The Use of The Nursing Process Nursing Diagnosis in the Care of The Older Adult

1. The Use of The Nursing Process Nursing Diagnosis in the Care of The Older Adult Chapter 3 (4thed) 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. 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 • 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

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