nursing care plqn

2. DEFINITION
Definition
According to the American Nurses Association (ANA)
Standard of Nursing Practice (1998) The Nursing Process
is a deliberate problem solving approach for meeting
people’s health needs.
This means that the Nursing process enables the nurse to
address the patient’s needs

3. COMPONENTS OF THE NURSING PROCESS
. The ANA established the initial steps that form the components of the
nursing process They are;
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

4. COMPONENTS OF THE NURSING PROCESS CONTD.
Later on the ANA also added another component called the Outcome
Identification before planning, making the steps follow the following
sequence:

5. COMPONENTS OF THE NURSING PROCESS CONTD.
1.Assessment
2.Diagnosis
3.Outcome Identification
4.Planning
5.Implementation
6.Evaluation

6. ASSESSMENT
Assessment is a systematic collection of
data to determine the patient’s health
status and any actual or potential health
problems, followed by the analysis of the
data. Some may make the analysis as
another stage of the Nursing Process.

7. ASSESSMENT CONTD.
The assessment data is collected
through the health history and,
physical assessment.

8. HEALTH HISTORY
The health history is collected
through interview of the patient,
his or her family or significant
others.
Purpose:
The health history is conducted to
determine the person’s state of
wellness or illness.

9. HEALTH HISTORY CONTD.
The health history needs to be collected systematically in order to achieve
your goal that is to determine the patient’s
health status
To obtain a good data depends a lot on the
nurse’s attitude and approach.
The patient or family will cooperate if the
nurse is respectful of their dignity as
humans.

10. HEALTH HISTORY CONTD.
. The interview is a personal
dialogue between the patient
and the nurse, and it is done to
achieve a mutual trust and
respect.
The nurse therefore must be
able to communicate in a very
sincere and respectful way.

11. CONTENTS OF THE HEALTH HISTORY
Biographical Data
Chief Complaint
Present Health concern or present illness
Past Medical History
Family History
Review of the Systems
Patient Profile.

12. BIOGRAPHICAL DATA
This information includes
the person’s name,
address, age, gender,
marital status, occupation
and ethnic origin and
Next of Kin.

13. CHIEF COMPLAINT
The chief complaint is the issue
that brings the patient to the
health care facility or hospital.
For example, diarrhea,
vomiting, fever and chills,
swollen lower legs, difficulty
breathing, pain etc.

14. CHIEF COMPLAINT CONTD.
This information can be
obtained by asking questions
such as why did you come to
the hospital? What is
bothering you today?
Sometimes the nurse will
observe certain signs in the
patient before the chief
complaint is even maid.

15. PRESENT HEALTH CONCERN OR ILLNESS
This is the history of the present illness. It
is a very important factor that helps the
health care team to arrive at a diagnosis,
and determine the patient’s health needs.
This includes time of onset of the chief
complaint, of signs and symptoms,
duration, what worsens the situation,
what makes it better, what medications
taken so far etc.

16. PAST MEDICAL /SURGICAL HISTORY
• This involves a person’s past health as an
important part of the health history. This are
disease conditions that the patient has ever
suffered from. For example:
• Childhood illnesses, adult illnesses, psychiatric
illnesses, injuries like fractures, burns, head
injuries, hospitalizations, surgeries, medications
including prescriptions and over the counter
medications, home remedies, herbs
complementary therapies, like physiotherapy,
occupational therapy, special diets, etc. and use
of alcohol and drugs use

17. FAMILY MEDICAL HISTORY
This is taken to identify diseases that may
be genetic like diabetes, hypertension.
Problems like drug abuse, alcoholism
and psychiatric illness. This disease
conditions might be identified to bear
some significance on the present illness.

18. REVIEW OF THE SYSTEMS
This helps to confirm the data
colected earlier
The review of the systems
include an overview of the of
the general health as well as
symptoms related to each
body system.

