NURSING CARE MANAGEMENT NCM 100A LC Carl Ian Samson BSN 1Y2-14 PRELIM: NURSING PROCESS: ADPIE Assessment

sment Diagnosis Planning Intervention / Implementation Evaluation

B. OBSERVATION use of the four senses

SOURCES OF DATA: PS

a. Primary first hand data; collected from the pt;

when pt answers the nurse

b. Secondary second hand; data from other

person other than the pt TYPES OF DATA TO BE COLLECTED: SOCV a. b. c. d. Subjective Objective Constant race, gender Variable age, anything related to health

ASSESSMENT: COVD To know the problem The following steps:

FOUR TYPES OF ASSESSMENT: AETI

a. Actual / Problem Focus done while nursing

process is ongoing; pt has changing needs

COLLECTION getting the data; compile data to form database of the pt

b. Emergency immediate assessment; you have to

make a quick decision

c. Time Lapse past to present assessment

comparison of data

A. INTERVIEW: (You collect data + explore pts

problem)

d. Initial happens after the confinement of pt, or

during the admission of pt; purpose is to make database information of pt; eg first vital signs you get Eg: Initial Emergency DOB (emergency) and Airway (actual problem focus) FACTORS TO BE CONSIDERED WHEN YOU ARE COLLECTING DATA VIA INTERVIEW: LPTRAD a. b. c. d. e. f. Language Place Time Relevance of the Topic Angle Distance

Parts: OBC

a. Opening greetings; time to develop

rapport; introduction mode; tell time limit of interview b. Body conversation + data collection c. Closing termination of conversation

Types: DN

a. Directive needed by the nurse; nurse

is in control of the interview; nurse asks questions; organized; with checklist b. Non-Directive the pt controls; the pt simply talks and nurse simply gathers data b.1 Close-Ended yes or no type b.2 Open-Ended answerable by long sentences of the pt; eg What happened to you? b.3 Neutral non-pressuring questions; non-offensive; no prejudice Eg How are you today? b.4 Leading answerable by yes or no, but leads you to an answer you expect Eg Are you having a hard time today?

PATTERN OF ASSESSMENT: IPPA

a. Inspection to look b. Palpation to touch; try to palpate abnormalities c. Percussion to tap; make a sound using hand to
the body of the patient

d. Auscultation use ear to hear sounds in the pts

body eg use of stethoscope THREE APPROACHES OF ASSESSMENT: CBS

a. Cephalocaudal head to foot b. Body System system by system examination c. System Review you are only focusing on one
system ORGANIZATION ELEVEN TYPOLOGY: HNEASCSRSSV DOCUMENTATION Recording the timely information without the nurses interpretation You will write as is No more, no less; what you see is what you write; record only what you can do; failure to do so will result to negligence, malpractice, or fraud

1. Health Perception / Management what you think

is the problem; everyone has his own perception of his health; what you know about yourself 2. Nutrition 3. Elimination 4. Activity Exercise 5. Sleep 6. Cognitive Perception 7. Self-Concept 8. Role Relationship 9. Sexual 10. Stress / Coping 11. Values MASLOWS HIERARCHY OF NEEDS: PSLSS 1. 2. 3. 4. 5. Physiological Needs Safety Love and Belongingness Self-Esteem Self-Actualization

CHARACTERISTICS: FAT

1. Factual realistic; accurate 2. Actual really happened 3. Timely updated; taken from the time of
assessment DIAGNOSIS THREE PARTS: PES 1. 2. 3. Problem Etiology Signs and Symptoms

TYPES OF NURSING DIAGNOSIS: WARPS

VALIDATION Confirmation; making sure False negative: wrong but looks true False positive: true but looks wrong*

1. Wellness this is your perception or your

response to your health level awareness; you are preparing yourself for disease; eg vaccination; Wellness Diagnosis; no disease, just concerned about health 2. Actual the present problem; the most common diagnosis; given information at the present; ongoing problem 3. Risk Dx ideas; problems that do not exist yet, but there are risk factors that are influencing or may influence the situation; eg smoking is a risk factor; probability of happening 4. Possible the problems are incomplete; starting point of disease but not a complete disease; presence of symptoms but not incomplete; eg HIV possibly becomes AIDS; vague but going there 3 STEPS IN DIAGNOSTIC PROCESS: AIF

