Medical Tech Prep 1Lancaster High SchoolMrs. Carpenter

CHAPTER 6: THE NURSING PROCESS

Pages 73-80

Objectives

• Explain the purpose of the nursing process• Describe the steps of the nursing process• Explain the role of the NA in each step of

the nursing process• Explain the difference between objective

data and subjective data• Identify the observations that you need to

report to the nurse• Explain the purpose of care conferences

THE NURSING PROCESS

• Nurses share information about the person through the nursing process.

• The nursing process has five steps:– Assessment– Nursing diagnosis– Planning– Implementation– Evaluation

• focuses on the person’s nursing needs.• Good communication is needed.• Each step is important.

THE NURSING PROCESS

• is organized and has purpose.• team members have the same goals• Team members do the same things • Person feels safe and secure. • ongoing• changes as new information is gathered• Changes as a person’s needs change.

THE NURSING PROCESS-ASSESSMENT

• involves collecting information about the person.

• many sources:– nursing history – family’s health history – Information from the doctor– Test results and past medical records

• The RN assesses the person’s body systems and mental status.

THE NURSING PROCESS-ASSESSMENT

• NA plays a key role in assessment.• make many observations as care is given • Observation=using the senses to collect

information • sight• hearing• touch• smell

ASSESSMENT-DATA

• objective data (signs). – Information that is seen, heard, felt, or smelled

• Subjective data (symptoms).– Information that a person tells you that you

cannot observe through your senses

• Box 5-1 on page 75 • Make notes of your observations.

APPLICATION: OBJECTIVE OR SUBJECTIVE

• Headache• Red nose• Vomiting• A red bruise• Moist skin• Tingling sensation• Nausea• Stomach pain• Crying• Oily hair• Toothache • Swollen feet

• Painful knees • Dirty fingernails• Bloody discharge• Nausea• Laceration• PERRLA• Loose stool• Blue lips• Aggressive behavior• Orange colored urine• Malaise• Nose bleed

Focus on long-term care: assessment

• OBRA requires the minimum data set (MDS) for nursing center residents.

• MDS – is an assessment and screening tool.– is completed when the person is admitted – is updated before each care conference.

• new MDS is completed once a year and whenever the person’s condition changes.

Focus on long-term care: assessment

• Information contained on the MSDS• Often uses information obtained

through NA records• Appendix B on page 822

APPLICATIONAPPLICATIONPATIENT OBSERVATIONSPATIENT OBSERVATIONS

-for each of the patients in the beds you will be making observations as if you are the nursing assistant in charge of their care. “Walk” into each room and make observations about the patient. Record the observations on a sheet of paper and be prepared to report to the RN (Mrs. Carpenter) what you observed.

THE NURSING PROCESS-NURSING DIAGNOSIS

The RN uses assessment information to make a nursing diagnosis.

• nursing diagnosis describes a health problem treatable through nursing measures.

• Nursing diagnoses and medical diagnoses are not the same.– medical diagnosis is the identification of a disease or

condition by a doctor.

A person can have many nursing diagnoses.

THE NURSING PROCESS-NURSING DIAGNOSIS

• Nursing diagnoses involves needs• Physical• Emotional• social• spiritual

• common nursing diagnoses (seeBox 5-2 on pages 76 and 77)

The Nursing Process-PLANNING

• involves setting priorities and goals.• measures or actions are chosen to help the

person meet the goals.• The person, family, and health team help plan

care.• Priorities are what is most important to the

person.– Maslow’s theory of basic needs is useful (Chapter 6).– Needs required for life and survival must be met before

all others

• .

The Nursing Process-PLANNING

• Goals – A goal=that which is desired in or by a person as a result

of nursing care.– aimed at the person’s highest level of well-being and

functioning.

• Nursing interventions– chosen after goals are set.– action or measure taken to help the person reach a goal.– does not need a doctor’s order.– Some nursing measures come from a doctor’s order

The Nursing Care Plan:

written guide about the person’s care• Includes nursing diagnoses and goals• measures or actions for each goal• Used as a communication tool

– See what care to give.– Ensure that the nursing team gives the same care.

• found in the medical record, Kardex, or on computer.• a care conference may be called to share information and• ideas about the person’s care.

– Nursing assistants usually take part in the conference.

• may change if the person’s nursing diagnoses change.

The Nursing Process-IMPLEMENTATION

• to perform or carry out nursing measures in the care plan.

• Care is given.– The nurse delegates measures and tasks that are within

your legal limits and job description.– The nurse may ask you to assist with complex

measures.– report the care given to the nurse.– record the care given if allowed by your agency

• Report or record new observations.– may change the nursing diagnoses.– know about any changes in the care plan.

The Nursing Process-IMPLEMENTATION:Assignment sheets

• Assignment sheets• used to communicate delegated measures/tasks t• An assignment sheet tells

– Each person’s care– What measures and tasks need to be done– When to take meal and lunch breaks– Which nursing unit tasks to do

• Talk to the nurse about any assignment that is unclear.

• Check the care plan and Kardex if you need more information.

The Nursing Process-EVALUATION

• measuring if the goals in planning were met.

1. Progress is evaluated.

2. Assessment information is used.

3. Changes in nursing diagnoses, goals, and the care plan may result.

The Nursing Process Never Ends.

NURSING DIAGNOSIS

IMPLEMENTATION

EVALUATION PLANNING

ASSESSMENTASSESSMENT

YOUR ROLE

• key role in the nursing process.• Use of your observations for nursing

diagnoses and planning.• develop the care plan.• perform nursing actions and measures in

the care plan.• Complete observations for evaluation

APPLICATIONAPPLICATION

STUDENT WORKBOOK #1-30STUDENT WORKBOOK #1-30