Orem
Nursing Operations
Nursing Process
Janet Secrest, Phd; RN
Handouts
1.
Nursing Operations: Nursing
Process/Nursing Care Plan
2.
Nursing Care Planning Guide
3.
Nursing Diagnoses by Self-care
Requisite
Objectives
1.
Relate Nursing Process to Standards of
Practice
2.
Explain each concept
3.
Link each concept
4.
Develop tentative self-care deficit statement
5.
Develop tentative design and plan
Level Objectives
Formulate a plan of care to promote self-care
agency
Curriculum Outcomes


Systematically evaluate the quality of nursing
practice
Evaluate own nursing practice in relation to
professional practice standards and relevant
statutes and regulations
ANA Scope & Standards of Practice
15
First 6—assessment, diagnosis, outcomes
identification, planning, implementation,
evaluation
9. Evaluate own nursing practice in relation to
professional practice standards and relevant
statutes and regulations

How do we know if
nursing is needed?
PURPOSE
Is there a need for nursing?
**theory of self care
What does nursing do?
What does nursing
uniquely add to
patient care?
Self (dependent)care Agency
Self -care
Carpenito attributes this more to PT–
We respectfully, but STRENUOUSLY disagree
Assess
Evaluate
Diagnose
Implement
Plan
Control
Diagnosis
(Evaluate)
(Assess, diagnose)
Regulate
Prescription
(Implement)
(goal/outcomes)
may also see
“diagnosis
and prescription”
Design
(Plan)
Health History
BCF
PC
USCR
DSCR
HDSCR
basic conditioning factors
1. Age,
2. Gender
3. Health State
4. Developmental State
5. Family System
6. Sociocultural Spiritual
basic conditioning factors
7.
Healthcare System Factors
8.
Patterns of Living
9.
Environmental Factors
10.Resources
Health state
Pneumonia
Is there a therapeutic demand on USCR:
Air
Yes, patient cannot sleep at night lying down.
When he walks to the bathroom without O2,
his sat drops to **%
Health state
Pneumonia
Does the patient have the ability to meet this
therapeutic demand on USCR: Air
Patient has hospital bed at home that he can raise the
head of; his wife is very knowledgeable about his
condition and has gotten extension tubing so his O2
will reach the bathroom. The home health nurse will
visit the day of discharge to assess home needs.
Health state
Pneumonia
Does the patient have the ability to meet
this therapeutic demand on USCR: Air
The patient’s dependent care agent will be
meeting therapeutic demand for air. YES
universal self-care requisites
1. Air
2. Food
3. Water
4. Elimination
universal self-care requisites
5. Balance: activity and rest
6. Balance: solitude and social interaction
7. Px hazards to life, functioning, well being
8. Promotion of normalcy
Air
Food
Water
Elimination
rest./activity
Solitude/social
interaction
Px hazards, Promote WB
Normalcy
Power Components
Body Control
Vigilance
Energy
Repertoire of
skills
Technical knowledge
Performing
integrating
skills
Motivation
Reasoning
Decision making
ABILITIES
Prioritize
Orem’s Developmental Stages
Intrauterine
Adulthood
Neonatal
Infancy
Pregnancy
Childhood
Adolescence
Orem, 2001, pp. 225-227
developmental self-care
requisites
1.
Provision of conditions that promote
development
2. Engagement in self-development
developmental self-care
requisites
3. Provide conditions that prevent /
overcome existent deleterious effects on
development
developmental self-care
requisites (1of3)
1. Educational deprivation
2. Problems of social adaptation
3. Failures of healthy individuation
developmental self-care
requisites (2of3)
4. Loss of relatives, friends, associates
5. Loss of possessions, loss of occupational
security
6. Abrupt change of residence to an unfamiliar
environment
7. Status-associated problems
developmental self-care
requisites (3of3)
8. Poor health or disability
9. Oppressive living conditions
10. Terminal illness and impending death
health deviation self-care
requisites
1.
Seeking/securing appropriate medical assistance
2.
Being aware of/attending to effects of
pathological conditions
3.
Effectively carrying out medical regimen
health deviation self-care
requisites
4. Attending to side effects of medical regimen
5. Modifying self concept
6. Learning to live with effects of pathologic
condition
Examine, analyze data;
make judgments about
Relationship of BCF/PC and
USCR
DSCR
HDSCR
and means for meeting therapeutic
demands

Power Components
universal
health deviation
Self Care Requisites
Assess, examine,
analyze, judge
BCF
Developmental
When a deficit occurs

