Nursing Implementation Des 2013

8/11/2019 Nursing Implementation Des 2013

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Nursing Process

Implementation

Moh. Afandi, SKep.,Ns.,MAN.,HNC

E-mail: [email protected].

+6281-908-134-304
mailto:[email protected]:[email protected]


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Nursing Process

Specific to the nursing profession

A framework for critical thinking

Its purpose is to:

Diagnose and treat human responses to

actual or potential health problems


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Nursing Process

Organized framework to guide practice

Problem solving method - client focused

Systematic- sequential steps Goal oriented- outcome criteria

Dynamic-always changing, flexible

Utilizes critical thinking processes


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Scientific Method of problemsolving

ID problem

Collect data

Form hypothesis Plan of action

Hypothesis testing

Interpret results

Evaluate findings


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Advantages of NursingProcess

Provides individualizedcare

Client is an active

participant Promotes continuity of

care

Provides more effective

communication amongnurses and healthcareprofessionals

Develops a clear andefficient plan of care

Provides personal

satisfaction as yousee client achievegoals

Professional growth

as you evaluateeffectiveness of yourinterventions


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5Steps in the Nursing Process

Assessment

NursingDiagnosis

Planning

Implementing Evaluating


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Assessment

First step of the Nursing Process Gather Information/Collect Data

Primary Source- Client / Family

Secondary Source- physical exam, nursing history,team members, lab reports, diagnostic tests..

Subjective-from the client (symptom)

I have a headache

Objective- observable data (sign) Blood Pressure 130/80


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Assessment-collecting data

Nursing Interview (history)

Health Assessment -Review of Systems

Physical Exam Inspection

Palpation

Percussion

Auscultation


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Assessment-collecting data

Make sure information is complete &accurate

Validate prn Interpret and analyze data

Compare to standard norms

Organize and cluster data


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Example of Assessment

Obtain info from nursing assessment,history and physical (H&P) etc...

Client diagnosed with hypertension

B/P 160/90

2 Gm Na diet and antihypertensivemedications were prescribed

Client statement I really dont watch mysalt Its hard to do and I ust dont et


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Nursing Diagnosis

Secondstep of the Nursing Process

Interpret & analyze clustered data

Identify clients problems and strengths

Formulate Nursing Diagnosis (NANDA :North American Nursing Diagnosis

Association)-Statement of how the client is

RESPONDING to an actual or potential


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Nsg Dx vs MD Dx

Within the scope ofnursing practice

Identify responses

to health and illness

Can changefromday to day

Within the scope ofmedical practice

Focuses on curing

pathology

Stays the sameaslong as the disease

is present


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Formulating a NursingDiagnosis

Composed of 3 parts:

Problem statement- the clientsresponse to a problem

Etiology- whats causing/contributing tothe clients problem

Defining Characteristics- whats theevidence of the problem


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Nursing Diagnosis

Problem( Diagnostic Label)-based onyour assessment of client(gathered

information), pick a problem from theNANDA list...

Etiology- determine what the problem is

caused by or related to (R/T)... Defining characteristics- then state as

evidenced by (AEB) the specific facts theproblem is based on...


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Example of Nursing Dx

Ineffective therapeutic regimenmanagement

R/Tdifficulty maintaining lifestyle changesand lack of knowledge

AEBB/P= 160/90, dietary sodiumrestrictions not being observed, and client

statements of I dont watch my salt Itshard to do and I just dont get it.


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Types of Nursing Diagnoses

ActualImbalanced nutrition; less than bodyrequirements RT chronic diarrhea, nausea,and pain AEB height 55 weight 105 lbs.

RiskRisk for falls RT altered gait and generalizedweakness

WellnessFamily coping: potential for growth RTunexpected birth of twins.


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Collaborative Problems

Require both nursing interventions andmedical interventions

EXAMPLE: Client admitted with medical dxof pneumonia

Collaborative problem = respiratory

insufficiencyNsg interventions: Raise HOB, Encourage

C&DB

MD interventions: Antibiotics IV, O2 therapy


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Planning

Thirdstep of the Nursing Process This is when the nurse organizes a nursing

care plan based on the nursing diagnoses.

Nurse and client formulate goals to help theclient with their problems

Expected outcomes are identified

Interventions (nursing orders) are selected toaid the client reach these goals.


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PlanningBegin by prioritizingclient problems

Prioritize list of clientsnursing diagnosesusing Maslow

Rank as high,intermediate or low

Client specific

Priorities can change


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PlanningDeveloping a goal and outcome statement

Goal and outcomestatements are clientfocused.

Worded positively Measurable, specific

observable, time-limited,and realistic

Goal = broad statement

Expected outcome =objective criterion formeasurement of goal

Utilize NOC as standard

EXAMPLE

Goal:

Client will achievetherapeutic managementof disease process.

