WE DON'T KNOW YET. SO WE'RE NOT SURE IF THIS IS A CHRONIC OR AN ACUTE FLARE-UP.
WE NEED MORE DATA.
IS THIS NEW OR IS THIS OLD?
CAN WE MAKE HIM BETTER OR NOT?
WE DON'T KNOW. WE NEED MORE INFORMATION.
IT IS AN INDIVIDUAL PROBLEM AND CERTAINLY WE WANT TO CONSIDER
THE AGE OF THE CLIENT AS WELL WHEN WE ARE LOOKING FOR OUR DIAGNOSIS.
BUT WE ALSO WANT TO CONSIDER THREE THINGS.
THERE ARE 3 KINDS OF POSITIONS IN THE CONTINUUM OF WELLNESS.
IS THIS A WELL CLIENT WHO IS IN A POSITION FOR BECOMING MORE HEALTHY?
NO. IT THIS AN AT-RISK CLIENT?
WHO HAS AN INCREASED CHANCE OF INJURY?
YES, BUT IS THIS AN ACTUAL EXISTING PROBLEM AT THE PRESENT TIME?
- YES. - YES. WE HAVE AN ACTUAL PROBLEM HERE THAT WE WANNA DEAL WITH.
WHAT WE WANT YOU TO CONSIDER WHEN YOU'RE DOING YOUR CARE PLANS
IN THE HOSPITAL AND YOU'RE PICKING WHAT TO DO AS A PRIORITY,
WE WANT YOU TO PICK ACTUAL PROBLEMS,
NOT AT-RISK RIGHT NOW.
THERE'S TOO MUCH ACTUAL TO DO AND WE NEED YOU TO LEARN DIAGNOSIS,
WE NEED YOU TO LEARN INTERVENTIONS RELATED TO REAL PROBLEMS.
HE AS AN ACTUAL EXISTING PROBLEM
AND THAT'S WHAT WE'RE GOING TO DEAL WITH AS OUR FIRST PRIORITY.
ALRIGHT, YOU WENT TO YOUR NANDA LIST AND THEY START FROM THE A'S
AND THEY WORK THEMSELVES DOWN.
WHAT DID YOU COME UP WITH FOR ONE OF YOUR PROBLEMS?
SOMEONE JUST HOLLER IT OUT.
- ACTIVITY INTOLERANCE. - OKAY, SO I HEAR SOME ACTIVITY INTOLERANCE WAS,
KIND OF, MUMBLED, SO THAT'S A GOOD ONE. WHAT ELSE? - ANXIETY.
ANXIETY.
- I PUT, IMPAIRED GAS EXCHANGE. - IMPAIRED GAS EXCHANGE. GIVE ME ONE MORE.
INEFFECTIVE BREATHING. - INEFFECTIVE BREATHING. OKAY.
I'M GOING TO ELIMINATE ANXIETY BECAUSE ANXIETY IS PSYCHO-SOCIAL.
IT IS A REALITY, IT'S A POSSIBILITY FOR HIM,
BUT LET'S STICK WITH OUR PRIORITY OF BREATHING.
NOW, I DO WANT TO SAY ONE OTHER THING.
ANXIETY CAN CAUSE SHORTNESS OF BREATH.
HAVE YOU EVER BEEN ANXIOUS AND HYPERVENTILATE? OKAY,
BUT LET'S STICK WITH OUR THREE THAT WE HAVE. ACTIVITY INTOLERANCE,
INEFFECTIVE. WHAT DO YOU SAY? GAS EXCHANGE AND INEFFECTIVE BREATHING.
ALRIGHT. HOW DO WE KNOW WHICH ONE IS THE BEST FOR HIM?
WE NEED TO DO TWO THINGS.
WE NEED TO LOOK UP THE DIAGNOSIS AND LOOK AT THE DEFINITION.
AND THEN WE NEED TO LOOK AT THE DEFINING CHARACTERISTICS
AND SEE IF THEY MATCH OUR CLIENT.
SO LET'S GO TO THE FRONT, CHAPTER TWO.
SINCE WE'RE WORKING RIGHT OFF THE LIST, LET'S GO TO THE NANDA CARE PLANS.
JUST THE PLAIN, OLD NURSING DIAGNOSTIC CARE PLANS.
THESE ARE NURSING DIAGNOSIS. DIAGNOSIS RELATED TO A RESPONSE
TO A MEDICAL CONDITION.
LET'S LOOK AT ACTIVITY INTOLERANCE.
ACTIVITY INTOLERANCE HAS TO DO WITH WEAKNESS,
IT'S A DE-CONDITIONED PATIENT WHO MAY BE SEDENTARY. SEDENTARY.
THE NANDA DIAGNOSIS STATES, IT'S INSUFFICIENT,
PHYSIOLOGICAL OR PSYCHOLOGICAL ENERGY
TO ENDURE OR COMPLETE, REQUIRED OR DESIRED DAILY ACTIVITIES.
DOES THAT FIT OUR CLIENT?
- YES. - OH, YES, LET'S JUST GO BACK.
HE CAN'T WALK, HIS HEART'S RACING AND HE'S TIRED ALL THE TIME.
NOW, LET'S GO TO OUR DEFINING CHARACTERISTICS
AND SEE IF WE HAVE A MATCH OF SIGNS AND SYMPTOMS OR ASSESSMENTS.
THAT'S WHAT DEFINING IS.
VERBAL REPORT OF FATIGUE OR WEAKNESS.
YES. INABILITY TO BEGIN OR PERFORM ACTIVITY.
WELL, HE'S BEGINNING, YET HE'S NOT PERFORMING IT WELL.
ABNORMAL HEART RATE OR BLOOD PRESSURE RESPONSE TO ACTIVITY.
WELL, HE'S COMPLAINING OF RACING HEART.
EXERTION, DISCOMFORT OR DYSPNEA.
YEAH. SO WE HAVE A PRETTY GOOD MATCH OF DEFINING CHARACTERISTICS.
DO YOU HAVE TO HAVE ALL OF THEM TO
DIAGNOSE HIM AS ACTIVITY INTOLERANT?
NO, YOU JUST HAVE TO HAVE A FEW.
THIS IS GIVING YOU A FAIRLY COMPREHENSIVE LIST
OF ALL SIGNS AND SYMPTOMS.
THERE'S NO PATIENT THAT PRESENTS EXACTLY THE SAME EVERY TIME,
BUT YOU WANNA HAVE A PRETTY GOOD MATCH.
SO WE HAVE A DIAGNOSIS WITH A DEFINITION THAT WORKS
WITH ABOUT 3 OUT OF THE 4, IF NOT ALL OF THEM
THAT MATCH THE SYMPTOMS THAT WE FOUND.
LOOK AT EVERYTHING BECAUSE WE'RE LEARNING AND YOU WANT TO PICK THE BEST ONE.
LET'S GO COMPARE IT TO - WHAT WAS THE OTHER ONE? INEFFECTIVE BREATHING.
SOMEONE HOLLER OUT THE PAGE NUMBER WHEN YOU GET TO IT.
I SHOULD HAVE MARKED MINE.
INEFFECTIVE BREATHING. - IT'S 26.
PAGE 26.
