Assisting with the Nursing Process Chapter 4

Nursing Process Methods in which nurses use to plan and deliver nursing care Focuses on the patient’s nursing needs & requires good communication with entire nursing team 5 Steps to the Nursing Process: Assessment Nursing Diagnosis Planning Implementation Evaluation

Nursing Process

Assessment Involves collecting information about the patient. Derived from many sources, including: Health history Current & past health problems Family health history Drug history Prescriptions, herbal products, street drugs, etc. Allergic RXNs Medical Records Past exams & laboratory diagnostics

Assessment (continued) Observations Uses the senses of sight, hearing, touch & smell to collect information Objective Data: Physical findings that are heard, felt or smelled Ex. Temperature, Pulse, BP, Weight, etc. Subjective Data: Finding that a person tells you about that you cannot observe through your senses Ex. Pain, discomfort, etc.

Nursing Diagnosis Information gathered in the ASSESSMENT is used to make a nursing diagnosis Describes a health problem that can be treated by nursing measures Nursing Diagnosis ≠ Medical Diagnosis Medical Diagnosis: Identification of a disease or condition by a doctor Ex. Cancer, Stroke, Heart Attack, etc.

Planning Involves setting priorities and goals Priorities: Goals: Related to what is most important for the person Goals: Aimed at the person’s highest level of well-being and function Promote health, prevent health problems and promote rehabilitation

Planning (continued) Nursing Intervention: Nursing Care Plan: Action or measure taken by the nursing team to help the person reach a goal Does not require a doctors order Ex. Medication side effect causes dry mouth….nursing invention involve a care plan to include frequent oral hygiene Nursing Care Plan: Written guide about the person’s care Includes the nursing diagnosis and goals Communication tool for entire nursing staff Ensures that the nursing team provides the same level of care

Implementation Perform and carry out nursing measures in the care plan Nursing care may be simple or complex Nurse will delegate nursing task as appropriate within legal boundaries Communicate the care provided back to the nurse, including you findings and observations

Evaluation Measuring if the goals in the PLANNING step were met. Goals may be met totally, in-part, or not at all Assessment information is used for this step Changes in nursing diagnoses, goals and the care plan may result

Assisting with Assessment Vital signs, weight and blood glucose are measurements used to assess and evaluate the patient’s response to drug therapy. Specific measurements may be require prior to administering a medication Ex. If a medication lowers heart rate, you may be required to check a pulse. If pulse is too low, the nurse may tell you to not administer the medication

Vital Signs Temperature Pulse Respirations Blood Pressure Vital signs will vary within certain limits May be affected by sleep, activity, eating, weather, noise, exercise, drugs, anger, fear, anxiety, pain and illness Report abnormal vital signs to supervising nurse

Review of Vital Signs Demonstration & Practice Skills…… Temperature Pulse Respirations Blood Pressure Height Weight

Blood Glucose Testing Used to determine patient blood sugar levels Test is performed by testing capillary blood through a skin puncture Finger tip is most common route of collection Earlobe could also be used Prior to collection, inspect the site carefully Look for signs of trauma, skin breaks. Avoid sites that are swollen, bruised, cyanotic, scarred or calloused Calluses often form over frequently used regions, therefore thumbs & index fingers are typically not good sites

Blood Glucose Collection Do not use the center fleshy part of the fingertip Use the side toward the tip of the fingertip on the middle or ring finger Use a lancet to puncture the skin Lancet: Short pointed blade that punctures but does not cut the skin

Site for Skin Punctures

Glucometer Glucose meter used to determine blood sugar levels Prior to inserting the reagent strip into the glucometer, follow manufacturers directions. One of the following is typically required: Dry Wipe: Blood is wiped off the reagent strip with a cotton ball Wet Wash: Reagent strip is flushed with water to rinse blood off No-Wipe: No wiping or rinsing. Reagent strip is inserted directly into glucometer

Communication Essential part of the nursing process For good communication: Use words that mean the same thing to you and the receiver Ex. “small” “moderate” and “large” can be perceived differently. Use a comparison that everyone one knows….Ex. “size of a dime” Use familiar words Be brief and concise Report information is a logical and orderly manner Organize your thoughts Provide only facts and be specific

Reporting & Recording Reporting: Recording: Oral account of care & observations Recording: Written account of care and observations

Reporting Follow these rules: Be prompt, thorough and accurate Give the patient’s name, room and bed number Provide the date/time of your observations Report only that you observes or did yourself Give reports as often as the patient’s condition requires Report any changes Be specific, concise and clear

Recording When recording you must communicate clearly and thoroughly. Anyone who reads your charting should know: What you observed What you did Patient response

Recording Time