1. 2011
IDA JEAN ORLANDO
THE NURSING PROCESS
The Collaboration of the Nursing Process in properly assessing an Elderly
Client and how it affects the old person in performance of Activities of
Daily Living
Maeah Stephanie Macapaz- Abadejos
1 IDA JEAN ORLANDO- PHILO THEO
3/18/2011

2. TABLE OF CONTENTS
Title Page Page………………………………………………1
Table of Contents Page……………………………………………..2
Ida Jean Photos Page……………………………………………..3
Conceptual Framework Page……………………………………………..4
Schematic Diagram Page……………………………………………..5
Discussion of Different Concepts of Page………………………………………………6
the Theory
Assumptions and Assertions Page……………………………………………7-8
Nursing Paradigm Page……………………………………………..9
Limitations Page…………………………………………….10
Assessment Tool Page………………………………………..11-17
Statement of the Problem Page……………………………………………..18
Nursing Care Plan Page…………………………………………19-23
Bibliography Page…………………………………………….24
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3. IDA JEAN ORLANDO
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4. Conceptual Framework
Distinguish the
Theory
NEED
PRESENTING
BEHAVIOUR OF
PATIENT
NURSING PROCESS
DISCIPLINE
ANA DNA
PATIENTS
NEED FOR
HELP
RESOLVED
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5. Analyze the
Theory
•PATIENTS VERBAL OR NON-VERBAL LANGUAGE
Sense of
Helplessness
•NURSES RESPONSE
Exploration of
patients behavior
•NURSES ACTION
Deliberative
approach
(Dynamic •PATIENT'S REACTION
Approach)
•PATIENTS NEED FOR HELP RESOLVED
Well Being
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6.  In the late 1950s, Orlando developed her theory inductively through
an empirical study of nursing practice.
 For 3 years, she recorded 2000 observations between a nurse and
patient interactions.
 She was only able to categorize the records as "good" or "bad"
nursing.
According to records:
 Good Nursing nurse's focus was on the patient's immediate verbal and
non verbal behavior from the beginning through the end of the
contact
 Bad Nursing nurse's focus was on a prescribed activity or something
that had nothing to do with the patient's behavior
From these observations, she formulated the Deliberative Nursing Process
which was published in 1961.
Conducted research at McLean Hospital through continuous tape recording of
nurses with patients and other health care members
Based on this research, her formulations were validated, thus she extended
her theory to include the entire nursing practice system which then evolved
as Nursing Process Discipline.
Orlando's theory remains one the of the most effective practice theories
available.
Many theory scholars utilized her concept as basis for their further studies.
Her work has been translated into six languages and was contained in the
international section.
A web page about her theory, developed by Schmieding in 1999, is updated
periodically and contains extensive references.
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7. Assumptions about Nurses:
The nurse's reaction to each patient is unique
Nurses should not add to the patient's distress
The nurse's mind is the major tool for helping patients
The nurse's use of automatic responses prevents the responsibility of
nursing from being fulfilled
Nurse's practice is improved through self-reflection
Assumptions about Patients:
Patients' needs for help are unique
Patients have an initial ability to communicate their needs for help
When patients cannot meet their own needs they become distressed
The patients’ behavior is meaningful
Patients are able and willing to communicate verbally (and non-
verbally when unable to communicate verbally)
Assumptions about the nurse-patient situation:
The nurse-patient situation is a dynamic whole
The phenomenon of the nurse-patient encounter represents a major
source of nursing knowledge
Assumptions about Nursing:
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8. Nursing is a distinct profession separate from other disciplines
Professional nursing has a distinct function and product (outcome)
There is a difference between lay and professional nursing
Nursing is aligned with medicine
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9. HEALTH
is not well-defined but
assumed as ³freedom
from
mental or physical
discomfort and feelings of
adequacy and well-being
NURSING
providing direct
assistance to individuals
in whatever setting for
ENVIRONMENT the purpose of
avoiding, relieving, dimi
is not clearly defined as nishing, or curing the
well but assumed as a person's sense of
nursing situation when helplessness
there is a nurse-patient
contact and that both
nurse and patient
perceive, think, feel, and
act in the immediate
situation PERSON
unique and
developmental beings
with needs, individuals
have their
own subjective
perceptions and
feelings that may not be
observable
directly
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10. Highly interactive nature Orlando's theory makes it hard to include the
highly technical and physical care that nurses give in certain settings.
