E2 2007Dx [Read-Only] · PDF fileNursing diagnosis A nursing diagnosis ... = Nurses intervention with other health care ... Qualifiers for Diagnosis Acute= Severe but short duration

Nursing ProcessNursing Process

ByBy

Associate Professor W. Associate Professor W. KusoomKusoom

Nursing ProcessNursing Process

The nursing process enables the nurse to The nursing process enables the nurse to organize and deliver nursing care.organize and deliver nursing care.

The nursing process involves scientific The nursing process involves scientific reasoning.reasoning.

The nursing process is used to identify, The nursing process is used to identify, diagnose and treat human responses to diagnose and treat human responses to health and illness.health and illness.

Nursing Process

= Critical Thinking Approach= Critical Thinking Approach= Critical Thinking Approach= Critical Thinking Approach= Critical Thinking Approach= Critical Thinking Approach= Critical Thinking Approach= Critical Thinking Approach

Nursing ProcessNursing Process

NURSING NURSING STANDARDSTANDARDPROCESSPROCESS NURSINGNURSING

Nursing ProcessNursing Process

Includes Includes 55 stepssteps

Evaluation Nursing Diagnosis

Assessment

Implementation Planning

Analysis

AssessmentAssessment

The assessment must be relevant to The assessment must be relevant to particular health problem.particular health problem.

The nurse uses critical thinking to collect The nurse uses critical thinking to collect and analyze data to determine what is and analyze data to determine what is relevant for the assessment database.relevant for the assessment database.

Types of DataTypes of Data

During assessment, the nurse must During assessment, the nurse must obtains two types of data. These are obtains two types of data. These are

Subjective data

Objectivedata

Subjective dataSubjective data

Subjective data Are clients perception Subjective data Are clients perception about their health problems.about their health problems.

For example, the presence of pain or For example, the presence of pain or meaning of an illness. meaning of an illness.

Objective dataObjective data

Objective data are observation or Objective data are observation or measurements made by the data collector.measurements made by the data collector.

Method of data collectionMethod of data collection

Interview, is a pattern of communication.Interview, is a pattern of communication.

Physical assessmentPhysical assessment

Nursing assessmentNursing assessment

Medical recordMedical record

ICU Patient& EnvironmentICU Patient& Environment

ICU PatientICU Patient

Nursing diagnosisNursing diagnosis

A nursing diagnosis is a statement that A nursing diagnosis is a statement that describes the clientdescribes the client’’s actual or potential s actual or potential response to health problem is licensed response to health problem is licensed and competent to treat.and competent to treat.

Nursing diagnose provide the basis for Nursing diagnose provide the basis for selection of nursing interventions to selection of nursing interventions to achieve outcome for which the nurse is achieve outcome for which the nurse is accountable.accountable.

=

Nursing Diagnosis StatementNursing Diagnosis Statement

Diagnostic LabelDiagnostic Label + + Related to (RT)Related to (RT)

Nursing diagnosisNursing diagnosis

Impaired skin integrity Impaired skin integrity related torelated todecreased mobilitydecreased mobility

Risk for infection Risk for infection related torelated to poor nutritional poor nutritional intake intake

Nursing Nursing DxDx

1. Acute pain 1. Acute pain RTRT TubalTubal rupturerupture

2. Risk for fluid volume deficit 2. Risk for fluid volume deficit

RT hemorrhagic loss, RT hemorrhagic loss, trictedtricted

fluidfluid

3. Anxiety 3. Anxiety RTRT pain& threat of pain& threat of

deaddead

Evolution of Nursing DiagnosisEvolution of Nursing Diagnosis

In 1973, the first national conference for In 1973, the first national conference for the classification and of nursing diagnosis the classification and of nursing diagnosis

was held to identify nursing functions and was held to identify nursing functions and

established a classification system.established a classification system.

NANDANANDA

North American Nursing Diagnosis AssociationNorth American Nursing Diagnosis Association

NANDANANDA’’ss work provides a common language for the health problems work provides a common language for the health problems

nurses deal with.nurses deal with.

ANA has officially sanctioned NANDA as the organizationANA has officially sanctioned NANDA as the organization

to govern the development ofto govern the development of

a classification system of nursing diagnosis.a classification system of nursing diagnosis.

