1. CNA Mosby’s Nursing Assistant Chapter 7 Assisting With the Nursing Process

2. 9/14/2018
The Whole Patient
The nursing process involves looking at the whole patient at all times. It personalizes the patient. He is not simply “214B."
The process provides a roadmap that ensures good nursing care and improves patient outcomes.

3. Nursing Process
Method nurses use to plan and deliver patient care
5 steps

4. Collecting Information
1. Assessment
Collecting Information
Observations -
Using the sense of sight, hearing, touch, and smell to collect information

5. 1. Assessment
Objective Data – signs
Seen, heard, felt or smelt
Subjective Data – symptoms
Something someone tells you

6. 1. Assessment
Objective or Subjective ?
Bloody urine

7. 1. Assessment
Objective or Subjective ?
Headache

8. 1. Assessment
Objective or Subjective ?
Productive cough

9. 1. Assessment
Objective or Subjective ?
Asleep

10. 1. Assessment
Objective or Subjective ?
Dizziness

11. 1. Assessment
Objective or Subjective ?
Abdominal pain

12. 1. Assessment
Objective or Subjective ?
Elevated temperature

13. 1. Assessment Ability to respond Movement Oriented? Speech?
Calm, restless?
Movement
Strength?
Shaky or jerky?
Complaints?

14. 1. Assessment Pain or Discomfort Where? When did it begin?
How long does it last?
Description?

15. Skin 1. Assessment Color? Lips and Nails? Temperature? Intact?
Moist or dry?
Bruises?

16. 1. Assessment Eyes, Ears,Nose, Mouth Drainage? Hearing? Breath odor?
Sensitive to light?
PEARL?

17. 1. Assessment Respirations Both sides of chest rise and fall?
Noisy? Sputum?
SOB? Cough?

18. 1. Assessment Bowel and Bladder Abdomen firm or soft? Flatus? BM?
Urine?
Incontinence?

19. 1. Assessment Appetite % eaten? Liquid intake? Swallow? Dentures? N/V?
Hiccups?

20. 1. Assessment ADLs Personal care? Feed himself?
Toilet, commode, bedpan or urinal?
Ambulation?

21. 2. Nursing Diagnosis
A health problem that can be treated by nursing measures
Not the same as a medical diagnosis

22. 2. Nursing Diagnosis Examples:
Ineffective airway clearance related to decreased energy as manifested by an ineffective cough.
Risk for injury related to altered mobility and disorientation.
Possible fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse rate.

23. What is most important for the patient
3. Planning
What is most important for the patient
Setting priorities and goals
(Maslow’s Hierarchy of Needs)

24. 3. Planning
Nursing Intervention according to goals.
Nursing Care Plan

26. Assignment sheet used to delegate duties
4. Implementation
Carrying out nursing measures in the care plan.
May be simple or complex
Assignment sheet used to delegate duties

27. Nursing process never ends
5. Evaluation
To measure whether the goals were met
Partially Totally Not at all
Nursing process never ends

28. Patient has a right to be part of the Care Process
Your role
Key
Observations
Provide care
Patient has a right to be part of the Care Process

29. Comprehensive care plan
Review
A written guide about the care a person should receive is the
Comprehensive care plan

30. The nursing process focuses on
Review
The nursing process focuses on
The person’s nursing needs

31. Review
Which is the first step of the nursing process?
Assessment

32. Review yes yes no yes Is it a nursing diagnosis? Anxiety Constipation
Heart attack
Pain, acute
yes
yes no
yes

33. Review
Nursing assistants have a role in the nursing process.
True False