SO WE GO TO PAGE 26 AND WE HAVE INEFFECTIVE BREATHING PATTERN.
INSPIRATION OR EXPIRATION THAT DOES NOT PROVIDE ADEQUATE VENTILATION.
INSPIRATION OR EXPIRATION
THAT DOES NOT PROVIDE ADEQUATE VENTILATION.
I DON'T HAVE ENOUGH INFORMATION RIGHT NOW
TO PICK THIS ASSESSMENT.
DO YOU THINK WE DO? - NO.
IT WOULD APPEAR THAT WE WOULD NEED A RESPIRATORY RATE,
THAT WE WOULD NEED TO HAVE SOME INFORMATION
THAT'S EFFECTIVELY RELATED TO EXERTION.
AND WHAT WE OBSERVE RELATED TO SHORTNESS OF BREATH,
EVEN POSSIBLY A PULSE MIGHT HELP US.
BUT LET'S GO SEE WHAT THE DEFINING CHARACTERISTICS ARE.
DYSPNEA, DOES SAY DIFFICULTY BREATHING.
TACHYPNEA, HEART FEELS LIKE IT'S RACING.
FREMITUS,
THAT'S ADVANCED ASSESSMENT, BUT THAT'S WHEN YOU PUT YOUR HANDS ON THEIR
OR YOUR FISTS ON THE BACK OF THEIR CHEST. AND YOU HAVE GO 99, 99, 99,
AND YOU FEEL BUZZING IN THE PALMS OF YOUR HANDS.
DO YOU MIND BEING ON TV REAL QUICKLY? YOU CAN FACE AWAY IF YOU WANT.
HAVE TO PUT MY HANDS TO HER SKIN AND SAY, "99."
99, 99, 99, 99, 99, 99.
IF THERE'S FLUID IN HER CHEST I WILL PICK UP MORE BUZZING
OR MORE DENSITY. I WON'T FEEL THE SAME AMOUNT OF BUZZ.
THAT'S WHAT FREMITUS IS.
OKAY, CYANOSIS.
BLUENESS, WE HAVE NOTHING ABOUT BLUENESS.
COPD, NOTHING ABOUT COPD. NASAL FLARING. WE DON'T KNOW.
RESPIRATORY DEPTH, ALTER CHEST EXERTION, USE OF ACCESSORY MUSCLES,
PURSED LIP BREATHING OR INCREASED ANTEROPOSTERIOR. WHAT'S THAT?
SIDE TO BACK DIAMETER AS COMPARED TO TRANSVERSE ANGLE.
SO WE'RE NOT ABLE TO CHOOSE.
SO THE INFORMATION WE HAVE
MAY NOT BE OUR BEST ONE, BUT IT HAS SOME POTENTIAL.
IN FACT IT MAY BE, IF WE HAD MORE OBJECTIVE DATA,
AS GOOD OF A DIAGNOSIS AS THE OTHER ONE.
OKAY, LET'S GO CHECK
IMPAIRED GAS EXCHANGE, IS I THINK WHAT SOMEONE SAID.
WHOEVER FINDS IT FIRST, HOLLER OUT THE PAGE NUMBER. - 63.
63, I HEARD. 68.
ALRIGHT, LET'S GO SEE WHAT IT HAS TO SAY.
IMPAIRED GAS EXCHANGE
IS A VENTILATION OR PERFUSION IMBALANCE.
NANDA DEFINES IT AS EXCESS OR DEFICIENT IN OXYGENATION
OR CARBON DIOXIDE ELIMINATION ALVEOLAR-CAPILLARY MEMBRANE.
WELL, DO WE HAVE ANY EVIDENCE WHATSOEVER?
NO.
WHAT WOULD WE NEED
AS A SYMPTOM TO USE THIS DIAGNOSIS?
LET'S GO TO DEFINING CHARACTERISTICS. CONFUSION. HE'S NOT CONFUSED.
SOMNOLENCE. WHAT'S THAT?
KIND OF LETHARGIC, YOU FEEL TIRED,
AND IF YOU DON'T KNOW, LOOK IT UP.
THAT'S WHY YOU'VE ALL GOT YOUR DICTIONARIES, RIGHT?
YEAH, I LOVE MY DICTIONARY. IT'S LIKE THE BEST BOOK EVER.
RESTLESSNESS.
MAYBE, BUT WE'RE NOT SURE. HE'S WRINGING HIS HANDS A LITTLE,
LIKE IT'S ALMOST MORE IRRITABLE THAN RESTLESS.
IRRITABLE.
I DON'T HAVE ANYTHING THERE THAT DESCRIBES THAT. INABILITY TO MOVE.
SECRETIONS. WE HAVE NOTHING. HYPERCAPNIA, WHAT'S THAT?
- CO2 ELEVATED. - CO2 ELEVATED.
WE HAVE NO GAS READING WHATSOEVER,
OR HYPOXIA, WHICH IS...? - OO2.
OO2. OKAY, WE TALKED ABOUT PULSE OX. WHAT'S NORMAL?
IT'S THE SP O2, RIGHT? SATURATED PULSE READING. SP O2.
WHAT'S NORMAL? 90 TO 100.
AND WE'VE GOT NO READING.
SO CAN WE EVALUATE IMPAIRED GAS EXCHANGE WITHOUT
SOME KIND OF GAS EXCHANGE READING?
NO. YOU MAY HAVE IT, BUT WE DON'T HAVE ANYTHING TO SUPPORT IT.
YOU SEE HOW YOU'RE WORKING WITH YOUR DIAGNOSIS, YOUR SYMPTOMS,
YOUR ASSESSMENTS HAVE TO APPLY TO THIS PARTICULAR PROBLEM.
ALRIGHT, SO OF THE THREE, WHAT SEEMS MOST APPLICABLE FOR THIS CLIENT?
- ACTIVITY INTOLERANCE. - ACTIVITY INTOLERANCE.
BASED ON THE INFORMATION WE HAVE.
WHAT HAVE YOU ALSO DECIDED AFTER LOOKING AT ALL OF THESE
DEFINING CHARACTERISTICS AND DIAGNOSIS?
DO YOU WANT MORE INFORMATION? - YES.
I NEED MORE INFORMATION.
I NEED SOME VITAL SIGNS.
I NEED TO DO A PHYSICAL ASSESSMENT OF THAT BRONCH AREA.
I NEED TO WATCH HIM WALK. I NEED TO GET SOME VITALS BEFORE AND AFTER.
I WANT TO LOOK AT HIS COLOUR. I WANT TO CHECK HIS CAPILLARY REFILL.
I WANT TO SEE IF THEY DID A CHEST X-RAY.
I WANT TO KNOW IF THEY DID ABG'S.
DO YOU SEE WHAT I'M SAYING? THE MORE INFORMATION, THE MORE HOLISTIC
YOUR ASSESSMENT IS, THE MORE...
THE BETTER ABLE YOU WILL BE TO PICK A RIGHT DIAGNOSIS.
BASED ON THE INFORMATION WE HAVE, WE'RE GOING TO GO WITH
ACTIVITY INTOLERANCE, BECAUSE THAT'S WHERE
THIS LITTLE ACTIVITY IS LEADING US TO.
SO LET'S GO TO ACTIVITY INTOLERANCE.
