1. Assisting with the Nursing Process
Chapter 4

2. Nursing Process
Methods in which nurses use to plan and deliver nursing care
Focuses on the patient’s nursing needs & requires good communication with entire nursing team
5 Steps to the Nursing Process:
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation

3. Nursing Process

4. Assessment Involves collecting information about the patient.
Derived from many sources, including:
Health history
Current & past health problems
Family health history
Drug history
Prescriptions, herbal products, street drugs, etc.
Allergic RXNs
Medical Records
Past exams & laboratory diagnostics

5. Assessment (continued)
Observations
Uses the senses of sight, hearing, touch & smell to collect information
Objective Data:
Physical findings that are heard, felt or smelled
Ex. Temperature, Pulse, BP, Weight, etc.
Subjective Data:
Finding that a person tells you about that you cannot observe through your senses
Ex. Pain, discomfort, etc.

6. Nursing Diagnosis
Information gathered in the ASSESSMENT is used to make a nursing diagnosis
Describes a health problem that can be treated by nursing measures
Nursing Diagnosis ≠ Medical Diagnosis
Medical Diagnosis:
Identification of a disease or condition by a doctor
Ex. Cancer, Stroke, Heart Attack, etc.

7. Planning Involves setting priorities and goals Priorities: Goals:
Related to what is most important for the person
Goals:
Aimed at the person’s highest level of well-being and function
Promote health, prevent health problems and promote rehabilitation

8. Planning (continued) Nursing Intervention: Nursing Care Plan:
Action or measure taken by the nursing team to help the person reach a goal
Does not require a doctors order
Ex. Medication side effect causes dry mouth….nursing invention involve a care plan to include frequent oral hygiene
Nursing Care Plan:
Written guide about the person’s care
Includes the nursing diagnosis and goals
Communication tool for entire nursing staff
Ensures that the nursing team provides the same level of care

9. Implementation Perform and carry out nursing measures in the care plan
Nursing care may be simple or complex
Nurse will delegate nursing task as appropriate within legal boundaries
Communicate the care provided back to the nurse, including you findings and observations

10. Evaluation Measuring if the goals in the PLANNING step were met.
Goals may be met totally, in-part, or not at all
Assessment information is used for this step
Changes in nursing diagnoses, goals and the care plan may result

11. Assisting with Assessment
Vital signs, weight and blood glucose are measurements used to assess and evaluate the patient’s response to drug therapy.
Specific measurements may be require prior to administering a medication
Ex. If a medication lowers heart rate, you may be required to check a pulse. If pulse is too low, the nurse may tell you to not administer the medication

12. Vital Signs Temperature Pulse Respirations Blood Pressure
Vital signs will vary within certain limits
May be affected by sleep, activity, eating, weather, noise, exercise, drugs, anger, fear, anxiety, pain and illness
Report abnormal vital signs to supervising nurse

13. Review of Vital Signs Demonstration & Practice Skills…… Temperature
Pulse
Respirations
Blood Pressure
Height
Weight

14. Blood Glucose Testing Used to determine patient blood sugar levels
Test is performed by testing capillary blood through a skin puncture
Finger tip is most common route of collection
Earlobe could also be used
Prior to collection, inspect the site carefully
Look for signs of trauma, skin breaks.
Avoid sites that are swollen, bruised, cyanotic, scarred or calloused
Calluses often form over frequently used regions, therefore thumbs & index fingers are typically not good sites

15. Blood Glucose Collection
Do not use the center fleshy part of the fingertip
Use the side toward the tip of the fingertip on the middle or ring finger
Use a lancet to puncture the skin
Lancet:
Short pointed blade that punctures but does not cut the skin

16. Site for Skin Punctures

17. Glucometer Glucose meter used to determine blood sugar levels
Prior to inserting the reagent strip into the glucometer, follow manufacturers directions.
One of the following is typically required:
Dry Wipe:
Blood is wiped off the reagent strip with a cotton ball
Wet Wash:
Reagent strip is flushed with water to rinse blood off
No-Wipe:
No wiping or rinsing. Reagent strip is inserted directly into glucometer

18. Communication Essential part of the nursing process
For good communication:
Use words that mean the same thing to you and the receiver
Ex. “small” “moderate” and “large” can be perceived differently. Use a comparison that everyone one knows….Ex. “size of a dime”
Use familiar words
Be brief and concise
Report information is a logical and orderly manner
Organize your thoughts
Provide only facts and be specific

19. Reporting & Recording Reporting: Recording:
Oral account of care & observations
Recording:
Written account of care and observations

20. Reporting Follow these rules: Be prompt, thorough and accurate
Give the patient’s name, room and bed number
Provide the date/time of your observations
Report only that you observes or did yourself
Give reports as often as the patient’s condition requires
Report any changes
Be specific, concise and clear

21. Recording When recording you must communicate clearly and thoroughly.
Anyone who reads your charting should know:
What you observed
What you did
Patient response

22. Recording Time