Nursing Process
Example: *Evaluation of nursing interventions* used to meet the STO (Short-Term Objective) of improving respirations of an adult male with pulse-ox below 93
"Did elevating his head help him breathe/improve his respirations?"
steps of the nursing process
(1) *Assessment*; (2) *Nursing Diagnosis*; (3) *Planning*; (4) *Implementation*; (5) *Evaluation*
*Scientific Rationales* - _____ step in Nursing Process:
*3rd step*; ensures that the intervention is based on accepted nursing practice reflecting knowledge of scientific principles, nursing standards of care, & agency policies
*Implementation* - ______ step in Nursing Process:
*4th step*; delivering the nursing care you have planned
*Evaluation* - _______ step in Nursing Process
*5th step*; a review of pt responses to determine effectiveness of care plan; evaluate intervention
*MEPLAN* is a mnemonic/format for...
*6 interventions* - *M*edications - *E*ducation/teaching - *P*rocedures (vital signs, cleaning wound) - *L*ab & other diagnostic data (checking K+ levels) - *A*ssessments - *N*utrition
*Step 1* of the Nursing Process
*Assessment*; systematic *collection of data* related to (R/T) the pt; collect *objective* & *subjective* data
the nursing process is *ever-changing* in response to the pt's needs - this makes it a _________ process
*DYNAMIC* proces
*Step 5* of the Nursing Process
*Evaluation*; determine *pt's progress toward attaining objectives & goal*; monitor *pt's responses* to nursing interventions; *evaluate nursing interventions*
*Step 4* of the Nursing Process
*Implementation*; putting plan of care into action
types of nursing interventions
*Independent* (*I*) Interventions; *Collaborative* (*C*) Interventions
*Step 2* of the Nursing Process
*Nursing Diagnosis*; *analyzing* data to identify *pt's problem*; identified *current needs of pt*
laboratory & diagnostic studies - *what type of data*
*OBJECTIVE* data
*Step 3* of the Nursing Process
*Planning*; *identify objectives & goals* to address the health & wellness needs; set appropriate nursing interventions; *long-term goals (LTG) speak to the short-term objectives (STO)*
"pt's pulse-ox will stay between 93-100 by the end of the shift" is an example of a(n)
*STO* (short-term objective)
what guides the whole nursing care for the pt; guides nursing interventions designed to accomplish objectives
*Short-Term Objectives* / *STO*
types of nursing diagnoses
*actual* diagnosis; *risk/potential* diagnosis; *wellness* diagnosis
*anxiety* & *fear* R/T separation from parents; Example of what type of ERROR in pt diagnostic statement
*combining 2 nursing diagnoses*; anxiety is 1 diagnosis, fear is another
advantages of nursing diagnoses
*common language*; identification of *appropriate goals*; aids in documentation; provides a *quality improvement base*
Short-Term Objectives (STO)
*desired result* of nursing actions; *performed in order to accomplish LTG*
*actual* problem: pt immobile; EXAMPLE of a *nursing diagnosis* would be ________
*impaired skin integrity*
constipation R/T *nutritional intake*; Example of what type of ERROR in pt diagnostic statement
*lack of specificity*; "nutritional intake" is too vague, doesn't tell you anything
impaired skin integrity R/T *not being turned frequently* Example of what type of ERROR in pt diagnostic statement
*making assumptions*
writing STOs - characteristics
*measurable*; obtainable/*realistic*; time-oriented
*immobility* R/T *pain*; Example of what type of ERROR in pt diagnostic statement
*relating one nursing diagnosis to another*; this one is **OK to use**
actual diagnosis
*response* to an *actual* health problem
self-care deficit R/T *stroke*; Example of what type of ERROR in pt diagnostic statement
*using medical diagnosis*
Nursing Diagnosis
- *focus on pt's response to stress &/or illness* - *identify actual or potential* nursing diagnosis, *then give a specific nursing diagnosis*
PES Format - what is it used for; what does is stand for
- *nursing diagnosis statements* - *P*roblem or need identified when you collect all the data - *E*tiology or cause of pt response - *S*igns & Symptoms
advantages of the nursing process
- *structured decision making*: minimize errors; avoids time-consuming repetition - uses a *common language* - aids in *documentation*; provides a format for charting
definition of nursing process
5-step process that provides an orderly, logical problem-solving approach for administering nursing care so that the client's needs are met comprehensively & effectively
laboratory & diagnostic studies
Complete Blood Count (*CBC*); Fluid & electrolyte studies; chest x-rays; Electrocardiogram (*EKG*); Arterial Blood Gases (*ABG*); other lab studies
risk/potential diagnosis
a condition that *may develop* in a *vulnerable individual*; potential - *has NOT happened yet*
what is the nursing process centered on?
client-pt centered; *nurse & pt work TOGETHER*
Example: What are *some nursing interventions* to meet the STO (Short-Term Objective) of improving respirations of an adult male with pulse-ox below 93
elevate head; have him breathe deeply
wellness diagnosis
has a *wellness focus* & is more of *an opportunity* than a need; *focus on pt response to stress & illness*
medical diagnosis
illness or condition for which Tx is directed by a physician; *focus on preventing & curing disease*
how should data be clustered
into *similar categories*
guidelines for history taking
listen carefully; *remain objective*; collect ONLY necessary info; *document*
Long-Term Goal (LTG)
overall broad direction in which to guide plan of care; end result of care you want to provide your pt; "global" statement; *nurse & pt WORK TOGETHER*
physical assessment
physical examination must be conducted during initial assessments; collecting data to be included in assessment data column
characteristics of the nursing process
planned & *goal directed*; universally applicable; *problem oriented*; *cognitive process*
risk for injury R/T *blindness*; Example of what type of ERROR in pt diagnostic statement
problem *R/T an unchangeable situation* (blindness is an unchangeable situation)
advantages of nursing care plan
provides continuity of care; enhances communication; aids in documenting the nursing process; serves as a teaching tool; coordinates provisions of care among disciplines
what is the nursing process based on
scientific process of *assessing*, *planning*, *evaluating*
hints for successful STO writing
use *pt as subject*; use *action verbs*; address activities &/or behaviors; must be *measurable*, *obtainable* & *time-oriented*
components of the nursing history
vital statistics (assessment data column); pt understanding of present illness; pt expectations & concerns; patterns of daily living; social & cultural history; allergies & current meds
What should be evaluated (in Evaluation Phase of Nursing Process)
was intervention performed; was intervention *successful*?; were *goals & objectives met?*; are there *any alternative approaches that need to be taken?*
