The Nursing Process. Teaching Plan
Content
1 Topic: Audience: Date: Time: Duration: Venue: The Nursing Process and the Nurse 3rd year BScN. Student Nurses (NCU) August 26th, 2013 1: 15 pm 45 Minutes Lecture Room
Methodology: Lecture Discussion Number of participants: To be added Learning Theories: Ausubel: Emphasized the use of advance organizers which he said was
different from overviews and summaries. His use of an advance organizer acted as a bridge the chasm between learning material and existing related ideas. The advanced organizer used; sought to bridge new knowledge with what was known (sometimes what is known is uncertain and not concrete). Though he specified that his theory applied only to reception learning in schools, it was utilized because it introduced the topic and aided the sequence of the information to be imparted. (Ormrod & Rice, 2003). Rogers: Dealt with the adult learner, he posited that learning is student centered and personalized and the educator’s role is that of a facilitator. Affective and cognitive needs are central and the goal is to develop self-actualized persons in a cooperative, supportive environment. This theory was used because all the participants were adult learners, thus they
2 were responsible for their learning experience and the teacher sought to guide them through this experience. (Quinn, 2006). Bruner: Believed that learners were not blank slates but bought past experiences to a new situation, he also stated that new information was linked to prior knowledge, thus mental representations are subjective. Bruner’s Discovery learning is an inquiry-based, constructivist learning theory that takes place in problem solving situations where the learner draws on his or her own past experience and existing knowledge to discover facts and relationships and new truths to be learned. (Quinn, 2006). Students interact with the world by exploring and manipulating objects, wrestling with questions and controversies, or performing experiments. As a result, students may be more likely to remember concepts and knowledge discovered on their own (in contrast to a transmissionist model). (Quinn, 2006). Models that are based upon discovery learning model include: guided discovery, problem-based learning, simulation-based learning, case-based learning, incidental learning, among others. The advantages of this theory are: it encourages active engagement, promotes motivation, a tailored learning experience, and promotes autonomy, responsibility, independence, the development of creativity and problem solving skills. (Quinn, 2006) Bruner’s theory was used because it encouraged active engagement, promotes motivation, a tailored learning experience, and promotes autonomy, responsibility, independence and the development of creativity and problem solving skills for this presentation. Vygotsky: Posited that individuals learn from each other through social interaction and the teacher and the learner collaborate in a reciprocal relationship where each learns from each other through the same process of social interaction (Quinn, 2006). This theory was chosen since it lays the overall foundation for human behaviours that of interaction, it coincides with the topic and the overall mode of delivery of the topic.
3 Aim of the activity: To educate/show students how the nursing process can be applied effectively to patient care situation. Scientific Principle: Orlando Jean’s Nursing Process theory- Focuses on the interaction between the nurse and the patient, perception validation and the use of the nursing process to produce positive outcome or patient improvement (Faust C. 2002). this scientific principle was utilized because its key focus defines the function of nursing and it is also congruent with the topic under consideration. Resources: Objectives: Registered nurse, lap top computer, multimedia, white board, markers At the end of 45 minutes interactive session students should be able to 1. Define the term Nursing Process according to Funnell, Koutoukidis & Lawrence, (2009) 2. State the characteristics of the Nursing Process as stated by Kozier, Erb, Berman and Burke (2006) 3. Describe the components of the Nursing Process according to Kozier et al (2006); Potter and Perry (2006) 4. Describe the management of an asthmatic client using the nursing process Evaluation: Formative and Summative. Questions will be asked before and after each objective as well as a demonstration followed by a test at the end
4 References:
Ackley, B & Ladwig. (2010). Nursing diagnosis handbook: A guide to planning care Amsterdam: Elsevier/Mosby
Kozier, B., Erb, G., Berman, A & Burke, K. (2006), Fundamentals of nursing: Concepts
process and practice, Upper Saddle, River New Jersey: Prentice Hall Faust, C, (2002, July). Orlando’s deliberative nursing process theory: a practice application in an Extended care facility. JGerontol Nursing. 28(7): 14-8 Funnell, R., Koutoukidis, G & Lawrence, K. (2009) Tabbner's Nursing Care. Australia: Elsevier Ormrod, J & Rice, F. (2003). Lifespan development and learning. Boston MA: Pearson
Publishing.