3 Type of NANDA 3 Type of NANDA International International DxDx

1. Actual nursing diagnosis1. Actual nursing diagnosis

2.Risk nursing diagnosis2.Risk nursing diagnosis

3.Wellness nursing diagnosis=Potential3.Wellness nursing diagnosis=Potential

1.Ineffective airway clearance RT1.Ineffective airway clearance RTthickened mucus secretionthickened mucus secretion

2.Activity intolerance RT imbalance O2 supply 2.Activity intolerance RT imbalance O2 supply and demandand demand

3.Pain RT inflammation& effect of3.Pain RT inflammation& effect ofcirculating toxincirculating toxin

Nursing Dx

Collaborative problemCollaborative problem

= = Actual /potential problems Actual /potential problems

= Nurses intervention with other health care = Nurses intervention with other health care

Ineffective airway clearance RT Ineffective airway clearance RT tracheotracheo

bronchial secretionbronchial secretion

Wound infection RTWound infection RT…………....

Impaired gas exchange RTImpaired gas exchange RT…………

Decrease cardiac output RT preload Decrease cardiac output RT preload

Planning for Nursing CarePlanning for Nursing Care

Planning for Nursing Care is a category of Planning for Nursing Care is a category of nursing behaviors in which clientnursing behaviors in which client-- centered centered goal and expected out comes are goal and expected out comes are established and nursing intervention.established and nursing intervention.

Planning for Nursing CarePlanning for Nursing Care

1.Drug administered 1.Drug administered (MO 4 mg dilute 1:1)(MO 4 mg dilute 1:1)

V push slowly as V push slowly as orderorder

2.Instruct 2.Instruct patienpatien in in relaxation exercise.relaxation exercise.

3.Encourage patient 3.Encourage patient to log roll when to log roll when turning.turning.

--Pain Pain decrease decrease by 3/10by 3/10--RespiratoryRespiratory

expansionexpansion

Pain related toPain related to

IncisionalIncisionalswellingswelling

Nursing Plan/Nursing Plan/

Nursing OrderNursing OrderExpect Expect

OutcomeOutcomeNursing Nursing DxDx

ImplementImplement

Cognitive skills= know the rationaleCognitive skills= know the rationaleInterpersonal skills=clientsInterpersonal skills=clients

Psychomotor skills= Psychomotor skills= as levelas level competencecompetence

Nursing ImplementationNursing Implementation

Nursing Nursing DxDx is is notnot � � Medical Medical DxDx

Nursing Nursing DxDx

= is describes the = is describes the response to health response to health problem problem

Medical Medical DxDx==is Diagnoses diseaseis Diagnoses disease

Qualifiers for DiagnosisQualifiers for Diagnosis

Acute= Severe but short durationAcute= Severe but short duration

Alter= a change from baselineAlter= a change from baseline

Chronic= Chronic= Lasting along time, recurring, constantLasting along time, recurring, constant

Decrease= lessenedDecrease= lessened

Increase = greater in sizeIncrease = greater in size

Deficient=inadequate in amount, not sufficientDeficient=inadequate in amount, not sufficient

Depleted= empty, exhausted of..Depleted= empty, exhausted of..

Disturbed= agitated, interruptedDisturbed= agitated, interrupted

Dysfunction=abnormalDysfunction=abnormal

Qualifiers for DiagnosisQualifiers for Diagnosis

Excessive= Excessive= QualtityQualtity is greateris greaterImpaired =made worse, damageImpaired =made worse, damage

Ineffective =Not producing the desired effectIneffective =Not producing the desired effect

Potential for =powerfulPotential for =powerful

Risk =hazard, chance of lossRisk =hazard, chance of loss

Hypothermia= Hypothermia= body temperature is reduced below normalbody temperature is reduced below normal

Hyperthermia =body temperature is elevated above normalHyperthermia =body temperature is elevated above normal

Enhanced = made greater, increase qualityEnhanced = made greater, increase quality

ExerciseExercise…….. Bronchitis?.. Bronchitis?

S&S :S&S :----���������� 38 38.5.5--������ ������������ ������ ������ ก�������ก�������

-- ���� �������������� �� ���� �� 32 32 ����������//�������� ���� ��� ���� ��� !� !�

�� �������� ������ RonchiRonchi--�"#���"#�� ����ก�#����ก�# $��$��

--#�������#������� ��ก$�����ก$��� %&�����%&����� $���$���

Please translate to Please translate to EnghlishEnghlish & Nursing diagnose and & Nursing diagnose and care plan care plan