Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 7 Chapter 7 Assisting With the Nursing Process

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  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 Slide 2

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  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. Slide 3

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment  Assessment involves collecting information about the person.  You make many observations as you give care and talk to the person. Objective data (signs) Objective data (signs) Subjective data (symptoms) Subjective data (symptoms)  The assessment step never ends.  New information is collected with every resident contact. Slide 4

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  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. Slide 5

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Slide 6

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 7

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  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 Slide 8

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 9

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Assignment Sheets  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 to set priorities.  What to do first  What to do when the person is at therapy or a meal  On which tasks will you need help  Check off tasks as you complete them. Slide 10

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 11

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 12

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 13