Chapter 5 Assisting with the Nursing Process All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

The Nursing Process   The nursing process is the method nurses use to plan and deliver nursing care.   The five steps of the nursing process are:   Assessment   Nursing diagnosis   Planning   Implementation   Evaluation 2 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

The Nursing Process Further Explained   If done in order with good communication:   Nursing care is organized and has purpose.   All nursing team members do the same things for the person.   All nursing team members have the same goals.   The person feels safe and secure with consistent care. 3 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Assessment   Assessment involves collecting information about the person.   You make many observations as you give care and talk to the person. Objective data (signs) Subjective data (symptoms)   The assessment step never ends.   New information is collected with every resident contact. 4 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

OBRA MDS Requirement   OBRA requires the minimum data set (MDS) for nursing center residents.   The MDS is begun when the person is admitted to the center.   The MDS is an assessment and screening tool.   The MDS is completed when the person is admitted to the center.   The MDS is updated before each care conference.   The MDS is completed once a year and whenever a change occurs in the person’s health status.   The MDS is signed by an RN to show that it is complete and accurate. 5 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Nursing Diagnosis   The RN uses assessment information to make a nursing diagnosis.   A person can have multiple nursing diagnoses.   Nursing diagnoses:   Involve the person’s physical, emotional, social, and spiritual needs   May change or new ones may be added as assessment information changes 6 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Planning   Planning involves setting priorities and goals.   Priorities relate to what is most important for the person.   Goals are set.   Nursing interventions are chosen after goals are set.   An interdisciplinary care planning conference is held to develop a comprehensive care plan. 7 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

The Comprehensive Care Plan   The care plan includes:   Nursing diagnoses and goals   The person’s problems and actions to take to help the person solve health problems   The person’s strengths   Care Area Assessments (CAAs)   Guidelines used to develop the person’s care plans   Minimum data set (MDS gives triggers for CAAs)   Care plan forms vary:   In the chart   In a notebook   In a Kardex   On computer 8 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Implementation   Care is given in this step.   You report the care given and your observations to the nurse.   The nurse uses the assignment sheet to communicate delegated measures and tasks to you.   If your assignment is unclear:   Talk to the nurse.   Check the care plan and Kardex. 9 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Assignment Sheets   An assignment sheet is used to communicate tasks to you.   Assignment sheets tell you about:   Each person’s care   What measurements and tasks need to be done   Which nursing unit tasks to do   Use the assignment sheet to organize your work and set priorities.   What to do first   What to do when the person is at therapy or a meal   With which tasks will you need help   Check off tasks as you complete them. 10 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Evaluation   The evaluation step involves measuring if the goals in the planning step were met.   Changes in nursing diagnoses, goals, and the care plan may result.   The nursing process never ends. 11 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Your Role   The nurse uses your observations for nursing diagnoses, planning, and evaluation.   You may help develop the care plan.   In the implementation step, you perform nursing actions and measures in the care plan. 12 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Quality of Life   The resident has the right to take part in his or her care planning.   The person may refuse actions suggested by the health team. 13 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.