Transcript Nursing process

Nursing process
1
2
Nursing Diagnosis
-Judgment or conclusion about the risk for-or
actual-need/problem of the pt. (NANDA format).
Nursing Diagnosis: Health issue that can be prevented,
reduced, resolved, or enhanced through independent
nursing measures by:
• Sorting, clustering, analyzing information
• Identifying potential problems and strengths
• Writing statement of problem or strength
• Prioritizing the problems
• Not a medical diagnosis
3
Diagnostic Statements:
• Name of the health-related issue or problem as
identified in the NANDA list
• Etiology (its cause)
• Signs and Symptoms
• The name of the nursing diagnosis is linked to
the etiology with the phrase “related to,” and
the signs and symptoms are identified with the
phrase “as manifested (or evidenced) by”
• Problem: (Risk of infection related to
compromised nutrition state) (No AEB)
4
Functional Health Pattern
(NANDA)
Health Perception-Health management pattern
Nutritional-Metabolic Pattern
Elimination Pattern
Activity-Exercise Pattern
Sexuality-Reproduction Pattern
Sleep-Rest Pattern
Sensory-Perceptual Pattern
Cognitive Pattern
Role-Relationship Pattern
Self-Perception-Self- Concept Pattern
Coping-Stress Tolerance Pattern
Value-Belief Pattern
5
Health Perception-Health Management Pattern
Energy Field Disturbance.
Altered Growth and Development.
Altered Health Maintenance.
Ineffective Management of Therapeutic Regimen: Individual.
Health Seeking Behaviors
Effective Management of Therapeutic Regimen
Risk for Injury
Risk for diagnoses
Risk for Suffocation
Risk for Poisoning
Risk for Trauma
Risk for Peri-operative Positioning Injury
6
Nutritional-Metabolic Pattern
Decreased Adaptive Capacity: Intracranial.
Ineffective Thermo regulation.
Fluid Volume Deficit
Fluid Volume Excess
Altered Nutrition: Less than body requirements
Altered Nutrition: More than body requirements
Ineffective Breastfeeding
Interrupted Breastfeeding
Ineffective Infant Feeding Pattern Impaired Swallowing
Altered Protection
Impaired Tissue Integrity
Altered Oral Mucous Membrane
Impaired Skin Integrity.
7
Elimination Pattern
Altered Bowel Elimination Constipation
Colonic constipation
Perceived constipation
Diarrhea
Bowel Incontinence
Altered Urinary Elimination Patterns of Urinary
Retention
Total Incontinence
Functional Incontinence
Reflex Incontinence
Urge Incontinence
Stress Incontinence
Risk for constipation
Risk for altered urinary elimination
8
Activity- Exercise Pattern
Activity Intolerance
Impaired Gas Exchange in effective Airway Clearance
Ineffective Breathing Pattern
Decreased Adaptive Intracranial Capacity
Decreased Cardiac Output
Disuse syndrome
Diversional Activity Deficit
Impaired Home Maintenance Management
Impaired Physical Mobility
Dysfunctional Ventilatory Weaning Response
Inability to Sustain Spontaneous Ventilation
Self-Care Deficit: (Feeding, Bathing/Hygiene, Dressing/Grooming,
Toileting)
Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral, and
Cardiopulmonary. Renal, Gastrointestinal, Peripheral)
Disorganized Infant Behavior
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function
9
Sexuality-Reproduction Pattern
Risk- Diagnoses
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
10
Sleep-Rest Pattern
Wellness Diagnoses:
Opportunity to enhance sleep
Risk Diagnoses:
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleeps Pattern Disturbance
11
Sensory-Perceptual Pattern
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses:
Risk for pain, Risk for Aspiration
Actual Diagnoses:
Pain, Chronic Pain and Dysreflexia.
12
Cognitive Pattern
*Actual diagnosis
Acute confusion
Chronic Confusion
Decisional Conflict
Impaired Environmental Interpretation Syndrome
Knowledge Deficit (Specify)
Altered Thought Processes
Impaired Memory
*Wellness Diagnosis:
Opportunity to enhance cognition
*Risk Diagnoses:
Risk for altered thought processes
13
Role-Relationship Pattern
*Actual Diagnoses
Impaired Verbal Communication
Altered Family Processes: Alcoholism
Anticipatory Grieving
Dysfunctional Grieving?
Altered Parenting
Parental Role Conflict
Altered Role Performance
Impaired Social Interaction: Social Isolation
*Risk Diagnoses
Risk for dysfunctional grieving, High risk for Loneliness.
Risk for Altered Parent/Infant/Child Attachment
14
Self-Perception-Self-Concept Pattern
*Actual Diagnoses
Anxiety fatigue - Fear - Hopelessness- PowerlessnessPersonal Identity.
