Saturday, March 23, 2013

Nursing Care Plan for Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder is characterized by recurrrent obsession (intruitive images,impulses and though) and compulsion (repetitive behaviour in response to an obsession.

The obsession and compulsion can cause intense stress and impairement of functioning. Fear of losing control, fear of losing the self esteem, overly conscientious, perfectionistic, have trouble to being spontaneously and filled with self-doubt are common experiences by client. Frequently the client will use defence mechanisms of denial, reaction formation, isolation and undoing.

Contributing factors client with obsessive compulsive are

likely because childhood trauma, multiple stressors, lack of role model to teach coping skills and brain lesions. Common obsessions are self doubt, germs and illness with common compulsions like checking, washing, avoiding and counting.

Assesment finding for obsessive-compulsive disorder;
  • Social impairment
  • Obsessive thought (repetitive worries, repeating and counting images or words)
  • Compulsive behaviour (repetitive activity, like touching, counting, doing or undoing)
Treatment for obsessive compulsive disorder;
  • Behavioral therapy and individual therapy
  • Monoamino oxidase inhibitor (nardil, parnate)
  • Benzodiazepine (ativan, klonopin)
  • Trycyclic antidepresant (norpramin, tofranil)
  • Selective serotonin reuptake inhibitor (paxil)
Nursing diagnoses for obsessive compulsive disorder;
  • Anxiety
  • Chronic low self-esteem
  • Ineffective individual coping
Planning and goal for obsessive compulsive disorder, the client will;
  • Learn coping strategis to decrease obsessive thinking and compulsions
  • Verbalize sign and symptoms of increasing anxiety
  • Develop and maintain an enhanced self esteem and increased sense of the competency
Implementation for obsessive compulsive disorder;
  • Encourage to express the feeling, in order to decrease the level of stress
  • Help the client to assess how the compulsive behavior affect his functioning
  • Help the client to engage in anticipatory planning, to feel in control of potentially anxiety-producing situations
  • Help the client to identify expectation of self an others
  • Instruct the client to keep a daily journal of thought, feeling and actions to identify immediately the onset of his obsessive compulsive
  • Work with client to develop appropiate coping skills
  • Encourage the client to identify situations that produce anxiety and precipitate obsessive compulsive behavior
Evaluation for obsessive compulsive disorder, the client will;
  • Identifies situations and activities that may precipitate obsessive compulsive
  • Able to verbalize thoughts openly and has realistic expectation self and others
  • Demonstrate a decreased reliance on negative coping mechanism such ritual, and will demonstrate the new coping strategies

Friday, March 22, 2013

How to Make a Scientific Poster

Be Wise When Choosing Wisely-MedScape

Introduction

   A scientific poster is an illustrated abstract of research that is displayed at meetings and conferences. A poster is a good way of presenting your information because it can reach a large audience, including people who might not be in your field. It is also a useful step towards publishing your research. Some conferences publish poster abstracts, which then count as publications in their own right.
   A successful poster captures the viewer’s attention and communicates the key points clearly and succinctly. One author reviewed 142 posters at a national meeting and found that 33% were cluttered or sloppy, 22% had fonts that were too small to be easily read, and 38% had research objectives that could not be located in a one minute review. Avoiding these mistakes is important to ensure your poster has a positive impact.

Where Do I Start?
   If you have completed a project, you will need to research the right meeting or conference to submit your abstract to, if you have not done so already. You might need to ask your supervisor or consultants in the field of your topic for information about relevant conferences at which you can present your work.
   You will usually be asked to submit an abstract online. The submission guidelines on the website should guide you on how to do this, as well as provide other valuable information such as formatting instructions and deadlines. Your abstract should state why your work is important, the specific objective or objectives, a brief but clear explanation of the methods, a summary of the main results, and the conclusions. I would not recommend adding the abstract to your poster unless this was stated in the conference guidelines because a poster is already a succinct description of your work; use it as an outline for your poster.
   Follow submission guidelines carefully because they differ among meetings. Start putting your poster together early to avoid the stress of last minute printing queues.

Designing the Poster
   According to the 10-10 rule, attendees spend only 10 seconds scanning posters as they stroll by from a distance of 10 feet.[2] Your poster should be well laid out, with a visual representation preferable to large chunks of text. Diagrams, tables, and photographs aid readability and attract people. Guide the viewers’s eyes from one frame to another in a logical fashion from beginning to end. Set up this pattern via a columnar format, so the viewer reads vertically first, from top to bottom, moving across the columns from left to right.

