CHAPTER 8 COPYRIGHT 2017 ELSEVIER INC ALL RIGHTS

NURSING PROCESS The nursing process is the method nurses use to plan and deliver

NURSING PROCESS (CONT. ) If the steps are done in order with good communication:

ASSESSMENT Assessment involves collecting information about the person. Information from the doctor is reviewed.

ASSESSMENT (CONT. ) You play a key role in assessment. You make many observations

NURSING DIAGNOSIS The RN uses assessment information to make a nursing diagnosis. A nursing

Planning involves setting priorities and goals. Goals are aimed at the person’s highest level

PLANNING (CONT. ) The nursing care plan (care plan): Care conferences Is a written

IMPLEMENTATION The implementation step is performing or carrying out nursing measures (interventions) in the

You report the care given to the nurse. In some agencies, you record

IMPLEMENTATION (CONT. ) The nurse uses an assignment sheet to communicate delegated tasks to

Evaluation involves measuring if the goals in the planning step were met. Progress

YOUR ROLE Your role Your observations are used for nursing diagnoses and planning. You

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NURSING PROCESS The nursing process is the method nurses use to plan and deliver nursing care. The nursing process has five steps. Assessment Nursing diagnosis Planning Implementation Evaluation COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 2

NURSING PROCESS (CONT. ) If the steps are done in order with good communication: Nursing care is organized and has purpose. All nursing team members do the same things for the person. They have the same goals. The person feels safe and secure with consistent care. The nursing process is ongoing. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 3

ASSESSMENT Assessment involves collecting information about the person. Information from the doctor is reviewed. A health history is taken. Test results and past medical records are reviewed. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. The family’s health history also is important. An RN assesses the person’s body systems and mental status. 4

ASSESSMENT (CONT. ) You play a key role in assessment. You make many observations as you give care and talk to the person. Objective data (signs) are seen, heard, felt, or smelled. Subjective data (symptoms) are things a person tells you about that you cannot observe through your senses. Make notes of your observations as you make them. The assessment step never ends. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 5

NURSING DIAGNOSIS The RN uses assessment information to make a nursing diagnosis. A nursing diagnosis describes a health problem that can be treated by nursing measures. A person can have many nursing diagnoses. They deal with the total person (physical, emotional, social, and spiritual). COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 6

Planning involves setting priorities and goals. Goals are aimed at the person’s highest level of well-being and function. The needs are arranged in order of importance. Goals are then set. Nursing interventions are chosen after goals are set. A nursing intervention is an action or measure taken by the nursing team to help the person reach a goal. PLANNING COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 7

PLANNING (CONT. ) The nursing care plan (care plan): Care conferences Is a written guide about the person’s nursing care The RN may conduct these to share information and ideas about the person’s care. Has the person’s nursing diagnoses and goals Has measures or actions for each goal Is a communication tool Is used by nursing staff to see what care to give Helps ensure that nursing team members give the same care 8

IMPLEMENTATION The implementation step is performing or carrying out nursing measures (interventions) in the care plan. Care is given in this step. Nursing care ranges from simple to complex. The nurse delegates tasks that are within your legal limits and job description. The nurse may ask you to assist with complex measures. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 9

You report the care given to the nurse. In some agencies, you record the care given. Report and record after giving care, not before. Report and record your observations. Observation is part of assessment. IMPLEMENTATIO N (CONT. ) New observations may change the nursing diagnoses. Changes in nursing diagnoses result in changes in the care plan. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 10

IMPLEMENTATION (CONT. ) The nurse uses an assignment sheet to communicate delegated tasks to you. The assignment sheet tells you about: Each person’s care What measures and tasks need to be done Which nursing unit tasks to do If an assignment is unclear: Talk to the nurse. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. Check the care plan and Kardex. 11

Evaluation involves measuring if the goals in the planning step were met. Progress is evaluated. Assessment information is used for EVALUATION this step. Changes in nursing diagnoses, goals, and the care plan may result. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 12

YOUR ROLE Your role Your observations are used for nursing diagnoses and planning. You may help develop the care plan. In the implementation step, you perform tasks in the care plan. Your assignment sheet tells you what to do. Your observations are used for the evaluation step. COPYRIGHT © 2017, ELSEVIER, INC. ALL RIGHTS RESERVED. 13