Alia Andriany S.

Kep, Ns
Bagian KDK Prodi S1 Ners
STIKES Graha Edukasi MKS
Problem Solving Scientific Method
Nursing Process

Encounter problem Recognize problem

Assessment
Collect data Collect data
Identify exact Formulate hypothesis Nursing

Diagnosis
nature of problem
Determine plan of Select plan for testing
Planning
action hypothesis
Carry out plan Test hypothesis
Interpret results
Implementation
Evaluate plan in Evaluate hypothesis
A. Characteristics
1. Open, flexible

2. Humanistic and individualized

3. Cyclical

4. Outcome focused ( results oriented)

5. Emphasizes feedback and validation

 B.  Nursing Process vs. Medical Process

1. Medical-identification of a disease and tx.

2. Nursing -identification of actual / potential

responses to illness

C. Why do we learn about the Nursing Process ?

• Practice Standards in the U.S.

• Basis for State Boards NCLEX

• Critical thinking skills

Data collection….data base

Types of Assessment

Types of Data

Sources

Methods

interview & physical assessment techniques

Cues = signs and Inference = what you think,
symptoms a judgement about the cues

Cues Inference

Swollen finger

Misshapen
Broken finger
Reddened

Painful
 Air Requisite Activity & Rest Requisite

Lungs clear Bed rest, full passive ROM

RR 18 labored P.T.daily, Reddened skin
O2, Chest X-ray shows on ankle & elbow, 40 degree
pneumonia contracture on left leg, atrophy
nonproductive cough of muscles

Respiratory Problem Possible Skin Problem

 

Ineffective Airway
Risk for Impaired Tissue
Integrity
 1953 term first used

1973 --- First national conference of

nursing diagnosis .(theorists, educators,
administrators and practioners)

1985 named NANDA

1990 ANA endorsed it as official diagnosis taxonomy

….Is incorporated in ANA standards of practice

Meets every two years

Local chapters 148 diagnoses

+ 16 Carpenito
1. Benefits of a Nursing Diagnosis

a. Communication between Nurses

b. Identification of patient goals

2. Types of Diagnostic Statements

• actual
• risk
• possible
• wellness
• syndrome.
 Three Part Statement
P E S
P=
Problem
( Precise qualifier / modifiers )
Altered High Risk Ineffective
Decreased
Deficit Excess Dysfunctional
Disturbance
Chronic Less than More than
Diagnostic Label = Problem + modifier
Anticipatory
= Chronic Pain
 E = Related Factors
Related factors are etiological or other contributing
factors
that have influenced the health status change.

Etiology sometimes = Causes or factors of risk

Chronic pain r/t Altered Tissue
perfusion

Pathophysiologic
………. secondaryAlteration
to Diabetes
in skin Integrity
r/t ( caused by)
Compromised immune system Inadequate circulation
Inadequate peripheral circulation

Treatment-related
Medications
Diagnostic studies Anxiety r/t (caused by)
lack of knowledge
Surgery of how to dress his wound
Treatments
 Situational
Environmental
Home Risk for Injury r/t
unsteady gait
Community
Institution
Personal
Life experiences
Roles

Maturational Nutrition Imbalance : Less than Body

Requirements r/t

Age related to inadequate sucking

S   =    Defining characteristics
S= signs / symptoms

Clinical cues--subjective and objective signs or symptoms

that point to the nursing diagnosis

• Are separated into major and minor

designations.
• Major defined as critical indicators present
80-100 of the time.
• Minor are supporting and present 50-79%

Major defining characteristics must be present for a
 diagnosis to be valid
 P E
Diagnostic Label Related factor
I impaired Skin Integrity related to prolonged
immobility

S
Defining characteristics
as evidenced by a 2 cm sacral lesion
A real problem exists !!!!!!!!
 Is a clinical judgment that an individual, family
or
community is more vulnerable to develop the
problem than others in the same or similar
situation.
.
Two part statement.---------P ( problem)
E ( related risk factors)

No defining characteristics

No signs or symptoms because

No problem yet
Risk nursing diagnoses

P E
Diagnostic label Etiological risk factors

Risk for Injury related to lack of awareness of

hazards

Factors present which present a risk situation for

a problem to occur
POSSIBLE NURSING DIAGNOSIS
Statements describing a suspected problem for which
additional data is needed.
Two part statement

P
nursing diagnostic label

Possible Self Concept Disturbance

E
etiological factors
related to recent loss of roll responsibilities
secondary to exacerbation of MS.
Nurse may take one of three actions

*confirm the presence of major signs and symptoms,

thus labeling an actual diagnosis

* confirm the presence of potential risk factors, thus

risk diagnosis

*rule out the diagnosis at this time.