Outcome Statement:

AEB B/P readings of

110-120 / 70-80 andclient statement ofunderstandingimportance of dietarysodium restrictions by

day of discharge.


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Planning- Types of goals

Short term goals

Long term goals

Cognitive goals

Psychomotor goals

Affective goals


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Goals are patient-centered andSMART

Specific

Measurable

Attainable

Relevant

Time Bound

Pt will walk 50 ft.

Pt will eat 75% of meal

Pt will be OOB 2-4hrs

Pt will maintain HR


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Planning-select interventions

Interventions are selected and written.

The nurse uses clinical judgment andprofessional knowledge to selectappropriate interventions that will aid theclient in reaching their goal.

Interventions should be examined for

feasibility and acceptability to the client

Interventions should be written clearlyand specifically.


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Interventions3 types

Independent ( Nurse initiated )- anyaction the nurse can initiate without

direct supervision Dependent ( Physician initiated )-

nursing actions requiring MD orders

Collaborative- nursing actionsperformed jointly with other health careteam members


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Implemention

The fourthstep in the Nursing Process

This is the Doing step

Carrying out nursing interventions(orders) selected during the planningstep

This includes monitoring, teaching,

further assessing, reviewing NCP,incorporating physicians orders andmonitoring cost effectiveness ofinterventions


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Implementing- Doing

Monitor VS q4h

Maintain prescribed diet

(2 Gm Na) Teach client amount of

sodium restriction,foods high in sodium,

use of nutrition labels,food preparation andsodium substitutes

Teach potentialcomplications ofhypertension to instill

importance ofmaintaining Narestrictions

Assess for cultural

factors affectingdietary regime


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ImplementingDoing

Teach the client-hypertension cant becured but it can becontrolled.

Remind the client tocontinue medicationeven though no S/Sare present.

Teach clientimportance of life stylechanges: (weight

reduction, smokingcessation, increasingactivity)

Stress the importanceof ongoing follow-upcare even though thepatient feels well.


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Evaluation- To determineeffectiveness of NCP

Final stepof the Nursing Process butalso done concurrently throughout client care

A comparison of client behavior and/or

response to the established outcome criteria Continuous review of the nursing care plan

Examines if nursing interventions are working

Determines changes needed to help clientreach stated goals.


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FOCUS

Types of interventions: Direct/Indirect

Protocols and Standing Orders

Collaborating with the Client

What is a personalized plan of care?

Implementation process

reassessing.

reviewing and revising existing care plans.

organizing and care delivery.

anticipating and preventing problems.

knowledge, skills, and qualifications.

requiring support and assistance.

Provision of care


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IMPLEMENTATION

The step in the nursing processwhere the nurse provides care to

the clients. The nurse initiates orcompletes interventionsnecessary for achieving goals and

expected outcomes.

Begins after the care plan has


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Implementation

Implementation includes nursinginterventions(any treatment

based upon clinical judgment andknowledge that the nurseperforms to enhance client

outcomes).

May involveassisting and

directing client ADLs, providing

ypes o urs ng


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ypes o urs ngInterventionsDirect Care Interventions:

Treatments performedthrough interaction withthe client i.e. medicationadministration, IVinfusion, grief counseling.


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Indirect Intervention

Treatments performed

away from the client buton behalf of the client orgroup of clients (i.e.documentation,interdisciplinarycollaboration).


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CYCLICAL PROCESS

The nursing process is cyclical.

Implement, evaluate and thenyou may have to review and

adjust your assessment, plan andimplementation based on new

information/data.


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Nursing Intervention: PROTOCOLS

Nursing interventions can bedeveloped, communicated, and

organized on the basis ofprotocols or standing orders.

Protocol:Provides a standard ofcare or clinical guideline that canbe individualized for each client

depending on how an institution


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Standing Order

Pre-printed document containingorders for the conduct of routine

therapies, monitoring guidelines,and/or diagnostic procedures forspecific clients with identified

clinical problems. Must be signedby a licensed

prescribing physician or HCP in

charge of care.

SIX FACTORS TO CONSIDER WHEN


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SIX FACTORS TO CONSIDER WHENSELECTING INTERVENTIONS

Desired or expected outcome:Each outcome should have an

intervention.

Characteristics of the nursingdiagnosis: Intervention will alterthe related factor or treat thesigns and symptoms (defining

characteristics).


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SIX FACTORS TO CONSIDER WHENSELECTING INTERVENTIONS

Feasibility for performing the intervention:cost/time and how it affects other interventions.