I DON'T KNOW WHERE I LEFT THIS OFF HERE.
NOW WE'VE READ THE DEFINITION, WE'VE GOT A GOOD FIT.
IS THIS WHAT THE PATIENT'S DEMONSTRATING?
DOES THE CLIENT AGREE THAT THIS IS HIS CONCERN?
WHAT COULD WE DO AT THIS POINT? GO TALK TO HIM?
YOU KNOW, I'VE LISTENED TO YOU AND I'VE OBSERVED YOU AND YOU'VE SAID,
AND YOU REPEAT THAT INFORMATION. I'VE HEARD YOU SAY
THAT YOUR HEART RACES WHEN YOU WALK.
I'VE HEARD YOU SAY THAT YOU CAN FEEL IT BEATING
AND YOU'RE HAVING SOME SHORTNESS OF BREATH,
DIFFICULTY BREATHING WHEN YOU WALK.
AND SO I'M THINKING THAT YOU'RE NOT TOLERATING ACTIVITY WELL.
WHAT DO YOU THINK?
DON'T SAY, "DO YOU AGREE WITH ME? I'M THE NURSE."
NO, YOU WANT IT TO BE INTERACTIVE AND SAY, "WHAT DO YOU THINK?"
AND SEE WHAT HAPPENS. SO, YES, I AGREE. I JUST, I'M NOT ABLE TO DO ANYTHING.
I HARDLY EVER BRUSH MY TEETH THESE DAYS.
YOU GET A LITTLE MORE INFORMATION.
THEN YOU DECIDE, IS THIS AN ACTUAL RISK OR WELLNESS DIAGNOSIS?
AND WE DECIDED, IT WAS ACTUAL. OKAY, WE HAVE AN ACTUAL PROBLEM.
ALRIGHT, SO WE WENT TO NANDA,
WE DISCOVERED THAT WE LIKED THE DEFINITION.
INSUFFICIENT PHYSIOLOGICAL OR PSYCHOLOGICAL ENERGY TO ENDURE ACTIVITIES.
WE COMPARED OUR PROBLEM
THAT WE FOUND OUR DATA WITH THE DIAGNOSIS
AND THE DEFINING CHARACTERISTICS.
WE ALSO COMPARED, WAS THE INFORMATION THAT WAS IN DEFINING
CHARACTERISTICS IN OUR ASSESSMENT? WE HAVE TO HAVE A MATCH.
WE ACTUALLY START THE WHOLE PROCESS, OKAY, THE NURSING PROCESS WITH WHAT?
ASSESSMENT. AND ASSESSMENT IS ACTUALLY DEFINING CHARACTERISTICS.
WE'VE GOT TO HAVE A MATCH THERE.
DOES IT REINFORCE OR CLARIFY THE RELATED TO STATEMENT WORKED INTO THAT
AND THE PHRASE AS EVIDENCED BY MAYBE USED? OKAY.
DEFINING CHARACTERISTICS IS EVERYTHING WE TALKED ABOUT HERE.
VERBAL REPORT OF FATIGUE, ABNORMAL HEART RATE OR BLOOD PRESSURE RESPONSE,
EXERTIONAL DISCOMFORT
AND EVEN LIKE CARDIO GRAPHIC CHANGES REFLECTING IN HIS RHYTHMIAS.
ALRIGHT, ONCE WE'VE DECIDED THAT WE HAVE A GOOD MATCH
OF OUR SYMPTOMS DIAG - DEFINING CHARACTERISTICS
AND WE HAVE A DIAGNOSIS THAT WE THINK IS A GOOD MATCH,
WE NEED TO THEN LOOK AT THE ETIOLOGY OR THE CAUSE OF THE PROBLEM.
SO WE CALL THIS A RELATED TO FACTOR.
SO IN OTHER WORDS, WE HAVE AN ACTIVITY INTOLERANCE RELATED TO WHAT?
WHAT'S CONTRIBUTING TO THIS RESPONSE?
GO TO YOUR BOOK. WELL, LET ME SEE IF I HAVE ANYTHING ELSE.
OH, I ADDED THIS STATEMENT.
PERRY & POTTER STATES THAT SOME OF YOU PICKED IT UP IN YOUR READING.
BUT PERRY & POTTER SAYS THIS IS NOT A CAUSE AND EFFECT.
JUST COME RIGHT IN. - I'M LATE, I'M SORRY.
NO, YOU'RE NOT. I WAS SUPPOSED TO TAKE MY BREAK.
PERRY & POTTER STATES THAT THIS IS NOT A CAUSE AND EFFECT,
THE ETIOLOGY.
IT CONTRIBUTES TO AND IT'S ASSOCIATED WITH
THE NURSING DIAGNOSIS.
I THINK WHAT SHE'S SAYING, I REALLY STRUGGLED WITH HER PHRASEOLOGY HERE,
BECAUSE IN THE VERY NEXT PARAGRAPH SHE SAYS AN ETIOLOGY
IS A CAUSE OF THE PROBLEM.
WELL, IF IT'S NOT A CAUSE AND EFFECT THEN HOW CAN IT BE THE CAUSE?
ARE YOU WITH ME ON THAT ONE? - NO.
ALRIGHT, I THINK WHAT SHE'S SAYING IS THAT THE ETIOLOGY,
BECAUSE THEY'RE WEAK AND DIDN'T CAUSE THEM TO HAVE COPD,
BECAUSE THEY'RE WEAK AND IT CAUSED THEM TO HAVE ACTIVITY INTOLERANCE.
BUT BECAUSE THEY HAVE AN ACTIVITY INTOLERANCE,
WEAKNESS IS CONTRIBUTING TO IT. WEAKNESS IS NOT HELPING THIS PROBLEM.
OKAY, AND IF THAT JUST CONFUSES YOU,
LET GO OF THAT CAUSE AND EFFECT STATEMENT. AND APPRECIATE THAT AN ETIOLOGY
BY PURE DEFINITION IN YOUR BOOK, IF YOU WENT TO THE DICTIONARY,
IT SAYS IT'S THE CAUSE OF THE PROBLEM.
IT IS. SO IT MAY NOT BE THE CAUSE
AND EFFECT OF THIS NURSING DIAGNOSIS PER SAY, OR A MEDICAL DIAGNOSIS.
WEAKNESS DOES NOT CAUSE YOU TO HAVE COPD.
IT DOES NOT CAUSE IT, BUT IT SURE CONTRIBUTES TO THE RESPONSE.
SO WE'RE LOOKING AT IT AS A CONTRIBUTOR.
SO WHAT CONTRIBUTES TO HIS ACTIVITY INTOLERANCE?
LET'S LOOK IN THE BOOK AT RELATED TO FACTORS.
IT SAYS GENERALIZED WEAKNESS.
DOES OUR CLIENT HAVE GENERALIZED WEAKNESS?
YES, IT APPEARS TO BE.
IS HE IN A DE-CONDITIONED STATE?
WELL, HE'S SURE NOT IN A CONDITIONED STATE.
HE CAN'T EVEN WALK WITHOUT SHORTNESS OF BREATH OR DIFFICULTY BREATHING.
DOES HE HAVE A SEDENTARY LIFESTYLE? I DON'T KNOW, HE DIDN'T TELL US.
