Nursing Fundamentals CHPTR 2

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Nursing FundamentalsCHPTR 2

• NURSING PROCESS
• The Recipe

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The Nursing Process

• A systematic method of providing care to clients.
• Its a system that nurses use to provide
  efficient and effective nursing care
• If we didnt use some sort of standardized care,
  nursing would be a chaotic mess

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Who writes the plan

• RN should begin the plan and sign it
• LPN can help and doesnt need to sign it
  necessarily
• The RN takes the lead role here

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The 5-Step Nursing Process

• Data collection (Assessment.)
• Diagnosis.
• Planning and outcome identification.
• Implementation.
• Evaluation.

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The Nursing Process uses Critical Thinking

• Critical thinking, problem-solving, and
  decision-making
• These skills can be learned!

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WHAT IS CRITICAL THINKING?

• Critical thinking is a process of objective
  reasoning or analyzing facts to reach a valid
  conclusion
• Critical thinking allows nurses to determine
  which problems are necessary to call the Dr.
  about or which fall into the domain of Nursing
  judgment (where you dont need a Drs order)

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Data Collection (assessment)
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Purpose of Data collection (Assessment)

• Why is data collection (assessment) important?

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• Data collection is important because it tells you
  facts about the patient.
• Data collection 1st begins when you see the pt.
  for the 1st time and it conts until the pt. is
  released

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• It is during data collection period that the
  nurse collects info. to determine areas of
  abnormal function, risk factors that contribute
  to the pts health problems and it helps the nurse
  find the pts strengths

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Sources of Data

• Primary Source The client.
• Secondary Source The clients family members,
  other health care providers, and medical records.

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Types of Data

• Subjective its what the patient SAYS or STATES.
  This is also the symptoms someone c/o
• Objective its what you observe. Its
  observable and measurable data obtained through
  physical examination and laboratory and
  diagnostic testing. This is also what signs the
  pt shows you

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Is it Asubjective Bobjective

• 125lbs
• Im starving
• greenish emesis
• The Pt tell you he vomited
• greenish fluid
• Erythematous toe
• Im burping a lot
• my heart is racing

• like a knife stabbing me
• Sleeps with 2 pillows
• 146/89
• Pinpoint pupils
• He is so tired
• Pale, diaphoretic
• O2 sat 91 on room air

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Is it Asubjective Bobjective

• Pulse 125

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Is it Asubjective Bobjective

• Im starving

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Is it Asubjective Bobjective

• Pt. tells you he vomited

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Is it Asubjective Bobjective

• Greenish emesis

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Is it Asubjective Bobjective

• Toe with erythema

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Is it Asubjective Bobjective

• Sleeping with 2 pillows

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Is it Asubjective Bobjective

• Im burping a lot

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Is it Asubjective Bobjective

• He is so tired

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Is it Asubjective Bobjective

• Blood pressure 146/82

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Is it Asubjective Bobjective

• He is crying and depressed

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Is it Asubjective Bobjective

• Pale, diaphoretic

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Is it Asubjective Bobjective

• My husband is acting like such a baby, he is
  whining about everything

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Types of Data Collection

• Comprehensive - Provides baseline data including
  complete health history and current needs
  assessment.
• Focused - Limited in scope in order to focus on a
  particular need or concern or potential risk.
• Ongoing - Includes systematic monitoring and
  observation related to specific problems.

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Organizing Data

• Collected information must be organized to be
  useful.

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Documenting Data

• Data collection must be recorded and reported.
• Accurate and complete recording of your data
  collection is essential for communicating
  information to health care team.

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Here is your client.

• 68 yr old male, lost wife three months ago, has
  not been out to his senior center since his wife
  died, loss of 15 lbs in 1month, disheveled
  appearance,
• Write out some data you collected and decide if
  subjective or objective.

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Diagnosis

• A medical diagnosis is a clinical judgment by the
  physician that determines a specific disease,
  condition or pathological state.
• A nursing diagnosis is a clinical judgment by the
  nurse about individual, family, or community
  responses to actual or potential health
  problems/life processes.

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Nursing Diagnosis is a Three Part Statement

• The name of the health-related issue or problem
  identified in the NANDA list (see the inside back
  cover of your book)
• Etiology - the cause or contributor to the
  problem.
• Signs and Symptoms

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TYPE OF DIAGNOSES

• You must state whether your nursing problem is
  one of the following
• An actual problem
• A risk for a problem to occur
• And then you must relate it to something

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• If a pt is obese, you would say its an ACTUAL
  problem
• Therefore, you would say that the nursing
  diagnoses for this pt is over-nutrition related
  to the lack of education

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• If your patient had troubling swallowing, you
  would say
• Potential for aspiration related to difficulty
  swallowing
• Or
• Possible airway obstruction related to difficulty
  swallowing

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Here is your client.