Some texts say one part statement

Is a clinical judgment about an individual, family or community
in transition from a specific level of wellness to a higher level
of wellness.
Two cues must be present:

1. desire for a higher level of wellness

2. effective present status or function.

One part statement beginning with Readiness for Enhanced

Diagnostic Label
Readiness for Enhanced Parenting
 One part statement

Diagnostic label
Disuse syndrome.
Comprise a cluster of actual or risk nursing diagnoses that
are predicted to be present because of a certain event or situation

Nursing Diagnoses Associated with Disuse

Syndrome
Risk for Constipation
Risk for Altered Respiratory Function
Risk for Infection
Risk for Thrombosis
Risk for Activity Intolerance
Risk for Injury
Risk for Altered Thought Processes
INEFFECTIVE BREATHING PATTERNS

DEFINITION
Ineffective Breathing Patterns: State in which a person
experiences an actual or potential loss of adequate
ventilation related to an altered breathing pattern

DEFINING CHARACTERISTICS
Major (Must Be Present, One or More)
Changes in respiratory rate or pattern (from baseline)
Changes in pulse (rate, rhythm, quality)

Minor (May Be Present)

Orthopnea Tachypnea, hyperpnea, hyperventilation
Dysrhythmic respirations. Splinted/guarded respirations
 Diagnosis Ineffective Breathing Patterns
( P)

Related to (E) Immobility and chest pain

r/t
Secondary to abdominal surgery

As evidenced by ↑ in respiratory rate from 12 to 22

(S)
pulse rate ↑ 88 to 104 and irregular
 Two practice situations

Nurse is primary provider

Nurse works in collaboration with others

COLLABORATIVE PROBLEMS PC

Physiological problems nurses monitor

Watching for complications ……..Potential Complications

 All collaborative problems begin with the label
POTENTIAL COMPLICATION (PC)

Potential complication: Sepsis

PC: Sepsis

Usually occur in association with a specific pathology

treatment
 Situation: Man admitted post gastric ulcer

Problem /complication: PC: G I bleeding

Nursing focus: Monitor for onset and manage

episodes of gastric bleeding

review exercise:
1. Intravenous Therapy PC: _____________
PC:_______________
2. Head Concussion PC: ____________ PC:________________

3. Nasogastric Suction PC:_____________

PC:________________
 1. Don’t use medical terms when writing a
diagnosis

I‑ Self‑Care Deficit Hygiene r/t Stroke

C- Self-care Deficit: Hygiene r/t weakness secondary

to Stroke

2. Don’t write a diagnosis for an

unchangeable situation

I‑ Anxiety r/t impending death aeb stating” I am

afraid to die”
C- Anxiety r/t fear of dying
 Common errors

3. Use of procedure / treatment instead of a human

response

I- Catherization r/t urinary retention

C- Risk for Infection Transmission r/t device with
contaminated drainage:urinary

4. Don’t write diagnoses that are too general

I- Constipation r/t nutritional intake aeb small hard

stools
C- Constipation r/t  dietary roughage and  fluid intake
 Common errors

5. Don’t combine two problems at the

same time

I- Pain and Fear r/t to upcoming abdominal

surgery
C- Pain r/t tissue trauma secondary to abdominal surgery
aeb “ Pain ranked 4/5”

6. Don’t use judgmental/value laden language or make

assumptions
.
I- Spiritual Distress r/t atheism aeb statement “ I don’t believe in
God
anymore”
C- Spiritual Distress r/t to feelings of abandonment
aeb “ I don’t think God cares about me”
 Common errors

7. Don’t make statements that are legally

inadvisable

I- Tissue Integrity Impaired r/t to infrequent

turning aeb 3 cm diameter ankle ulcer
C- Tissue Integrity Impaired r/t immobility
secondary to fracture