VALIDATION PROCESS: CCDDR

1. Compare compare taken data from normal data 2. Clarify always clarify the information. Be sure
that the data you get from pt is true

3. Double-Check double check the data before

recording to avoid mistakes that will give further problems 4. Determine determine if data is normal or abnormal 5. Reference use other persons as reference to double check Cues observable data; data from pt; what nurse senses and what pt says Inference the nurses interpretation To check meds, follow: Pharmacy-Nursing Station-pt

1. Analyzing Data do three things: a. Compare make sure to know difference

between normal and abnormal

b. Cluster Cues Put altogether all the data

about pain, separate other issues

c. Identify gaps and Inconsistencies for

further evaluation, check again 2. Identify the Problem go to subjective data and look for chief complain problem; assess what you should do; look for the: a. Risk potential and actual problems b. Strength look for strength in the middle of complications; more strength = doing well; more risks = longer term for treatment 3. Formulating the Dx Statement: a. 2-Part: PE b. 3-Part: PES 3-Part is better so that you can further identify the problem

3. Discharge Continuity of Care; there must be

continuous caring even if the pt is outside the hospital; care must not be cut; prescriptions are part of discharge; follow-up dates PLANNING PROCESS: SESI

1. Setting Priority prioritize what problem must

be attended; what should be solved first a. High critical; life and death situations; 5050 c. Medium can be delayed; brought by diseases or improper function of the body; NOT life threatening, eg fever, you have to lessen / eradicate the extent of the damage / disease; plan so that disease will not get worse b. Low due to improper development of the person; not physically related, but more on psychological and social aspects 2. Establishing Patients Goal the patient should be involved here; when you tell what the medicine is for; let the pt know so that he can cooperate; mostly done by the nurse; you are making expectations: Outcomes: Goal something you want to happen Desired Outcome expected to happen a. Long Term long period of planning; can be done in the future; takes time; eg cancer b. Short Term short period of planning; needs immediate attention; emergency cases; eg pain 3. Setting Proper Nursing Intervention always done with rapport - think of this after planning; this will depend on the nature of the problem; eg pt with fever, loosen clothes and dont give blanket or give paracetamol? 4. Individualized NCP Writing part when you start action; do the interventions; individualized because every shift has a new problem FACTORS TO BE CONSIDERED IN PLANNING: PRPU

SKILLS IN DX PROCESS: CAS

1. Critical Thinking use of intelligent guessing;

make a review of pt and data; try to simulate ideas and identify what is the proper diagnosis 2. Analysis (Deductive) general to specific; like in collection + organization; you are given data, your job is to separate critical data from other data; you are getting the important information; get the chief complain; analysis is also called decuctive, because you are separating the important details so that you can give proper diagnosis 3. Synthesis (Inductive) put together all the data so that you can create nursing intervention afterwards; for every problem, there is an intervention; compile all data; after deductive, compile them but indicate borders to emphasize important data PLANNING Systemtic phasing of nursing process; goal / plan of objective; what you want to happen

THREE TYPES OF PLANNING: IOD

1. Initial planning after the admission of the pt;

you will be dealing with the immediate problem; attend to the first problem you see; act on the first problem presented 2. Ongoing happens from the time of admission up to the discharge of the patient; beginning to end; has the following purposes: a. Check the condition of the pt you need to check again because the condition of pt is changing; can be better or worse b. Know when a nurse needs assistant

1. Pts Beliefs take note of religion 2. Resource Available consider the financial
status of pt and capacity of the hospital; eg manpower 3. Pts Priority some pts prioritize life, some go for money, some for belief

4. Urgency of the Problem give priority if

problem is severe; eg dizziness IMPLEMENTATION Starts from individualized NCP writing; transition Act how to achieve the goal Before you act, segregate nursing intervention into three parts:

PART OF NURSING INTERVENTION [Supplement Only]

THREE TYPES OF NURSING INTERVENTION OR IMPLEMENTATION: IDC

1. Independent nursing action that can be done

without doctors order; nurse alone acts, as long as it is independent; eg positioning of the pt 2. Dependent nurses action that depends on Dr.s order; there is always an order; eg giving medication 3. Collaborative teamwork; two or more health professionals working for the health of the pt INTERVENTION / IMPLEMENTATION SKILLS: CITT

