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.
Nursing Process Nursing Fundamentals
Introduction: Nursing Process • Communication tool • Organization tool
Overview of the Nursing Process • Purpose is to provide client care that is: • Individualized • Holistic
Holistic Health • Treat the Whole person • Mental • Spiritual • Social • Physical
Overview of the Nursing Process • Process: • Purpose: • Individualized • Holistic • Effective • Efficient • Nursing CARE
Overview of the Nursing Process • Consists of 5 steps • AD-PIE
Nursing Process • Used throughout the life span
Small group questions: • What are the names of each of the steps? • What is the purpose of the nursing process?
Assessment • Step #1 • Involves • Collecting data • Validating the data • Organizing the data • Interpreting the data • Documenting the data
Assessment • Types of assessment: • Comprehensive • Focused • Ongoing
Assessment • Comprehensive assessment • Baseline • Physical & psychosocial
Assessment • Focused Assessment • Limited in scope • Screening for a specific problem • Short stay
Assessment • Ongoing • Follow-up • Monitoring changes
Assessment • Types of data • Subjective • Data from the client’s viewpoint • Interview • Objective • Observable & measurable • Physical assessment • Labs • Tests
iClicker John is being admitted to the psychiatric facility, after being transferred from the acute hospital with a diagnosis of schizophrenia and multiple sclerosis. What type of assessment should be performed on John? • Comprehensive • Focused • Ongoing
Small group questions: • Baby Jane a 2 month infant goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform? A. Comprehensive B. Focused C. Ongoing
Which one of the following is objective data? • Nausea • Pain • Dizziness • Unsteady gait • Anxiety
Which one of the following is subjective data? • Vomiting • Warm, moist skin • Head ache • Bruise on the right arm • Temperature 99.3 o F
Diagnosis • Step 2 in the nursing process
Nursing diagnosis: • “A clinical judgment… • about an individual, family or community… • responses to actual or potential health problems” • Forms the basis for nursing interventions
Planning & Outcome identification • Step 3
Planning & Outcome identification • Types of planning • Initial • Ongoing • Discharge
Planning & Outcome identification • Outcome identification = Goals • Short term • Hrs - days (< week) • Long term • Wks. – mons.
Planning & Outcome identification • Interventions • Independent interventions • No MD order needed • Interdependent interventions • With interdisciplinary team member • Dependent interventions • MD order required
The nursing care plan includes “administer digoxin per MD order”. What type of intervention is this? • Dependent • Interdependent • Independent
Prioritizing Nrs Dx • Maslow’s hierarchy of needs
Maslow’s Hierarchy of Needs • Physiological: • Breathing, food, water, sleep, homeostasis, excretion • ABC’s
Maslow’s Hierarchy of Needs • Safety • Security of body, employment, resources, morality, family, health or property • Physiological
Maslow’s Hierarchy of Needs • Love/Belonging • Friendship, family, sexual intimacy • Safety • Physiological:
Maslow’s Hierarchy of Needs • Esteem • Self esteem, confidence, achievement, respect of others, respect by others • Love/Belonging • Safety • Physiological
Maslow’s Hierarchy of Needs • Self-Actualization • Creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts • Esteem • Love/Belonging • Safety • Physiological:
Which of the following client issues should receive the highest priority? • John’s best friend just stormed out of the room mad. • Todd feels like not one respects his work • Mary feels scared she is going to die • Anna feels like she is lacking in creativity
Which of the following client issues should receive the highest priority? • George is climbing out of bed and he can’t walk • Paul is having a difficulty breathing • Susan is crying hysterically because she just found out the person who was driving in the car with her, died in the car accident. • Jane has severe hip pain due to post-op hip surgery
Implementation • 4th step: • Execution of the care plan • DO IT • DO IT RIGHT • DO IT RIGHT NOW! • Direct • Assist • Supervise • Delegate • Teach • Monitor
Implementation • 5 Rights of Implementation • Right patient • Right medication • Right route • Right dose / amount • Right time
Evaluation • 5th step • Have the clients goals have been met, partially met or not met.
Small group questions: • What is the purpose of the nursing process and where is it used? • Name & describe the steps of the nursing process • Explain the difference between objective and subjective data. • Define holistic and explain how it relates to nursing.
Role of the LVN & Psych Tech • Use the nrs process • Contribute to Dx & nrs care plan • Provide info • Implement • The RN has ultimate responsibility
Critical Thinking & the Nursing Process • Critical thinking • Thinking like a nurse
Critical Thinking • Inquisitive • Open-minded • Flexible • Fairminded