Disturbance - Body Image
Disturbance- self Esteem
Disturbance.
*Risk Diagnoses
Risk for hopelessness
Risk for body image disturbance
Risk for low self esteem
15
Coping-Stress Tolerance Pattern
*Actual Diagnoses
Impaired Adjustment
Ineffective Individual Coping
Ineffective Family Coping: Disabling
Ineffective Family Coping: Compromised
Ineffective Community Coping: Post-Trauma Response,
Rape-Trauma Syndrome Relocation and Stress Syndrome.
*Risk Diagnoses
Risk for ineffective coping (individual, family, or community)
Risk for self-harm
Risk for self- abuse.
Risk for Self-Mutilation
Risk for suicide
Risk for Violence; Self- directed or directed at others
16
Value-Belief Pattern
*Actual Diagnosis
Spiritual disturbance (distress of the human spirit).
*Risk diagnosis
Risk for spiritual distress
*Wellness Diagnosis
Potential for enhanced spiritual Well- Being
17
**PRACTICAL STEPS
• Perform assessment
• Look at the NANDA list
• Look for the defining characteristics or symptoms
from your assessment
• Look for the related factors - things that cause the
symptoms
• Make the sentence read: NANDA
Diagnosis…RT…AEB…
18
Nursing Care Plan 1
*Nursing Diagnosis: ALTERED THOUGHT PROCESSES
*Definition: A state in which an individual experiences a
disruption in cognitive operations and activities
19
*Possible Etiologies (related to)
• Withdrawal into the self
• Underdeveloped ego; punitive superego
• Impaired cognition fostering negative
perception of self or the environment
20
*Defining Characteristics (evidenced by)
• Inaccurate interpretation of environment
• Delusional thinking
• Hypovigilance (lack of attention or concentration)
• Altered attention span-distractibility
• Egocentricity
• Impaired ability to make decisions, problem-solve,
reason
• Negative ruminations
21
*Goals/objectives
**Short-Term Goal
• Patient will recognize and verbalize when
interpretations of the environment are inaccurate
within 1 week.
**Long-Term Goal
• Patient will experience no delusional or distorted
thinking by discharge.
22
*Interventions with Selected Rationales
• Convey your acceptance of pt’s need for false belief,
while letting him know that you don’t share delusion.
Positive response would convey to pt. that you accept
the delusion as reality.
• Do not argue to deny belief. Use REASONABLE
DOUBT as therapeutic technique: “I find that hard to
believe.” An arguing with pt. or denying belief serves
no useful purpose; delusional ideas are not
eliminated by this approach, and development of
trusting relationship may be impeded.
23
• Use CONSENSUAL VALIDATION & SEEKING
CLARIFICATION technique when communication
reflects alteration in thinking. (Ex: “Is it that you
mean? “or“ I don’t understand what you mean by
that. Would you please explain?”) These techniques
reveal to pt. how he is being perceived by others,
while responsibility for not understanding is accepted
by nurse.
• Reinforce & focus on reality. Talk about real events &
real people. Use real situations & events to divert pt.
away from long, purposeless, repetitive
verbalizations of false ideas.
24
• Give positive reinforcement, as pt. is able to
differentiate b/w reality- & nonreality-based
thinking. Positive reinforcement enhances selfesteem & encourages repetition of desirable
behaviors.
• Teach pt. to intervene, using thought-stopping
techniques, when irrational or negative thoughts
prevail. Thought stopping involves using command
stop!” or loud noise (ex. hand clapping) to interrupt
unwanted thoughts. This noise or command distracts
individual from undesirable thinking that often
precedes undesirable emotions or behaviors.
25
• Use touch cautiously, particularly if thoughts reveal
ideas of persecution. Pts who are suspicious may
perceive touch as threatening and may respond with
aggression.
26
*Desired Patient Outcomes/Discharge Criteria
1.Pt’s thinking processes reflect accurate
interpretation of environment.
2.Pt is able to recognize negative or irrational
thoughts and intervene to stop their progression.
27
Nursing Care Plan 2
*Nursing Diagnosis: ALTERED NUTRITION, LESS
THAN BODY REQUIREMENTS
*Definition: The state in which an individual
experiences an intake of nutrients insufficient to
meet metabolic needs
28
*Possible Etiologies (related to)
**Inability to ingest food due to:
• Depressed mood
• Loss of appetite
• Energy level too low to meet own nutritional
needs
• Regression to lower level of development
• Ideas of self-destruction
• Lack of interest in food
29
*Defining Characteristics (evidenced by)
• Loss of weight
• Pale conjunctiva and mucous membranes
• Poor muscle tone
• Amenorrhea
• Poor skin turgor
• Edema of extremities
• Electrolyte imbalances
• Weakness
• Constipation
• Anemias
30
*Goals/Objectives
**Short-Term Goal
• Patient will gain 2 Ib per week for the next 3
week.
