AS YOU CAN --
WE'RE GOING TO START NURSING PROCESS.
AND I'M GOING TO START IT BY REVIEWING WHAT WE'VE DONE.
SO, WHAT IS NURSING PROCESS? WHAT ARE THE COMPONENTS?
- ASSESSMENT.
- ASSESSMENT, DIAGNOSIS OR ANALYSIS.
THEY ACTUALLY GO TOGETHER
COS WE'VE GOT TO ANALYZE OUR INFORMATION TO MAKE A DIAGNOSIS.
AND THAT'S THE STEP WE'RE GOING TO BE ON TODAY.
AND THEN NEXT? - PLANNING.
THAT'S GOING TO BE YOUR SECOND HOUR. THEN?
- IMPLEMENTATION. - IMPLEMENTATION AND?
- EVALUATION.
INTERESTINGLY, WE ALL BECAME NURSES, PROBABLY, BECAUSE WE LIKE THE IMPLEMENTATION PHASE.
WE WANT TO DO SOMETHING FOR PEOPLE AND WE WANT TO KNOW WHAT TO DO FOR PEOPLE.
BUT THE BEST WAY FOR US TO DO RIGHT THINGS THAT ARE HELPFUL
IS TO HAVE A PLAN BASED ON RIGHT INFORMATION.
SO, WE'VE GOT TO GET GOOD ASSESSMENT TO GET GOING.
ALRIGHT, WHAT WE'RE GOING TO DO IS DEVELOP A NURSING DIAGNOSIS.
OUR FIRST STEP AS WE'VE TALKED ABOUT IS ASSESSMENT.
THEN WE'VE GOT TO ANALYZE OUR INFORMATION AND FORMULATE A NURSING DIAGNOSIS.
ALRIGHT, LET'S JUST REVIEW.
TO DO NURSING DIAGNOSIS, WE'VE GOT TO ASSESS
AND OUR ASSESSMENT NEEDS TO BE HOLISTIC AND DETAILED.
WHAT THAT MEANS IS THIS.
WHEN YOU ASSESS SOMEONE, IT'S MORE THAN JUST THE PHYSICAL ASSESSMENT.
IT'S MORE THAN JUST THAT DATA.
THERE'S TWO KINDS OF OF WAYS OF DOING IT, WHICH IS SUBJECTIVE AND OBJECTIVE.
SO, WE'VE GOT TO TALK TO THE CLIENT AND GET SOME INFORMATION.
AND ONE OF THE KEY PHRASES THAT YOU'RE GOING TO SEE A LOT IS THE CC.
YOU'RE GOING TO SEE THAT ON FORMS AND IT MEANS,
WHAT'S THEIR CHIEF COMPLAINT? WHAT CONCERNS THEM THE MOST?
THEY MAY HAVE A BIGGER PHYSIOLOGICAL ISSUE THAT WE'RE RECOGNIZING,
BUT THEY HAVE A COMPLAINT AND THAT'S WHAT DREW THEM TO GET MEDICAL ATTENTION.
WE'RE GOING TO GATHER PHYSICAL DATA. WE'RE GOING TO GATHER SUBJECTIVE, OBJECTIVE DATA.
AND IN OUR OBJECTIVE DATA, WE'RE GOING TO TAKE IT A STEP FURTHER.
I HAVE ANOTHER LIST THAT'S COMING UP.
WE'RE GOING TO LOOK AT OTHER THINGS BESIDES JUST WHAT WE FOUND
WHEN WE DID OUR HEAD TO TOE.
WE'RE GOING TO LOOK AT LAB.
WE'RE GOING TO LOOK AT HISTORY AND PHYSICAL.
WE'RE GOING TO LOOK AT RESULTS OF X-RAYS
AND WHATEVER DIAGNOSTIC TESTS WERE DONE.
WE MAY TALK TO A FAMILY MEMBER.
WE MAY OBSERVE A RELATIONSHIP INTERACTION
THAT GAVE US LOT MORE INFORMATION THAN WHAT OUR PHYSICAL ASSESSMENT DID.
WE'RE GOING TO TAKE IN AS MUCH INFORMATION AS WE CAN TO MAKE CORRECT A CARE PLAN.
THE MORE RIGHT INFORMATION YOU HAVE, THE CLOSER YOU'RE GOING TO GET
TO A CORRECT AND HELPFUL CARE PLAN FOR THAT CLIENT.
WE NEED CARE PLANT THAT SUPPORTS CRITICAL THINKING.
AND THIS IS WHAT SEE HAPPENING A LOT IN THE CLINICAL AREA.
THEY'VE CREATED FORMS FOR US TO HELP US NOT MISS THINGS.
AND PEOPLE SOMEHOW SWITCH GEARS AND THEY LOOSE TRACK
OF WHAT THEY CAME TO NURSING TO DO,
AND THAT WAS TO HELP PEOPLE.
AND SO THEY TAKE ON THAT FORM AND THEY JUST CHECK, CHECK, CHECK.
GOOD. FORM'S DONE.
AND THEN THEY JUST DO DOCTOR'S ORDERS. WE MISSED IT.
IF WE'RE NOT THINKING ABOUT WHAT WE'RE SEEING AS A WHOLE PICTURE,
AND HOW THE CLIENT'S RESPONDING TO IT,
HOW CAN WE HELP THEM BEYOND JUST DOING FEW DOCTOR'S ORDERS?
THERE IS MORE TO DO FOR PEOPLE.
AND THAT'S GOING TO ENTAIL CRITICAL THINKING FOR THE CLIENT.
WE'RE THEIR ADVOCATE.
WE'RE LIKE THIS OBJECTIVE THIRD PARTY THAT LOOKS AT THE WHOLE PICTURE
AND GOES, "WELL, WHY ISN'T ANYONE DOING ANYTHING ABOUT THIS?"
IF THAT WAS MY MOTHER, I'D WANT THEM TO DO THIS.
THIS ISN'T MAKING SENSE, WHY DOES -
DO YOU SEE WHERE I'M GOING? SOMEBODY'S GOT TO THINK ABOUT THE WHOLE PICTURE.
I'M NOT SAYING DOCTORS DON'T. I'M SAYING WE'RE THE PARTY OUTSIDE OF IT
THAT'S SEES SOMETIMES THE MORE PERSONABLE AND PRACTICAL ASPECTS OF CARE.
WE NOT ONLY WANT TO LOOK AT THEIR PROBLEMS
AND WHAT THEY'RE EXPLAINING OR DEFINING AS THEIR CHIEF COMPLAINT,
BUT WE WANT TO LOOK AT WHAT ARE THEIR STRENGTHS.
PEOPLE HAVE THINGS TO OFFER TO HELP THEMSELVES
AS WELL AS HAVING DEFICIENCIES OR PROBLEMS.
SO, DON'T JUST GO, "OH, I FOUND THIS PROBLEM."
WHAT ARE THEIR STRENGTHS AS WELL.
AND APPRECIATE THAT THE WHOLE PROCESS IS ONGOING.
BECAUSE WHAT WE MIGHT ASSESS TODAY MAYBE TOTALLY DIFFERENT AND CHANGED TOMORROW.
IN FACT, IT MAY BE DIFFERENT FOR THE NEXT SHIFT.