Acceptability to the client: Explain how the client

is to participate, what the intervention involves,and how the client might be affected. Importantto collaborate with the client, as they need tomake informeddecisions Consider values,beliefs and culture leads to a personalized plan

of care Capability of the nurse: knowledge of the

scientific rationale, necessary skills, functionwithin the setting, consultation is critical.


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CRITICAL THINKING andIMPLEMENTATION

Consider:

Interventions that have worked in the past.

Review professional and standards of practice.Consider all possible nursing actions.

List the consequences associated with each action.

Determine the probability of consequencesassociated with each action.

Judge the value of the consequence to the client.


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Implementation ProcessSteps in the implementation process

include:

1. Reassess-determine whether the plannednursing action is still appropriate.

2. Review and revision of the presentnursing care plan-may need to revise

assessment data, diagnoses, specificinterventions, and methods ofevaluation.


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Implementation Process

3.Organize resources and care delivery-Determine equipment, personnel and environmentrequired to carry out the interventions. (privacy,reduce distractions, adequate space and lighting,physically and psychologically comfortable,administering comfort measures)

4.Anticipate and prevent complications-Weigh thebenefit of the treatment with the possible risks

and initiate risk preventing measures.


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Implementation Methods:Direct Care

Assist with activities of daily living (ADLs)-activities done through out a day. Ex. Help theclient get dressed, brush teeth, comb hair etc.

Instrumental Activities of Daily Living: skills suchas shopping, preparing meals, taking medicationsect.

Physical Care Techniques: turning and positioning

clients, administering meds, providing comfortmeasures.


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Direct Care

Counseling-Help the individual to use a problemsolving process to manage stress and help withinterpersonal interaction among the client, family

and the HCP. Focus on the development of newattitudes and feelings.

Teaching- Illustrate appropriate techniques andprocedures to clients. Ex. How to use an aerosol.

Focus is on intellectual growth. Observing for adverse reactions: Anticipate and

know potential adverse reactions, nurse actionsreduce or counteract the reaction.


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Indirect Care

Actions that support theeffectiveness of direct care

Communicating nursinginterventions-orally betweennurses and other HCPs.

Unless communication is timelyand accurate, caregivers may

become uninformed,


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APPLICATION TO THE CARE PLAN


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Nursing Interventions

The nursing care plan includes two types ofinterventions nursing interventions (5interventions), and when applicable, client

interventions (4 interventions). Interventions can be implemented by the nurse,

client, family member, depending on the level ofskill and knowledge needed. Maintaining a

partnershipis essential. Interventions must be specific andaddress the

need or desire for a changein client responsewith in the context of a particular situation.


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While there are severalinterventions derived for each

diagnosis, some interventionscan only be implemented by theclient. For example it is the client

that uses the incentivespirometer q1h while awake, it isthe client who attends the fitnessprogram, it is the client who does


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NOTE

Client interventions do NOT mirror nursinginterventions.Forexample, if the nurse administers an oral medication, onecan assume the client will swallow it. If not then it wouldnot be appropriate for the nurse to make a diagnosis that

reflects the situation, for example, impairedswallowingand derive the appropriate care plan. If thenurse is going to assist the client with something (e.g.,assist with dressing), there is no need for a correspondingclient action.

There are times however when a nursing action mustprecede a client actionsuch as when the nurse must teachthe client how to do something, and then the client canproceed unassisted. In this case the nursing intervention isto teach, and following the successful implementation ofthis intervention, the client intervention is to do.


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WRITING/FORMATTINGINTERVENTIONS

VERB-NOUN-MODIFIER

Where applicable the action verbshould be accompanied by what(noun) as well as by how much,how often, and/or under whatconditions/circumstances(modifiers).


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Intervention may include , but are not limited to those listedin the categories below:

Act for/do for: adjust, aspirate, decrease, empty, give,assess, auscultate, examine, measure, monitor, note,

observe, palpate.

Guide: guide, inform, discuss, show, counsel, assist, etc.

Support:share, suggest, talk, promote, encourage, assist,maintain, explain, ask, reinforce, etc.

Teach:demonstrate, discuss, explain, inform, instruct, list,review, show, etc.

Provide and environment that promotes physical,psychosocial and spiritual development and or positive lifestyle change: provide, promote, encourage, suggest, give,etc.


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The literature based rationale forinterventions

The literature based rationale forinterventions describes the basis

or reason for the interventions.Rationale is based on scientificresearched-based, and or

theoretical information fromcurrent nursing and or healthrelated texts and journals.


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Summary

Types of interventions: Direct/Indirect

Protocols and Standing Orders

Collaborating with the Client

What is a personalized plan of care?

Implementation process

reassessing.

reviewing and revising existing care plans.organizing and care delivery.

anticipating and preventing problems.

knowledge, skills, and qualifications.

requiring support and assistance.


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ALHAMDULILLAH

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Nursing Implementation Des 2013