Nursing Process presentation by Rebira .pptx

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1. NURSING PROCESS Set by: Rebira W.

2. Objectives By the end of this presentation participants will be able to : Explain historical perspective of nursing process Define nursing process Explain the characteristics of the Nursing process Mention the components/steps of nursing process

3. Outline Historical perspective of nursing process Definition of N ursing process Characteristics of Nursing Process Components/Steps of Nursing Process Summary

4. Historical Perspective of Nursing Process In 1955 by Lydia Hall Mentioned the term nursing process for the first time She introduced three steps of nursing process: Observation Administration of care & Validation

5. Historical Perspective of Nursing Process… In the late 1950 th Johnson & In the early 1960 th Orlando & Wiedenbach They introduced three steps of nursing process Assessment Planning & Evaluation . In the late 1960 th Yura & Walsh identified four steps in the nursing process Assessment Planning Implementation & Evaluation

6. Historical Perspective of Nursing Process… Nursing diagnosis was added as a separate and distinct step in the nursing process by the North American Nursing Diagnosis Association ( NANDA ) in 1974 . Prior to this, nursing diagnosis had been included as a natural conclusion to the first step, assessment.

7. Historical Perspective of Nursing Process… Latter in 1991 ANA included outcome identification as a specific part of the planning phase making the nursing process five steps. Currently the nursing process consists of six phases or steps : assessment, diagnosis, outcome identification , planning interventions, implementation, and evaluation.

8. Historical Perspective of Nursing Process…

9. Nursing Process Definition of nursing process Is a systematic problem- solving approach toward giving individualized nursing care. Is a systematic method that directs the nurse and patient as together they accomplish each steps in the nursing process. The diagnosis and treatment of human responses to actual and potential health problems or illness ( ANA, 1995 )

10. Nursing Process … An organized and systematic process of giving goal oriented (problem solving) and humanistic nursing care (holistic) that is both effective and efficient to patient/client (individual, family or community ). It is the “tool” and methodology of the nursing profession and, as such, helps nurses in arriving at decisions and in predicting and evaluating consequences.

11. Nursing Process … Definition of nurse Is a person who trained and experienced in nursing profession and interested in care of sick/well person. Has completed a program of basic, generalized nursing education and is authorized by the appropriate regulatory authority to practice nursing (ICN 1987 ).

12. Nursing Process … Examples of Responses Pain and discomfort Daily experience such as:- Anxiety Loss Loneliness Grief

13. Nursing Process … Self care limitation in the area of ADL such as: Communicating Eliminating Maintaining body temperature Expressing sexuality Working and playing Sleeping

14. Characteristics of Nursing Process Within the scope of practice Planned Based on knowledge-Research based Patient centered Goal directed Prioritized Dynamic and cyclic Interpersonal and collaborative Universally applicable

15. Steps In Nursing P rocess (ADOPIE) 1) Assessment Data Collection -Primary / Symptoms-Directly from the pt -Secondary/ Signs-By health providers 2) Diagnosis -Analysis of data 3) Outcome Identification -Setting measurable criteria 4 ) Planning -Goals Prioritized

16. Steps In Nursing Process ( ADOPIE)… 5 ) Implementation Intervention Action 6 ) Evaluation Goal met? Reassessment NB Today Outcome Identification is added as the sixth step of nursing process

17. Steps In Nursing Process ( ADOPIE )…

18. Summary Nursing process is a dynamic, systematic, cyclic, client centered way of providing individualized and holistic nursing care. It encompasses six sequential and interlinked steps (assessment, diagnosis, outcome identification, planning intervention, implementation, and evaluation).

19. NURSING ASSESSMENT Set by: Rebira W.

20. Objectives By the end of this presentation participants will be able to : Define nursing assessment Describe types of assessment Identify the four phases of assessment List the sources of data Discriminate between subjective and objective data Describe how data is collected Describe a method of organizing data Assess patients using 11 Gordon’s functional health patterns as nursing assessment tool

21. Outline Definition of assessment Types of assessment Phases of assessment S ources of data Method of data collection Functional health patterns Summary

22. What is Nursing Assessment? Breakout 1

23. Nursing Assessment Definition A systematic collection of subjective and objective data from patients, family, or community with the goal of making clinical judgment about patient , family, or community . Is the 1 st phase of nursing process. Is the collection of data for nursing purposes.

24. Note Remains accessible to the entire health care team during the course of patient stay Do not duplicate medical assessments Medical assessments -Target pathologic conditions Nursing assessments - F ocus on the patient’s responses

25. Breakout 2 Why we do nursing assessment?

26. Purpose 1.To establish baseline information on the client 2. To determine the client’s Normal function Abnormal function Risk for dysfunction & Strengths 3. To provide data for the diagnosis phase

27. PREPARING FOR ASSESSMENT Type Aim Time Frame 1. Initial Ass’t -Initial ass’t of normal function, functional status, & collection of data concerning actual or potential dysfunction -Baseline for reference & future comparison Within the specified time frame after admission to hospital, nursing home, ambulatory healthcare center 2. Focus-Assessment Status determination of a specific problem identified during previous assessment Ongoing process, integrated with nursing care, a few minutes to a few hours b/n ass’t

28. ... … … … 3. Time- lapsed Rea ss’t -Comparison of ct’s current status to baseline obtained previously -Detection of changes in all functional health patterns after an extended period of time has passed Several months( 3,6,9 months or more ) b/n ass’t 4. Emergency Ass’t Identification of life –threatening situation At any time

29. Phases of Assessment Data collection Data validation Data organization / Clustering Recording and reporting

30. Sources of data Primary Most reliable From patient 2 . Secondary Family members Significant others Other health professionals Health records

31. Types of data Objective data Subjective Data Breakout 3: Describe and Give Examples

32. Subjective Data Symptoms or covert cues including patient feeling Information perceived only by the affected person Cannot be perceived or verified by another person Examples: I feel sick I have stomach ache Nausea

33. Objective data Sign or overt cues Observable, perceptible/detectable and measurable data Seen, validated , heard or felt by someone other than the person experiencing it Obtained through observation, standard assessment techniques (physical examination, laboratory and diagnostic testing)

34. Objective data… Examples: Pulse: Rate 100 beats per minute, strong and regular Distended abdomen Hemoglobin 9 mg/ dL

35. Breakout 4 Ato Hailu is 51 years old admitted 2 days ago with chest pain. The physician in charge ordered the following studies- ECG, and complete blood counts. He states “I feel much better today, no more pain. It is a relief to get rid of discomfort”. You think he appears a little tired, and seems to be talking slowly and exhale noisily more often than you think. He denies being tired. V/S: Tep 37oC, PR 74 bpm , RR 20 breaths pm, B/P 140/90 mmHg. Draw subjective and objective data from the above case history

36. Data Summarization Breakout 5 CASE STUDY 1: W/ ro Alem Kebede, 28 years old woman admitted with Medical Diagnosis of Acute Gastroenteritis Subjective: States… “I am weak and worried about my condition.”, “My stool is very watery and frequent” and “I’m feeling very feverish” Objective: Temp = 38.0 C (oral), Pulse = 110 per minute Respiration rate = 32 per minute, Decreased PaO2 , the nurse observed that the patient had diarrhea x 2-3 times of ½ cup per bout following admission

37. Assessment … GROUP WORK How will you summarize the subjective data? What other information would you collect and record using the nursing admission assessment form? 5 minutes!

38. Breakout 6 What are methods of data collection used during patient assessment?

39. Methods of data collection Client interview Doing physical examination Reviewing charts for other diagnostic findings Interviewing Is a planned communication or a conversation with a purpose Essential skill in obtaining history

40. Methods of data collection… Two approaches to interviewing 1. Direct interview: is highly structured and elicits specific information. 2. Non-direct interview or rapport-building interview : the nurse allows the client to control the purpose, subject matter, and pacing

41. Methods of data collection… It has four phases 1. Reparatory phase /pre interaction phase Occur before the nurse meet the patient Pre collecting of some information about the patient 2. Introductory phase/orientation phase Establishing rapport Clarifying role Alleviating anxiety 3. Maintenance phase /working phase 4. Concluding phase

42. Interviewing skills Questioning : Using open-ended questions that cannot be answered with a simple “yes” or “no’’ Facilitation : “Go on…I am listening.” (including non-verbal nodding) Direction : “I understand that many things are bothering you…could we focus on the diarrhoea for just a minute?” Summarising: "So, from what I understand, you have had a lot of nausea and some cramping, you have taken all of the pills each day this week and you want some help with these symptoms…do I have it all right?

