Nursing process33

2. Out Line

3. It is the framework for nursing practice in that it provides the
mechanism by which nurses use their belief, knowledge and skills to
diagnose and treat the patient’s response to actual or potential
health problems.

4. The major purpose is to provide framework
within which the individualized needs of the
patient, family and community can be met.
Purpose of nursing process:

5. 1- Assessment
5- Evaluation
4- Implementation
2- Nursing diagnosis
3- Planning

8. Physical
Psychological
Emotional
1- To establish data base about patient condition

9. 1- Comprehensive
assessment
3- Ongoing
assessment
2- Focused
assessment

10. Elements of assessment process:
A. Data collection
B. Data verification
C. Data Organization
D. Data interpretation
E. Data documentation

11. Priorities in data collection:
A system must be established to determine
which data will be collected first. One of such
systems is Maslow's hierarchy of needs that
include: physiological, safety and security,
social, self-esteem and self-actualization
needs.

12. Current data
Historical data Objective data
Subjective data
The nurse during assessment collects four types of data:

13. Data from patient's point of view and include
feelings, perceptions, and concerns. They cannot
be readily observed by another e.g. pain, nausea.
Are observable and measurable data that are obtained
through observation, standard assessment
techniques performed during the physical
examination, and laboratory and diagnostic testing
e.g. blood pressure, edema.
Subjective data
Objective data

14. Includes situations or events that have occurred in
the past, which are important in identifying patient's
health patterns and past experiences that may have
an impact upon patient's health e.g. previous
hospitalization.
Data related to events that are occurring now e.g.
vomiting, post operative pain.
Historical data
Current data

15. A- Primary sources B- Secondary sources
Patient
- Family members and friends
- Health team members
- Patient’s health record

17. Laboratory
investigation
Physical
examination
Observation
Interview
Health history
The nurse collects information through the following methods:

19. Health history
* Demographic information (name, age, sex, education... etc).
* Reason for seeking health care
* Previous hospitalization, illnesses, and surgeries.
* Patient/family medical history
Medical
Family
Surgical
Past history

20. Physical examination:
The purpose of physical examination is to make direct
observations of any deviations from normal and to
validate subjective data gathered through the
interview.

22. Diagnosis
Lab
investigation
Head to toe
assessment
Past & present
history

23. Head to toe
assessment

25. Data documentation:
Accurate and complete recording of assessment
data, which is essential for communicating
information to other health care team members. It is
the basis for determining quality of care and should
include appropriate data to support identified
problems.

26. 1- Social condition of the patient.
2- Physical condition.
3- Mental and psychological condition.
4- Therapeutic aspect.

27. Subjective
- These conditions that perceived by the patient such as
pain and the observer may not see the deviation
Pain ---- Nausea
Objective
- These conditions are identified by the observer
whether the nurse or the physician.
Pallor – Cyanosis --Swelling

28. e are abnormalities in the vital signs (temperature,
pulse, and respiration).
Those that are produced by the effect of the disease
on the whole body.
These are occurring in the initial stages of the
disease e.g. running nose as an initial stage of
measles.

29. It is a combination of symptoms that make up a
characteristic picture of a particular disease.
These are noticed in special area or part of the body
as swelling in hands.

30. Recording and reporting any sign or
symptom

31. 1- Location or site and radiation of pain .
2- Frequency.
3- Precipitating factors.
4- Aggravating factors.
5- Alleviating factors.
6- Associated manifestations.
7- Duration.
8- Pain character.
9- Effect of pain upon activities of daily living.

32. Vomits- Stool – Sputum- Discharge from wound
1- Amount or volume. 2- Frequency.
3- Precipitating factors
4- Constituents.
5- Odor
6- Associated symptoms or abnormal manifestation.

33. Preparation for Nurse
Hand washing
Keep fingernails clean, short & smooth
Avoid undesirable nonverbal communication
Initiate physical contact in nonthreatening ways
Nurse should be stand at the right side of the
patient to perform the examination

35. Preparation of the Equipment
- Gather necessary equipment
- Secure the forms required for documenting the
assessment findings
- Draping
- Warm instruments before placing it on a
patient

36. Equipments
needed

37. Preparation of the Environment
- Adjust the environment to perform the
examination
- Check that nothing is on floor that place the
patient at risk for falling
- Keep the room quiet, warm, without drafts
- Maintain privacy