WHAT IS A SEDENTARY LIFESTYLE?
COUCH POTATO SYNDROME, SITTING.
UNABLE TO COMPLETE ADL'S, UNABLE TO MOVE. HE CAN'T EVEN WALK RIGHT NOW.
SO POSSIBLY, WE MIGHT WANT TO ASK MORE QUESTIONS
COS WE'VE ALREADY DECIDED THAT WE DON'T HAVE ENOUGH INFORMATION.
INSUFFICIENT SLEEP OR REST PERIODS.
WE HAVE NO IDEA.
DEPRESSION OR LACK OF MOTIVATION.
WE HAVE NO IDEA, OTHER THAN THERE'S THIS WRINGING OF HANDS
AND LOOKING OUT THE WINDOW THING THAT WE'RE NOT REALLY SURE
WHAT THAT MEANS QUITE YET.
POSSIBLY, BUT WE'RE NOT SURE. PROLONGED BED REST.
WE HAVE NO IDEA.
IMPOSED ACTIVITY RESTRICTION. WHAT DOES THAT MEAN?
- FOR EXAMPLE YOU'RE ORDERED NOT TO.
- YES. SOMEONE'S IMPOSING IT ON YOU.
MAKING YOU, REQUESTING IT OF YOU, AND WE'RE NOT SURE
THAT THAT EXISTS RIGHT NOW.
IMBALANCE BETWEEN OXYGEN SUPPLY AND DEMAND.
I HAVE A REAL STRONG FEELING THAT THAT'S WHAT'S GOING ON WITH HIM,
COS HE'S HAVING DIFFICULTY BREATHING, HIS HEART IS RACING,
HE'S NOT GETTING ANY OXYGEN, OR HE DOESN'T FEEL LIKE
HE'S GETTING WHAT HIS BODY'S DEMANDING.
SO WE HAVE A MATCH THERE. ARE WE HAVING PAIN?
WE DON'T KNOW. AND IS HE HAVING SIDE EFFECTS WITH THE MED?
WE DON'T KNOW, BUT DOES HE HAVE SOME RELATED TO FACTOR?
IF YOU ARE GOING TO PICK ONE OF THOSE FROM THAT LIST,
DO YOU HAVE A POSSIBLE MATCH THAT CONTRIBUTES TO HIS ACTIVITY INTOLERANCE
THAT WE BELIEVE EXISTS RELATED TO THE ASSESSMENT THAT WE DID?
WHAT WOULD YOU PICK?
- IMBALANCE OF SUPPLY AND DEMAND.
- IMBALANCE OF SUPPLY AND DEMAND OR GENERALIZED WEAKNESS?
WE DON'T HAVE A LOT OF INFORMATION,
BUT WHAT WE DO HAVE IS IT APPEARS THAT HE'S RELATIVELY WEAK.
YOU CAN LOOK BACK ON YOUR PAPER. HE'S NOT ABLE TO GO ANY DISTANCE
WITHOUT SHORTNESS OF BREATH.
WHEN YOU'RE PICKING AN ETIOLOGY OR RELATED TO, YOU ONLY NEED ONE.
YOU DON'T WRITE THE WHOLE LIST. THIS IS GIVING YOU SUGGESTIONS
AND THINGS THAT CONTRIBUTE TO YOUR DIAGNOSIS.
SO YOU GO AND YOU DECIDE IF YOU HAVE ONE OF THESE, POSSIBLY TWO
THAT ARE CONTRIBUTING OR CAUSING ACTIVITY INTOLERANCE FOR YOUR CLIENT.
IT'S NOT ALL OF THEM. IT'S ONE OF THEM.
THAT'S ALL YOU NEED. ALRIGHT.
SO WE'RE ASKING OURSELVES, ARE THEY CONTRIBUTING TO THE NURSING DIAGNOSIS?
DO ANY OF THESE CONTRIBUTE?
WE ALSO WANNA ASK OURSELVES ARE THERE ENVIRONMENTAL,
PHYSIOLOGICAL, PSYCHOLOGICAL, SOCIO-CULTURAL
OR SPIRITUAL THINGS THAT ARE CONTRIBUTING?
THERE COULD BE ANY CATEGORY OF CAUSE.
DON'T LIMIT YOURSELF TO JUST THE PHYSICAL THINGS THAT YOU'RE SEEING.
WHEN WE TALKED ABOUT ANXIETY A LITTLE BIT.
ANXIETY IS A PSYCHO-SOCIAL CAUSE TO SHORTNESS OF BREATH.
SO IT MAY BE THAT SOMETHING PSYCHO-SOCIAL,
PSYCHOLOGICAL IS CONTRIBUTING TO A PHYSICAL PROBLEM. DON'T ELIMINATE IT.
LOOK AT ALL OF YOUR POSSIBILITIES.
ARE YOU ACCURATE?
DON'T MAKE THE DIAGNOSIS FIT AND THEN COME UP WITH SIGNS AND SYMPTOMS.
YOU HAVE IT. MAKE YOUR SIGNS AND SYMPTOMS
CREATE AN ACCURATE DIAGNOSIS.
AND THEN FINALLY, WE'LL TALK, WHAT YOU FOUND
AND WHAT YOU'VE DECIDED HELP DIRECT YOUR NURSING INTERVENTIONS.
IS IT GOING TO HELP YOU DO NURSING THINGS?
WE HAVEN'T GOT THAT FAR, YET, BUT THOSE ARE QUESTIONS.
AND REMEMBER THAT YOUR RELATED TO FACTOR
IS NEVER A MEDICAL DIAGNOSIS.
WE COULDN'T SAY THIS, THAT OUR CLIENT HAS ACTIVITY INTOLERANCE
RELATED TO COPD
AS EVIDENCED BY OUR DEFINING CHARACTERISTICS,
COMPLAINTS OF SHORT DYSPNEA WITH WALKING AND YOUR SYMPTOMS.
WE HAVE TO SAY OUR CLIENT HAS WHAT?
ACTIVITY INTOLERANCE RELATED TO WEAKNESS.
IT'S WHAT CONTRIBUTES TO FROM A NURSING PERSPECTIVE,
WHAT'S THE RESPONSE TO THAT NURSING DIAGNOSIS?
IT HAS TO COME FROM OUR RELATED TO FACTORS, NOT A MEDICAL DIAGNOSIS.
WE ARE NOT DOCTORS, THAT'S THEM.
IT MAY GUIDE US TO A PLACE IN THE BOOK, BUT NOT SO.
ALRIGHT, SO IT'S NOT A MEDICAL DIAGNOSIS.
WE ALREADY TALKED ABOUT THAT. IT'S NOT COPD.
ALRIGHT, 1:15, GOT ENOUGH, TAKE A BREAK. THINK ABOUT IT
AND WE'RE GOING TO PICK UP AND FINISH UP OUR THREE-PART DIAGNOSIS.
TWO IS COMPLAINING OF? - SHORTNESS OF --
- SHORTNESS OF BREATH WHEN WALKING. WHAT HAPPENS TO HIS HEART?
RACING. RACING. WE KNOW HE HAS COPD.
SO WE'VE DECIDED AS A NURSE THAT HIS RESPONSE TO THIS -
THESE COMPLAINTS FALL UNDER THE DIAGNOSIS OF...
