Pt c/o dizzinessPt c/o dizziness– Skin is intact, flushed, warm/hot, dry to touchSkin is intact, flushed, warm/hot, dry to touch– Pt reports he was working outside, mowing Pt reports he was working outside, mowing

lawn for 3 hours; “had a couple of beers”lawn for 3 hours; “had a couple of beers”– Outside temp 97, humidity 17%Outside temp 97, humidity 17%– Pt is 22 year old malePt is 22 year old male– Caucasian, appears stated age, Ht/Wt//BMI Caucasian, appears stated age, Ht/Wt//BMI

WNLWNL


Example Data Set Cont.Example Data Set Cont.

• Slept well last nt; ate usual food in a.m.; none Slept well last nt; ate usual food in a.m.; none since 8 a.m. Hx of Rt rotator cuff repair last year, since 8 a.m. Hx of Rt rotator cuff repair last year, immunizations up to date; describes self as immunizations up to date; describes self as ‘healthy’. No previous similar problems‘healthy’. No previous similar problems


• Pt with temp 103 F, dry, flushed skin, c/o Pt with temp 103 F, dry, flushed skin, c/o dizziness, tachycardiadizziness, tachycardia– Open to interpretation [judgment]Open to interpretation [judgment]– Fever? Infection? Something else….Fever? Infection? Something else….

• ““FeverFever” doesn’t tell us much ” doesn’t tell us much – Interventions? Antipyretic? Antibiotics?Interventions? Antipyretic? Antibiotics?

• ““Hyperthermia r/t environmental stressors and Hyperthermia r/t environmental stressors and overexertion AEB dry, flushed skin, temp 103F overexertion AEB dry, flushed skin, temp 103F and “dizziness”and “dizziness” tells us what is going on and tells us what is going on and what we what we thinkthink caused the problem… caused the problem…

Example – Nsg. DxExample – Nsg. Dx


N.D.N.D.• ……. And leads us to goals and . And leads us to goals and

interventionsinterventions

Hyperthermia r/t environmental stressors Hyperthermia r/t environmental stressors and overexertion AEB dry, flushed skin, and overexertion AEB dry, flushed skin, temp 103F and “dizziness”temp 103F and “dizziness”

Environment Environment andand overexertion overexertion are things are things to educate pt about, control if possibleto educate pt about, control if possible


N.D. and goalsN.D. and goals• R/T …overexertion AEB dry, flushed R/T …overexertion AEB dry, flushed

skin, temp 103F and “dizziness”skin, temp 103F and “dizziness”

• Clues toward goals and interventionsClues toward goals and interventions

• Pt will.. have temp WNL, …report Pt will.. have temp WNL, …report absence of dizzy absence of dizzy feeling, ..demonstrate understanding feeling, ..demonstrate understanding of risks of overexertion in heat.. of risks of overexertion in heat.. increase fluid intake at work [by …]increase fluid intake at work [by …]


N.D. and InterventionsN.D. and Interventions

• EtiologyEtiology [R/T] leads us to appropriate [R/T] leads us to appropriate interventionsinterventions

• NO antipyretics, antibioticsNO antipyretics, antibiotics – wrong – wrong etiology for this ‘fever’etiology for this ‘fever’

• Hydrate, change environment, cool Hydrate, change environment, cool pt, educate re: risks and need for pt, educate re: risks and need for H2OH2O


Nsg. DxNsg. Dx resourcesresources

• Care plan BookCare plan Book

• NANDA List [Craven p 209-210]NANDA List [Craven p 209-210]

Start with plain English THEN find Start with plain English THEN find NANDA DXNANDA DX

With use, language will come more With use, language will come more easilyeasily

• PRACTICE!PRACTICE!


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Sample ASSESSMENT DATA Sample ASSESSMENT DATA 22• SUBJECTIVESUBJECTIVE

– Family states that pt. Family states that pt. developed increasing developed increasing confusion prior to fallingconfusion prior to falling

– Family states that pt. Family states that pt. complained of severe complained of severe headacheheadache

– Family states that patient Family states that patient continues to be in pain. continues to be in pain.

– Pt c/o pain; points to face Pt c/o pain; points to face = >6/10 or ‘severe’ pain= >6/10 or ‘severe’ pain

– Pt is 88 y.o malePt is 88 y.o male

• OBJECTIVEOBJECTIVE– VITAL SIGNSVITAL SIGNS

• Bp 182/90, P-110 irreg.Bp 182/90, P-110 irreg.• R-22, T-99.0, Pulse Ox. R-22, T-99.0, Pulse Ox.