8. Both parts of a diagnostic statement are the same

I- Self care deficit : feeding r/t feeding problem aeb unable to

bring food to mouth

C- Self Care Deficit: feeding r/t neurological impairment

of rt. hand aeb unable to bring food to mouth

Don’t use due to or caused

 Review exercise:   Put a “ C “ in front of the correct nursing diagnosis:

1._____Risk for Constipation related to being on strict

bedrest

2._____Risk for Injury related to lack of side rails on bed

3._____Fear and Anger related to lack of knowledge of

Hypertension

4._____Hopelessness related to progressive disease

process

5._____ Risk for Spiritual Distress due to inability to

attend church services
Review exercise: Put a “ C “ in front of the correct nursing diagnosis:
1.__C___Risk for Constipation related to being on strict bedrest

2._____Risk for Injury related to lack of side rails on bed

3._____Fear and Anger related to lack of knowledge of

Hypertension

4._____Hopelessness related to progressive disease

process

5.__C___ Risk for Spiritual Distress related to inability to

attend church services
6.__C__Impaired Tissue Integrity ( 2" stage 2 ulcer on ankle)
related to ankle pressure and rubbing on sheets

7._____Impaired Walking related to Stroke

8._____Mastectomy related to cancer

9______Imbalanced Nutrition : Less than Body Requirements related to

being NPO aeb inability to take food in mouth

10._____Impaired Physical Mobility related to pain in leg joints aeb

patient reports pain in leg joints

                
 Risks of Diagnostic Errors

1. may aggravate problems

2. omit essential interventions

3. allow problems to exist

4. wasteful interventions

5. influence others

6. danger of legal liability

 G. PLANNING PHASE
" Determination of nursing care in an organized,
individualized and goal directed manner"

1. Determine priorities and list problems

Which do you think need immediate attention? What does

the patient think?

Maslow hierarchy + severity of problem + patient input

Review question: Which of the following problems would you

treat first ?

Severe breathing
Diarrhea
Itching
 planning
2. Establishment of ( goals) OUTCOME and OUTCOME
CRITERIA

( What will the patient be able to do?

and in what time frame ? = OUTCOME

And how will I know it was successful? = OUTCOME

CRITERIA
Diagnosis --------------- Ineffective Airway Clearance

r/t Etiology -----------------------Weakness secondary to

Stroke
aeb Maj. Defining Characteristic (Symptoms)- Nonproductive
Ineffective cough

Broad Outcome ----------------Effective Airway by 10/4/04 Time

frame

aeb Outcome Criteria--------- (symptoms) Productive

cough
 plannin
g
Purpose of Outcomes and Criteria

Indicators of achievement was the airway effective?

Did problem ( cough) stay the same,

Measuring sticks
get  or  , disappear ?

Interventions will be directed

Direct Interventions
toward facilitating a productive
cough

Motivating factors Goal motivates, something to aim for

 Planning

Guidelines

Relate to a human response…..

response
Dx. Altered Elimination: Constipation r/t immobility aeb
hard stools, no bowel movement for 5 days

Outcome: Normal elimination aeb

Outcome criteria: soft stools at least q. 2-3 days

Be patient centered
Dx. Risk for impaired skin integrity r/t decreased mobility

Incorrect= Prevent skin breakdown

Correct Outcome: Pt. will not experience any skin breakdown

Planning
outcomes clear and concise

Incorrect = CDBPD indep q2

Correct = cough, deep breath, postural drainage

outcome criteria describes behavior that is

measurable and observable

Incorrect = drinks enough amounts of fluid

Drinks 2000 ml. Fluid in 24 hours

Planning

realistic
Considers strengths/weaknesses of staff
and patient and resources

  time limited - long/short term

ex. within 4 hrs Before d/c

          ongoing

should be determined by patient and nurse

Ex. Nurse Pain free patient addicted

 Planning

Goals

Cognitive=     Knowledge of Hyper and Hypoglycemia

Psychomotor =   Will Effectively Breast Feed

Affective =     Will be less Anxious

Functioning of Body  =   Have Effective Airway Clearance

Planning

Diagnosis Broad Outcome

1. Imbalanced Nutrition Pt will experience

  Balanced Nutrition

2.   Acute Pain Pt will experience minimal or no pain

3. Risk for Injury Pt will not experience an injury

4. Activity Intolerance Pt will experience improved

tolerance to activity
 Plannin
g
 Write the outcome criteria for the following diagnostic statements
 1. Ineffective Health Maintenance R/T lack of motivation
AEB reports eating high fat diet
goal= Will have effective health maintenance by
4/23/ 05 Aeb

