Nursing Fundamentals CHPTR 2

1. Nursing FundamentalsCHPTR 2 NURSING PROCESS “The Recipe”

2. The Nursing Process • A systematic method of providing care to clients. • It’s a system that nurses use to provide efficient and effective nursing care • If we didn’t use some sort of standardized care, nursing would be a chaotic mess

3. Who writes the plan • RN should begin the plan and sign it • LPN can help and doesn’t need to sign it necessarily • The RN takes the lead role here

4. The 5-Step Nursing Process • Data collection (Assessment.) • Diagnosis. • Planning and outcome identification. • Implementation. • Evaluation.

5. The Nursing Process uses Critical Thinking • Critical thinking, problem-solving, and decision-making • These skills can be learned!

6. WHAT IS CRITICAL THINKING? • Critical thinking is a process of objective reasoning or analyzing facts to reach a valid conclusion • Critical thinking allows nurses to determine which problems are necessary to call the Dr. about or which fall into the domain of Nursing judgment (where you don’t need a Dr’s order)

7. Data Collection (assessment)

8. Purpose of Data collection (Assessment) • Why is data collection (assessment) important?

9. Data collection is important because it tells you facts about the patient. • Data collection 1st begins when you see the pt. for the 1st time and it cont’s until the pt. is released

10. It is during data collection period that the nurse collects info. to determine areas of abnormal function, risk factors that contribute to the pts health problems and it helps the nurse find the pts strengths

11. Sources of Data • Primary Source: The client. • Secondary Source: The client’s family members, other health care providers, and medical records.

12. Types of Data • Subjective:it’s what the patient SAYS or STATES. This is also the symptoms someone c/o • Objective:it’s what you observe. It’s observable and measurable data obtained through physical examination and laboratory and diagnostic testing. This is also what signs the pt shows you

13. 125lbs “I’m starving” greenish emesis The Pt tell you he vomited greenish fluid Erythematous toe “I’m burping a lot” “my heart is racing” “like a knife stabbing me” Sleeps with 2 pillows 146/89 Pinpoint pupils “He is so tired” Pale, diaphoretic O2 sat = 91% on room air Is it: A=subjective B=objective

14. Is it: A=subjective B=objective • Pulse 125

15. Is it: A=subjective B=objective • “I’m starving”

16. Is it: A=subjective B=objective • Pt. tells you he vomited

17. Is it: A=subjective B=objective • Greenish emesis

18. Is it: A=subjective B=objective • Toe with erythema

19. Is it: A=subjective B=objective • Sleeping with 2 pillows

20. Is it: A=subjective B=objective • I’m burping a lot

21. Is it: A=subjective B=objective • He is so tired

22. Is it: A=subjective B=objective • Blood pressure 146/82

23. Is it: A=subjective B=objective • He is crying and depressed

24. Is it: A=subjective B=objective • Pale, diaphoretic

25. Is it: A=subjective B=objective • My husband is acting like such a baby, he is whining about everything

26. Types of Data Collection • Comprehensive - Provides baseline data including complete health history and current needs assessment. • Focused - Limited in scope in order to focus on a particular need or concern or potential risk. • Ongoing - Includes systematic monitoring and observation related to specific problems.

27. Organizing Data • Collected information must be organized to be useful.

28. Documenting Data • Data collection must be recorded and reported. • Accurate and complete recording of your data collection is essential for communicating information to health care team.

29. Here is your client. • 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, • Write out some data you collected and decide if subjective or objective.

30. Diagnosis • A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state. • A nursing diagnosis is a clinical judgment by the nurse about individual, family, or community responses to actual or potential health problems/life processes.

31. Nursing Diagnosis is a Three Part Statement • The name of the health-related issue or problem identified in the NANDA list (see the inside back cover of your book) • Etiology - the cause or contributor to the problem. • Signs and Symptoms

32. TYPE OF DIAGNOSES • You must state whether your nursing problem is one of the following: • An actual problem • A risk for a problem to occur • And then you must relate it to something

33. If a pt is obese, you would say it’s an ACTUAL problem • Therefore, you would say that the nursing diagnoses for this pt is: over-nutrition related to the lack of education

34. If your patient had troubling swallowing, you would say: • Potential for aspiration related to difficulty swallowing • Or • Possible airway obstruction related to difficulty swallowing

35. Here is your client. • 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

36. Types of Nursing Diagnosis • Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms. • Hi Risk nursing diagnosis: A problem does not yet exist, but special risk factors are present.

37. Here is your client. • 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, • Write a nursing diagnosis • ___________ r/t ____________ #1 #2 #3

38. Planning • Set nursing goals • Nursing Orders

39. Here is your client. • 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, • Write a goal related to the diagnosis

40. Intervention • A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes. • It’s what you are ACTUALLY GOING TO DO OR CARRY OUT

41. Types of Nursing Interventions • Specific order - written by physician or nurse especially for an individual client. • Standing order - A standardized intervention written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention. • Protocol - A series of standing orders or procedures.

42. Here is your client. • 68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance, • What interventions will you plan to do or have others do?

43. WHAT DO YOU DO WITH ALL THE INFO. COLLECTED? • You write a nursing care plan • This plan tells others how to care for the pt. IN A SYSTEMATIC, CONSISTENT WAY • Nurses won’t have to reinvent the wheel everyday that they care for this pt.

44. The Nursing Care Plan • A written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.

45. Implementation • execution of the nursing care plan • It’s what YOU ARE ACTUALLY GOING TO DO

46. Evaluation • determining whether client goals have been met, partially met, or not met. • It is in this stage that you will decide what needs to be changed to make the goal happen even more • It’s improvement after you see how it’s going

47. Here is your client. • 3 weeks later…gain 2 lbs……states “ I went to the senior center twice last week and had lunch. • Evaluate progress

48. Take blood pressure every 3 hours • A. Data collection • B. Diagnosis • C. Planning • D. Implementation • E. Evaluation

49. Instruct client to self medicate • A. Data collection • B. Diagnosis • C. Planning • D. Implementation • E. Evaluation

50. Client state “ I exercise every day” • A. Data collection • B. Diagnosis • C. Planning • D. Implementation • E. Evaluation