19. REVIEW OF THE SYSTEMS CONTD.
Review of the systems can
be organized in a formal
check list or a
questionere

20. REVIEW OF THE SYSTEMS CONTD.
Here the nurse goes through all the body
systems, asking the patient if he or she
has ever had any problems or diseases
in a particular system. This helps to
reveal any relevant data negative as well
as positive that may have a connection
to the present condition

21. PATIENT PROFILE
This is a further collection of
biographical data, but the data
here is more personal. The
patient is encouraged to
honestly express himself or
herself. The general contents
of the patient profile are as
follows;

22. PATIENT PROFILE CONTD.
• Past life events related to health e.g.
place of birth, places of residence.
• Education, finding out about educational
level may help in planning the way to
educate the patient. This is a very
sensitive area, and the nurse needs to be
tactful. You can start by asking about
the patient’s job, and then proceed to
ask what kind of education you need to
be in that job.

23. PATIENT PROFILE CONTD
Occupation; Knowing the
occupation can give the
nurse an idea about the
economic status, to
determine whether the
patient can afford the
treatment or not.

24. PATIENT PROFILE CONTD.
Lifestyle patens and habits; e.g.
smoking, alcohol use and drug use.
Presence of physical and mental
disabilities
Stresses the patient has gone
through before; divorce, deaths in
the family etc..
The strategies the patient uses to
cope with stress.

25. PHYSICAL ASSESSMENT
the main purpose of physical
assessment is to identify
those aspects of a patient’s
physical psychological and
emotional state that may
have a bearing on the
present ill health.

26. PHYSICAL ASSESSMENT CONTD.
Physical assessment must
focus first on the chief
complaint.
Its focus also depends on the
immediate priorities that
indicate a need for nursing
care.

27. PHYSICAL ASSESSMENT CONTD.
It is an organized and
systemic examination done
to obtain data in the
shortest possible time. All
relevant body systems are
tested during this
examination

28. PHYSICAL ASSESSMENT CONTD.
A complete physical
examination is not routine, the
body systems are selectively
assessed giving priority to the
presenting problem at the
time. A complete physical
examination of follows the
following sequence

29. PHYSICAL ASSESSMENT CONTD.
1. Skin
2. Head and neck
3. Thorax and lungs
4. Breast
5. Cardiovascular system
6. Abdomen
7. Pelvis
8. Genitalia
9. Neurological System
10. Musculoskeletal system

30. PROCEDURE
1. Provide privacy
2. The procedure is explained to the
patient
2.The patient is asked to or helped to
undress
3.The clinician washes his or her
hands
4.The relevant examination is carried
out

31. PROCEDURE CONTD.
The basic tools the nurse uses for the
physical examination are: vision,
hearing, smell, and touch. The
human senses may be
supplemented by the following
equipment like stethoscope,
ophthalmoscope, reflex hummer,
tunning falk and many others

32. COMPONENTS OF PHYSICAL ASSESSMENT
1. Inspection
This is the first technique and it is
done mostly by observation. The
general inspection begins with the
first contact with the patient. As
soon as the patient is in front of the
nurse, the nurse begins to observe
the patient critically from head to toe.

33. COMPONENTS CONTD.
• To enhance a proper observation the
nurse needs to ally the patient’s anxiety
by introducing herself, shaking the
patient’s hands if possible. The
observations that can be made are as
follows:
• Is the patient conscious or
unconscious? Does the he or she look
anxious, depressed, relaxed, observe the
body structure looking for any
abnormalities like contractures, swelling,
restricted movement etc.

34. COMPONENTS CONTD.
Establish whether the patient appears
very sick, and in what way?
Observe the skin for clamminess,
parlor, jaundice, wounds, rashes,
sweating, and cyanosis. All
significant observations made are
properly documented in the
patient’s chart.

35. COMPONENTS CONTD.
Another important observation that should
be made is:
Posture
• Observing the patient’s posture is very
critical, because the posture provides
valuable information that will aid in
establishing a diagnosis. For example, a
patient with respiratory difficulty will not
be able to lay flat, but will want to sit up
in order to be able to breathe properly.

