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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.

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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)



Purpose of data collection assessment
Purpose of Data collection (Assessment)

  • Why is data collection (assessment) important?




Sources of data
Sources of Data 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

  • Primary Source: The client.

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


Types of data
Types of Data 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

  • 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 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

“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 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 B=objective

  • Pulse 125


Is it a subjective b objective2
Is it: A=subjective 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 B=objective

  • “I’m starving”


Is it a subjective b objective3
Is it: A=subjective 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 B=objective

  • Pt. tells you he vomited


Is it a subjective b objective4
Is it: A=subjective 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 B=objective

  • Greenish emesis


Is it a subjective b objective5
Is it: A=subjective 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 B=objective

  • Toe with erythema


Is it a subjective b objective6
Is it: A=subjective 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 B=objective

  • Sleeping with 2 pillows


Is it a subjective b objective7
Is it: A=subjective 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 B=objective

  • I’m burping a lot


Is it a subjective b objective8
Is it: A=subjective 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 B=objective

  • He is so tired


Is it a subjective b objective9
Is it: A=subjective 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 B=objective

  • Blood pressure 146/82


Is it a subjective b objective10
Is it: A=subjective 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 B=objective

  • He is crying and depressed


Is it a subjective b objective11
Is it: A=subjective 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 B=objective

  • Pale, diaphoretic


Is it a subjective b objective12
Is it: A=subjective 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 B=objective

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


Types of data collection
Types of Data Collection 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

  • 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 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

  • Collected information must be organized to be useful.


Documenting data
Documenting Data 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

  • 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. 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

  • 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 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

  • 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 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

  • 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 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

  • 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


  • If a pt is obese, you would say it’s an ACTUAL problem 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

  • Therefore, you would say that the nursing diagnoses for this pt is: over-nutrition related to the lack of education


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

  • Potential for aspiration related to difficulty swallowing

  • Or

  • Possible airway obstruction related to difficulty swallowing


Here is your client1
Here is your client. 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

  • 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 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

  • 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. 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

  • 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 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

  • Set nursing goals

  • Nursing Orders


Here is your client3
Here is your client. 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

  • 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 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

  • 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 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

  • 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. 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

  • 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? 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

  • 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 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

  • 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 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

  • execution of the nursing care plan

  • It’s what YOU ARE ACTUALLY GOING TO DO


Evaluation
Evaluation 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

  • 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. 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

  • 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 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

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Instruct client to self medicate
Instruct client to self medicate 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

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Client state i exercise every day
Client state “ I exercise every day” 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

  • 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 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

  • A. Data collection

  • B. Diagnosis

  • C. Planning

  • D. Implementation

  • E. Evaluation


Anxiety related to hospitalization
Anxiety related to hospitalization 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

  • 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 pressure now.

  • 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 REVIEW pressure now.So 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 pressure now.

  • 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… pressure now.

  • 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 pressure now.


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