**Long-Term Goal
• Patient will exhibit no s&s of malnutrition by
discharge (ex: electrolytes & blood counts within
normal limits; steady wt gain will be
demonstrated; constipation will be corrected; pt
will exhibit increased energy in participation of
activities).
31
*Interventions with Selected Rationales
• In collaboration with dietitian, determine number
of calories required to provide adequate nutrition
& realistic weight gain.
• Ensure that diet includes foods high in fiber to
prevent constipation. Encourage pt to increase
fluid consumption & physical exercise to promote
normal bowel functioning. Depressed pts are
particularly vulnerable to constipation due to
psychomotor retardation. Constipation is also a
common side effect of many antidepressant
medications.
32
• Keep strict documentation of intake, output, &
calorie count. This is necessary to make accurate
nutritional assessment & maintain pt’s safety.
• Weigh pt daily. Weight loss or gain is important
assessment information.
• Determine pt’s likes & dislikes & collaborate with
dietitian to provide favorite foods. Pt is more
likely to eat foods that he particularly enjoys.
33
• Ensure that pt receives small, frequent feedings,
including a bedtime snack, rather than three
larger meals. Large amounts of food may be
objectionable, or even intolerable, to pt.
• Administer vitamin, mineral supplements & stool
softeners or bulk extenders, as ordered.
• If appropriate, ask family members or significant
others to bring in special foods that pt
particularly enjoys.
34
• Stay with pt during meals to assist as needed and
to offer support and encouragement.
• Monitor laboratory values, & report significant
changes to physician. Laboratory values provide
objective data regarding nutritional status.
• Explain importance of adequate nutrition & fluid
intake. Pt may have inadequate or inaccurate
knowledge regarding contribution of good
nutrition to overall wellness.
35
*Desired Patient Outcomes/Discharge Criteria
1.Patient has shown a slow, progressive weight gain
during hospitalization.
2.Vital signs, blood pressure, and laboratory serum
studies are within normal limits.
3.Patient is able to verbalize importance of adequate
nutrition and fluid intake.
36
Nursing Care Plan 3
*Nursing diagnosis: SLEEP PATTERN DISTURBANCE
• Definition: Disruption of sleep time which causes
patient discomfort or interferes with desired lifestyle
37
*Possible Etiologies (related to)
• Depressed mood
• Repressed fears
• Feelings of hopelessness
• Fear of failure
• Anxiety, moderate to severe
• Hallucinations
• Delusional thinking
38
*Defining Characteristics (evidenced by)
• Verbal complaints of difficulty falling asleep
• Awakening earlier or later than desired
• Interrupted sleep
• Verbal complaints of not feeling well rested
• Remaining awake 30 minutes after going to bed
• Awakening very early in morning and being
unable to go back to sleep
• Excessive yawning & desire to nap during day
• Hypersomnia; using sleep as an escape
39
*Goals/Objectives
**Short-Term Goal
• Patient will be able to sleep 4 to 6 hours with the
aid of a sleeping medication within 5 days.
**Long-Terms Goal
• Patient will be able to fall asleep within 30
minutes of retiring, and obtain 6 to 8 hours of
uninterrupted sleep each night without
medication by discharge.
40
*Interventions with Selected Rationales
• Keep strict records of sleeping patterns. Accurate
base line data are important in planning care to assist
pt. with this problem.
• Discourage sleep during day to promote restful sleep
at night.
• Administer antidepressant medication at bedtime so
pt does not become drowsy during day.
• Assist with measures that may promote sleep, such
as warm, non-stimulating drinks, light snacks, warm
baths, backrubs.
41
• Performing relaxation exercises to soft music (or
other technique) may be helpful before sleep.
• Limit intake of caffeinated drinks (tea, coffee,
coals). Caffeine is a CNS stimulant that interfere
with sleep.
• Administer sedative meds, as ordered, to assist pt
achieve sleep until normal sleep pattern is
restored.
• For pt experiencing hypersomnia, set limits on
time spent in room. Plan stimulating diversionary
activities on structured, daily schedule. Explore
fears & feelings that sleep is helping to suppress.
42
*Desired Patient Outcomes/Discharge Criteria
1.Patient is sleeping 6 to 8 hours per night without
medication.
2.Patient is dealing to fall asleep within 30 minutes
of retiring.
3.Patient is dealing with fears and feelings rather
than escaping from them through-excessive sleep.
43