FUNDAMENTALS OF NURSING

LESSON #25

THENURSING PROCESS

FUNDAMENTALS OF NURSING

Review Maslow’s HierarchyReview ADPIEKnow conversion:

Gram to mgTsp to mlEtc.

THE NURSING PROCESS

ASSESSMENT:Appraisal of a conditionContinuous throughout pt careGathering of info to determine health

statusAll phases dependent upon

accurateness of initial data collectionNurse judgment on how in depth or

focused an assessment should be

5 PHASES: THE NURSING PROCESS

ASSESSMENT:METHODS TO COLLECT DATA:

Interview for health history Physical exam for objective data


ASSESSMENT:Physical exam:

By system Head to toe

Uses inspection, percussion, palpation, & auscultation


ASSESSMENT:DATA CLUSTERING:

Use assessment data Use past medical data Use biographical data Use psychosocial status


Maslow’s will help assist with prioritization of problems

DIAGNOSING:Identifying type & cause of health

condition & factors causing problem Problem:

Any health care condition requiring:•Diagnostic tests•Therapeutic care•Education


DIAGNOSING:Guidelines to cue need for action:

Change in pt’s usual pattern Change from normal fx of body systems

Difference from normal patterns of growth and development


DIAGNOSING:NANDA:

North American Nursing Diagnosis AssociationA clinical judgment about an individual,

family, or community’s response to actual or high risk health problems

Changed every two years…


DIAGNOSING:Nursing diagnosis:

Basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

NOTE: the nurse must be legally able to ID and prescribe interventions to treat or prevent a problem If this cannot be done, it is not a nursing

diagnosis



DIAGNOSING:Nursing diagnosis components:

Nursing diagnosis or title…use adjectives Definition: needs to be differentiated from similar diagnosis

Contributing/etiological/related factors in the development of the problem

Defining characteristics: subjective/objective data, clinical s/s

Written “as evidenced by”


DIAGNOSING:4 Types of nursing diagnosis:

Actual: a condition that presently exists High Risk: clinical judgment of risks the

nurse is aware of Possible: need additional information

prior to making a diagnosis Wellness: clinical judgment of wellness

with goal to reach higher level of wellness


DIAGNOSING:Establish the nursing diagnosis:

First part must be NANDA approved Diagnosis can be actual or high risk CANNOT be a medical diagnosis Diagnosis addresses what nurse can do

for pt


DIAGNOSING:Establish the nursing diagnosis:

Second part is etiology or contributing factors

More than one contributing factor may be indentifiedExamples…

CANNOT use words that mean the same thing…fluid volume deficit and dehydration


DIAGNOSING:Other types of diagnosis:

CollaborativeA complication from every pathophysiologic response from the body

MedicalIdentification of a disease or condition by scientific evaluation of s/s

Diagnosed by physicians


PLANNING: Goal to decrease, solve, or prevent the problem Have to set priorities using Maslow’s Hierarchy

Lower level must be met first Life threatening problems are ranked HIGHEST The pt should be consulted as to how they would

prioritize their problems Diagnosis and priorities are constantly changing


NURSES PRIORITIZE:#1 MASLOW’S

#2 DEGREE OF THREAT TO LIFE#3 PT PREFERENCE

PLANNING:Establish desired outcomes

Pt centered goals or desired pt outcome State what pt will be able to do, not nursing actionExample:

•Pt will be able to ambulate 400 ft within 2 days with assist


PLANNING:Establish desired outcomes

The nurse predicts the degree of wellness desired or expected

The goal is purpose to which effort is directed Goals should be patient centered, specific, & measurable behavior that the pt will exhibit, NOT THE NURSE

Start with PT WILL……


PLANNING:GOALS:

Should be measurable whether met or not A well written goal:

Uses the word “patient”Uses a measurable verbIs specific for the pt and the problemIs realisticIncludes time frame for re-evaluation


PLANNING:GOALS:

Goal statement should begin with “pt will”Pt will consume 20% of meal…Pt will ambulate

Use action verb Be specific Be realisticShort term goals: 24 hours, 3 hours, etc.

Long term goals: 1 week or more


PLANNING:NURSING INTERVENTIONS:

Actions that should promote achievement of goal

Can be:Nursing skill activityMonitoring high risk problemsCarrying out physician orders

•Example:•Encourage intake by offering 250cc of fluid q

2 hours for a goal of 2000cc daily



Actions that should promote achievement of goal

Can be:Independent: the nurse performs on ownDependent: prescribed by physician

•Nurse must use own judgment and pt assessment skills

Interdependent: nurse and other members of health care team perform•PT, OT, social worker, etc



When determining interventions:Consider disease etiologyRelated factorsThe goalsThe nursing diagnosis



Writing nursing orders:Use care plan books

Nursing orders must include:Date and signatureSubjectAction verbQualifying details



Writing nursing orders:If nurse is the subject this does not need

to be writtenOther agencies should be listed when

applicable



Writing nursing orders:Order should be:

•Written for nurses•Realistic for pt•Correlate with medical plan of care (POC)•Based on scientific problems



Writing nursing orders:Communicate POC to all nurses for

continuity of careBest individualized care plans are hand

written• Only use books/internet as guidelines


IMPLEMENTING: Putting interventions into action or

performing nursing actions This is where DOCUMENTATION takes

place Ongoing data collection takes place:

Prioritizing actions Cancelling planned actions


IMPLEMENTING: Interventions may be nursing or physician

prescribed Documentation important in this phase You might also:

Teach Counsel Monitor Administer meds Etc


EVALUATING: Have the outcomes or goals been achieved?

Compare desired outcomes with actual outcomesReview the goalsReassess the ptAssess the data to see if the measurable

goal has been achievedUse critical judgment to determine if the

goal was achieved



3 choicesGoal metGoal not metGoal partially met

If goal achieved:Care plan is resolved



If goal is not achieved:Care plan is revisedReview all phases of the nursing process


***CHANGES DONE BASED ON ONGOING EVALUATION

ROLE OF THE LPN:Key as bedside nurse to assess, prioritize, document, implement, and reevaluate

A key team member


THAT’S ALL FOLKS!!!

FUNDAMENTALS OF NURSING

Documents

nursing processdiagnosing

nursing processassessment

nursing process5 phases

nursing diagnosis5 phases

nursing processmaslows

nursing processplanning

types of nursing diagnosis

nursing diagnosis components