FUNDAMENTALS OF NURSING

1. FUNDAMENTALS OF NURSING Lesson #25 THE NURSING PROCESS

2. THE NURSING PROCESS • Review Maslow’s Hierarchy • Review ADPIE • Know conversion: • Gram to mg • Tsp to ml • Etc.

3. 5 PHASES: THE NURSING PROCESS • ASSESSMENT: • Appraisal of a condition • Continuous throughout pt care • Gathering of info to determine health status • All phases dependent upon accurateness of initial data collection • Nurse judgment on how in depth or focused an assessment should be

4. 5 PHASES: THE NURSING PROCESS • ASSESSMENT: • METHODS TO COLLECT DATA: • Interview for health history • Physical exam for objective data

5. 5 PHASES: THE NURSING PROCESS • ASSESSMENT: • Physical exam: • By system • Head to toe • Uses inspection, percussion, palpation, & auscultation

6. 5 PHASES: THE NURSING PROCESS • ASSESSMENT: • DATA CLUSTERING: • Use assessment data • Use past medical data • Use biographical data • Use psychosocial status Maslow’s will help assist with prioritization of problems

7. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • Identifying type & cause of health condition & factors causing problem • Problem: • Any health care condition requiring: • Diagnostic tests • Therapeutic care • Education

8. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • Guidelines to cue need for action: • Change in pt’s usual pattern • Change from normal fx of body systems • Difference from normal patterns of growth and development

9. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • NANDA: • North American Nursing Diagnosis Association • A clinical judgment about an individual, family, or community’s response to actual or high risk health problems • Changed every two years…

10. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • Nursing diagnosis: • Basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable • NOTE: the nurse must be legally able to ID and prescribe interventions to treat or prevent a problem • If this cannot be done, it is not a nursing diagnosis

11. 5 PHASES: THE NURSING PROCESS

12. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • Nursing diagnosis components: • Nursing diagnosis or title…use adjectives • Definition: needs to be differentiated from similar diagnosis • Contributing/etiological/related factors in the development of the problem • Defining characteristics: subjective/objective data, clinical s/s • Written “as evidenced by”

13. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • 4 Types of nursing diagnosis: • Actual: a condition that presently exists • High Risk: clinical judgment of risks the nurse is aware of • Possible: need additional information prior to making a diagnosis • Wellness: clinical judgment of wellness with goal to reach higher level of wellness

14. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • Establish the nursing diagnosis: • First part must be NANDA approved • Diagnosis can be actual or high risk • CANNOT be a medical diagnosis • Diagnosis addresses what nurse can do for pt

15. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • Establish the nursing diagnosis: • Second part is etiology or contributing factors • More than one contributing factor may be indentified • Examples… • CANNOT use words that mean the same thing…fluid volume deficit and dehydration

16. 5 PHASES: THE NURSING PROCESS • DIAGNOSING: • Other types of diagnosis: • Collaborative • A complication from every pathophysiologic response from the body • Medical • Identification of a disease or condition by scientific evaluation of s/s • Diagnosed by physicians

17. 5 PHASES: THE NURSING PROCESS • PLANNING: • Goal to decrease, solve, or prevent the problem • Have to set priorities using Maslow’s Hierarchy • Lower level must be met first • Life threatening problems are ranked HIGHEST • The pt should be consulted as to how they would prioritize their problems • Diagnosis and priorities are constantly changing NURSES PRIORITIZE: #1 MASLOW’S #2 DEGREE OF THREAT TO LIFE #3 PT PREFERENCE

18. 5 PHASES: THE NURSING PROCESS • PLANNING: • Establish desired outcomes • Pt centered goals or desired pt outcome • State what pt will be able to do, not nursing action • Example: • Pt will be able to ambulate 400 ft within 2 days with assist

19. 5 PHASES: THE NURSING PROCESS • PLANNING: • Establish desired outcomes • The nurse predicts the degree of wellness desired or expected • The goal is purpose to which effort is directed • Goals should be patient centered, specific, & measurable behavior that the pt will exhibit, NOT THE NURSE • Start with PT WILL……

