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  • 1.To be, or not tobe--that is thequestion!

2. The Nursing Process &Nosocomial Infections in Relation to IV Therapy Nelia B. Perez RN, MSN 3. Definition: Nosocomial infection(NI) is every infectious process,appearing during hospital stay,despite its clinical picture, carrierstatus and time of manifestation -during hospital treatment or afterdischarge. 4. Infections that develop inoutpatient departments, dayclinics or other closed humangroups such as in nursinghouses or orphanages and areassociated to medical ordentalprocedures arenosocomial too. 5. NURSING PROCESS The cornerstone of the nursing profession. Includes: ADOPIE Assessment, Diagnosis,Outcome identification, Planning,Implementation and Evaluation 6. NURSING PROCESS IS: ORGANIZED & SYSTEMATIC HUMANISTIC : The plan of care is developedand implemented with great consideration tothe unique needs and concerns of theindividual client It is individualized It involvesaspect of human dignity 7. EFFICIENT : Relevant to the needs of the clientand Promotes client satisfaction and progress EFFECTIVE :Utilizes resources wisely in termsof human, time, cost resources 8. THE HEART OF THE NURSING PROCESS K knowledge; S skills; C - caring Knowledge broad, varied A. MANUAL B. INTELLECTUAL C. INTERPERSONAL TECHNICAL SKILLS CRITICAL THINKING : careful deliberate, goal-directed to solve problems/make decisions check forevidence. Keeping an open mind and Avoid jumpinginto conclusions TO ESTABLISH POSITIVE INTERPERSONAL 9. ASSESSMENT Collecting, validating, organizing andrecording data about the clients health status(individual, family, community) PURPOSE: To establish a data base ACTIVITIES:COLLECTING DATA: Gathering information.Include the physical, psychological, emotional,socio-cultural, and spiritual factors 10. TYPES OF DATA: SUBJECTIVE DATA (SYMPTOMS) - experienced bythe client - EX. Pain, dizziness, OBJECTIVE DATA (SIGNS) - those that can beobserved and measured - EX. Pallor, diaphoresis,blood pressure, reddish urine, body temp. METHODS OF COLLECTING DATA: INTERVIEW. Planned purposeful conversation OBSERVATION. (use of senses, lab resultsinterpretation, physical examination) 11. SOURCE OF DATA: PRIMARY: Patient/ Client SECONDARY: Family members, S.O., patientschart/record, health team members, relatedliterature VERIFYING / VALIDATING DATA. Make sureyour information is accurate. ORGANIZING DATA. Cluster facts into groupsof information (subjective and objectiveinformation) 12. Lets review! SUBJECTIVE OROBJECTIVE??? Headache Temp 37.9 C RR: 20 bpm Redness in the IV site Client states, My IV site hasnt been changedsince Friday (3 days). Cyanosis Urine output: 60ml Ate only half of the food served 13. DIAGNOSING Is a process which results to a diagnosticstatement or nursing diagnosis The clinical act of identifying problems It means to analyze assessment and derivemeaning from this analysis. PURPOSE: To identify the clients health careneeds and to prepare diagnostic statements 14. NURSING DIAGNOSIS Is a statement of clients potential or actualalteration of health status. Uses critical thinkingand skills analysis Uses PRS/PES format P- PROBLEM R-RELATED TO FACTORS S- SIGNS AND SYMPTOMS P-PROBLEM E-ETIOLOGY S-SIGNS AND SYMPTOMS 15. ACTIVITIES DURING DIAGNOSING: Organize cluster or group data. Ex. Pallor,dyspnea, weakness, fatigue pertain to problemswith oxygenation Compare data against standards (acceptednorms). Ex. Amber, clear urine VS cloudy urine ortea colored urine. Analyze data after comparing with standardsIdentify gaps and inconsistencies in data Determine the clients health problems, healthrisks, strengths Formulate Nursing Diagnosis statements 16. Examples of Nursing Diagnoses: Anxiety related to insufficient knowledgeregarding IV Catheter Insertion Ineffective airway clearance related totracheobronchial infection as manifested byweak cough, adventitious breath sounds, andcopious green sputum production. 