Assisting with the Nursing Process 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: Assessment Nursing diagnosis Planning Implementation Evaluation Nurses communicate with each other about the person’s strengths, problems, needs, and care. This information is shared through the nursing process. The nursing process focuses on the person’s nursing needs. Each step is important. You will see the continuous nature of the nursing process as each step is explained. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

The Nursing Process Further 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. The nursing process is used in all health care settings and for all age groups. The person and nursing team need good communication. Focusing on the shared goals of the nursing team fosters cooperation. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

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. An RN (registered nurse) assesses the person’s body systems and mental status. You play a strategic role in assessment. You make many observations as you give care and talk to the person. Observation is using the senses of sight, hearing, touch, and smell to collect information. Review Box 5-1 and Box 5-2 on pp. 67-68 lists observations that you must report at once. Objective data are seen, heard, felt, or smelled. You can feel a pulse. You can see urine color. Subjective data are things a person tells you that you cannot observe through your senses. You cannot feel or see the person’s pain, fear, or nausea. Note your observations as you make them. Carry a note pad and pen or the center may provide electronic devices for this purpose (Fig. 5-1 on p. 68). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

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. The Omnibus Budget Reconciliation Act of 1987 (OBRA) requires the Minimum Data Set (MDS) for nursing center residents. The MDS provides extensive information about the person. It may show whether a person can perform various activities of daily living (ADLs). See Figure 5-2 on pp. 69-70. The nurse uses your observations to complete the MDS. The RN responsible for the person’s care makes sure the MDS is complete. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

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 A nursing diagnosis describes a health problem that can be treated by nursing measures. Nursing diagnoses and medical diagnoses are not the same. A medical diagnosis is the identification of a disease or condition by a doctor. Nursing diagnoses deal with the total person. The North American Nursing Diagnosis Association (NANDA) approves diagnoses. Review Box 5-3 on pp. 72-74. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

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. Nursing measures or actions are chosen to help the person meet the goals. The person, family, and health team help the registered nurse to plan care. A goal is that which is desired for or by a person as a result of nursing care. Goals are aimed at the person’s highest level of well-being and function—physical, emotional, social, and spiritual. A nursing intervention is an action or measure taken by the nursing team to help the person reach a goal. Nursing intervention, nursing action, and nursing measure mean the same thing. A nursing intervention does not need a doctor’s order. OBRA requires regular interdisciplinary care planning (IDCP) conferences for each person. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

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 The comprehensive care plan (care plan) is a written guide about the care a person should receive. The care plan includes nursing diagnoses and goals. It has the person’s problems, goals for care, and actions to take to help the person solve health problems. A comprehensive care plan is developed for each person. The RN may conduct a care conference to share information and ideas about the person’s care. Nursing assistants usually take part in the conference. The care plan is revised as the person’s needs change. See Focus on Communication: Interdisciplinary Care Planning Conference on p. 75. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

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. To implement means to perform or carry out. The implementation step is performing or carrying out nursing measures in the care plan. To give correct care, you need to know about any changes in the care plan. In some centers, you record the care given. Report and record after giving care, not before. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

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. Talk to the nurse about any unclear assignment. You can also check the care plan and Kardex if you need more information. Review Figure 5-5 Sample Assignment Sheet on p. 75. Review Teamwork and Time Management: Assignment Sheets on p. 76. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

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. Evaluation means to measure. Progress is evaluated. Assessment information is used for this step. Nurses constantly collect information about the person. Goals may be met totally, in part, or not at all. Nursing diagnoses, goals, and the care plan may change as the person’s needs change. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11

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. You have a strategic role in the nursing process. Your assignment sheet tells you what to do. Your observations are used by the nurse for nursing diagnoses and planning. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12

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. The resident has the right to take part in his or her care planning. OBRA requires that the person be included in the process. The person may refuse actions suggested by the health team. Involving the person in the care planning process helps the team better meet the person’s needs. You are a strategic member of the team. Share your observations and ideas. They can help the team provide better care. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13