36. COMPONENTS CONTD.
Patients having abdominal pain due to
peritonitis will prepare to lay perfectly
still, a patient with biliary colic are
often very restless, and a patient
with fracture of a limb will not like
to move the limb due to pain.
All observation must be well
documented.

37. COMPONENTS CONTD.
• c. Body Movements
• Another important thing to observe is
body movement. Important observations
to make are:
• Asymmetry of movement; Weakness and
Paralysis of some parts of the body,
drooping of one side of the face, twisting
of the mouth to one side all in the case
of cerebro - vascular accident (Stroke)
and multiple sclerosis.

38. COMPONENTS CONTD.
• Speech Pattern
• Here it is observed whether the speech
is slurred interrupted in flow as in cases
of CVA, if there is hoarseness as in
cases of laryngeal problems, and
swelling of the vocal cords. There may
be aphasia (Inability to speak). All
observations are well documented and
abnormalities reported to the physician
for appropriate action to be taken.

39. VITAL SIGNS
• Recording of vital signs is a part of every
physical examination (Bickley &Szilagyi)
Body temperature, pulse, respiration
oxygen saturation and blood pressure
are measured.
• Abnormalities may indicate a particular
disease condition. For example, fever
may be indicative of an infection. Any
deviations from the normal over time are
properly documented and brought to the
attention of the physician for appropriate
action.

40. BODY WEIGHT, HEIGHT AND BODY MASS INDEX
Weight, height and Body Mass
Index (BMI) are also added to vital
signs depending on the specific
condition of the patient. BMI is a
ratio based on weight and height,
and the obtained value is
compared to an established
standard.

41. BODY WEIGHT, HEIGHT AND BODY MASS INDEX
Formula for calculating BMI is;
Weight in Kilogram
Height in meters

42. PALPATION
This is a vital part of any physical
assessment (Rasmor and Brown
2003). Through palpation many
organs of the body although not
visible may be assessed. Both
hands are used to palpate these
organs.

43. PALPATION CONTD.
Organs that can be assessed by palpation
are; superficial blood vessels, lymph
nodes, thyroid gland, organs of the
abdomen and pelvis, and rectum.
Sounds generated within the body can
be felt by the hands, e.g. heart murmurs,
thrills, and voice transmitted through
the bronchi to the lungs may be
perceived by touch.

44. PALPATION CONTD.
This sensation may be altered in cases of
diseases of the lungs, and the
phenomenon is called tactile fremitus.
They are useful in diagnosing diseases
of the chest.
Technique Light palpation can be done
with one hand and deep palpation can be
done with both hands.

45. PALPATION

46. PERCUSSION
Percussion translates the
application of physical force into
sound. The principle behind
percussion is to set the cavity
wall into vibration by striking it
with a firm object The sound that
is produced reflects the density
of the underlying structures in
the cavity.

47. PERCUSSION CONTD.
• Percussion can be performed on the
chest wall and the abdominal wall. The
sounds are listed in a sequence from the
least to the most dense. They are
Tympany, hyperresonance, resonance,
dull and flat
• Tympany is a drum like sound produced
when an air filled stomach is percussed.
• Hyperresonance is an audible noice
heard when an inflated lung is
percussed. Usually heard in a patient
suffering from emphysema.

48. PERCUSSION CONTD.
Resonance is the sound heard when an
air-filled lung is percussed.
A dull sound is produced when the liver is
percussed
A flat sound is heard when the thigh is
percussed.

49. PERCUSSION CONTD.
Percussion can also be used to examine
anatomic details like the boarders of the
heart and the movement of the
diaphragm during inspiration, to
determine the level of pleural effusion,
the location of consolidation in the lungs
in pneumonia and atelectasis

50. AUSCULTATION
Auscultation is the skill of listening
to sounds created in the body by
the movement of air or fluid. For
example breath sounds, spoken
voice, bowel sound, which are all
normal physiologic sounds, and
abnormal sounds like heart
murmurs, and crackles in the
lungs.