Text and Font
   It’s important to make the writing in your poster clear and easily understandable—remember that readers won’t give it much time. Use plain language and write in the active voice (“We did this,” rather than, “This was done.”) Avoid jargon and acronyms. Use simple language and short sentences. Edit ruthlessly. If it’s not relevant to your message, remove it.
   Avoid using uppercase text for more than one sentence because it becomes difficult to read. Keep text to a minimum. Whenever possible, use bulleted text rather than blocks of sentences and leave blank space around the text and throughout the poster.
   Use sans serif fonts such as Arial or Helvetica, or fonts such as Times or Times New Roman, which are generally considered to help legibility for posters. If you want a different look, consider Baskerville, Century Schoolbook, or Palatino. The font should be consistent throughout the poster and text should be legible 5 to 6 feet away. Use at least 85 point for the title, 56 point for the authors’ names, 36-44 point for subheadings, 24-34 point for text in the main body, and 18 point for captions.

Colour
   Use colour to attract attention, organise, and emphasise, but don’t overdo it. Use a maximum of two or three colours and consider people who have problems differentiating colours. One of the most common forms of colour blindness is an inability to tell green from red. Black type on a white background is standard practice, and patterned backgrounds should be used with caution.

Software
   Microsoft Powerpoint is easy to use and most people have access to it. Lay your poster out on a single slide. There are several other programs that can be used to design a poster, such as QuarkXPress, InDesign LaTeX and Scribus (a free download).These programs allow control of text wrapping around images and text flow among associated text blocks. One piece of software specifically targets the scientific poster market: PosterGenius.

Layout
   The title is most effective when it refers to its overall “take home message.” It should include the scope of the investigation, the study design, and the goal. In general the title should highlight your subject matter, but need not state all your conclusions. It should be about 10-12 words long and the font size should be large, 85 point. If things don’t fit, shorten the title; don’t reduce the typesize. And remember, titles that are in uppercase lettering are hard to read.
   The author who was involved most is listed first and the most senior author is listed last. Some posters will have the addresses of the institution to which the authors are affiliated.
   Break up your poster into sections, much like a scientific article. Label all the sections with titles: introduction, methods, results, conclusion, references, and acknowledgements.

Some detail
   Introduction: Write a few brief sentences to identify what is known about the topic, why you did the research, and the aim or aims of your work. This section can also include your hypotheses, which usually go at the end of the introduction.
   Methods: Explain what you did. For a study involving people, you should explicitly state whether the study was retrospective or prospective, and whether there was randomisation. Your data analysis and statistics used should also be described, including what P value you chose to indicate significant differences.
   Results: Select the most important results that support your message. Images and graphs say more than words. Tables and figures should be used to illustrate your study’s results, and they should be clear, self explanatory, and uncomplicated. They should be numbered, and referred to by number in the text—for example, “see figure 1”). Make sure figures have a title and a legend. Keep text to a minimum. Graphs and charts should have an appropriate scale and labelled axes. Orient text for graphs horizontally, including labels for vertical axes.
   Conclusion: Write short, clear statements explaining the main outcomes of the study and why your results are interesting or important. You can also suggest future directions for research that build on your current study.
   References: References should be limited to five, and the font size should be smaller than the poster text. Check on the organisation’s website for formatting instructions.
   Acknowledgements: Write up a short acknowledgement section to thank those who helped you to complete your research, such as your research group or funding source. You should disclose any conflicts of interests that might exist.

Practicalities
   Find out if the library based at your hospital site has the facilities to print your poster. Alternatively, you could upload your poster onto an internet site that will print and deliver the poster to you. Some conferences print posters on site so that you can collect them when you arrive.
   If you do upload your poster online, make sure you set the dimensions on the file to match those in the conference guidelines. If you are travelling with your poster, make sure it is packaged in a plastic tube to protect the paper from getting damaged. If you are travelling by air, you should inform the staff at the check-in desk that you have extra hand luggage so that you do not have any problems taking your poster onto the aircraft.

