1. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 5 Assisting With the Nursing Process

2. Slide 2 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  The nursing process is the method nurses use to plan and deliver nursing care. Assessment Assessment Nursing diagnosis Nursing diagnosis Planning Planning Implementation Implementation Evaluation Evaluation

3. Slide 3 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  If done in order with good communication: Nursing care is organized and has purpose. Nursing care is organized and has purpose. All nursing team members do the same things for the person. All nursing team members do the same things for the person. All nursing team members have the same goals. All nursing team members have the same goals. The person feels safe and secure with consistent care. The person feels safe and secure with consistent care.

4. Slide 4 Copyright © 2007, 2003 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. You make many observations as you give care and talk to the person.  Objective data (signs)  Subjective data (symptoms) The assessment step never ends. The assessment step never ends. New information is collected with every resident contact. New information is collected with every resident contact.

5. Slide 5 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  OBRA requires the minimum data set (MDS) for nursing center residents. The MDS is an assessment and screening tool. The MDS is an assessment and screening tool. The MDS is completed when the person is admitted to the center. The MDS is completed when the person is admitted to the center. The MDS is updated before each care conference. 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 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. The MDS is signed by an RN to show that it is complete and accurate.

6. Slide 6 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  NURSING DIAGNOSIS  The RN uses assessment information to make a nursing diagnosis.  A person can have many nursing diagnoses.  Nursing diagnoses: Involve the person’s physical, emotional, social, and spiritual needs Involve the person’s physical, emotional, social, and spiritual needs May change or new ones may be added as assessment information changes May change or new ones may be added as assessment information changes

7. Slide 7 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  PLANNING  Planning involves setting priorities and goals.  The needs are arranged in order of importance.  Goals are set.  Nursing interventions are chosen after goals are set. Interdisciplinary care planning conference is held to develop a comprehensive care plan. Interdisciplinary care planning conference is held to develop a comprehensive care plan.  The care plan includes: Nursing diagnoses and goals Nursing diagnoses and goals The person’s problems and actions to take to help the person solve health problems The person’s problems and actions to take to help the person solve health problems The person’s strengths The person’s strengths

8. Slide 8 Copyright © 2007, 2003 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 Talk to the nurse Check the care plan and Kardex Check the care plan and Kardex

9. Slide 9 Copyright © 2007, 2003 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. Changes in nursing diagnoses, goals, and the care plan may result.  The nursing process never ends.

10. Slide 10 Copyright © 2007, 2003 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.  You perform nursing actions and measures in the care plan.  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. The person may refuse actions suggested by the health team.