Outcome Criteria: Reports eating RDA of fat in diet

2.       Impaired Urinary Elimination R/T related to diagnostic

instrumentation
AEB reports urgency, frequency
goal= Will have improved or normal elimination by 3/12/05
AEB
Outcome Criteria: Reports absence of urgency and frequency
Planning

   3. Self Care Deficit: Bathing /Hygiene R/T lack of motivation

secondary to depression AEB Unwilling to wash body parts
goal = Will experience no self care hygiene deficit by
11/05/05 AEB

Outcome Criteria: Patient washing arms and legs

 Diagnosis ( P) Ineffective Breathing Patterns

Related to (E) Immobility and chest pain

r/t
Secondary to abdominal surgery

As evidenced by (S) ↑ in respiratory rate from 12 to 22

pulse rate ↑ 88 to 104 and irregular

Outcome /goal Effective Breathing

Date: by 10/22/04 aeb ↓ respiratory rate to 12 to 16

↓ pulse rate to 80 and regular

 Intervention
s
( actions, orders )
" Specific nursing activities /actions that a
nurse must perform to prevent complications ,
provide comfort(physical, psychological and
spiritual) and promote, maintain and restore
health."
Categories
a. Dependent‑implementing M.D. orders-- give Vioxx
medication per order

b. Interdependent‑in cooperation with other health team

members----follow P.T. plan for exercise

c. Independent‑ performed without M.D. order----turn patient

q.2. hrs
interventions

Diagnosis → → Broad Outcome

Altered Skin Integrity Pt. will experience

wound healing

Etiology

R/t immobility → → INTERVENTIONS

secondary to
fracture

Defining → → Outcome Criteria

Characteristics

aeb 3cm diameter aeb ↓ diameter to 2cm

ankle wound
 interventions

Characteristics

a. consistent
b. scientific basis
c. law, professional standards, agency accrediting bodies

    Intervention                     Rationale
  Teach client to rotate              Repeated use of the same      insulin 
injection sites                      site may cause fibrosis, 
       and decreased insulin
absorption
interventions
INDIVIDUALIZED
 Donna‑‑17 year old, immobilized by skeletal traction for a
FX. Lt. leg due to a motorcycle accident

Betsy‑‑84 year old nursing home resident, slightly

dehydrated , confused and confined to bed from a hip
fracture

Dx Risk for skin breakdown r/t immobility secondary to

...........................
  Donna Betsy
Bed trapeze specialized, air mattress

Position cue to turn turn q. 2 hours

Nutrition ↑ protein, zinc etc. tube feeding, ↑ fluids

interventions

•strengths / weaknesses
*power components
*resources
*family/others

•safe environment

•assessment as an intervention

•teaching as an intervention

•consulting/referring as an intervention
interventions

4. Guidelines for Writing

a. date and sign
b. list specific activities

Incorrect Correct
Teach colostomy care 1. demonstrate steps us
applying colostomy
pouch
2. identify equipment needed
with colostomy care
3. provide printed instructions
and discuss content
4. Have client do return
demonstration
interventions

 define Who, What, Where, When, How and How Often

ex. Irrigation of a wound

? which one
? who will irrigate
? when
? How
? How long

d. individualized
I. Documentation‑‑Care plan
1. Purpose
a. continuity of care
b. permanent record
c. documentation

2. Characteristics
a. R.N. authored
b. initiated after first contact
c. readily available
d. current
3. Forms
( all have diagnosis, outcomes and interventions)
a. standardized
b. computerized
. IMPLEMENTATION–
" Initiation of the care plan to achieve specific outcomes”

***performing the planned interventions

Guidelines
1. Review the interventions
2. Analyze the skills, time and equipment involved
3. Know reasons, expected effect and potential hazards 4.
Consider combining interventions
5. Should not be mechanical
6. Include the family
7. Know institutional procedures
 EVALUATION  
Outcome and outcome criteria comparison

" To determine how well the plan worked"

Process
1. Gathering data
2. Compare data with outcome criteria

3. Make judgment
a. outcome achieved
b. outcome not achieved
c. partially achieved

If not----‑check
interventions
human responses
outcomes
related factors
THE END!!!!!!