Nursing fundamentals chptr 2
This presentation is the property of its rightful owner.
Sponsored Links
1 / 59

Nursing Fundamentals CHPTR 2 PowerPoint PPT Presentation


  • 106 Views
  • Uploaded on
  • Presentation posted in: General

Nursing Fundamentals CHPTR 2. NURSING PROCESS “The Recipe”. 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.

Download Presentation

Nursing Fundamentals CHPTR 2

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Nursing fundamentals chptr 2

Nursing FundamentalsCHPTR 2

NURSING PROCESS

“The Recipe”


The nursing process

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


Who writes the plan

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


The 5 step nursing process

The 5-Step Nursing Process

  • Data collection (Assessment.)

  • Diagnosis.

  • Planning and outcome identification.

  • Implementation.

  • Evaluation.


The nursing process uses critical thinking

The Nursing Process uses Critical Thinking

  • Critical thinking, problem-solving, and decision-making

  • These skills can be learned!


What is critical thinking

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)


Data collection assessment

Data Collection (assessment)


Purpose of data collection assessment

Purpose of Data collection (Assessment)

  • Why is data collection (assessment) important?


Nursing fundamentals chptr 2

  • 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


Nursing fundamentals chptr 2

  • 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


Sources of data

Sources of Data

  • Primary Source: The client.

  • Secondary Source: The client’s family members, other health care providers, and medical records.


Types of data

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


Is it a subjective b objective

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


Is it a subjective b objective1

Is it: A=subjective B=objective

  • Pulse 125


Is it a subjective b objective2

Is it: A=subjective B=objective

  • “I’m starving”


Is it a subjective b objective3

Is it: A=subjective B=objective

  • Pt. tells you he vomited


Is it a subjective b objective4

Is it: A=subjective B=objective

  • Greenish emesis


Is it a subjective b objective5

Is it: A=subjective B=objective

  • Toe with erythema


Is it a subjective b objective6

Is it: A=subjective B=objective

  • Sleeping with 2 pillows


Is it a subjective b objective7

Is it: A=subjective B=objective

  • I’m burping a lot


Is it a subjective b objective8

Is it: A=subjective B=objective

  • He is so tired


Is it a subjective b objective9

Is it: A=subjective B=objective

  • Blood pressure 146/82


Is it a subjective b objective10

Is it: A=subjective B=objective

  • He is crying and depressed


Is it a subjective b objective11

Is it: A=subjective B=objective

  • Pale, diaphoretic


Is it a subjective b objective12

Is it: A=subjective B=objective

  • My husband is acting like such a baby, he is whining about everything


Types of data collection

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.


Organizing data

Organizing Data

  • Collected information must be organized to be useful.


Documenting data

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.


Here is your client

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.


Diagnosis

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.


Nursing diagnosis is a three part statement

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


Type of diagnoses

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


Nursing fundamentals chptr 2

  • 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


Nursing fundamentals chptr 2

  • If your patient had troubling swallowing, you would say:

  • Potential for aspiration related to difficulty swallowing

  • Or

  • Possible airway obstruction related to difficulty swallowing


Here is your client1

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,


Types of nursing diagnosis

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.


Here is your client2

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


Planning

Planning

  • Set nursing goals

  • Nursing Orders


Here is your client3

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


Intervention

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


Types of nursing interventions

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.


Here is your client4

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?


What do you do with all the info collected

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.


The nursing care plan

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.


Implementation

Implementation

  • execution of the nursing care plan

  • It’s what YOU ARE ACTUALLY GOING TO DO


Evaluation

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


Here is your client5

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


Take blood pressure every 3 hours

Take blood pressure every 3 hours

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Instruct client to self medicate

Instruct client to self medicate

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Client state i exercise every day

Client state “ I exercise every day”

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Client will eat 75 of meal with assist

Client will eat 75% of meal with assist

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Anxiety related to hospitalization

Anxiety related to hospitalization

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Goal met client was able to state signs and symptoms of infection

Goal met-Client was able to state signs and symptoms of infection

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


The nursing assistants are taking the patients blood pressure now

The nursing assistants are taking the patients blood pressure now.

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Charting

CHARTING

  • In the world of nursing…

  • “if it’s not written, it was never done”

  • This turns into legal issues

  • Just because you did it and didn’t chart it, means it was NEVER done.


In review so what is the nursing process anyway

IN REVIEWSo what is the Nursing Process anyway

  • The fact that you have to do all the parts:D-D-P-I-E…takes a long time to get through therefore, it’s a process

  • Get it? It’s a process…NURSING PROCESS

  • And why do we take time out of our busy schedule to do this process….so nursing care can be consistent and not forgotten


Priority

PRIORITY

  • Remember that you may be able to choose 10 NANDAS for 1 pts problems but you really should only use the top 2 or maybe 3 at the most

  • You prob. Won’t have time to write more than 3


Remember

Remember…

  • The interventions you write down in order to care for the pt come from:

  • The Dr.s order

  • Your own idea of what you think needs to be done

  • Every nurse MUST follow the Dr.s orders. You don’t have to follow every intervention made by a nurse 


The end

THE END


  • Login