1. To be, or not to
be--that is the
question!

2. The Nursing Process &
Nosocomial Infections in
Relation to IV Therapy
Nelia B. Perez RN, MSN

3. Definition: Nosocomial infection
(NI) is every infectious process,
appearing during hospital stay,
despite its clinical picture, carrier
status and time of manifestation -
during hospital treatment or after
discharge.

4. Infections that develop in
outpatient departments, day
clinics or other closed human
groups such as in nursing
houses or orphanages and are
associated to medical or
dental procedures are
nosocomial too.

5. NURSING PROCESS
• The cornerstone of the nursing profession.
• Includes: ADOPIE – Assessment, Diagnosis,
Outcome identification, Planning,
Implementation and Evaluation

6. NURSING PROCESS IS:
• ORGANIZED & SYSTEMATIC
• HUMANISTIC : The plan of care is developed
and implemented with great consideration to
the unique needs and concerns of the
individual client It is individualized It involves
aspect of human dignity

7. • EFFICIENT : Relevant to the needs of the client
and Promotes client satisfaction and progress
• EFFECTIVE :Utilizes resources wisely in terms
of human, time, cost resources

8. THE HEART OF THE NURSING PROCESS
• K – knowledge; S – skills; C - caring
• Knowledge – broad, varied
A. MANUAL
B. INTELLECTUAL
C. INTERPERSONAL TECHNICAL
• SKILLS
CRITICAL THINKING : careful deliberate, goal-
directed – to solve problems/make decisions check for
evidence. Keeping an open mind and Avoid jumping
into conclusions
• TO ESTABLISH POSITIVE INTERPERSONAL

9. ASSESSMENT
• Collecting, validating, organizing and
recording data about the client’s health status
(individual, family, community)
• PURPOSE: To establish a data base
• ACTIVITIES:
COLLECTING DATA: Gathering information.
Include the physical, psychological, emotional,
socio-cultural, and spiritual factors

10. TYPES OF DATA:
• SUBJECTIVE DATA (SYMPTOMS) - experienced by
the client - EX. Pain, dizziness,
• OBJECTIVE DATA (SIGNS) - those that can be
observed and measured - EX. Pallor, diaphoresis,
blood pressure, reddish urine, body temp.
• METHODS OF COLLECTING DATA:
– INTERVIEW. Planned purposeful conversation
– OBSERVATION. (use of senses, lab results
interpretation, physical examination)

11. • SOURCE OF DATA: PRIMARY: Patient/ Client
• SECONDARY: Family members, S.O., patient’s
chart/record, health team members, related
literature
• VERIFYING / VALIDATING DATA. Make sure
your information is accurate.
• ORGANIZING DATA. Cluster facts into groups
of information (subjective and objective
information)

12. Let’s review! SUBJECTIVE OR
OBJECTIVE???
– Headache
– Temp 37.9 C RR: 20 bpm
– Redness in the IV site
– Client states, “ My IV site hasn’t been changed
since Friday (3 days).”
– Cyanosis
– Urine output: 60ml
– Ate only half of the food served

13. DIAGNOSING
• Is a process which results to a diagnostic
statement or nursing diagnosis
• The clinical act of identifying problems
• It means to analyze assessment and derive
meaning from this analysis.
• PURPOSE: To identify the client’s health care
needs and to prepare diagnostic statements

14. NURSING DIAGNOSIS
• Is a statement of client’s potential or actual
alteration of health status. Uses critical thinking
and skills analysis
• Uses PRS/PES format
– P- PROBLEM
– R-RELATED TO FACTORS
– S- SIGNS AND SYMPTOMS
– P-PROBLEM
– E-ETIOLOGY
– S-SIGNS AND SYMPTOMS

15. ACTIVITIES DURING DIAGNOSING:
• Organize cluster or group data. Ex. Pallor,
dyspnea, weakness, fatigue – pertain to problems
with oxygenation
• Compare data against standards (accepted
norms). Ex. Amber, clear urine VS cloudy urine or
tea colored urine.
• Analyze data after comparing with standards
Identify gaps and inconsistencies in data
• Determine the client’s health problems, health
risks, strengths
• Formulate Nursing Diagnosis statements

16. Examples of Nursing Diagnoses:
• Anxiety related to insufficient knowledge
regarding IV Catheter Insertion
• Ineffective airway clearance related to
tracheobronchial infection as manifested by
weak cough, adventitious breath sounds, and
copious green sputum production.

