1 Unit 7 (Chapter 6) Nursing Process: LPN can contribute, but cannot develop plans. Phases include Assessment Diagnosis Planning Implementation Evaluation Table 6.1 pg] 03Understand roles of an LPN and an RN related to phases of the nursing process Assessment Gathering information Difference between subjective data (nausea, headache, pain)) and objective data (Vital signs, appearance of wound,) Give examples of each. Assessment takes place during each interaction. Data collection methods Interview (Subjective) Observation(Objective) Physical assessment (Head to Toe Assessment) (both) Organization of data: Into subjective and objective Validating Read the case study on page10 Organize the data into subjective and objective components. Nursing Diagnosis Identifying a problem; may be an actual, potential, or wellness o Actual: Pain, Ineffective tissue perfusion, knowledge deficit o Potential: Risk for infection, risk for falls, potential for skin breakdown o If an actual problem, it has to be evidenced by something, if it is potential problem it is only related to. Syndromes are only one step. Identifying etiology; usually written as "related to" or R/T ' Identifying signs and symptoms; may also include statements made by the patient; usually written as "as evidenced by" or AEB Example: A diabetic client with peripheral neuropathy who also has a diabetic foot ulcer due to decreased circulation can be assigned a nursing diagnosis: Ineffective peripheral tissue perfusion related to diabetes mellitus as evidenced by delayed peripheral wound healing and diminished pedal pulses. ** You must use a nursing diagnosis book to choose the "related to" criterion and use the nursing diagnosis book and your patient assessment to identify the AEB criteria. This will be a standard throughout your RN program in the nursing theory and clinical courses. It is important for LPN to RN students to grasp formulation of correct nursing diagnoses. This skill is usually not a large part of LPN school but is essential in associate degree clinicals as well 2 as NCLEX-RN. A nursing diagnosis book is an essential step in understanding this phase of the nursing process. Understanding and applying NANDA (North American Nursing Diagnosis Association) approved diagnoses are an important aspect of LPN to RN program. Prioritizing nursing diagnoses is an essential skill. (most important to least important) A registered nurse needs to be able to identify a priority patient or a priority condition from a list. This is an essential skill for NCLEX-RN and practice environments. Planning This phase involves identifying objectives and goals and planning interventions. Short-term goals Long-term goals Critical pathways NOC (Nursing Outcomes Classification) are standard outcomes related to NANDA diagnoses. Outcomes should be Specific: Should describe exactly what will be measured. Measurable: You should be able to provide an evidence that the outcomes have been achieved Attainable: Should be a goal that is possible to be achieved Realistic: Should be something that is achievable given the patient assessment and capabilities. Timed: Should include a definite time frame within which the objectives will be met. Example: For our diabetic patient who had peripheral neuropathy, an objective can be: "The patient will identify changes in lifestyle needed to increase tissue perfusion by the end of my shift." NIC (Nursing Interventions Classification) are standard interventions related to NANDA diagnoses. Implementation This phase involves carrying out the plan of care. Delegation and Prioritization occur in this phase. Evaluation This phase involves examining effectiveness of the interventions and adjusting the nursing process to meet the needs of the patient. Critical Thinking Eight Elements of Reasoning and Critical Thinking pg Purpose What we are looking for Question at issue: What is the information we are looking for Point of view: Be able to analyze data, clarify the meaning from the data that weve collected from different points of view. 3 Available information: Do we have data at hand that will give us a better understanding of the problem we are working on. Concepts: As your thought processes develop concepts, you’re able to start seeing a bigger picture of the problem. Assumptions: Educated guess Implications and Consequences: Defined through our outcomes Inferences: Conclusion that is drawn at the end of the whole thought process. Did we meet our expectations?