- ACTIVITY INTOLERANCE. - ACTIVITY INTOLERANCE RELATED TO?
- GENERALIZED WEAKNESS. - GENERALIZED WEAKNESS AS EVIDENCED BY?
OKAY, SO HERE WE GO.
I SCARED YOU, BUT YOU ALREADY KNOW BECAUSE THOSE WERE HIS SYMPTOMS.
BUT THIS IS HOW IT WORKS. A WORKING NURSING DIAGNOSIS
MAY HAVE TWO OR THREE PARTS. THERE ARE SOME INSTITUTIONS
THAT JUST WORK OFF OF THE DIAGNOSIS AND THE RELATED TO.
AND LEAVE OFF THE SYMPTOMS BELIEVING THAT THE SYMPTOMS ARE ACTUALLY
DOCUMENTED IN OTHER PLACES AND SO WE DON'T HAVE TO RE-DOCUMENT THEM.
BUT FOR OUR PURPOSES AND OTHER SYSTEMS,
PUT THOSE SYMPTOMS ALL TOGETHER IN THE NURSING DIAGNOSIS.
AND THAT'S WHAT WE'RE GOING TO DO.
THE REASON WE DO IT IS THIS. YOU'RE GOING TO GATHER UP
A BUNCH OF INFORMATION WHEN YOU DO YOUR ASSESSMENT.
BUT NOT EVERYTHING IN YOUR ASSESSMENT APPLIES TO THAT PROBLEM.
YOU'RE GOING TO HAVE TO PICK OUT, CLUSTER THE DATA
AND ONLY PUT WHAT APPLIES TO THAT PROBLEM AS YOUR DEFINING CHARACTERISTIC.
YOU'RE NOT GOING TO PUT
ACTIVITY INTOLERANCE RELATED TO WEAKNESS AS EVIDENCED BY,
GIVE ME SOMETHING OFF THE WALL. CUT ON CALF.
WHAT DOES THAT HAVE TO DO? MOLE ON RIGHT SHOULDER.
IT MAY BE SOMETHING ABNORMAL, BUT IT HAS NOTHING TO DO WITH THIS PROBLEM.
THEY MAY HAVE ANOTHER PROBLEM IF THEY HAVE A MOLE.
THEY MAY HAVE A SKIN INTEGRITY ISSUE OR A HEALTH MAINTENANCE ISSUE.
THAT'S ANOTHER PROBLEM.
IN FACT, YOUR CLIENT COULD HAVE MANY PROBLEMS, MANY NURSING DIAGNOSIS.
AND WE'RE GOING TO SEPARATE OUT ALL OF OUR FINDINGS
AND APPLY THEM TO THAT PARTICULAR DIAGNOSIS.
SOMETIMES THAT'S THE HARDEST THING YOU DO IS
PULLING THE RIGHT INFORMATION TOGETHER TO SUPPORT YOUR DIAGNOSIS.
TO EVERYTHING UNDER THE SUN IN THE DEFINING CHARACTERISTICS
BECAUSE YOU FOUND IT AND IT WAS ABNORMAL.
OF THOSE ABNORMAL FINDINGS WHAT SUPPORTS THAT DIAGNOSIS?
DID I SAY THAT? OKAY.
YOU'LL GET MORE EXPERIENCE WITH IT, BUT THAT'S WHAT WE'RE AIMING TO DO.
SO WE'RE GOING TO CREATE A STATEMENT THAT LOOKS LIKE THIS.
A PROBLEM WITH AN ETIOLOGY WITH A SYMPTOM.
OUR PROBLEM IS THE NURSING DIAGNOSIS, IT'S THAT CONCISE PHRASE,
ACTIVITY INTOLERANCE RELATED TO, WHICH IS WHAT CONTRIBUTES TO THE PROBLEM.
IMBALANCE OF OXYGEN SUPPLY OR DEMAND OR WEAKNESS WE CAME UP WITH
AND S...WHERE WAS IT?
PES, OUR SYMPTOMS OR DEFINING CHARACTERISTICS
OR WHAT YOU'RE GOING TO HEAR THE FACULTY AROUND HERE.
WE USE THE PHRASE AS EVIDENCED BY, AEB.
THAT'S OUR SYMPTOMS. SO PES, PROBLEMS, ETIOLOGY,
SYMPTOMS IS OUR DEFINING CHARACTERISTICS.
SYMPTOMS THAT YOU FOUND WHEN YOU ASSESSED.
AND OUR FINDINGS FOR THIS CLIENT WAS, HIS VERBAL REPORT OF FATIGUE,
HIS ABNORMAL HEART IN RESPONSE TO ACTIVITY AND HIS EXERTIONAL DYSPNEA.
THOSE WERE OUR FINDINGS. THAT'S WHAT INITIATED THE WHOLE CARE PLAN.
SO IT'S, KIND OF, FUNNY THAT WHAT INITIATED IT
IS THE LAST PIECE OF THE STATEMENT.
BUT THE S, THE AS EVIDENCED BY IS YOUR ASSESSMENT.
ALRIGHT, THOSE ARE OUR THREE PARTS.
IT LOOKS LIKE THIS. IF YOU'RE GOING TO WRITE A NURSING DIAGNOSIS,
OUR CLIENT HAS ACTIVITY INTOLERANCE RELATED TO IMBALANCE BETWEEN OXYGEN
SUPPLY AND DEMAND AS EVIDENCED BY A VERBAL REPORT OF FATIGUE,
ABNORMAL HEART RATE, EXERTIONAL DYSPNEA.
NOTICE, THERE'S NO WRINGING OF HANDS OR LOOKING OUT THE WINDOW.
WE GATHERED THAT DATA, BUT IT DOESN'T APPLY TO THAT DIAGNOSIS.
SO IT WOULD GO WITH SOMETHING ELSE,
AS YOU ADDRESS THAT,
AND THEN YOU WRITE IT.
NOW, AT THIS POINT, WE'RE GOING TO MOVE TO THE PLANNING,
BUT I WANNA PAUSE HERE A MINUTE.
I GAVE EVERYBODY A TAN PIECE OF PAPER, RIGHT.
SO EVERYONE GOT THIS PIECE OF PAPER.
THIS IS WHAT FRESNO CITY COLLEGE USES
AND PARTICULARLY FIRST SEMESTER USES
AS OUR WAY OF CREATING A NURSING CARE PLAN.
SO WHEN YOU HAVE A PATIENT THAT HAS COPD,
WE WANT YOU TO WRITE UP A PATHO-PHYSIOLOGY
OF WHAT COPD IS BECAUSE WE'RE IN A LEARNING CURVE HERE.
WHAT IS COPD?
THE NICE THING ABOUT IT IS YOUR BOOK
GIVES YOU A LITTLE BLURB ON WHAT COPD IS,
BUT YOU'VE ALSO GOT A PATHO-PHYS BOOK
THAT'S GOING TO GIVE YOU SOME INFORMATION SO LOOK AT THAT.
YOU'VE ALSO A FUNDAMENTALS BOOK, LOOK AT THAT.
YOU'VE GOT DICTIONARIES, LOOK AT THAT.
YOU'VE GOT THE INTERNET, CHECK IT OUT.