93% Pain 8/1093% Pain 8/10• Blood Sugar 113Blood Sugar 113

– HEAD TO TOE HEAD TO TOE ASSESSMENTASSESSMENT

• Neuro A & O X1 [person]Neuro A & O X1 [person]• VS as notedVS as noted• Heart sounds clear -Heart sounds clear -

rhythm irregularrhythm irregular• BS clearBS clear• + Bowel sounds x4+ Bowel sounds x4• 0 edema0 edema• Rt. Extremities flaccidRt. Extremities flaccid• Rt. Leg externally rotatedRt. Leg externally rotated


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Significant ASSESSMENT Significant ASSESSMENT DATA DATA • SUBJECTIVESUBJECTIVE– Family states that pt. Family states that pt.

developed increasing developed increasing confusionconfusion prior to prior to fallingfalling

– Family states that pt. Family states that pt. complained of severe complained of severe headacheheadache

– Family states that patient Family states that patient continues to be in continues to be in painpain. .

– Pt c/o pain; points to face Pt c/o pain; points to face = >6/10 or = >6/10 or ‘severe’ pain‘severe’ pain

– Pt is 88 yo malePt is 88 yo male

• OBJECTIVEOBJECTIVE– VITAL SIGNSVITAL SIGNS

• Bp Bp 182/90182/90, , P-110 irregP-110 irreg..• R-22, T-99.0, Pulse Ox. R-22, T-99.0, Pulse Ox.

93% 93% Pain 8/10Pain 8/10• Blood Sugar 113Blood Sugar 113

– HEAD TO TOE HEAD TO TOE ASSESSMENTASSESSMENT

• Neuro Neuro A & O X1A & O X1 [person] [person]• VS as notedVS as noted• Heart sounds clear -Heart sounds clear -

rhythmrhythm irregularirregular• BS clearBS clear• + Bowel sounds x4+ Bowel sounds x4• 0 edema0 edema• Rt. Extremities flaccidRt. Extremities flaccid• Rt. Leg externally rotatedRt. Leg externally rotated


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Additional Findings from Additional Findings from chartchart

• FRACTURED Rt. HIP [x-ray]FRACTURED Rt. HIP [x-ray]

• CONFUSIONCONFUSION

• HYPERTENSION X 15 yearsHYPERTENSION X 15 years

• INSULIN DEPENDENT DIABETES [25 INSULIN DEPENDENT DIABETES [25 yrs]yrs]

• HISTORY OF FALLS [ 3 last year]HISTORY OF FALLS [ 3 last year]

• IRREGULAR HEART BEAT [a fib]IRREGULAR HEART BEAT [a fib]


PrioritiesPriorities

• ABC’sABC’s

• SafetySafety

• PainPain

• Pretty universal priorities – apply to Pretty universal priorities – apply to most all situationsmost all situations

• Actual Diagnoses before Risk DxActual Diagnoses before Risk Dx


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POTENITIAL NURSING POTENITIAL NURSING DIAGNOSESDIAGNOSES

• SAFETY [Risk for injury] R/TSAFETY [Risk for injury] R/T– confusion, history of falls, impaired mobilityconfusion, history of falls, impaired mobility

• SKIN INTEGRITY [risk for or actual SKIN INTEGRITY [risk for or actual impaired] R/T impaired] R/T – Pressure/ischemia 2* to immobility, delicate Pressure/ischemia 2* to immobility, delicate

skin /age, tissue traumaskin /age, tissue trauma

• PAIN [acute] R/TPAIN [acute] R/T– Tissue damage, swelling 2* to FRACTURED Tissue damage, swelling 2* to FRACTURED

HIPHIP


Other Possible N.DXOther Possible N.DX

• Risk for impaired tissue/cerebral Risk for impaired tissue/cerebral perfusion R/T irregular heartbeat perfusion R/T irregular heartbeat [potential clots][potential clots]

• Risk for powerlessness R/T Risk for powerlessness R/T dependent status after injurydependent status after injury

• Risk for delayed surgical recovery Risk for delayed surgical recovery R/T altered immune and healing R/T altered immune and healing response 2* to IDDM, ageresponse 2* to IDDM, age


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BUILDING A NURSING BUILDING A NURSING DIAGNOSISDIAGNOSIS

11. . PROBLEMPROBLEM

2. 2. ETIOLOGYETIOLOGY

3. 3. SYMPTOMSSYMPTOMS


PES Diagnosis PES Diagnosis [for actual problems][for actual problems]