Presenting the Poster
   When someone stops to look, you should be able to introduce your poster in 10 seconds and that person should be able to assimilate all of the information and discuss it with you in 10 minutes. Some conferences will allocate time for you to present your poster to a small group of colleagues who also have posters in the same category as you. Check the conference website for details.
   Place a note on your poster board listing the times you will be available by the board for those who would like to discuss the poster outside the formal presentation time. Prepare mini sized poster handouts or handouts of the key points for participants to take away. Make it easy for a conference attendee to contact you afterwards. Have your contact details clearly displayed on your poster and handouts. Posters are a great way to gain feedback from your colleagues and for networking and collaborating, and this should support you in writing up your research for publication.

Tuesday, March 12, 2013

Annoying Hospital Politics

Brian Fishman, DO, General Practice, 06:45PM Dec 21, 2012 (Medscape)

   A couple of weeks ago, I saw a young girl in the ER who came in with her husband to be evaluated for postpartum psychosis. We tend to get a lot of psychiatric patients coming through our emergency department because we have an entire floor (roughly half of our hospital) devoted to inpatient psychiatric care. This girl had a history of bipolar disorder and was 9 weeks postpartum. She was extremely depressed and hearing voices. She is normally very compliant with her medications and has a good support structure. Her husband was very attentive, and it was obvious they both cared a lot about each other. Unfortunately, that's more than I can say for a lot of the patients who come through the ER, psychiatric or otherwise. After she was evaluated, the psychiatric team adjusted her medications, and she went home.
   A couple of days ago, she came back to the ER. This time, her psychiatrist sent her in to be evaluated for neuroleptic malignant syndrome. We were a bit skeptical of the diagnosis, because it's so rare, but we did have a patient with NMS a few months back who used up our hospital's entire supply of dantrolene. Her psychiatric symptoms from her previous visit had resolved completely, but she was complaining of muscle rigidity and tremors (that were obvious on exam), skin burning, and tongue stiffness (that was obvious from a notable change in her speech from her last visit). Apparently, her CK level was elevated earlier that morning, but we didn't have the results from her doctor to confirm.
   We decided to consult with a neurologist about whether he thought she required admission to a medical floor. He was skeptical of the NMS diagnosis, but he recommended she come in for observation based on the severity of her symptoms. It's the policy of our hospital that any patient without a primary care physician be admitted under the care of one of the community physicians rather than to the hospitalist service. That way, they have a new doctor to follow up with on discharge. The hospitalist, however, just happened to be walking by to see another patient. I mentioned the case to him because I thought he might be interested. He took care of the patient with NMS a few months ago and helped me prepare the grand rounds presentation. He stopped in to see her, and he came back with a diagnosis of tardive dyskinesia. He recommended she go home with heavy hydration if her CK came back normal, but the community physican had already accepted the admission.
   A few minutes later, when he found out that she was being admitted, he got upset. He came back into the ER and had a few words with me and my attending. Since he didn't feel the patient needed to come in, he assumed that we'd gone over his head to find a different doctor to handle the admission. In reality, the admission was done before he was even aware of the patient, but there was obviously some miscommunication.
   The next morning, after some aggressive hydration and symptomatic treatment, our patient was doing much better and was eager to get home to her newborn. The attending who'd yelled at me the previous day approached me in the ER and apologized for yelling, saying that the way he reacted was unprofessional. I appreciated that he made a point of apologizing, and it was probably one of the first times I felt an attending was addressing me as a colleague rather than a student or intern.

Therapeutic Dialogue
(Medscape)


Introduction
   'You're a doctor. Can I ask you a medical question?' It isn't easy to refuse when someone asks, so I said yes and waited to hear what would follow. The questioner on this occasion was a Greek builder called Costas. We were standing in my back garden, where Costas and his team of eastern European labourers were doing some work. He said the question was a very simple one—at least in his view: 'What are the chances of dying after a stroke?' I took a deep breath and asked him to tell me more.
   The story, as it turned out, wasn't related to Costas himself. It concerned one of his labourers, whose father was in hospital in Rumania and being kept on strict bed rest following a stroke. The doctors had told his family he would almost certainly die—a 99% chance of doing so. However, when I asked how severe the stroke was, Costas said the patient could apparently walk and talk normally. The only problem seemed to be partial vision in one eye. Cautiously, I explained to Costas that this didn't sound such a grave picture. In this country the doctors would get him out of bed and mobilise him quickly. They would regard his general outlook as pretty good. Costas beamed at me when I said this and he summoned his Rumanian worker over to join us. 'I told you so!' he said triumphantly. 'This doctor says your father will live! Your family must ignore the doctors and get him out of bed!' I squirmed at his version of what I had said, but I couldn't do much about it. I tried to have a conversation with the Rumanianman himself, but his English was poor. He understood enough to confirm the story Costas had told, but not enough for me to add any notes of caution to his boss's reassurance.
   Later, I shared some concerns with Costas. Maybe we didn't know the full history, I explained. Perhaps there were other problems the doctors in Bucharest were worried about. Besides, I told Costas, traditions of treatment differ in other countries. So do medical outcomes. Costas would hear none of this. His own mother had died of a stroke, he told me, and she did so in exactly the same circumstances. 'They made her stay in bed', he explained. 'They kept feeding her. Day in and day out. She got bigger and bigger. I begged the doctors to give her an enema to get it all out. They refused. Then she exploded. I could kill them!'

