Chapter 3 (4th ed) Pati L.H. Cox, RN, BSN, M.Ed. The Use of The Nursing Process Nursing Diagnosis in the Care of The Older Adult Chapter 3 (4th ed) Pati L.H. Cox, RN, BSN, M.Ed.

OBJECTIVE Describe the nursing process as a problem solving technique in the context of the older adult’s assessment, plan of care, nursing interventions, and documentation

Objective Identify the use of the nursing process, Minimum Data Set (MDS) and Resident Assessment Protocols (RAPS) in developing nursing care plans for residents in LTC

Objective Use the nursing process to develop a care plan for a presented case study

Nursing Process A creative way to solve problems from a nursing standpoint

Nursing Process Assessment Planning Implementation Evaluation

Patient, Family/Significant Other Nursing Process Interdisciplinary Approach Patient, Family/Significant Other Health Care Team

Assessment Collect information Nursing History Focused Admission Assessment Observation of pt./resident/client Physical Examination Review of laboratory/diagnostic tests Interview of pt./resident/client Interview of family/significant other

Nursing Diagnosis Function of RN to define – LPN assists in the formulation Nursing Problem related to ___?????___ Utilize NANDA Approved List Example: Mobility, Impaired as related to weakness and unsteady gait 2nd to R total hip

Planning Setting goals Maslow’s Hierarchy of Needs STG = 30 days LTG = 90 days Maslow’s Hierarchy of Needs Must consider pt’s goals for compliance – active role Must be measurable, realistic, specific, timely and attainable – Ask yourself these questions

Planning Example = Improved Mobility as evidenced by: ambulating with SBA x1, steady gait and denies dizziness in 30 days ( upon discharge, in 24 hours, etc) Specific, attainable, timely, realistic and measurable

Implementation Nursing Actions/measures This is the part nurses do best Staff (CNA) and nurses carry out Documentation = Important Component

Documentation = DAR/AAP D/A = Data/Assessment Observations, assessed Objective measurements (VS, lab) Subjective – What resident said Action Nursing interventions ( treatments, procedures, turning a pt., etc) Response/Plan Nurse’s plans (phone Dr., phone family, refer to Social Services) Response to Action

Evaluation Final step in Nursing process Determine if goal has been met Assess the outcomes of nursing plan of care Reassess the pt/resident/client and nursing process = Strength of problem solving approach

Ongoing Process Assessment Planning Implementation Evaluation

Computer & The Nursing Process MDS Minimum Data Set RAP Resident Assessment Protocol