• 68 yr old male, lost wife three months ago, has
  not been out to his senior center since his wife
  died, loss of 15 lbs in 1month, disheveled
  appearance,

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Types of Nursing Diagnosis

• Actual nursing diagnosis A problem exists it is
  composed of the diagnostic label, related
  factors, and signs and symptoms.
• Hi Risk nursing diagnosis A problem does not yet
  exist, but special risk factors are present.

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Here is your client.

• 68 yr old male, lost wife three months ago, has
  not been out to his senior center since his wife
  died, loss of 15 lbs in 1month, disheveled
  appearance,
• Write a nursing diagnosis
• ___________ r/t ____________ 1
  2 3

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Planning

• Set nursing goals
• Nursing Orders

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Here is your client.

• 68 yr old male, lost wife three months ago, has
  not been out to his senior center since his wife
  died, loss of 15 lbs in 1month, disheveled
  appearance,
• Write a goal related to the diagnosis

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Intervention

• A nursing intervention is an action performed by
  the nurse that helps the client achieve the
  results specified by the goals and expected
  outcomes.
• Its what you are ACTUALLY GOING TO DO OR CARRY
  OUT

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Types of Nursing Interventions

• Specific order - written by physician or nurse
  especially for an individual client.
• Standing order - A standardized intervention
  written, approved and signed by a physician that
  is kept on file to be used in predictable
  situations or in circumstances requiring
  immediate attention.
• Protocol - A series of standing orders or
  procedures.

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Here is your client.

• 68 yr old male, lost wife three months ago, has
  not been out to his senior center since his wife
  died, loss of 15 lbs in 1month, disheveled
  appearance,
• What interventions will you plan to do or have
  others do?

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WHAT DO YOU DO WITH ALL THE INFO. COLLECTED?

• You write a nursing care plan
• This plan tells others how to care for the pt. IN
  A SYSTEMATIC, CONSISTENT WAY
• Nurses wont have to reinvent the wheel everyday
  that they care for this pt.

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The Nursing Care Plan

• A written guide that organizes data about a
  clients care into a formal statement of the
  strategies that will be implemented to help the
  client achieve optimal health.

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Implementation

• execution of the nursing care plan
• Its what YOU ARE ACTUALLY GOING TO DO

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Evaluation

• determining whether client goals have been met,
  partially met, or not met.
• It is in this stage that you will decide what
  needs to be changed to make the goal happen even
  more
• Its improvement after you see how its going

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Here is your client.

• 3 weeks latergain 2 lbsstates I went to the
  senior center twice last week and had lunch.
• Evaluate progress

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Take blood pressure every 3 hours

• A. Data collection
• B. Diagnosis
• C. Planning
• D. Implementation
• E. Evaluation

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Instruct client to self medicate

• A. Data collection
• B. Diagnosis
• C. Planning
• D. Implementation
• E. Evaluation

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Client state I exercise every day

• A. Data collection
• B. Diagnosis
• C. Planning
• D. Implementation
• E. Evaluation

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Client will eat 75 of meal with assist

• A. Data collection
• B. Diagnosis
• C. Planning
• D. Implementation
• E. Evaluation

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Anxiety related to hospitalization

• A. Data collection
• B. Diagnosis
• C. Planning
• D. Implementation
• E. Evaluation

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Goal met-Client was able to state signs and
symptoms of infection

• A. Data collection
• B. Diagnosis
• C. Planning
• D. Implementation
• E. Evaluation

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The nursing assistants are taking the patients
blood pressure now.

• A. Data collection
• B. Diagnosis
• C. Planning
• D. Implementation
• E. Evaluation

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CHARTING

• In the world of nursing
• if its not written, it was never done
• This turns into legal issues
• Just because you did it and didnt chart it,
  means it was NEVER done.

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IN REVIEWSo what is the Nursing Process anyway

• The fact that you have to do all the
  partsD-D-P-I-Etakes a long time to get through
  therefore, its a process
• Get it? Its a processNURSING PROCESS
• And why do we take time out of our busy schedule
  to do this process.so nursing care can be
  consistent and not forgotten

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PRIORITY

• Remember that you may be able to choose 10 NANDAS
  for 1 pts problems but you really should only use
  the top 2 or maybe 3 at the most
• You prob. Wont have time to write more than 3

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Remember

• The interventions you write down in order to care
  for the pt come from
• The Dr.s order
• Your own idea of what you think needs to be done
• Every nurse MUST follow the Dr.s orders. You
  dont have to follow every intervention made by a
  nurse ?

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THE END