17. Types of Nsg. Diagnoses:
• ACTUAL NURSING DIAGNOSIS
• A judgment about the client’s response to a
health problem that is present at the time of
nursing assessment
• Based on the presence of signs and symptoms
• Ex. - ALTERED COMFORT: PAIN – PAIN

18. RISK NURSING DIAGNOSIS
• A clinical judgment that a problem does not
exist, but the presence of risk factors indicates
that a problem is likely to develop
• Ex. RISK FOR INFECTION , RISK FOR
CONSTIPATION

19. POSSIBLE NURSING DIAGNOSIS
• Is one in which evidence about a health
problem is unclear or the causative factors are
unknown.
• Requires more data either to support or to
refute it.
• Ex. Possible Vein Thrombosis related to
prolonged IV Therapy

20. COMPONENTS of a NANDA NURSING
DIAGNOSIS
• PROBLEM (diagnostic label) and DEFINITION
• Describes the client’s health status clearly and
concisely in a few words
• Qualifiers: Deficient – inadequate in amount,
quality, or degree; not sufficient Impaired –
made worse, weakened, damaged

21. • Ineffective – not producing the desired effect
• ETIOLOGY (related factors & risk factors)
Identifies one or more probable causes of
health problem
• Gives direction to what health needs to attend
to.

22. DEFINING CHARACTERISTICS
• A cluster of signs and symptoms that indicate
the presence of a particular diagnostic label
• ACTUAL DX: signs and symptoms
• HIGH RISK/ RISK: factors that cause the client
to be more vulnerable to the problem

23. • Ex. ACTIVITY INTOLERANCE RELATED TO
IMMOBILITY as manifested by verbal reports
of fatigue or weakness during leg exercises
• Formulating statements: Problem – Etiology
format Problem – etiology – signs and
symptoms format

24. OUTCOME IDENTIFICATION
• Refers to formulating and documenting
measurable, realistic, client – focused goals.
• Provides the basis for evaluating nursing
diagnosis and interventions.

25. ACTIVITIES INCLUDE:
• ESTABLISH PRIORITIES.
• Life-threatening should be given highest
priority ABC’s (airway, breathing, circulation)
• Maslow’s hierarchy of needs (physiologic
needs over psychosocial)
• Unstable clients vs. clients with stable
conditions
• Actual problems vs. potential concerns

26. ESTABLISH GOALS & OUTCOME
CRITERIA
• GOALS: broad statements
• SHORT-TERM GOAL (STG) LONG-TERM GOAL
(LTG)
• OUTCOME CRITERIA: specific, measurable,
realistic statements of goal attainment
• S–M–A–R–T
• Specific, measurable, attainable, time-framed

27. • Ex. GOAL: The client will be able to improve
mobility.
• DESIRED OUTCOMES: By the end of the week,
client will be able to ambulate with crutches.
By end of the month, client will be able to
stand without assistance.

28. PLANNING
• Involves determining beforehand the strategies
or course of actions to be taken before
implementation of nursing care. Involve the client
and his family
• Begins with the first client contact until client is
discharged from the facility
Activities:
• Plan nursing interventions (also called nursing
orders); may be dependent, independent,
interdependent.

29. TYPES OF PLANNING
• Initial planning - starts upon initial
assessment/admission
• Ongoing planning - Done by all nurses who work
with the client to:
Determine change in the health status.
Set priorities for the client’s care during the
shift.
Decide which problems to focus on during the
shift.
Plan nursing activities during the shift.

30. Discharge planning
• The process of anticipating and planning for
needs after discharge. Includes: ff. up care,
referrals, medications, diet modifications,
significant other/care provider, health
teachings, which signs and symptoms to watch
for.

31. IMPLEMENTATION
• Putting the nursing care plan into action Purpose:
to carry out planned nursing interventions to help
the client attain goals and achieve optimal level
of health Activities:
– Set priorities.
– To determine the order in which nsg interventions are
carried out.
– Perform nsg. Interventions Record actions.
SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT
DONE!!!

32. EVALUATION
• Is assessing the client’s response to nsg
intervention and then comparing the response
to predetermined standards or outcome
criteria.
• Purpose: To appraise the extent to which goals
and outcome criteria of nsg care have been
achieved

33. Activities:
• Collect data about the client’s response
• Compare response to goals and outcome
criteria
• Assess whether goals are met
(partially/completely) or unmet Analyze
reasons for outcomes
• Modify care plan as needed

34. BENEFITS OF THE NURSING PROCESS
FOR THE CLIENT
• Quality client care.
• It meets standards of care.
• Continuity of care.
• Participation by the clients in their health
care.

35. BENEFITS OF THE NURSING PROCESS
FOR THE NURSE
• Consistent and systematic nursing education
• Job satisfaction
• Professional growth
• Avoidance of legal action
• Meeting professional nsg standards
• Meeting standards of accredited hospitals

36. Thank you for
listening!!!