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...