NUR 100 Week 4

Ch. 7 Caring in Nursing Practice Notes from Sherpath Lesson

A Assessment Pregnant patient is hospitalized at 27 weeks of gestation due to

Nurse gathers patient data through chest pain and shortness of breath
 Observation Nurse:
 Interviews assesses the patient observes consistent high blood pressure
 Physical assessment. readings. The nurse plans to assess the patient on an ongoing
basis as the other steps of the nursing process are implemented.
D Diagnosis The nurse:
Nurse  selects and individualizes nursing diagnoses that include
 Analyzes addressing:
 Validates
 clusters patient data - patient comfort - dietary needs
to identify patient problems. - gas exchange - self-care
- activity intolerance
Patient data clusters are:
 stated in standardized language  uses these nursing diagnoses as the basis for the patient’s
 provides clarity and universal care plan.
understanding by all health care providers.
P Planning MD orders:
Nurse  heparin injection therapy for blood clot.
 prioritizes the nursing diagnoses  limited dietary intake of vegetables like spinach,
 identifies goals that are: which may reduce the effect of blood-thinning
 realistic medications.
 Measurable  bed rest  compression stockings
 patient-focused with specific The nurse:
outcomes.  creates a customized care plan for the patient, which
o Short term includes modified rest, diet, and exercise.
o Long term  plans to teach the patient how to self-inject heparin.
I Implementation The nurse implements nursing measures to ensure that:
Nurse initiates specific nursing interventions  gets an appropriate amount of exercise
and treatments designed to help the patient  the patient rests  eats a proper diet
achieve established goals and outcomes.
For five days, the nurse:
 conducts regular patient education to teach the patient to
self-inject heparin.
Soon the patient demonstrates the effectiveness of the teaching
by:
 successfully self-injecting heparin
 by making proper dietary choices that will not interfere with
the blood-thinning effects of the medication.
E Evaluation At 30 weeks gestation, the patient is ready for discharge.
Nurse The nurse:
 determines if the patient’s goals are met  coordinates with the entire health care team to monitor
 examines the effectiveness of  continually evaluate the effectiveness of the plan of care.
interventions Regular blood tests and office visits are maintained to assess:
 decides whether the plan of care should  heparin levels
be:  the resolution of the blood clots.
 discontinued The patient’s blood pressure, diet, and lifestyle habits are also
 continued continually evaluated.
 revised.

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 NUR 100 Week 4
Ch. 7 Caring in Nursing Practice Notes from Sherpath Lesson

Nursing process
- the systematic method of critical thinking that helps nurses work in an organized, methodical, and effective
manner as they develop individual care plans for patients.
nurses gather patient data, and assess and communicate patient needs, goals, and interventions with other members of
the health care team.

Historical Development of the

Nursing Process

Nurse Lydia Hall  pioneered the usage of the term nursing process in 1955
 presented her theory of nursing by drawing three interlocking circles, each
representing a distinct aspect of nursing: care, core, and cure

Dorothy E. Johnson  believed that nursing should focus on the patient as an individual, instead of the
(1959) disease.
 identified two areas that nurses could concentrate on to bring the patient back to
a state of mental and physical balance:
1. reducing stressful stimuli
2. supporting natural and adaptive processes.

Ida Jean Orlando  suggested that nurses use interpersonal relationships to meet the needs of the
(1961) patient as defined by the patient, not as defined by the nurse.
 This approach supported the patient as a member of the health team.

Ernestine Wiedenbach  identified four main elements of nursing:

(1963)  philosophy  practice
 purpose  the art of nursing.

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NUR 100 Week 4
Ch. 7 Caring in Nursing Practice Notes from Sherpath Lesson

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