2The Nursing Process A systematic method of providing care to clients. It’s a system that nurses use to provide efficient and effective nursing careIf we didn’t use some sort of standardized care, nursing would be a chaotic mess
3Who writes the plan RN should begin the plan and sign it LPN can help and doesn’t need to sign it necessarilyThe RN takes the lead role here
4The 5-Step Nursing Process Data collection (Assessment.)Diagnosis.Planning and outcome identification.Implementation.Evaluation.
5The Nursing Process uses Critical Thinking Critical thinking, problem-solving, and decision-makingThese skills can be learned!
6WHAT IS CRITICAL THINKING? Critical thinking is a process of objective reasoning or analyzing facts to reach a valid conclusionCritical 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 don’t need a Dr’s order)
8Purpose of Data collection (Assessment) Why is data collection (assessment) important?
9Data 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 cont’s until the pt. is released
10It is during data collection period that the nurse collects info 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
11Sources of Data Primary Source: The client. Secondary Source: The client’s family members, other health care providers, and medical records.
12Types of DataSubjective: it’s what the patient SAYS or STATES. This is also the symptoms someone c/oObjective: it’s what you observe. It’s observable and measurable data obtained through physical examination and laboratory and diagnostic testing. This is also what signs the pt shows you
13Is it: A=subjective B=objective 125lbs“I’m starving”greenish emesisThe Pt tell you he vomitedgreenish fluidErythematous toe“I’m burping a lot”“my heart is racing”“like a knife stabbing me”Sleeps with 2 pillows146/89Pinpoint pupils“He is so tired”Pale, diaphoreticO2 sat = 91% on room air
25Is it: A=subjective B=objective My husband is acting like such a baby, he is whining about everything
26Types 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.
27Organizing DataCollected information must be organized to be useful.
28Documenting 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.
29Here 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.
30DiagnosisA 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.
31Nursing 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
32TYPE OF DIAGNOSESYou must state whether your nursing problem is one of the following:An actual problemA risk for a problem to occurAnd then you must relate it to something
33If a pt is obese, you would say it’s an ACTUAL problem Therefore, you would say that the nursing diagnoses for this pt is: over-nutrition related to the lack of education
34If your patient had troubling swallowing, you would say: Potential for aspiration related to difficulty swallowingOrPossible airway obstruction related to difficulty swallowing
35Here 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,
36Types 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.
37Here 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 ____________ # # #3
39Here 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
40InterventionA nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.It’s what you are ACTUALLY GOING TO DO OR CARRY OUT
41Types 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.
42Here 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?
43WHAT DO YOU DO WITH ALL THE INFO. COLLECTED? You write a nursing care planThis plan tells others how to care for the pt. IN A SYSTEMATIC, CONSISTENT WAYNurses won’t have to reinvent the wheel everyday that they care for this pt.
44The Nursing Care PlanA written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.
45Implementation execution of the nursing care plan It’s what YOU ARE ACTUALLY GOING TO DO
46Evaluationdetermining 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 moreIt’s improvement after you see how it’s going
47Here is your client.3 weeks later…gain 2 lbs……states “ I went to the senior center twice last week and had lunch.Evaluate progress
48Take blood pressure every 3 hours A. Data collectionB. DiagnosisC. PlanningD. ImplementationE. Evaluation
49Instruct client to self medicate A. Data collectionB. DiagnosisC. PlanningD. ImplementationE. Evaluation
50Client state “ I exercise every day” A. Data collectionB. DiagnosisC. PlanningD. ImplementationE. Evaluation
51Client will eat 75% of meal with assist A. Data collectionB. DiagnosisC. PlanningD. ImplementationE. Evaluation
52Anxiety related to hospitalization A. Data collectionB. DiagnosisC. PlanningD. ImplementationE. Evaluation
53Goal met-Client was able to state signs and symptoms of infection A. Data collectionB. DiagnosisC. PlanningD. ImplementationE. Evaluation
54The nursing assistants are taking the patients blood pressure now. A. Data collectionB. DiagnosisC. PlanningD. ImplementationE. Evaluation
55CHARTING In the world of nursing… “if it’s not written, it was never done”This turns into legal issuesJust because you did it and didn’t chart it, means it was NEVER done.
56IN REVIEW So what is the Nursing Process anyway The fact that you have to do all the parts: D-D-P-I-E…takes a long time to get through therefore, it’s a processGet it? It’s a process…NURSING PROCESSAnd why do we take time out of our busy schedule to do this process….so nursing care can be consistent and not forgotten
57PRIORITYRemember 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 mostYou prob. Won’t have time to write more than 3
58Remember…The interventions you write down in order to care for the pt come from:The Dr.s orderYour own idea of what you think needs to be doneEvery nurse MUST follow the Dr.s orders. You don’t have to follow every intervention made by a nurse