Potter, P & Griffin, A. (2006) Fundamentals of nursing. St Louis: Elsevier Mosby Quinn, F. (2006). The principles and practice of nurse education. London: Stanley Thornes
5
Time
Objectives
Contents
2mins Ice breaker
Teacher Activity Teacher will ask students to identify the main theme in the scenario and how it relates to the topic to be taught
Learner’s Activity Students will attempt to identify the main theme in the scenario (by looking at the picture) and how it relates to the topic to be taught
Evaluation
3mins Define the term Nursing process
A systematic, rational, modified scientific method of planning and providing individualized nursing care. (Funnell, Koutoukidis & Lawrence, 2009)
Teacher will randomly ask students to define the terms the nursing process in their own words.
Students will attempt to define the nursing process in their own words.
Students will correctly define the terms the nursing process utilizing at least two words according to
6 Teacher will define the terms the nursing process with the aid of PowerPoint according to the content Students will sit and listen attentively as term the nursing process is defined the context such as: A systematic, rational method of planning and providing individualize d nursing care
Teacher will ask one student to define the term the nursing process according to the content
10mi ns
State the five characteristics of the nursing process
1.
Systematic The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it.
2. Dynamic The nursing process has great interaction and
Teacher will distribute the five characteristics of the nursing process to five students and ask them to match them to their correct
Student will define the term nursing process according to the content using at least two key words such as: A systematic, rational method of planning and providing individualized patient care Five students will match the five characteristic of the nursing process with the five correct explanations that five other students will have, then they will read
Students will be able to correctly state the five characteristic s of the nursing process according to the content
7 overlapping among the activities; each activity is fluid and flows into the next activity. 3. Interpersonal The nursing process ensures that nurses are clientcentered rather than task-centered and encourages them to work to help clients use their strengths to meet human needs. (Kozier, Erb, Berman & Burke, 2006) 4. Goal-Directed The nursing process is a means for nurses and clients to work together to identify specific goals related to wellness promotion, disease and illness prevention, health restoration, coping and altered functioning, which are most important to the client, and to match them with the appropriate nursing actions. 5. Universally Applicable The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting. (Kozier et al, 2006) explanation that five other students will receive, then they will read the correct matches aloud Teacher will state the characteristics of the nursing process utilizing the PowerPoint presentation. Teacher will ask two students to the back and three at the front to state one each, the five characteristics of the nursing process them aloud
Students will sit and listen attentively as the characteristics of the nursing process are stated.
Two students at the back and three at the front will state one each, the five characteristics of the nursing process according to the content
15mi ns
Describe the components of the nursing process
The components of the nursing process includes four overlapping processes, which includes, Assessment, Planning,(Diagnoses) Implementation and Evaluation (Kozier et al, 2006) ASSESSMENT: involves the gathering of all possible data
Teacher will ask a student from each row to write on
One student from each row will write on white board one
Students will be able to correctly describe the
8 regarding patients, to identify problems. The data gathering methods include 1. Interviews, 2. Observation, 3. Physical assessment, 4. Consultation with other members of the health care team through records/reports related to the patient as well as through verbal interaction and 5. Review of literature. Data is gathered essentially through five sources: (1) The patient; (2) Family members, friends and associates; (3) other members of the health care team; (4) Records of the patient’s present and past health status; and (5) Written information regarding the problem or problems and treatment facing the patient ( Potter & Griffin, 2006). DIAGNOSIS: This is a statement of the clients’ problems based on the assessment that was done. It includes all the assessment data taken. Nursing diagnoses fall into four main categories. (Potter el al, 2006) 1. Potential/Risk Diagnoses: For example Risk for Injury, the situation has not occurred, thus nursing care is focused on factors preventing any incidents of injury from occurring. 2. Actual Diagnoses: For example, Ineffective airway clearance, and a problem has actually occurred, nursing is focused on alleviating/correcting the signs and symptoms of the problem. 3. Syndrome Diagnoses: This is a cluster (of two or more) of client problems grouped together. For example RapeTrauma-(Stress) Syndrome. 4. Health Promotion Diagnoses: These are also called wellness diagnoses. They are aimed at education, promoting and preventing illnesses. For example, Readiness for enhanced learning, they may or may not carry a manifestation.(Potter el, 2006) PATIENT OBJECTIVE: This is decided on in conjunction with the client, it is what he or white board one component of the nursing process and briefly say what it is; she may call on anyone in her row for assistance. Teacher will describe the components of the nursing process with the aid of the PowerPoint Presentation component of the nursing process and will briefly say what it is, she can call on her row members for assistance components of the nursing process according to the content by explaining phases such as: Assessment, Diagnosis, patient outcome, interventions, rationales and outcomes
Students will sit, listen ask questions and follow on PowerPoint as the components of the process are described.