• Acute Pain R/T tissue trauma AEB c/o Acute Pain R/T tissue trauma AEB c/o pain >6/10, fractured Rt hippain >6/10, fractured Rt hip

• Tells us [Tells us [etiologyetiology] Tissue Trauma ] Tissue Trauma [which we see ([which we see (symptomsymptom) as a ) as a fracture on X-ray] is fracture on X-ray] is causingcausing PAIN PAIN ((ProblemProblem) We also know because the ) We also know because the pt says he is in pain (pt says he is in pain (SymptomSymptom))


An ‘At Risk’ DiagnosisAn ‘At Risk’ Diagnosis

• PProblemroblem

• EEtiologytiology

• No symptoms ….No symptoms ….– Because the problem is not actual [yet]Because the problem is not actual [yet]– We want to prevent the problem!We want to prevent the problem!


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PEPE

PROBLEMPROBLEM

P - P - AT RISK FOR IMPAIRED SKIN AT RISK FOR IMPAIRED SKIN INTEGRITYINTEGRITYRELATED TORELATED TO

E – pressure/ ischemia 2* to E – pressure/ ischemia 2* to immobilization, delicate skin, tissue immobilization, delicate skin, tissue

damagedamage


Wellness DiagnosisWellness Diagnosis

• P P only only – Diagnostic labelDiagnostic label– Describes human responses to levels of Describes human responses to levels of

wellness in individual/populations that have wellness in individual/populations that have a readiness for enhancement to a higher a readiness for enhancement to a higher statestate

• Readiness for enhanced health Readiness for enhanced health maintenancemaintenance


Choosing Priority Choosing Priority NURSING DIAGNOSESNURSING DIAGNOSES

• Risk for injury Risk for injury R/t history of falls, R/t history of falls, impaired mobility, confusionimpaired mobility, confusion

• Acute Pain Acute Pain r/t tissue injury 2* to Hip r/t tissue injury 2* to Hip FX AEB c/o pain “severe” 6/10FX AEB c/o pain “severe” 6/10

• Risk for impaired skin integrity Risk for impaired skin integrity R/T R/T ischemia/pressure 2* to Immobility ischemia/pressure 2* to Immobility AEB bedrest and tractionAEB bedrest and traction

Which is the priority? Why?Which is the priority? Why?


PrioritiesPriorities• PainPain

• If pain is 8 on a scale from 1-10, will pt If pain is 8 on a scale from 1-10, will pt be able to comply with interventions be able to comply with interventions until pain is relieved?until pain is relieved?

• Probably notProbably not

• This is a clinical judgmentThis is a clinical judgment

• Standard priorities – ABC, Safety, PainStandard priorities – ABC, Safety, Pain

• ActualActual before Risk before Risk


Resources in CravenResources in Craven• Box 12-1 on page 208Box 12-1 on page 208

• Box 12-2 on page 209-210Box 12-2 on page 209-210

• Help you find N DX by area [cluster] Help you find N DX by area [cluster] of data, functional health patternsof data, functional health patterns

• Practice! “Practicing for NCLEX” Practice! “Practicing for NCLEX” questions pg. 211questions pg. 211



Chapter 13: Chapter 13: Outcome Identification and Outcome Identification and PlanningPlanning


Outcome IdentificationOutcome Identification

Outcome IdentificationOutcome Identification

• PurposePurpose– Providing individualized careProviding individualized care– Promoting patient participationPromoting patient participation– Planning care that is realistic and Planning care that is realistic and

measurablemeasurable– Allowing for involvement of support Allowing for involvement of support

peoplepeople


Outcome Identification Outcome Identification

• ActivitiesActivities– Establish prioritiesEstablish priorities– Establish patient goals and Establish patient goals and

outcome criteriaoutcome criteria


Nursing SensitiveNursing Sensitive

• Patient outcomes Patient outcomes

• Nursing Outcomes Classification Nursing Outcomes Classification


Outcome Identification Outcome Identification ActivitiesActivities• Establish prioritiesEstablish priorities

– High priorityHigh priority– Medium priorityMedium priority– Low priorityLow priority


NCLEX QuestionNCLEX Question

Which of the following is a high-priority Which of the following is a high-priority nursing diagnosis?nursing diagnosis?

a. Impaired Gas Exchangea. Impaired Gas Exchangeb. Fatigueb. Fatiguec. Stress Incontinencec. Stress Incontinenced. Dysfunctional Grievingd. Dysfunctional Grieving