Consult Nsg Dx list by USCR

Form tentative
Self-care deficit statement
also known as Nursing Diagnosis
UNIVERSAL SELF CARE REQUISITES
AIR
SOLITUDE-SOCIAL INTERACTION
Airway clearance, ineffective
Aspiration, risk for
Breathing pattern, ineffective
Gas exchange, impaired
Spontaneous ventilation: inability to
sustain
Ventilatory weaning response,
dysfunctional
Ventilation, impaired spontaneous
Relocation stress syndrome
Relocation stress syndrome, risk for
Self-concept, readiness for enhanced
Self-esteem, chronic low
Self-esteem, situational low
Self-esteem, situational low, risk for
Sorrow, chronic
Spiritual distress
Spiritual distress, risk for
Caregiver role strain
Caregiver role strain, risk for
Communication impaired, verbal
Communication, readiness for enhanced
Community coping, enhanced, potential for
Community coping, ineffective
Environmental interpretation syndrome,
impaired
Failure to thrive, adult
Family coping, ineffective: compromised
Family coping, ineffective: disabling
Family coping, potential for growth
Family process, dysfunctional: alcoholism
Family processes, interrupted
Family processes, readiness for enhanced
Loneliness, risk for
Parent/infant/child attachment impaired, risk
for
Parental role conflict
Parenting, impaired
Parenting, impaired, risk for
WATER
Cardiac output, decreased
Dysreflexia
Tissue perfusion, ineffective (specify:
cerebral, cardio-pulmonary, renal,
gastrointestinal peripheral)
Fluid volume deficit
Fluid volume deficit, risk for
Fluid volume excess
Fluid volume imbalance, risk for
Fluid volume, readiness for enhanced
Oral mucous membranes, impaired
Swallowing, impaired
FOOD
Breastfeeding, effective
Breastfeeding, ineffective
Breastfeeding, interrupted
Dentition, impaired
Infant feeding pattern, ineffective
Ineffective airway clearance (p. 537)
Self Care Deficit Statement
(Nursing Diagnosis)

Definition

Defining characteristics
 Major?
 Minor?

? Focus assessment needed
Self-Care Deficit Statement
(diagnosis)



Includes diagnostic label and etiology
Label & etiology linked by relationship
(“related to”)
Direct causation NOT attributed
 (NO “due to”)
Ineffective airway clearance related to
ineffective cough secondary to paralysis
of quadriplegia
Diagnostic Label


Definition must “fit” patient’s selfcare deficit
Defining characteristics must be in
health history
Etiology


Nurse must be able to assess (i.e.,
no medical diagnosis)
Evidence must be in health history
Etiology


May be more than 1 etiology; all
etiologies should be included
Use etiologies in Carpenito (hint: at
this level it would be unusual that you would not
find one to fit your patient  in this book)
Ineffective airway clearance related to
ineffective cough
secondary to quadriplegia and r/t
excessive secretions secondary to
pneumonia
Power Components
health deviation
universal
Self Care Requisites
Assess, examine,
analyze, judge
BCF
Developmental
Self care deficit statement
“diagnostic label related to etiology”
Prescription and Design
Particularized Self-Care Requisite Statement
(Goal)
1.
From patient’s perspective
(the patient will . . .
2. Relate to the diagnostic label
Prescription and Design
Particularized Self-Care Requisite Statement
(Goal)
3. Measurable (see list of verbs), within time
frame
4. Realistic
the patient will not experience aspiration
(Carpenito, p. 628)
The patient will report clear airway q. shift; will
verbalize measures to maintain clear airway
Planning for regulatory
operations
Nursing System Utilized
Wholly Compensatory
Partially Compensatory
Supportive-Educative
Power Components
health deviation
universal
Self Care Requisites
Assess, examine,
analyze, judge
BCF
Developmental
Self care deficit statement
“diagnostic label related to etiology”
Particularized self care requisite statement
“by Feb. 1 the patient will . . . “
Regulation
1. Assess O2 sat
Nursing system
?wholly
 ?partially
 ?supportive-educative

Nursing interventions
Written as nursing orders
Directed toward the etiology
individualized
Short clear commands
direct who, what, when where, how
Nursing interventions
Caveat
Carpenito has a menu of interventions to
choose from—your task is to make the
intervention individualized for your
patient
Methods of Helping
Acting/doing
Guiding
Supporting
Teaching
Providing developmental environment
Interventions:
4 categories
1. Evaluative
2. Attending to the Etiology eliminating /
reducing/ mitigating /adapting to
3. Teaching
4. Referring
Interventions
1. evaluative
1.
Assess breath sounds and pt’s
subjective feeling of airway clearance
q 4 h
Interventions
2. “attend” to etiology
2. Instruct pt to call for assistive cough
q 1hour while awake
3. Maintain hourly assistive check list at
bedside
Interventions
2. “attend” to etiology
4. Instruct pt to call for assistive
cough every hour while awake
5. Suction secretions pt is able to
bring to posterior oral pharynx with
assistive cough
Interventions
3. teach 4. refer
6. Teach wife assistive cough technique
7. Complete home health referral on
9/30
Evidence