43. Physical examination Is a systematic data collection method that uses the senses of Sight Hearing Smell touch Four techniques are used: Inspection Palpation Percussion auscultation

44. Inspection Is concentrated watching Begins the moment you first meet the individual Good to develop a “general assessment“ Start with the inspection of each body system Compare the right and left sides of the body Requires good lighting, adequate exposure, and occasional use of certain instruments

45. Palpation Uses the sense of touch to assess: texture , temperature, moisture , organ location and size , vibrations and pulsations , swelling , masses , and tenderness Requires a calm, gentle approach Done systematically: light palpation preceding deep palpation and palpation of tender areas performed last

46. Different parts of the hands to assess different factors Fingertips- best for skin texture, swelling, pulsation, and presence of lumps. A grasping action of the fingers - to detect the position, shape, and consistency of an organ or mass The dorsa (backs) of hands and fingers - best for determining temperature Base of the fingers (metatarsophalangeal joints) or ulna surface for vibration

47. Percussion Uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. It is used for assessing the density of structures or determining the location and the size of organs in the body.

48. The Five Percussion notes and their characteristics

49. Auscultation Involves listening to sounds in the body that are created by movement of air or fluid Areas most often Auscultated include : Lungs Heart Abdomen blood vessels.

50. Equipment and Supplies Used for a Physical Examination

51. Equipment and Supplies Used for a Physical Examination

52. Equipment and Supplies Used for a Physical Examination…

53. Equipment and Supplies Used for a Physical Examination…

54. Equipment and Supplies Used for a Physical Examination…

55. Equipment and Supplies Used for a Physical Examination…

56. Data validation Double -checking of the information Verifying and clarifying cues and inference Confirm the accuracy of data Methods of validation Comparing cues to normal function Referring text books, journals & research report Rechecking cues Clarifying the patient statement (ask closed end question) Seeking consensus with colleagues about inferences

57. Organization of data This process is known as data clustering . How data are organized depends on the assessment model used. One of these models is head – to – toe model.

58. D ata i nterpretation

59. Data interpretation Is important to identify cues and reach at inferences Helps make clinical judgments about the client

60. Identifying Cues and Making Inferences Cues are hints, or reminders, that prompt you to reach a conclusion about a patient needs. Subjective and objective data that you have identified act as cues Cues Subjective Data Patient states, “generalized body weakness following three days of passing loose stool in average four times a day”

61. Identifying Cues and Making Inferences… Inference: how you interpret or perceive a cue: Generalized body weakness following passage of loose stool, dry oral mucosa, PR: 120 beats per minute, BP: 80/50 mmHg, skin pinch going back slowly Dehydration Cues and correct inferences need: observational skills, nursing knowledge and clinical expertise

62. Identifying Cues and Making Inferences… Examples of cues and inferences Group of cues client has Blurry vision or visual defect, headache Tingling and numbness in extremities, dizziness Possible inferences Client has a brain tumor Client is having warning signals of a stroke Client may be diabetic, client is anxious

63. Identifying Cues and Making Inferences… Cues Persistent vomiting Diarrhea 4 times per day Taking nothing per os Dry oral cavity PR: 140 beats per min PB: 80/50 mmHg Wt: loss of 0.5 kg

64. Identifying Cues and Making Inferences… Possible inferences Imbalanced body nutrition: less than body requirement Fluid volume deficit Risk for electrolyte imbalance Diarrhea Dysfunctional gastrointestinal motility

65. Functional health pattern/ FHP approach

66. Functional health pattern/ FHP approach

67. Functional Health Pattern Using nursing assessment format discuss each of the pattern separately considering its practicality at patient assessment level Present discussion output Breakout 7: Make a group of 5 members

68. Patient Identification

69. G roup R eflection Health Perception-Health Management

70. 1. Health Perception-Health Management

71. G roup R eflection Nutrition and Metabolism

72. 2 . Nutrition and metabolism pattern Focuses on the pattern of food and fluid consumption relative to metabolic need. Subjective data Typical daily food: compare previous and current Special diet Appetite: as usual, increased or decreased) Average fluid intake per day

73. 2. Nutrition and metabolism pattern … Subjective data… Difficulty in chewing Nausea , vomiting Abdominal pain Antacid Use of supplements, vitamins, types of snacks Weight loss/gain Sore tongue ,sore throat Dental problem

74. 2. Nutrition and metabolism pattern … Objective data Skin , oral mucous membranes, teeth, abdominal assessment Wt : __ Ht :___ BMI : ___ MUAC ___ Skin Colour : jaundice, Pallor or Cyanosis Lesion: Texture: Smooth and Soft  Rough  Thick  Temperature: Warm  Extremely warm  Extremely cool  other____ Moisture: Dry, Wet , Oily Turgor/skin pinch: Immediately , Slowly , Very Slow Bilateral pitting oedema

75. 2. Nutrition and metabolism pattern … Objective data ….

76. 2. Nutrition and metabolism pattern … Objective data ….

77. 2. Nutrition and metabolism pattern … Objective data ….

78. 2. Nutrition and metabolism pattern … Objective data …. Oral cavity Mucosa: Intact , lesion Pink , pallor or red Moist or dry Teeth: malformation, Dental caries Tongue: Pink , Pale Dry , Moist Lesions or Intact Trash

79. G roup R eflection Elimination

80. 3. Elimination pattern Describes the function of the bowel, bladder and skin Helps determine regularity, quality, and quantity of stool and urine. Subjective data Bowel habits Frequency, consistency and colour Pain: Yes  No  Use laxative: Yes  No  Enema: Yes  No  Hx of Bowel surgery Colostomy Yes  No  Illeostomy Yes  No 

81. 3. Elimination pattern… Subjective data… Bladder habit Frequency ,amount and colour Pain : Yes  No  Haematuria: Yes  No  Incotinenance: Yes  No  Nocturia: Yes  No  Retention: Yes  No  Urinary Catheter: Yes  No  Type ____

82. 3. Elimination pattern… Objective data Examine excretions for characteristics/color, and consistency Abdominal assessment

83. 3 . Elimination pattern… Abdominal Exam

84. Abdominal Organs

85. Abdomen: Inspection

86. Abdomen Inspection…

87. Abdomen Inspection… Is the abdomen symmetric ? Are there visible organs or masses? Look for an enlarged liver or spleen that has descended below the rib cage. Asymmetry  an enlarged organ or mass. Lower abdominal mass  an ovarian or a uterine tumor.

88. Abdomen Inspection… Peristalsis Observe for several minutes if you suspect intestinal obstruction. Peristalsis may be visible normally in very thin people. Increased peristaltic waves  intestinal obstruction  diarrhea

89. Abdomen Inspection…

90. Abdomen Inspection… The skin , including: Scars: Describe or diagram their location. Striae: Old silver striae or stretch marks are normal. Dilated veins: A few small veins may be visible normally. Rashes and lesions The umbilicus: contour and location, signs of inflammation or hernia .

91. Abdomen Inspection…

92. Auscultation

93. Abdominal Auscultation … Auscultation  bowel motility Listen to the abdomen before performing percussion or palpation these maneuvers may alter the frequency of bowel sounds. Bowel sounds: frequency and character Normal sounds consist of clicks and gurgles Frequency of 5 to 30 per minute

94. Abdominal Auscultation … Note that Use diaphragm of stethoscope Skin depressed to approximately 1 cm Listening in one spot is usually sufficient Listening for 15-20 or 30-60 seconds Bowel sounds cannot be said to be absent unless they are not heard after listening for 3-5 minutes in all 4 quadrants

95. Abdominal Auscultation

96. Abnormal Findings Related to Bowel Sounds Absent/hypoactive Listen for 3-5 minutes Bowel obstruction, peritonitis, paralytic ileus Low Potassium Surgical manipulation Increased Bowel sounds/hyperactive Increased motility of fluids Diarrhea

97. Abdominal Percussion Helps to assess: the amount and distribution of gas in the abdomen to identify possible masses that are solid or fluid filled Percuss the abdomen lightly in all four quadrants to assess the distribution of tympani and dullness . A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction

98. Abdominal Percussion… Abdominal fluid Shifting dullness

99. Abdominal Percussion… Determine the size of solid organs and presence of masses, fluid and gas Percuss for liver Percuss for spleen Percuss bladder if indicated Normal percussion sound of the abdomen is tympani c Normally dull sound

100. Abdominal Percussion …

101. Abdominal Percussion and Palpation Liver Size Span of liver Midclavicular line 6-12 cm Midsternal line: 4-8 cm

102. Abdominal Percussion and Palpation Spleen Size If tympany existed : - ve sign (normal spleen size) If tympany changed to dullness : + ve sign (spleenomegally)

103. Abdominal Palpation With fingers together and flat on the abdominal surface, palpate the abdomen with a light, gentle, dipping motion On palpation watch the person's face, not your hands!

