MIDTERM WEEK 4 (IDA JEAN ORLANDO)

IDA JEAN ORLANDO

• A prominent American nurse, psychiatric nurse specialist, theorist, educator, and researcher.

• Born: August 12, 1926

• Died: November 28, 2007

• She is best known for developing the Deliberative Nursing Process Theory

DELIBERATIVE NURSING PROCESS THEORY

• The theory proposes a flexible, patient-centered approach to nursing care.

• It centers on the idea that:

1. All patient behaviors– verbal or nonverbal– are meaningful expressions of needs or distress.

2. Nurses should deliberately interpret these behaviors, validate their understanding with patients, and plan care collaboratively– not merely follow routines or orders.

5 COMPONENTS OF THE NURSING PROCESS

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

1. ASSESSMENT

• C- Collecting data – the process of gathering information

• O- Organizing data – the process of categorizing data systematically

• V- Validating is the act of “double-checking” or verifying data to confirm that it is accurate and factual

• D- Documenting data

• Goal:

  Establish database about the clients response to health concerns or illness

TWO (2) CLASSIFICATIONS OF ASSESSMENT

1. Subjective Data

2. Objective Data

SUBJECTIVE DATA

• Symptoms or Covert Data

• Apparent only to the person affected

• Can be described only by the person affected

• Includes sensations, feelings, values, beliefs, attitudes, and perceptions of personal health status and life situations

OBJECTIVE DATA

• Signs or Overt Data

• Detectable by an observer

• Can be measured or tested against an accepted standard

• Can be seen, heard, felt, or smelled

• Obtained through observation or physical examination

SOURCES OF DATA

1. Primary Source

   • the CLIENT

2. Secondary Source

   • All other sources of data

   • Should be validated, if possible

METHODS OF DATA COLLECTION

1. Observing

2. Interviewing

3. Examining (Physical Examination)

OBSERVING

• Gathering data using the senses

• Skin Color (vision)

  Body or Breath Odors (smell)

  Lung or Heart Sounds (hearing)

  Skin Temperature (touch)

INTERVIEWING

• Planned communication or a conversation with a purpose

• Used to:

  • Identify problems of

    mutual concern

  • Evaluate change

  • Teach

  • Provide support

  • Provide counseling or

    therapy

EXAMINING (PHYSICAL EXAMINATION)

• Systematic data-collection method

• Uses observation and inspection, auscultation, palpation, and percussion

• Blood pressure

• Pulses

• Hear and lungs sounds

• Skin temperature and moisture

• Muscle strength

• NURSING DIAGNOSIS

• Analyzing and synthesizing data

• Goals:

  1. Identify client strengths

  2. Identify health problems that can be prevented or resolved

  3. Develop a list of nursing and collaborative problems

TYPES OF NURSING DIAGNOSIS

1. Actual

2. Risk

ACTUAL DIAGNOSIS

• Problem present at the time of the assessment

• Presence of associated signs and symptoms

• Example:

  Hyperthermia, Acute Pain Ineffective breathing pattern, impaired gas exchange, ineffective airway clearance

RISK DIAGNOSIS

• Problem does not exist

• Presence of risk factors

• Risk diagnoses focus on prevention by identifying factors that may increase the likelihood of a problem developing so that early interventions can be implemented to prevent it. (PREVENTION-ORIENTED)

• Example:

  Risk for infection, risk for bleeding, risk for ineffective airway clearance

NURSING VS MEDICAL DIAGNOSIS

Nursing Diagnosis

• Ineffective Airway Clearance

• Disturbed Body Image

• Risk for Unstable Blood Glucose

• Impaired Urinary Elimination

• Self-Care Deficit: Dressing

Medical Diagnosis

• Pneumonia

• Amputation

• Type 2 Diabetes Mellitus

• Post-op Prostatectomy

• Cerebrovascular Accident

COMPONENTS OF NURSING DIAGNOSIS

P – Problem → describes the client’s health problem / diagnostic label

E – Etiology → the study of the cause or origin of a disease or condition / cause of the problem

S – Signs & Symptoms

PLANNING

• Determining how to prevent, reduce, or resolve identified priority client problems

• Goals:

1. Develop an individualized care plan that specifies client goals/ desired outcomes

2. Related nursing interventions

• Setting Priorities (S – M – A – R – T)

• Establishing a preferential sequence for addressing nursing diagnoses and interventions

High-priority (life-threatening)

Medium-priority (health-threatening)

Low priority (developmental needs)

IMPLEMENTATION / INTERVENTION

• Carrying out (or delegating) and documenting planned nursing interventions

• Goals:

  1. Assist client to meet desired goals/outcomes

  2. Promote wellness

  3. Prevent illness and disease

  4. Restore health

  5. Facilitate coping with altered functioning

TYPES OF NURSING INTERVENTIONS

1. Independent Interventions

2. Dependent Interventions

INDEPENDENT INTERVENTIONS

• Those activities that nurses are licensed to initiate based on their knowledge and skills

• Example:

  Performing TSB, positioning the patient

DEPENDENT INTERVENTIONS

• Activities carried out under the primary care provider’s orders or supervision, or according to specified routines

• Example:

  Ordered medications

5. EVALUATION

• Measuring the degree to which goals/outcomes have been achieved

• Identifying factors that positively or negatively influence goal achievement

• Goals:

  1. Determine whether to continue, modify or terminate the plan of care

• Goal Met

  Partially Met

  Not Met