Nursing Fundamentals CHPTR 2 NURSING PROCESS “The Recipe”

The Nursing Process A systematic method of providing care to clients. It’s a system that nurses use to provide efficient and effective nursing care If we didn’t use some sort of standardized care, nursing would be a chaotic mess

Who writes the plan RN should begin the plan and sign it LPN can help and doesn’t need to sign it necessarily The RN takes the lead role here

The 5-Step Nursing Process Data collection (Assessment.) Diagnosis. Planning and outcome identification. Implementation. Evaluation.

The Nursing Process uses Critical Thinking Critical thinking, problem-solving, and decision-making These skills can be learned!

WHAT IS CRITICAL THINKING? Critical thinking is a process of objective reasoning or analyzing facts to reach a valid conclusion Critical thinking allows nurses to determine which problems are necessary to call the Dr. about or which fall into the domain of Nursing judgment (where you don’t need a Dr’s order)

Data Collection (assessment)

Purpose of Data collection (Assessment) Why is data collection (assessment) important?

Data collection is important because it tells you facts about the patient. Data collection 1st begins when you see the pt. for the 1st time and it cont’s until the pt. is released

It is during data collection period that the nurse collects info It is during data collection period that the nurse collects info. to determine areas of abnormal function, risk factors that contribute to the pts health problems and it helps the nurse find the pts strengths

Sources of Data Primary Source: The client. Secondary Source: The client’s family members, other health care providers, and medical records.

Types of Data Subjective: it’s what the patient SAYS or STATES. This is also the symptoms someone c/o Objective: it’s what you observe. It’s observable and measurable data obtained through physical examination and laboratory and diagnostic testing. This is also what signs the pt shows you

Is it: A=subjective B=objective 125lbs “I’m starving” greenish emesis The Pt tell you he vomited greenish fluid Erythematous toe “I’m burping a lot” “my heart is racing” “like a knife stabbing me” Sleeps with 2 pillows 146/89 Pinpoint pupils “He is so tired” Pale, diaphoretic O2 sat = 91% on room air

Is it: A=subjective B=objective Pulse 125

Is it: A=subjective B=objective “I’m starving”

Is it: A=subjective B=objective Pt. tells you he vomited

Is it: A=subjective B=objective Greenish emesis

Is it: A=subjective B=objective Toe with erythema

Is it: A=subjective B=objective Sleeping with 2 pillows

Is it: A=subjective B=objective I’m burping a lot

Is it: A=subjective B=objective He is so tired

Is it: A=subjective B=objective Blood pressure 146/82

Is it: A=subjective B=objective He is crying and depressed

Is it: A=subjective B=objective Pale, diaphoretic

Is it: A=subjective B=objective My husband is acting like such a baby, he is whining about everything

Types of Data Collection Comprehensive - Provides baseline data including complete health history and current needs assessment. Focused - Limited in scope in order to focus on a particular need or concern or potential risk. Ongoing - Includes systematic monitoring and observation related to specific problems.

Organizing Data Collected information must be organized to be useful.

Documenting Data Data collection must be recorded and reported. Accurate and complete recording of your data collection is essential for communicating information to health care team.

Here is your client. 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, Write out some data you collected and decide if subjective or objective.

Diagnosis A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state. A nursing diagnosis is a clinical judgment by the nurse about individual, family, or community responses to actual or potential health problems/life processes.

Nursing Diagnosis is a Three Part Statement The name of the health-related issue or problem identified in the NANDA list (see the inside back cover of your book) Etiology - the cause or contributor to the problem. Signs and Symptoms

TYPE OF DIAGNOSES You must state whether your nursing problem is one of the following: An actual problem A risk for a problem to occur And then you must relate it to something

If a pt is obese, you would say it’s an ACTUAL problem Therefore, you would say that the nursing diagnoses for this pt is: over-nutrition related to the lack of education

If your patient had troubling swallowing, you would say: Potential for aspiration related to difficulty swallowing Or Possible airway obstruction related to difficulty swallowing

Here is your client. 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

Types of Nursing Diagnosis Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms. Hi Risk nursing diagnosis: A problem does not yet exist, but special risk factors are present.

Here is your client. 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, Write a nursing diagnosis ___________ r/t ____________ #1 #2 #3

Planning Set nursing goals Nursing Orders

Here is your client. 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, Write a goal related to the diagnosis

Intervention A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes. It’s what you are ACTUALLY GOING TO DO OR CARRY OUT

Types of Nursing Interventions Specific order - written by physician or nurse especially for an individual client. Standing order - A standardized intervention written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention. Protocol - A series of standing orders or procedures.

Here is your client. 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, What interventions will you plan to do or have others do?

WHAT DO YOU DO WITH ALL THE INFO. COLLECTED? You write a nursing care plan This plan tells others how to care for the pt. IN A SYSTEMATIC, CONSISTENT WAY Nurses won’t have to reinvent the wheel everyday that they care for this pt.

The Nursing Care Plan A written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.

Implementation execution of the nursing care plan It’s what YOU ARE ACTUALLY GOING TO DO

Evaluation determining whether client goals have been met, partially met, or not met. It is in this stage that you will decide what needs to be changed to make the goal happen even more It’s improvement after you see how it’s going

Here is your client. 3 weeks later…gain 2 lbs……states “ I went to the senior center twice last week and had lunch. Evaluate progress

Take blood pressure every 3 hours A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Instruct client to self medicate A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Client state “ I exercise every day” A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Client will eat 75% of meal with assist A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Anxiety related to hospitalization A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

Goal met-Client was able to state signs and symptoms of infection A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

The nursing assistants are taking the patients blood pressure now. A. Data collection B. Diagnosis C. Planning D. Implementation E. Evaluation

CHARTING In the world of nursing… “if it’s not written, it was never done” This turns into legal issues Just because you did it and didn’t chart it, means it was NEVER done.

IN REVIEW So what is the Nursing Process anyway The fact that you have to do all the parts: D-D-P-I-E…takes a long time to get through therefore, it’s a process Get it? It’s a process…NURSING PROCESS And why do we take time out of our busy schedule to do this process….so nursing care can be consistent and not forgotten

PRIORITY Remember that you may be able to choose 10 NANDAS for 1 pts problems but you really should only use the top 2 or maybe 3 at the most You prob. Won’t have time to write more than 3

Remember… The interventions you write down in order to care for the pt come from: The Dr.s order Your own idea of what you think needs to be done Every nurse MUST follow the Dr.s orders. You don’t have to follow every intervention made by a nurse 

THE END