104. Abdominal Palpation… Light palpation Identify any superficial organs or masses Identify any area of tenderness Identify increased resistance to your hand If resistance is present, try to distinguish voluntary guarding from involuntary muscular spasm Involuntary rigidity (muscular spasm) typically persists despite these maneuvers indicates peritoneal inflammation

105. Abdominal Palpation… Deep palpation This is usually required to detect any organ enlargement, abdominal masses or swellings Use one hand on top of another and push down slowly. Assess for rebound tenderness by pushing slowly and then releasing your hand quickly off the tender area. Pain on withdrawal may indicate peritonitis

106. Abdominal Palpation… Palpate deeply in all 4 quadrants Use two hands Press down around 4 cm

107. Abdominal Palpation… Gentle palpation Tenderness Increased resistance Deep palpation Tenderness Mass Peritonitis Involuntary muscular rigidity Ask the patient to cough to localize pain Pain Rebound tenderness (pain on withdrawal)

108. Abdominal Palpation…

109. Assessing Possible Appendicitis The pain of appendicitis classically begins near the umbilicus, then shifts to the RLQ, where coughing increases it Localized tenderness anywhere in the RLQ, even in the right flank, may indicate appendicitis

110. Possible Appendicitis … a. Rebound tenderness b. Rovsing’s sign & referred rebound tenderness Press deeply and evenly in the LLQ Then quickly withdraw your fingers Rebound tenderness: Suggests peritoneal inflammation, as from appendicitis Pain in the RLQ during left-sided pressure  Positive Rovsing’s sign RLQ pain on quick withdrawal  Referred rebound tenderness

111. Possible Appendicitis… c . Psoas Sign: Two methods 1 st Method Place your hand just above the patient’s right knee Ask the patient to raise that thigh against your hand (extending right thigh) 2 nd Method Ask the patient to turn onto the left side Then extend the patient’s right leg at the hip Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it  ed abdominal pain on either maneuver  positive psoas sign (irritation of the psoas muscle by an inflamed appendix)

112. Possible Appendicitis-- Psoas Sign …

113. Possible Appendicitis… d. Obturator Sign Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip This maneuver stretches the internal obturator muscle Right hypogastric pain Positive obturator sign Suggests irritation of the obturator muscle by an inflamed appendix

114. Possible Appendicitis-- Obturator Sign…

115. Possible Appendicitis… Summary possible appendicitis Psoas sign —pain on extension of right thigh (retroperitoneal retrocecal appendix) Obturator sign —pain on internal rotation of right thigh (pelvic appendix) Rovsing's sign —pain in right lower quadrant with palpation of LLQ Dunphy's sign —increased pain with coughing If the appendix has ruptured The pain becomes more diffuse Abdominal distention develops The patient’s condition worsens

116. G roup R eflection Activity-Exercise

117. 4 . Activity- Exercise Focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities Subjective data Daily Living Activities (ADL), any difficulties with: Hygiene, cooking, house work, shopping, eating , toileting Dyspnea: During Minor activity  During vigorous activity  Chest pain, Stiffness Weakness Effect of illness on activity of daily living:_______

118. 4. Activity- Exercise… Objective Data Vital signs For every patient vital signs should be taken Pulse rate Respiratory rate Blood pressure Temperature Prior to measuring vital signs, the patient should have had the opportunity to sit for approximately five minutes

119. 4. Activity- Exercise… Blood Pressure Nursing alert! The following condition may result in falsely high blood pressure If the brachial artery is much below heart level. The patient’s own effort to support the arm. A loose cuff or a bladder that balloons outside the cuff leads Cuffs those are too short or too narrow. Using a regular-size cuff on an obese arm.

120. 4. Activity- Exercise… Normal BP Normal blood pressure SBP : 90 to 14o mmHg DBP: 60 to 90 mmHg The two arm readings should be within 5-10 mm Hg.

121. 4. Activity- Exercise… 2. Pulse Assessment of pulse includes: rate, rhythm and quality The normal pulse for healthy adults ranges from 60-100bpm < 60bpm bradycardia >100bpm tachycardia

122. 4. Activity- Exercise… 2. Pulse… Factors affecting PR Age Blood loss Pain Emotion Characteristics of pulse Rate: 60-100bpm Rhythm : regular, irregular Quality : absent, weak, palpable, bounding

123. 4. Activity- Exercise… 3. Respiratory Rate Try to do this as surreptitiously as possible. Observe the R ate, R hythm, D epth, and E ffort of breathing

124. 4. Activity- Exercise…

125. 4. Activity- Exercise… 3. Temperature Can be taken from oral, rectal or axillary . Rectal temperatures are higher than oral temperatures by an average of 0.4 to 0.5°C ( 0.7 to 0.9°F ). Axillary temperatures are lower than oral temperatures by approximately 1°C , but take 5 to 10 minutes to register. Generally axillary temperature is considered less accurate than other measurements.

126. 4. Activity- Exercise…

127. 4. Activity- Exercise… Rectal temperature measurement Contraindicated in clients with cardiovascular alterations because the thermometer may stimulate the vagus nerve and cause an irregular cardiac rhythm . Also contraindicated in leukemia and rectal surgery clients because the insertion of the thermometer may traumatize the mucosa or incision line, causing bleeding.

128. 4 . Activity- Exercise… Objective data Examination of the musculoskeletal system Patient for gait: steady or unsteady Any deformity Swelling of the lower extremities Symmetry of the body ROM : Active ROM if not Passive ROM Decreased or optimal

129. 4. Activity- Exercise… , Musculoskeletal system … A gait lacking coordination (reeling & instability)  ataxia Gait Ask the patient to: Walk across the room or down the hall, then turn, and come back. Observe posture, balance, swinging of the arms, and movements of the legs. Normally balance is easy, the arms swing at the sides, and turns are accomplished smoothly .

130. 4. Activity- Exercise… ,Musculoskeletal system … Gait

131. 4. Activity- Exercise… ,Musculoskeletal system … Objective data ROM

132. 4. Activity- Exercise… ,Musculoskeletal system … Determine muscle tone Assess by feeling the muscle’s resistance to passive stretch Take one hand with yours and, while supporting the elbow, flex and extend the patient’s fingers, wrist, and elbow, and put the shoulder through a moderate range of motion. On each side, note muscle tone-The resistance offered to your movements If you suspect decreased resistance, hold the forearm and shake the hand loosely back and forth-Normally the hand moves back and forth freely but is not completely floppy

133. 4. Activity- Exercise …, Muscle tone Decreased resistance disease of the peripheral nervous system, cerebellar disease, or acute stages of spinal cord injury Marked floppiness: Hypotonic or flaccid muscles Increased resistance Worse at the extremes of the range  spasticity Resistance that persists throughout the range and in both directions

134. 4 . Activity- Exercise…, Muscle Strength Ask the patient to move actively against your resistance or to resist your movement If the muscles are too weak to overcome resistance, test them against gravity alone or with gravity eliminated

135. 4. Activity- Exercise…, Muscle Strength…

136. 4. Activity- Exercise …,Musculoskeletal …

137. 4. Activity- Exercise…, Decreased Muscle Strength Impaired strength is called weakness  paresis Absence of strength  paralysis (plegia) Weakness of one half of the body  h emiparesis Paralysis of one half of the body  hemiplegia Paralysis of the legs  p araplegia Paralysis of all four limbs  quadriplegia

138. 4. Activity and exercise… Examination of respiratory system First examine posterior then anterior chest Posterior chest : Place client in a sitting position, arms folded across chest (separates scapulae), back exposed Anterior chest : patient sitting or lying

139. 4. Activity and exercise…,Examination of Posterior Chest Posterior Chest Inspection Symmetry Shape of chest: AP ≈ ½ Transverse diameter Signs of respiratory difficulty: Use of accessary muscles

140. Observe the shape of the chest Normally antero -posterior (AP) diameter is half of transverse diameter The AP diameter may increase in COPD. 4. Activity and exercise …, Posterior Chest Inspection…

141. 4. Activity and exercise …, Posterior Chest Inspection… Shape of the chest… A . Barrel Chest AP>Transverse diameter Occurs in Infancy normally Normal aging (often) COPD

142. 4 . Activity and exercise…, Posterior Chest Inspection… Shape of the chest… B . Pigeon Chest ( Pectus Carinatum ) The sternum is displaced anteriorly AP>transverse diameter The costal cartilages adjacent to the protruding sternum are depressed

143. 4. Activity and exercise…, Posterior Chest Inspection… Shape of the chest… C . Funnel Chest ( Pectus Excavatum ) Depression in the lower portion of the sternum Compression of the heart and great vessels may cause murmurs

144. Shape of the chest… D . Thoracic kypho-scoliosis Abnormal spinal curvatures and vertebral rotation Distortion of the underlying lungs 4. Activity and exercise…, Posterior Chest Inspection…

145. 4 . Activity and exercise…, Posterior Chest Inspection… Intercostal Retraction Abnormal retraction during inspiration Most apparent in the lower interspaces May be caused by: Severe asthma COPD Upper airway obstruction

146. Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement Unilateral impairment or lagging of respiratory movement suggests disease of the underlying lung or pleurae. 4 . Activity and exercise…, Posterior Chest Inspection…

147. 4. Activity and exercise…, Posterior Chest Palpation Palpate for Tenderness Masses Lesions Respiratory excursion Vocal fremitus

148. 4 . Activity and exercise…, Posterior Chest Palpation… Testing chest expansion-Respiratory excursion Place thumbs at 10 th ribs close to client’s spine and spread hands over thorax On deep inhalation and full exhalation: note divergence of thumbs, feel for range note symmetry of movement during

149. 4 . Activity and exercise…, Posterior Chest Palpation… Testing chest expansion (Respiratory excursion) Cause of unilateral decrease or delay: Pleural effusion Lobar pneumonia Pneumothorax Unilateral bronchial obstruction Cause of bilateral decrease or delay: When alveoli do not fully expand Emphysema Pleurisy

150. 4. Activity and exercise…, Posterior Chest Palpation… Tactile Fremitus Detection of sound vibration generated by the larynx traveling distally along the bronchial tree.

