Nursing Process3

8/11/2019 Nursing Process3

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NURSING PROCESS


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PRE TEST

1. Identify all steps of the nsg process

2. Identify the step of the Nsg process

where goals are identified.

3. Identify the step of the Nsg. Process

where expected outcomes are

identified.

4. What does NANDA stand for?

5. Identify 1 benefit of the Nsg Process

for the Pt.


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NSG PROCESS

DEFINITION 1. Systematic, rational method of

planning & providing NSG care

2. Goal is to: identify a Pt.s healthcarestatus, actual or potential health

problems

3. To establish plans to meet theidentified needs

4. To deliver specific NSG interventions

to address those needs


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(Cont)

NSG process is an organized,

systematic method of giving goal-

oriented, humanistic care thats botheffective and efficient


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BENEFITS (5)

1. Improves quality of care Pts. Receive

2. Promotes efficient use of time &

resources

3. Serves as framework for nurses

accountability

4. Enhances collaboration

5. Assists NSG to define its unique role

in healthcare system


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STEPS OF NSG PROCESS

1. Assessment =A

2. Diagnosis =Delicious

3. Planning =P

4. Implementation =I

5. Evaluation/Reassessment =E


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NSG PROCESS & THE LVN

COMPETENCIES NLN (1989) defines role of LPN/LVN:

Primary role of LPN/LVN is to provide

nsg. Care for clients in structured healthcare settings who are experiencing

common, well defined health problems.

2 Roles are designated for LPN/LVN: Care Provider

Member of the Discipline of Nsg.


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COMPETENCIES IN CARE

PROVIDER ROLE LPN/LVN 1. Assessment: assesses basic needs

of Pts.=collecting data & identifying

deviations from normal. Documentsthese data & communicates findings.


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PLANNING

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


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IMPLEMENTATION

Provides care using effective

communication, collaborating with other

health team members and instructingPts. Regarding health maintenance.

Uses accepted standards of practice &

records & reports implementationactivities


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EVALUATION

Seeks guidance & continues

collaboration with others in modifying

Nsg. Approaches and revising Nsg.Care plans


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In Member of Discipline Role

LVN COMPETENCIES 1. Identifies personal strengths,

weaknesses & potential, using

educational opportunities 2. Adheres to Nsgs code of ethics

3. Functions as a healthcare consumer

advocate


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NCLEX-PN TEST PLAN (1989)

LVN ROLE IN NSG PROCESS

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

Assists with collection of data about Pt., contributes

to plan of care, performs basic therapeutic &

preventive Nsg measures, assists in evaluating

outcomes & nsg orders


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ADN & NSG. PROCESS

COMPETENCIES NLN (1990) identified 3 roles of AND:

1. Provider of Care

2. Manager of care

3. Member within the Discipline of Nsg.


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ADN in Care Provider Role

ASSESSMENT 1. In addition to competencies at LVN

level, ADN conducts a more extensive

data collection process, using a varietyof resources

2. Contributes this information to a data

base & is able to identify changes inPt.s health status


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DIAGNOSIS

The ADN has educational preparation

to analyze & interpret data, identifying

actual or potential healthcare needs &selecting Nsg Diagnoses


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PLANNING

1. In addition to competencies at LVN

level, A.D.N. establishes Pt.-centered

goals, develops client-specific careplans

2. Develops individualized teaching

plans in collaboration with otherhealthcare workers


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IMPLEMENTATION

1. In addition to LVN competencies,

A.D.N. initiates Nsg. Interventions,

implementing care plans according topriorities of goals & making adjustments

as client conditions change.

2. Also fosters a health-supportiveenvironment, promoting rehab potential


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(cont)

3. Provides environment with physical

& psychological safety

4. Uses communication techniques thatassist clients with coping & problem

solving.

4. Individualized, client- centered caremanagement & teaching plans are

implemented, providing continuity of

care & referrals prn


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EVALUATION

Evaluates clients progress toward goals

& the effects of interventions, revising

care plans as needed


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A.D.N. post 6 months of practice

competencies Clinical competence, effective

communication, decision making, ability

to develop, implement evaluateindividualized plans of care, promoting

participation by client and others


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NCLEX-RN TEST PLAN &

ROLE IN NSG PROCESS 1. Establishes a data base

2. Identifies health care needs/problems,

formulating Nursing Diagnoses 3. Sets goals & strategies to meet Pt. needs,

involving Pt. & others & collaborating with

other health team members

4. Implements & manages Delivery of Pt.

care; counsels & teaches Pt


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(cont)

5. Evaluates outcomes, Pt. ability with

self-care, & impact of teaching on health

team members 6. Communicates findings, analysis,

responses


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ASSESSMENT

1. Data collection

2. Data organization

3. Data validation

4. Communication/documentation of

data


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TYPES OF DATA

1. Objective

2. Subjective

3. Primary

4. Secondary


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How nurses collect data

1. Observation

2. Examination

3. Interview

4. Consultation


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ORGANIZATION OF DATA

1. Biological data

2. Psychological data

3. Social data

4. Cultural data

5. Communication


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DATA VALIDATION

Complete, factual, accurate? 1. Cues: subjective & objective

2. Inferences = nurses interpretation of

the cues

3. Premature closure= making

inferences based on insufficient data


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COMMUNICATING &

DOCUMENTING DATA 1. Assessment flow sheets

2. Narrative assessment

documentation sheets

3. Report


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DIAGNOSING

DEFINITION Nsg Diagnosis is a clinical judgement

about individual, family or community

responses to actual & potential healthproblems/life processes provide the

basis for selection of NSRG

interventions to achieve outcomes forwhich the nurse is accountable


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TYPES OF NURSING

DIAGNOSES 1. Actual

2. Risk for

3. Possible

4. Wellness


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North American Nursing

Diagnosis Association (NANDA) Established a classification system of

diagnostic labels or problem statements


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PARTS OF THE NURSING

DIAGNOSIS 1. P = Problem

2. E= Etiology

3. S= Signs & symptoms or

manifestations


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PLANNING

1. Prioritize

2. Develop goals/expected outcomes or

outcome criteria

3. Develop Nsg. Orders or prescriptions


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NURSING INTERVENTIONS

1. Implement or put into use these in

order to assist the client in achieving the

stated goal 2. Interventions will prevent, reduce,

eliminate the clients health problems


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TYPES OF NSG

INTERVENTIONS 1. Independent

2. Dependent

3. collaborative


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COMPONENTS OF NSG

ORDERS 1. Date written

2. Specific as to: who will do what,

when, where, how long or how often

3. Signature/title at end of orders

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


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EVALUATION &

REASSESSMENT 1. Goal met

2. Goal partially met

3. Goal not met

4. Goal in progress

Reassessment= the entire plan of care

(data, ND, goal/EO, Nsg orders) must

be reassessed


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USING NURSING CARE PLAN

PUBLICATIONS 1. Carpenito Text & handbook

2. Kozier

3. deWitt

4. Gulanik


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USING NURSING CARE PLAN

GRADING CRITERIA


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NURSING DIAGNOSIS &

RESPIRATORY


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NURSING DIAGNOSIS &

CARDIOVASCULAR


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NURSING DIAGNOSIS &

UROLOGICAL


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NURSING DIAGNOSIS &

Psychosocial Health


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DEVELOPMENTAL FACTORS

& NURSING PROCESS


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SOCIOCULTURAL FACTORS

& NSG PROCESS


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PEDIATRICS & NURSING

PROCESS

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