Medical Tech Prep 1
Lancaster High School
Mrs. Carpenter
CHAPTER 6: THE NURSING PROCESS
Pages 73-80
Objectives
• Explain the purpose of the nursing process
• Describe the steps of the nursing process
• Explain the role of the NA in each step of
the nursing process
• Explain the difference between objective
data and subjective data
• Identify the observations that you need to
report to the nurse
• Explain the purpose of care conferences
THE NURSING PROCESS
• Nurses share information about the person
through the nursing process.
• The nursing process has five steps:
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Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
• focuses on the person’s nursing needs.
• Good communication is needed.
• Each step is important.
THE NURSING PROCESS
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is organized and has purpose.
team members have the same goals
Team members do the same things
Person feels safe and secure.
ongoing
changes as new information is gathered
Changes as a person’s needs change.
THE NURSING PROCESSASSESSMENT
• involves collecting information about the
person.
• many sources:
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nursing history
family’s health history
Information from the doctor
Test results and past medical records
• The RN assesses the person’s body
systems and mental status.
THE NURSING PROCESSASSESSMENT
• NA plays a key role in assessment.
• make many observations as care is given
• Observation=using the senses to collect
information
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sight
hearing
touch
smell
ASSESSMENT-DATA
• objective data (signs).
– Information that is seen, heard, felt, or smelled
• Subjective data (symptoms).
– Information that a person tells you that you
cannot observe through your senses
• Box 5-1 on page 75
• Make notes of your observations.
APPLICATION:
OBJECTIVE OR SUBJECTIVE
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Headache
Red nose
Vomiting
A red bruise
Moist skin
Tingling sensation
Nausea
Stomach pain
Crying
Oily hair
Toothache
Swollen feet
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Painful knees
Dirty fingernails
Bloody discharge
Nausea
Laceration
PERRLA
Loose stool
Blue lips
Aggressive behavior
Orange colored urine
Malaise
Nose bleed
Focus on long-term care: assessment
• OBRA requires the minimum data set
(MDS) for nursing center residents.
• MDS
– is an assessment and screening tool.
– is completed when the person is admitted
– is updated before each care conference.
• new MDS is completed once a year and
whenever the person’s condition changes.
Focus on long-term care: assessment
• Information contained on the MSDS
• Often uses information obtained
through NA records
• Appendix B on page 822
APPLICATION
PATIENT OBSERVATIONS
-for each of the patients in the beds you
will be making observations as if you are
the nursing assistant in charge of their
care. “Walk” into each room and make
observations about the patient. Record
the observations on a sheet of paper
and be prepared to report to the RN
(Mrs. Carpenter) what you observed.
THE NURSING PROCESSNURSING DIAGNOSIS
The RN uses assessment information to make a
nursing diagnosis.
• nursing diagnosis describes a health problem
treatable through nursing measures.
• Nursing diagnoses and medical diagnoses are not
the same.
– medical diagnosis is the identification of a disease or
condition by a doctor.
A person can have many nursing diagnoses.
THE NURSING PROCESSNURSING DIAGNOSIS
• Nursing diagnoses involves needs
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Physical
Emotional
social
spiritual
• common nursing diagnoses (seeBox 5-2
on pages 76 and 77)
The Nursing ProcessPLANNING
• involves setting priorities and goals.
• measures or actions are chosen to help the
person meet the goals.
• The person, family, and health team help plan
care.
• Priorities are what is most important to the
person.
– Maslow’s theory of basic needs is useful (Chapter 6).
– Needs required for life and survival must be met before
all others
• .
The Nursing ProcessPLANNING
• Goals
– A goal=that which is desired in or by a person as a result
of nursing care.
– aimed at the person’s highest level of well-being and
functioning.
• Nursing interventions
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chosen after goals are set.
action or measure taken to help the person reach a goal.
does not need a doctor’s order.
Some nursing measures come from a doctor’s order
The Nursing Care Plan:
written guide about the person’s care
• Includes nursing diagnoses and goals
• measures or actions for each goal
• Used as a communication tool
– See what care to give.
– Ensure that the nursing team gives the same care.
• found in the medical record, Kardex, or on computer.
• a care conference may be called to share information and
• ideas about the person’s care.
– Nursing assistants usually take part in the conference.
• may change if the person’s nursing diagnoses change.
The Nursing ProcessIMPLEMENTATION
• to perform or carry out nursing measures in the
care plan.
• Care is given.
– The nurse delegates measures and tasks that are within
your legal limits and job description.
– The nurse may ask you to assist with complex
measures.
– report the care given to the nurse.
– record the care given if allowed by your agency
• Report or record new observations.
– may change the nursing diagnoses.
– know about any changes in the care plan.
The Nursing ProcessIMPLEMENTATION:Assignment sheets
• Assignment sheets
• used to communicate delegated measures/tasks t
• An assignment sheet tells
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Each person’s care
What measures and tasks need to be done
When to take meal and lunch breaks
Which nursing unit tasks to do
• Talk to the nurse about any assignment that is
unclear.
• Check the care plan and Kardex if you need more
information.
The Nursing ProcessEVALUATION
• measuring if the goals in planning were
met.
1. Progress is evaluated.
2. Assessment information is used.
3. Changes in nursing diagnoses, goals, and
the care plan may result.
The Nursing Process Never Ends.
ASSESSMENT
NURSING DIAGNOSIS
PLANNING
EVALUATION
IMPLEMENTATION
YOUR ROLE
• key role in the nursing process.
• Use of your observations for nursing
diagnoses and planning.
• develop the care plan.
• perform nursing actions and measures in
the care plan.
• Complete observations for evaluation
APPLICATION
STUDENT WORKBOOK #1-30