151. 4. Activity and exercise…, Posterior Chest Palpation… Tactile Fremitus Palpation Pattern for Tactile Fremitus

152. 4 . Activity and exercise…, Posterior Chest Palpation… Tactile Fremitus Place ulnar aspect of your open hand at right apex of lung and place the hand at each location on the chest Instruct client to say “44” Use one hand or both Note areas of increased or decreased fremitus An increase in solid tissue per unit volume of lung will enhance fremitus– pneumonia An increase in air per unit volume of lung will impede sound

153. 4 . Activity and exercise…, Posterior Chest Palpation… Tactile Fremitus Cause of decreased or absent Fremitus Obstructed bronchus COPD Separation of the pleural surfaces by: Fluid (pleural effusion) Fibrosis (pleural thickening) Air (pneumothorax) A very thick chest wall

154. 4. Activity and exercise …,Posterior Chest Percussion Avoid surface contact by any other part of the hand, because this dampens out vibrations. Note that the thumb, 2nd, 4th, and 5th fingers are not touching the chest Use quick sharp but relaxed wrist motion, to strike the pleximeter finger using the right plexor finger The striking finger should be almost at right angles to the pleximeter Use the tip of the plexor finger, not the finger pad Withdraw the striking finger quickly to avoid damping the vibrations

155. Use To establish whether the underlying tissues are air-filled, fluid-filled, or solid To estimate the size and location of certain structures within the thorax (e.g., diaphragm, heart, liver) 4. Activity and exercise…,Posterior Chest Percussion …

156. Percussion Notes Have the patient keeps both arms crossed in front of the chest When percussing the lower posterior chest, stand somewhat to the side rather than directly behind the patient When comparing two areas, use the same percussion technique in both areas Learn to identify five percussion notes 4. Activity and exercise…,Posterior Chest Percussion…

157. 4. Activity and exercise…,Posterior Chest Percussion…

158. 4. Activity and exercise…,Posterior Chest Percussion … Location of percussion

159. Pathologic Examples Flatness  Large pleural effusion Dullness --fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath percussing fingers, occurring in: Lobar pneumonia, Pleural effusion, Hemothorax, Empyema, Fibrous tissue, or tumor Hyper-resonance  Emphysema, pneumothorax Tympany  Large pneumothorax 4 . Activity and exercise…,Posterior Chest Percussion…

160. 4 . Activity and exercise…, Auscultation of Posterior Chest Used to assess air flow through the tracheobronchial tree Auscultation involves Listening to the sounds generated by breathing Listening for any adventitious (added) sounds Listening to the sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall

161. Listen to the chest as the patient breathes deeply with mouth open Compare symmetric areas of the lungs Note the intensity of breath sounds Identifying any variations from normal vesicular breathing Identify any adventitious sounds Listen for transmitted voice sounds 4 . Activity and exercise…, Auscultation of Posterior Chest…

162. 4. Activity and exercise…, Chest Auscultation Breath Sounds (Lung Sounds) Known by their normal location Normal breath sounds are: A. Vesicular Inspiratory sounds last longer than expiratory ones heard through inspiration Normally heard over most of both lungs B. Bronchovesicular Normally heard in the 1 st and 2 nd interspaces anteriorly and between the scapulae Inspiratory and expiratory sounds are about equal

163. 4. Activity and exercise…, Chest Auscultation C. Bronchial Expiratory sounds last longer than inspiratory ones Normally heard Over the manubrium , if heard at all D. Tracheal Inspiratory and expiratory sounds are about equal Normally heard over the trachea in the neck

164. 4. Activity and exercise…, Breath sounds... If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect that air-filled lung has been replaced by fluid-filled or solid lung tissue

165. 4. Activity and exercise…, Adventitious (Added) Sounds Crackles Lung fibrosis Early CHF Chronic bronchitis Asthma Pleural Rub Inflamed and roughened pleural surfaces Stridor Partial obstruction of the larynx or trachea Wheezes Asthma Chronic bronchitis COPD CHF (cardiac asthma)

166. 4. Activity and exercise…, Adventitious (Added) Sounds …

167. 4. Activity and exercise…, Adventitious (Added) Sounds … Breath sounds may be decreased when air flow is decreased Obstructive lung disease or Muscular weakness Breath sounds may be decreased when the transmission of sound is poor Pleural effusion, Pneumothorax , or Emphysema

168. I. Crackles (Rales) Result from delayed reopening of deflated airways It may or may not be cleared by coughing Heard predominantly on inspiration over the base of the lungs 4 . Activity and exercise…, Adventitious (Added) Sounds …

169. Fine Crackle Dry, high-pitched crackling, popping sound of short duration Sounds like a piece of hair being rolled between the fingers in front of the ear or Coarse Crackle Moist, low-pitched crackling, gurgling sound of long duration Sounds like water going down the drain after the plug has been pulled on a full tub of water 4. Activity and exercise…, Adventitious (Added) Sounds …

170. 4. Activity and exercise…, Adventitious (Added) Sounds … Pathological Examples Crackles may be due: Pneumonia Fibrosis Early congestive heart failure Bronchitis Bronchiectasis

171. 4. Activity and exercise…, Adventitious (Added) Sounds … II. Friction Rubs Are specific examples of crackles Result from pleurisies/ pleuritis that induces a crackling, grating sound usually heard in inspiration and expiration Imitated by rubbing the thumb and index finger together near the ear Heard best over the anterior lateral lungs during inspiration alone or during both inspiration and expiration

172. 4. Activity and exercise…, Adventitious (Added) Sounds … III. Wheezes Heard predominantly on expiration all over the lungs Wheezes suggest narrowed airways, as in: Asthma COPD Bronchitis

173. 4. Activity and exercise…, Adventitious (Added) Sounds … IV. Rhonchi Heard predominantly on expiration over the trachea and bronchi as a continuous, low-pitched musical sound Suggest secretions in large airways Clearing of crackles, wheezes, or rhonchi after cough suggests that secretions caused them as in bronchitis or atelectasis

174. 4. Activity and exercise …, Anterior Chest Inspection Inspect for Shape of the patient’s chest Movement of the chest wall Note Deformities or asymmetry Abnormal retraction of the lower interspaces during inspiration- Severe asthma, COPD, or upper airway obstruction Local lag or impairment in respiratory movement- Underlying disease of lung or pleura

175. 4. Activity and exercise…, Anterior Chest Inspection… Respiratory rate and depth Observe: Rate Rhythm Depth Effort of breathing Prolonged expiration  narrowed lower airways

176. 4 . Activity and exercise…, Anterior Chest Inspection… Signs of Respiratory Difficulty Patient’s color for Cyanosis signals hypoxia Clubbing of the nails Chronic obstructive pulmonary disease (COPD) Congenital heart disease

177. 4. Activity and exercise…, Anterior Chest Inspection… Inspect the neck Inspiratory contraction of the sternomastoids at rest S evere difficulty breathing Lateral displacement of the trachea Pneumothorax Pleural effusion Atelectasis

178. Purposes of chest palpation Identification of tender areas Assessment of observed abnormalities Further assessment of chest expansion Assessment of tactile fremitus 4. Activity and exercise…, Anterior Chest Palpation

179. Chest Expansion Place thumbs along each costal margin Place hands along the lateral rib cage Hold loose skin folds between thumbs Ask the patient to inhale deeply Feel as thumbs diverge as the thorax expands Feel for the extent and symmetry of respiratory movement 4. Activity and exercise…, Anterior Chest Palpation…

180. 4. Activity and exercise …, Locations For Feeling Fremitus

181. 4. Activity and exercise…, Locations For Percussion & Auscultation

182. 4 .Activity&exercise…,Cardiovascular assessment Inspection : JVD, heaves and lifts, abdominal blood vessels, peripheral circulation Palpation : Pulses, PMI Percussion : Heart size Auscultation : Heart sounds, bruits

183. 4.Activity & exercise …, CVS Assessment… Inspection Jugular vein distension Elevating the head of the bed to 30-45 o observe for the distension of the jugular vein, which is not usually appearing.

