Nursing Process Nursing Fundamentals

Introduction: Nursing Process Communication tool Organization tool

Overview of the Nursing Process Purpose is to provide client care that is: – Individualized – Holistic

Holistic Health Treat the Whole person – Mental – Spiritual – Social – Physical

Overview of the Nursing Process Process: Purpose: – Individualized – Holistic – Effective – Efficient Nursing CARE

Overview of the Nursing Process Consists of 5 steps – AD-PIE

Nursing Process Used throughout the life span

Used in every care setting

Small group questions: 1.What are the names of each of the steps? 2.What is the purpose of the nursing process?

Assessment Step #1 Involves – Collecting data – Validating the data – Organizing the data – Interpreting the data – Documenting the data

Assessment Types of assessment: 1.Comprehensive 2.Focused 3.Ongoing

Assessment Comprehensive assessment – Baseline – Physical & psychosocial

Assessment Focused Assessment – Limited in scope – Screening for a specific problem – Short stay

Assessment Ongoing – Follow-up – Monitoring changes

Assessment Types of data – Subjective Data from the client’s viewpoint – Interview – Objective Observable & measurable – Physical assessment – Labs – Tests

iClicker John is being admitted to the psychiatric facility, after being transferred from the acute hospital with a diagnosis of schizophrenia and multiple sclerosis. What type of assessment should be performed on John? A.Comprehensive B.Focused C.Ongoing

Small group questions: 1.Baby Jane a 2 month infant goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform? A. Comprehensive B. Focused C. Ongoing

Which one of the following is objective data? A.Nausea B.Pain C.Dizziness D.Unsteady gait E.Anxiety

Which one of the following is subjective data? A.Vomiting B.Warm, moist skin C.Head ache D.Bruise on the right arm E.Temperature 99.3 o F

Diagnosis Step 2 in the nursing process

Nursing diagnosis: “A clinical judgment… about an individual, family or community… responses to actual or potential health problems” Forms the basis for nursing interventions

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Identifies conditions the MD is licensed & qualified to treat Identifies situations the nurse is licensed & qualified to treat

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Identifies conditions the MD is licensed & qualified to treat Identifies situations the nurse is licensed & qualified to treat Focuses on illness, injury or disease processes Focuses on the clients responses to actual or potential health / life problems

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Remains constant until a cure is effected Changes as the clients response and/or the health problem changes

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Remains constant until a cure is effected Changes as the clients response and/or the health problem changes i.e. Breast canceri.e. Knowledge deficit Powerlessness Grieving, anticipatory Body image disturbance Individual coping, ineffective

Diangosis Nursing diagnosisMedical diagnosis Breathing patterns, ineffective Chronic obstructive pulmonary disease Activity intoleranceCerebrovascular accident PainAppendectomy Body image disturbanceAmputation Body temperature, risk for altered Strep throat

Planning & Outcome identification Step 3

Planning & Outcome identification – Types of planning Initial Ongoing Discharge

Planning & Outcome identification Outcome identification = Goals – Short term Hrs - days (< week) – Long term Wks. – mons.

Planning & Outcome identification Interventions – Independent interventions No MD order needed – Interdependent interventions With interdisciplinary team member – Dependent interventions MD order required

The nursing care plan includes “administer digoxin per MD order”. What type of intervention is this? A.Dependent B.Interdependent C.Independent

The nursing care plan includes “Check apical pulse before administering digoxin”. What type of intervention is this? A.Dependent B.Interdependent C.Independent

A Client is dehydrated. The nursing care plan includes “encourage the patient to drink fluids every hour”. What type of intervention is this? A.Dependent B.Interdependent C.Independent

Prioritizing Nrs Dx Maslow’s hierarchy of needs

Maslow’s Hierarchy of Needs

Physiological: – Breathing, food, water, sleep, homeostasis, excretion – ABC’s

Maslow’s Hierarchy of Needs Safety – Security of body, employment, resources, morality, family, health or property Physiological

Maslow’s Hierarchy of Needs Love/Belonging – Friendship, family, sexual intimacy Safety Physiological:

Maslow’s Hierarchy of Needs Esteem – Self esteem, confidence, achievement, respect of others, respect by others Love/Belonging Safety Physiological

Maslow’s Hierarchy of Needs Self-Actualization – Creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts Esteem Love/Belonging Safety Physiological:

Which of the following client issues should receive the highest priority? A.John’s best friend just stormed out of the room mad. B.Todd feels like not one respects his work C.Mary feels scared she is going to die D.Anna feels like she is lacking in creativity

Which of the following client issues should receive the highest priority? A.George is climbing out of bed and he can’t walk B.Paul is having a difficulty breathing C.Susan is crying hysterically because she just found out the person who was driving in the car with her, died in the car accident. D.Jane has severe hip pain due to post-op hip surgery

Implementation 4 th step: – Execution of the care plan – DO IT – DO IT RIGHT – DO IT RIGHT NOW! Direct Assist Supervise Delegate Teach Monitor

Implementation 5 Rights of Implementation 1)Right patient 2)Right medication 3)Right route 4)Right dose / amount 5)Right time

Evaluation 5 th step – Have the clients goals have been met, partially met or not met.

Small group questions: 1.What is the purpose of the nursing process and where is it used? 2.Name & describe the steps of the nursing process 3.Explain the difference between objective and subjective data. 4.Define holistic and explain how it relates to nursing.

Role of the LVN & Psych Tech Use the nrs process Contribute to Dx & nrs care plan Provide info Implement The RN has ultimate responsibility

Critical Thinking & the Nursing Process Critical thinking Thinking like a nurse

Critical Thinking Inquisitive Open-minded Flexible Fairminded