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NURSING PROCESS. PRE TEST n 1. Identify all steps of the nsg process n 2. Identify the step of the Nsg process where goals are identified. n 3. Identify.

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Presentation on theme: "NURSING PROCESS. PRE TEST n 1. Identify all steps of the nsg process n 2. Identify the step of the Nsg process where goals are identified. n 3. Identify."— Presentation transcript:


2 PRE TEST n 1. Identify all steps of the nsg process n 2. Identify the step of the Nsg process where goals are identified. n 3. Identify the step of the Nsg. Process where expected outcomes are identified. n 4. What does NANDA stand for? n 5. Identify 1 benefit of the Nsg Process for the Pt.

3 NSG PROCESS DEFINITION n 1. Systematic, rational method of planning & providing NSG care n 2. Goal is to: identify a Pt.’s healthcare status, actual or potential health problems n 3. To establish plans to meet the identified needs n 4. To deliver specific NSG interventions to address those needs

4 (Con’t) n NSG process is an organized, systematic method of giving goal- oriented, humanistic care that’s both effective and efficient

5 BENEFITS (5) n 1. Improves quality of care Pts. Receive n 2. Promotes efficient use of time & resources n 3. Serves as framework for nurses’ accountability n 4. Enhances collaboration n 5. Assists NSG to define its unique role in healthcare system

6 STEPS OF NSG PROCESS n 1. Assessment =A n 2. Diagnosis =Delicious n 3. Planning =P n 4. Implementation =I n 5. Evaluation/Reassessment =E

7 NSG PROCESS & THE LVN COMPETENCIES n NLN (1989) defines role of LPN/LVN: n “Primary role of LPN/LVN is to provide nsg. Care for clients in structured health care settings who are experiencing common, well defined health problems.” n 2 Roles are designated for LPN/LVN: –Care Provider –Member of the Discipline of Nsg.

8 COMPETENCIES IN CARE PROVIDER ROLE LPN/LVN n 1. Assessment: assesses basic needs of Pts.=collecting data & identifying deviations from normal. Documents these data & communicates findings. n

9 PLANNING n Contributes to development of Nsg care plans, prioritizes Pt. care needs & assists in revising such care plans. Uses established Nsg. Diagnoses in this planning process for Pts. With common, well-defined health problems

10 IMPLEMENTATION n Provides care using effective communication, collaborating with other health team members and instructing Pts. Regarding health maintenance. Uses accepted standards of practice & records & reports implementation activities

11 EVALUATION n Seeks guidance & continues collaboration with others in modifying Nsg. Approaches and revising Nsg. Care plans

12 In Member of Discipline Role LVN COMPETENCIES n 1. Identifies personal strengths, weaknesses & potential, using educational opportunities n 2. Adheres to Nsg’s code of ethics n 3. Functions as a healthcare consumer advocate

13 NCLEX-PN TEST PLAN (1989) LVN ROLE IN NSG PROCESS n Acts in a more dependent role when participating in planning and evaluation phases and in a more independent role when participating in data collecting & implementing phases n Assists with collection of data about Pt., contributes to plan of care, performs basic therapeutic & preventive Nsg measures, assists in evaluating outcomes & nsg orders

14 ADN & NSG. PROCESS COMPETENCIES n NLN (1990) identified 3 roles of AND: n 1. Provider of Care n 2. Manager of care n 3. Member within the Discipline of Nsg.

