Chapter 7

1. Chapter 7 Assisting With the Nursing Process

2. The nursing process is the method nurses use to plan and deliver nursing care. • The five steps of the nursing process are: • Assessment • Nursing diagnosis • Planning • Implementation • Evaluation

3. If done in order with good communication: • Nursing care is organized and has purpose. • All nursing team members do the same things for the person. • All nursing team members have the same goals. • The person feels safe and secure with consistent care.

4. Assessment • Assessment involves collecting information about 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. • New information is collected with every resident contact.

5. OBRA requires the minimum data set (MDS) for nursing center residents. • The MDS is begun when the person is admitted to the center. • The MDS is an assessment and screening tool. • The MDS is completed when the person is admitted to the center. • 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 signed by an RN to show that it is complete and accurate.

6. Nursing Diagnosis • The RN uses assessment information to make a nursing diagnosis. • A person can have multiple nursing diagnoses. • Nursing diagnoses: • Involve the person’s physical, emotional, social, and spiritual needs • May change or new ones may be added as assessment information changes

7. Planning • Planning involves setting priorities and goals. • Priorities relate to what is most important for the person. • Goals are set. • Nursing interventions are chosen after goals are set. • An interdisciplinary care planning conference is held to develop a comprehensive care plan.

8. The care plan includes: • Nursing diagnoses and goals • The person’s problems and actions to take to help the person solve health problems • The person’s strengths • Care Area Assessments (CAAs) • Guidelines used to develop the person’s care plans • Minimum data set (MDS gives triggers for CAAs) • Care plan forms vary: • In the chart • In a notebook • In a Kardex • On computer

9. 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. • Check the care plan and Kardex.

10. Assignment Sheets • Assignment sheet is used to communicate tasks to you. • Assignment sheets tell you about: • Each person’s care • What measurements and tasks need to be done • Which nursing unit tasks to do • Use the assignment sheet to organize your work and to set priorities. • What to do first • What to do when the person is at therapy or a meal • On which tasks will you need help • Check off tasks as you complete them.

11. 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. • The nursing process never ends.

12. Your Role • The nurse uses your observations for nursing diagnoses, planning, and evaluation. • You may help develop the care plan. • In the implementation step, you perform nursing actions and measures in the care plan.

13. 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.