IT'S SO INTERESTING SOMETIMES YOU SEE A CLIENT
AND THE NURSES FROM THE SHIFT BEFORE WILL SAY,
"OH, IT WAS JUST AWFUL. HE WAS SO CONFUSED AND COMBATIVE.
AND HE HAD EIGHT INCONTINENT STOOLS."
AND YOU'RE, LIKE, THINKING, "OH, WOW. I'M GOING TO HAVE BUSY DAY."
THE NEXT SHIFT, TOTALLY ALERT AND ORIENTED. NO INCONTINENCE WHATSOEVER.
AND YOU KNOW -- DO YOU SEE?
THINGS CHANGE AS WE BREATH. AND SO WE CONTINUALLY ASSESS
TO BRING THAT LOCATION FOR WHAT WE'RE GOING TO DO.
NURSING ASSESSMENT IS ALL OF THESE THINGS THAT I MENTIONED. AND HERE'S COUPLE MORE.
IT'S NOT ONLY THE HEALTH HISTORY,
WHICH WE GET FROM BOTH, NURSING AND THE PHYSICIAN.
BUT IT'S OUR PHYSICAL ASSESSMENT, THINGS IN THE MEDICAL RECORDS,
DIAGNOSTIC TEST, IT'S HEALTH TEAM MEMBERS.
I HAVE TO TELL YOU MY NURSES AIDES WHEN I'M WORKING WITH THEM,
BECAUSE THEY IN THERE DOING A LOT OF [BATHS],
AND WATCHING THE FAMILY -- ARE HUGE SOURCE OF INFORMATION.
PHYSICAL THERAPY WILL PICK UP SOMETHING THAT I DIDN'T PICK UP
BECAUSE THEY'RE DOING AN ACTIVITY I DIDN'T DO.
SO YOU REALLY NEED TO BE TALKING TO EVERYBODY, RESPIRATORY THERAPY,
BECAUSE YOU HAVE THIS WEALTH OF INFORMATION
BY GETTING IN TOUCH WITH ALL THE TEAM MEMBERS.
AND THEN ANYTHING ELSE THAT JUST STICKS OUT TO YOU.
SO, EVERYTHING HELPS US IN OUR ASSESSMENT.
WE HAVE TO DEVELOP THE QUALITY OF ASKING OPEN-ENDED QUESTIONS.
THINGS LIKE, DESCRIBE WHAT YOU ARE FEELING?
HOW LONG HAVE YOU HAD THESE SYMPTOMS?
HOW LONG HAVE YOU BEEN FEELING THIS WAY?
HOW WOULD YOU LIKE TO FEEL? HOW HAVE YOU FELT BEFORE?
SOMETIMES IT FEELS LIKE THESE ARE CONTRIVED, AWKWARD QUESTIONS.
LIKE, WHEN WAS THE LAST TIME YOU SAID TO SOMEONE, "DESCRIBE TO ME HOW YOU'RE FEELING?"
DOES THAT SOUND WEIRD?
WELL, GET OVER IT. BECAUSE HOW ELSE ARE WE GOING TO KNOW.
SO, TRY OUT SOME OF THOSE QUESTIONS EVEN THOUGH THEY FEEL LITTLE --
OH, I DON'T KNOW, CONTRIVED, IF YOU WILL.
HOW ELSE CAN WE GET THE ARRANGEMENT? TRY HARDER.
ALRIGHT, WE'LL GET MORE ON THAT.
WE'RE GOING TO DO A THOROUGH PHYSICAL ASSESSMENT.
PHYSICAL ASSESSMENT CAN BE ONE OR TWO THINGS.
IT CAN BE HEAD TO TOE, WHICH IS WHAT WE'VE INTRODUCED TO YOU,
OR IT CAN BE BY BODY SYSTEM.
ONE OF THE THINGS WE'VE ALLUDED TO,
AND I'VE HEARD THE INSTRUCTORS TALK ABOUT -- FOR EXAMPLE,
IF HAVE A CLIENT THAT WAS ADMITTED WITH AN APPENDECTOMY,
THEY'RE 21 YEARS OLD, ALERT AND ORIENTED.
THEY WERE OUT PLAYING SOCCER YESTERDAY AND HAVE AN APPENDICES ATTACK TODAY.
I'M PROBABLY NOT GOING TO DO NEURO ASSESSMENT.
BUT IF I HAVE SOMEONE COMING WITH A STROKE, BOY, I'M DOING IT ALL.
DO YOU SEE WHAT I MEAN?
SO WE WANT TO EITHER BE LOOKING AT SYSTEMS IN PARTICULAR
OR COMPLETE HEAD TO TOE TO GATHER OUR ASSESSMENTS.
YOU WANT TO CAREFULLY ASSESS EACH AREA FOR NORMAL AND ABNORMAL FINDINGS,
AND THEN BE SURE AND USE AS MANY OF THE METHODS
OR MODES OF ASSESSMENT AS ARE TYPICAL.
WE'RE LOOKING FOR NORMAL AND ABNORMAL FINDINGS.
AND THEN WHAT YOU WANT TO DO IS AFTER YOU GATHER YOUR DATA
YOU WANT TO ASK THE CLIENT TO VALIDATE
OR CONFIRM WHAT YOUR FINDINGS ARE.
IT'S NOT ALL ABOUT YOU. IT'S ABOUT TALKING TO THE CLIENT.
SO, THIS IS WHAT I NOTICED.
AND THEY'LL GO, "OH I KNOW."
"DOES THIS DESCRIBE HOW YOU FEEL?" "NO, NOT REALLY."
THIS IS WHAT I MEAN.
TALK TO THEM, REPLAY IT, RESTATE IT BACK.
"TELL ME MORE. WHAT CAN I DO TO HELP?"
THEY -- I HAVE AN IDEA OF WHAT I THINK I NEED.
THAT WILL HELP YOU PLAN EDUCATION, EXPERIENCES.
OR HOW YOU'LL BEST SERVICE THAT CLIENT,
BY MEETING THEIR NEEDS AS WELL AS WHAT OUR OBSERVATIONS WERE.
AND THOSE ARE CRITICAL THINKING PERFORMANCES.
ONCE WE'VE GOTTEN OUR INFORMATION, WE WANT TO REPORT
AND RECORD THE INFORMATION.
SO LET'S SAY THEY HAVE PAIN. THEY'RE GOING TO REPORT,
THEY HAVE SHARP, UNRELENTING PAIN.
THEY'RE VITAL SIGNS ARE GREATLY DEVIATED FROM NORMAL AND THEN OF COURSE, WE WOULD LIST THEM.
THERE'S A CHANGE IN THE LEVEL OF CONSCIOUSNESS.
IF YOU ARE TO FIND ANY OF THESE THINGS ON YOUR CLIENT
WHAT DOES IT MEAN BY REPORT?
FIRST YOU'RE GOING TO REPORT TO YOUR INSTRUCTOR.
THEN YOU'RE GOING TO REPORT TO THE NURSE OR VICE VERSA.
BECAUSE REMEMBER WHO'S CHARGE OF YOUR CLIENT IN THE FLOORS?
THE NURSE IS. BOTTOM-LINE, THE NURSE IS RESPONSIBLE.