184. Heaves and lifts Look at the apex of the heart at 5 th ICS MCL for heaves and lifts Visible blood vessels On the abdomen 4.Activity & exercise …, CVS Assessment …

185. 4.Activity & exercise…, Inspection … Peripheral circulation - color and swollen twisted veins Visible pulsations on the neck and precardium, epigastric area at the tip of the sternum for pulsation of the abdominal aorta

186. 4.Activity & exercise…, Palpation Palpate the carotid artery Useful for detecting stenosis or insufficiency of the aortic valve. Quality of the carotid upstroke, Its amplitude and contour Presence or absence of any overlying thrills or bruits

187. 4.Activity & exercise…, Palpation… Character and Volume: best checked on carotid arteries. Place fingers behind the patient's neck and compress the carotid on one side The amplitude of the pulse. The contour of the pulse wave. Variations in amplitude from beat to beat or with respiration During palpation of the carotid artery, you may detect humming vibrations, or thrills, that feel like the throat of a purring cat.

188. 4.Activity & exercise…, CVS Palpation … For pulsation & thrill (vibration) in all areas of the pericardium Apical area Palpate apical impulse ( PMI)-If pulsation present determine its size, diameter, location & time it pulsates within cardiac cycle Normally no pulsation palpable over the aortic and pulmonic areas but at the PMI

189. Abnormal finding In the left lateral decubitus position, a diameter greater than 3 cm Left ventricular enlargement PMI diameter Usually 1-2.5cm Occupies only one interspace May be larger in the left lateral decubitus position 4.Activity & exercise…, CVS Palpation …

190. 4.Activity & exercise…, JVD

191. 4.Activity & exercise…, JVD Auscultate for the heart sound on S1, S2, Murmur and Gallop At the shown sites

192. 4.Activity & exercise…, Auscultation… Use of stethoscope Diaphragm is better for picking up the relatively high-pitched sounds of S1 and S2, Murmurs of aortic and mitral regurgitation, and Pericardial friction rubs Press the diaphragm firmly against the chest Bell is more sensitive to the low-pitched sounds of S3 and S4 Murmur of mitral stenosis Apply the bell lightly, with just enough pressure to produce an air seal with its full rim.

193. 4.Activity & exercise…, Heart Sounds: S1 and S2

194. 4.Activity & exercise…, Murmur & Gallop

195. G roup R eflection Sleep - Rest

196. Assesses sleep and rest patterns. Subjective data Sleep time Adequacy Difficulty falling sleep Sleep aid Sleep medications 5. Sleep & Rest

197. Subjective data… Change in sleeping pattern Difficulty remaining sleep What facilitate sleep ? What hinders sleep? 5 . Sleep & Rest …

198. 5. Sleep & rest… Objective data Yawning Concentration Flushed face

199. G roup R eflection Sexuality - Reproductive

200. Focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions Subjective data Female Menstruation Date began: ______ Last cycle _________ Length______ Gravida: ____ Para____ Abortion___ still birth______ Current Pregnancy: Yes  No  LNMP:_________EDD--------GA--------- 6. Sexuality reproductive

201. 6. Sexuality reproductive Fertility: Fertile  infertile  Male/Female Contraception: Yes  No  Undesirable side effects of contraceptives Problem with Sexual activities:________ Effect of illness on Sexual activities:________ STI: __________________________________ Pain during intercourse: Yes  No  Burning during intercourse: Yes  No  Discomfort during intercourse: Yes  No 

202. 6 . Sexuality reproductive… Objective data Breast exam Exam of genitalia

203. G roup R eflection Cognitive-Sensory-Perceptual

204. focused on the ability to comprehend and use information and on the sensory functions Assesses the five senses. Subjective data Educational status: Able to read ____Write _____ Primary language:______________ Visual problem Aids for vision: 7 . Cognitive-Sensory-Perceptual

205. 7. Cognitive-perceptual… Subjective data… Hearing problem Aid for hearing Taste problem Smelling problem Problem in sensation(skin)

206. 7. Cognitive-perceptual… Pain assessed by PQRST Descriptions of pain P recipitating/aggravating Q uality R adiation S everity/Site T iming, including: onset, duration, and frequency,

207. 7. Cognitive-perceptual … Objective data Level of consciousness : Orientation to TPP: Glasgow coma scale : Ability to speak Yes  No  Ability articulate words Yes  No 

208. The Glasgow coma scale for adults and older children Response Score Eyes open: Spontaneously To speech To pain Never 4 3 2 1 Best verbal response: Orientated Confused, disoriented Inappropriate words Incomprehensible sounds None 5 4 3 2 1 Best motor response: Obeys commands Localizes pain Withdraws (flexion) Abnormal Flexion posturing Extension posturing None 6 5 4 3 2 1 TOTAL 3-15 A total score Score 3 or 4 : P atients have an 85% of chance of dying or remaining vegetative Score <7 : State of coma Score <10 : Semi-coma Score above 11 : P atients have only a 5 to 10% likelihood of death or vegetative state and 85 % of chance of moderate disability or good recovery .

209. 7. Cognitive-perceptual… NB: Un- rousable come is defined as having a score of < 3 The scores can be used repeatedly to assess improvement or deterioration.

210. 7. Cognitive-perceptual… , Visual Acuity

211. 7. Cognitive-perceptual …, Visual Acuity… Have the person cover one eye at a time with a card Ask the person to read progressively smaller letters until they can go no further Record the smallest line the person read successfully Repeat with the other eye

212. 7. Cognitive-perceptual…, Visual Acuity … Visual acuity is reported as a pair of numbers (e.g., 20/20) where: The first number is how far the person is from the chart and The second number is the distance from which the "normal“ eye can read a line of letters For example, 20/40 means that, at 20 feet the person can only read letters that a "normal" person can read from 40 feet

213. 7. Cognitive-perceptual …,Inspection : Eyes Observe for ptosis, exophthalmos, lesions, deformities, or asymmetry Ask the person to look up and pull down both lower eyelids inspect the conjunctiva and sclera Next spread each eye open with your thumb and index finger Ask the person to look to each side, upward and downward to expose the entire bulbar surface. Note any discoloration, redness, discharge, or lesions Note any deformity of the iris or lesion cornea

214. 7. Cognitive-perceptual …, Inspection of Conjunctiva…

215. 7. Cognitive-perceptual…, Pupil examination Using pen light shine on one of the eyes to check for PERRLA (pupil equal, round, and reactive to light and accommodation ) N ormally both pupils should be E qual in size, R ound and R eactive to light and accommodation Further examination with ophthalmoscope

216. 7. Cognitive-perceptual…, Examination of the Ear

217. 7. Cognitive-perceptual… Examination of the Ear Auricle inspect the auricle for any deformities, lumps, skin lesions and discharge palpate for any tenderness Ear canal and drum Straighten the ear canal by grasp the auricle firmly but gently and pull it upward, backward, and slightly away from the head Using otoscope inspect the ear canal and drum

218. 7. Cognitive-perceptual …,Examination of the Ear… Inspect the eardrum, noting its color and contour. Red bulging drum  acute purulent otitis media Amber drum  a serous effusion

219. 7 . Cognitive-perceptual…, Examination of the Ear … Auditory acuity Test one ear at a time by asking the patient to occlude one ear with a finger or, better still, occlude it yourself. Stand at 1 or 2 feet away, exhale fully (so as to minimize the intensity of your voice) and whisper softly toward the un occluded ear.

220. 7 . Cognitive-perceptual…, Examination of the Ear… Air and Bone Conduction If hearing is diminished, try to distinguish between conductive and sensorineural hearing loss Prepare a quiet room and a tuning folk with the frequency in the range of human speech 300 Hz to 3000 Hz (usually 512Hz or 1024Hz).