15 ADN in Care Provider Role ASSESSMENT n 1. In addition to competencies at LVN level, ADN conducts a more extensive data collection process, using a variety of resources n 2. Contributes this information to a data base & is able to identify changes in Pt.’s health status

16 DIAGNOSIS n The ADN has educational preparation to analyze & interpret data, identifying actual or potential healthcare needs & selecting Nsg Diagnoses

17 PLANNING n 1. In addition to competencies at LVN level, A.D.N. establishes Pt.-centered goals, develops client-specific care plans n 2. Develops individualized teaching plans in collaboration with other healthcare workers

18 IMPLEMENTATION n 1. In addition to LVN competencies, A.D.N. initiates Nsg. Interventions, implementing care plans according to priorities of goals & making adjustments as client conditions change. n 2. Also fosters a health-supportive environment, promoting rehab potential

19 (con’t) n 3. Provides environment with physical & psychological safety n 4. Uses communication techniques that assist clients with coping & problem solving. n 4. Individualized, client- centered care management & teaching plans are implemented, providing continuity of care & referrals prn

20 EVALUATION n Evaluates client’s progress toward goals & the effects of interventions, revising care plans as needed

21 A.D.N. post 6 months of practice competencies n Clinical competence, effective communication, decision making, ability to develop, implement evaluate individualized plans of care, promoting participation by client and others

22 NCLEX-RN TEST PLAN & ROLE IN NSG PROCESS n 1. Establishes a data base n 2. Identifies health care needs/problems, formulating Nursing Diagnoses n 3. Sets goals & strategies to meet Pt. needs, involving Pt. & others & collaborating with other health team members n 4. Implements & manages Delivery of Pt. care; counsels & teaches Pt

23 (con’t) n 5. Evaluates outcomes, Pt. ability with self-care, & impact of teaching on health team members n 6. Communicates findings, analysis, responses n

24 ASSESSMENT n 1. Data collection n 2. Data organization n 3. Data validation n 4. Communication/documentation of data

25 TYPES OF DATA n 1. Objective n 2. Subjective n 3. Primary n 4. Secondary

26 How nurses collect data n 1. Observation n 2. Examination n 3. Interview n 4. Consultation

27 ORGANIZATION OF DATA n 1. Biological data n 2. Psychological data n 3. Social data n 4. Cultural data n 5. Communication

28 DATA VALIDATION Complete, factual, accurate? n 1. Cues: subjective & objective n 2. Inferences = nurse’s interpretation of the cues n 3. Premature closure= making inferences based on insufficient data

29 COMMUNICATING & DOCUMENTING DATA n 1. Assessment flow sheets n 2. Narrative assessment documentation sheets n 3. Report

30 DIAGNOSING DEFINITION n Nsg Diagnosis is a clinical judgement about individual, family or community responses to actual & potential health problems/life processes… provide the basis for selection of NSRG interventions to achieve outcomes for which the nurse is accountable

31 TYPES OF NURSING DIAGNOSES n 1. Actual n 2. Risk for n 3. Possible n 4. Wellness

32 North American Nursing Diagnosis Association (NANDA) n Established a classification system of diagnostic labels or problem statements

33 PARTS OF THE NURSING DIAGNOSIS n 1. P = Problem n 2. E= Etiology n 3. S= Signs & symptoms or manifestations

34 PLANNING n 1. Prioritize n 2. Develop goals/expected outcomes or outcome criteria n 3. Develop Nsg. Orders or prescriptions

35 NURSING INTERVENTIONS n 1. Implement or put into use these in order to assist the client in achieving the stated goal n 2. Interventions will prevent, reduce, eliminate the client’s health problems

36 TYPES OF NSG INTERVENTIONS n 1. Independent n 2. Dependent n 3. collaborative

37 COMPONENTS OF NSG ORDERS n 1. Date written n 2. Specific as to: who will do what, when, where, how long or how often n 3. Signature/title at end of orders n 4. Each order must be accompanied by the scientific rationale ( and its source) that addresses why a particular Nsg. Order addresses the Nsg. Diagnosis and goal

38 EVALUATION & REASSESSMENT n 1. Goal met n 2. Goal partially met n 3. Goal not met n 4. Goal in progress n Reassessment= the entire plan of care (data, ND, goal/EO, Nsg orders) must be reassessed

39 USING NURSING CARE PLAN PUBLICATIONS n 1. Carpenito Text & handbook n 2. Kozier n 3. deWitt n 4. Gulanik





44 NURSING DIAGNOSIS & Psychosocial Health




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