Week One N112: Nursing Process and Interdisciplinary Care Team

Nursing Process

1. assessment

2. diagnosis

3. planning

4. intervention

5. evaluation

Primary and Secondary sources when gathering assessment data

• family

• patient

• research data

Objective and Subjective data examples

• obeservation

• interview

• focused

• data trends

Nursing assessments can be either

comprehensive or focused

What do we look for when we assess. (2)

1. health promoting behaviors

2. potential health problems

The assessment supports the identification of a

real or potential process: Nursing diagnosis

Nursing Diagnosis treats the

human response, not disease

prioritization of diagnoses

• Airway

• breathing

• circulation

Planning

Determining client/patient outcome goals and how to achieve them

Outcomes

Long-term or short-term goals that must be SMART

SMART goal is

• specific

• measurable

• attainable

• relevant

• timebound

Example of SMART GOAL

The patient will be able to describe when to self-administer home asthma medicine Albuterol prior to discharge

Interventions

Carry out the outcome., and related to the scope of nursing., and supported by EBP

Implementation

Doing the actual interventions, following EBP, acting with care and compassion and collaborating with the patient.

Evaluation

Determining progression to client goals

We may need to reassess and adjust based on

patient progress

Care Plan

Documenation of the nursing process including patient response

Role of LVN

Continue plan of care established by RN, monitor and care for patients with stable needs, do not provide new education

Role of RN

Liason between patient and everyone else, give meds, take vitals. Assess patient preferences needs, values and holistic assessment.

Highly Effective Teams

Mutaul respect among team members, undertand values and scopes, clear timely communication and better patietn outcomes.

Communication format with healthcare team

SBAR

Respiratory Therapist

Evaluate and treat pulmonary disordrees though diagnostic testing and airway clearance. Mechanical Ventilation techniques

Physical Therapy

improve movement during illness and injury through exercise, stretches, manipulation and work to restore function and relieve pain.

Dietician

Assess nutritional needs and develop dietary plan.

Speech Language Pathologist

Diagnose and treat communicaiton and swallowing problems.

Nurse Aide

basic care ADLs under supervision of a liscenced person

Physician

Diagnose, treat an dprevent illness

Pharmacist

Dispenses and fine tunes medications

Chaplain

Spiritual experts, help patients and families through hard times

Liscenced clinical social worker

Counsels patients with menta/emotinoal disorders or other psychosocial issues

Occupational therapist

improve ADLs