YOU'RE GOING TO GATHER UP INFORMATION RELATED TO
THE DIAGNOSIS OF YOUR CLIENT.
WE NEED THAT INFORMATION HERE.
THEN YOU'RE GOING TO LIST SIGNS AND SYMPTOMS
THAT OCCUR RELATED TO THAT DIAGNOSIS.
THESE ARE THE SIGNS AND SYMPTOMS THAT YOU HAVE RESEARCHED.
IN OTHER WORDS, YOU LOOKED UP COPD AND THE BOOK SAYS PEOPLE WITH COPD
HAVE SHORTNESS OF BREATH WITH EXERTION,
THERE'S BLUE PUFFERS AND PINK PUFFERS.
I'LL JUST LET YOU BE CURIOUS ABOUT THAT, FIND OUT WHAT THAT MEANS.
THEY MAY HAVE CLUBBING OF THEIR FINGERNAILS, THEY -
THEY'RE GOING TO GIVE YOU SOME THINGS THAT ARE INDICATIVE,
THAT MATCH UP WITH THAT DIAGNOSIS AND YOU'RE GOING TO WRITE IT HERE.
AND THEN YOU'RE GOING TO DO YOUR ASSESSMENT AND OVER ON THIS SIDE,
YOU WILL THEN COME UP WITH
SOMETHING THAT APPLIES TO YOUR PATHO-PHYSOIOLOGY.
DON'T WRITE ME A PATHO-PHYSOIOLOGY ABOUT COPD
AND THEN DO A PROBLEM RELATED TO SKIN IMPAIRMENT.
WHAT DOES THAT HAVE TO DO WITH ANYTHING? THESE GOT TO GO TOGETHER.
IF YOU'RE WRITING UP ON COPD, THEN I WANT TO KNOW ABOUT ACTIVITY INTOLERANCE
OR INEFFECTIVE AIRWAVE EXCHANGE OR GAS EXCHANGE.
I WANT A - I WANT A MATCHING SET HERE.
IF THERE'S A PROBLEM WITH SKIN THAT'S BEEN IMPAIRED OR RISK OF INFECTION,
THEN WRITE UP SOMETHING RELATED TO INFECTION OR BROKEN SKIN
OR WOUND CARE AND A PROBLEM THAT MATCHES.
THIS NEEDS TO MAKE SENSE.
IT SHOULDN'T JUST BE ALL OVER THE MAP, LIKE,
"OH, I THINK THEY WANT ME TO WRITE ABOUT THIS, AND THIS IS WHAT I SAW."
AND EVERYBODY'S ALL CONFUSED, OKAY?
SO YOU'LL WRITE UP PATHO. AND RIGHT NOW WE HAVE A PROBLEM THAT SAYS...
YOU COULD JUST PUT A, 'P' ACTIVITY INTOLERANCE WITH A 'RT', RELATED TO
WEAKNESS OR GAS EXCHANGE ISSUE WE HAVE HERE
AND THEN AS EVIDENCED BY OR THE S, FOR SYMPTOMS, YOUR FINDINGS.
OKAY, SO WE'VE DONE THIS MUCH ALREADY.
PATHO, NURSING DIAGNOSIS.
WHAT'S THE NEXT STEP IN THE NURSING PROCESS?
P, PLAN.
NOW WE TAKE A BIG HOP OVER TO THE END.
SEEMS, KIND OF, STRANGE,
BUT IF WE'VE ALREADY IDENTIFIED THAT THEY HAVE THIS GOING ON,
THEN WHAT IS OUR PLAN? WHAT IS OUR GOAL?
WHAT IS OUR OBJECTIVE FOR THIS CLIENT?
WE'RE GOING TO GO TO SLIDES, SO LET ME SWITCH GEARS HERE FOR A SECOND.
GET US ANOTHER POWERPOINT GOING.
OKAY.
NOW WE'RE GOING TO MAKE A PLAN.
WE'VE GOT INFORMATION, WE'VE GOT DIRECTION AND WE NEED A PLAN.
SO STEP ONE WAS WE DID AN ASSESSMENT.
STEP TWO WE FORMED A NURSING DIAGNOSIS.
STEP THREE IS OUR PLANNING PHASE.
OUR PLANNING PHASE IS THAT WE'RE GOING TO WRITE MEASURABLE
OUTCOMES BASED ON THE DIAGNOSIS.
NOW WHEN YOU DID YOUR READING, YOU PROBABLY HEARD WORDS IN YOUR READING
THAT SAID GOAL AND OUTCOME.
DID YOU FIGURE OUT THE DIFFERENCE BETWEEN THE TWO?
IT WAS A LITTLE CONFUSING, I THOUGHT.
THE GOAL IS A GLOBAL STATEMENT.
THE GOAL IS BECAUSE OUR CLIENT HAS ACTIVITY INTOLERANCE,
WHAT DO WE WANT THEM TO DO?
WE COULD TOLERATE ACTIVITY.
IT'S DOABLE. WE WANT THEM TO IMPROVE THEIR ACTIVITY LEVEL.
BUT IS THAT MEASURABLE? IF I SAY, I'M WRITING UP THIS PLAN
AND I SAID I WANT THEIR ACTIVITY IMPROVED.
AND YOU CAME ON THE NEXT SHIFT AND YOU WENT,
"WELL, I SAW HIM GET UP TO GO TO THE BATHROOM. I GUESS, IT'S IMPROVED."
HOW DO YOU KNOW?
MAYBE THEY'VE BEEN GETTING UP AND GOING TO THE BATHROOM ALL ALONG.
THE OUTCOME STATEMENT IS THE MEASURABLE PHRASE
THAT SAYS ACTIVITY WILL BE IMPROVED AS EVIDENCED BY
ABILITY TO WALK 300 FEET.
AND HEART RATE STAYS BELOW 100
BY A PARTICULAR TIME FRAME. ALRIGHT.
THAT'S WHAT WE'RE AIMING TO DO AND WE'RE GOING TO WORK THROUGH THAT.
ALRIGHT, WE'RE GOING TO ESTABLISH AN OVERALL GOAL,
WE'RE GOING TO WRITE OUTCOMES
AS PHRASES BASED ON THE NURSING PROCESS.
THEY'RE GOING TO BE MEASURABLE
AND THE CLIENT IS GOING TO BE INVOLVED IN THE PROCESS.
YOU DON'T ASSESS A CLIENT, COME UP WITH A DIAGNOSIS
AND YOU DECIDE ALL BY YOURSELF WHAT THEY'RE GOING TO DO.
WHAT IF THEY HAVE NO DESIRE TO DO WHAT YOU COME UP WITH?
IT'S BEAUTIFUL, BUT THEY WON'T DO IT.
SO IT'S SOMETHING YOU WORK WITH THE CLIENT ABOUT. WHAT WOULD -
IF THEY'RE COMPLAINING ABOUT THEIR HEART RACING
AND THEIR INABILITY TO WALK, WHAT WOULD THEY LIKE TO DO?
AND THAT'S WHAT WE TALK TO THEM ABOUT.
ALRIGHT, THERE'S TWO WAYS TO WRITE AN OUTCOME STATEMENT
AND ONE IS CALLED THE NOC STATEMENT, NURSING OUTCOME CLASSIFICATIONS
OR THE OUTCOME STATEMENT.