17. Types of Nsg. Diagnoses: ACTUAL NURSING DIAGNOSIS A judgment about the clients response to ahealth problem that is present at the time ofnursing assessment Based on the presence of signs and symptoms Ex. - ALTERED COMFORT: PAIN PAIN 18. RISK NURSING DIAGNOSIS A clinical judgment that a problem does notexist, but the presence of risk factors indicatesthat a problem is likely to develop Ex. RISK FOR INFECTION , RISK FORCONSTIPATION 19. POSSIBLE NURSING DIAGNOSIS Is one in which evidence about a healthproblem is unclear or the causative factors areunknown. Requires more data either to support or torefute it. Ex. Possible Vein Thrombosis related toprolonged IV Therapy 20. COMPONENTS of a NANDA NURSING DIAGNOSIS PROBLEM (diagnostic label) and DEFINITION Describes the clients health status clearly andconcisely in a few words Qualifiers: Deficient inadequate in amount,quality, or degree; not sufficient Impaired made worse, weakened, damaged 21. Ineffective not producing the desired effect ETIOLOGY (related factors & risk factors)Identifies one or more probable causes ofhealth problem Gives direction to what health needs to attendto. 22. DEFINING CHARACTERISTICS A cluster of signs and symptoms that indicatethe presence of a particular diagnostic label ACTUAL DX: signs and symptoms HIGH RISK/ RISK: factors that cause the clientto be more vulnerable to the problem 23. Ex. ACTIVITY INTOLERANCE RELATED TOIMMOBILITY as manifested by verbal reportsof fatigue or weakness during leg exercises Formulating statements: Problem Etiologyformat Problem etiology signs andsymptoms format 24. OUTCOME IDENTIFICATION Refers to formulating and documentingmeasurable, realistic, client focused goals. Provides the basis for evaluating nursingdiagnosis and interventions. 25. ACTIVITIES INCLUDE: ESTABLISH PRIORITIES. Life-threatening should be given highestpriority ABCs (airway, breathing, circulation) Maslows hierarchy of needs (physiologicneeds over psychosocial) Unstable clients vs. clients with stableconditions Actual problems vs. potential concerns 26. ESTABLISH GOALS & OUTCOMECRITERIA GOALS: broad statements SHORT-TERM GOAL (STG) LONG-TERM GOAL(LTG) OUTCOME CRITERIA: specific, measurable,realistic statements of goal attainment SMART Specific, measurable, attainable, time-framed 27. Ex. GOAL: The client will be able to improvemobility. DESIRED OUTCOMES: By the end of the week,client will be able to ambulate with crutches.By end of the month, client will be able tostand without assistance. 28. PLANNING Involves determining beforehand the strategiesor course of actions to be taken beforeimplementation of nursing care. Involve the clientand his family Begins with the first client contact until client isdischarged from the facilityActivities: Plan nursing interventions (also called nursingorders); may be dependent, independent,interdependent. 29. TYPES OF PLANNING Initial planning - starts upon initialassessment/admission Ongoing planning - Done by all nurses who workwith the client to: Determine change in the health status. Set priorities for the clients care during theshift. Decide which problems to focus on during theshift. Plan nursing activities during the shift. 30. Discharge planning The process of anticipating and planning forneeds after discharge. Includes: ff. up care,referrals, medications, diet modifications,significant other/care provider, healthteachings, which signs and symptoms to watchfor. 31. IMPLEMENTATION Putting the nursing care plan into action Purpose:to carry out planned nursing interventions to helpthe client attain goals and achieve optimal levelof health Activities: Set priorities. To determine the order in which nsg interventions arecarried out. Perform nsg. Interventions Record actions.SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOTDONE!!! 32. EVALUATION Is assessing the clients response to nsgintervention and then comparing the responseto predetermined standards or outcomecriteria. Purpose: To appraise the extent to which goalsand outcome criteria of nsg care have beenachieved 33. Activities: Collect data about the clients response Compare response to goals and outcomecriteria Assess whether goals are met(partially/completely) or unmet Analyzereasons for outcomes Modify care plan as needed 34. BENEFITS OF THE NURSING PROCESS FOR THE CLIENT Quality client care. It meets standards of care. Continuity of care. Participation by the clients in their healthcare. 35. BENEFITS OF THE NURSING PROCESS FOR THE NURSE Consistent and systematic nursing education Job satisfaction Professional growth Avoidance of legal action Meeting professional nsg standards Meeting standards of accredited hospitals 36. Thank you forlistening!!!