Nursing Intervention should be holistic perceiving the person as a whole human being; all aspect of person is equally recognized Provide support person to pt When pt is asking something, give appropriate answer with gesture When doing intervention, give dignity and respect to pt There should be adaptation of Nursing activity to the pts activity While nurse is doing something, make it a part of the pts activity Right-handed, put IV on the left Base nursing knowledge on a problem, so that there will be no conflict between theoretical and applied When you are giving intervention to pt, make sure you give health teaching to pt Ensure safety for every nursing intervention Clearly understand intervention for implementation; justify reasons for actions

1. Cognitive mental capacity; IQ tests

Separated into: KCAASE: Knowledge, Comprehension, Application, Analysis, Synthesis (making conclusions), Evaluation (assessing whether you are able or not able) 2. Interpersonal having contact with the pt; give rapport or trust; be good in communication 3. Technical hands-on skills; how to do the procedure 4. Therapeutic Use of Self Helping; counselling; offer self to the pt IMPLEMENTING PROCESS: RIDDS

IMPLEMENTATION CRITERIA: VDP 1. Validating the Case have you done

2. Documenting Nursing Care Plan write what 3. Pts Chart / Records has three types: a. Traditional - used by medical practitioners
to record pts condition before and after treatment b. Narrative not specific; mostly used by nurses for their convenience; narrating what happened; a paragraph of events c. Problem-Oriented record that only focuses on the problem and only the problem DIFFERENT FORMS RECORDS: KF / SHEETS OF PTS

1. Reassessment check again after intervention; to

know changes within the pt

2. Implementation of Intervention act now; do

your selected nursing intervention

3. Determine the needs for assistance when it is

impossible to do everything; partial failure; when difficulty is arising 4. Documenting Nursing Intervention chart intervention immediately 5. Supervising Nursing Activities the reason why single shifts are not allowed; 2 or more in one ward Implementation = Action ROM Range of Motion (capacity of joint)

1. Kardex made of index card; most accessible to

use; always have this while inside the hospital; separate from chart because it is already the summary of chart; changes every day; used in endorsement, because it is turned over to the next shift 2. Flow Sheet sheet or paper document showing numerical data + other data being assess from past to present Types:

a. Graphical Record graphical charts used in

recording vital signs b. Intake and Output same amount of food eaten and defecated; drunk and urinated c. Medication Record where the schedule for medication is located as well as the types of medications themselves; give on the right time; paper where you sign that you have administered the meds d. Skin Test Record / Allergy Record for pts allergic to medication ANST After Negative Skin Test; you will only give med when it is negative 3. Progress Notes a note done by nurse or doctor which will state the health of the pt Prognosis whether pt is getting better or worse 4. Nursing Discharge / Referral Summaries done when you are about to discharge the pt; narrative report before pt is discharged; you recorded that pt is about to go out of the hospital 5. Long Term Documents documents that are being used in long-term treatments; pt is going in and out of the hospital; eg cancer TYPES OF CASE: SI

3. Outcome Evaluation demonstrate the

changes in the condition of the pt

Sentinel Event happened in the hospital; may be death or a serious injury that caught attention; significant phenomenon that must be known Root Care Analysis you will identify the factors / causes of the phenomenon; source of sentinel event; what triggered the action Audit Review of Record; check or recheck record; audit for the sake of reassessing a. Retrospective Auditing past records b. Concurrent Auditing present records

1. Skilled Care intensive in nature; you

should be skilled enough to do the procedure; only a licensed nurse does this 2. Intermediate Care given to pts who have chronic cases and should be able to do Activities of Daily Living (ADL) EVALUATION Analyzing the result of the nursing process PARTS OF EVALUATION: CS

1. Conclusion you are referring to types of

outcome a. Goal Met b. Goal Partially Met c. Goal Not Met 2. Supportive Data data that supports the evidence that the goal is met THREE COMPONENTS OF CARE IN EVALUATION: SPO

1. Structured Evaluation focuses on the

setting; to evaluate workplace or place where nursing intervention took place 2. Process Evaluation how you deliver care to pt