Assisting With the Nursing Process

Chapter 8

Assisting With the Nursing Process

Objectives

• Define the key terms and key abbreviations in this chapter.

• Explain the purpose of the nursing process.

• Describe the 5 steps of the nursing process.

• Explain your role 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.

• Explain how to use assignment sheets.

• Explain how to promote PRIDE in the person, the family, and yourself.

Key Terms

assessment Collecting information about the person; a step in the nursing process

evaluation To measure if goals in the planning step were met; a step in the nursing process

goal That which is desired for or by a person as a result of nursing care

implementation To perform or carry out nursing interventions (nursing measures or nursing actions) in the care plan; a step in the nursing process

medical diagnosis The identification of a disease or condition by a doctor

nursing care plan A written guide about the person’s nursing care; care plan

nursing diagnosis Describes a health problem that can be treated by nursing measures; a step in the nursing process

nursing intervention An action or measure taken by the nursing team to help the person reach a goal; nursing action, nursing measure

nursing process The method nurses use to plan and deliver nursing care; its 5 steps are assessment, nursing diagnosis, planning, implementation, and evaluation

objective data Information that is seen, heard, felt, or smelled by an observer; signs

observation Using the senses of sight, hearing, touch, and smell to collect information

planning Setting priorities and goals; a step in the nursing process

signs See “objective data”

subjective data Things a person tells you about that you cannot observe through your senses; symptoms

symptoms See “subjective data”

Key Abbreviations

BMs	Bowel movements
CAA	Care Area Assessment
CMS	Centers for Medicare & Medicaid Services
IDCP	Interdisciplinary care planning
MDS	Minimum Data Set
OASIS	Outcome and Assessment Information Set
RN	Registered nurse

Nurses communicate with each other about the person’s strengths, problems, needs, and care. This information is shared through the nursing process. The nursing process is the method nurses use to plan and deliver nursing care. It has 5 steps.

• Nursing diagnosis

• Implementation

The nursing process focuses on the person’s nursing needs. The person and nursing team need good communication.

Each step is important. With good communication, nursing care is organized and has purpose. All nursing team members do the same things for the person. They have the same goals. The person feels safe and secure with consistent care.

The nursing process is used in all health care settings and for all age-groups. It is on-going. New information is gathered and the person’s needs may change. However, the steps are the same. You will see how the nursing process is continuous as each step is explained (Fig. 8-1, p. 84).

FIGURE 8-1 The nursing process is continuous.

Assessment

Assessment involves collecting information about the person. The nurse takes a health history about current and past health problems. The family’s health history is important. Many diseases are genetic. That is, the risk for certain diseases is inherited from parents. For example, a mother had breast cancer. Her daughters are at risk. The nurse reviews information from the doctor, test results, and past medical records.

An RN (registered nurse) assesses the person’s body systems and mental status. You play a key role in assessment. You make many observations as you give care and talk to the person.

Observation is using the senses of sight, hearing, touch, and smell to collect information.

• You see how the person lies, sits, or walks. You see flushed or pale skin. You see red and swollen body areas.

• You listen to the person breathe, talk, and cough. You use a stethoscope to listen to the heartbeat and to measure blood pressure.

• Through touch, you feel if the skin is hot or cold, or moist or dry. You use touch to take the person’s pulse.

• Smell is used to detect body, wound, and breath odors. You also smell odors from urine and bowel movements (BMs).

Objective data (signs) are seen, heard, felt, or smelled by an observer. You can feel a pulse. You can see urine color. Subjective data (symptoms) are things a person tells you about that you cannot observe through your senses. You cannot feel or see the person’s pain, fear, or nausea.

Box 8-1 lists the observations to report at once. Box 8-2 lists the basic observations you need to make and report to the nurse. Make notes of your observations. Use them to report and record observations. Carry a note pad and pen in your pocket. Note your observations as you make them. The agency may provide electronic devices for recording (Fig. 8-2).

Box 8-1

Observations To Report at Once

• A change in the person’s ability to respond

• A responsive person no longer responds.

• A non-responsive person now responds.

• A change in the person’s mobility

• The person cannot move a body part.

• The person can now move a body part.

• Complaints of sudden, severe pain

• A sore or reddened area on the person’s skin

• Complaints of a sudden change in vision

• Complaints of pain or difficulty breathing

• Abnormal respirations

• Complaints of or signs of difficulty swallowing

• Vital signs outside their normal ranges—temperature, pulse, respirations, and blood pressure (Chapter 29)

Box 8-2

Basic Observations

Ability to Respond

• Is the person easy or hard to wake up?

• Can the person give his or her name, the time, and location when asked?

• Does the person identify others correctly?

• Does the person answer questions correctly?

• Does the person speak clearly?

• Are instructions followed correctly?

• Is the person calm, restless, or excited?

• Is the person conversing, quiet, or talking a lot?

Movement

• Can the person squeeze your fingers with each hand?

• Can the person move arms and legs?

• Are movements shaky or jerky?

• Does the person complain of stiff or painful joints?

Pain or Discomfort

• Where is the pain located? (Ask the person to point to the pain.)

• Does the pain go anywhere else?

• How does the person rate the severity of the pain—mild, moderate, severe?

• How does the person rate the pain on a scale of 0 to 10 (Chapter 31)?

• When did the pain begin?

• What was the person doing when the pain began?

• How long does the pain last?

• How does the person describe the pain?

• Comes and goes

• Depends on position

• Was a pain-relief drug given?

• Did the pain-relief drug relieve pain? Is the pain still present?

• Is the person able to sleep and rest?

• What is the position of comfort?

Skin

• Is the skin pale or flushed?

• Is the skin cool, warm, or hot?

• Is the skin moist or dry?

• Does the skin appear mottled (blotchy, spotted with color)?

• What color are the lips and nail beds?

• Is the skin intact? Are there broken areas? If so, where?

• Are sores or reddened areas present? If yes, where?

• Are bruises present? Where are they located?

• Does the person complain of itching? If yes, where?

Eyes, Ears, Nose, and Mouth

• Is there drainage from the eyes? What color is the drainage?

• Are the eyelids closed? Do they stay open?

• Are the eyes reddened?

• Does the person complain of spots, flashes, or blurring?

• Is the person sensitive to bright lights?

• Is there drainage from the ears? What color is the drainage?

• Can the person hear? Is repeating necessary? Are questions answered correctly?

• Is there drainage from the nose? What color is the drainage?

• Can the person breathe through the nose?

• Is there breath odor?

• Does the person complain of a bad taste in the mouth?

• Does the person complain of painful gums or teeth?

• Do the person’s gums bleed with oral hygiene (Chapter 22)?

Respirations

• Do both sides of the person’s chest rise and fall with respirations?

• Is breathing noisy?

• Does the person complain of pain or difficulty breathing?

• What is the amount and color of sputum?

• What is the frequency of the person’s cough? Is it dry or productive?

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Tags: Mosbys Textbook for Nursing Assistants

Apr 13, 2017 | Posted by admin in NURSING | Comments Off

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