Rusty's Nursing Process Lecture
Terms
undefined, object
copy deck
- nursing used to be by the seat of the pants. each nurse doing their own thing. pre 1955 patient care was based on ...
- MD orders
- what person in 1955 coined the term nursing process?
- Lydia Hall
- 1959-1063 a 3 step process was introduced. . who introduced the nursing process as a scientific model in 1966?
-
Virginia Henderson
think Virginia Slims - in 1967 a 4 step process was proposed. assessment, planning, intervention, and evaluation. what happened in 1973 by the ANA?
- published standards of clinical nursing practice
- 1982 the nclex was revised. what happened?
- it included nursing process concepts
- in 1984, jacho required what?
-
the use of the nursing process
jacho assess and evaluated hospitals on their quality of care, infection control, for certification for medicare payments. - what is the purpose of the nursing process?
-
id the health problem/care needs
establish patient goals
determine priorities
establish nursing interventions
evaluate effectiveness - what is a process?
-
a series of events
one event leads to another
all events work toward a goal achievement -
there are 5 steps in nursing process? assesssment, anaylsis, planning, impemenet, evaluation
how do you assess? -
physical assessment
health history
lab/diagnostic exams
team members
medical records
patient themselves
family too -
so the physical assessment part
what happens here? -
inspection
palpation
percussion
auscultation - what happens with the health history part of the assesssment?
-
establish a relationship
communication skills are needed
verbal and nonverbal - the lab results help the physical assessment too. how?
-
verify knowlege
it is objective information
suggest new findings - what do we glean from the team members?
-
new info
a new slant
this requires good com skills - what can we pick up from the family?
-
meds
mobility
reality info
its all subjective but critical info - what can medical records tell us?
-
past hospitalizations
past medical history - how should we proceed in data collections?
-
be descriptive
concise
complete
NO interpretive statements - what are the types of data?
-
subjective and objective data
sub = what the patient says
what pain feels like
Ex. patient says they are nausea
anything we cannot see is subjectve - what is objective data?
-
what you see
lab results are objective
concrete data, we can see it
smell - there is the anaylsis of nursing diagnosis. This is the 2nd part after assessement. what is it?
-
description of patient's actual/potential response to health problems.
It purpose it to:
analysis data, id problems, provide direction for the care plan - there is an evolution to the diagnosis part of the nursing process. can you describe it?
-
used to be only MD could diagnose.
conference in 1973 was held to classify nursing diagnosises. yea woopie! - what is NANDA and so what?
- north american nursing diagnsos ass. formed in 1982. it listed acceptable nursing diagnosis,
- there is the medical diagnosis and there is the nursing diagnosis. YOU BETTER KNOW the difference. describe the MD diagnosis
-
determined by MD
indicates a disease
diagnosis remains same until recovery
Ex. pneumonia, COPD, renal failure - what is an example of the nursing diagnosis?
-
well first of all its determined by a nurse and not a doctor.
the nursing diagnosis indicates a patient's response to treatment
Ex. risk of impaired skin integrity
Ex. knowledge deficit
Ex. self care deficit -
there is a 3 part format to nursing diagnosis:
diagnosis statement
related factors
what else? -
problem dia. statment
cause related factors
symptoms as manifested - Then the 3rd part of the nursing process is planning. you establish priorities. how do you establish the planning priorities?
-
rank diagnosis in order of important
maslov's hieracrhy
basic needs
when possible, involve patient -
planning has goals and outcomes right?
so what ? -
what = specific statement of patient behavior response.
why? provides direction of care
shows if interventions are effective
ishow we evaluate patients response to care
then we can go back to the goal and see if it has been achieved - the goals of the planning should be:
-
specific and measurable
have a time frame
are patient driven - what about intervention of the nursing process? what is intervention?
-
selected after goals are established
what are they? actions to accomplish the goals
are nurse driven
should indicate who, what , when, and how -
then the implementation of the nursing process, step 4.
what is this? the implementation? -
putting the plan into action!
you do this by delegation.
who, how to decide?
by their level of education and scope of the job/practice
expertise/competence - so the internventions are continually reassess why?
- to re evlauate to make sure the interventions are approapriate b/c the patient's condition could of changed.
- the last step, step 5 is evaluation. did it work? what now?
- we use the nursing care plan here: