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Nursing Process. Roy, C. & Andrews, H.A. (1999). The Roy Adaptation Model. (2nd. ed.). Norwalk, Conn: Appleton & Lange. Chapter 3. Assess of behavior Assessment of stimuli Nursing diagnosis. Goal setting Intervention Evaluation. Nursing Process. FIRST LEVEL ASSESSMENT.
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Nursing Process Roy, C. & Andrews, H.A. (1999). The Roy Adaptation Model. (2nd. ed.). Norwalk, Conn: Appleton & Lange. Chapter 3
Assess of behavior Assessment of stimuli Nursing diagnosis Goal setting Intervention Evaluation Nursing Process
FIRST LEVEL ASSESSMENT • Gather info in each mode • Behaviors: Internal, External, Verbal, Nonverbal
FIRST LEVEL ASSESSMENT • Objective • Subjective
FIRST LEVEL ASSESSMENT • Nurse uses skills observation, measurement, and interviewing.
FIRST LEVEL ASSESSMENT • Assess behavior, compare to criteria, identify strengths and strains of coping process. • Make judgment
FIRST LEVEL ASSESSMENT • Adaptation difficulty indicated by regulator activity with cognator ineffectiveness
Pronounced Regulator ActivityExamples: • Increased heart rate or B/P • Tension • Loss of appetite • Increase in serum cortisol.
Cognator Ineffectiveness Examples • Faulty perception/information processing • Ineffective learning • Poor Judgment • Inappropriate Affect
Adaptive/To be Supported/Ineffective • Adaptive • Ineffective • Adaptive To Be Supported (TU category)Adaptive behavior that needs support to continue or almost adaptive but needs increase or decrease to be adaptive
Second Level Assessment • Stimuli: Provokes a response, internal or external, environment
Second Level Assessment • Focal • Contextual • Residual
Common Stimuli • Culture • Family • Developmental Stage • Lack of integrity of function • Environmental Setting
Nursing Diagnosis • Statement of behaviors within one mode with their most relevant stimuli orIneffective behavior related to focal stimulus USE THIS METHOD ONLY FOR NSG 1012
Nursing Diagnosis • Summary label for behaviors in one mode with relevant stimuli • A label that summaries a behavioral pattern when more than one mode is being affected by the same stimuli
Goals • Goals of nursing to maintain and enhance adaptive behavior and to change ineffective behavior to adaptive
Goals • Specific goals--use client behavior as the focus • Realistic • Measurable
Goals • Identifies behavior • Change expected • Time frame
Define List Name Recognize Identify State Compare Plan Describe Explain Cognitive Verbs
Express Share Verbalize Reply Choose Value Exhibit Demonstrate Follow Select Affective Verbs
Demonstrate Use Measure Perform Record Plan Write Walk Drink Follow Psychomotor Verbs
Interventions • Nurse manipulates focal and contextual stimuli--altering, increasing, decreasing, removing, or maintaining. • Validate residual stimuli
Evaluation • Judging the effectiveness of the intervention in relation to the person’s behavior. • Use observation, measurement and interview methods.
Evaluation • Was client goal met • NOT was nursing interventions done. • May need to modify goal and/or interventions
Goal Example • The client will state causative factors and methods of preventing anginal attacks, in one week. • Who, will do, what
Evaluation Example • In one week, the nurse will ask the client causative factors and methods of preventing anginal attacks and the client will list most the factors and methods.