9 she hopes to achieve at the end of the period of care. It should be realistic, time bound and achievable (Potter et al, 2006) PLANNING: The establishment of client goals/outcomes by the provider, working with the client, that prevent, reduce, or resolve problems and the determination of related nursing interventions most likely to assist client in achieving goals During planning, the provider: Establishes Priorities-Oxygenation/breathing Writes Client Goals-client will experience a reduction in current respiratory rate. Selects Nursing Intervention-place client in fowler’s position Communicates The Plan-client to be placed in fowler position. (Potter et al, 2006) IMPLEMENTATION: The provider carries out the plan of care-client placed in fowler’s position During implementation, the care provider: Carries out The Plan Of Nursing Care Continues data collection and modifies the Plan of Care as needed Documents care-client was placed in high fowler’s position…10am..H. Williams R/N EVALUATING: The measuring of the extent to which client goals have been met During evaluating, the care provider: Measures The Clients achievement of desired Goals/OutcomesClient experienced a reduction of respiratory rate (20bpm) (Potter et al, 2006)
10 15mi ns Describe the management for an asthmatic client using the nursing process Mrs. Jones is brought to the UHWI’s Emergency room with SOB, Dyspnea, and use of accessory muscles, thick viscous secretions crackling cough and frightened look on her face, her vital signs revealed: T 37. 2 C; P100bpm; R32bpm; B/P100/65..She is diagnosed with an acute asthmatic attack. You are asked to outline the Nursing Management for her under the following need: -Oxygenation Teacher will ask students to form themselves into three groups, one group will note the assessment details, the other the nursing diagnoses and the patient’s outcome and the third group at least five priority interventions Teacher will provide clarity and feedback on the scenario and answer question asked with the aid of marker and white board Students will form themselves into three groups, one will look at the nursing assessment, the other the possible diagnoses and the third group at least five priority interventions Students will be able to correctly describe the management for an asthmatic utilizing the nursing process
Students will ask questions and listen to the feedback given by teacher
11 CAREPLAN Assessment Diagnosis Patient Objective/Goal Client has SOB, Dyspnea, Use of accessory muscles, thick viscous secretions. Assessment revealed V/S P100Bpm, R32Bpm, BP 100/65 Diagnosis of Acute Asthmatic attack Ineffective Airway Clearance related to inflammatory process/excess mucous production as evidence by thick viscous secretions, Dyspnea, use of accessory muscles Client will demonstrate signs of patent airway and adequate oxygen exchange within the 8hr shift following nursing and other interventions Ineffective Breathing Pattern related to trachea-bronchial Within ½ hour of nursing and other interventions client 1. Assess respiratory status lung sounds, respiratory rate and depth, presence and severity of wheezing, breathing pattern, use of accessory muscles - Some degree in bronchospasm is present with obstruction in airway and may be manifested with wheezing or absent breath sounds in severe asthma. Tachypnea is usually present to some degree and respiratory dysfunction is variable depending on underlying process such as allergic reaction 2. Assess then monitor V/S – Initially for baseline and then for comparison 3. Administer Humidified Oxygen Client will verbalize reduction or absence in difficulty in breathing and feeling of chest constriction, respiration and cardiac rate within normal range, absence or reduction of inspiratory and expiratory wheezing following nursing and other interventions (What is hoped to be achieved) Outcome Criteria: Intervention and Rationales Evaluation/Outcomes
obstruction/inflammatory will demonstrate an process as evidence by SOB, use of accessory muscles, V/S P100bpm, R32bpm, BP 100/65 improvement in respiratory rate as evidence by respiratory rate of 1624bpm
12 2-5l as required – to improve tissue oxygenation and prevent drying of the nares 4. Assist patient to assume to comfortable position, i.e. elevate head of bed, (fowler’s position) have client lean on over bed table or sit on the edge of bed Elevation of head of the bed facilitates respiratory function by use of gravity, however client in distress may seek position that most eases work load of breathing. 5. Keep environmental pollution to a minimum according to individual situation - Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. 6. Encourage and assist abdominal and pursed – lip breathing
