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The Nursing Process

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by

Dawn McMeekin

on 23 August 2013

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Transcript of The Nursing Process

The Nursing Process
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
Consists of
6 Steps
The Nursing Process
Involves Problem Solving & Critical Thinking
Lesson Objectives
1. Verbalize the purpose of the Nursing Process.
2. Explain the 6 steps of the Nursing Process.
3. Apply the Nursing Process to a patient scenario.
Patient Centered
Guides Nursing Care
Collection of Patient Data
Subjective
What the Patient Says
Objective Data
What the Nurse Observes
Inspection
Palpation
Percussion
Auscultation
"I have smoked a pack a day
since I was 14 years old""
"I feel like I can't catch my breath"
"My chest hurts when I cough"
"I have trouble breathing when I lay down"
"I am allergic to penicillin"

Vital Signs
Lab values
Diagnostic Test Results
Interprofessional Notes
Not a Medical Diagnosis
How as Nurses we care for patients!
3 types
NANDA
Actual Diagnoses
Risk Diagnoses
Wellness Diagnoses

How a Nursing Diagnosis is Written
Ineffective airway clearance related to retained thick pulmonary secretions as evidenced by ineffective cough, adventitious breath sounds, dyspnea
Identify
Patient Specific Outcomes
Short or Long Term Outcomes
Culturally Appropriate
Mutually Agreeable
Identify Interventions
Establish Priorities
Evidence-based
Put Plan into Action!
Remember this includes Patient/Family Teaching!
Were Outcome Goals Met?
Why or Why Not?
Back to the Drawing Board?
The Nursing Process is Continuous & Dynamic
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
What Have You Learned?
maintain patent airway
mobilize secretions
To mobilize secretions:
1. Keep head of bed elevates 30-40 degrees
2. Encourage deep breathing & coughing q 2hours
3. Increase fluid intake
4. Provide humidified O2
5. Administer expectorants and analgesics.
Maintain patent airway!
Was patient able to increase mobilization of secretions by demonstrating effective DB & C?
Full transcript