For each intervention, state detailed
rationale with the strongest scientific
evidence
Pathophysiology text
 CINAHL search for recent study/literature
discussions
 Carpenito (though often, too vague—need to
delve deeper)

Evidence


This is where you demonstrate your
understanding of concepts, processes,
reasoning, rationale, as well as your
ability to discern relevant data.
Cite your sources
Production of Regulatory Care


Implementing the prescription, design,
plan
Evaluate the self-care abilities of the
pt with respect to this self-care
deficit
Control Operations
Evaluation of the
Prescription,
Design, Plan
Self-care deficit statement #2

Pt with the previous self-care deficit will
likely have >1 self-care deficit

Others may come from USCR

Developmental SCR

HDSCR
Review
1. Self-care deficit statement
Diagnostic Label
related to
Etiology
Review
1.
Diagnostic Label
NANDA approved
a. definition
b. defining characteristics
2.
Nurse must be able to independently
assess
3.
Derived from health history
4.
Must be something the nurse can change
Review
Etiology
1.Nurse must be able to assess
2. Nurse must be able to independently treat
3. May be several etiologies for one
diagnostic label
Review
Diagnostic label + Related to + Etiology
=Self-care deficit statement
Review
Particularized self-care requisite statement
What patient requires to achieve
self-care for that requisite
Particularized self-care requisite statement
Review

Stated from patient perspective (pt will . . .)

Measurable

Realistic

**Relates to the Diagnostic Label
Review
Self-care deficit statement
(Diagnostic label r/t Etiology)
Particularized self-care requisite statement
Review
Interventions
1.
2.
3.
Four categories (evaluative, toward etiology,
teaching, referral)
Short commands (who, what, when, where
Individualized for each patient
Review
Evidence
Cite rationale and strongest evidence you
can find to support your rationale
Dig deep!
Orem


Self-Care Deficit
Statement
Particularized Self
care Requisite
Statement
Carpenito


Nursing Diagnosis
Goal; Expected
Outcome, Outcome
Criteria
Orem



Prescription, design,
plan
Carpenito

Plan
Regulate

Implement
Control

Evaluate
Power Components
health deviation
universal
Self Care Requisites
Assess, examine,
analyze, judge
BCF
developmental
Self care deficit statement
“diagnostic label related to etiology”
Particularized self care requisite statement
“by Feb. 1 the patient will . . . “
Regulation
1. Assess O2 sat
Basic conditioning factors
Self care requisites
Power components
Basic Conditioning Factors
26 year old, mother of infant, 2 year old, and 4 year old
Self-care Requisites
Unable to sleep,
unwanted weight loss
Power Components
Alert, attentive to infant
Universal
Self-Care Requisites
•Meets air requisites
•Lost weight from pregnancy and then
another 12 pounds
•Meets fluid requisites
•Meets elimination requisites
•Exhausted all the time
•Can’t sleep at night; baby wakes
every 4 hours
• all vaccinations, other health exams
up-to-date
•“what’s normal?” I don’t have normal”
I operate minute to minute.”
At this point, began crying.
Self-Care Requisites
Developmental
•Therapeutic demand on
development as mother, and as
adult
•Interferences with healthy
individuation
•Living conditions: close
quarters,
•limited play areas for
children;
• limited adult interaction for her
Basic conditioning factors
Assess
Examine
Analyze
Judge
Self care requisites
Power components
Self-Care Requisites
Health Deviation Self-Care Requisite
•No identified deviation at this
time
Basic conditioning factors
•Health State: has been healthy
•26,
•3 children,
•husband home w-e only
•no other family close by
•does not belong to/ Church
•2 years College
•At home with children
•2 Bedroom apt
•On a “tight budget”; husband’s
job temporary
•Health insurance does not
include prescriptions
Basic conditioning factors
Power Components
•Alert, Vigilant to infant
•Distracted with children during interaction and did not fully attend to any
part of the assessment
•Able to carry infant while attending to other 2 children.
•Children’s hygiene and appearance well cared for; her hair is in clumps,
oily in appearance. Her shirt had many food stains.
Bring to class
1. tentative self care deficit statement
2. a beginning design and plan that
includes
a
particularized self care requisite
statement
 4 tentative interventions