13 exercises - Provides some means to cope with or control dyspnea and reduce air trapping. 7. Increase fluid intake to 25003000ml within cardiac tolerance Hydration helps thin secretions, facilitating expectoration and using warm liquids may decrease bronchospasm. 8. Provide warm liquids and recommend intake of fluids between meals, instead of during meals - Fluids during meals can increase gastric distension and pressure on the diaphragm. 9. Administer medications as indicated. (Atrovent) Anticholinergic medications are the first line drugs for clients with this condition. 10. Monitor side effects of bronchodilator (Salbutamol) –
14 Bronchodilators are known to cause (tremors/ tachycardia, bronchospasm). 11. Provide supplemental humidification, e.g., nebulizer in respiratory treatments - Humidity helps reduce viscosity of secretions, facilitating/stimulate expectoration, and reduce bronchospasm 12. Monitor ABGs, pulse oximetry, chest x- ray, capillary refill – indicates acid-base balance, oxygen saturation levels, level of obstruction and Establishes baseline for monitoring progression/ regression of disease process (Ackley & Ladwig, 2010)
15
EXAMINATION/EVALUATION Questions 1. The Nursing Process is _____________, ____________modified scientific method of planning and providing individualized Nursing care. 2. Three characteristics of the nursing process are: 3. Name the five sources of data Gathering TRUE OR FALSE 4. The Nursing Diagnosis is a summation into one phrase or diagnostic label all the available data on a patient’s condition Answers 1. Systematic, rational, modified scientific method of planning and providing individualized nursing care. 2. Dynamic, interpersonal, goal-directed, interpersonal, universally applicable 3. Data are gathered essentially through five sources: (1) The patient; (2) Family members, friends and associates; (3) other members of the health care team; (4) Records of the patient’s present and past health status; and (5) Written information regarding the problem or problems and treatment
16 facing the patient( Potter & Griffin, 2006). 4. True
Methodology: Lecture Discussion Number of participants: To be added Learning Theories: Ausubel: Emphasized the use of advance organizers which he said was
different from overviews and summaries. His use of an advance organizer acted as a bridge the chasm between learning material and existing related ideas. The advanced organizer used; sought to bridge new knowledge with what was known (sometimes what is known is uncertain and not concrete). Though he specified that his theory applied only to reception learning in schools, it was utilized because it introduced the topic and aided the sequence of the information to be imparted. (Ormrod & Rice, 2003). Rogers: Dealt with the adult learner, he posited that learning is student centered and personalized and the educator’s role is that of a facilitator. Affective and cognitive needs are central and the goal is to develop self-actualized persons in a cooperative, supportive environment. This theory was used because all the participants were adult learners, thus they
2 were responsible for their learning experience and the teacher sought to guide them through this experience. (Quinn, 2006). Bruner: Believed that learners were not blank slates but bought past experiences to a new situation, he also stated that new information was linked to prior knowledge, thus mental representations are subjective. Bruner’s Discovery learning is an inquiry-based, constructivist learning theory that takes place in problem solving situations where the learner draws on his or her own past experience and existing knowledge to discover facts and relationships and new truths to be learned. (Quinn, 2006). Students interact with the world by exploring and manipulating objects, wrestling with questions and controversies, or performing experiments. As a result, students may be more likely to remember concepts and knowledge discovered on their own (in contrast to a transmissionist model). (Quinn, 2006). Models that are based upon discovery learning model include: guided discovery, problem-based learning, simulation-based learning, case-based learning, incidental learning, among others. The advantages of this theory are: it encourages active engagement, promotes motivation, a tailored learning experience, and promotes autonomy, responsibility, independence, the development of creativity and problem solving skills. (Quinn, 2006) Bruner’s theory was used because it encouraged active engagement, promotes motivation, a tailored learning experience, and promotes autonomy, responsibility, independence and the development of creativity and problem solving skills for this presentation. Vygotsky: Posited that individuals learn from each other through social interaction and the teacher and the learner collaborate in a reciprocal relationship where each learns from each other through the same process of social interaction (Quinn, 2006). This theory was chosen since it lays the overall foundation for human behaviours that of interaction, it coincides with the topic and the overall mode of delivery of the topic.