Establish Patient Outcomes Establish Patient Outcomes and Outcome Criteriaand Outcome Criteria

• Patient outcomesPatient outcomes– Short- versus long termShort- versus long term

• Outcome criteriaOutcome criteria– Specific, measurable, realisticSpecific, measurable, realistic



PlanningPlanning

PlanningPlanning

• PurposesPurposes– Direct patient care activitiesDirect patient care activities– Promote continuity of carePromote continuity of care– Focus charting requirementsFocus charting requirements– Allow for delegation of specific Allow for delegation of specific

activitiesactivities


Nursing Interventions Nursing Interventions Classification (NIC)Classification (NIC)• Physiologic: BasicPhysiologic: Basic• Physiologic: ComplexPhysiologic: Complex• BehavioralBehavioral• SafetySafety• FamilyFamily• Health systemHealth system• CommunityCommunity


Planning ActivitiesPlanning Activities

•Planning nursing interventionsPlanning nursing interventions

•Writing a patient plan of careWriting a patient plan of care

– Patient centeredPatient centered

– Step-by-step processStep-by-step process


Types of Patient Plans of Types of Patient Plans of CareCare

• Instructional patient plans of careInstructional patient plans of care

• Instructional concept mapsInstructional concept maps

• Clinical plans of careClinical plans of care


Clinical Patient Plans of CareClinical Patient Plans of Care

•Individual Plan of CareIndividual Plan of Care

•Standardized Plan of CareStandardized Plan of Care

•Generic Plan of CareGeneric Plan of Care

•Computerized Plan of CareComputerized Plan of Care


The The GoalGoal leads to leads to InterventionsInterventions• Instructions to Nurses [and HCT]Instructions to Nurses [and HCT]

• NotNot Patient instructions Patient instructions

• [RN will] preface… Include timing[RN will] preface… Include timing……Administer analgesics q 4hrs per orders for pain Administer analgesics q 4hrs per orders for pain

>4/10>4/10

… … Assess and document pain at least hourly throughout Assess and document pain at least hourly throughout shiftshift

… … teach pt/family about pain scale, pain meds [onset teach pt/family about pain scale, pain meds [onset and duration, side effects] as indicated by assessmentand duration, side effects] as indicated by assessment


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TYPES OF TYPES OF INTERVENTIONSINTERVENTIONS

• NURSE INITIATEDNURSE INITIATED– INDEPENDENT INDEPENDENT [focus on these][focus on these]

• PHYSICIAN INITIATEDPHYSICIAN INITIATED– DEPENDENTDEPENDENT

• COLLABORATIVE COLLABORATIVE – INTERDEPENDENT INTERDEPENDENT [referrals, teamwork][referrals, teamwork]


Types of Types of InterventionsInterventions• CognitiveCognitive::

– Educational: teaching/ pt./family educationEducational: teaching/ pt./family education– SupervisorySupervisory

•Delegation to UAPDelegation to UAP

•Delegation to pt/family [learning for home]Delegation to pt/family [learning for home]

• InterpersonalInterpersonal::– Coordination, advocacy, refferral Coordination, advocacy, refferral – Support, modeling, listeningSupport, modeling, listening


Types of Interventions Types of Interventions [cont.][cont.]

• TechnicalTechnical Interventions Interventions– Maintenance [hygiene, skin care, etc]Maintenance [hygiene, skin care, etc]

•Help prevent complications, maintain Help prevent complications, maintain functionfunction

– Monitoring: assess and note changesMonitoring: assess and note changes•Communicate to HCT [VS, pulses, Communicate to HCT [VS, pulses,

bleeding…]bleeding…]

– Psychomotor : technical interventions Psychomotor : technical interventions • Insert Foley, IV, Suction, AssessInsert Foley, IV, Suction, Assess


Implementation ActivitiesImplementation Activities

• ReassessReassess– During each encounterDuring each encounter

• Set PrioritiesSet Priorities– As condition changes, resources changeAs condition changes, resources change

• PerformPerform Interventions Interventions

• RecordRecord [document] Interventions [document] Interventions


ImplementationImplementation of planof plan

• The action phaseThe action phase– Providing nursing careProviding nursing care– Delegating appropriate careDelegating appropriate care– Maintaining accountabilityMaintaining accountability– Documenting care providedDocumenting care provided


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ImplementingImplementing Nursing Care Nursing Care• DECIDING ON DECIDING ON InterventionsInterventions