Challenges of Interpretation
   On a superficial level, this encounter was just about as suboptimal as any consultation can get. It was unplanned, in a fairly public setting. It involved problems of translation and a passionately biased middleman, not to mention a patient and doctors 2000 km away. Yet I want to suggest this conversation wasn't a particularly aberrant one. In some ways, you could say it was entirely typical of what goes on in encounters between doctors and patients. The only difference in this instance was that the challenges of interpretation were obvious rather than concealed.
   The encounter reminded me of a wonderful book about medical ethics originally written in the 1980s by the Yale physician and law professor Jay Katz, and called The Silent World of Doctor and Patient.[1] Katz discusses the difficulties of communication in medicine and he writes as follows: 'Even in their most intimate relationships, human beings remain strangers to one another. One can only understand another to a limited extent. But the problem runs even deeper. One can only understand oneself to a limited extent. The latter impediment powerfully reinforces the former, making it even more difficult to know another. Physicians and patients are not exempt from this human tragedy. Its pervasive impact on all human encounters contradicts one of the most basic and revered professional dogmas: that doctors can be totally trusted because they act only 'in their patients' best interests'. This dogma only compounds the tragedy by assuming an identity of interests and brushing aside the need to clarify differences in expectations and objectives through conversation.'
   According to Katz, all encounters between doctors and patients involve immense difficulties of mutual interpretation. These aren't just the consequences of overt differences of culture and language such as the ones in my conversation with Costas. They are intrinsic to human psychology. As Katz says, we listen to each other selectively, if at all. We listen to ourselves selectively, if at all. When we interact, we forget both these facts. We are overtaken by the bland and totally wrong assumption that effective communication is easy. It isn't. It requires constant, focused effort


Overarching Idea
   The Silent World of Doctor and Patient sets out the predicament that all doctors and patients face, and it offers ethical principles for dealing with this. However, it doesn't give specific advice about the skills needed to bridge the gulf between doctors and patients. Fortunately, a great deal of work has been done on this since Katz wrote his book. In my view, the most helpful guidance falls under the heading of 'therapeutic dialogue'. Therapeutic dialogue isn't a particular school of thought or a method of training. It's an overarching idea held by a range of clinicians who share the view that good and ethical communication with patients is invariably hard work, but possible with the right skills.
   One of the most eloquent proponents of the approach is the Italian psychiatrist Paolo Bertrando.[2] He describes how he uses a wide range of conversational techniques in his work with families and individuals so that he can enter and share their worlds. These techniques include questions that are 'essential but seem silly or too naïve, like children's questions'. He talks about applying 'amiable impertinence', venturing outside the limits of usual politeness while still remaining within the boundaries of professionalism. He describes how he tries to be transparent in explaining his thinking processes to patients, how he judges when to offer some self-disclosure and how he allows metaphor to emerge in his conversations. Bertrando's writing isn't a do-it-yourself guide to therapeutic dialogue. Instead he lays out the kind of territory that everyone who wants to communicate with patients at more than a superficial level needs to explore.
   He gives a compelling account of how we create meaning during conversations with patients: 'I cannot fully choose any meaning, because my meanings—and, above all, the meaning my interlocutors give to what I am saying and doing—are shaped by the context we are embedded in. Of course, this is also true of the meanings I give to my interlocutor's words and actions. Treatment, in this view, is a continuous process of negotiation of meanings, where it is impossible to reach an end point but, rather, any negotiation opens new contexts that create new meanings, and so on. Both therapists and clients are extremely active in this process, as indeed are other persons and institutions not directly involved in the therapeutic dialogue but involved in generating contexts: all those who contribute to the significant system that surrounds—and shapes, and participates in—the therapeutic dialogue.' To put it another way, there were more people present in my back garden conversation about strokes than Costas, the Rumanian labourer and me. We were part of a vast conversational drama played out by uncountable Greek, eastern European and British speakers, all struggling to make sense of each others' stories, to the best of our ability.

