103 Notes

• Problem Solving Process

  1. Identifying the problem - recognizing and defining

  2. Analyzing the problem - assess and gather data

  3. Formulating possible solutions - potential options and considering their consequences

  4. Determine the best course of action - choosing what is the most effective solutions

  5. Implementing the solutions - carry out chosen solutions

  6. Evaluating the outcomes - reflect on the results of your actions
• Nursing Process

  1. Note observation

  2. Ministration of care

  3. Validation
• Nursing Process

  1. Assessment

  2. Decision

  3. Nursing Action
• Nursing Process

  1. Client's behavior

  2. Nurse's reaction

  3. Nurse's action
• Nursing Process

  1. Assessing

  2. Planning

  3. Implementing

  4. Evaluating
• Clients


  well person that are at risk
• Patients


  person with disease
• ANA (American Nurses Association) introduced nursing diagnosis
• Characteristics of Nursing Process

  • Patient-centered: focus on patient's needs, values, and preferences
  • Interpersonal: provides basis for therapeutic process; growth-facilitating
  • Collaborative: coordinate and cooperate with others to develop the most efficient interventions and patient care; having open communication and shared decisions
  • Dynamic and cyclical: each cycle interacts with one another and influence other phases
  • Requires critical thinking: to come up with a good assessment; vital in identifying client's problems
• Phases of the Nursing Process


  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation
• Assessment


  Collecting, validating, organizing, and recording data about the client's health status
• Sources of Data

  • Primary - patient/client
  • Secondary - family members, significant others, patient's record/chart, members of the healthcare team
  • Tertiary - related studies, literature as reference
• Validation


  Making sure that data collected is accurate
• Diagnosis


  Clinical act of identifying problems
• Nursing diagnosis


  Statement of client's potential or actual problem
• Types of Identifying Nursing Process

  • PRS - Problem, Related Factors, Signs & Symptoms
  • PES - Problem, Etiology, and Signs & Symptoms
• Outcome Identification


  Formulating and documenting measurable, realistic, client-focused goals
• Establishing Priorities


  • Life threatening situations
  • Principles of ABCDs: Airway, Breathing, Circulation, Disability
  • Maslow Hierarchy of Needs
  • Consider what is important to the patient (e.g. pain or anxiety)
• Classification of Goals


  • Short-term goal - can be met in a short period of time; within days or less than a week
  • Long-term goal - requires more time; several weeks or months
• Planning


  Strategies or course of action to be taken before implementation of nursing care
• SMART

  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time Building
• Types of Plan

  • Initial plan - done by the nurse that conducted the admission assessment; initial plan
  • Ongoing plan - start at the beginning of the shift; depends on the condition of the patient that is different based on timed assessments
  • Discharge plan - needs of the patient after discharge; health teachings
• Nursing Care Plan


  Blueprint of the nursing process
• Implementation


  Carry out planned nursing interventions to help client attain goals and achieve optimal level of health
• Fields/Classes of Interventions Based on NIC

  • Behavioral Nursing Intervention - changing the behavior of the patient
  • Community Nursing Intervention - anything related to the community that helps in achieving optimal health status
  • Family Nursing Intervention - influencing the patient's family
  • Health System Nursing Intervention - related to the interventions and guidelines planned by the medical facility and how they are efficient to achieve optimal health status; safe medical facility
  • Physiological Nursing Interventions - basic interventions (hands-on interventions; e.g. feeding hygiene); complex interventions (invasive procedures; e.g. IV infusion, placing catheter, IGT)
  • Safety Nursing Interventions - ensuring the safety of the patient
• Skills Needed


  • Cognitive Skills - intellectual skills in problem solving and identifying priorities; health teachings
  • Technical Skills - carried out as treatment and procedures to the patient to relieve; nursing procedures
  • Interpersonal Skills - communication skills with therapeutic techniques; creating rapport
  • Therapeutic Use of Self - willingness and ability to care for others
• Evaluation


  Appraise the extent to which goals and outcome criteria of nursing care have been achieved
• Evaluation Outcomes

  • Goal-met: client's response is the same as what you anticipated; results are according to what you expect
  • Goal-partially met: either short term or long term goal was not or incompletely attained
  • Goal-not met: desirable outcomes were not achieved
• Infection


  invasion of body tissue by microorganisms
• Asepsis


  absence of disease-producing microorganisms
• Sepsis


  the presence of microorganisms
• Sterilization


  process by which all microorganisms including their spores are destroyed
• Pathogenicity


  the ability to produce a disease
• Stages of Infection

  • Incubation period - 1 - 4 days; exposure to pathogen until symptoms start
  • Prodromal period - nonspecific symptoms
  • Period of illness - noticeable symptoms; laboratory exams; 5 - 7 days; localized
  • Period of decline - pathogen decreased in number; secondary infection; pathogen can still transmit to other host
  • Period of convalescence - recovery period; depending on the severity of the infection

  
• Chain of Infection


  • Pathogen
  • Reservoir
  • Portal of Exit
  • Mode of Transmission
  • Portal of Entry
  • Susceptible Host
• Pathogen


  • Bacteria, virus, fungi, parasite
  • Ability to thrive: Pathogenicity - ability to produce and reproduce, Virulence - severity/harmfulness, Invasiveness - tendency to spread
• Key Portals

  • Alimentary (GI; Gastrointestinal) - vomiting, diarrhea, biting
  • GU (Genital Urinary) - sexual contact, urination, bowel elimination
  • Skin - lesions
  • Trans-placental - from mother to fetus
  • Respiratory - coughing, sneezing, talking
• Types of Portal of Entry

  • Inhalation
  • Absorption
  • Ingestion
  • Inoculation
  • Introduction
• Factors of Susceptible Host


  • Age
  • Underlying health conditions
  • Environmental factors
• Break the Chain of Infection

  • Immunization
  • Asepsis
  • Cleaning
  • Disinfection
  • Sterilization
  • Use of Barriers
  • Isolation System