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UNIVERSITY of NORTH CAROLINA WILMINGTONSCHOOL of NURSINGFALL SEMESTER 2011OPT GUIDELINESREFERENCES: Faculty expect the students to read and use their textbook – Clinical Reasoning: The Art & Science of Critical & Creative Thinking to help complete each week’s OPT. Chapters 3, 5, and 7 provide students with detailed explanation and application of the OPT to the patient/client. These guidelines are just that - “guides” to completing your client’s OPT each week. In addition, you will need to use your Potter & Perry, Lewis, and Ackley & Ladwig textbooks for identifying appropriate interventions, rationales, and nursing diagnoses for your client each week. The NIC & NOC texts are useful as well for identifying specific interventions and outcomes appropriate for your client. These texts are available on reserve in Randall Library.All OPTs MUST be typed/word processed (no exceptions!) including the “Reasoning Web.”The following guidelines are here to assist you in the OPT development:Client in Context Story should include: Signs and symptomsPsychosocial, roles/relationship, coping/stress issues or any other that appliesMedical Diagnosis [Admitting Diagnosis]Labs pertinent to the diagnosisActive Hospital/LTC Medication Orders (list drug names only)This section should include only the physical exam that is pertinent to admitting medical or nursing diagnoses, not a head-to-toe exam unless it was absolutely necessary for this particular client’s story. The “client story” should tell the story of “how/why the client got there” Example: Mr. X is a 45 year-old male admitted 11/2 with R/O MI. Admitted through ED with C/O chest pain (5/10) x 24 hours unrelieved with rest. He has no PMH to date of significance. Presently, his skin is warm, dry, and pink. Heart sounds are normal S1 S2 with no auscultated murmurs, or irregular beats. Pulse rate is 80 and regular. BP ranging 120-130s/ 70s-80s. No c/o of chest pain, SOB. Tolerating ADLs without dyspnea and/or chest discomfort. He presently appears in NAD and is awaiting a cardiac cath to evaluate for CAD.He is married with 2 children and is a partner in a local law firm. He is normally very active participating in the firm’s softball team and runs every morning.1Reasoning WebMust have 9 nursing diagnoses* from these domains --- physiologic, behavior/psychosocial, safety, family --- may also use community and health systems if applicable. [*It is possible that you may have a client where achieving 9 nursing diagnoses is difficult, however you should be able to determine a minimum of 5-6 for all hospitalized clients.] Use your Ackley & Ladwig (9th ed.) Section II (p.13-115) textbook to identify which nursing diagnoses are related to specific client symptoms &/or medical diagnoses. Check “Nursing Diagnoses Arranged by Gordon’s Functional Health Patterns” beginning on p. 908 in Ackley & Ladwig text. You may use more than one nursing diagnosis per health pattern. However, you should avoid using similar nursing diagnoses. For example “Risk for Aspiration”- dysphagia and “Impaired Swallowing”- aspiration (same health pattern (Use of duplicate diagnosis will affect the number of lines drawn in the web and may skew the results.)Students must provide supporting data for all the chosen nursing diagnoses in the Reasoning Web. Data must be specific. For example: Imbalanced nutrition: Less than body requirements should have clients BMI, nutritional lab values, % of meals consumed, etc. The data should clearly support the specific reasons for this client having this diagnosis.Use only NANDA-I approved nursing diagnoses as noted on the inside back cover of Ackley & Ladwig textbook. Cluster the cues according to Nursing Diagnosis groups and decide which ones from each group are most appropriate. Check the definition of the nursing diagnosis to be sure you have chosen correctly. In addition, be sure to review the defining characteristics listed for the nursing diagnosis to assure your choice matches your CIC Story.Cue Logic: This comes directly from the circle in the web. In other words, list all nursing diagnoses identified in the web.Consider Maslow’s hierarchy (see p. 905 in A&L) to determine which diagnosis is most important. You can also use Erikson’s if it applies.Determine the keystone issue by counting the number of arrows to and from the ‘bubbles’. The nursing diagnosis that has the most arrows is your keystone issue provided it is not a ‘risk for’ diagnosis. If it is, use the next highest diagnosis.As you count the number of arrows, please put the number of connections in the bubbles.Keystone Issue: This is the circle that has the most lines going to and from it. It drives the rest of the OPT model (i.e.: present state, outcome state, interventions, etc are all specific ONLY to the keystone issue).2Present State/Outcome StateStudents must list 5 each of “present state” and “outcome state.”Present State: Supports keystone issue(s). In other words, information specific to primary problem(s) identified through web. Keep information specific to patient i.e.: febrile w/ temps ranging 100 to 101 or pain score 9/10Outcome State: Outcomes for tests specific to keystone issue. Keep information specific i.e.: afebrile or client will have pain score less than 4/10.Line up the present state information with the outcome state information. Number them.Outcomes can be obtained from readings in textbooks, journal articles, Nursing Outcomes Classification [NOC] (copies in LRC Conference Room and Library). See NOC Part Four for general outcomes for your client. (Reference the outcomes selected, provide citation/book, pagenumber). Can use NOC Part Three for specific outcomes relevant to your client.Ackley & Ladwig lists “suggested NOC outcomes” as well as “client outcomes”. Use these to guide you.Use qualifiers for all outcomes: for example, BP will remain between 150/80 to 166/90 monitor q 2hrs. (measurable & specific time frame).Tests: Also called indicators in NOC. Choose those that are appropriate to your client and tailor to your client’s needs.Testing: Determines how to get from present state to future state. What you need to look at, what needs corrected, etc. Information is also in Ackley & Ladwig.InterventionsNeed 5 interventions - one for each outcome state. The numbers should


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UNCW NSG 326 - NSG 326 AH I OPT Guidelines

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