Despite significant progress on development goals, many challenges remain – UN official

Dylan Lowthian

   27 February 2013 – While countries have made remarkable progress in the achievement of some of the eight anti-poverty targets known as the Millennium Development Goals (MDGs), there are still areas where too little has occurred since nations first committed to work on these issues in 2000, a United Nations official said today.
   “There has undoubtedly been progress on many of the indicators targeted by the MDGs,” the Administrator of the UN Development Programme (UNDP), Helen Clark, told participants at the 2013 global conference “Making the MDGs work” in Bogotá, Colombia.
   Miss Clark warned, however, that “there are also the goals and targets where too little progress has been made – for example on maternal mortality reduction, universal access to reproductive health, and improved sanitation. We must learn from these shortcomings too.”
   The eight MDGs set specific targets on poverty alleviation, education, gender equality, child and maternal health, environmental stability, HIV/AIDS reduction, and a ‘Global Partnership for Development.’
   Miss Clark said that the proportion of people living in extreme poverty – on less than $1.25 per day – is now half of what it was in 1990. Progress has also been registered in increasing access to improved water sources and meeting the goal of providing universal primary school access for all children.
   In addition, low-income countries have made great strides since countries began to focus on the MDGs, and in particular, considerable progress has been made on goal six, which seeks to stop the spread and reverse diseases such as HIV/AIDS, malaria and tuberculosis.
   In spite of these achievements, Miss Clark underlined that countries should focus on ways to address the remaining challenges, as well as the disparities within and across countries in the achievement of the MDGs.
   “Previous assessments of MDG progress have shown that national ownership and local champions are indispensable for MDG success,” Miss Clark said, adding that the post-2015 development agenda will need to incorporate the lessons from the MDGs.
   “Overall the next global development agenda needs to address the significant problem of inequality which has stood in the way of reaching the MDG targets,” she said.
   Miss Clark noted that to accelerate progress in the last 1,000 days before the 2015 deadline, 45 countries are now using the MDG Acceleration Framework (MAF) developed by UNDP. The framework identifies pragmatic solutions to speed up progress on lagging MDGs, and to reduce disparities in progress to date.
   The MAF works by bringing a wide range of stakeholders together to tackle the obstacles to progress. It draws on existing evidence, policies, and strategies to devise concrete and prioritized country action plans.

Sunday, March 10, 2013

Nursing Care Plan for Bipolar Disorder

Also known as manic-depression is a severe disturbance in affect, manifested by episodes of extreme sadness alternating with episode euphoria. There are two common patterns of bipolar disorder;
bipolar I, in which depressive episode alternate with full manic episodes.
bipolar II, characterized by recurrent depressive episodes and occasional with manic episodes.

Assesment findings for bipolar disorder

    During periods of mania;

  • bizarre and eccentric appereance
  • difficulty concentration, flight of idea, delusion of grandeur and impaired judgment
  • decreased sleep
  • motor agitation
  • feeling of grandiosity
  • rapid jumbled speech
  • deteriorated physical appearance
  • euphoria, hostility
  • dry mouth, tremors, tachycardia, labored respirations
  • inflated sense of self-worth
  • increased social contact
  • increased libido
  • lack of inhibition, recklessness

  • During periods of depression;

  • anorexia and weight loss, constipation
  • altered sleep patterns
  • decreased alertness, difficulty thinking logically
  • confusion and indecisiveness
  • guilt, helplessness, sadness and crying
  • amenorrhea
  • lack of motivation, low self-esteem, poor self-hygiene
  • irritability, pessimism
  • impotence and lack of interest in sex
  • inability to experience pleasure


