1. Assisting with the Nursing Process
Chapter 7
Assisting with the Nursing Process
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

2. Nursing Process
The nursing process is the method nurses use to plan and deliver nursing care.
The nursing process has five steps.
Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
The nursing process focuses on the person’s nursing needs.
The person and nursing team need good communication.
Each step is important.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

3. Nursing Process (cont’d)
If the steps are done in order with good communication:
Nursing care is organized and has purpose.
All nursing team members do the same things for the person.
They have the same goals.
The person feels safe and secure with consistent care.
The nursing process is ongoing.
The nursing process is used in all health care settings.
The nursing process is used for all age groups.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

4. Assessment
Assessment involves collecting information about the person.
A health history is taken.
The family’s health history also is important.
Information from the doctor is reviewed.
Test results and past medical records are reviewed.
An RN assesses the person’s body systems and mental status.
Many sources are used for the assessment step.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

5. Assessment (cont’d) You play a key role in assessment.
You make many observations as you give care and talk to the person.
Objective data (signs) are seen, heard, felt, or smelled.
Subjective data (symptoms) are things a person tells you about that you cannot observe through your senses.
Make notes of your observations as you make them.
The assessment step never ends.
Observation is using the senses of sight, hearing, touch, and smell to collect information.
Review the contents of Box 7-1 on p. 80 in the Textbook.
Review the contents of Box 7-2 on p. 81 in the Textbook.
New information is collected with every patient or resident contact.
Review the Focus on Long-Term Care and Home Care: Assessment Box on p. 82 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

6. Nursing Diagnosis
The RN uses assessment information to make a nursing diagnosis.
A nursing diagnosis describes a health problem that can be treated by nursing measures.
A person can have many nursing diagnoses.
They deal with the total person (physical, emotional, social, and spiritual).
Review the contents of Box 7-3 on pp in the Textbook.
Nursing diagnoses and medical diagnoses are not the same.
A medical diagnosis is the identification of a disease or condition by a doctor.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

7. Planning Planning involves setting priorities and goals.
The needs are arranged in order of importance.
Goals are then set.
Goals are aimed at the person’s highest level of well-being and function.
Nursing interventions are chosen after goals are set.
A nursing intervention is an action or measure taken by the nursing team to help the person reach a goal.
The person, family, and health team help the registered nurse (RN) plan care.
Priorities relate to what is most important for the person.
A goal is that which is desired for or by a person as a result of nursing care.
Goals promote health and prevent health problems.
They also promote rehabilitation.
A nursing intervention does not need a doctor’s order.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

8. Planning (cont’d) The nursing care plan (care plan): Care conferences
Is a written guide about the person’s nursing care
Has the person’s nursing diagnoses and goals
Has measures or actions for each goal
Is a communication tool
Is used by nursing staff to see what care to give
Helps ensure that nursing team members give the same care
Care conferences
The RN may conduct these to share information and ideas about the person’s care.
The purpose of a care conference is to develop or revise the person’s care plan.
Effective care is the goal.
Nursing assistants usually take part in the conference.
Review the Focus on Communication: Care Conferences Box on p. 84 in the Textbook.
Review the Focus on Long-Term Care and Home Care: Care Conferences Box on p. 85 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

9. Implementation
The implementation step is performing or carrying out nursing measures (interventions) in the care plan.
Care is given in this step.
Nursing care ranges from simple to complex.
The nurse delegates tasks that are within your legal limits and job description.
The nurse may ask you to assist with complex measures.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

10. Implementation (cont’d)
You report the care given to the nurse.
In some agencies, you record the care given.
Report and record after giving care, not before.
Report and record your observations.
Observation is part of assessment.
New observations may change the nursing diagnoses.
Changes in nursing diagnoses result in changes in the care plan.
To give correct care, you must know about any changes in the care plan.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

11. Implementation (cont’d)
The nurse uses an assignment sheet to communicate delegated tasks to you.
The assignment sheet tells you about:
Each person’s care
What measures and tasks need to be done
Which nursing unit tasks to do
If an assignment is unclear:
Talk to the nurse.
Check the care plan and Kardex.
Review the Focus on Communication: Assignment Sheets Box on p. 87 in the Textbook.
Review the Teamwork and Time Management: Assignment Sheets Box on p. 87 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

12. Evaluation
Evaluation involves measuring if the goals in the planning step were met.
Progress is evaluated.
Assessment information is used for this step.
Changes in nursing diagnoses, goals, and the care plan may result.
Goals may be met totally, in part, or not at all.
The nursing process never ends.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

13. Your Role
Your role
Your observations are used for nursing diagnoses and planning.
You may help develop the care plan.
In the implementation step, you perform tasks in the care plan.
Your assignment sheet tells you what to do.
Your observations are used for the evaluation step.
You have an important role in the nursing process.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.