Chapter 5 Assisting with the Nursing Process All items and derived items © 2015, 2011 by Mosby,...

Chapter 5

Assisting with the Nursing Process

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

The Nursing Process

The nursing process is the method nurses use to plan and deliver nursing care.

The five steps of the nursing process are:AssessmentNursing diagnosisPlanning ImplementationEvaluation

2All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

The Nursing ProcessFurther Explained

If done in order with good communication: Nursing care is organized and has purpose. All nursing team members do the same things for

the person. All nursing team members have the same goals. The person feels safe and secure with consistent

care.


Assessment

Assessment involves collecting information about the person. You make many observations as you give care

and talk to the person.• Objective data (signs)

• Subjective data (symptoms)

The assessment step never ends. New information is collected with every resident

contact.


OBRA MDS Requirement

OBRA requires the minimum data set (MDS) for nursing center residents. The MDS is begun when the person is admitted to the

center. The MDS is an assessment and screening tool. The MDS is completed when the person is admitted to the

center. The MDS is updated before each care conference. The MDS is completed once a year and whenever a change

occurs in the person’s health status. The MDS is signed by an RN to show that it is complete and

accurate.


Nursing Diagnosis

The RN uses assessment information to make a nursing diagnosis.

A person can have multiple nursing diagnoses.

Nursing diagnoses: Involve the person’s physical, emotional, social,

and spiritual needs May change or new ones may be added as

assessment information changes


Planning

Planning involves setting priorities and goals. Priorities relate to what is most important for

the person. Goals are set. Nursing interventions are chosen after goals

are set. An interdisciplinary care planning conference is

held to develop a comprehensive care plan.


The Comprehensive Care Plan

The care plan includes: Nursing diagnoses and goals The person’s problems and actions to take to help the person solve

health problems The person’s strengths

Care Area Assessments (CAAs) Guidelines used to develop the person’s care plans Minimum data set (MDS gives triggers for CAAs)

Care plan forms vary: In the chart In a notebook In a Kardex On computer


Implementation

Care is given in this step. You report the care given and your

observations to the nurse. The nurse uses the assignment sheet to

communicate delegated measures and tasks to you.

If your assignment is unclear: Talk to the nurse. Check the care plan and Kardex.


Assignment Sheets

An assignment sheet is used to communicate tasks to you.

Assignment sheets tell you about: Each person’s care What measurements and tasks need to be done Which nursing unit tasks to do

Use the assignment sheet to organize your work and set priorities. What to do first What to do when the person is at therapy or a meal With which tasks will you need help Check off tasks as you complete them.


Evaluation

The evaluation step involves measuring if the goals in the planning step were met. Changes in nursing diagnoses, goals, and the

care plan may result. The nursing process never ends.


Your Role

The nurse uses your observations for nursing diagnoses, planning, and evaluation.

You may help develop the care plan. In the implementation step, you perform

nursing actions and measures in the care plan.


Quality of Life

The resident has the right to take part in his or her care planning. The person may refuse actions suggested by the

health team.


Chapter 5 Assisting with the Nursing Process All items and derived items © 2015, 2011 by Mosby,...

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