Her theory struggles with the authority derived from the function of
profession and that of the employing institution's commitment to the public.
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11. Nursing process
•Subjective Data
Assessment
•Objective Data
•Nursing Diganosis
Diagnosis •Validation of Patient's Need
•Short Term Goals
Planning
•Long Term Goals
•Strategies to Achieve Goals
Implementation
•Intervention
•Patient Outcome
Evaluation
•Success on Care Plan
The patient must be the central character
Nursing care needs to be directed at improving outcomes for the
patient; not about nursing goals
The nursing process is an essential part of the nursing care plan
Assessment
Involves taking vital signs, performing a head to toe assessment, listening
to the patient's comments and questions about his health status, observing
his reactions and interactions with others. It involves asking pertinent
questions about his signs and symptoms, and listening carefully to the
answers.
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12.  the most critical step
Answers the questions: “What is happening?” (Actual problem), or
“What could happen?” (Potential problem)
 Involves collecting, organizing, and analyzing information/data about
the patient
Results in Nursing Diagnoses
Two parts: Data collection & Data analysis
1. Data Collection: A Holistic Approach
Types of data
Subjective: “symptoms” that the patient describes; e.g. “I can’t do
anything for myself”
Objective: signs that can be observed, measured, and verified; e.g.
swollen joints
Sources of data
Primary: the patient; is always the best source
Secondary: everything/everybody else
Methods of Data Collection
Observation
Requires practice and skill
Systematic, head-to-toe (cephalocaudal)
Results in objective, factual information
Document exactly what you observe
e.g. “Yawned frequently, had dark circles under eyes”
NOT “Patient seems tired”
Observation results in a General Survey
The General Survey: a brief description of patient’s appearance and
behavior.
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13. A 64 year old, well groomed African-American male in acute
distress. Awake, alert, and oriented. Approximately 6’, 1 170lbs. Hair
sparse and gray, eyes brown. Sitting on side of bed, holding side rail for
support. Verbal responses coherent but halting.
Methods of data collection
Interview
Structured form of communication
Purpose: to provide care specific to this individual’s needs and problems
Focus: patient’s perceptions
Nurse must: explain purpose of interview, provide comfort and privacy,
ensure confidentiality
Result: A comprehensive Health History
Components of the Health History
Demographic data
CC: chief complaint
HPI: history of present illness
PMH: past medical history
FMH: family medical history (genogram)
ROS: review of systems
Psychosocial history
Methods of Data Collection
Examination
Inspect
Palpate
Percuss
Auscultate
Nurse must: explain what you are doing, provide privacy, and ask
permission before you touch the patient
2. Data Analysis
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14. Data review
Are data accurate and complete?
Data interpretation
What are the patient’s actual and/or potential problems?
Develop a problem list based on the data
Prioritize the patient’s problems
Diagnosis
Nurses only make nursing diagnoses, except in the case of Nurse
Practitioners who have been trained and licensed to make medical
diagnoses. Once you have identified the patient's problems related to his
health status, you formulate a nursing diagnosis for each of them. You will
also prioritize the problems in formulating your plan and goals.
Step Two of the Nursing Process
Nursing Diagnosis: a statement that describes a specific human response
to an actual or potential health problem that requires nursing intervention
Written in P E format
P = Problem: use North American Nursing Diagnosis Association (NANDA)
category
[due to or related to]
E = Etiology: cause of the problem
Rheumatoid Arthritis Self-care deficit: bathing, related to joint stiffness
Planning
Setting goals to improve the outcomes for the patient is a primary focus of
the nursing process. Based on the nursing diagnoses, what are the
expectations for this patient? This not about nursing goals. They are patient
goals. This is about improving the health status and quality of life for your
patient. This is about what your patient needs to do to improve his health
status and/or better cope with his illness.