SO THAT NURSE NEEDS THAT INFORMATION WITHIN A FEW MINUTES.
THEN, YOU RIGHT NOW AREN'T ABLE TO TAKE DOCTOR'S ORDERS.
SO DON'T CALL THE DOCTOR BECAUSE THEY'RE GOING TO WHIP OUT SOME ORDERS TO YOU.
BUT FOLLOW THAT NURSE AND SAY,
"CAN I LISTEN TO YOU WHEN YOU CALL THE DOCTOR?"
GET ON A EXTENSION AND HEAR WHAT THE DOCTOR SAYS,
HEAR HOW THEY DIALOGUE TOGETHER.
ONE OF THE MOST INTIMIDATING THINGS YOU'LL DO OR FEEL MOST INSECURE ABOUT
IS CALLING PHYSICIANS, ESPECIALLY IF YOU FEEL LIKE
YOU DON'T REALLY KNOW WHAT YOU'RE TALKING ABOUT
OR YOU DON'T KNOW WHAT THEY'RE GOING TO SAY BACK.
SO PRACTICE IT WITH THE NURSES
SO THAT YOU GET USED TO THE DIALOGUE AND WHAT THEY ARE DOING,
BUT THAT'S GOING TO GET REPORTED FOR THE DOCTOR.
WHENEVER IN DOUBT, YOU'RE NOT EVEN SURE.
YOU'LL GO, "OH, I'M NOT EVEN GOING TO TELL HIM. HE'LL THINK I'M STUPID.
NO, YOU BETTER BE TELLING. IT'S BETTER TO JUST
GET OUT THERE AND LET PEOPLE KNOW WHAT YOU'RE IN DOUBT ABOUT.
ALL THE INFORMATION HAS TO BE REPORTED
IN THE HEALTH HISTORY OR PHYSICAL ASSESSMENT OR IN THEIR COMPUTER,
OR HOWEVER YOUR INSTITUTION IS DOCUMENTING INFORMATION RIGHT NOW.
BE CAREFUL, IN REGARDS TO CONFIDENTIALITY, THE INFORMATION THAT YOU SHARE.
I KNOW THEY'VE TALKED TO YOU ABOUT IT, I JUST WANT TO EMPHASIZE
HIPAA IS SERIOUS. CONFIDENTIALITY IS A HUGE ISSUE.
YOU CAN'T BE TALKING IN THE ELEVATOR TO YOUR INSTRUCTOR ABOUT YOUR CLIENT
IF THERE'S SOMEBODY ELSE IN THAT ELEVATOR.
BECAUSE YOU DON'T KNOW WHAT THEY'RE HEARING.
YOU CAN'T GO UP IN THE CAFETERIA AS STUDENTS AND GO,
"OH, MY GOSH! YOU SHOULD HAVE SEEN THAT PATIENT. THAT WOUND WAS SO GROSS. DID YOU SEE THAT?"
RIGHT THERE IS THEIR FAMILY, TABLE NO.2. YOU DON'T KNOW.
SO YOU HAVE TO BE VERY, VERY CAREFUL ABOUT WHAT WE SHARE.
KEEP YOUR NOTES SAFE. DON'T LEAVE ANY THING OUT OF SIGHT.
YOU HAVE TO KEEP YOUR STUFF WITH YOU.
ONE OF THE THINGS I SEE HAPPENING SOMETIMES
IS WE PUT OUR INFORMATION ON A CLIPBOARD
AND MAYBE THEY'RE IN ISOLATION,
SO THERE'S A LITTLE CARD OUTSIDE THE ROOM IN THE HALLWAY.
SO, WE DON'T WANT OUR STUFF COMING IN FOR SURE.
WE LEAVE IT ON THE CARD OUTSIDE THE HALLWAY,
GO IN AND DO OUR THING, COME BACK AGAIN OUR PAPER SITTING
IN THE HALLWAY, WITH EVERYTHING ON IT.
NO GOOD. GOT TO MAKE SURE YOU STUFF IS PROTECTED SO THAT NO ONE'S READING IT.
WE ARE STUDENTS SO WHAT DO WE DO
AND HOW DO WE GET THAT INFORMATION?
WELL, JUST MAKE SURE THAT ON YOUR PAPER,
YOU'RE JUST PUTTING INITIALS DOWN AND NO IDENTIFIERS
THAT PEOPLE CAN SAY, "OH THAT'S MY NEIGHBOR."
BECAUSE THAT WOULD BREACH CONFIDENTIALITY.
IS THAT EVERYTHING I JUST SAID?
ALRIGHT.
WHAT WE'RE GOING TO DO AFTER WE GATHER ALL OUR INFORMATION
IS NOW WE'RE GOING TO PURPOSE AT ANALYZING OUR INFORMATION
TO MAKE A NURSING DIAGNOSIS.
WE'RE GOING TO CREATE A DIAGNOSIS THAT HAS THREE PARTS TO IT.
THERE ARE TWO PART DIAGNOSIS AND THREE PART.
WE WANT YOU TO DO A THREE PART DIAGNOSIS
WHICH IS A DIAGNOSIS, A RELATED TO FACTOR AND DEFINING CHARACTERISTICS.
OR TRANSLATE IT, WE'RE GOING TO TALK ABOUT MORE.
A NURSING DIAGNOSIS AS PER OUR LIST OF -- OUR TAXONOMY LIST.
IT'S IN THE BACK OF THE BOOK WE'LL LOOK AT IT IN A MINUTE.
RELATED TO FACTORS BEING THE CAUSE OR THE IDEOLOGY,
THE THING THAT'S CONTRIBUTING TO THAT DIAGNOSIS.
AND THEN WHAT ARE THE DEFINING CHARACTERISTICS.
AFTER YOU DID YOUR READING WHAT ARE THE DEFINING CHARACTERISTICS?
IT'S YOUR ASSESSMENT.
IT IS THE SYMPTOMS, IT IS THE COMPLAINTS,
IT IS WHAT YOU ASSESSED THAT MADE YOU DECIDE
I HAVE AN ISSUE TO DEAL WITH.
SO DEFINING CHARACTERISTICS ARE THE ASSESSMENT, THE SYMPTOMS.
THOSE ARE THE WORDS I HEAR MOST, BUT IT'S YOUR ASSESSMENT
THAT RELATE TO THAT DIAGNOSIS.
ALRIGHT, LET'S START FROM THE BEGINNING.
WHAT IS A NURSING DIAGNOSIS? WHO ARE WE?
THIS IS SO CRITICAL TO WHAT WE ARE AS NURSES
AND OUR SCOPE OF PRACTICE.
THIS IS YOUR DEFINITION, IT'S ON WHATEVER PAGES ON YOUR BOOK.
IT'S THE FIRST PAGE OF THE CHAPTER.
BROKEN DOWN A LITTLE BIT. IT'S A CLINICAL JUDGMENT.
WHICH MEANS, THAT SOMETHING THAT YOU OBSERVE IN YOUR --
IN YOUR ASSESSMENT GATHERING
IN THE CLINICAL SETTING.
IT HAS TO DO WITH EITHER AN INDIVIDUAL, A FAMILY, OR A COMMUNITY.
BECAUSE WHERE ELSE WOULD A CLINICAL JUDGMENT TAKE PLACE?