221. 7 . Cognitive-perceptual…, Examination of the Ear…

222. 7 . Cognitive-perceptual …, Test for lateralization (Weber test) Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head Normally the sound is heard in the midline or equally in both ears. In unilateral conductive hearing loss , sound is heard in (lateralized to) the impaired ear. May indicate A cute otitis media, P erforation of the eardrum, and O bstruction of the ear canal, as by cerumen In unilateral sensorineural hearing loss, sound is heard in the good ear

223. 7 . Cognitive-perceptual …, Examination of the Ear… Compare air conduction (AC) and bone conduction (BC) (Rinne test). Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal. When the patient can no longer hear the sound, quickly place the fork close to the ear canal (facing the ‘U’ of tuning fork forward) and ascertain whether the sound can be heard again Normally the sound is heard longer through air than through bone (AC > BC) Conductive hearing loss: BC = AC or BC > AC Sensorineural hearing loss: AC >BC

224. G roup R eflection Self-perception- Self Concept

225. F ocused on the person's attitudes toward self, including identity, body image, and sense of self-worth. Subjective data What do you feel differently about yourself? Perception of abilities:____ Things frequently make you angry ,fearful or anxious 8. Self perception/self concept

226. Objective data Eye contact Body posture Appearance Grooming Mood (expression): Nervous ____ relaxed ____ Speech: Pace of conversation: Appropriate  inappropriate  Tone of voice: Appropriate to the situations  Inappropriate to situations  8. Self perception/self concept…

227. G roup R eflection Coping - Stress

228. F ocused on the person's perception of stress and on his or her coping strategies Subjective data Any big changes in your life in last year or two years Any Crisis Tense or relaxed most of the time When tense, what helps? Use any medications, drugs, alcohol to relax? When (if) there are big problems in your life, how do you handle them 9. Coping-stress tolerance

229. G roup R eflection Role - Relationship

230. F ocused on the person's roles in the country, community, work area or home and relationships with others Subjective data Living arrangements, Family structure Marital status Family or others dependants concern of families/ about families after illness Belong to social groups, Close friends work environment distress If appropriate – income sufficient for needs Feel part of (or isolated in) your neighborhood 10. Role relationship

231. 10. Role relationship… Role and Responsibility in family : _______ Work role:__________ Social role:________________ Level of satisfaction:_____________ Effect of illness on roles :____________________ Lives alone? Employee? Self employee? Ability to pay:  Yes  No Comments:_____

232. 10. Role relationship… Objective data Interaction with family members or others if present

233. G roup R eflection Value - Belief

234. F ocused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions Subjective data Important plans for future? Religion important to you? Religious Restrictions Religious practices 11. Value-Belief Pattern

235. 11. Value-Belief Pattern … Objective data Presence of religious materials, leaders When doing ritual process

236. Additional information Clinical data Investigations Result, compared with reference value

237. Summary Nursing assessment Phases of assessment Data: Type and Source Techniques of physical examination Gordon’s Functional Health Pattern

238. NURSING DIAGNOSIS Set by: Rebira W.

239. After completing this session, the trainees will be able to Describe nursing diagnoses Distinguish nursing diagnoses from medical diagnoses Formulate various kinds of nursing diagnoses Identify Collaborative problems Objectives

240. Outline Introduction Definition of nursing diagnosis P urpose of nursing diagnosis Nursing diagnoses Vs Medical diagnoses Components of nursing diagnosis Types of nursing diagnosis Collaborative problem Summary

241. Introduction Transition from assessment to nursing diagnoses   Data collection Data validation Organizing data in cluster Making inferences Consult NANADA Writing nursing diagnostic Statement

242. Definition of Nursing diagnosis N ursing diagnosis Is the second step in the nursing process involving further analysis & synthesis of data that have been collected. Statement describing client’s actual or potential response to health problems. That the nurse is licensed and competent to treatment. Is clinical judgment about an individual, family or community response to actual or potential health problem & life processes. Provides basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

243. Definition of Nursing diagnosis… NANDA : North American Nursing Diagnoses Association It is a professional organization of nurses that standardizes nursing terminology that develops researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing

244. NURSING DIAGNOSIS… PURPOSE Nursing diagnosis Is unique in that it focuses on a ct’s response to a health problem, rather than on the problem itself, & it provides the structure through which nursing care can be delivered. Nursing diagnosis also provide a means of effective communication Holistic client, family, & community –focused care are facilitated with the use of nursing diagnosis

245. Exercise 3.1: Nursing diagnoses Vs Medical diagnosis ? Instruction : Make 4 group & discuss Time allotted: 5 min Breakout

246. Differentiation of Nursing & Medical Diagnosis Nursing diagnosis -Focus on un healthy response to health & illness. -Describe problems treated by nurses within the scope of independent nursing practice. -Describes clients response -May change from day to day as the client’s responses change. Medical Diagnosis -Identify disease Describe problems for which the physician directs the primary treatment Refers to the disease process Remains the same for as long as the disease is present.

247. Differentiation of Nursing & Medical Diagnosis… Nursing di Nursing diagnosis Deals with two types of health problems (1) Human response problems (2) Pathological problems Uses the six sequential steps which need to be followed strictly within the scope of nursing practice Considers the whole person. Medical Diagnosis Deals mostly with problems with structure and function of organs or systems Uses medical approach within the scope of medical practice Mainly considers organ and system function

248. Differentiation of Nursing & Medical Diagnosis… Nursing diagnosis Focuses on teaching individuals or groups how to be independent on activities of daily living Involve individuals, their significant others, and with groups in nursing care provision Medical Diagnosis Focuses on teaching about how diseases and trauma are treated Mostly involved with individuals, sometimes with groups and families

249. Examples Nursing & Medical Diagnosis 1) Nursing Diagnosis Fear Altered Health maintenance Knowledge deficit Pain Altered tissue perfusion 2)Medical Diagnosis Myocardial infarction / Heart Attack

250. Examples Nursing & Medical Diagnosis… Nursing Diagnosis -Ineffective breathing pattern -Activity Intolerance -Acute pain -Body Image disturbance -Risk for altered body temperature Medical Diagnosis - Chronic obstructive pulmonary disease -Cerebrovascular accident -Appendectomy -Amputation -Strep throat

251. Components of nursing diagnosis 1) Diagnostic Label P-Problem Statement Q-Qualifier 2) Etiology E 3) Defining Characteristics S

252. Components of nursing diagnosis … Diagnostic Label Problem :- Refers to health problem or health state of an Individual , family, or community. Name of nursing diagnosis as listed in Taxonomy, expressed in a short, clear, & precise word, words or phrase. A taxonomy is a way of classifying or ordering things into categories; is a hierarchical classification scheme of main groups, subgroups, and items. Qualifier :- Used to give additional meaning to the nursing diagnosis.

253. Components of nursing diagnosis … Note to Write Diagnostic Label DO NOT use medical diagnosis Must be a problem the nurse and /or the client can change to do something about DO NOT relate the problem to unchangeable situation DO NOT confuse the etiology with the problem ( statement) Focus on the human response to the problem Avoid the use of one piece of assessment data as a nursing diagnosis. Example . Edema

254. Components of nursing diagnosis … Be specific DO NOT combine nursing diagnosis DO NOT relate one nursing diagnosis to another Nursing interventions should not be included in the nursing diagnosis Keep your language non judgmental DO NOT make assumptions or statements you can’t prove with assessment data Be sure your statement is legally advisable

255. Components of nursing diagnosis … Etiology Are any internal or external elements that have an effect on the person, family, or community. And contribute to the existence or maintenance of the person’s problem This is the related to, “R/T” portion of the diagnosis What caused the client to have the problem listed? At which will be affected by nursing intervention

256. Components of nursing diagnosis … Note to Write Etiology DO NOT use medical diagnosis Must be a problem the nurse and /or the client can change to do something about

257. Components of nursing diagnosis … Defining Characteristics-signs & symptoms These are the major and minor clinical cues that validate the present of an actual nursing diagnosis. Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the nursing diagnosis.

258. Components of nursing diagnosis … The Two- part Statement Consists of two parts Problem statement or diagnostic label The diagnostic label is the name of the nursing diagnosis as listed in the NANDA. Examples: Stress urinary incontinence, Anxiety,etc. II. The etiology Is the related cause of contributor to the problem These two parts are linked by term related to, “R/T”.

259. Components of nursing diagnosis … Descriptive words Terms that may be added to clarify specific nursing diagnosis These descriptive terms are called qualifiers. Examples:-Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, and risk. These terms specify a degree of qualification for the identified nursing diagnosis and are placed before the problem statement.

260. Components of nursing diagnosis … The Three- Part Statement Consists of three parts. The first two components are the diagnostic label and etiology, and The third component consists of defining characteristics or collected data that are also known as signs and symptoms, Subjective and objective data, or clinical manifestations. The third part is joined to the first two components with the connecting phrase “ as evidenced by”, ( AEB).

261. Components of nursing diagnosis … Nursing Diagnosis Two-Part Statement Three-Part Statement Feeding self-care deficit Ineffective airway clearance Anxiety Feeding self-care deficit R/T decreased strength and endurance. Ineffective air way clearance R/T fatigue Anxiety R/T change in role functioning. Feeding self-care deficit R/T decreased strength and endurance AEB inability to maintain fork in hand from plate to mouth. Ineffective air way clearance R/T fatigue AEB difficulty of breathing at rest. Anxiety R/T change in role functioning AEB sleeplessness, poor eye contact & quivering voice.

