Medical Tech Prep 1 Lancaster High School Mrs. Carpenter

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Medical Tech Prep 1Lancaster High SchoolMrs.
Carpenter

• CHAPTER 6 THE NURSING PROCESS
• Pages 73-80

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Objectives

• Explain the purpose of the nursing process
• Describe the steps of the nursing process
• Explain the role of the NA in each step of the
  nursing process
• Explain the difference between objective data and
  subjective data
• Identify the observations that you need to report
  to the nurse
• Explain the purpose of care conferences

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THE NURSING PROCESS

• Nurses share information about the person through
  the nursing process.
• The nursing process has five steps
• Assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation
• focuses on the persons nursing needs.
• Good communication is needed.
• Each step is important.

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THE NURSING PROCESS

• is organized and has purpose.
• team members have the same goals
• Team members do the same things
• Person feels safe and secure.
• ongoing
• changes as new information is gathered
• Changes as a persons needs change.

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THE NURSING PROCESS-ASSESSMENT

• involves collecting information about the person.
• many sources
• nursing history
• familys health history
• Information from the doctor
• Test results and past medical records
• The RN assesses the persons body systems and
  mental status.

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THE NURSING PROCESS-ASSESSMENT

• NA plays a key role in assessment.
• make many observations as care is given
• Observationusing the senses to collect
  information
• sight
• hearing
• touch
• smell

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ASSESSMENT-DATA

• objective data (signs).
• Information that is seen, heard, felt, or smelled
• Subjective data (symptoms).
• Information that a person tells you that you
  cannot observe through your senses
• Box 5-1 on page 75
• Make notes of your observations.

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APPLICATION OBJECTIVE OR SUBJECTIVE

• Painful knees
• Dirty fingernails
• Bloody discharge
• Nausea
• Laceration
• PERRLA
• Loose stool
• Blue lips
• Aggressive behavior
• Orange colored urine
• Malaise
• Nose bleed

• Headache
• Red nose
• Vomiting
• A red bruise
• Moist skin
• Tingling sensation
• Nausea
• Stomach pain
• Crying
• Oily hair
• Toothache
• Swollen feet

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Focus on long-term care assessment

• OBRA requires the minimum data set (MDS) for
  nursing center residents.
• MDS
• is an assessment and screening tool.
• is completed when the person is admitted
• is updated before each care conference.
• new MDS is completed once a year and whenever the
  persons condition changes.

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Focus on long-term care assessment

• Information contained on the MSDS
• Often uses information obtained through NA
  records
• Appendix B on page 822

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APPLICATIONPATIENT OBSERVATIONS-for each of
the patients in the beds you will be making
observations as if you are the nursing assistant
in charge of their care. Walk into each room
and make observations about the patient. Record
the observations on a sheet of paper and be
prepared to report to the RN (Mrs. Carpenter)
what you observed.
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THE NURSING PROCESS-NURSING DIAGNOSIS

• The RN uses assessment information to make a
  nursing diagnosis.
• nursing diagnosis describes a health problem
  treatable through nursing measures.
• Nursing diagnoses and medical diagnoses are not
  the same.
• medical diagnosis is the identification of a
  disease or condition by a doctor.
• A person can have many nursing diagnoses.

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THE NURSING PROCESS-NURSING DIAGNOSIS

• Nursing diagnoses involves needs
• Physical
• Emotional
• social
• spiritual
• common nursing diagnoses (seeBox 5-2 on pages 76
  and 77)

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The Nursing Process-PLANNING

• involves setting priorities and goals.
• measures or actions are chosen to help the person
  meet the goals.
• The person, family, and health team help plan
  care.
• Priorities are what is most important to the
  person.
• Maslows theory of basic needs is useful (Chapter
  6).
• Needs required for life and survival must be met
  before all others
• .

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The Nursing Process-PLANNING

• Goals
• A goalthat which is desired in or by a person as
  a result of nursing care.
• aimed at the persons highest level of well-being
  and functioning.
• Nursing interventions
• chosen after goals are set.
• action or measure taken to help the person reach
  a goal.
• does not need a doctors order.
• Some nursing measures come from a doctors order

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The Nursing Care Plan

• written guide about the persons care
• Includes nursing diagnoses and goals
• measures or actions for each goal
• Used as a communication tool
• See what care to give.
• Ensure that the nursing team gives the same care.
• found in the medical record, Kardex, or on
  computer.
• a care conference may be called to share
  information and
• ideas about the persons care.
• Nursing assistants usually take part in the
  conference.
• may change if the persons nursing diagnoses
  change.

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The Nursing Process-IMPLEMENTATION

• to perform or carry out nursing measures in the
  care plan.
• Care is given.
• The nurse delegates measures and tasks that are
  within your legal limits and job description.
• The nurse may ask you to assist with complex
  measures.
• report the care given to the nurse.
• record the care given if allowed by your agency
• Report or record new observations.
• may change the nursing diagnoses.
• know about any changes in the care plan.

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The Nursing Process-IMPLEMENTATIONAssignment
sheets

• Assignment sheets
• used to communicate delegated measures/tasks t
• An assignment sheet tells
• Each persons care
• What measures and tasks need to be done
• When to take meal and lunch breaks
• Which nursing unit tasks to do
• Talk to the nurse about any assignment that is
  unclear.
• Check the care plan and Kardex if you need more
  information.

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The Nursing Process-EVALUATION

• measuring if the goals in planning were met.
• 1. Progress is evaluated.
• 2. Assessment information is used.
• 3. Changes in nursing diagnoses, goals, and the
  care plan may result.

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The Nursing Process Never Ends.
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YOUR ROLE

• key role in the nursing process.
• Use of your observations for nursing diagnoses
  and planning.
• develop the care plan.
• perform nursing actions and measures in the care
  plan.
• Complete observations for evaluation

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APPLICATION

• STUDENT WORKBOOK 1-30

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QUESTIONS ???