51. AUSCULTATION CONTD.
The equipment used in
auscultation is the
stethoscope. The bell of the
stethoscope is used for low
frequency sounds like heart
murmurs, and the diaphragm
is used for high frequency
sounds like lung sounds

52. AUSCULTATION CONTD.
Technique
The stethoscope surface is held firmly
against the skin over the area, with the
ear piece in the ear. To improve the
quality of the sound, avoid rubbing the
surface of the stethoscope over hair and
cloths.
The sounds heard are characterized by
intensity, frequency and quality

53. AUSCULTATION CONTD.
Intensity refers to the loud or low nature of
the sound.
Frequency refers to the pitch, and it is on a
spectrum, from low to high.
Quality refers to overtones. Sound quality
enables the examiner to distinguish
between high pitch sounds like wheezing
and low pitch sounds like heart murmur.

54. NURSING DIAGNOSIS
1.Nursing diagnosis is a process that
the nurse uses to independently
identify the patient’s nursing
problems
2.Identify the defining characteristics
of the nursing problems
3.Identify the etiology of the nursing
problems

55. NURSING DIAGNOSIS CONTD.
To establish a nursing diagnosis
nurses must identify the
commonalities in the
assessment data collected
that will reveal the existence of
a problem, and the need for
nursing intervention.

56. NURSING DIAGNOSIS CONTD.
Nursing diagnosis represent
actual or potential health
problems that can be managed
by independent nursing action.
Nursing diagnosis is different
from medical diagnosis; they
are not medical treatments,
and not diagnostic studies.

57. NURSING DIAGNOSIS CONTD.
They are statements that guide
nurses to develop a nursing
plan of care for individual
patients. That is why the
etiology of the problem s are
identified and included as part
of the nursing diagnosis.

58. NURSING DIAGNOSIS CONTD.
For example take the following scenario:
Mrs. Mensah age 57 a cloth seller at the
Makola market, was rushed to the
emergency room by her daughter this
morning. According to the daughter, her
mother has been complaining of severe
headache, blurred vision, restlessness
and feeling weak for the past two days.

59. NURSING DIAGNOSIS CONTD.
• Suddenly this morning, she became
confused, she is unable to move the left
side of her body. Her vital signs were
checked and they were as follows:
Temperature 36.4, Pulse; 90, Blood
Pressure 160/104. She is obese with a
weight of 150 kg. In interviewing her she
revealed that her mother has been
hypertensive for many years, and
suffered a massive stroke two years ago.
She has been bed ridden since then and
died five months ago.

60. NURSING DIAGNOSIS CONTD.
. In conducting a physical examination on
her, she is slightly confused, her speech
is slightly slurred, she has a slight left
sided facial droop, and a left sided
paralysis. She failed her swallowing
examination, and has urinary
incontinence. She had a CT scan of the
brain that revealed haemorrhage in the
right hemisphere of the brain. Her
medical diagnosis is Cerebrovascular
accident (CVA)

61. NURSING DIAGNOSIS CONTD.
Let us look at this patient’s assessment data and see what nursing
problems (diagnosis) will be revealed that will need specific nursing
interventions.
First her chief complaints are; severe headache, blurred vision,
restlessness, feeling weak, unable to move the left side of her body

62. NURSING DIAGNOSIS CONTD.
From the physical
assessment; her vital signs
reveal a high blood
pressure (160/104), she has
a slurred speech, a left
sided facial droop, and left
sided paralysis.

