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PATEL INSTITUTE OF NURSING &
ALLIED HEALTH SCIENCES
M. Farooq Marwat
RN, Dip. Card, BSN
9/27/2013 1
9/27/2013 2
Objectives:
1. At the end of this presentation, students will be able to
know about:
2. What is Nursing Process
3. What are the characteristics of Nursing Process
4. What are the benefits of Nursing Process
5. Phases of Nursing Process including:
a) Assessment (purpose, types, steps, skills)
b) Nursing diagnosis (types, benefits, components)
c) Planning (steps & elements)
d) Implementation
e) Evaluation
9/27/2013 3
9/27/2013 4
Nursing Process
 The nursing process is a modified form of
scientific method used in nursing profession to
assess client needs and create a course of action to
address and solve patient problems.
 Nursing process is a rational problem solving
framework on which professional nursing practice
is based. It provides an organized, systematic
approach to nursing care thereby improving the
probability of positive outcomes for individuals
and groups.
9/27/2013 5
Nursing Process
Assessment
Diagnosis
Planning
Implantation
Evaluation
Ask Question
Identify Problem
Hypothesis
Experiment
Analyze/Conclusion
Scientific Method
9/27/2013 6
Benefit Of Nursing Process
1. Provides an orderly & systematic method for planning
& providing care
2. Enhances nursing efficiency by standardizing nursing
practice
3. Facilitates documentation of care
4. Provides a unity of language for the nursing profession
5. Nursing Process is economical
6. Stresses the independent function of nurses
7. Increases care quality through the use of deliberate
actions
8. Provide continuity of care and prevent duplication
9/27/2013 7
Characteristics Of Nursing Process
1. Interactive, Purposeful and Systematic (organized)
2. Client-centered
3. Goal-directed, outcome focused
4. Within the legal scope of nursing
5. Prioritizing the needs
6. The steps are interrelated and dependent on the
accuracy of each of the preceding steps
7. It is used to identify, diagnose, and treat human
responses to health and illness
9/27/2013 8
9/27/2013 9
Assessment
 Assessment is the first step of nursing process and
may be defined as
collecting, organizing, validating and
documenting client data
 During this phase, the nurse gathers information
about a patient's
psychological, physiological, sociological, and
spiritual status through
observation, interviewing, physical
examination, health records and family members.9/27/2013 10
Assessment (cont….)
 Nursing assessments do not duplicate medical
assessments (which target to pathologic
conditions) but focus on the patient’s responses
to health problems or potential health problems
9/27/2013 11
Types of Assessment
1. Initial assessment: Also known as triage, is performed within a
specified time after admission to establish a complete database for
problem identification, reference, and future comparison.
2. Problem-focused assessment: is an ongoing process integrated
with nursing care to determine the status of a specific problem
identified in an earlier assessment.
3. Emergency assessment: occurs during any physiologic or
psychological crisis of the client to identify the life-threatening
problems and to identify new or overlooked problems.
4. Time-lapsed assessment: occurs several months after the initial
assessment to compare the client’s current status to baseline data
previously obtained.
9/27/2013 12
Purpose Of Assessment
1. To establish baseline information on the client
2. To determine the client’s normal function
3. To determine the client’s risk for dysfunction
4. To determine the client’s strengths
5. To provide data for the diagnosis phase
9/27/2013 13
Assessment Skills
1. Observation
2. Interview:
 a conversation with purpose to get or give information, to
teach and provide support.
3. Physical Examination:
 a systematic data collection method by
inspection, palpation, percussion and auscultation.
4. Intuition (Insight):
 Use of insight, instinct, and clinical experience to make
clinical judgments about the client.
9/27/2013 14
Assessment Activities
 Activities or action performed during
assessment are:
1. Collect Data
2. Validate Data: Double checking the data to confirm
accuracy
3. Organize Data : Grouping the data using Head to Toe
model, Systemic Review etc
4. Document Data: Documents subjective data in client own
words and objective using medical terms, key, abbreviations etc.