3 Aim of the activity: To educate/show students how the nursing process can be applied effectively to patient care situation. Scientific Principle: Orlando Jean’s Nursing Process theory- Focuses on the interaction between the nurse and the patient, perception validation and the use of the nursing process to produce positive outcome or patient improvement (Faust C. 2002). this scientific principle was utilized because its key focus defines the function of nursing and it is also congruent with the topic under consideration. Resources: Objectives: Registered nurse, lap top computer, multimedia, white board, markers At the end of 45 minutes interactive session students should be able to 1. Define the term Nursing Process according to Funnell, Koutoukidis & Lawrence, (2009) 2. State the characteristics of the Nursing Process as stated by Kozier, Erb, Berman and Burke (2006) 3. Describe the components of the Nursing Process according to Kozier et al (2006); Potter and Perry (2006) 4. Describe the management of an asthmatic client using the nursing process Evaluation: Formative and Summative. Questions will be asked before and after each objective as well as a demonstration followed by a test at the end
4 References:
Ackley, B & Ladwig. (2010). Nursing diagnosis handbook: A guide to planning care Amsterdam: Elsevier/Mosby
Kozier, B., Erb, G., Berman, A & Burke, K. (2006), Fundamentals of nursing: Concepts
process and practice, Upper Saddle, River New Jersey: Prentice Hall Faust, C, (2002, July). Orlando’s deliberative nursing process theory: a practice application in an Extended care facility. JGerontol Nursing. 28(7): 14-8 Funnell, R., Koutoukidis, G & Lawrence, K. (2009) Tabbner's Nursing Care. Australia: Elsevier Ormrod, J & Rice, F. (2003). Lifespan development and learning. Boston MA: Pearson
Publishing.
Potter, P & Griffin, A. (2006) Fundamentals of nursing. St Louis: Elsevier Mosby Quinn, F. (2006). The principles and practice of nurse education. London: Stanley Thornes
5
Time
Objectives
Contents
2mins Ice breaker
Teacher Activity Teacher will ask students to identify the main theme in the scenario and how it relates to the topic to be taught
Learner’s Activity Students will attempt to identify the main theme in the scenario (by looking at the picture) and how it relates to the topic to be taught
Evaluation
3mins Define the term Nursing process
A systematic, rational, modified scientific method of planning and providing individualized nursing care. (Funnell, Koutoukidis & Lawrence, 2009)
Teacher will randomly ask students to define the terms the nursing process in their own words.
Students will attempt to define the nursing process in their own words.
Students will correctly define the terms the nursing process utilizing at least two words according to
6 Teacher will define the terms the nursing process with the aid of PowerPoint according to the content Students will sit and listen attentively as term the nursing process is defined the context such as: A systematic, rational method of planning and providing individualize d nursing care
Teacher will ask one student to define the term the nursing process according to the content
10mi ns
State the five characteristics of the nursing process
1.
Systematic The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it.
2. Dynamic The nursing process has great interaction and
Teacher will distribute the five characteristics of the nursing process to five students and ask them to match them to their correct
Student will define the term nursing process according to the content using at least two key words such as: A systematic, rational method of planning and providing individualized patient care Five students will match the five characteristic of the nursing process with the five correct explanations that five other students will have, then they will read
Students will be able to correctly state the five characteristic s of the nursing process according to the content
7 overlapping among the activities; each activity is fluid and flows into the next activity. 3. Interpersonal The nursing process ensures that nurses are clientcentered rather than task-centered and encourages them to work to help clients use their strengths to meet human needs. (Kozier, Erb, Berman & Burke, 2006) 4. Goal-Directed The nursing process is a means for nurses and clients to work together to identify specific goals related to wellness promotion, disease and illness prevention, health restoration, coping and altered functioning, which are most important to the client, and to match them with the appropriate nursing actions. 5. Universally Applicable The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting. (Kozier et al, 2006) explanation that five other students will receive, then they will read the correct matches aloud Teacher will state the characteristics of the nursing process utilizing the PowerPoint presentation. Teacher will ask two students to the back and three at the front to state one each, the five characteristics of the nursing process them aloud
Students will sit and listen attentively as the characteristics of the nursing process are stated.