63. NURSING DIAGNOSIS CONTD.
• From the above data, the nursing
problems that can be identified are as
follows;
• 1. Acute pain (Head ache)
• 2. Self-care deficit
• 3. Altered nutrition
• 4. Disturbed thought process
• 5. Anxiety
• 6. Urinary incontinence
• 7. Knowledge deficit

64. NURSING DIAGNOSIS CONTD.
• From the above identified problems,
the following nursing diagnosis can be
made:
• 1. Acute pain (Head ache) related to
elevated blood pressure
• 2. Self-care deficit (bathing, dressing,
toileting, grooming and feeding) related
to immobility of the left side of the body
• 3. Altered nutrition related to difficulty
swallowing

65. NURSING DIAGNOSIS CONTD.
4.Disturbed thought process (Inability
to follow instructions) related to
confusion
5.Anxiety related to disease condition
6.Urinary incontinence related to
flaccid bladder.
7.Knowledge deficit about disease
condition.

66. NURSING DIAGNOSIS CONTD.
• 3. Altered nutrition related to difficulty
swallowing
• 4. Disturbed thought process (Inability to
follow instructions) related to confusion
• 5. Anxiety related to disease condition
• 6. Urinary incontinence related to flaccid
bladder.
• 7. Knowledge deficit about disease condition
• . The above are the actual problems that will
need intervention in caring for Mrs. Mensah

67. COLLABORATIVE
PROBLEMS
In addition to nursing diagnosis
and their related nursing
interventions nursing practice
involves certain situations and
interventions that do not fall
within the definition of nursing
diagnosis..

68. COLLABORATIVE PROBLEMS CONTD.
These activities pertain to
potential problems or
complications that are medical
in nature and require
collaborative interventions
with the physician and other
members of the health team

69. COLLABORATIVE PROBLEMS CONTD.
• Collaborative problems are
certain physiologic complications
that nurses monitor, to detect
changes in status or onset of
complications. Collaborative
problems are managed by
physician prescribed and nursing
prescribed interventions to
minimize complications.

70. COLLABORATIVE PROBLEMS CONTD.
The problems can be
related to the disease
process, treatments
medications and
diagnostic studies.

71. COLLABORATIVE PROBLEMS CONTD.
The nurse recommends the
nursing
interventions that are
appropriate for managing the
complications and also
implements the treatment
prescribed by the physician.

72. COLLABORATIVE PROBLEMS CONTD.
An example of a collaborative
problem
a) Mrs. Mensah is put on iv fluids
for nutrition because of her
inability to swallow
The collaborative problem is:
She has the potential to develop
circulatory overload

73. COLLABORATIVE PROBLEMS CONTD.
Intervention
The nurse needs to watch and
monitor a strict fluid intake
and output chart to prevent
that complication from
developing.
Monitoring fluid intake and output chart

74. COLLABORATIVE PROBLEMS CONTD.
• b) Mrs. Mensah also has the
potential to develop pressure
sore because she unable to move
her left side and is also
incontinent of urine.
• c) Mrs. Mensah also has the
potential to injure herself,
because she is confused.

75. PLANNING (NURSING CARE PLAN)
Once a nursing diagnosis
has been identified, the
planning component of
the nursing process
begins.
The planning follows the
following steps;

76. PLANNING (NURSING CARE PLAN) CONTD.
1. Setting Priorities
In establishing nursing diagnosis,
prioritization is key in achieving
success. The urgency of each
problem is considered very
carefully. Physical needs have to
be attended to first before other
needs should be attended to.

77. PLANNING (NURSING CARE PLAN) CONTD.
For example If a patients is
rushed in to ER with difficulty
breathing, chest pain, anxiety
and weakness. In prioritizing
the patient’s problems,
breathing must be the first to
attend to followed by pain
before anxiety.

78. PLANNING (NURSING CARE PLAN) CONTD.
• At this stage, the immediate,
intermediate and long term goals
of the nursing interventions are
specified. The expected
outcomes of the interventions are
expressed in the behavior the
patients exhibits and the time
period during which the outcome
is to be achieved.

79. PLANNING (NURSING CARE PLAN) CONTD.
The outcome must be
realistic and
measurable. For
example the expected
outcome for difficulty
breathing must be

80. PLANNING (NURSING CARE PLAN) CONTD.
normal breathing and
oxygenation must be
restored with 10minutes,
whilst the expected
outcome for knowledge
deficit can be achieved in
72 hours.