Treatment for bipolar disorder
  • Anticonvulsant agent : carbamazepine (tegretol), divalproex sodium.
  • Selective serotonin reuptake inhibitor : paroxetine
  • Antimanic agent : lithium carbonate(eskalith), lithium citrate(cibalith-S)
  • Individual therapy and family therapy
  • Electroconvulsive therapy if drug therapy fails
Nursing diagnoses for bipolar disorder
  • Disturbed thought processes
  • Impaired social interaction
  • Risk for injury
  • Disturbed sleep pattern
Planning and goal for bipolar disorder, the client will;
  • demonstrate a stable mood and practice self-care activities
  • control thought processes
  • demonstrate a normal sleep pattern
  • interact adequately with others
  • not harm himself
Nursing implementation for bipolar disorder
    During manic phase;

  • decrease environmental stimuli, to promote relaxation and enable to sleep
  • monitor drug level, especially lithium
  • ensure safe environment to protect the client
  • define and explain acceptable behaviors and then set limits
  • if a mood swing to depression, implement suicide precaution for client
  • channel the client's energy in one direction and pace activities, to decrease client's energy expenditure, prevent overstimulation and have soothing effect

  • During depressive phase;

  • assess the risk of suicide and formulate a safety contract with client
  • assess the level and intensity if client's depression to obtain baseline information
  • ensure a safe environment to client to protect from self-inflicted harm
  • encourage the client to identify current problems and stressors, so that can begin with therapeutic treatment
  • select activities that ensure success and accomplishment to increase self esteem
  • spend time with the client, evens if he's too depressed to talk, in order to enhance therapeutic relationship
  • help the client to modify negative expectations and think more positively
  • promote opportunities for increased involvement in activities through a structures and daily program
  • observe the client for medication compliance and adverse effect
Evaluation for bipolar disorder, the client ;
  • doesn't harm himself or others
  • maintains adequate on medication and nutrition
  • sleeps throught the night
  • expresses understanding of the illness and states how to obtain assistance or support from others
  • engages in goal-directed activity and no longer exhibits disturbed thinking

Friday, March 1, 2013

Nursing Process

From Wikipedia, the free encyclopedia

   The nursing process is a modified scientific method.Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958.It should not be confused with nursing theories or Health informatics. The diagnosis phase was added later.
   The nursing process uses clinical judgement to strike a balance of epistomology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing.Nursing knowledge has embraced pluralism since the 1970s
   Some authors refer to a mind map or abductive reasoning as a potential alternative strategy for organizing care.Intuition plays a part for experienced nurses.

Assessing phase
Main article: Nursing assessment
   The nurse completes an holistic nursing assessment of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective data and objective data using a nursing framework, such as Marjory Gordon's functional health patterns.

Models for data collection
   Nursing assessments provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessment framework is best practice.

Methods
   - Client Interview
   - Physical Examination
   - Obtaining a health history (including dietary data)
   - Family history/report
   - Diagnostic Data
   - Observation

Diagnosing phase
Main article: Nursing diagnosis
   Nursing diagnoses represent the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patient's assessment. Multiple nursing diagnoses may be made for one client.

Planning phase
Main article: Nursing care plan
   In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. When there are multiple nursing diagnoses to be addressed, the nurse prioritizes which diagnoses will receive the most attention first according to their severity and potential for causing more serious harm. For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome. A common method of formulating the expected outcomes is to use the evidence-based Nursing Outcomes Classification to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan

Implementing phase
   The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established. Delegated tasks and the monitoring of them is included here as well.

Evaluating phase
   The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely, if the goal has been achieved then the care can cease. New problems may be identified at this stage, and thus the process will start all over again.

Characteristics
   The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well.
   - Cyclic and dynamic
   - Goal directed and client centered
   - Interpersonal and collaborative
   - Universally applicable
   - Systematic
   The entire process is recorded or documented in order to inform all members of the health care team.

Variations and documentation
   The PIE method is a system for documenting actions, especially in the field of nursing. The name comes from the acroynm PIE meaning Problem, Intervention, Evaluation


NANDA International Leg

NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses. In 2002, NANDA relaunched as NANDA International in response to the broadening scope of its membership. NANDA International published Nursing Diagnosis quarterly, which became the International Journal of Nursing Knowledge in 2002. Other related international associations are ACENDIO (Europe), AENTDE (Spanish language), AFEDI (French language) and JSND (Japan). The Membership Network Groups foster collaboration among NANDA-I members in countries (Brazil, Colombia, Ecuador, Mexico and Nigeria-Ghana) and for languages: the German Language Group (Germany, Austria, Switserland) and the Dutch Language Group (Netherlands and Belgium)