262. Components of nursing diagnosis … Nursing Diagnosis Two-Part Statement Three-Part Statement Deficient Knowledge Spiritual distress Deficient Knowledge R/T misinterpretation of information Spiritual distress R/T separation of religious ties Deficient Knowledge R/T misinterpretation of information AEB inaccurate return demonstration of self-injection. Spiritual distress R/T separation of religious ties AEB crying and withdrawal. Data from the ANA 1997

263. Nursing diagnosis versus Collaborative Problems If such problems require physician –prescribed and nurse-prescribed action In case the nurse intervenes in collaboration with personnel of other disciplines. C ollaborative problems are complications from a disease, test, or treatment that nurses cannot treat independently. Nurses focus mainly on monitoring and preventing such problems. Alerts the nurse that the client is either experiencing or is at high risk to experience the problem.

264. Nursing diagnosis versus Collaborative Problems… The focus of nursing accountability for collaborative problems is three- folds. Detecting and reporting early signs and symptoms of potential complications Implementing Physician prescribed interventions; Initiating interventions within the nursing domain to manage the problem. e.g. Potential complications: paralytic ileus related to back surgery. Arrhythmia, stroke, congestive heart failure related to MI.

265. Types of Nursing Diagnosis Actual Nursing Diagnosis Describe a human response to a health problem that is being manifested. Written as three-part statements: diagnostic label, Related factors or etiology and defining characteristics. Example :- Acute pain R/T surgical trauma and inflammation AEB grimacing and verbal reports of pain.

266. Types of Nursing Diagnosis… Rule for writing a ctual nursing diagnosis Using the PRS /PES format (Problem, Related factors, and Signs and Symptoms). Use the words “Related to” and “As evidenced by” to link the parts. Diagnostic label Or Problem Related to Related factor Or Etiology As evidenced /as manifested by Defining characteristics Or Sign and symptoms

267. Types of Nursing Diagnosis… 2. Risk / P otential nursing diagnosis As defined by NANDA, “describes human responses to health conditions that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability. Risk nursing diagnosis is a two-part statement. Example :-Risk for infection R/T surgery and immunosuppression, Risk for impaired skin integrity R/T inability to turn self from side to side.

268. Types of Nursing Diagnosis… Rule for writing Risk /Potential nursing diagnosis Use a two-part statement, using “related to” to link the potential problem with the risk factors present. Risk for Or High risk for Diagnostic label Or Problem Related to Risk factor Or Etiology

269. Types of Nursing Diagnosis… 3. Wellness-Nursing Diagnosis Is a diagnostic statement that describe the human response to levels of wellness in an individual, family or community that have a potential for enhancement to a higher state ( NANDA,2005). Wellness-nursing diagnosis is one part statement i.e. diagnostic label. Two items should be present: An increased desire for greater wellness & Effective level of function should be present

270. Types of Nursing Diagnosis… Example Readiness for enhanced spiritual well being. Readiness for enhanced self-esteem. Rule for writing wellness nursing diagnosis Statement will begin with “ potential for Enhanced or Readiness for enhanced. Readiness for enhanced Diagnostic label

271. Types of Nursing Diagnosis… 4. Possible nursing diagnosis Is made when not enough evidence supports the presence of the problem but The nurse thinks that is highly probable and wants to collect more information. Possible nursing diagnosis is a two part statement. i.e. diagnostic label and related factors (unknown). Example : Possible self-esteem disturbance R/T unknown etiology, Possible self-care deficit R/T IV in right hand, Possible impaired adjustment related to unknown etiology

272. Types of Nursing Diagnosis… Rule for writing possible nursing diagnosis List suspected problem and cause Possible Diagnostic label Or Problem Related to Etiology

273. Types of Nursing Diagnosis… 5. Syndrome nursing diagnosis A cluster or group of nursing diagnoses that almost always occur together. Example: Rape Trauma Syndrome, Disuse Syndrome, Post-trauma Syndrome, Relocation Stress Syndrome Rule: ...Syndrome.

274. Avoiding Errors in Writing Diagnostic Statements 1. Don’t write the diagnostic statement in such a way that it may be legally incriminating . Incorrect- High risk for injury related to lack of side rails on bed. Correct - High risk for injury R/T disorientation. 2.Don’t state the nursing diagnosis using medical diagnostic terminology; focus on the person’s response to the medical problems. Incorrect- Mastectomy related to cancer. Correct- High Risk for Self-concept Disturbance related to effects of mastectomy.

275. Avoiding Errors in… 3. Don’t rename a medical problem to make it sound like a nursing diagnosis . Incorrect - Alteration in hemodynamics related to hypovolemia . 4. Don’t state the nursing diagnosis based on a value judgment. Incorrect- Spiritual Distress related to atheism as evidenced by statements that she has never believed in God. 5. Don’t state two problems at the same time. Incorrect- Pain and Fear related to diagnostic procedures

276. Instruction : Make 4 groups Identify correctly stated nursing diagnosis Discuss and present Time allotted: 8 min Breakout Group Activities

277. Collaborative Problems Collaborative problems are complications from a disease, test, or treatment that nurses cannot treat independently. Nurses focus mainly on monitoring and preventing such problems. Alerts the nurse that the client is either experiencing or is at high risk to experience the problem

278. Collaborative Problems/Complications… The focus of nursing accountability for collaborative problems is three- folds. Detecting and reporting early signs and symptoms of potential complications Implementing Physician prescribed interventions; Initiating interventions within the nursing domain to manage the problem.

279. Collaborative Problems/Complications… e.g. Potential complications: paralytic ileus related to back surgery. Arrhythmia, stroke, congestive heart failure related to MI.

280. Nursing Diagnosis Vs Collaborative Problems Nursing Diagnosis Collaborative Problems/Medical diagnosis Focuses on identifying and treating actual or potential unhealthy responses to diseases or life changes. Related signs and symptoms respond to nurse-prescribed interventions. Focuses on identifying problems with structure or function of organs or systems. Related signs and symptoms don’t respond to nurse-prescribed interventions alone.

281. Summary Actual nursing diagnosis has three parts PES Risk diagnosis has two parts Risk for P E Collaborative problems Resolved by both nurse initiated and physician initiated interventions

282. NURSING PLANNING Set by: Rebira W.

283. By the end of this presentation, trainees will be able to: Define planning and outcome identification Prioritize nursing diagnoses Set goal for identified nursing diagnoses Write statement of client centered SMART expected outcomes Develop individualized plan of nursing care for a patient Objectives

284. Outline Definition of planning Purpose of planning Types of planning Establishing priorities Fundamental Principles of Setting Priorities Setting goal Outcome identification

285. Outline … Steps in writing outcome identification Components of outcome identification Nursing intervention Types of nursing intervention Nursing instructions/orders Elements of nursing instructions/orders

286. Breakout Planning? 2 min

287. Definition of Nursing Planning Is t he formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.

288. Breakout Purposes of planning? 5 min

289. Purpose of planning To facilitates communication between care givers To d irects care and documentation To provide a record that can later be used for evaluation and research

290. Types of Nursing Planning Initial planning : Comprehensive plan of care on admission assessment Ongoing planning : Continuous updating of the client’s plan of care. Discharge planning : Critical anticipation and planning for the client’s needs after discharge

291. Breakout Activities of planning? 5 min

292. Planning involves the following activities Setting priorities Setting goals G lobally written statement describing the intended change in the client’s behavior, response, or outcome Outcome identification Determining nursing interventions Recording the plan of care

293. Breakout How do you set priority? 5 min

294. Setting Priorities The first step to get organized To set priorities, look at the identified problems and ask some key questions: What problems need immediate attention ? What problems have simple solutions ? How many problems- list of all problems What problems must be done by nurse or referred ? What problems must be recorded on the plan of care?

295. Fundamental Principles of Setting Priorities (Maslow, 1943)

296. Priority 1 - Life threatening problems and those interfering with physiological needs . E.g. Problems with respiration, etc. Priority 2 - Problems interfering with safety and security e.g. fear Priority 3 - Problems interfering love & belonging e.g. Isolation Priority 4 - Problems interfering with self esteem . e.g. Inability to wash hair, perform normal activities. Priority 5 - Problems interfering with the ability to achieve personal goals. Fundamental Principles of Setting Priorities…

297. Nursing Diagnosis Maslow’s hierarchy of needs Rank Anxiety related to hospitalization Safety and security Moderate Ineffective coping Self-esteem Low Ineffective airway clearance related to excessive secretion Physiologic High

298. Breakout If you had someone with the following problems, which problem would you need to treat immediately? Diarrhea related to bacterial infection as evidenced by passage of loose stool 3-4 times/day Ineffective breathing pattern as evidenced by labored breathing High risk for fluid volume deficit 10min

299. Breakout Identify at least 3 nursing diagnoses Set priority 5 min

300. Planning: Goal Setting Goal is a broad term derived using the problem statement in the nursing diagnoses. It should indicate the identified health problem has been resolved , improved or prevented . Examples To reduce anxiety before undergoing surgery To maintain a patent airway To relive pain

301. Definition Is a detailed, specific statement that describes goal is achieved. Writing Outcome Measures Identifying outcomes that clearly describe the evidence that tells you the problems have been prevented, corrected, or controlled. e.g. of goal:- will demonstrate effective breathing pattern Outcome Measures:- clear lungs and practicing deep breathing and coughing every 2 hours. Planning: Outcome Identification

