The Nursing Process

1. The Nursing Process

2. Why The Nursing Process • Important when seeking articulation with post secondary institutions • Problem Solving Method when providing patient care; Critical Thinking • Encourages students to focus on the patient instead of just the skills they are doing

3. What is the Nursing Process • Systematic process used by nurses to identify patient problems and develop an individualized plan of care • It achieves for the patient scientifically based, holistic, individualized care; the opportunity to work collaboratively with other nurses and continuity of care

4. The Parts of the Nursing Process: Assessment • Establish a database: Interview the patient to obtain a history Perform an examination Talk to the patient’s family and/or significant other Review the patient’s chart

5. Nursing Diagnosis • Interpret data obtained during the assessment Identify patient strengths and health problems Identify etiologies or causes of the problem

6. Outcome Identification and Planning • Establish priorities: Maslow’s Hierarchy Establish a goal (broad) and outcomes (more specific measurable criteria) Begin to plan interventions

7. Implementation • Perform nursing actions planned in the previous step Continue to collect data and to modify the plan of care as needed

8. Evaluation • Measures how well the patient has achieved the outcomes Based on this evaluation the nurse decides to terminate the plan of care, modify the plan of care, or continue the plan of care

9. How to Use the Nursing Process Patient Situation: Mr. Smith is a 70 y/o widower who is paralyzed from the waist down d/t an automobile accident he was involved in 1 year ago. He admitted himself into a Long Term Care Facility a month ago after the death of his wife. He has a loving relationship with his daughter who comes to visit him everyday and brings him lots of goodies to eat. He is 5 ft. 5 in. tall and weighs 250 lbs. He eats every- thing in sight and asks for double portions. He has a foley catheter in place, draining clear yellow urine. His vital signs are within normal limits. He has difficulty moving d/t his weight. In report in the morning, the nurse tells you that when she turned him, she noticed a quarter sized broken down area on his coccyx.

10. Assessment • Students underline all information which is important. • Students discuss why they feel this information is important • Students list all assessment data and break it down into psychosocial or physical( do not paraphrase) e.g. he is overweight instead of 5 ft. 5 in. and weighs 250 pounds

11. Nursing Diagnosis (Problem) Have students list the problems they feel Are the most important based on the data From the assessment 5 ft. 5 in. weighs 250 pounds Difficult to move d/t his weight Quarter sized broken area on his coccyx

12. Outcome Identification and Planning • Students use Maslow’s Hierarchy to prioritize (Physiological is high and becomes less important as needs move up the triangle) • Develop a goal Lose weight Increase activity Healing of broken down area

13. Outcome Identification, cont. • Have students decide how they will measure the goal (outcome) Lose weight Increase activity Healing of broken down area

14. Implementation • What can the student do to help with each problem? • Have students look up the problem in their books and list things they can do for each problem. • Students can speak to health care providers where they train.

15. Evaluation • Students decide if what they did helped the problem they chose or if new things need to be considered

16. PROBLEM SHEET NURA: 1160 Nurse Aide for Health Care Organizations I Client’s Initials:_____________________________Age:_____Diet:_______________ Medical/Surgical Diagnosis:_______________________________________________ Dictionary Definition of Medical/Surgical Diagnosis____________________________ ASSESSMENT DATA Vital Signs: Frequency______________________ T________P________R________BP________ Is your client receiving Oxygen?_____ Rate:_____ Route:__________ Does your client have an IV?_____ Solution:_______________ Rate:__________ MUSCULOSKELETAL Does your client require assistance with motor activity? Explain. Ambulation _______________ Transfer _______________ Positioning _______________ Turning _______________ Active/Passive Exercise ________________ Explanation:

17. INTEGUMENTARY SYSTEM Does your client need assistance with personal hygiene? Bath _______________ Oral Hygiene _______________ Bed Making _______________ Explanation: Is your client at risk of developing a decubitus ulcer?_____ Explain. CENTRAL NERVOUS SYSTEM Is your client experiencing pain?_____ Explain: Location:_______________________________________________________________ Frequency:______________________________________________________________ Severity:________________________________________________________________ Does your client have seizures?_____ Explain: Frequency:______________________________________________________________ Severity:________________________________________________________________ Does your client have sensory deficits?__________Explain type. Is your client confused?_____ Explain

18. GASTROINTESTINAL SYSTEM Type of diet your client is receiving:_________________________________________ Does your client need assistance with eating?_________ Explain: Is the amount of food or fluid consumed by your client measured?_____ If so indicate intake and/or percentage for 24 hours. Food Intake:__________% Breakfast Fluid Intake:__________cc Breakfast Food Intake:__________% Lunch Fluid Intake:__________cc Lunch Food Intake:__________% Supper Fluid Intake__________cc Supper Does your client have a feeding tube?_____ If so what type?_______________ Name of Feeding:____________________ Rate:__________ Does your client have a problem with bowel elimination?_____ Explain. URINARY SYSTEM Does your client have a foley catheter?_____ Is your client’s urine output measured?_____ If so indicate output for your shift. Output:__________cc Does your client require assistance in using the bed pan, urinal or bedside commode?_____ Explain why?

19. 1. List all problems which your client has. (Anything that has a yes answer is a problem. Remember to consider the vital signs, oxygen delivery, special diet, feeding tube, and IV.) List all data which supports the problem. (From assessment sheets) 2. List all the things that you can do to help with the problems that you listed above. Please have the number assigned to the problem correspond with the number for the interventions. PROBLEM IDENTIFICATION