#nursing process

06/28/2020

So I have finally caught up on my notes and readings... actually I’m ahead. All I have to do the practice questions (10/10 recommend). Also side note I got this book stand and I’m in love with it. I might paint it as a soothing relaxation tactic post exam season. 

Onto today’s topic of reviewing I guess. 

The Nursing Process

For those of you that are taking fundamentals or Health assessment get VERY FAMILIAR with this concept. This will be the basis for pretty much every single class you take from here on out. 

There are five steps. 

Fun little way to remember the steps in the process ADPIE

Assessment 

Assessment consists of taking a health history and acquiring both subjective (from the patient and descriptive) and objective data (measurable data like weight and HR) from the patient. 

Assessment begins from the instant you first make contact with the patient because there are some things that you simply have to observe without telling the patient

ex: you should not tell your patient that you are assessing gait or respiratory rate because they may then alter how they normally walk or breathe. 

There are many different types of assessments catered for the situation that one is is 

head to toe assessment 

shift/ periodic assessment 

focused assessment 

screening assessment 

To yield the best results during a patient interview make sure to ask open ended questions to prompt the patient to elaborate

during the patient interview you can also passively assess

mental state and awareness

hearing 

posture

anything that would indicate pain such as wincing, sweating, or irritability

Diagnosis 

The diagnosis is based off of the information gathered in the assessment. 

Also please know that the diagnosis you’re giving is a NURSING diagnosis, not, a MEDICAL diagnosis. They are very different. A medical diagnosis would be outside of the scope of nursing practice. 

Planning 

During the planning phase you look at the nursing diagnosis and you create a plan of treatment

You will plan both treatment and education 

Most importantly you will set goals 

Goals should be specific, measurable, have a time limit, and be realistic

Mrs. Walker will be able to move from her bed to the chair unassisted by the end of the shift 

Be able to acknowledge when you are in over your head and need to call for inter professional help. Call a consult if needed 

Implementation 

This is where you enact your plan

This is where you use the incentive spirometer, where you have them ambulate, where you use the Foley catheter etc. etc. 

Delegate appropriately to CNA’s and other health care professionals when needed 

always remember that you cannot administer anything to a patient without an order, not even oxygen

Make sure to assess the patient as the implementation continues and be vigilant for anaphylaxis or tasks that are too demanding

Evaluation

Evaluation should be done throughout the entirety of the process but it is most important to do after implementation

One has to evaluate if the treatment plan is working

Were the goals met? 

Do changes have to be made?

What part of the plan did not work?

Modify the care plan to get the desired outcomes 

Now this isn’t a specific letter of the nursing process but its because it’s so obvious that it doesn’t need to be said. 

DOCUMENT EVERYTHING.