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The Nursing Process

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by

Mandy Gibson

on 31 July 2013

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Transcript of The Nursing Process

The
Nursing
Process

Assess
Diagnose

Plan
Implement
Evaluate
The "Nursing Process" simply put, is the systematic approach to nursing care

The key components include: Assessing, Diagnosing, Planning, Implementing, and Evaluating.

It is systematic, dynamic, interpersonal, and outcome oriented.

Each step is a unique and continual process.

Components may happen step by step or simultaneously.


So what's the nursing process?
Data Collection
Types of assessment
Subjective vs. Objective
Patient history (medical, surgical, social)
Head- to- toe assessment
Review previous medical records
Consultation with patient
Organize and prioritize data
Initial: First physical assessment when patient is admitted
Focused: Narrowing in on a specific problem
Emergent: Acknowledging life threatening conditions (A-B-C's)
Time-Lapsed: Comparison over a length of time
Reports, perceptions, cannot be directly verified
Concrete, measurable, can be verified
I am so anxious!
My pain is a 10/10!
My chest hurts
I am really afraid of needles
I feel better
I feel like throwing up!
57 yr Female
Height: 6'2" Weight: 78 kg
Right anterior patella
Left Lateral Chest
750 mL of pale yellow urine
4+ pitting edema
Subjective or objective?
The patient is tall and looks good
My face really hurts!
I feel nauseated
Weight: 76.3 kg
Redness across the left lateral chest
My pain is in my leg and it's a 6!
BP 126/89 HR 77 RR 16 Temp 36.7
Blood pressures have been okay
It's cold in here
The patient has a right midline abdominal incision with 12 staples.
interpret
North American Nursing Diagnosis Association
NANDA
page 252 Box 13-3 NANDA-Approve Nursing Diagnoses
The focus of a nursing diagnosis is the response to illness, which is separate from a medical diagnosis which clearly identifies a specific disease or disease process. pg 246
"Actual" nursing diagnosis
(the patient actively has this problem)
NANDA approved
Nursing dx
Etiology
"related to"
why is this happening?
Signs & Symptoms
"as evidenced by"
subjective or
objective
Deficient Fluid Volume | related to vomiting | AEB emesis 1500 mL in 24 hrs
"At risk" nursing diagnosis
NANDA approved At Risk For Nursing Diagnosis
Etiology
"Related to"
At Risk for falls | related to right sided weakness
Identify
outcomes
&
Priorities
Long term & Short Term Outcomes
All outcomes need to be measurable and realistic for the setting in which the patient is receiving care.
Nursing Interventions
Should be evidence based
Realistic
Compatible with patients needs and medical care
Take patients preferences into consideration
Typically services that can be provided autonomously without a physicians orders, for example: offer assistance, massage, ice packs, ambulation, more frequent rounding

Nursing Intervention Classification (NIC) Taxonomy
Table 15-2 pg 292
Include

How you plan to help the patient achieve the outcome (what you need to do, and what the patient needs to do).
Timeline to evaluate effectiveness of goal (make sure you allow enough time).
What resources are needed to achieve these goals?
Make outcomes (goals) as clear and easy to follow as you can.
Deficient Fluid Volume | related to vomiting | AEB emesis 1500 mL in 24 hrs
The nurse will monitor for blood pressure and heart rate Q1 x 12 hours for s/s of hypovolemic shock.
Lets put these steps together....
Nursing Diagnosis
Nursing Intervention
Plan
The nurse will take patient vital signs once every hour for 12 hours straight.
Outcome
The nurse will identify s/s of hypovolemic shock through vital sign assessments Q1 hour and notify MD for SBP >90 and HR <100.
How will the nurse and patient work to achieve the plan?
Now you are ready to act out that carefully planned nursing care!
"NIC defines a Nursing Intervention as any treatment based upon the clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes" (Taylor, et. al, pg 290, 2011).
Make sure you include your patient and their family in this process.
Ensure that your interventions are within your scope of practice.
Consider alternatives to your interventions.
Keep your outcomes (goal) in mind.
Use your resources- delegate when you can (Page 300 box 15-3).
involve members of the interdisciplinary team.
Nursing interventions vary depending on the patient.
Deficient Fluid Volume | related to vomiting | AEB emesis 1500 mL in 24 hrs
The nurse will monitor for blood pressure and heart rate Q1 x 12 hours for s/s of hypovolemic shock.
Lets put these steps together....
Nursing Diagnosis
Nursing Intervention
Plan
The nurse will take patient vital signs once every hour for 12 hours straight.
Outcome
The nurse will identify s/s of hypovolemic shock through vital sign assessments Q1 hour and notify MD for SBP >90 and HR <100.
Could this task be delegated? Why or why not?
Who could you delegate it to?
What were the results of the intervention?
Re-assess
Revise
Adjust
Did it work?
What the desired outcome met? - outcomes can be fully met, partially met, or not met. (Don't be afraid to say that something didn't work!).
Include your patient in the evaluation process.
What was the outcome?
You must include measurable and objective data.

Deficient Fluid Volume | related to vomiting | AEB emesis 1500 mL in 24 hrs



The nurse will monitor for blood pressure and heart rate Q1 x 12 hours for s/s of hypovolemic shock.




The nurse will take patient vital signs once every hour for 12 hours straight.




The nurse will identify s/s of hypovolemic shock through vital sign assessments Q1 hour and notify MD for SBP >90 and HR <100.


Outcome Met. The nurse assessed patients vital signs once every hour for a 12 hour period. The patient had two episodes of hypotention with SBP < 90 and HR > 100. MD was notified. Patient received a total of 3L of Normal Saline over 4 hours. Patients most recent BP is 122/ 69 and HR 80. Will continue to monitor vital signs every 2 hours for a 12 hour period with the same parameters and re-evaluate. Patient has requested vital signs not be taken during the night while patient is trying to sleep. Will discuss with MD to ensure patients safety.

Let's put the last step in place!
Nursing Diagnosis
Nursing Intervention
Plan
Desired Outcome
Evaluation
By: Mandy Gibson RN, CCRN, MSNed
Full transcript