WHAT IF YOU'RE A SCHOOL NURSE?
AND THERE'S HEAD LICE?
IS THAT AN INDIVIDUAL PROBLEM, A FAMILY PROBLEM OR A COMMUNITY PROBLEM?
ALL THREE. THE PERSON THAT'S GOT IT,
THE FAMILY'S THAT'S GOING TO CATCH IT
AND THE COMMUNITY THAT'S BEEN EXPOSED.
OKAY? SO, HOW ARE WE GOING TO ADDRESS THOSE ISSUES?
AND THEN IT'S A RESPONSE
TO THIS ACTUAL PROBLEM OR THIS POTENTIAL PROBLEM.
IN OTHER WORDS, A PATIENT MIGHT HAVE COPD.
THAT'S WHAT WE'RE GOING TO WORK WITH A LITTLE TODAY.
WE KNOW WHAT THAT IS, CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
BUT WE DON'T DEFINE IT, WE DON'T DIAGNOSE MEDICALLY
THAT THEY HAVE COPD. WHAT IS THEIR RESPONSE TO COPD?
WHAT'S A RESPONSE TO CHRONIC OBSTRUCTIVE PULMONARY DISEASE?
RESTRICTED AIRWAY. - EDEMA.
- EDEMA, SOMETIMES, BUT NOT NECESSARILY.
IT'S MORE BREATHING.
- SHORTNESS OF BREATH. - SHORTNESS OF BREATH.
- COUGHING, - LACK OF OXYGEN.
THAT IS THE RESPONSE TO THE DIAGNOSIS.
THAT HOW THEY'RE HANDLING IT. WHAT'S A RESPONSE TO APPENDICITIS?
- PAIN. VOMITING.
THAT IS A RESPONSE TO A DIAGNOSIS.
WE'RE LOOKING AT HOW THE CLIENT IS HANDLING WHAT THEY'VE GOT.
AND WE CAN DEAL WITH THAT AND MAKE NURSING DIAGNOSIS.
IT'S BASED ON OUTCOMES AND INTERVENTION --
OR IT'S THE BASIS FOR OUR OUTCOMES AND INTERVENTIONS.
OUTCOMES ARE OUR GOALS WHAT WE WANT TO DO TO HELP THAT CLIENT
AND WHAT WE'RE DOING TO HELP THAT CLIENT.
AND THE NURSE IS TOTALLY ACCOUNTABLE FOR THOSE ACTIONS.
IT'S OUR SCOPE OF PRACTICE.
OKAY. THAT'S WHAT WE ARE. WHAT ARE WE NOT?
WE ARE NOT A MEDICAL DIAGNOSIS. SO, WHAT IS A MEDICAL DIAGNOSIS?
IT'S BASED ON PHYSICAL SIGNS. WE DO THAT TOO, IN SYMPTOMS,
IN MEDICAL HISTORY AND RESULTS OF DIAGNOSTIC TESTING.
BUT A DOCTOR IS LICENSED TO TREAT DISEASES AND PATHOLOGIES
DESCRIBED IN THEIR MEDICAL DIAGNOSTIC STATEMENTS.
THEY HAVE THEIR OWN TAXONOMY.
THEY HAVE THEIR OWN LIST OF MEDICAL DIAGNOSIS.
HAVE ANY OF YOU WORKED IN A DOCTOR'S OFFICE
WHERE YOU DID BILLING?
AND YOU WERE -- WHAT'S THAT BOOK?
[AND DRAWING DRG'S. IT'S THAT SALE.]
UH-HUH. IT'S ALL YOUR CODING.
BASED ON APPENDICITIS, COPD,
ECZEMA, JUST THINK OF ANYTHING THAT'S A MEDICAL DIAGNOSIS
THAT YOU HAVE -- CANCER.
WE DON'T GET TO DIAGNOSE CANCER, WE RESPOND TO IT.
HOW IS THE CLIENT RESPONDING TO THEIR CANCER?
PHYSICALLY AND EMOTIONALLY? THAT'S NURSING.
SO, WHAT WE'RE NOT IS A MEDICAL DIAGNOSTIC STATEMENT.
ALRIGHT, ONCE WE'VE GATHERED ALL OUR INFORMATION, WE'RE GOING TO ANALYZE IT
AND THEN WE'RE GOING TO GROUP ALL OUR INFORMATION.
WE CALL IT CLUSTERING THE DATA.
AND WE'RE GOING TO PUT IT INTO COMMON GROUPS OF INFORMATION.
PATIENTS MAY PRESENT WITH A LOT OF DIFFERENT CONCERNS, PROBLEMS, STRENGTHS.
AND WE'RE GOING TO GROUP THEM INTO SYSTEMS OR COMMON AREAS OF COMPLAINT.
FOR EXAMPLE, A CLIENT MAY COMPLAIN THAT, "I'M NOT SLEEPING WELL.
I WAKE UP IN THE MIDDLE OF THE NIGHT
AND I'M HAVING TERRIBLE PAIN IN MY STOMACH."
WELL, MAYBE THEY'RE HAVING A SLEEP DISTURBANCE.
WE DON'T KNOW. WE GOT TO PURSUE THAT. AND THEY'RE HAVING A PAIN ISSUE.
BUT THEY MAY ALSO HAVE -- BECAUSE THE PAINS IS RELATED
TO A SURGICAL SITE, A RISK FOR INFECTION.
SO, WE'RE GOING TO GROUP ALL OUR INFORMATION
INTO THOSE KINDS OF CATEGORIES
TO SEE WHAT'S OUR PRIORITY AND WHAT WE'RE GOING TO DO ABOUT IT.
ONCE WE'VE, KIND OF, GATHERED OUR INFORMATION,
WE'RE GOING TO TAKE WHAT WE BELIEVE TO BE THEIR PRIORITY RESPONSES
OR CONCERNS AND WE'RE GOING TO THEN APPLY TO THE 172 DIAGNOSIS
THAT HAVE BEEN CREATED BY NANDA.
WHO IS NANDA?
NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION.
ALRIGHT. WE'RE GOING TO TALK ABOUT THEM IN JUST A SECOND.
BUT WE HAVE THESE, 172 DIAGNOSIS THAT THEY'VE CREATED.
AND WE WANT TO BE THINKING AS WE'RE LOOKING AT THOSE.
CAN A CHANGE OCCUR WITH THE NURSING INTERVENTION?
IS THERE SOMETHING NURSING CAN DO TO IMPACT OR INFLUENCE THIS ISSUE?
DOES IT FIT THE NANDA DEFINITION?
YOU'RE GOING, "WHAT THE HECK IS THAT? I DON'T KNOW. WILL YOU LOOK AT THAT!"
NOT ONLY DO THAT CREATE THESE DIAGNOSIS, CATEGORIES,
BUT THEY GIVE A DEFINITION TO IT SO WE UNDERSTAND WHAT THEY MEAN.
AND THEN, ARE THE DEFINING CHARACTERISTICS IN THE ASSESSMENT APPROPRIATE
FOR THE DIAGNOSIS? WHAT ARE THE DEFINING CHARACTERISTICS?
YOUR ASSESSMENT. OKAY?