38. Preparation of the Patient
- Keep the patient informed while performing the
examination
- Positioning
- Draping
- Encourage the patient to void
- Measuring & recording Vital signs , weight &
height
- Keep the patient warm

39. Explain the procedure & the aim
of assessment

40. Techniques used in physical examination

44. General appearance

45. Body alignment

47. Baldness
Alopecia
Scalp examination

48. Alopecia
Skin disease in the scalp

49. Ear examination
Up – out in adult Down – out in children

51. Peripheral
circulation

53. Bilateral checkTest capillary refill
Skin color

54. Skin turger

56. Temp
Pain
B.P
Pulse
]]
Resp
Measuring Vital Signs

59. Measuring body temperature :

62. Abdominal examination

63. Musculoskeletal
system

64. Neurological examination

66. Clinical ObservationsClinical Observations
AnthropometricAnthropometric
measurementmeasurement
1- Weight1- Weight
2- Height2- Height
3- Arm Circumference3- Arm Circumference
4- Skin fold thickness4- Skin fold thickness

67. AnthropometricAnthropometric
measurementmeasurement

69. ‫ججججج‬ ‫ججججج‬
‫ججججج‬
‫ججججججج‬:
‫ججججج‬:
‫جج‬ ‫ججج‬ ‫جج‬
‫ججججججج‬:
‫جججججج‬ ‫ججججج‬
‫ججججججج‬:

71. - A clinical judgment about individual, family, or
community responses to actual and potential
health problems/life processes.
- Nursing diagnoses provide the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is accountable"

72. -Nursing diagnosis is a standardized statement
about the health of a patient (who can be an
individual, a family, or a community) for the
purpose of providing nursing care.
- Nursing diagnoses are developed during the
course of performing the nursing assessments.

73. Nurses only make nursing diagnoses

74. The diagnostic process
• The diagnostic process uses the critical-
thinking skills of analysis. The diagnostic
process has three steps:
● Analyzing data.
● Identifying health problems, risks for health
problem.
● Formulating diagnostic statements.

75. - Once the nurse have identified the
patient's problems related to his health
status, then formulate a nursing
diagnosis for each of them.
-The nursing diagnoses are categorized
by a system commonly referred to as
NANDA. (North American nursing
diagnosis association)

76. Identifying a Nursing Diagnosis
The types of Nursing Diagnoses can be
broken down into two subsets:
• Actual problem
• Risk for problem

77. 1- Diagnostic Label
5- Related Factors
4- Risk Factors
2- Qualifiers
3- Definition and Defining
Characteristics

78. Components of a nursing diagnosis
I. Diagnostic Label
- Name of nursing diagnosis listed in
taxonomy, describes essence of problem
- Example: Stress Incontinence; Anxiety; Self-
Care Deficit
II. Qualifiers
- add additional meaning to a nursing
diagnosis, changes in condition, etc.
- Example: Altered; Impaired; Ineffective; etc.

79. III. Definition and Defining Characteristics
- NANDA approved, gives major and minor clinical
cues that validate presence of actual nursing
diagnosis
IV. Risk Factors
- Intrinsic and extrinsic characteristics of patient
- makes patient vulnerable or at risk

80. V. Related Factors
- Conditions, circumstances, etiologies that
contribute to the problem
- Can be described as "related to. "It is helpful
to formulate a nursing diagnosis using a PES
Statement (problem, etiology, and signs &
symptoms).

81. The NANDA-International system of
nursing diagnosis provides for two
categories.
Components of a nursing diagnosis
- airway clearance (Diagnostic Label)
- Ineffective (Qualifiers)
- stagnation of secretion. (Definition and Defining Characteristics)
- related to decreased energy secondary to prolonged bed rest( Related
Factors)
-as manifested by an ineffective cough ( symptoms)
A- Actual diagnosis: a statement about a health problem
that the patient has and the benefit from nursing care.
Example of an actual nursing diagnosis is: Ineffective
airway clearance stagnation of secretion related to
decreased energy secondary to prolonged bed rest as
manifested by an ineffective cough

82. B- Risk diagnosis: a statement about health
problems that a patient doesn't have yet, but is
at a higher than normal risk of developing in the
near future.
Example of a risk diagnosis is :
- Risk for injury related to altered mobility and
disorientation.
Components of a nursing diagnosis
Risk for injury (Diagnostic Label)
altered mobility and disorientation
( Related Factors)
.

