Академический Документы
Профессиональный Документы
Культура Документы
NURSING
PROCESS
Daniel francis despojo sustento, rn, usrn
THE NURSING PROCESS
Daniel francis despojo sustento, rn, usrn
CARE
NURSING PROCESS
STEPS
IMP
LEM EVA
EN LUA
T IO
PER
FO T ME
RM ASU N
RE
COLLECT
DEVELOP
PLANNING
ASSESSMENT
AN
IDE
NT DIA ALYZE
OU IF Y GN
TCO OS
IS
ME
THE
ASSESSMENT
ASSESSMENT
C
O
L
ASSESSMENTL
E
C
T
ASSESSMENT
INITIAL FIRST
SUBSEQUENT FOLLOW-UP
DATA COLLECTION
#1 Observation
5 senses
DATA COLLECTION
#1 Observation
NOSE
SMEL
L
DATA COLLECTION
#1 Observation
ear S
HEAR
DATA COLLECTION
#1 Observation
T AS T E
TONGU
E
DATA COLLECTION
#1 Observation
NOT I S E
TOUCH
DATA COLLECTION
#1 Observation
IS
SIGHT
DATA COLLECTION
#2 Interview
communication
2-3 feet
DATA COLLECTION
#2 Interview
questions
Open ended vs
Closed ended questions
DATA COLLECTION
#2 Interview
types
Directive vs Non directive
DATA COLLECTION
#3 Physical Examination
examination
IPPA
DATA COLLECTION
#3 Physical Examination
types
Cepahalocaudal vs
Systemic
DATA COLLECTION
DATA VALIDATION
Double Checking
ASSESSMENT
DATA ORGANIZATION
Arrange Systemically
ASSESSMENT
DATA DOCUMENTATION
Record Accurately
Types of nsg
ASSESSMENT
NURSING
ASSESSMENT
INITIAL Comprehen
ASSESSMENT Upon
sive
Admission
NURSING
ASSESSMENT
PROBLEM Specific
-FOCUSED Continuousl
Problem
y
NURSING
ASSESSMENT
EMERGENCY Fast-paced
ASSESSMENT Life and
Death
NURSING
ASSESSMENT
A
N
A
DIAGNOSISL
Y
S
E
diagnosis
NURSING
DIAGNOSIS
patient’s response to health problems
diagnosis
Antecedent to, associated with,
Diagnostic Label / Problem
contributing to, abetting
Etiology/ Cause
ACTUAL NSG. DX
Existing
diagnosis
RISK NSG. DX
May exist
diagnosis
POSSIBLE NSG. DX
Noticeable but lacks
evidence
diagnosis
SYNDROME NSG. DX
Collection of Nursing
Diagnoses
diagnosis
3 PHASES:
1. PRIORITY SETTING
2. MAKING GOALS
3. MAKING OUTCOMES
PRIORITY SETTING
MASLOW’S HIERARCHY
OF NEEDS
“Keep“Physiologic
them breathing,
FIRST,keep
them safe”
Psychologic LAST”
PRIORITY SETTING principles
PRINCIPLE OF ABC
“Airway FIRST, Breathing
NEXT, Circulation LAST”
PRIORITY SETTING principles
PRINCIPLE OF
OCCURENCE
“Focus on the HERE & NOW
rather than on what is
ABOUT TO OCCUR”
OUTCOME
IDENTIFICATION
3 PHASES:
1. PRIORITY SETTING
2. MAKING GOALS
3. MAKING OUTCOMES
MAKING GOALS &
OUTCOMES
NURSING
ITEM STANDARD DESCRIPTION EXAMPLE
LANGUAGE
Nursing To establish
GOAL Outcome Broad adequate hydration
Classification
Will be able to
consume 1,500-
OUTCOMES Indicators SMART 2,000 mL of water
in 24 hours
Types of
outcomes
TYPES OF OUTCOMES
SHORT-TERM OUTCOMES
Easily achievable
TYPES OF OUTCOMES
LONG-TERM OUTCOMES
Takes longer
THE pLanning
planning
NURSING CARE
PLANNING
PLAN
Types of
planning
TYPES OF planning
INITIAL PLANNING
Initial NCP
TYPES OF planning
ONGOING PLANNING
Update NCP
TYPES OF planning
DISCHARGE PLANNING
NCP after discharge
Types of ncp
TYPES OF NCP
INFORMAL NCP
Nurse’s mind
TYPES OF NCP
FORMAL NCP
Written
TYPES OF NCP
STANDARDIZED NCP
Clients with the same
condition
TYPES OF NCP
INDIVIDUALIZED NCP
Specific client
Types nursing
interventions
TYPES OF nsg interventions
NURSE-INITIATED INT.
INDEPENDENT NSG INT
No prescription
TYPES OF nsg interventions
PHYSICIAN-INITIATED INT.
DEPENDENT NSG INT
With prescription
TYPES OF nsg interventions
COLLABORATIVE INT.
INTERDEPENDENT NSG
INT
Working with the HEALTH
TEAM
TYPES OF nsg interventions
OBSERVATION INT.
Assessment
categories OF nsg int
PREVENTION INT.
Complication prevention
and
Risk factor reduction
categories OF nsg int
TREATMENT INT.