Two students at the back and three at the front will state one each, the five characteristics of the nursing process according to the content
15mi ns
Describe the components of the nursing process
The components of the nursing process includes four overlapping processes, which includes, Assessment, Planning,(Diagnoses) Implementation and Evaluation (Kozier et al, 2006) ASSESSMENT: involves the gathering of all possible data
Teacher will ask a student from each row to write on
One student from each row will write on white board one
Students will be able to correctly describe the
8 regarding patients, to identify problems. The data gathering methods include 1. Interviews, 2. Observation, 3. Physical assessment, 4. Consultation with other members of the health care team through records/reports related to the patient as well as through verbal interaction and 5. Review of literature. Data is gathered essentially through five sources: (1) The patient; (2) Family members, friends and associates; (3) other members of the health care team; (4) Records of the patient’s present and past health status; and (5) Written information regarding the problem or problems and treatment facing the patient ( Potter & Griffin, 2006). DIAGNOSIS: This is a statement of the clients’ problems based on the assessment that was done. It includes all the assessment data taken. Nursing diagnoses fall into four main categories. (Potter el al, 2006) 1. Potential/Risk Diagnoses: For example Risk for Injury, the situation has not occurred, thus nursing care is focused on factors preventing any incidents of injury from occurring. 2. Actual Diagnoses: For example, Ineffective airway clearance, and a problem has actually occurred, nursing is focused on alleviating/correcting the signs and symptoms of the problem. 3. Syndrome Diagnoses: This is a cluster (of two or more) of client problems grouped together. For example RapeTrauma-(Stress) Syndrome. 4. Health Promotion Diagnoses: These are also called wellness diagnoses. They are aimed at education, promoting and preventing illnesses. For example, Readiness for enhanced learning, they may or may not carry a manifestation.(Potter el, 2006) PATIENT OBJECTIVE: This is decided on in conjunction with the client, it is what he or white board one component of the nursing process and briefly say what it is; she may call on anyone in her row for assistance. Teacher will describe the components of the nursing process with the aid of the PowerPoint Presentation component of the nursing process and will briefly say what it is, she can call on her row members for assistance components of the nursing process according to the content by explaining phases such as: Assessment, Diagnosis, patient outcome, interventions, rationales and outcomes
Students will sit, listen ask questions and follow on PowerPoint as the components of the process are described.
9 she hopes to achieve at the end of the period of care. It should be realistic, time bound and achievable (Potter et al, 2006) PLANNING: The establishment of client goals/outcomes by the provider, working with the client, that prevent, reduce, or resolve problems and the determination of related nursing interventions most likely to assist client in achieving goals During planning, the provider: Establishes Priorities-Oxygenation/breathing Writes Client Goals-client will experience a reduction in current respiratory rate. Selects Nursing Intervention-place client in fowler’s position Communicates The Plan-client to be placed in fowler position. (Potter et al, 2006) IMPLEMENTATION: The provider carries out the plan of care-client placed in fowler’s position During implementation, the care provider: Carries out The Plan Of Nursing Care Continues data collection and modifies the Plan of Care as needed Documents care-client was placed in high fowler’s position…10am..H. Williams R/N EVALUATING: The measuring of the extent to which client goals have been met During evaluating, the care provider: Measures The Clients achievement of desired Goals/OutcomesClient experienced a reduction of respiratory rate (20bpm) (Potter et al, 2006)
10 15mi ns Describe the management for an asthmatic client using the nursing process Mrs. Jones is brought to the UHWI’s Emergency room with SOB, Dyspnea, and use of accessory muscles, thick viscous secretions crackling cough and frightened look on her face, her vital signs revealed: T 37. 2 C; P100bpm; R32bpm; B/P100/65..She is diagnosed with an acute asthmatic attack. You are asked to outline the Nursing Management for her under the following need: -Oxygenation Teacher will ask students to form themselves into three groups, one group will note the assessment details, the other the nursing diagnoses and the patient’s outcome and the third group at least five priority interventions Teacher will provide clarity and feedback on the scenario and answer question asked with the aid of marker and white board Students will form themselves into three groups, one will look at the nursing assessment, the other the possible diagnoses and the third group at least five priority interventions Students will be able to correctly describe the management for an asthmatic utilizing the nursing process