9/27/2013 15
Collect Data
 The process of gathering information about the client
that begin with the first client contact, using
method/skills of assessment
(Observation, PE, Interview etc). Two type of data to
be collected:
 Subjective Data: including symptoms, client's feeling
and statement about his/her health problems which
should be recorded as direct quotations from the
client, such as '' Every time I move, I feel pain.'‘
 Objective data: including signs or observable and
measurable data that are obtained through
observation, physical examination, and laboratory testing.
9/27/2013 16
Sources of data
 Primary
 The client is the primary source of data.
 Secondary
 Family members or other supporting persons,
 Health professionals,
 Health records and reports,
 Laboratory and diagnostic analyses,
9/27/2013 17
9/27/2013 18
 Nursing Diagnosis is a clinical judgment
about individual, family, or community
responses to actual or potential health
problems/life processes.
 Nursing diagnoses provide the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is
accountable.
Nursing Diagnosis
9/27/2013 19
Benefits Of Nursing Diagnosis
 Gives Nurses a Common Language.
 Promotes identification of appropriate goals or correct
choice.
 Can create a standard for nursing practice.
 Provides a quality improvement base.
9/27/2013 20
Components of Nursing Diagnosis
 A typical nursing diagnosis statement has two or three
parts/statements.
 In two parts nursing diagnosis, the first component is a problem
statement or diagnostic label (as listed in NANDA), while
second component is the etiology. Both of these parts are linked
by the term related to (RT). E.g. Disturbed Body Image RT loss
of left lower extremity
 The three part nursing diagnosis statement consists
Problem, Etiology and Sign, Symptoms (defining
characteristics) joined to the first two component by connecting
phrase “as evidence by” (AEB). E.g. “ineffective Airway
clearance RT fatigue AEB dyspnea at rest”
9/27/2013 21
Descriptive Words
 To clarify nursing diagnosis, descriptive words or
terms may be added before or after the problem
statement. These words include
Acute, Chronic, Decreased, Deficient, Depleted, Distu
rbed, Dysfunctional, Enhanced, Excessive, Impaired, I
ncreased, Ineffective, Intermittent, Potential, and Risk
for.
9/27/2013 22
9/27/2013 23
Types Of Nursing Diagnosis
 Actual nursing diagnosis
 Risk nursing diagnosis
 Wellness nursing diagnosis
 Syndrome nursing diagnosis
9/27/2013 24
Actual
 An actual nursing diagnosis is the diagnosis about
current problem that is present at the time of the
nursing assessment, based on the presence of signs
and symptoms.
 Examples of an actual nursing diagnosis are anxiety
characterized by fear, panic, apprehension and sleep
disturbances, or an ineffective airway clearance
characterized by an ineffective cough, abnormal
breathing or a fever.
9/27/2013 25
Risk Nursing Diagnosis
 Risk nursing diagnosis describes human responses to
health conditions that may develop in a vulnerable
individual, family, or community.
 Risk nursing diagnoses are two – part statements, do not
include defining characteristics.
 Examples –
 Risk for infection related to surgery or immunosuppression.
 Risk for aspiration related to reduced level of consciousness
9/27/2013 26
Wellness nursing diagnosis
 A clinical judgment about a person’s, family’s or
community’s motivation and desire to increase
wellbeing as expressed in the readiness to enhance
specific health behaviors, and can be used in any
health state.
 Wellness nursing diagnosis are one part statement
includes diagnostic label.
 Example
 Readiness for enhanced spiritual well being
 Readiness for Enhanced Self-Esteem.
9/27/2013 27
Syndrome Nursing Diagnosis
 A clinical judgment describing a specific cluster of
nursing diagnoses that occur together, and are best
addressed together and through similar
interventions.“
 An example of a syndrome diagnosis is: Relocation
stress syndrome.