83. Risk diagnosis
• The persons data base contains evidence
of risk factors of the diagnosis, but no
evidence of the defining characteristics
• Problem + etiology
• Risk for impaired skin integrity/related
to excessive diaphoresis and
confinement to bed
• No signs and symptoms

84. Activity 1
• Identify what step in the nursing process is
the following?
• Pain related to myocardial ischemia as
evidence by guarding left chest,
grimacing, moaning pain score of 10/10,
Bp 170/80 HR123
• Actual nursing diagnosis

85. Activity 2
• Identify what kind of nursing diagnosis
• Impaired communication /related to
language barrier/as evidenced by inability
to speak or understand Arabic and use of
Spanish
actual nursing diagnosis

86. Activity # 3
• Identify if the statement is correct. If
not correct the statement
• Risk for injury related to lack of the side
rails on bed
X
• do not write statement in such a way that it
maybe legally incriminating
• √: risk for injury related to disorientation

87. Activity # 4
• Mastectomy related to cancer
X
• do not state the nursing diagnosis using
medical terminology. Focus on the
persons response to medical problems
• √:Risk for self concept disturbance related
to effects of the mastectomy

88. Activity # 5
• Pain and fear related to diagnostic
procedure
X
• do not state two problems at the same
time
√:fear related unfamiliarity with diagnostic
procedures
√ pain related to diagnostic procedure

89. Domain 1 Health Promotion
• Deficient diversional activity
• Sedentary lifestyle
Domain 2 Nutrition
Imbalanced nutrition: less than body
requirements
Risk for imbalanced nutrition: more than body
requirements

90. Domain 3 Elimination and Exchange
• Functional urinary incontinence
Domain 4 Activity/ Rest
• Disturbed sleep pattern
• Impaired bed mobility

91. Guidelines for writing goals
•Patient centered
•Singular goal or outcome
•Observable
•Measurable
•Time-limited
•Realistic

93. - Setting goals to improve the outcomes for the
patient are a primary focus of the nursing process.
- Based on the nursing diagnoses, what are the
expectations for this patient? This not about
nursing goals. This is about improving the quality of
life for the patient.
-Planning involves making plans to carry out the
necessary interventions to achieve those goals.
-The use of formal care plans or care maps and
protocols is highly advised.

94. Characteristics of the nursing care plan
1. It focuses on actions which are designed to solve or
minimize the existing problem.
2. It is a product of a deliberate systematic process.
3. It relates to the future.
4. It is based upon identifiable health and nursing
problems.
5. Its focus is holistic.

96. - All members of the health care team should be
informed of the patient's status and nursing
diagnosis, the goals and the plans.
They are also responsible to report back to the
nurse all significant findings and to document
their observations and interventions as well as
the patient's response and outcomes.

97. The nurse selects interventions based on:
1. Characteristics of the nursing diagnosis.
2 expected outcomes.
3. Research base, or nursing knowledge/or interventions
4. Feasibility of the intervention.
5. Acceptability to the patient.
6. Competencies of the nurse.

98. Types of Interventions
Three categories of nursing interventions:
-Nurse-initiated interventions.
- Physician-initiated interventions.
- Collaborative interventions

100. - The nursing process is an ongoing event.
- Evaluation involves not only analyzing the success of the
goals and interventions, but examining the need for
adjustments and changes as well.
- Evaluation leads back to assessment and the whole process
begin again. The evaluation incorporates all input from the
entire health care team, including the patient.

101. Summary of Nursing Process
Assessment
Purpose
To gather, verity, and communicate data about
the patient so data base is established.
To identify health care need of the patient
steps
1. Collecting nursing health history
2. Assessing physical, psychological, social,
and spiritual needs/desires
3. Assisting with physical examination
4. Collecting all relevant data.

102. Planning
Purpose
To identify the patient's goals;
to determine priorities of care;
to determine expected outcomes,
to design nursing strategies to achieve goals of care
steps
1. Identifying patient goals.
2. Establishing expected outcomes
3. Selecting nursing actions
4. Delegating actions
5. Writing nursing care plan
6. Consulting

103. Implementation
Purpose
To complete nursing actions necessary for
accomplishing plan
steps
1 -Reassessing patient
2. Reviewing and modifying existing care plan
3. Performing nursing actions

104. Evaluation
Purpose
To determine the extent to which goals of care have
been achieved
steps
1. Comparing patient response to criteria
2. Analyzing reasons for results and conclusions
3. Modifying care plan

105. Thank You