DO THEY MATCH UP WITH WHAT YOU THINK THIS IS THE PROBLEM?
OKAY, YOU'RE GOING TO ORGANIZE YOUR INFORMATION.
DO YOU SEE ANY PATTERNS? I'M GOING TO HIGHLIGHT PATTERNS.
YOU'RE GOING TO LIST ALL THEIR PROBLEMS, GROUP THEM TOGETHER.
MAKE SOME INFERENCES OR IMPRESSIONS.
I THINK, THIS IS WHAT'S GOING ON OR THIS SOUNDS LIKE THIS TO ME.
AND YOU'RE GOING TO MAKE SOME APPLICATION.
AND THEN WE'RE GOING TO PRIORITIZE THE PROBLEMS.
REMEMBER, I SAID THEY MAY PRESENT YOU WITH A LIST OF THINGS.
HOW DO YOU KNOW WHAT'S THE HIGHEST PRIORITY
AND WHAT'S A LOWER LEVEL PRIORITY.
WE'RE GOING TO APPLY MASLOW'S HIERARCHY
TO SET UP OUR PRIORITY LISTING.
WHAT DO WE KNOW ABOUT MASLOW? WHAT'S THE FIRST PRIORITY?
PHYSIOLOGICAL. PHYSICAL ISSUES.
SO ARE THEY BREATHING? ARE THEY BLEEDING?
WE'RE GOING TO ADDRESS THOSE ISSUES FIRST.
THEN THERE ARE SOME SAFETY ISSUES,
THEN THERE ARE PYSCHO-SOCIAL ISSUES.
IT DOESN'T MEAN THAT WE'RE GOING TO IGNORE PYSCHO-SOCIAL ISSUES,
IT JUST MEANS, THAT OUR HIGHEST PRIORITY
IS TO MAKE SURE THAT THEY'RE BREATHING AND MOVING
BEFORE WE TAKE CARE OF THEIR SELF-ESTEEM ISSUES.
AND THEN WE'RE GOING TO REPORT ALL OUR INFORMATION.
ALRIGHT, THERE YOU HAVE IT. NURSING DIAGNOSIS. OKAY.
IT'S VERY CONFUSING AND THE ONLY WAY TO DO IT IS TO DO IT.
SO, THIS IS WHAT WE'RE GOING TO DO, DO IT.
EVERYONE SHOULD HAVE GOT A WHITE PIECE OF PAPER.
OKAY, THIS ONE. DID EVERYONE GET IT?
NO?
IF YOU DIDN'T GET IT, COME UP HERE AND GET ALL FOUR.
WHAT WE'RE GOING TO DO IS JUST APPLY THIS NURSING PROCESS.
WE'RE GOING TO COME UP WITH OUR DIAGNOSIS.
WE'RE GOING TO COME UP WITH OUR IDEOLOGY
AND WE'RE GOING TO APPLY OUR ASSESSMENTS.
NOW, BEFORE WE DO THAT,
I HAVE A POST-IT NOTE, SO I WOULDN'T FORGET.
AND THIS SAYS, 'BRING YOUR MED BOOK NEXT WEDNESDAY.'
ALRIGHT, SO YOU GOT IT MED BOOK. A LITTLE, FAT, WHITE THING.
BRING IT NEXT WEDNESDAY.
ALRIGHT, HOW ARE WE EVER GOING TO FIND
OR DECIDE ON A NURSING -- THAT ONE. HOLD IT UP -- THE OTHER WAY.
OKAY, HOW DO WE PICK THE NURSING DIAGNOSIS?
FIRST OFF, GO TO THE BACK OF YOUR BOOK.
IN THE BACK OF YOUR BOOK ARE THE --
I DIDN'T COUNT THEM, THERE SHOULD BE 172.
IF THERE'S NOT, THERE'S 167, I THINK.
THEY JUST ADDED A FEW NEW ONES IN 2005 AND 6.
THIS IS WHAT A NURSING DIAGNOSIS IS.
NURSING DIAGNOSIS IS A VERY SUCCINCT PHRASE.
YOU PROBABLY PICKED UP IN YOUR BOOK, IT SAID,
"THEY USED THE LEAST AMOUNT OF WORDS TO DESCRIBE A PROBLEM."
AND MOST OF US WERE SAYING,"WELL, YOU COULD HAVE USED A FEW MORE.
THAT WOULD HAVE BEEN HELPFUL." BUT IT'S A -- JUST A VERY SUCCINCT PHRASE
TO DESCRIBE WHAT'S GOING ON WITH THE CLIENT.
AFTER YOU'VE LOOKED AT YOUR CLIENT
AND YOU COME UP WITH A LIST OF PROBLEMS,
THIS BOOK IS GOING TO GIVE YOU THE ANSWERS.
YOU DON'T HAVE TO KNOW IT ALL. YOU DON'T HAVE TO KNOW WHAT TO DO YET.
THAT'S WHY YOU HAVE A BOOK TO GIVE YOU THE ANSWERS.
THERE'S TWO WAYS THAT WE CAN GO ABOUT GATHERING OUR INFORMATION
OR GETTING OUR INFORMATION,
AND THAT IS AFTER WE LOOK AT WHAT'S GOING ON WITH OUR CLIENT,
YOU CAN COME BACK TO THE BACK OF THE BOOK
AND GO "WELL, DO I THINK IT'S ANY OF THESE?"
AND JUST START LOOKING AT EACH ONE AND GO,
"YOU KNOW WHAT? I THINK IT MAY HAVE TO DO WITH THE INEFFECTIVE AIRWAY CLEARANCE
OR ACTIVITY INTOLERANCE.
I'M GOING TO PURSUE THOSE TWO THINGS."
BECAUSE YOU JUST LOOKED AT THE LIST AND YOU JUST STARTED...
..LOOKING AND DECIDING.
SOMETIMES YOU GET A DIAGNOSIS OR A PATIENT
AND YOU DON'T REALLY EVEN KNOW WHERE TO LOOK.
ONE OF THE THINGS THIS BOOK DID TO HELP US
WAS THEY TOOK MEDICAL DIAGNOSIS CATEGORIES
AND PUT NURSING DIAGNOSIS IN THAT CATEGORY
TO HELP US KNOW WHAT MIGHT APPLY TO THEM.
SO, YOU CAN EITHER GO HERE AND JUST LOOK 'NURSING DIAGNOSIS'
OR LET'S JUST LOOK AND SEE WHERE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE IS. FIND
THERE IT IS. SO GO TO YOUR INDEX,
LOOK UP CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
SO, IS IT UNDER COPD OR CHRONIC OBSTRUCTIVE?
CHRONIC OBSTRUCTIVE. ALWAYS WISH IT WAS COPD,
BUT THERE IT SAYS IN LITTLE PARENTHESIS, COPD.
WHAT PAGE DID YOU GUYS COME UP WITH?
- 379. - THANK YOU.
SO YOU GO TO PAGE 379
AND YOU SEE CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
AND YOU SEE THAT IT COULD BE SOMEBODY THAT HAS CHRONIC BRONCHITIS,
EMPHYSEMA, ASTHMA, CHRONIC AIRWAY LIMITATIONS.
SO YOU SAY TO YOUR SELF "YEAH, THAT'S WHAT MY CLIENT HAD, THAT'S GOOD."
