Transcript Week 6

Transition to Registered
Nursing
Putting It All Together
West Coast University
Week 6
6-1
Review and Application of the
Nursing Process
6-2
The Nursing Process Group at West Coast University:
Working together in the quest of human response
Hi, I’m Ns.
Diagnosis
I’m Ns.
Assessmen
t
Yo, I’m
Ns. FHP
¡Hola!, I’m
Ns. Planning
Hey, I’m Ns.
Implementation
with Scientific
Rationale
Dude, it’s me,
Ns. Evaluation
6-3
Nursing Process
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Cyclic
Ongoing
Client centered
Promotes organization
Promotes problem resolution
6-4
Step One: Assessment
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Data collection
Verification and validation
Organization of data
Data interpretation
Database is formed
6-5
Types of Data
• Subjective
– feelings, perceptions, concerns
• Objective
– observable
– measurable
– felt by others
6-6
Recording Assessment Data
• Tools with a purpose
• Holistic data collection
6-7
Data Clustering
• Relatedness
• Patterns
• Support facts
6-8
Subjective Data Examples
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Progressive difficult breathing
Report of elevated temperature & chills
Chest discomfort with cough or inhalation
Headache, muscle aches
Fatigue
Husband smokes (environmental exposure)
No energy, not rested
Dyspnea with exertion
6-9
Objective Data Examples
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Blood pressure 152/84, Temperature 99.2°F
Pulse 116 per minute
Temperature 102.2 degrees F.
Respiratory rate 26 per minute with use of
accessory muscles
• Oxygen via nasal cannula
• Crackles to bilateral lower lobes; wheezing in
bilateral lobes
• Consolidation in left lower lobe with radiograph
revealing infiltrate
continues
6-10
Objective Data Examples
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Ineffective nonproductive cough
Capillary refill sluggish
Oxygen saturation low on room air
Restless
Difficulty vocalizing
Observed dyspnea with exertion
6-11
Data Clustering
• Cognitive-Perceptional Pattern
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Headache for three days
Pointing to occipital region of head
Holds head
Requests pain medications
Rates pain “seven” on scale of one to ten
Pain described as sharp, continuous, severe
Blood pressure 152/84
6-12
Data Clustering
• Activity-Exercise Pattern
– Reports mild difficulty breathing
– Oxygen two liters via nasal cannula
– Skin color dull, pale pink-yellow undertones, capillary
refill greater than two seconds
– Decreased pulse in left foot
– Cold extremities
– Requires assistance with transfer
– Left hand, left leg weakness
– Reports, “Can’t move my leg and hand”
6-13
Data Clustering
• Nutritional Metabolic Pattern
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Corner of mouth droops
Difficulty pronouncing words
Has not eaten since symptoms began
Nausea
6-14
Step Two: Diagnosis
• Problems identified
• Potential problems identified
• Diagnostic labels determined
6-15
Step Three: Planning
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Identify priorities
Determine realistic goals and expected outcomes
Determine interventions and rationale
Communicate and document
6-16
Priorities
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Data may determine
Discovered during interview, assessment
Client’s preference
Consider Maslow’s hierarchy
6-17
Goals and Expected Outcomes
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Unique to client
Give direction to plan
Focus on etiology
Indicate intent or desired change
6-18
Planning Components
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Subject
Behavior
Criteria of performance
Time frame
Condition
6-19
Step Four: Implementation
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Begins with assessment
Assessment is ongoing
Execute the care plan
Has independent nursing function
6-20
Scientific Rationale
• Scientific principles
• Underlying reason
• Utilizing resources
6-21
Acute Pain
• Nursing Interventions + Scientific Rationales
– Intervention
• Encourage client to report pain/discomfort location,
intensity, duration, etc. using the
pain scale. Obtain an exact description.
– Scientific Rationale
• Changes in pain description may indicate
a change in the client’s condition.
6-22
Acute Pain
• Nursing Interventions + Scientific Rationales
– Nursing Interventions
• Administer smallest narcotic analgesic
dose possible to aid in comfort, as
per physician order.
– Scientific Rationales
• Narcotic analgesics affect the level of consciousness and
may interfere with neurological assessment.
6-23
Mobility, Impaired Physical
• Nursing Interventions + Scientific Rationales
– Nursing Interventions
• Monitor and screen client for mobility skills
and activities.
– Scientific Rationales
• Screening and monitoring the client aids in identifying the
level of impairment and provides a baseline of mobility
abilities. Interventions may be planned appropriately.
6-24
Mobility, Impaired Physical
• Nursing Interventions + Scientific Rationales
– Nursing Interventions
• Consult with physical therapy for further evaluation and
development of a mobility plan.
– Scientific Rationales
• Allows staff to integrate collaborative plan, which will
enhance and maximize client’s mobility.
6-25
Mobility, Impaired Physical
• Nursing Interventions + Scientific Rationales
– Nursing Interventions
• Perform passive range of motion to weakened extremities
at least twice daily. Encourage active range of motion and
assist when needed.
– Scientific Rationales
• Strengthens muscles and prevents atrophy
of muscle tissue.
6-26
Tissue Perfusion,
Altered (cerebral/peripheral)
• Nursing Interventions + Scientific Rationales
– Nursing Interventions
• Monitor dorsalis pedis and posterior tibial pulses
bilaterally for equal quality and rate.
– Scientific Rationales
• Diminished or absent peripheral pulses
insufficiency.
indicate arterial
6-27
Tissue Perfusion, Altered
(cerebral/peripheral)
• Nursing Interventions + Scientific Rationales
– Nursing Interventions
• Monitor for change in neurological status. Use
neurological flow sheets to record results of neurological
assessments.
– Scientific Rationales
• Any change may indicate that the brain is deprived of
adequate amount of oxygen due to further bleeding,
increased intracranial pressure, or spasm of cerebral
artery.
6-28
Tissue Perfusion, Altered
(cerebral/peripheral)
• Nursing Interventions + Scientific Rationales
– Nursing Interventions
• Maintain extremities in dependent position and maintain
physical rest.
– Scientific Rationales
• To facilitate arterial blood flow through vessel narrowed by
a thrombus.
6-29
Step Five: Evaluation
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To measure effectiveness of plan
To determine appropriateness of plan
Focus on changes in client’s health status
Progress toward goal attainment
Document:
– Goal met
– Goal not met
– Goal partially met
• AEB (statement based on planning)
6-30
Revision, Modification,
Discontinuation
• Progress
• Lack of progress
6-31
Assignment
• Reading:
– Duncan & DePew: Chapter 6, 7
• Topic:
– Patient Education and Therapeutic Communication
6-32