Plan: to provide consistent, continuous care that will meet the patient’s
unique needs.
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15. Includes Patient Goals & Nursing Orders
Patient Goals: describe the desired result of nursing care
What will the patient (or part of the patient) do to resolve or lessen the
problem identified in the nursing diagnosis?
By when will this be accomplished?
Patient Goals are directly related to the patient’s problem as stated in the
nursing diagnosis:
One goal should describe resolution of the problem
Additional goals should describe steps that contribute to problem
resolution
Patient Goals can be long term or short term
Patient Goals are:
Focused on the patient
Clear and Concise
Observable, Measurable, Realistic: how much? how far? how long? how
well?
Written with a specific time frame: by when should the goal be
accomplished?
Determined by the nurse and the patient
Mr. H. will perform entire bath unassisted by 4-4-11
Nursing Orders
Describe what the nurse will do to help the patient achieve the goals.
Nursing Orders must:
Focus on nursing actions
Describe when and how the nurse will perform nursing actions
Include the date & be signed by the nurse 3/30/11
The nurse will assist Mr. H. with bathing until he is able to bathe
independently. M.S.Macapaz, RN
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16. Planning also involves making plans to carry out the necessary interventions
to achieve those goals. The use of formal care plans or care maps and
protocols is highly advised.
For example: "after instruction insulin therapy, the patient will successfully
return demonstrate the ability to accurately draw up the insulin by Monday
and safely self inject by Tuesday."
Implementation
Implementation is setting your plans in motion and delegating
responsibilities for each step. Communication is essential to the nursing
process. All members of the health care team should be informed of the
patient's status and nursing diagnosis, the goals and the plans. They are
also responsible to report back to the RN all significant findings and to
document their observations and interventions as well as the patient's
response and outcomes.
Implement: Carry out the care plan
Reassess the patient
Validate that the care plan is accurate
Carry out nurses’ orders
Document on patient’s chart
Evaluation
The nursing process is an ongoing process. Evaluation involves not only
analyzing the success (or failure) of the current goals and interventions, but
examining the need for adjustments and changes as well. The evaluation
process incorporates all input from the entire health care team, including the
patient. Evaluation leads back to Assessment and the whole process begins
again.
Evaluate: Compare the patient’s current status with the stated Patient
Goals
Were the goals achieved? Why not?
Review the nursing process
Problem: “I can’t do anything for myself”
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17. Nursing Diagnosis: Self care deficit: bathing, related to joint stiffness
Patient Goal (resolution): Mr. H. will perform entire bath unassisted by 4-4-
11
Patient Goal (contributory): Mr. H. will bathe his upper body unassisted by
4-1-00.
Nursing order: 3/30/11 The nurse will assist Mr. H. with bathing until he is
able to bathe independently. M.S.Macapaz RN
Evaluation: Was Mr. H. able to bathe unassisted by 4-4-00?
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18. The Collaboration of the Nursing Process in properly assessing an Elderly
Client and how it affects the old person in performance of Activities of Daily
Living
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19. Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
 Activity intolerance
 Perceptual or cognitive impairment
 Musculoskeletal impairment
 Neuromuscular impairment
 Medical restrictions
 Prolonged bed rest
 Limited strength
 Pain or discomfort
 Depression or severe anxiety
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
 Ambulation: Walking
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
 Exercise Therapy: Ambulation
 Fall Precautions
Ongoing Assessment
Assess for impediments to mobility (see Related Factors in this care
plan).--Identifying the specific cause (e.g., chronic arthritis versus
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20. stroke versus chronic neurological disease) guides design of optimal
treatment plan.
Assess patient’s ability to perform ADLs effectively and safely on a
daily basis.
Suggested Code for Functional Level Classification
0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person for assistance, supervision, or
teaching
3 Requires help from another person and equipment or device
4 Is dependent, does not participate in activity--Restricted movement
affects the ability to perform most ADLs. Safety with ambulation is an
important concern.