Cure
categories OF nsg int
Assess TPR-BP
categories OF nsg int
Act of transferring
tasks
PRINCIPLES OF DELEGATING
“Only the
responsibility is
DELEGATED not the
ACCOUNTABILITY”
PRINCIPLES OF DELEGATING
Delegate according to
level of EXPERTISE or
EDUCATION
PRINCIPLES OF DELEGATING
Assessment
Diagnosis Stable Patients
Planning Routine Bedside Care
Evaluation Routine Assessment
Documentation Assistance in ADL
Sterile Procedures
THE
IMPLEMENTATIO
N
IMPLEMENTATION
N
S
G
IMPLEMENTATION
I
N
T
IMPLEMENTATIO
N
SKILLS
IMPLEMENTATION SKILLS
INTELLECTUAL SKILLS
Mind
IMPLEMENTATION SKILLS
TECHNICAL SKILLS
Hands
IMPLEMENTATION SKILLS
INTERPERSONAL SKILLS
Heart
THE evaluation
evaluation
M
E
A EVALUATION
S
U
R
E
evaluation
Conclusion
GOAL NOT MET :
Urinary output 300 mL / 24
hours
Evidence
Types of
evaluation
Types of evaluation
1. QUALITY ASSURANCE
2. QUALITY IMPROVEMENT
3. NURSING AUDIT
QUALITY
ASSURANCE
QUALITY ASSURANCE
QUALITY ASSURANCE
3 CATEGORIES OF
QUALITY
ASSURANCE
3 CAT. OF QUALITY
ASSURANCE
STRUCTURE Environment
EVALUATION
PROCESS Performance of
EVALUATION Care
OUTCOME Result of
EVALUATION
Care
QUALITY
IMPROVEMENT
QUALITY
IMPROVEMENT
QUALITY IMPROVEMENT
QUALITY
IMPROVEMENT
CONTINUOUS QUALITY
IMPROVEMENT (CQI)
TOTAL QUALITY
MANAGEMENT (TQM)
PERFORMANCE
IMPROVEMENT (PI)
PERSISTENT QUALITY
IMPROVEMENT (PQI)
NURSING AUDIT
NURSING AUDIT
NURSING AUDIT
RECORDSREVIEW
TYPES OF
NURSING AUDIT
NURSING AUDIT
CONCURRENT During
AUDIT
RETROSPECTIVE After
AUDIT
PEER Fellow
REVIEW
nurses
NURSING AUDIT
PATIENT’S
RECORDINGCharting
R esearch
E ducation
C ommunication
O dit (audit)
R eimbursement
D ata to court
recording
FOCUS
CHARTING Problem
Strengths
SOAPIER
SOAPIE SOAP Subjective, Objectiv
CHARTING CHARTING Assessment, Planni
PIE Problem,
Interventions,
CHARTING
BY EXCEPTION Evaluation
Significant /
CHARTING
Types of records
Types of records
SOURCE-ORIENTED
RECORD
PROBLEM-ORIENTED
RECORD
CASE MANAGEMENT
RECORD
ELECTRONIC
RECORD
Types of records
SOURCE-ORIENTED
RECORD
SSOURCE-ORIENTED
RECORD
T
O
R Narrative
Y Charting
Types of records
PROBLEM-ORIENTED
RECORD
Health Problem
Types of records
Assessment Database Problem List
PPROBLEM-ORIENTED
RECORD
E
R
L
A SOAP Charting
Types of records
CASE MANAGEMENT
RECORD
Critical
TOOL
Pathways
Types of records
Assessment Database Problem List
__ Pallor __ Hyperthermia
__ Jaundice __ Hypothermia
__ Pinkish __ Fluid Vol. Excess
__ Reddish __ Fluid Vol. Deficit
CASE MANAGEMENT
RECORD
LONGEST
Charting by Exception
Types of records
ELECTRONIC
RECORD
Computerized
CHARTING
GUIDELINES
CHARTING
GUIDELINES
- urine specimen
sent to
dfs 7/1/11 12:05 am
pharmacy
laborato
ry
reporting
rePORTING
REPORTING
EAM
Recording
documents
ASSESSMENT Nursing History
DATABASEand
Assessment
NURSING CARE Diagnoses,
PLAN Interventions
and Outcomes
Graphic Record,
FLOW
SHEETS I&O Record, IV Flow
Sheet
Ordered
MEDICATION
medication w/
ADMIN. RECORD
END-OF-SHIFT-REPORT
SUMMARY REPORT
TYPES OF rePORTING
NURSE’S ROUNDS
WALKING ROUNDS
Room
TYPES OF rePORTING
PROGRESS NOTES
NURSE’S NOTES
TYPES OF rePORTING
DISCHARGE SUMMARY
DISCHARGE PLAN
Care
TYPES OF rePORTING
Department or
Hospital
REFERRAL SUMMARY
Care &
Instructions
TYPES OF rePORTING
Nurses
TYPES OF rePORTING
INCIDENT REPORT
OCCURENCE REPORT
Only
ItDo
isstate
done
not
It’sIt’s
just
tell
Be
what
to
not
OBJECTIVE!
tales
an
prevent
ayou
explanation.
DEMERIT.
nor
have
same
jump
observed.
thing
into
from happening
conclusions.
again.
TYPES OF rePORTING
TELEPHONE
COMMUNICATION
7/11/11 5:03 pm
T.O.: Give Digoxin 5 mcg, 1 tab
per orem daily
J. Smith, M.D. / D.F. Sustento, RN
/ M.J. Genzola, RN
within 24
hours