the nursing process craven unit 2 – ch. 10-14 cathi collings msn & peggy korman cnm
Post on 30-Dec-2015
36 Views
Preview:
DESCRIPTION
TRANSCRIPT
04/19/2304/19/23 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
04/19/2304/19/23 11
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 22
Chapter 11: Chapter 11: Nursing AssessmentNursing Assessment
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 33
Nursing ProcessNursing Process
Nursing Assessment Nursing Assessment ActivitiesActivities
–Collection of dataCollection of data–Validation of dataValidation of data–Organization of dataOrganization of data
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 44
Preparing for AssessmentPreparing for Assessment
•Types of assessmentTypes of assessment–Admission assessmentAdmission assessment–Focused assessmentFocused assessment–Time-lapse assessmentTime-lapse assessment–Emergency assessmentEmergency assessment
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 55
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 66
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 77
Preparing for AssessmentPreparing for Assessment
• Setting and environmentSetting and environment– Quiet, private settingQuiet, private setting– Restricted or secludedRestricted or secluded– Minimal distractionsMinimal distractions
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 88
Assessment SkillsAssessment Skills
• ObservationObservation– VisionVision– SmellSmell– HearingHearing– TouchTouch
• InterviewingInterviewing– Preparatory Preparatory
phasephase– Introductory Introductory
phasephase– Maintenance Maintenance
phasephase– Concluding Concluding
phasephase
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 99
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1010
Assessment During an Assessment During an InterviewInterview
Assessment Skills Assessment Skills
• Physical examination techniquesPhysical examination techniques– InspectionInspection– PalpationPalpation– PercussionPercussion– AuscultationAuscultation
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1111
Data CollectionData Collection
• Types of dataTypes of data– SubjectiveSubjective– ObjectiveObjective
• Sources of dataSources of data– PrimaryPrimary– SecondarySecondary
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1212
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.
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1313
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1414
Organize DataOrganize Data
• Functional health approachFunctional health approach
• Head-to-toe modelHead-to-toe model
• Body systems modelBody systems model
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1515
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.
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1616
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.
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1717
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.
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 1818
04/19/2304/19/23 191904/19/2304/19/23 1919
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
NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 202004/19/2304/19/23 2020
NURSING PROCESSNURSING PROCESS(ADPIE)(ADPIE)
• AASSESSMENTSSESSMENT
• NURSING NURSING DDIAGNOSISIAGNOSIS
• PPLANNINGLANNING
• IIMPLEMENTATION OF NURSING ACTIONSMPLEMENTATION OF NURSING ACTIONS
• EEVALUATIONVALUATIONNRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 212104/19/2304/19/23 2121NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 222204/19/2304/19/23 2222
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)
04/19/2304/19/23 2222NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 232304/19/2304/19/23 2323
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
04/19/2304/19/23 2323NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 242404/19/2304/19/23 2424
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
NRS320 Collings2012NRS320 Collings2012
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”]
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 2525
04/19/2304/19/23 262604/19/2304/19/23 2626
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
NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 2727
04/19/2304/19/23 282804/19/2304/19/23 2828
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
04/19/2304/19/23 2828NRS320 Collings2012NRS320 Collings2012
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)
04/19/2304/19/23 2929NRS320 Collings2012NRS320 Collings2012
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3030
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3131
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3232
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3333
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3434
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3535
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3636
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3737
• 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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3838
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 3939
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 …]
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 4040
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 4141
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!
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 4242
04/19/2304/19/23 434304/19/2304/19/23 4343
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
NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 444404/19/2304/19/23 4444
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
NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 454504/19/2304/19/23 4545
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]
NRS320 Collings2012NRS320 Collings2012
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 4646
04/19/2304/19/23 474704/19/2304/19/23 4747
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
NRS320 Collings2012NRS320 Collings2012
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 4848
04/19/2304/19/23 494904/19/2304/19/23 4949
BUILDING A NURSING BUILDING A NURSING DIAGNOSISDIAGNOSIS
11. . PROBLEMPROBLEM
2. 2. ETIOLOGYETIOLOGY
3. 3. SYMPTOMSSYMPTOMS
NRS320 Collings2012NRS320 Collings2012
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))
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 5050
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!
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 5151
04/19/2304/19/23 525204/19/2304/19/23 5252
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
NRS320 Collings2012NRS320 Collings2012
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 5353
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?
04/19/2304/19/23 5454NRS320 Collings2012NRS320 Collings2012
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
04/19/2304/19/23 5555NRS320 Collings2012NRS320 Collings2012
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 5656
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 5757
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 5858
Chapter 13: Chapter 13: Outcome Identification and Outcome Identification and PlanningPlanning
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 5959
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6060
Outcome Identification Outcome Identification
• ActivitiesActivities– Establish prioritiesEstablish priorities– Establish patient goals and Establish patient goals and
outcome criteriaoutcome criteria
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6161
Nursing SensitiveNursing Sensitive
• Patient outcomes Patient outcomes
• Nursing Outcomes Classification Nursing Outcomes Classification
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6262
Outcome Identification Outcome Identification ActivitiesActivities• Establish prioritiesEstablish priorities
– High priorityHigh priority– Medium priorityMedium priority– Low priorityLow priority
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6363
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6464
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6565
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6666
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6767
Nursing Interventions Nursing Interventions Classification (NIC)Classification (NIC)• Physiologic: BasicPhysiologic: Basic• Physiologic: ComplexPhysiologic: Complex• BehavioralBehavioral• SafetySafety• FamilyFamily• Health systemHealth system• CommunityCommunity
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6868
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 6969
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7070
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7171
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7272
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7373
04/19/2304/19/23 747404/19/2304/19/23 7474
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]
NRS320 Collings2012NRS320 Collings2012
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7575
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7676
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7777
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 7878
04/19/2304/19/23 797904/19/2304/19/23 7979
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
04/19/2304/19/23 7979NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 808004/19/2304/19/23 8080
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??
04/19/2304/19/23NRS320 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
04/19/2304/19/23 8181NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 828204/19/2304/19/23 8282
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.
04/19/2304/19/23 8282
NRS320 Collings2012NRS320 Collings2012
04/19/2304/19/23 838304/19/2304/19/23 8383
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
04/19/2304/19/23 8383NRS320 Collings2012NRS320 Collings2012
Next/ New Nursing Next/ New Nursing Diagnoses ?Diagnoses ?
• Assessment to support DX:Assessment to support DX:
• Goal StatementGoal Statement
• Interventions/ImplementationInterventions/Implementation
• RationaleRationale
• EvaluationEvaluation
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 8484
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 8585
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 8686
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 8787
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
04/19/2304/19/23 NRS320 Collings2012NRS320 Collings2012 8888
top related