WE'RE ACTUALLY GOING TO WORK WITH THE OUTCOME STATEMENT.
BUT I WANT YOU TO LOOK AT YOUR BOOK, PAGE SEVEN,
TO SEE WHAT AN OUTCOME CLASSIFICATION IS.
WHEN YOU'RE LOOKING AT YOUR BOOK AND YOU'RE GOING,
"OKAY. I'VE DECIDED MY CLIENT HAS ACTIVITY INTOLERANCE,
MY ASSESSMENT MATCHES THE DEFINING CHARACTERISTICS,
THEREFORE I'M GOING TO PICK A RELATED TO FACTOR AND IT'S ONE OF THESE."
YOU CAN THEN, ONCE YOU'VE ESTABLISHED THAT, GO UP AND LOOK AT THE NOC,
THAT'S CALLED THE NURSING OUTCOME CLASSIFICATION.
AND THESE ARE GLOBAL PHRASES
THAT'S DIRECTING YOU TOWARDS WHAT YOU WANT YOUR CLIENT TO DO.
AND IS THIS THE DIRECTION YOU WANT TO HEAD FOR YOUR CLIENT?
SO IN OTHER WORDS, ARE YOU GOING TO AIM FOR ACTIVITY TOLERANCE,
ENERGY CONSERVATION, KNOWLEDGE
AND/OR TREATMENT,
KNOWLEDGE ABOUT TREATMENT REGIMENT?
ARE THOSE REASONABLE THINGS YOU WANT YOUR CLIENT TO DO
AFTER YOU'VE PROVIDED SOME NURSING INTERVENTIONS?
YES.
UNDER THOSE GLOBAL PHRASES ARE GOING TO BE SPECIFIC OUTCOMES
THAT WE WILL LOOK AT.
BUT THEY'RE JUST GLOBAL STATEMENTS.
THE SAME WITH OUR INTERVENTIONS THAT ARE GLOBAL,
WE'RE GOING TO LOOK AT ENERGY MANAGEMENT
TEACHING ABOUT ACTIVITY AND EXERCISE.
THAT'S WHAT THE FOCUS OF THIS CARE PLAN WILL BE.
ALRIGHT, WE'RE GOING TO -
SO THAT'S JUST GLOBAL, WE'RE NOT GOING TO SPEND A LOT OF TIME
ON THE NOC STATEMENTS, BUT WE ARE GOING TO BE WRITING OUTCOMES
STATEMENTS SO THAT YOU'RE PUTTING THE WHOLE CONCEPT TOGETHER.
WHEN WE WRITE AN OUTCOME STATEMENT,
IT HAS TO BE MEASURABLE, WHICH MEANS THERE HAS TO BE A TIMEFRAME.
IN OTHER WORDS, I WANT SOMEONE TO WALK FIVE FEET BY WHEN?
AT THE END OF THE DAY, AT THE END OF THE SHIFT,
AT THE END OF THE WEEK, BEFORE DISCHARGE, IN AN HOUR?
THERE HAS TO BE A TIMEFRAME IN WHICH YOU WANT TO ACCOMPLISH THIS GOAL.
THAT MAKES IT MEASURABLE.
IT ALSO HAS TO BE CLIENT-CENTER.
IT'S NOT ABOUT WHAT I'M GOING TO DO,
I'M GOING TO HAUL THEM OUT OF BED, GET THEM IN A WHEELCHAIR AND TAKE THEM.
NO, IT'S NOT ABOUT ME AT ALL, IT'S ABOUT CLIENT ACTIVITY.
IT HAS TO BE ATTAINABLE AND REALISTIC.
WE DON'T WANNA CREATE ANYTHING THAT SOUNDS GOOD.
IS THIS GUY EVER GOING TO RUN A MARATHON?
NO, SO LET'S NOT MAKE A GOAL OF IT.
I MEAN, MAYBE IN HIS DREAMS, YOU KNOW,
MAYBE HE'S FANTASIZING ABOUT GOING TO HEAVEN
AND RUNNING A MARATHON, BUT IT'S NOT GOING TO HAPPEN THIS WEEK
SO WE WANT TO SET SOMETHING
THAT'S REASONABLE AND REACHABLE, ATTAINABLE.
THOSE ARE GOING TO BE THE COMPONENTS OF OUR GOAL.
SO IF WE GO BACK TO OUR SAME CLIENT, NO CHANGE HERE.
WE HAVE OUR SAME DIAGNOSIS,
LET'S MAKE AN OUTCOME.
WHAT WILL THE CLIENT CHANGE?
HOW WILL YOU KNOW IT'S BEEN CHANGED?
WHAT INFORMATION WILL YOU NEED TO DEMONSTRATE THE CHANGE?
AND WHAT WILL THE CLIENT STATE
SO THAT WE KNOW THERE'S BEEN CHANGE?
THERE'S TWO KINDS OF GOALS THAT WE CAN WRITE.
ONE IS WE CAN DO SOMETHING VERY OBJECTIVE THAT SAYS
AND WE'LL LOOK AT SOME OF THOSE,
THAT THE CLIENT'S HEART RATE WILL STABLE BELOW 100
WITH ALL THAT ACTIVITY BY... IN 48 HOURS, LET'S SAY.
BUT THE PATIENT CAN ALSO REPORT SATISFACTION WITH THIS CARE,
EVEN THOUGH IT MAY NOT BE MEASURABLE IN CLINICAL TERMS OR OBJECTIVE TERMS.
IF THE PATIENT FEELS LIKE THEY'RE BETTER, THEN THEY'RE BETTER.
SO TWO THINGS THAT WE CAN LOOK AT.
OKAY, WE HAVE OUR STATEMENT,
WHAT ARE OUR OVERALL GOALS?
REMEMBER THESE ARE GLOBAL.
WE MAY WANT THE CLIENT TO PARTICIPATE IN PRESCRIBED PHYSICAL ACTIVITY
WITH THE APPROPRIATE DECREASE IN HEART RATE AND BLOOD PRESSURE
AND BREATHING RATE.
OR WE MAY WANT THEM TO DEMONSTRATE INCREASED ACTIVITY TOLERANCE.
IS ANYTHING MEASURABLE YET?
NOT REALLY, BUT IT'S OUR INTENT.
THAT'S OUR GLOBAL STATEMENT. IT'S LIKE SAYING, "I WANT THEM TO GET BETTER."
HOW? OKAY, WE NEED A GOAL WITH WHAT ARE WE AIMING FOR?
SO WHAT ARE WE GOING TO MEASURE? HOW WILL WE MEASURE IT
AND HOW WILL ACTIVITY TOLERANCE BE DEMONSTRATED?
SO THINK TO YOURSELF FOR A MINUTE. OKAY, I WANT HIM TO GET BETTER.
LOOK AT YOUR PATIENT AND THOSE DEFINING CHARACTERISTICS.
WHAT WOULD BE MEASURABLE
OF THOSE THAT IF YOU SAW IT TODAY AND YOU WROTE UP THE CARE PLAN,
AND I CAME IN WORK TOMORROW, I WOULD BE ABLE TO TELL IT'S BETTER?