Students will ask questions and listen to the feedback given by teacher
11 CAREPLAN Assessment Diagnosis Patient Objective/Goal Client has SOB, Dyspnea, Use of accessory muscles, thick viscous secretions. Assessment revealed V/S P100Bpm, R32Bpm, BP 100/65 Diagnosis of Acute Asthmatic attack Ineffective Airway Clearance related to inflammatory process/excess mucous production as evidence by thick viscous secretions, Dyspnea, use of accessory muscles Client will demonstrate signs of patent airway and adequate oxygen exchange within the 8hr shift following nursing and other interventions Ineffective Breathing Pattern related to trachea-bronchial Within ½ hour of nursing and other interventions client 1. Assess respiratory status lung sounds, respiratory rate and depth, presence and severity of wheezing, breathing pattern, use of accessory muscles - Some degree in bronchospasm is present with obstruction in airway and may be manifested with wheezing or absent breath sounds in severe asthma. Tachypnea is usually present to some degree and respiratory dysfunction is variable depending on underlying process such as allergic reaction 2. Assess then monitor V/S – Initially for baseline and then for comparison 3. Administer Humidified Oxygen Client will verbalize reduction or absence in difficulty in breathing and feeling of chest constriction, respiration and cardiac rate within normal range, absence or reduction of inspiratory and expiratory wheezing following nursing and other interventions (What is hoped to be achieved) Outcome Criteria: Intervention and Rationales Evaluation/Outcomes
obstruction/inflammatory will demonstrate an process as evidence by SOB, use of accessory muscles, V/S P100bpm, R32bpm, BP 100/65 improvement in respiratory rate as evidence by respiratory rate of 1624bpm
12 2-5l as required – to improve tissue oxygenation and prevent drying of the nares 4. Assist patient to assume to comfortable position, i.e. elevate head of bed, (fowler’s position) have client lean on over bed table or sit on the edge of bed Elevation of head of the bed facilitates respiratory function by use of gravity, however client in distress may seek position that most eases work load of breathing. 5. Keep environmental pollution to a minimum according to individual situation - Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. 6. Encourage and assist abdominal and pursed – lip breathing
13 exercises - Provides some means to cope with or control dyspnea and reduce air trapping. 7. Increase fluid intake to 25003000ml within cardiac tolerance Hydration helps thin secretions, facilitating expectoration and using warm liquids may decrease bronchospasm. 8. Provide warm liquids and recommend intake of fluids between meals, instead of during meals - Fluids during meals can increase gastric distension and pressure on the diaphragm. 9. Administer medications as indicated. (Atrovent) Anticholinergic medications are the first line drugs for clients with this condition. 10. Monitor side effects of bronchodilator (Salbutamol) –
14 Bronchodilators are known to cause (tremors/ tachycardia, bronchospasm). 11. Provide supplemental humidification, e.g., nebulizer in respiratory treatments - Humidity helps reduce viscosity of secretions, facilitating/stimulate expectoration, and reduce bronchospasm 12. Monitor ABGs, pulse oximetry, chest x- ray, capillary refill – indicates acid-base balance, oxygen saturation levels, level of obstruction and Establishes baseline for monitoring progression/ regression of disease process (Ackley & Ladwig, 2010)
15
EXAMINATION/EVALUATION Questions 1. The Nursing Process is _____________, ____________modified scientific method of planning and providing individualized Nursing care. 2. Three characteristics of the nursing process are: 3. Name the five sources of data Gathering TRUE OR FALSE 4. The Nursing Diagnosis is a summation into one phrase or diagnostic label all the available data on a patient’s condition Answers 1. Systematic, rational, modified scientific method of planning and providing individualized nursing care. 2. Dynamic, interpersonal, goal-directed, interpersonal, universally applicable 3. Data are gathered essentially through five sources: (1) The patient; (2) Family members, friends and associates; (3) other members of the health care team; (4) Records of the patient’s present and past health status; and (5) Written information regarding the problem or problems and treatment
16 facing the patient( Potter & Griffin, 2006). 4. True
