NURSING PROCESS
PRE TEST
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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 PROCESS
DEFINITION
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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)
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NSG process is an organized,
systematic method of giving goaloriented, humanistic care that’s both
effective and efficient
BENEFITS (5)
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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
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1. Assessment
2. Diagnosis
=A
=Delicious
3. Planning
=P
4. Implementation
=I
5. Evaluation/Reassessment =E
NSG PROCESS & THE LVN
COMPETENCIES
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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
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1. Assessment: assesses basic needs
of Pts.=collecting data & identifying
deviations from normal. Documents
these data & communicates findings.
PLANNING
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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
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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
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Seeks guidance & continues
collaboration with others in modifying
Nsg. Approaches and revising Nsg.
Care plans
In Member of Discipline Role
LVN COMPETENCIES
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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
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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
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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 Role
ASSESSMENT
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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
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The ADN has educational preparation
to analyze & interpret data, identifying
actual or potential healthcare needs &
selecting Nsg Diagnoses
PLANNING
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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
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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)
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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
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Evaluates client’s progress toward goals
& the effects of interventions, revising
care plans as needed
A.D.N. post 6 months of practice
competencies
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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
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1. Establishes a data base
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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
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(con’t)
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5. Evaluates outcomes, Pt. ability with
self-care, & impact of teaching on health
team members
6. Communicates findings, analysis,
responses
ASSESSMENT
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1. Data collection
2. Data organization
3. Data validation
4. Communication/documentation of
data
TYPES OF DATA
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1.
2.
3.
4.
Objective
Subjective
Primary
Secondary
How nurses collect data
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1.
2.
3.
4.
Observation
Examination
Interview
Consultation
ORGANIZATION OF DATA
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1.
2.
3.
4.
5.
Biological data
Psychological data
Social data
Cultural data
Communication
DATA VALIDATION
Complete, factual, accurate?
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1. Cues: subjective & objective
2. Inferences = nurse’s interpretation of
the cues
3. Premature closure= making
inferences based on insufficient data
COMMUNICATING &
DOCUMENTING DATA
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1. Assessment flow sheets
2. Narrative assessment
documentation sheets
3. Report
DIAGNOSING
DEFINITION
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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
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1.
2.
3.
4.
Actual
Risk for
Possible
Wellness
North American Nursing
Diagnosis Association (NANDA)
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Established a classification system of
diagnostic labels or problem statements
PARTS OF THE NURSING
DIAGNOSIS
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1. P = Problem
2. E= Etiology
3. S= Signs & symptoms or
manifestations
PLANNING
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1. Prioritize
2. Develop goals/expected outcomes or
outcome criteria
3. Develop Nsg. Orders or prescriptions
NURSING INTERVENTIONS
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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
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1. Independent
2. Dependent
3. collaborative
COMPONENTS OF NSG
ORDERS
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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
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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
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1.
2.
3.
4.
Carpenito Text & handbook
Kozier
deWitt
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