YOU'RE ABOUT TO SAY SOMETHING, BE BRAVE. - AN ENERGY SAP?
- OKAY, SO O2 SAPPED. - AFTER WALKING.
- AFTER WALKING WILL BE?
- 90 OR ABOVE.
- ABOVE 90...ABOVE SPO2 OF 90
BY WHEN?
WITHIN 24 HOURS?
SHE LIKES THAT, OKAY. WHAT DO YOU THINK?
SURE, WHAT ELSE?
YOU WANT THEM TO BE BETTER, BUT HOW COULD YOU TELL?
LET'S TAKE THE FIRST COMPLAINT THAT HE HAD. WHAT WAS IT?
I'M HAVING DIFFICULTY WITH BREATHING WHEN WALKING.
WHAT DOES DIFFICULT BREATHING LOOK LIKE TO YOU?
LET'S START WITH WHAT WE DO KNOW. WHAT'S A NORMAL RESPIRATORY RATE?
- 12 TO 20. - 12 TO 20.
SO LET'S SAY DIFFICULT BREATHING IS DEEP AND GREATER THAN 20.
SO WHAT WOULD BE ACCEPTABLE?
- LESS THAN 20. - LESS THAN 20.
- WHILE WALKING. - WHILE WALKING,
FIVE MINUTES AFTER WALKING. I MEAN, MAYBE THEY GET A LITTLE, LIKE UP TO 22.
SO YOU MAY SAY RESPIRATORY RATE WILL NOT EXCEED 24 WITH ACTIVITY,
AND WILL RETURN TO LESS THAN 20 WITHIN FIVE MINUTES OF ACTIVITY.
WHAT IN THE WORLD IS THAT?
OKAY, BUT WHEN? WELL, WE ALREADY SAID BY ACTIVITY.
RIGHT? OKAY, LET'S LOOK AT NO.2, WHAT WAS HIS COMPLAINT?
- HIS HEART WAS RACING. - I NEED TO PUT THE LITTLE THING UP.
- THE HEART FEELS LIKE IT'S RACING.
WHAT WOULD A RACING HEART FEEL LIKE? WHAT WOULD THE RATE BE?
WHAT'S NORMAL?
60 TO 100.
SO IT IF IT'S RACING, MY GUESS WOULD BE.
BUT WE DON'T HAVE OBJECTIVE DATA, BUT MY GUESS WOULD BE IT'S GREATER THAN?
100. SO WHAT WOULD WE LIKE IT TO BE?
LESS THAN 100. - LESS THAN 100, BETWEEN 60 AND 100,
BETWEEN 80 AND 100. YOU SET THE PARAMETERS. THAT IS SO MEASURABLE,
THAT'S HOW WE'LL KNOW THAT IT IMPROVED. WHEN DO YOU WANT THAT TO HAPPEN?
- BETWEEN OR DURING ACTIVITY.
- DURING ACTIVITY WITHIN FIVE MINUTES AFTER ACTIVITY.
YOU SET THE PARAMETERS WITH THE PATIENT
AS TO HOW WE'RE GOING TO DO THAT.
ALRIGHT, THAT'S HOW WE'LL KNOW.
SO WE'RE GOING TO USE A TERM AS EVIDENCED BY OR THE ACRONYM AEB.
SO WE WOULD SAY PATIENT DEMONSTRATES INCREASED ACTIVITY INTOLERANCE
AS EVIDENCED BY
HEART RATE LESS THAN 100, RESPIRATION'S LESS THAN 20 AFTER ACTIVITY.
CLIENT WILL STATE SUBJECTIVE FEELINGS OF IMPROVEMENT AFTER ACTIVITY.
HE'S THE ONE THAT REPORTED DISSATISFACTION,
LET HIM REPORT IMPROVEMENT.
ALRIGHT, MEASURABLE,
BUT IT'S OUR AS EVIDENCED OUTCOME THAT'S GOING TO HELP US.
HOW OFTEN WILL WE DO THIS ACTIVITY OR HOW LONG WILL ACTIVITY BE DONE?
WE HAVEN'T EVEN DEFINED WHAT WE WANT THEM TO DO.
WE JUST KNOW WHEN THEY DO IT, WE WANT THEM TO HAVE THIS RESPONSE.
BUT WHAT'S REASONABLE FOR THAT CLIENT AND WHAT SHOULD THEY DO?
WELL, LET'S TALK TO THEM. WHEN DO YOU GET SHORT OF BREATH?
WELL, YOU KNOW, I'VE BEEN ABLE TO WALK FOR
TWO TIMES AROUND THE NURSING STATION AND I'M JUST WHIPPED.
WELL, LET'S DO ONE TIME AROUND THE NURSING STATION FOUR TIMES A DAY
AND SEE IF WE CAN BUILD UP SOME STAMINA.
WHAT DO YOU THINK ABOUT THAT? THAT'LL GIVE YOU SOME EXERCISE,
SOME REST AND SOME MORE EXERCISE. AND THE PATIENT GOES,
"LET'S TRY THAT."
SO YOU TALK TO THEM, HOW OFTEN WILL YOU DO SOMETHING
AND HOW LONG WILL YOU DO IT?
SO YOU MAY DECIDE, WELL, LET'S WALK IN THE HALL FOR FIVE MINUTES,
THREE TIMES A DAY. GET A CLOCK OUT.
BUT YOU'VE ESTABLISHED A GOAL FOR YOUR CLIENT.
HOW WILL WE INDIVIDUALIZE THIS? THAT'S -
REMEMBER WHEN I WAS TALKING ABOUT IN THE PROCESS OF
DOING NURSING CARE PLAN, WE USED TO PUT THESE FORMS OUT.
AND IT WOULD SAY, EVERYONE WOULD AMBULATE IN HALLWAY.
NOT EVERYONE CAN AMBULATE IN THE SAME TIME FRAME, THE SAME AMOUNT
AS EVERYBODY'S DIFFERENT. WE HAVE TO INDIVIDUALIZE OUR PLAN.
SO OUR CLIENT WILL WALK IN THE HALL FOR FIVE MINUTES THREE TIMES A DAY.
IT'S INDIVIDUALIZED FOR OUR CLIENT AND THAT PARTICULAR ACTIVITY
WHEREAS ANOTHER CLIENT MAY NEED TO WALK TEN MINUTES.
ANOTHER CLIENT, WE MAY BE HAPPY IF THEY COULD TRANSFER FROM BED TO A CHAIR.
IT DEPENDS ON THE CLIENT.
IS THIS REASONABLE AND ATTAINABLE FOR THE CLIENT
THAT HE WOULD BE ABLE TO WALK IN THE HALL THREE TIMES A DAY
FOR FIVE MINUTES? WE HAVE TO ALWAYS APPLY THAT FINAL CRITERIA.
AND WE MAY DEFINE REALISTIC BY SAYING,
"WERE THEY ABLE TO DO IT BEFORE?"
MAYBE HE'S NEVER BEEN ABLE TO DO IT, WHAT MAKES US THINK
WE'RE GOING TO BE ABLE TO DO IT NOW?
OR BEFORE HE GOT SICK,
MAYBE HE WAS WALKING AROUND THE BLOCK AT HIS HOUSE WITHOUT A PROBLEM.
IS CHANGE...