Chapter 8 Assisting with the Nursing Process

Terms to define: assessment evaluation goal implementation medical diagnosis nursing care plan nursing diagnosis nursing intervention nursing process objective data  observation planning subjective data

The nursing process has FIVE steps:

What is the purpose of the nursing process? Makes nursing care organized To have same goals for the person Helps person feel safe and secure Provides consistent care

ASSESSMENT:  Observation is part of the assessment -  See how they are sitting, see what their skin looks like Listen to their breathing, the way they talk Touch their skin to see if moist or dry, touch to take pulse Smell body odors, urine and bowel movements Objective data (signs) and subjective data (symptoms) are part of the assessment. Objective – feel a pulse, see urine color Subjective – the person reports pain or nausea

Objective (signs) data vs. Subjective (symptoms) data A measurement, observation using 5 senses Subjective Things person tells you that cannot be observed with 5 senses Blood pressure Temperature Bleeding Heart rate Pt feels nauseated Pt feels dizzy Pt fell yesterday

Nursing Diagnosis A nursing diagnosis is NOT the same as a medical diagnosis. Can problem be treated by nursing measures? Examples of nursing diagnoses: Aspiration, risk for Bathing self-care deficit Constipation, risk for Feeding self-care deficit Pain: acute, chronic

Goals, intervention and care plan are all part of planning. Set priorities and goals Goals aimed at highest level of well-being and function Physical, emotional, social, and spiritual Nursing interventions help the person reach the goal The written guide (care plan) includes actions for each goal and serves as a communication tool between nurses

Planning Care Conference – share information about person’s care, develop and revise nursing care plan, nursing assistants take part of this planning Family and resident may attend conference Resident may refuse actions suggested by health team

Implementation Performing or carrying out the nursing measures in the care plan.  Assignment sheets may be used to delegate tasks. It will tell you: The person's care What tasks need to be done Which tasks on nursing unit to be done Evaluation Measuring whether the goals were met. Evaluate the progress Goals may have not been met, partially met or fully met.