81. PLANNING (NURSING CARE PLAN) CONTD.
In the case of Mrs. Mensah, her
first expected outcome will be;
Patient will be free of pain in
the next 30 minutes.
Mrs. Mensah will become
knowledgeable about her
disease condition in 72 hours.

82. PLANNING (NURSING CARE PLAN) CONTD.
Specifying the immediate,
intermediate and long term
goals of nursing action
After the nursing diagnosis,
prioritization and expected
outcomes are established,
goals (immediate, intermediate
and long term) and the nursing
actions appropriate for
attaining them are identified.

83. PLANNING (NURSING CARE PLAN) CONTD.
Immediate goals are those that
can be achieved within the
shortest possible time,
intermediate and a long term
goal require a longer time to
be achieved and also involve
prevention of complications.

84. PLANNING (NURSING CARE PLAN) CONTD.
4.Specifying specific nursing
interventions appropriate for attaining
the outcomes
This is the stage where the nurse
identifies the individualized
interventions based on the
patient’s circumstance and
preferences that address each
outcome.

85. PLANNING (NURSING CARE PLAN) CONTD.
The interventions should
identify the activities
needed and who will
implement them. This
also includes patient
teaching and education.

86. PLANNING (NURSING CARE PLAN) CONTD.
Example, using our scenario above, the
nursing interventions that can be
identified are as follows:
1.Administer prescribed pain medications
and make patient comfortable in bed.
2.Assist patient in performing activities of
daily living twice daily; bathing,
grooming, toileting and dressing.

87. PLANNING (NURSING CARE PLAN) CONTD.
4. Change patient’s position every two
hours to avoid pressure sore.
5. Pass NG tube and feed patient as
needed.
6. Educate patient on disease condition.
7. Pass urinary catheter for proper urinary
drainage
8.Monitor fluid intake and output

88. IMPLEMENTATION
(NURSING INTERVENTIONS)
The immediate, inter mediate
and long term goals are the
bases for the nursing
interventions. This is
Identifying interdependent
interventions and carrying out
the proposed plan of care.

89. IMPLEMENTATION
(NURSING INTERVENTIONS) CONTD.
• The nurse must bear the
responsibility for the
implementation, and
coordinate the activities of all
those involved including the
patient’s family and other
members of the health team.

90. IMPLEMENTATION
(NURSING INTERVENTIONS) CONTD.
Whiles implementing the plan of
care, the nurse must
continuously assess the
patient and note how he or she
responds to the nursing care.
All interventions carried out
and their response must be
properly documented.

91. IMPLEMENTATION
(NURSING INTERVENTIONS) CONTD.
• Whiles implementing the plan
of care, the nurse must
continuously assess the
patient and note how he or she
responds to the nursing care.
All interventions carried out
and their response must be
properly documented.

92. IMPLEMENTATION
The nurse must Communicate to
the appropriate personnel any
needed intervention that does not
fall under nursing skills. For
example in the case of Mrs.
Mensah, the nurse needs to
contact the physiotherapist for
passive exercises. The
nutritionist must also be

93. EVALUATION
This is the last stage of the nursing
process. The nurse determines
the patient’s response to the
nursing interventions, and the
extent to which the goals have
been met. In evaluating, the
nurse will ask the following
questions, and answer them very
honestly.

94. EVALUATION CONTD.
Has all the goals been met?
Has the behavior of the patient
changed?
In reassessing the patient, has the
physiological problems associated
with the disease returned to normal?
Has any collaborative problem arisen,
and have they been solved?

95. EVALUATION CONTD.
Has the patient gain enough
knowledge about the disease to
help cooperate with the treatment
regimen?
If there is the need for adjusting
some interventions, have they
been done, and what was the
result.

96. EVALUATION CONTD.
After evaluating, if some
goals have not been
met, new goals can be
set and new
interventions be made.