302. Short-term goals (STG) are those that can be met relatively quickly , often in less than a week L ong-term goals (LTG) are those that are to be achieved over a longer period of time , often weeks or months. LTG may also include goals that are ongoing e.g. of long term goal “ Tigist will dress herself every morning.” “Ato Daniel will maintain a fluid intake of 2000 ml a day.” Short and Long Term Outcomes

303. Short-Term Outcome Long-Term Outcome ““Fatuma will demonstrate how to hold her newborn infant by tomorrow ( 6/7).” “Fatuma will demonstrate how to dress, feed , and bathe her newborn infant by discharge (15/7).” 305 Examples of Long-Term and Short-Term Outcomes Priority_Goal_Outcome_Instruction “ Ato Hailu will turn and reposition himself from side to side every 2 hours. “ Ato Hailu will maintain good skin integrity while he is on bed rest.” “ Ato Sium will demonstrate how to change his colostomy bag within 2 days (by 7/7).” “ Ato Sium will demonstrate how to give complete colostomy care according to Hospital standards by discharge (by 7/21).” “Tekle will walk with crutches with assistance by 3 days after surgery (by 7/28).” “Tekle will walk unassisted with a crutch by discharge (by 8/10)/” 7/5/2023

304. Breakout Identify at least 3 nursing diagnoses Set realistic STO or LTO 5 min

305. Writing more than one outcome statement Sometimes you may decide to write more than one outcome for a problem. T he outcomes probably relate to the causes, or related factors, of the problem rather than to the problem itself only. However, make sure at least one of the outcomes demonstrates resolution , improvement , control or prevention of the nursing diagnosis.

306. Writing more than one outcome statement… Example Nursing Diagnosis : Overweight ( wt 76kg, ht 1.5m) related to poor eating habits and minimal physical activity AEB BMI of 28kg/m 2 . Outcome #1 : Abera will verbalize his feelings about changing eating habits, taking more vegetables and fruits. Outcome # 2: Abera will attend daily exercise classes. Outcome #3: Abera will lose 1 Kg per week beginning 26/01/2017 until he weighs between 60 and 70 Kg.

307. Look at first clause of the nursing diagnoses itself or problem statement (the word or words before “related to”) Example- High risk for impaired skin integrity related to immobility. Now restate the first clause in a statement that describes improvement, control, or absence of the problem Example- The person will demonstrate no signs of skin irritation or breakdown by discharge Restate the related factor and evidence that they are controlled , prevented, improved, or absent Example: The patient will use safety and comfort devises (pillow, cotton ring, air ring) over bony prominence areas as of tomorrow. Steps in identifying Outcomes from Nursing Diagnoses

308. Nursing Diagnosis Corresponding Client Outcome Imbalanced nutrition : Less than Body requirements The client will demonstrate inclusion of vegetables and fruits in lunch and dinner to increase appetite The client will record of eating balanced meals with few snacks every day . Clients Outcomes Derived from Nursing Diagnoses Ineffective Individual Coping The client will demonstrate and relate effective coping The client will self report coping better and The client will ability to demonstrate good problem solving. Constipation The client will demonstrate normal bowel function The client will have a normal stool every 1-2 per day by statements of feeling as though bowels are moving well.

309. Outcomes that are clear and specific address: Who is to do it? What is to be done? How they are to do it? & How well they are to do it? Where they are to do it? When they are to do it? Making Outcomes Clear and Specific

310. Subject : the person expected to achieve the goal? Verb : actions the person take to achieve the goal? Choosing verbs that measure progress will avoid ambiguity and focuses on the behavior that will measure progress. Use measurable verbs in order to be specific : Verbs like -identify, describe, perform, relate, state, list, verbalize, hold, demonstrate, etc. Don’t use Non Measurable Verbs : include -know, understand, appreciate, think, accept, and feel . Components of the outcome Identification

311. Components of the outcome Identification… Condition : circumstances under which the person perform the actions? Criteria : how well is the person to perform the actions? Specific Time : when the person expected to perform the actions? Example: Ato Hailu will walk with a crutch at least to the end of the hall and back by Friday (Feb. 5, 2018) Subject: Ato Hailu Verb : will walk Condition: with a crutch Criteria: at least to the end of the hall and back Specific time- by Feb 5, 2018

312. During determining client centered outcomes Be realistic in establishing goals. S et goals mutually with the client and others involved in his/her health care. E stablish both short and long term goals Be sure that the outcomes describe a client behavior or action Follow the rules for writing outcome statements. Use measurable, observable verbs to describe actions Components of the outcome Identification…

313. Breakout Choose the outcomes that are written correctly below. Identify what is wrong with the statements that are written incorrectly . 10 min

314. Tesfaye will know the four basic food groups by Tahsas 1, 2009. Wrt . Saba will demonstrate how to use her walker unassisted within 3 days. Ato Lemma will improve his appetite by Meskerm 11, 2010 Tullu will list the equipment needed to change sterile dressing by 09/05/2009 EC. David will walk independently in the hall the day after surgery. Wrt . Genet will understand the importance of maintaining a salt-free diet. Wrt . Tadeletch will appreciate the importance of exercise for pt. with diabetes. Ato Sium will feel less pain by Thursday (Jan 10, 2012) Exercise

315. Planning: Nursing intervention Definition A nursing intervention is an action planned by a nurse that helps the client to achieve the results specified by the goals and expected outcome. Identify as many nursing interventions as possible so that if one proves to be unsuitable, others are readily available. Prioritize interventions according to the order in which they will be implemented .

316. Planning: Nursing intervention… It could be carried out through: Helping/assisting Teaching Counseling Consulting & Determining problem specific Interventions. Priority_Goal_Outcome_Instruction

317. Planning: Nursing intervention… Nursing Interventions are activities performed by the nurse to: Monitor health status Prevent, resolve, or control a problem Assist with ADL (bathing and so forth) Promote optimum health and independence.

318. Planning : Nursing intervention… , Types 1. Independent interventions I nterventions that require no supervision or directions from others E.g. Demonstrating client about insulin self-injection. This intervention do not require any physicians order 2. Interdependent interventions Are type of interventions that are implemented in a collaborative manner by the nurse with other health care professionals

319. e.g. Nursing interventions in operation theatre with other health care team 3. Dependent interventions A re based on the interaction or written orders by other health care provider e.g. Administering a medication, preparing a client for different procedure Planning : Nursing intervention …, Types…

320. Nursing Instructions/Orders Definition A nursing order is a statement written by the nurse that is within the realm of nursing practice to plan and initiate. These statements specify direction and individualize the client’s plan of care.

321. Elements of nursing order/instruction Date The date on which the order is written. This information is updated to reflect review and revision. Action Verb Directs the nurses’ action. Example : Explain, demonstrate, auscultate

322. Detailed description Precisely clarifies what the nurse’s action will be. This phrase explains what, when, where, and how . Time frame Describes when, how often, and how long the nursing order is to be performed. Signature Indicates the nurse who writes the order. This element implies legal and ethical accountability Elements of nursing order/instruction…

323. Making Nursing Instructions/Actions Specific To make it specific and clear, include the following: Date : The date the order was written Verb : Action to be performed Subject : Who is to do it Descriptive phrase :: How, when, where, how often, how long Signature : Whoever wrote the order should sign it. e.g . 4/29/2012 Assist Guta to sit on the side of the bed for 10 minutes tid. Tekle G. RN

324. Nursing actions vs nursing instructions Nursing Action Nursing instructions Ambulate patient Ambulate patient the length of the hall using the walker 3 times a day Monitor ability to use walker appropriately and record response daily on flow sheet. Provide periods of uninterrupted rest Do not wake up the patient from midnight to 7 am Allow flow to rest from 1 pm to 3 pm (no visitors) Record the patient’s perception of hours slept Manage airway clearance Elevate head of bed. Avoid use of pillow under head, as indicated.  Encourage coughing/deep-breathing exercises and frequent position changes.  Suction (if necessary) with extreme care, maintaining sterile technique. 

325. Consider the following when writing nursing instructions What to look for (assessing, or seeing) What to do What to teach or counsel What to record Example : High risk for ineffective airway clearance related to history of smoking and incision pain.

326. Nursing instructions to be carried in caring for such a patient are: Put the patient in upright sitting position Check the respiration rate every hour A uscultate lungs every 4 hours for secretions Assist the person to perform coughing and deep breathing exercises with pillow and hand over incision area every 4 hours. Reinforce the importance of coughing and deep breathing. Record lung sounds and sputum production once a shift

327. Breakout Write specific nursing instructions

328. Summary Nursing Planning Planning: Establishing priority Planning: Setting goal Planning: Outcome identification Planning: Nursing intervention Planning: Nursing instruction or order

329. Implementation