1. 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.

2. 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

3. 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

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

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

6. Nursing Process
Assessment
Planning
Implementation
Evaluation

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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. Ongoing Process
Assessment
Planning
Implementation
Evaluation

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