the use of the nursing process nursing diagnosis in the care of the older adult chapter 3 (4 th ed)...
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![Page 1: The Use of The Nursing Process Nursing Diagnosis in the Care of The Older Adult Chapter 3 (4 th ed) Pati L.H. Cox, RN, BSN, M.Ed](https://reader035.vdocuments.net/reader035/viewer/2022080915/56649de55503460f94addc17/html5/thumbnails/1.jpg)
The Use of The Nursing Process Nursing Diagnosis in the Care of The Older
Adult
Chapter 3 (4Chapter 3 (4thth ed) ed)
Pati L.H. Cox, RN, BSN, M.Ed.Pati L.H. Cox, RN, BSN, M.Ed.
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OBJECTIVE Describe the nursing process as
a problem solving technique in the context of the older adult’s assessment, plan of care, nursing interventions, and documentation
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Objective Identify the use of the
nursing process, Minimum Data Set (MDS) and Resident Assessment Protocols (RAPS) in developing nursing care plans for residents in LTC
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Objective Use the nursing process to
develop a care plan for a presented case study
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Nursing ProcessA creative way to solve
problems from a nursing standpoint
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Nursing Process Assessment Planning Implementation Evaluation
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Nursing Process
Interdisciplinary ApproachPatient, Family/Significant Other
Health Care Team
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Assessment Collect information
Nursing History Focused Admission Assessment
Observation of pt./resident/client Physical Examination Review of laboratory/diagnostic tests Interview of pt./resident/client Interview of family/significant other
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Nursing Diagnosis Function of RN to define – LPN assists
in the formulation Nursing Problem related to ___?????___ Utilize NANDA Approved List Example:
Mobility, Impaired as related to weakness and unsteady gait 2nd to R total hip
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Planning Setting goals
STG = 30 days LTG = 90 days
Maslow’s Hierarchy of Needs Must consider pt’s goals for
compliance – active role Must be measurable, realistic, specific,
timely and attainable – Ask yourself these questions
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Planning Example = Improved Mobility as evidenced by:
ambulating with SBA x1, steady gait and denies dizziness in 30 days ( upon discharge, in 24 hours, etc)
Specific, attainable, timely, realistic and measurable
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Implementation Nursing Actions/measures This is the part nurses do best Staff (CNA) and nurses carry out Documentation = Important Component
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Documentation = DAR/AAPD/A = Data/AssessmentObservations, assessedObjective measurements (VS, lab)Subjective – What resident said
Action
Nursing interventions ( treatments, procedures, turning a pt., etc)
Response/Plan
Nurse’s plans
(phone Dr., phone family, refer to Social Services)Response to Action
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Evaluation Final step in Nursing process Determine if goal has been met Assess the outcomes of nursing plan of
care Reassess the pt/resident/client and
nursing process = Strength of problem solving approach
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Ongoing ProcessAssessment
Planning
Implementation
Evaluation
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Computer & The Nursing Process
MDS Minimum Data Set
RAP Resident Assessment
Protocol