1. Nursing Process Nursing Fundamentals

2. Introduction: Nursing Process Communication tool Organization tool

3. Overview of the Nursing Process Process: Purpose: – Individualized – Holistic – Effective – Efficient Nursing CARE

4. Holistic Health Treat the Whole person – Mental – Spiritual – Social – Physical

5. Overview of the Nursing Process Consists of 5 steps – AD-PIE

6. Nursing Process Used throughout the life span Used in every care setting

7. Assessment Step #1 Involves – Collecting data – Validating the data – Organizing the data – Interpreting the data – Documenting the data

8. Assessment Comprehensive assessment – Baseline – Physical & psychosocial

9. Assessment Focused Assessment – Limited in scope – Screening for a specific problem – Short stay

10. Assessment Ongoing – Follow-up – Monitoring changes

11. Assessment Types of data – Subjective Data from the client’s viewpoint – Interview – Objective Observable & measurable – Physical assessment – Labs – Tests

12. Diagnosis Step 2 in the nursing process

13. Nursing diagnosis: “A clinical judgment… about an individual, family or community… responses to actual or potential health problems” Forms the basis for nursing interventions

14. Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Identifies conditions the MD is licensed & qualified to treat Identifies situations the nurse is licensed & qualified to treat Focuses on illness, injury or disease processes Focuses on the clients responses to actual or potential health / life problems

15. Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Remains constant until a cure is effected Changes as the clients response and/or the health problem changes i.e. Breast canceri.e. Knowledge deficit Powerlessness Grieving, anticipatory Body image disturbance Individual coping, ineffective

16. Diangosis Medical diagnosis Chronic obstructive pulmonary disease Cerebrovascular accident Appendectomy Amputation Strep throat Nursing diagnosis Breathing patterns, ineffective Activity intolerance Pain Body image disturbance Nutritional deficit

17. Planning & Outcome identification Step 3

18. Planning & Outcome identification – Types of planning Initial Ongoing Discharge

19. Planning & Outcome identification Outcome identification = Goals – Short term Hrs - days (< week) – Long term Wks. – mons.

20. Planning & Outcome identification Interventions – Independent interventions No MD order needed – Interdependent interventions With interdisciplinary team member – Dependent interventions MD order required

21. Evidence based practices

22. 4 basic steps Step 1 - Question Step 2 - Data Step 3 - Check Step 4 - Apply

23. Prioritizing Nrs Dx Maslow’s hierarchy of needs

24. Maslow’s Hierarchy of Needs Physiological: – Breathing, food, water, sleep, homeostasis, excretion – ABC’s

25. Maslow’s Hierarchy of Needs Safety – Security of body, employment, resources, morality, family, health or property Physiological

26. Maslow’s Hierarchy of Needs Love/Belonging – Friendship, family, sexual intimacy Safety Physiological:

27. Maslow’s Hierarchy of Needs Esteem – Self esteem, confidence, achievement, respect of others, respect by others Love/Belonging Safety Physiological

28. Maslow’s Hierarchy of Needs Self-Actualization – Creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts Esteem Love/Belonging Safety Physiological:

29. Implementation 4 th step: – Execution of the care plan – DO IT – DO IT RIGHT – DO IT RIGHT NOW! Direct Assist Supervise Delegate Teach Monitor

30. Implementation 5 Rights of Implementation 1)Right patient 2)Right medication 3)Right route 4)Right dose / amount 5)Right time

31. Evaluation 5 th step – Have the clients goals have been met, partially met or not met.

32. Critical Thinking & the Nursing Process Critical thinking Thinking like a nurse

33. Critical Thinking Inquisitive Open-minded Flexible Fairminded