WHAT IS COPD, ANYWAYS?
WHAT THIS BOOK DOES IS IT GIVES YOU A LITTLE PATHOLOGY,
PATH STATEMENT RELATED TO THIS DIAGNOSIS.
SO THAT YOU'RE NOW LEARNING A LITTLE BIT ABOUT THE DISEASE ITSELF.
THEN YOU GO OVER HERE AND UNDER THAT BIG HEADING
THERE IS A WHOLE BUNCH OF NURSING DIAGNOSIS.
THAT SAYS, MAYBE, 'INEFFECTIVE AIRWAY CLEARANCE,' WOULD BE YOUR CONCERN,
OR MAYBE 'IMPAIRED GAS EXCHANGE,'
OR MAYBE YOU WANT TO CONSIDER 'IMBALANCED NUTRITION,
LESS THAN BODY REQUIREMENTS.'
I WONDER WHY THAT?
WE'RE GOING TO HAVE TO DO BREATHING.
OR 'RISK FOR INFECTION' MIGHT BE WHAT'S GOING ON WITH YOUR CLIENT,
OR 'DEFICIENT KNOWLEDGE.'
SO IT GIVES YOU SOME IDEAS ABOUT WHAT'S GOING ON WITH YOUR CLIENT.
ALRIGHT, JUST A QUICK MINUTE.
WE'RE JUST PERUSING. I HAVEN'T MADE A DECISION.
I JUST WANT YOU TO UNDERSTAND THE BOOK.
WHEN THE NURSING GROUP GOT TOGETHER, THEY CREATED THESE DIAGNOSIS FOR US.
THEY KNEW IT WAS REALLY SIGNIFICANT THAT WE UNDERSTAND
EVERYONE HAD THE SAME DEFINITION OF WHAT THESE DIAGNOSIS WERE
AND THAT WE'RE WORKING WITH IT APPROPRIATELY.
I WANT YOU TO LOOK ON PAGE -- WELL, 386 IS FINE.
THE NURSING DIAGNOSIS IS DEFICIENT KNOWLEDGE.
WHAT DOES THAT MEAN?
I BELIEVE THERE'S NO DEFINITE ANSWER.
THIS IS WHAT YOU NEED TO KNOW ABOUT THE BOOK.
NOW TO THE FRONT OF THE BOOK,
ON PAGE...ROLL OVER TO 13.
JUST LOOK AT THE CONTENTS OF THE BOOK.
CHAPTER ONE EXPLAINS HOW TO DO CARE PLANS.
SO YOU MIGHT REVISIT IT, BUT IT'S REALLY PRETTY MUCH WHAT YOU'RE GOING TO COVER.
IT'S ALWAYS GOOD TO SEE WHAT SOMEONE ELSE HAS TO SAY.
NOW IF YOU LOOK UNDER...
..DEFICIENT KNOWLEDGE. WELL -- CHAPTER TWO.
CHAPTER TWO IS WHERE YOU WOULD GO IF YOU HAD LOOKED AT THE BACK OF THE BOOK,
AND YOU'RE GOING TO GO DIRECTLY TO A NURSING DIAGNOSIS THAT YOU'VE CHOSEN.
YOU ALREADY KNOW THAT YOU THINK HOPELESSNESS IS THE BEST CHOICE FOR YOUR CLIENT.
SO YOU'RE GOING TO GO TO CARES BASED ON HOPELESSNESS DIRECTLY.
YOU DON'T NEED TO GO TO A MEDICAL DIAGNOSIS FOR HELP.
WELL, LET'S GO OVER TO WHAT WE WERE TALKING ABOUT, DEFICIENT KNOWLEDGE.
GO TO PAGE 103, KEEPING YOUR FINGER IN PAGE 386.
GO OVER TO 103.
AND NOW WE HAVE DEFICIENT KNOWLEDGE BETWEEN PATIENT, TEACHING
OR HEALTH INFORMATION OF THE PATIENT.
BUT NOW WE HAVE OUR NANDA DEFINITION.
IN THIS BOOK, THE DEFINITIONS FOR THE DIAGNOSIS ARE ONLY IN THE CHAPTER TWO CARE PLANS.
I DON'T KNOW WHY THEY DIDN'T SPRING FOR A DEFINITION.
REALLY ON ALL THESE OTHER ONES, ONLY TWO LINES, BUT THEY DIDN'T.
SO IF YOU'RE TRYING TO MAKE THE BEST DECISION AND YOU'RE DOING IT BY MEDICAL DIAGNOSIS,
YOU'RE STILL GOING TO HAVE TO FLIP OVER AND MAKE SURE THAT'S THE DEFINITION THAT YOU WANT,
BECAUSE RIGHT NOW, YOU'RE NOT REALLY SURE WHAT IS THE DIFFERENCE BETWEEN
INEFFECTIVE AIRWAY CLEARANCE AND INEFFECTIVE GAS EXCHANGE.
WHAT'S THE DIFFERENCE? YOU'VE GOT TO LOOK AT THE DEFINITION.
ALRIGHT, I WANT YOU TO APPRECIATE THAT. NANDA HAS FOUR PARTS.
IT HAS A DIAGNOSIS. IT HAS A DEFINITION.
IT HAS IDEOLOGIES AND DEFINING CHARACTERISTICS.
SO WHEN WE'RE LOOKING AT THE DIAGNOSIS ITSELF. WE WANT TO LOOK AT ALL FOUR PARTS.
NOTICE HERE ON PAGE 103, YOU GOT KNOWLEDGE DEFICIENT,
WE HAVE A NANDA DEFINITION, WE'VE GOT A WONDERFUL LIST OF DESCRIPTION
OF WHAT THAT IS, HERE ON PATHOLOGY.
AND THEN IF YOU TURN THE PAGE, YOU HAVE RELATED TO FACTORS,
IDEOLOGY AND YOU HAVE DEFINING CHARACTERISTICS,
WHICH ARE SYMPTOMS.
ALRIGHT, THAT'S JUST A BASIC OVERVIEW OF HOW WE'RE GOING TO USE THE BOOK.
WE'LL DO THE REST RIGHT HERE.
ALRIGHT, LET'S GO OVER OUR CASE STUDY.
WELL, LET ME JUST...
I NEED TO EXPLAIN TO YOU ONE THING THAT YOU'RE GOING TO NOTICE IN CLINICAL SETTING
AND I NEED YOU TO APPRECIATE IT.
YOU'RE IN SCHOOL AND YOU'RE GOING TO LEARN HOW TO DO THIS WELL,
EFFICIENTLY AND YOU'RE GOING TO WORK REALLY HARD AT IT.
AND YOU'RE GOING TO BE A LITTLE FRUSTRATED
BECAUSE YOU'RE GOING TO GO TO THE CLINICAL SETTING
AND YOU'RE NOT GOING TO HEAR OF NURSES ALWAYS USING A CHART.
THAT WE'VE BEEN EMPHASIZING. LET ME EXPLAIN TO YOU WHY.
THIS IS REALLY A VERY NEW PROCESS.
ACTUALLY, IF YOU'VE READ THE HISTORY,
IT'S A BEAUTIFUL LITTLE HISTORY. I THOUGHT, THIS IS SO TRUE.