History
   In 1973, Kristine Gebbie and Mary Ann Lavin called the First National Conference on the Classification of Nursing Diagnoses. It was held in St. Louis, Missouri. Attendees produced a beginning classification, an alphabetized list of nursing diagnoses. The conference also created three structures: A National Clearinghouse for Nursing Diagnoses, located at Saint Louis University and led by Ann Becker; a Nursing Diagnosis Newsletter, edited by Anne Perry; and a National Conference Group to standardize nursing terminology and led by Marjory Gordon. In 1982 NANDA was formed. It included members from the United States and Canada.
   NANDA developed a nursing classification to organize nursing diagnoses into different categories. Although the taxonomy was revised to accommodate new diagnoses, in 1994 it became apparent that an overhaul was needed. In 2002 Taxonomy II, which was a revised version of Gordon's functional health patterns, was released.
   In 2002, NANDA became NANDA International in response to requests from its growing base of membership from outside North America. The acronym of NANDA was retained in the name because of the name recognition, but it is no longer merely "North American", and in fact boasts members from 32 countries as of 2010.


Lihat juga
NANDA
Taxonomy II : Domain
Taxonomy II : Domains, Diagnosis
 Nursing Outcome Classification
Nursing Interventions Classification

Why Are MDs Burning Out in Record Numbers?

(Medscape and Dr. Paul Griner)

   Physicians who feel a sense of burnout, take heart — you're not alone. A recent study of 7288 doctors published in the Archives of Internal Medicine showed that nearly one half — 46% — reported at least 1 symptom of burnout, as measured by the Maslach Burnout Inventory.
   According to physician Paul Griner, MD, author of The Power of Patient Stories: Learning Moments in Medicine, the figure is especially alarming considering that burnout can lead to inadequate assessment of patients and misdiagnoses.
   Further, a recent study published in General Hospital Psychiatry suggested that job stress, coupled with inadequate treatment for mental illness, may account for the higher than average suicide rate among US physicians.
   In an interview with Medscape Medical News, Dr. Griner discussed the importance of identifying the clues of burnout, stepping back to regain a focus on the patient, and seeking the empathetic advice of a mentor who just may have been there once him- or herself.
   Dr. Griner, a professor emeritus of medicine at the University of Rochester School of Medicine and Dentistry, in New York, implemented mentorship programs at the Massachusetts General Hospital and more recently at Danbury Health Systems, in Connecticut. He has been a senior lecturer at Harvard Medical School and has served as president of a number of national medical organizations, including the American College of Physicians.

Medscape: What are some key signs that the everyday stress of clinical practice has crossed the line into a more risky realm of burnout?
   Dr. Griner: Some key signs of burnout for clinicians can include a lack of interest, chronic fatigue, and unprofessional behaviors with patients, such as lack of empathy, anger, impatience, and irritation. Some physicians with burnout may be in denial, while others may recognize they are under stress but attempt to hide it from family and colleagues.

Medscape: What are some of the most notable risks and consequences of physician burnout?
   Dr. Griner: Any or all of the characteristics of good patient care may be compromised when the physician experiences burnout. The most serious risk is that the physician may make an incorrect diagnosis or prescribe an inappropriate treatment, and there are potential consequences of burnout to the physician as well. He or she is at risk for serious depression, abuse of alcohol, use of habituating drugs, and family problems. Some physicians experiencing burnout may even make the decision to leave the field of medicine. This outcome is particularly disturbing given the investment in time and energy that the physician has made in the profession of medicine and the experience that is lost to future patients.

Medscape: The Archives of Internal Medicine study on burnout indicated that the specialties most at risk were family medicine, general internal medicine, and emergency medicine — what are the unique implications of burnout in these specialties?
   Dr. Griner: These are the physicians who are on the firing line of first contact with patients, and as such, they must be readily available. The brunt of paperwork, regulation, and hassle from health insurance companies falls upon these physicians and their staffs, and primary care physicians are less well paid than their subspecialty colleagues, yet they work longer hours. The combination of these factors helps explain why burnout is more common among these specialties.