Assess patient or caregiver’s knowledge of immobility and its
implications.--Even patients who are temporarily immobile are at risk
for effects of immobility such as skin breakdown, muscle weakness,
thrombophlebitis, constipation, pneumonia, and depression.
Assess for developing thrombophlebitis (e.g., calf pain, Homans’ sign,
redness, localized swelling, and rise in temperature).--Bed rest or
immobility promote clot formation.
Assess skin integrity. Check for signs of redness, tissue ischemia
(especially over ears, shoulders, elbows, sacrum, hips, heels, ankles,
and toes).
Monitor input and output record and nutritional pattern. Assess
nutritional needs as they relate to immobility (e.g., possible
hypocalcemia, negative nitrogen balance).--Pressure sores develop
more quickly in patients with a nutritional deficit. Proper nutrition also
provides needed energy for participating in an exercise or
rehabilitative program.
Assess elimination status (e.g., usual pattern, present patterns, signs
of constipation).--Immobility promotes constipation.
Assess emotional response to disability or limitation.
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21. Evaluate need for home assistance (e.g., physical therapy, visiting
nurse).
Evaluate need for assistive devices.--Proper use of wheelchairs, canes,
transfer bars, and other assistance can promote activity and reduce
danger of falls.
Evaluate the safety of the immediate environment.--Obstacles such as
throw rugs, children’s toys, and pets can further impede one’s ability
to ambulate safely.
Therapeutic Interventions
Encourage and facilitate early ambulation and other ADLs when
possible. Assist with each initial change: dangling, sitting in chair,
ambulation.--The longer the patient remains immobile the greater the
level of debilitation that will occur.
Facilitate transfer training by using appropriate assistance of persons
or devices when transferring patients to bed, chair, or stretcher.
Encourage appropriate use of assistive devices in the home setting.--
Mobility aids can increase level of mobility.
Provide positive reinforcement during activity.--Patients may be
reluctant to move or initiate new activity due to a fear of falling.
Allow patient to perform tasks at his or her own rate. Do not rush
patient. Encourage independent activity as able and safe.--Hospital
workers and family caregivers are often in a hurry and do more for
patients than needed, thereby slowing the patient’s recovery and
reducing his or her self-esteem.
Keep side rails up and bed in low position.--This promotes a safe
environment.
Turn and position every 2 hours or as needed.--This optimizes
circulation to all tissues and relieves pressure.
Maintain limbs in functional alignment (e.g., with pillows, sandbags,
wedges, or prefabricated splints). This prevents footdrop and/or
excessive plantar flexion or tightness. Support feet in dorsiflexed
position.
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22. Use bed cradle. This keeps heavy bed linens off feet.
Perform passive or active assistive ROM exercises to all extremities.--
Exercise promotes increased venous return, prevents stiffness, and
maintains muscle strength and endurance.
Promote resistance training services.--Research supports that strength
training and other forms of exercise in older adults can preserve the
ability to maintain independent living status and reduce risk of falling.
Turn patient to prone or semiprone position once daily unless
contraindicated.--This drains bronchial tree.
Use prophylactic antipressure devices as appropriate.--This prevents
tissue breakdown.
Clean, dry, and moisturize skin as needed.
Encourage coughing and deep-breathing exercises. These prevent
buildup of secretions.
Use suction as needed.
Use incentive spirometer. This increases lung expansion.
Decreased chest excursions and stasis of secretions are
associated with immobility.
Encourage liquid intake of 2000 to 3000 ml/day unless
contraindicated.--Liquids optimize hydration status and prevent
hardening of stool.
Teach energy-saving techniques.--These optimize patient’s limited
reserves.
Assist patient in accepting limitations. Emphasize abilities.
Education/Continuity of Care
Explain progressive activity to patient. Help patient or caregivers to
establish reasonable and obtainable goals.
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23. Instruct patient or caregivers regarding hazards of immobility.
Emphasize importance of measures such as position change, ROM,
coughing, and exercises.
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