Transcript Nursing Process

POKOK BAHASAN
1. Mendiskusikan pentingnya memprioritas diagnosa
2.
3.
4.
5.
keperawatan
Mendiskusikan Intervensi perencanaan yang berfokus
pada klien yang dibuat perawat dan kolaborasi tim
kesehatan lainnya
Mediskusikan peran mandiri & kolaborasi perawat
dalam intervensi.
Mendiskusikan peran perawa dalam kaitan dengan
tidakan penceahan terjadinya eror intervensi yang
dilakukan sendiri maupun team kesehatan
Mendemonstrasikan kemampuan menulis tujuan dan
kriteria hasil pada contoh kasus
Definition
• According to (Potter, Perry, Ross-Kerr &
Wood, 2006), planning “involves establishing
client goals and expected outcomes and selecting
nursing interventions” (p.198).
Planning
Determine desired outcomes and plan specific nursing interventions to
achieve them
This is done with the patient (and family/whanau as appropriate)
Objective
Of or relating
to a goal or
aim
Outcome
Something that follows from
an action; result; consequence
Goal
The aim or object
towards which an
endeavour is directed
Planning
• It is third stage of the nursing process.
• Interventions are selected to solve the
client’s health needs and to attain goals and
outcomes.
• Decision-making and problem solving skills
are required
Planning
• Planning require:
 review of the literature
 collaborates with client, family and other
health team members
Planning
Effective planning depends on the quality and
comprehensiveness of the assessment
• Determine the problems
• Establish the risks and priorities- How ill are they?
• Can they breath adequately (safe airway?)
• Are they in pain? (physical/ psychological)
• Can they maintain a safe environment? If not why
not? (Drugs, drink, mental or psychological
problem?)
• Non-compliance with medical advice
Priorities
• Priorities are required to help the nurse
determine nursing interventions when a
client has a number of problems.
• Because often clients have a number of
problems, the client and nurse can decide
urgency of the problem, nature of treatment
and relationship between diagnoses.
General Guidelines for Setting
Priorities
1. Take care of immediate
life-threatening issues.
2. Safety issues.
3. Patient-identified issues.
4. Nurse-identified priorities based on the
overall picture, the patient as a whole
person, and availability of time and
resources.
Nurse Identified Priorities
• Composite of all patient’s strengths and
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health concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.
Priorities
• Priorities may be high, intermediate or low.
Depends on the urgency of the situation.
• High priority if untreated could be harmful to the
client Ex: Decreased cardiac output would be high
priority
• Intermediate would be considered non urgent, non
life-threatening. Ex. sore throat
• Low priority may not be connected to the direct
illness or prognosis but may affect the individual’s
future well-being. Ex. dressing change in the
ambulatory setting.
(See Priority Setting Potter et al., 2006 p.199)
Client Goals
• Broad statements that represent the health
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state/level of self care for the client
Should be realistic and based on the client’s needs
Should also aim to prevent and rehabilitate the
client
Develop collaboratively between client and nurse
Note: if the client is cognitively or physically impaired, the
healthcare team works on behalf of the client
Client Goals
• Client Goals can be short or long term goals
• Short-Term Goal- objective is to be attained
within a short time i.e.: a week
 Ex: client will achieve comfort within 24 hours post surgery
Long-Term Goal- achieve over a longer period of
time i.e: weeks or months.
 Ex: client will follow post-op activity restriction for 1 month
Short-Term Goals
• Outcomes achievable in a few days or 1
week
• Developed form the problem portion of the
diagnostic statement
• Client-centered
• Measurable
• Realistic
• Accompanied by a target date
Long-Term Goals
• Desirable outcomes that take weeks or
months to accomplish for client’s with
chronic health problems
Expected Outcomes
• Expected Outcomes are developed on the basis of
the nursing diagnoses and client goals.
• Also known as evaluative criteria
• Desired behaviours or responses that the nurse and
where applicable, the client expect to occur as a
result of the interventions taken by the nurse
• Enable the nurse and client evaluate whether the
pan of care has been successful in meeting the
goal(s)
Outcomes need to be:
S pecific
What will happen?
M easurable
How will you know it has happened?
A chievable
Can it happen?
R ealistic
Is it realistic to expect it to happen?
T imeframed
When will it happen?
