CNA Mosby’s Nursing Assistant Chapter 7 Assisting With the Nursing Process

9/14/2018 The Whole Patient The nursing process involves looking at the whole patient at all times. It personalizes the patient. He is not simply “214B." The process provides a roadmap that ensures good nursing care and improves patient outcomes.

Nursing Process Method nurses use to plan and deliver patient care 5 steps

Collecting Information 1. Assessment Collecting Information Observations - Using the sense of sight, hearing, touch, and smell to collect information

1. Assessment Objective Data – signs Seen, heard, felt or smelt Subjective Data – symptoms Something someone tells you

1. Assessment Objective or Subjective ? Bloody urine

1. Assessment Objective or Subjective ? Headache

1. Assessment Objective or Subjective ? Productive cough

1. Assessment Objective or Subjective ? Asleep

1. Assessment Objective or Subjective ? Dizziness

1. Assessment Objective or Subjective ? Abdominal pain

1. Assessment Objective or Subjective ? Elevated temperature

1. Assessment Ability to respond Movement Oriented? Speech? Calm, restless? Movement Strength? Shaky or jerky? Complaints?

1. Assessment Pain or Discomfort Where? When did it begin? How long does it last? Description?

Skin 1. Assessment Color? Lips and Nails? Temperature? Intact? Moist or dry? Bruises?

1. Assessment Eyes, Ears,Nose, Mouth Drainage? Hearing? Breath odor? Sensitive to light? PEARL?

1. Assessment Respirations Both sides of chest rise and fall? Noisy? Sputum? SOB? Cough?

1. Assessment Bowel and Bladder Abdomen firm or soft? Flatus? BM? Urine? Incontinence?

1. Assessment Appetite % eaten? Liquid intake? Swallow? Dentures? N/V? Hiccups?

1. Assessment ADLs Personal care? Feed himself? Toilet, commode, bedpan or urinal? Ambulation?

2. Nursing Diagnosis A health problem that can be treated by nursing measures Not the same as a medical diagnosis

2. Nursing Diagnosis Examples: Ineffective airway clearance related to decreased energy as manifested by an ineffective cough. Risk for injury related to altered mobility and disorientation. Possible fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse rate.

What is most important for the patient 3. Planning What is most important for the patient Setting priorities and goals (Maslow’s Hierarchy of Needs)

3. Planning Nursing Intervention according to goals. Nursing Care Plan

Assignment sheet used to delegate duties 4. Implementation Carrying out nursing measures in the care plan. May be simple or complex Assignment sheet used to delegate duties

Nursing process never ends 5. Evaluation To measure whether the goals were met Partially Totally Not at all Nursing process never ends

Patient has a right to be part of the Care Process Your role Key Observations Provide care Patient has a right to be part of the Care Process

Comprehensive care plan Review A written guide about the care a person should receive is the Comprehensive care plan

The nursing process focuses on Review The nursing process focuses on The person’s nursing needs

Review Which is the first step of the nursing process? Assessment

Review yes yes no yes Is it a nursing diagnosis? Anxiety Constipation Heart attack Pain, acute yes yes no yes

Review Nursing assistants have a role in the nursing process. True False