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Nursing Process
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  1. Nursing Process Nursing Fundamentals

  2. Introduction: Nursing Process • Communication tool • Organization tool

  3. Overview of the Nursing Process • Purpose is to provide client care that is: • Individualized • Holistic

  4. Holistic Health • Treat the Whole person • Mental • Spiritual • Social • Physical

  5. Overview of the Nursing Process • Process: • Purpose: • Individualized • Holistic • Effective • Efficient • Nursing CARE

  6. Overview of the Nursing Process • Consists of 5 steps • AD-PIE

  7. Nursing Process • Used throughout the life span

  8. Used in every care setting

  9. Small group questions: • What are the names of each of the steps? • What is the purpose of the nursing process?

  10. Assessment • Step #1 • Involves • Collecting data • Validating the data • Organizing the data • Interpreting the data • Documenting the data

  11. Assessment • Types of assessment: • Comprehensive • Focused • Ongoing

  12. Assessment • Comprehensive assessment • Baseline • Physical & psychosocial

  13. Assessment • Focused Assessment • Limited in scope • Screening for a specific problem • Short stay

  14. Assessment • Ongoing • Follow-up • Monitoring changes

  15. Assessment • Types of data • Subjective • Data from the client’s viewpoint • Interview • Objective • Observable & measurable • Physical assessment • Labs • Tests

  16. 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

  17. 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

  18. Which one of the following is objective data? • Nausea • Pain • Dizziness • Unsteady gait • Anxiety

  19. Which one of the following is subjective data? • Vomiting • Warm, moist skin • Head ache • Bruise on the right arm • Temperature 99.3 o F

  20. Diagnosis • Step 2 in the nursing process

  21. Nursing diagnosis: • “A clinical judgment… • about an individual, family or community… • responses to actual or potential health problems” • Forms the basis for nursing interventions

  22. Medical vs. Nursing diagnosis

  23. Medical vs. Nursing diagnosis

  24. Medical vs. Nursing diagnosis

  25. Medical vs. Nursing diagnosis

  26. Diangosis

  27. Planning & Outcome identification • Step 3

  28. Planning & Outcome identification • Types of planning • Initial • Ongoing • Discharge

  29. Planning & Outcome identification • Outcome identification = Goals • Short term • Hrs - days (< week) • Long term • Wks. – mons.

  30. Planning & Outcome identification • Interventions • Independent interventions • No MD order needed • Interdependent interventions • With interdisciplinary team member • Dependent interventions • MD order required

  31. The nursing care plan includes “administer digoxin per MD order”. What type of intervention is this? • Dependent • Interdependent • Independent

  32. Prioritizing Nrs Dx • Maslow’s hierarchy of needs

  33. Maslow’s Hierarchy of Needs

  34. Maslow’s Hierarchy of Needs • Physiological: • Breathing, food, water, sleep, homeostasis, excretion • ABC’s

  35. Maslow’s Hierarchy of Needs • Safety • Security of body, employment, resources, morality, family, health or property • Physiological

  36. Maslow’s Hierarchy of Needs • Love/Belonging • Friendship, family, sexual intimacy • Safety • Physiological:

  37. Maslow’s Hierarchy of Needs • Esteem • Self esteem, confidence, achievement, respect of others, respect by others • Love/Belonging • Safety • Physiological

  38. Maslow’s Hierarchy of Needs • Self-Actualization • Creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts • Esteem • Love/Belonging • Safety • Physiological:

  39. 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

  40. 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

  41. Implementation • 4th step: • Execution of the care plan • DO IT • DO IT RIGHT • DO IT RIGHT NOW! • Direct • Assist • Supervise • Delegate • Teach • Monitor

  42. Implementation • 5 Rights of Implementation • Right patient • Right medication • Right route • Right dose / amount • Right time

  43. Evaluation • 5th step • Have the clients goals have been met, partially met or not met.

  44. 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.

  45. Role of the LVN & Psych Tech • Use the nrs process • Contribute to Dx & nrs care plan • Provide info • Implement • The RN has ultimate responsibility

  46. Critical Thinking & the Nursing Process • Critical thinking • Thinking like a nurse

  47. Critical Thinking • Inquisitive • Open-minded • Flexible • Fairminded