– Who Who can do them? can do them? •Cannot delegate essential nursing actions Cannot delegate essential nursing actions

like assessmentlike assessment

•Referral when out of nursing Referral when out of nursing domain/personal abilitydomain/personal ability

– WhenWhen??•consider patient preference, time, resourcesconsider patient preference, time, resources

•New info, feedback, assessment dataNew info, feedback, assessment data

•Schedule multiple patients realistically Schedule multiple patients realistically


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Writing INTERVENTIONSWriting INTERVENTIONS• NURSING ORDERS [independent]NURSING ORDERS [independent]

– RN/CNA will REPOSITION EVERY TWO HOURSRN/CNA will REPOSITION EVERY TWO HOURS– RN/CNA will provide SKIN CARE TO ALL BONY RN/CNA will provide SKIN CARE TO ALL BONY

PROMINENCES WITH REPOSITIONINGPROMINENCES WITH REPOSITIONING– ASSESSMENTS [pain, skin.. How often? When?]ASSESSMENTS [pain, skin.. How often? When?]– Education [teach pt/ family..]Education [teach pt/ family..]

• Dependent OrdersDependent Orders– RN will Administer Percocet 650 mg PO q 4hrs RN will Administer Percocet 650 mg PO q 4hrs and and – reassess pain Q 30 min [independent] until <4/10reassess pain Q 30 min [independent] until <4/10

• Interventions should direct team – Interventions should direct team – what/when/how oftenwhat/when/how often??

04/18/2304/18/23NRS320 Collings2012NRS320 Collings2012

RATIONALE FOR RATIONALE FOR INTERVENTIONINTERVENTION

• Research Evidence in support of a Research Evidence in support of a nursing intervention [nursing intervention [for schoolfor school]]

• CitationCitation– Frequent turning and repositioning … can Frequent turning and repositioning … can

prevent localized obstruction of blood flow prevent localized obstruction of blood flow caused by increased pressure (Craven, p. 946)caused by increased pressure (Craven, p. 946)

• ReferenceReference– Craven, Hirnle & Jensen (2013) Craven, Hirnle & Jensen (2013) Fundamentals Fundamentals

of Nursing Human Health and Functionof Nursing Human Health and Function (7 (7thth Ed.) Ed.) Philadelphia: Lippincott Williams & WilkinsPhiladelphia: Lippincott Williams & Wilkins


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EVALUATIONEVALUATION• Was the expected Was the expected GoalGoal/ Outcome / Outcome metmet??

– Goal met/partially met/not metGoal met/partially met/not met

• How do you know? [AEB]How do you know? [AEB]

• Will you Will you reviserevise or or continuecontinue the plan of the plan of care?care?

Goal met: pt skin intact at shift change. Continue with Goal met: pt skin intact at shift change. Continue with plan of care.plan of care.

Goal partially met: pt pain at 6/10 after 30 min. Revision: Goal partially met: pt pain at 6/10 after 30 min. Revision: Reposition q 2 hrs, ice to hip. Pain 4/10 at shift change.Reposition q 2 hrs, ice to hip. Pain 4/10 at shift change.

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EVALUATION IS ONGOINGEVALUATION IS ONGOING AS IS AS IS THE NURSING PROCESSTHE NURSING PROCESS

• EACH CARE PLAN MUST EVOLVE AS EACH CARE PLAN MUST EVOLVE AS THE PATIENT PROGRESSESTHE PATIENT PROGRESSES

• Based on evaluation (reassessment), Based on evaluation (reassessment), the nursing diagnoses, priorities, and the nursing diagnoses, priorities, and interventions will changeinterventions will change


Next/ New Nursing Next/ New Nursing Diagnoses ?Diagnoses ?

• Assessment to support DX:Assessment to support DX:

• Goal StatementGoal Statement

• Interventions/ImplementationInterventions/Implementation

• RationaleRationale

• EvaluationEvaluation


Remember:Remember:

SMART goals help students SMART goals help students ADPIE to their diet of P’s , V’S ADPIE to their diet of P’s , V’S and R’sand R’s



AcronymsAcronyms• ADPIEADPIE: nursing process: nursing process

• SMART + PCSMART + PC: goals: goals

• 4 P’s4 P’s: hourly rounding checks: hourly rounding checks– pain, position, potty, personal needspain, position, potty, personal needs

• VSVS: vital signs: vital signs

• R’sR’s: rights : rights – 7 rights of medication administration7 rights of medication administration

6/9/2015NRS320 Collings20121 The Nursing Process Craven Unit 2 – Ch. 10-14 Cathi Collings MSN &...

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