Sample outcome statements
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Wound will show 50% granulation within 2 weeks
Wound will show evidence of epithelialisation within 3
weeks
Comfort will be maintained during episode of care, as stated
by patient
Oedema will be reduced within 3 weeks with the use of
compression bandaging
Exudate will be contained and strike through prevented until
infection resolved
Expected Outcomes
• Client Centered -reflect client behavior & response
• Singular - address only one behavior or specify one
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outcome
Measurable to the extent possible-the desired outcome can
be determined or not
Client specific-where possible the degree of proficiency
required for the outcome to be considered achieved by the
client is stated
Time limited- where appropriate, the time frame for an
expected response should be included
Mutual- where possible, the client should be in agreement
with the outcomes to ensure a greater chance of being
successful
Realistic -must be attainable
Examples of Expected Outcomes
• Client will explain reasons for activity restriction by day of
discharge.
• Client will sit up in chair 20 minutes without abnormal
heart rate by day 2.
• See handout for examples of verbs to help formulate client
outcomes (p.4)
Goals and Expected Outcomes
• Critical thinking is required
• Nursing knowledge coupled with experience will
help the nurse determine the ‘goal’
• A client centered goal is specific and able to be
measured and reflects the person’s highest level of
wellness.
• Goal needs to lead to prevention.
Nursing Interventions
• Nursing interventions are decided after
goals and expected outcomes are confirmed.
• Assist the client to move form his/her
present state of health to that which is
identified in the goal and outcomes.
Interventions should:
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Monitor, prevent & manage health
problems/concerns & risk factors
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Promote optimum function, independence & sense
of wellbeing
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Achieve expected outcomes
Interventions
• Direct interventions: actions
performed through interaction
with clients.
• Indirect interventions: actions
performed away from the client,
on behalf of a client or group of
clients.
Selecting Nursing
Interventions
• Planning the measures that the client and
nurse will use to accomplish identified goals
involves critical thinking.
• Nursing interventions are directed at
eliminating the etiologies.
Selecting an intervention
• The nurse selects strategies based on the
knowledge that certain nursing actions
produce desired effects.
• Nursing interventions must be safe, within
the legal scope of nursing practice, and
compatible with medical orders.
Communicating The Plan
• The nurse shares the plan of care with
nursing team members, the client, and
client’s family.
• The plan is a permanent part of the record.
Types of Planned Client Focused
Interventions
• Nurse-Initiated Interventions
• Physician-Initiated Interventions
• Collaborative Interventions
Nurse-Initiated Interventions
• Nurse-Initiated Interventions – are the
independent response of the nurse to the
client’s health care requirements. They are
automatic reactions based on scientific
rationale that are expected to benefit the
client
• No order required from the physician
• Ex. Interventions to increase person’s knowledge of
nutrition- Discuss Canada’s food guide
Physician-Initiated Interventions
• Physician-Initiated Interventionsinterventions based on physician’s response
to treat the client.
• Nurses carry out physician’s orders
• Requires expertise in technological nursing
knowledge and nursing responsibility
• Ex. Give a medication or change a dressing
Collaborative Interventions
• Collaborative Interventions-therapies that
require the knowledge and skills of a
number of professionals to provide care to a
client.
• Ex. Client with a stroke-requires multiple interventions
from nursing, physiotherapy etc.
Client Interventions
• Client Interventions- are interventions
carried out by the client to meet his/her
goals and expected outcomes.
• Also remember that client interventions are
not mirror nursing interventions
• Ex: Client attends the fitness program three times per week
Writing Interventions
• Interventions must be written in the following
format: verb-noun-modifier
• Ex: Administer Tylenol 325 mg po for
temperature > than 38.5
• Note: Interventions are action verbs
Independent and Interdependent Role of
the Nurse
• A nurse thinks clearly and does not
select interventions randomly
• Nurse considers a number of
factors such as: characteristics of
the nursing diagnosis, expected
outcomes, nursing knowledge,
feasibility of the intervention,
acceptability to the client, and
nursing competencies.
• Collaboration with the client,
family and other members of the
health team is necessary
• Review
previous
clinical
experiences and priorities to select
the best nursing interventions
Prevention of Intervention Errors
• Nurse initiated, physician
initiated and collaborative
interventions require the
nurse to us critical
thinking and decision
making.
• Nurse must decide if the
interventions are
appropriate for the client
• Important to recognize
errors such as a
physician’s order,
incorrect therapy, etc.
Summary
 Prioritization of nursing diagnosis
 Discussion on the types of planned client focused
interventions
 Discussion on the independent and interdependent role
of the nurse in relation to interventions directed by other
health care professionals.
 Discussion on the role of the nurse as it relates to the
prevention of intervention errors
 Demonstrate ability to write short and long term goals
and expected client outcomes based on simulated client
situations
Thank you
Thank you