Putting It All Together
West Coast University
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The Nursing Process Group at West Coast University:
Working together in the quest of human response
¡Hola!, I’m
Ns. Planning
I’m Ns.
Assessmen t
Hi, I’m Ns.
Diagnosis
Hey, I’m Ns.
Implementation with Scientific
Rationale
Yo, I’m
Ns. FHP
Dude, it’s me,
Ns. Evaluation
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• Cyclic
• Ongoing
• Client centered
• Promotes organization
• Promotes problem resolution
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• Data collection
• Verification and validation
• Organization of data
• Data interpretation
• Database is formed
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• Subjective
– feelings, perceptions, concerns
• Objective
– observable
– measurable
– felt by others
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• Tools with a purpose
• Holistic data collection
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• Relatedness
• Patterns
• Support facts
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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
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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
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• Ineffective nonproductive cough
• Capillary refill sluggish
• Oxygen saturation low on room air
• Restless
• Difficulty vocalizing
• Observed dyspnea with exertion
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• Cognitive-Perceptional Pattern
– 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
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• 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”
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Data Clustering
• Nutritional Metabolic Pattern
– Corner of mouth droops
– Difficulty pronouncing words
– Has not eaten since symptoms began
– Nausea
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• Problems identified
• Potential problems identified
• Diagnostic labels determined
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• Identify priorities
• Determine realistic goals and expected outcomes
• Determine interventions and rationale
• Communicate and document
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• Data may determine
• Discovered during interview, assessment
• Client’s preference
• Consider Maslow’s hierarchy
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• Unique to client
• Give direction to plan
• Focus on etiology
• Indicate intent or desired change
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• Subject
• Behavior
• Criteria of performance
• Time frame
• Condition
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• Begins with assessment
• Assessment is ongoing
• Execute the care plan
• Has independent nursing function
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• Scientific principles
• Underlying reason
• Utilizing resources
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• 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.
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• 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.
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• 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.
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• 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.
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• 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.
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• 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 indicate arterial insufficiency.
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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.
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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.
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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)
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• Progress
• Lack of progress
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• Reading:
– Duncan & DePew: Chapter 6, 7
• Topic:
– Patient Education and Therapeutic Communication
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