Medscape: How is the risk for burnout unique to this generation of practitioners compared with others?
   Dr. Griner: Burnout is more frequent with this generation of physicians than their counterparts in eras gone by, for a number of reasons. For one thing, new medical knowledge and technology are advancing more quickly than most physicians can keep up with and utilize wisely.
   Further, physicians must process much more information about each patient than was the case among their peers in years past. In addition, many physicians are asked to see more patients in the same amount of time than their predecessors did.
   In many cases, the physician is not able to spend the time with any one patient that he or she feels is necessary. Realizing this can be extremely frustrating and demoralizing.

Medscape: Can you summarize some of the most important strategies for avoiding burnout?
   Dr. Griner: To begin with, in order to remain physically and mentally healthy, physicians should follow the advice they give their patients — eat a healthy diet, exercise, rest, take time with and enjoy their families. At the end of each day, reflect on what went well, who you helped, and what challenging diagnoses you made.
   Physicians need to nurture relationships and should avoid colleagues who are always negative. Associate as much as possible with those who remain upbeat.
   Retain the passion that brought you into medicine in the first place. For instance, steal some time from administrative meetings to share a fascinating patient story with your colleagues.
   Many physicians, particularly male physicians, are reluctant to share feelings. They find it easier to "stuff" their feelings even while recognizing that this tendency may not be healthy.
   Engaging in a 1-on-1 session with a trusted advisor or mentor can help physicians begin to understand how therapeutic it may be to share feelings, including feelings about patients and feelings about their lives in general.
   A recent article in the Journal of Physician Executives reported the results of a survey showing that as many as 25% of physicians would suggest a mentor to help reduce burnout. The ideal mentor is a good listener, is nonjudgmental, and is practical. He or she can give good advice on how to achieve a better balance among one's personal and professional life.
   Paying attention to what's going on in patients' lives can be very helpful in reducing burnout. The patient will be more empathetic. Knowledge of the psychological, social, and economic aspect of a patient's life helps the physician better understand the patient and leads to greater professional satisfaction.
   Physicians would do well to remember this comment by Sir William Osler, generally acknowledged as the greatest physician of his time: "The good physician knows the disease the patient has. The great physician knows the patient who has the disease."
   Physicians should participate actively in health reforms that return a greater level of control to their patients and themselves. Embracing the concept of team care is important. Moving from a philosophy of "I am responsible" or "I am in charge" to "We are responsible" or "We are in charge" is an important step.
   Supporting the concept of payment for quality instead of "the more you do, the more you get paid" is an equally important step. Reimbursement to physicians and hospitals is moving toward various forms of global payment, such as payment for an episode of illness or payment for the care of a patient for an entire year.
   Such payment arrangements will favor primary care physicians — those at greatest risk for burnout — by giving them greater control and by reducing paperwork and hassle.

Medscape: Can you share any personal experiences you have had with burnout — and how you responded to the situation?
   Dr. Griner: It's interesting that you should ask. I have experienced burnout, but it was very early in my career in hematology, in an era when most of the patients we saw had fatal disease.
   had Hodgkin's disease, for example, and the average life expectancy back then was only about 5 years. Today, at least 90% of patients with Hodgkin's are cured. Also, most patients with leukemia passed on within a few months, so there was a lot of mortality, and I had a constant concern of losing patients.
   suppose the most important lesson I learned from the experience was the importance of being able to share these feelings and frustrations with someone else, but I don't know if I ever had anyone that I felt comfortable opening up to about it. In many cases, I think I suffered needlessly because those were the days when you kept your feelings to yourself.

Medscape: What has been the response to the most recent mentoring program you implemented at Danbury Health Systems?
   Dr. Griner: The program was initially focused on primary care physicians as the target group, and we've now branched out into the subspecialties. Many physicians have come forward, and many of those have come back for additional sessions.
Very few physicians have an opportunity to spend an hour with a trusted advisor in a quiet setting, and the insights that can be gained through such an approach are amazing. In addition, being with a mentor doesn't engender a feeling of having failed — much of this is just talking to a wise senior person who has had a great deal of life experience, who is a good listener, who is nonjudgmental, is supportive, and has practical advice to give.

Medscape: How can physicians find out about mentorship programs available to them?
Dr. Griner: There is not a lot in the literature on the subject, but an interested physician should inquire with the administration of his or her hospital and ask if such a program is available. Such mentorship programs are often offered to residents at teaching hospitals but not as much for practicing physicians. But the more inquiries a hospital receives on the issue, the more likely they may be to realize this is something they can offer to their doctors.

Share

Twitter Delicious Facebook Digg Stumbleupon Favorites More