I WENT TO SCHOOL BACK IN THE '70S.
WE HEARD THIS RUMOR THAT NURSING DIAGNOSES WERE COMING
AND WE'RE LIKE, "WHATEVER."
BUT THEY DIDN'T KNOW WHAT THEY WERE TALKING ABOUT.
THEY DIDN'T EVEN TEACH IT AT SCHOOLS BECAUSE IT WAS NEW.
I GRADUATED IN '79. AND OF COURSE,
WE WORKED JUST TOTALLY AND SOLELY WITH MEDICAL DIAGNOSIS.
AND WE DID DOCTOR'S ORDERS AND WE HAD OUR NURSING SKILLS AND THAT'S WHAT WE DID.
AND THEN THEY TOLD US, ABOUT 1985,
THESE DIAGNOSES CAME OUT IN 1982, BUT NOBODY KNEW WHAT TO DO WITH IT.
WHEN YOU'RE OUT OF SCHOOL, YOU DON'T SEE IT THAT FIRST YEAR.
PARTICULARLY IF THEY WERE SAYING YOU GUYS HAVE TO DO NURSING DIAGNOSIS.
SO THEY APPEARED AND NONE OF US KNEW WHAT TO DO WITH THEM
BECAUSE THEY JUST APPEARED.
SO JOINT COMMISSION SAID,
EVERYBODY'S GOT TO HAVE A NURSING CARE PLAN WITH A NURSING DIAGNOSIS.
BUT NOBODY KNEW WHAT TO DO WITH THEM.
IF SOMEONE'S THROWING UP COFFEE GROUNDS,
AND THEY'RE HAVING BLACK, TARRY STOOLS, WHAT DO YOU KNOW ABOUT THEM?
THEY'RE A GI BLEED. WHICH IS WHAT?
A MEDICAL DIAGNOSIS.
SO WE WERE STUBBORN ABOUT IT AND WE SAID, "WHY DO WE HAVE TO WRITE DOWN THAT THEY HAVE --"
WHATEVER DIAGNOSIS IT IS. INSUFFICIENT CIRCULATION OR POTENTIAL HEMORRHAGE,
WHAT DID WE ALREADY LEARN ABOUT GI BLEED? SO THERE IS SOME VALUE IN THE RANKS.
ABOUT TRYING TO DO THIS NURSING THING.
SO WHAT DID TO ACCOMPLISH WHAT JOINT COMMISSION SAID WE HAD TO DO,
WAS THEY NEED THESE FORMS THAT WERE ALREADY PRE-PRINTED CARE PLANS.
SO THE GI BLEED CAME IN AND WE WOULD GO TO THE GI BLEED FOLDER,
GRAB A NURSING CARE PLAN, STICK IT IN THE CHART AND CALLED IT DONE.
THEY DIDN'T THINK THAT WAS GOOD. THEY SAID, "YOU GUYS HAVE TO INDIVIDUALIZE THESE CARE PLANS.
NOT EVERY ONE'S THE SAME, JUST BECAUSE THEY HAVE GI BLEEDS."
WE SAID, "OKAY, FINE." SO WE PUT A FEW BLANKS IN,
AND FILLED IN SOME DATES AND SOME TIME FRAMES AND SAID," THAT WILL DO."
AND WE JUST FILLED THEM OUT, STUCK THEM IN AND DIDN'T DO ANYTHING WITH THEM.
BY NOW ABOUT 1992 TO ABOUT 1995,
AND WE'RE STARTING TO GET AWAY WITH THE LANGUAGE,
BUT NOW WE'VE GOT NURSING STUDENTS COMING OUT OF SCHOOL
WHO'VE WORKED WITH AND LEARNED THEM WHO ARE TEACHERS NOW.
AND I WAS LIKE, "OH, OKAY. WHAT IN THE WORLD."
JOINT COMMISSION STAYED PERSISTENT ABOUT IT AND THEY SAID,
"WE ARE SERIOUS. YOU GUYS HAVE TO WRITE CARE PLANS FOR EVERY CLIENT.
AND YOU HAVE TO INDIVIDUALIZE THEM USING NURSING DIAGNOSIS. YOU'RE NURSES."
SO THE COMMUNITY SAYS, "FINE. YOU BETTER TEACH OUR NURSES HOW TO DO IT."
THEY CREATED A KIND OF SKELETON OF CARE PLAN FOR US
THAT WE FILL IN THAT'S VERY INDIVIDUALIZED.
HOWEVER, YOU'LL SEE IT FILLED OUT ON ADMISSION DAY,
IT'S STUCK IN THE BACK OF THE CHART.
HERE'S THE DEAL. NURSES HAVE ALREADY LEARNED WHAT TO DO FOR A PATIENT.
THAT'S WHAT THE NURSES PRACTICE. SO THEY SET UP THE CARE PLAN AND THEN THEY DO THE CARE.
AND THEY EVALUATE THEIR CLIENTS, BUT IT DOESN'T ALWAYS GET FOLLOWED THROUGH
AND IT'S A SYSTEMATIC WAY AS WHAT WE'RE GOING TO PUSH TO DO.
SO YOU MAY GET A LITTLE FRUSTRATED IF YOU'RE NOT SEEING IT
AND DON'T KNOW WHAT YOU'RE DOING HERE.
BUT REMEMBER IT'S A TWO-FOLD PROCESS.
WE HAVE TO TEACH YOU WHAT TO DO AS NURSES BECAUSE YOU DON'T KNOW YET.
AND YOUR EXPERIENCE AND WORK WITH THE BOOK IS GOING TO BE
WHAT HELPS YOU COMMUNICATE WITH THE NURSES IN THE CLINICAL AREA.
IT'S STILL A VERY YOUNG PROCESS, WE'RE REALLY GETTING MUCH BETTER AT IT.
YOU'RE ON THE BETTER END LEARNING IT, BECAUSE THAT WILL HELP YOU?
BECAUSE YOU'RE GOING TO GET A LITTLE FRUSTRATED WHEN YOU GO TO CLINICAL AREAS.
WHEN YOU GO TO THE CLINICAL AREAS,
I REALLY, REALLY ENCOURAGE YOU TO LOOK INTO THE CHART AND FIND WHERE'S THE NURSING CARE PLAN.
IT SOUNDS LIKE UMC IS USING IT AS KIND OF A COMMUNICATION TOOL
ON THE BASIS TO REPORT.
AND THAT'S SO FORWARD THINKING OF THEM BECAUSE WE HAVE TO FIND A WAY
TO PUT OUR INFORMATION, OUR LANGUAGE AND OUR PRACTICE
OUT IN THE FOREFRONT NO MORE THAN WHAT IT ALWAYS HAS BEEN.
THAT'LL HELP YOU UNDERSTAND WHAT'S GOING ON.
ALRIGHT, CASE STUDY.
WE HAVE A 73-YEAR-OLD MALE THAT'S BEEN ADMITTED TO THE UNIT
WITH AN ADMITTING MEDICAL DIAGNOSIS OF COPD.
HE STATES THAT HE HAS DIFFICULTY BREATHING
WHEN WALKING SHORT DISTANCES.
HE ALSO STATES THAT HIS HEART FEELS LIKE IT'S RACING AT THE SAME TIME.
