NURSING PROCESS

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.

NSG PROCESSDEFINITION 1. Systematic, rational method of

planning & providing NSG care 2. Goal is to: identify a Pt.’s healthcare

status, actual or potential health problems 3. To establish plans to meet the

identified needs 4. To deliver specific NSG interventions to

address those needs

(Con’t)

NSG process is an organized, systematic method of giving goal-oriented, humanistic care that’s both effective and efficient

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

STEPS OF NSG PROCESS

1. Assessment =A 2. Diagnosis =Delicious

3. Planning =P 4. Implementation =I 5. Evaluation/Reassessment =E

NSG PROCESS & THE LVNCOMPETENCIES NLN (1989) defines role of LPN/LVN: “Primary role of LPN/LVN is to provide

nsg. Care for clients in structured health care settings who are experiencing common, well defined health problems.”

2 Roles are designated for LPN/LVN:– Care Provider– Member of the Discipline of Nsg.

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

of Pts.=collecting data & identifying deviations from normal. Documents these data & communicates findings.

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

IMPLEMENTATION

Provides care using effective communication, collaborating with other health team members and instructing Pts. Regarding health maintenance. Uses accepted standards of practice & records & reports implementation activities

EVALUATION

Seeks guidance & continues collaboration with others in modifying Nsg. Approaches and revising Nsg. Care plans

In Member of Discipline Role LVN COMPETENCIES

1. Identifies personal strengths, weaknesses & potential, using educational opportunities

2. Adheres to Nsg’s code of ethics 3. Functions as a healthcare consumer

advocate

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

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.

ADN in Care Provider RoleASSESSMENT 1. In addition to competencies at LVN

level, ADN conducts a more extensive data collection process, using a variety of resources

2. Contributes this information to a data base & is able to identify changes in Pt.’s health status

DIAGNOSIS

The ADN has educational preparation to analyze & interpret data, identifying actual or potential healthcare needs & selecting Nsg Diagnoses

PLANNING

1. In addition to competencies at LVN level, A.D.N. establishes Pt.-centered goals, develops client-specific care plans

2. Develops individualized teaching plans in collaboration with other healthcare workers

IMPLEMENTATION

1. In addition to LVN competencies, A.D.N. initiates Nsg. Interventions, implementing care plans according to priorities of goals & making adjustments as client conditions change.

2. Also fosters a health-supportive environment, promoting rehab potential

(con’t)

3. Provides environment with physical & psychological safety

4. Uses communication techniques that assist clients with coping & problem solving.

4. Individualized, client- centered care management & teaching plans are implemented, providing continuity of care & referrals prn

EVALUATION

Evaluates client’s progress toward goals & the effects of interventions, revising care plans as needed

A.D.N. post 6 months of practice competencies Clinical competence, effective

communication, decision making, ability to develop, implement evaluate individualized plans of care, promoting participation by client and others

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

(con’t)

5. Evaluates outcomes, Pt. ability with self-care, & impact of teaching on health team members

6. Communicates findings, analysis, responses

ASSESSMENT

1. Data collection 2. Data organization 3. Data validation 4. Communication/documentation of

data

TYPES OF DATA

1. Objective 2. Subjective 3. Primary 4. Secondary

How nurses collect data

1. Observation 2. Examination 3. Interview 4. Consultation

ORGANIZATION OF DATA

1. Biological data 2. Psychological data 3. Social data 4. Cultural data 5. Communication

DATA VALIDATIONComplete, factual, accurate? 1. Cues: subjective & objective 2. Inferences = nurse’s interpretation of

the cues 3. Premature closure= making

inferences based on insufficient data

COMMUNICATING & DOCUMENTING DATA 1. Assessment flow sheets 2. Narrative assessment

documentation sheets 3. Report

DIAGNOSINGDEFINITION Nsg Diagnosis is a clinical judgement

about individual, family or community responses to actual & potential health problems/life processes… provide the basis for selection of NSRG interventions to achieve outcomes for which the nurse is accountable

TYPES OF NURSING DIAGNOSES 1. Actual 2. Risk for 3. Possible 4. Wellness

North American Nursing Diagnosis Association (NANDA) Established a classification system of

diagnostic labels or problem statements

PARTS OF THE NURSING DIAGNOSIS 1. P = Problem 2. E= Etiology 3. S= Signs & symptoms or

manifestations

PLANNING

1. Prioritize 2. Develop goals/expected outcomes or

outcome criteria 3. Develop Nsg. Orders or

prescriptions

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 client’s health problems

TYPES OF NSG INTERVENTIONS 1. Independent 2. Dependent 3. collaborative

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

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

USING NURSING CARE PLAN PUBLICATIONS 1. Carpenito Text & handbook 2. Kozier 3. deWitt 4. Gulanik

USING NURSING CARE PLAN GRADING CRITERIA

NURSING DIAGNOSIS & RESPIRATORY

NURSING DIAGNOSIS & CARDIOVASCULAR

NURSING DIAGNOSIS & UROLOGICAL

NURSING DIAGNOSIS & Psychosocial Health

DEVELOPMENTAL FACTORS & NURSING PROCESS

SOCIOCULTURAL FACTORS & NSG PROCESS

PEDIATRICS & NURSING PROCESS