20. 5 PHASES: THE NURSING PROCESS • PLANNING: • GOALS: • Should be measurable whether met or not • A well written goal: • Uses the word “patient” • Uses a measurable verb • Is specific for the pt and the problem • Is realistic • Includes time frame for re-evaluation

21. 5 PHASES: THE NURSING PROCESS • PLANNING: • GOALS: • Goal statement should begin with “pt will” • Pt will consume 20% of meal… • Pt will ambulate • Use action verb • Be specific • Be realistic Short term goals: 24 hours, 3 hours, etc. • Long term goals: 1 week or more

22. 5 PHASES: THE NURSING PROCESS • PLANNING: • NURSING INTERVENTIONS: • Actions that should promote achievement of goal • Can be: • Nursing skill activity • Monitoring high risk problems • Carrying out physician orders • Example: • Encourage intake by offering 250cc of fluid q 2 hours for a goal of 2000cc daily

23. 5 PHASES: THE NURSING PROCESS • PLANNING: • NURSING INTERVENTIONS: • Actions that should promote achievement of goal • Can be: • Independent: the nurse performs on own • Dependent: prescribed by physician • Nurse must use own judgment and pt assessment skills • Interdependent: nurse and other members of health care team perform • PT, OT, social worker, etc

24. 5 PHASES: THE NURSING PROCESS • PLANNING: • NURSING INTERVENTIONS: • When determining interventions: • Consider disease etiology • Related factors • The goals • The nursing diagnosis

25. 5 PHASES: THE NURSING PROCESS • PLANNING: • NURSING INTERVENTIONS: • Writing nursing orders: • Use care plan books • Nursing orders must include: • Date and signature • Subject • Action verb • Qualifying details

26. 5 PHASES: THE NURSING PROCESS • PLANNING: • NURSING INTERVENTIONS: • Writing nursing orders: • If nurse is the subject this does not need to be written • Other agencies should be listed when applicable

27. 5 PHASES: THE NURSING PROCESS • PLANNING: • NURSING INTERVENTIONS: • Writing nursing orders: • Order should be: • Written for nurses • Realistic for pt • Correlate with medical plan of care (POC) • Based on scientific problems

28. 5 PHASES: THE NURSING PROCESS • PLANNING: • NURSING INTERVENTIONS: • Writing nursing orders: • Communicate POC to all nurses for continuity of care • Best individualized care plans are hand written • Only use books/internet as guidelines

29. 5 PHASES: THE NURSING PROCESS • IMPLEMENTING: • Putting interventions into action or performing nursing actions • This is where DOCUMENTATION takes place • Ongoing data collection takes place: • Prioritizing actions • Cancelling planned actions

30. 5 PHASES: THE NURSING PROCESS • IMPLEMENTING: • Interventions may be nursing or physician prescribed • Documentation important in this phase • You might also: • Teach • Counsel • Monitor • Administer meds • Etc

31. 5 PHASES: THE NURSING PROCESS • EVALUATING: • Have the outcomes or goals been achieved? • Compare desired outcomes with actual outcomes • Review the goals • Reassess the pt • Assess the data to see if the measurable goal has been achieved • Use critical judgment to determine if the goal was achieved

32. 5 PHASES: THE NURSING PROCESS • EVALUATING: • Have the outcomes or goals been achieved? • 3 choices • Goal met • Goal not met • Goal partially met • If goal achieved: • Care plan is resolved

33. 5 PHASES: THE NURSING PROCESS • EVALUATING: • Have the outcomes or goals been achieved? • If goal is not achieved: • Care plan is revised • Review all phases of the nursing process ***CHANGES DONE BASED ON ONGOING EVALUATION

34. 5 PHASES: THE NURSING PROCESS • ROLE OF THE LPN: • Key as bedside nurse to assess, prioritize, document, implement, and reevaluate • A key team member

35. THAT’S ALL FOLKS!!!