1. MNA M osby ’ s Long Term Care Assistant Chapter 7 Assisting With the Nursing Process

2. Nursing Process Method nurses use to plan and deliver patient care 5 steps

3. 1. Assessment Collecting Information Observations - Using the sense of sight, hearing, touch, and smell to collect information

4. 1. Assessment Objective Data - signs Subjective Data - symptoms

5. 1. Assessment Objective or Subjective ? Bloody urine

6. 1. Assessment Objective or Subjective ? Headache

7. 1. Assessment Objective or Subjective ? Productive cough

8. 1. Assessment Objective or Subjective ? Asleep

9. 1. Assessment Objective or Subjective ? Dizziness

10. 1. Assessment Objective or Subjective ? Abdominal pain

11. 1. Assessment Objective or Subjective ? Elevated temperature

12. 1. Assessment Ability to respond Oriented? Speech? Calm, restless? Movement Strength? Shaky or jerky? Complaints?

13. 1. Assessment Pain or Discomfort Where? When did it begin? How long does it last? Description? See page 70…. What terms are used to describe pain?

14. 1. Assessment Skin Color? Lips and Nails? Temperature? Intact? Moist or dry? Bruises?

15. 1. Assessment Eyes, Ears,Nose, Mouth Drainage? Hearing? Breath odor? Sensitive to light? PEARL?

16. 1. Assessment Respirations Both sides of chest rise and fall? Noisy?Sputum? SOB?Cough?

17. 1. Assessment Bowel and Bladder Abdomen firm or soft? Flatus? BM? Urine? Incontinence?

18. 1. Assessment Appetite % eaten? Liquid intake? Swallow? Dentures? N/V? Hiccups?

19. 1. Assessment ADLs Personal care? Feed himself? Toilet, commode, bedpan or urinal? Ambulation?

20. 2. Nursing Diagnosis A health problem that can be treated by nursing measures Not the same as a medical diagnosis

21. 2. Nursing Diagnosis Examples: Ineffective airway clearance related to decreased energy as manifested by an ineffective cough. Risk for injury related to altered mobility and disorientation. Possible fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse rate.

22. 3. Planning Setting priorities and goals ( Maslow’s Hierarchy of Needs) What is most important for the patient

23. 3. Planning Nursing Intervention according to goals. Nursing Care Plan

25. 4. Implementation Carrying out nursing measures in the care plan. May be simple or complex Assignment sheet used to delegate duties

26. 5. Evaluation To measure whether the goals were met Partially Totally Not at all Nursing process never ends

27. Your role Key Observations Provide care Patient has a right to be part of the Care Process

28. Review A written guide about the care a person should receive is the Comprehensive care plan

29. Review The nursing process focuses on The person ’ s nursing needs

30. Review Which is the first step of the nursing process? Assessment

31. Review Is it a nursing diagnosis? Anxiety Constipation Heart attack Pain, acute yes no yes

32. Review Nursing assistants have a role in the nursing process. TrueFalse