Nursing Process Nursing Fundamental

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Nursing Process

• Nursing Fundamentals

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Introduction Nursing Process

• Communication tool
• Organization tool

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Overview of the Nursing Process

• Purpose is to provide client care that is
• Individualized
• Holistic

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Holistic Health

• Treat the Whole person
• Mental
• Spiritual
• Social
• Physical

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Overview of the Nursing Process

• Process
• Purpose
• Individualized
• Holistic
• Effective
• Efficient

• Nursing CARE

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Overview of the Nursing Process

• Consists of 5 steps
• AD-PIE

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Nursing Process

• Used throughout the life span

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• Used in every care setting

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Small group questions

1. What are the names of each of the steps?
2. What is the purpose of the nursing process?

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Assessment

• Step 1
• Involves
• Collecting data
• Validating the data
• Organizing the data
• Interpreting the data
• Documenting the data

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Assessment

• Types of assessment
• Comprehensive
• Focused
• Ongoing

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Assessment

• Comprehensive assessment
• Baseline
• Physical psychosocial

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Assessment

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

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Assessment

• Ongoing
• Follow-up
• Monitoring changes

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Assessment

• Types of data
• Subjective
• Data from the clients viewpoint
• Interview
• Objective
• Observable measurable
• Physical assessment
• Labs
• Tests

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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

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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

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Which one of the following is objective data?

1. Nausea
2. Pain
3. Dizziness
4. Unsteady gait
5. Anxiety

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Which one of the following is subjective data?

1. Vomiting
2. Warm, moist skin
3. Head ache
4. Bruise on the right arm
5. Temperature 99.3 o F

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Diagnosis

• Step 2 in the nursing process

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Nursing diagnosis

• A clinical judgment
• about an individual, family or community
• responses to actual or potential health
  problems
• Forms the basis for nursing interventions

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Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Identifies conditions the MD is licensed qualified to treat Identifies situations the nurse is licensed qualified to treat

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Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Identifies conditions the MD is licensed qualified to treat Identifies situations the nurse is licensed qualified to treat
Focuses on illness, injury or disease processes Focuses on the clients responses to actual or potential health / life problems
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Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Remains constant until a cure is effected Changes as the clients response and/or the health problem changes

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Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Remains constant until a cure is effected Changes as the clients response and/or the health problem changes
i.e. Breast cancer i.e. Knowledge deficit Powerlessness Grieving, anticipatory Body image disturbance Individual coping, ineffective
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Diangosis
Nursing diagnosis Medical diagnosis
Breathing patterns, ineffective Chronic obstructive pulmonary disease
Activity intolerance Cerebrovascular accident
Pain Appendectomy
Body image disturbance Amputation
Body temperature, risk for altered Strep throat
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Planning Outcome identification

• Step 3

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Planning Outcome identification

• Types of planning
• Initial
• Ongoing
• Discharge

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Planning Outcome identification

• Outcome identification Goals
• Short term
• Hrs - days (lt week)
• Long term
• Wks. mons.

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Planning Outcome identification

• Interventions
• Independent interventions
• No MD order needed
• Interdependent interventions
• With interdisciplinary team member
• Dependent interventions
• MD order required

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The nursing care plan includes administer
digoxin per MD order. What type of intervention
is this?

1. Dependent
2. Interdependent
3. Independent

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The nursing care plan includes Check apical
pulse before administering digoxin. What type of
intervention is this?

• Dependent
• Interdependent
• Independent

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A Client is dehydrated. The nursing care plan
includes encourage the patient to drink fluids
every hour. What type of intervention is this?

• Dependent
• Interdependent
• Independent

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Prioritizing Nrs Dx

• Maslows hierarchy of needs

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Maslows Hierarchy of Needs
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Maslows Hierarchy of Needs

• Physiological
• Breathing, food, water, sleep, homeostasis,
  excretion
• ABCs

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Maslows Hierarchy of Needs

• Safety
• Security of body, employment, resources,
  morality, family, health or property
• Physiological

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Maslows Hierarchy of Needs

• Love/Belonging
• Friendship, family, sexual intimacy
• Safety
• Physiological

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Maslows Hierarchy of Needs

• Esteem
• Self esteem, confidence, achievement, respect of
  others, respect by others
• Love/Belonging
• Safety
• Physiological

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Maslows Hierarchy of Needs

• Self-Actualization
• Creativity, spontaneity, problem solving, lack of
  prejudice, acceptance of facts
• Esteem
• Love/Belonging
• Safety
• Physiological

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Which of the following client issues should
receive the highest priority?

1. Johns best friend just stormed out of the room
   mad.
2. Todd feels like not one respects his work
3. Mary feels scared she is going to die
4. Anna feels like she is lacking in creativity

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Which of the following client issues should
receive the highest priority?

1. George is climbing out of bed and he cant walk
2. Paul is having a difficulty breathing
3. Susan is crying hysterically because she just
   found out the person who was driving in the car
   with her, died in the car accident.
4. Jane has severe hip pain due to post-op hip
   surgery

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Implementation

• 4th step
• Execution of the care plan
• DO IT
• DO IT RIGHT
• DO IT RIGHT NOW!

• Direct
• Assist
• Supervise
• Delegate
• Teach
• Monitor

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Implementation

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

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Evaluation

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

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Small group questions

1. What is the purpose of the nursing process and
   where is it used?
2. Name describe the steps of the nursing process
3. Explain the difference between objective and
   subjective data.
4. Define holistic and explain how it relates to
   nursing.

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Role of the LVN Psych Tech

• Use the nrs process
• Contribute to Dx nrs care plan
• Provide info
• Implement
• The RN has ultimate responsibility

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Critical Thinking the Nursing Process

• Critical thinking
• Thinking like a nurse

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Critical Thinking

• Inquisitive
• Open-minded
• Flexible
• Fairminded