Nursing FundamentalsCHPTR 2

NURSING PROCESS“The Recipe”

The Nursing Process

A systematic method of providing care to clients.

It’s a system that nurses use to provide efficient and effective nursing care

If we didn’t use some sort of standardized care, nursing would be a chaotic mess

Who writes the plan

RN should begin the plan and sign it LPN can help and doesn’t need to sign it

necessarily

The RN takes the lead role here

The 5-Step Nursing Process

Data collection (Assessment.) Diagnosis. Planning and outcome identification. Implementation. Evaluation.

The Nursing Process uses Critical Thinking

Critical thinking, problem-solving, and decision-making

These skills can be learned!

WHAT IS CRITICAL THINKING?

Critical thinking is a process of objective reasoning or analyzing facts to reach a valid conclusion

Critical thinking allows nurses to determine which problems are necessary to call the Dr. about or which fall into the domain of Nursing judgment (where you don’t need a Dr’s order)

Data Collection (assessment)

Purpose of Data collection (Assessment)

Why is data collection (assessment) important?

Data collection is important because it tells you facts about the patient.

Data collection 1st begins when you see the pt. for the 1st time and it cont’s until the pt. is released

It is during data collection period that the nurse collects info. to determine areas of abnormal function, risk factors that contribute to the pts health problems and it helps the nurse find the pts strengths

Sources of Data

Primary Source: The client.

Secondary Source: The client’s family members, other health care providers, and medical records.

Types of Data

Subjective: it’s what the patient SAYS or STATES. This is also the symptoms someone c/o

Objective: it’s what you observe. It’s observable and measurable data obtained through physical examination and laboratory and diagnostic testing. This is also what signs the pt shows you

125lbs “I’m starving” greenish emesis The Pt tell you he

vomited greenish fluid Erythematous toe “I’m burping a lot” “my heart is racing”

“like a knife stabbing me”

Sleeps with 2 pillows 146/89 Pinpoint pupils “He is so tired” Pale, diaphoretic O2 sat = 91% on room

air

Is it: A=subjective B=objective

Is it: A=subjective B=objective

Pulse 125

Is it: A=subjective B=objective

“I’m starving”

Is it: A=subjective B=objective

Pt. tells you he vomited

Is it: A=subjective B=objective

Greenish emesis

Is it: A=subjective B=objective

Toe with erythema

Is it: A=subjective B=objective

Sleeping with 2 pillows

Is it: A=subjective B=objective

I’m burping a lot

Is it: A=subjective B=objective

He is so tired

Is it: A=subjective B=objective

Blood pressure 146/82

Is it: A=subjective B=objective

He is crying and depressed

Is it: A=subjective B=objective

Pale, diaphoretic

Is it: A=subjective B=objective

My husband is acting like such a baby, he is whining about everything

Types of Data Collection

Comprehensive - Provides baseline data including complete health history and current needs assessment.

Focused - Limited in scope in order to focus on a particular need or concern or potential risk.

Ongoing - Includes systematic monitoring and observation related to specific problems.

Organizing Data

Collected information must be organized to be useful.

Documenting Data

Data collection must be recorded and reported.

Accurate and complete recording of your data collection is essential for communicating information to health care team.

Here is your client.

68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

Write out some data you collected and decide if subjective or objective.

Diagnosis

A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state.

A nursing diagnosis is a clinical judgment by the nurse about individual, family, or community responses to actual or potential health problems/life processes.

Nursing Diagnosis is a Three Part Statement The name of the health-related issue or

problem identified in the NANDA list (see

the inside back cover of your book)

Etiology - the cause or contributor to the problem.

Signs and Symptoms

TYPE OF DIAGNOSES

You must state whether your nursing problem is one of the following:

An actual problem A risk for a problem to occur And then you must relate it to something

If a pt is obese, you would say it’s an ACTUAL problem

Therefore, you would say that the nursing diagnoses for this pt is: over-nutrition related to the lack of education

If your patient had troubling swallowing, you would say:

Potential for aspiration related to difficulty swallowing

Or Possible airway obstruction related to

difficulty swallowing

Here is your client.

68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

Types of Nursing Diagnosis

Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms.

Hi Risk nursing diagnosis: A problem does not yet exist, but special risk factors are present.

Here is your client. 68 yr old male, lost wife three months

ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

Write a nursing diagnosis ___________ r/t ____________

#1 #2 #3

Planning

Set nursing goals Nursing Orders

Here is your client.

68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

Write a goal related to the diagnosis

Intervention

A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.

It’s what you are ACTUALLY GOING TO DO OR CARRY OUT

Types of Nursing Interventions

Specific order - written by physician or nurse especially for an individual client.

Standing order - A standardized intervention written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention.

Protocol - A series of standing orders or procedures.

Here is your client.

68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

What interventions will you plan to do or have others do?

WHAT DO YOU DO WITH ALL THE INFO. COLLECTED?

You write a nursing care plan This plan tells others how to care for the

pt. IN A SYSTEMATIC, CONSISTENT WAY

Nurses won’t have to reinvent the wheel everyday that they care for this pt.

The Nursing Care Plan

A written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.

Implementation

execution of the nursing care plan It’s what YOU ARE ACTUALLY GOING

TO DO

Evaluation

determining whether client goals have been met, partially met, or not met.

It is in this stage that you will decide what needs to be changed to make the goal happen even more

It’s improvement after you see how it’s going

Here is your client.

3 weeks later…gain 2 lbs……states “ I went to the senior center twice last week and had lunch.

Evaluate progress

Take blood pressure every 3 hours

A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Instruct client to self medicate

A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Client state “ I exercise every day”

A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Client will eat 75% of meal with assist

A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Anxiety related to hospitalization

A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Goal met-Client was able to state signs and symptoms of infection

A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

The nursing assistants are taking the patients blood pressure now.

A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

CHARTING

In the world of nursing… “if it’s not written, it was never done” This turns into legal issues Just because you did it and didn’t chart it,

means it was NEVER done.

IN REVIEWSo what is the Nursing Process anyway

The fact that you have to do all the parts:D-D-P-I-E…takes a long time to get through therefore, it’s a process

Get it? It’s a process…NURSING PROCESS

And why do we take time out of our busy schedule to do this process….so nursing care can be consistent and not forgotten

PRIORITY

Remember that you may be able to choose 10 NANDAS for 1 pts problems but you really should only use the top 2 or maybe 3 at the most

You prob. Won’t have time to write more than 3

Remember… The interventions you write down in order to

care for the pt come from: The Dr.s order Your own idea of what you think needs to be

done

Every nurse MUST follow the Dr.s orders. You don’t have to follow every intervention made by a nurse

THE END