HE STATES THAT HE'S TIRED ALL THE TIME.
AND WHILE TALKING TO YOU, HE'S CONTINUING WRINGING HIS HANDS AND LOOKING OUT THE WINDOW.
ALRIGHT, IS THAT A COMPLETE ASSESSMENT?
NO. WE WANT TO GET MORE.
BUT FOR OUR PURPOSES OF JUST TRYING TO COME UP WITH A DIAGNOSIS AND SO FORTH,
THIS IS WHAT WE'RE GOING TO WORK WITH.
I CERTAINLY WANT TO GET HIS VITALS AFTER WALKING.
I WANT TO SEE HOW HE TOLERATES IT. I WANT TO GATHER SOME MORE INFORMATION BECAUSE I'M CURIOUS
WHAT HE'S GOING TO DO, BUT I WOULD NEED SOME MORE OBJECTIVE DATA.
WE'RE GOING TO WORK WITH THIS HOWEVER.
AND THIS IS WHAT WE NEED TO DO.
ALRIGHT, WITH YOUR PAPER BUT WITH A PEN
I WANT YOU TO CIRCLE AREAS THAT YOU THINK ARE PROBLEMS IN THE ASSESSMENT.
SO JUST LOOK AT THIS, CIRCLE UP WHAT YOU BELIEVE TO BE PROBLEMS.
THIS IS ALL THE DATA YOU HAVE RIGHT NOW.
OKAY?
THAT'S WHAT YOU SHOULD HAVE CIRCLED UP.
YOUR PATIENT HAS COPD. THAT IS A PROBLEM.
IT'S NOT NURSING, IT'S MEDICAL. BUT NEVERTHELESS,
IT'S THE PLACE THAT WE'RE STARTING FROM, SUBJECTIVE DATA.
WE HAVE A LOT OF SUBJECTIVE DATA.
DIFFICULTY BREATHING AND HEART RACING,
TIRED ALL THE TIME.
AND THEN WHAT WE HAVE IS OBJECTIVE DATA IN HERE.
HE'S WRINGING HIS HANDS AND LOOKING OUT THE WINDOW.
ALRIGHT, MAKE A LIST OF THE PROBLEMS THAT HAVE BEEN HIGHLIGHTED.
TAKE A MINUTE AND JUST WRITE THEM DOWN UNDERNEATH
SO THAT WE KNOW EXACTLY WHAT WE'RE WORKING WITH.
PENCILS DOWN.
YOU SHOULD HAVE COME UP WITH THIS.
YOUR LIST WAS COPD, DIFFICULTY BREATHING, HEART FEELS LIKE IT'S RACING,
TIRED ALL THE TIME AND THEY'RE WRINGING THEIR HANDS.
CLUSTER THAT. YOU WANT TO JUST CIRCLE IT,
BUT CLUSTER SIMILAR PROBLEMS.
YOU SHOULD HAVE TWO GROUPS OF PROBLEMS, I'LL GIVE YOU THAT LITTLE INFORMATION.
BUT CLUSTER IT INTO SIMILAR GROUPS.
OKAY. YOU SHOULD HAVE COME UP WITH THESE TWO.
COPD, DIFFICULTY BREATHING, HEART RACING, TIRED ALL THE TIME
AND WRINGING HANDS, LOOKING OUT THE WINDOW.
YOUR PSYCHO-SOCIALS, OKAY?
LOOKING AT THIS GROUP, ARE YOU ABLE TO PRIORITIZE
WHICH ONE IS MORE SIGNIFICANT BASED ON MASLOW'S HIERARCHY.
- NUMBER ONE?
- PROBABLY THE TOP ONE. WHY?
IT HAS TO DO WITH BREATHING ISSUES.
AND BREATHING IS A NUMBER ONE PRIORITY IN OUR PHYSIOLOGICAL ASSESSMENT.
SO WE'RE GOING TO TAKE HIS BREATHING COMPLAINTS OVER WHAT SEEMS LIKE ANXIETY.
WE'RE NOT SURE. I NEED SOME MORE INFORMATION.
I'M NOT SURE IF HIS ANXIETY IS RELATED TO LOW OXYGEN.
I NEED SOME MORE INFORMATION OR IF HE HAS SOME PERSONAL ISSUES.
I DON'T KNOW. MAYBE HIS WIFE'S LATE. I DON'T KNOW.
THAT'S NOT IN HERE, BUT IT APPEARS TO BE PSYCHO-SOCIAL.
I'VE GOT TO PURSUE IT A LITTLE MORE.
BUT I KNOW FOR SURE THESE ARE COMPLAINTS RELATED TO SHORTNESS OF BREATH.
BREATHING. THEY'RE GOING TO BE MY PRIORITY.
OKAY, KNOWING THIS -- LET ME SEE WHAT I'VE GOT.
ALRIGHT, WE'RE GOING TO GO TO OUR NANDA LIST.
WE'RE GOING TO GO TO THE BACK OF THE BOOK. WE'RE JUST GOING TO START HERE AS ALTERNATIVE.
AND LOOK AT THIS LIST AND SEE WHICH THINGS YOU THINK MIGHT APPLY.
WITHOUT TALKING OR YELLING THEM OUT,
BECAUSE I WANT EVERYONE TO HAVE AN OPPORTUNITY TO SEARCH THE LIST OVER.
I WANT YOU TO PICK TWO OR THREE POSSIBLE DIAGNOSIS
THAT MIGHT HELP YOU --
THAT YOU THINK MIGHT APPLY. IF YOU'RE NOT SURE JUST LOOK AT DEFINITIONS.
BUT PICK TWO OR THREE RELATED TO --
I'LL FLIP IT BACK SO YOU CAN SEE. THOSE PROBLEMS.
ALRIGHT, I'M SEEING MANY -- COUPLE OF PEOPLE WITH NO BOOKS.
WHO DOESN'T HAVE A BOOK? YOU DON'T HAVE A BOOK?
YOU BACK THERE?
ANYONE ELSE DON'T HAVE A BOOK?
OKAY, EVERYONE COME UP WITH ONE OR TWO
THINGS THAT YOU CAN LOOK AT.
OKAY. COUPLE OF THINGS THAT YOU MIGHT WANT TO CONSIDER
AS YOU'RE LOOKING AT THE LIST.
YOU'LL RECALL IN YOUR READING THAT WE HAD SOME --
THEY REFERRED TO THEM SOMETIMES AS AXES OR PROBLEMS,
BUT IS THE PROBLEM ACUTE? WHAT DOES THAT MEAN?
- SHORT TERM. - SHORT TERM.
USUALLY, FOUR TO SIX WEEKS.
OR IS THIS CHRONIC? WHICH IS?
- LONG TERM. - LONG TERM.
WHICH CAN BE ANYWHERE FROM SIX WEEKS TO THREE MONTHS AND ON.
INTERMITTENT --
- VERSUS CONTINUOUS. OKAY, THAT'S WHAT WE'RE CONSIDERING.
IS THIS AN INDIVIDUAL PROBLEM, FAMILY, GROUP OR COMMUNITY PROBLEM?
WHAT DO WE HAVE GOING ON NOW?
LET'S GO BACK TO THE BEGINNING.