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!!!!!!