1. Chapter 8 Assisting with the Nursing Process

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

3. The nursing process has FIVE steps:

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.