Quote from ashfost
Hey Guys. I have a quick question about the "Nursing Process". Ive been goin over my notes and re-reading the text but Im still on that great on the the understanding of each Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation thing. Heres my understanding and just let me know if I have it or not. Ok:
Assessment- nurse will assess the patient by getting personal information, med history, collects info (sub. and obj.), any allergic reactions to meds (part of med history), etc. basically just a "getting to know you" type of thing
Nursing Diagnosis ( <--- one im mainly confused on) now this is when the nurse puts "what the patient just explained to me" and "what i already know from being a nurse" together to figure whats exactly wrong with the patient. then they go further to explain the risk of injury from the current (?) ailment of the patient or future (?) ailment of the patient.
Planning- nurse will put together a plan to teach the patient about the ailment and the recovery process as well as set up a recovery process
Initiating- putting the "plan" into action
Evaluation- Did the plan work?
I know it seems rough around the edges on how i explained it but do i have it almost right? any suggestions and thoughts are greatly appreciated! thanks! btw, my first pharm exam is next monday! yikes!
let's do an example to help you....
as you're assessing your pt, you learn he has hypertension and he takes no meds. you ask if he is on a special diet and he says no.
you just realized this man doesn't understand htn well. so there's your nsg dx...he has a knowledge deficit regarding htn.
he is started on beta blockers with diuretics and is put on a low sodium diet. you PLAN on teaching the pt exactly how a beta blocker helps the heart (in layman's terms) and discuss pulse taking etc. you also plan to discuss about how salt in his diet retains fluid, further increasing the workload on the heart. you can also PLAN on discussing kidney failure as a long term effect of untreated htn. also you know that beta blockers mask the signs and symptoms of hypoglycemia, so be certain to check if he's a diabetic.
IMPLEMENTING the plan is when you do get around to the discussion, handing him (and his significant other) pamphlets and maybe showing him a video. you can also consult the dietician to further discuss diet with him.
you GOAL is to have the pt take away more of an understanding of this disease and his meds.
you EVALUTE this by asking the pt questions and see how much he took in.
see how what we do every day actually comes from well executed plans!