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Welcome back everyone.
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In this video, we are discussing a critical element
and fundamental element to clinical judgement,
The nursing process.
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The nursing process is the essential core
of practice for the registered nurse
to deliver holistic,
patient-focused care.
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It involves five steps.
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The first step of the nursing
process is Assessment.
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It includes subjective data which are verbal
statements from the patient or the caregiver.
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It also includes objective data.
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this is measurable, tangible data such as vital
signs, intake and output, height and weight.
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Things that you can collect yourself.
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Now, it's important to remember that data may come
from the patient directly or from a primary care giver
who may or may not be a direct
relation family member.
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When thinking of electronic health records, they
can be very helpful to the assessment process.
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If a patient has been in the system before, it can
prepopulate this information into your assessment record,
allowing you the opportunity to
review it for it's accuracy.
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Second, it can also assist by having
certain questions to remind you
to complete a holistic assessment
so you don't forget anything.
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The second step of the nursing
process is the diagnosis.
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And this is the formulation of a nursing
diagnosis really assist in planning
and the implementation of patient care.
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Don't forget about the North American
Nursing Diagnosis Association.
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This is an organization that maintains an
up-to-date list of nursing diagnosis at all times.
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The diagnosis includes clinical judgement about
responses to actual or potential health problems
on the part of the patient,
family or community.
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And it includes Maslow's hierarchy of needs
which helps to prioritize and plan care
based on the patient-centered outcomes.
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The third step is Planning.
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This includes goals and outcomes, and they directly impact
patient care based on evidence-based practice guidelines.
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Now, patient specific goals and attainment
do assist in ensuring a positive outcome.
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So when you think about a nursing care plan,
they are essential in this phase of goal-setting.
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And they provide a course of direction for personalized
care, tailored to an individual's unique needs.
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When you're thinking about setting
goals, you want to create SMART goals.
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SMART goals are goals that are
Specific, Measurable or Meaningful,
they're Attainable
or Action-oriented,
they're Realistic or
Results-oriented,
and finally, they are
Timely or Time-oriented
meaning there is a specific time
by which they need to be attained.
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And the fourth step of the nursing
process is Implementation.
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And this involves implementing
interventions according to the care plan
and provides for continuity of care for the patient
during hospitalization and in preparation for discharge.
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It involves action and the actual carrying out of the nursing
interventions that are outlined in the plan of care.
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It does require nursing interventions such
as applying a cardiac monitor or oxygen,
direct or indirect care, medication
administration and standard treatment protocols.
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And it's really important after you initiate
an intervention and you implement it
that you document it in
the patient's records.
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The fifth step of the nursing
process is evaluation
and it is vital to a
positive patient outcome.
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It stands to reason that whenever a healthcare
provider intervenes or implements care,
they must re-assess or evaluate to ensure
that this desired outcome has been met.
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Now, depending on the overall patient condition,
you might need frequent reassessments.
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And finally, you may need to adapt the plan of care
based on new assessment data that you received.
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So remember, the utilization of the nursing
process to guide care is clinically significant
going forward in this dynamic,
complex world of patient care.
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So let's review what we've learned today.
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First, the assessment includes both
subjective and objective data.
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Meaning you have information that comes from
others and information that you collect yourself.
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Second, a nursing diagnosis assist in the
planning and implementation of patient care.
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Now, patient-specific goals and attainment
actually assist in ensuring a positive outcome.
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Goals should be created
using the SMART format.
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Implementation invloves action and the actual carrying out
of nursing intervention outlined in the plan of care.
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And finally, whenever a healthcare
provider intervenes or implements care,
they must reasses or evaluate to ensure
the desired outcome has been met.
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I hope you've enjoyed this
video on the nursing process.
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Thank you so much for watching.