9/27/2013 28
Difference b/w Medical & Nursing Diagnosis
Nursing Diagnosis Medical Diagnosis
Clinical judgment about individual,
family, or community responses to
actual and potential health problems
or life processes
Identification of a disease condition
based on a specific evaluation of
physical signs, symptoms, history,
diagnostic tests, and procedures
The goal of a nursing diagnosis is to
identify actual and potential
responses
The goals of a medical diagnosis is to
identify the cause of a illness or injury
and design a treatment plan
Nurse treats problem within scope of
independent nursing practice
Physician directs treatment for
medical diagnosis
May change from day to day as the
patient’s responses change
Remains the same as long as the
disease is present
9/27/2013 29
Nursing diagnosis for Medical diagnosis
9/27/2013 30
Planning
9/27/2013 31
Planning
 Planning is to formulate the way to manage the problem.
 The third step of the nursing process includes the
formulation of guidelines that establish the proposed
course of nursing action in the resolution of nursing
diagnoses and the development of the client’s plan of care.
 Planning consists three stage:
 Initial Planning
 On-going planning
 Discharge planning
9/27/2013 32
Steps Of Planning
 Initial Planning
 Done by the nurse who perform admission assessment in
order to prioritize problems, identify goals and correlate
nursing care to resolve the problems.
 Ongoing planning
 Involves continuous updating of the client’s plan of care. Every
nurse who cares for the client is involved in ongoing planning.
 Discharge planning
 involves anticipation and planning for the client’s needs after
discharge.
9/27/2013 33
Elements Of Planning
 Prioritizing the problems/nursing diagnosis
 Formulate goals/desired outcomes
 Short Term (to resolve in few hours or days)
 Long Term (to resolve over weeks or months)
 Select nursing interventions
 Write nursing interventions
9/27/2013 34
9/27/2013 35
Implementation
9/27/2013 36
Implementation
 Implementing phase, provide the actual
nursing activities and client responses.
Implementation consists of doing and
documenting the activities that are the
specific nursing actions needed to carry out
the interventions or nursing orders.
9/27/2013 37
Nursing Skills during Implementation
 To implement nursing care plan successfully , nurse
need to have following skills
 Cognitive Skills
 Including problem solving and decision making
 Interpersonal Skills
 Include verbal and non-verbal
response, communication,
 Technical Skills
 Includes hand on skills need to perform procedures such
as administrating injection, drugs, lifting, moving
9/27/2013 38
Evaluation
9/27/2013 39
Evaluation
 The last phase of the nursing process which include
the judgment of the effectiveness of nursing care to
meet client goals based on the client’s behavioral
responses.
 This step determine the success/effectiveness of the
whole nursing process and the decision either to
continue, modify or repeat the process is depend on
evaluation.
9/27/2013 40
Evaluation
 While documenting evaluation phase, the nurse can
draw one of the three possible conclusions:
 The goal was met,
 The client response is the same as the desired outcomes.
 The goal was partially met,
 Either a short term goal was achieved but the long term
was not, or the desired outcome was only partially
attained.
 The goal was not met
9/27/2013 41
Relationship of Evaluation to Nursing Process
9/27/2013 42
9/27/2013 43
9/27/2013 44
9/27/2013 45

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Nursing Process Explained

  • 1. PATEL INSTITUTE OF NURSING & ALLIED HEALTH SCIENCES M. Farooq Marwat RN, Dip. Card, BSN 9/27/2013 1
  • 3. Objectives: 1. At the end of this presentation, students will be able to know about: 2. What is Nursing Process 3. What are the characteristics of Nursing Process 4. What are the benefits of Nursing Process 5. Phases of Nursing Process including: a) Assessment (purpose, types, steps, skills) b) Nursing diagnosis (types, benefits, components) c) Planning (steps & elements) d) Implementation e) Evaluation 9/27/2013 3
  • 5. Nursing Process  The nursing process is a modified form of scientific method used in nursing profession to assess client needs and create a course of action to address and solve patient problems.  Nursing process is a rational problem solving framework on which professional nursing practice is based. It provides an organized, systematic approach to nursing care thereby improving the probability of positive outcomes for individuals and groups. 9/27/2013 5
  • 6. Nursing Process Assessment Diagnosis Planning Implantation Evaluation Ask Question Identify Problem Hypothesis Experiment Analyze/Conclusion Scientific Method 9/27/2013 6
  • 7. Benefit Of Nursing Process 1. Provides an orderly & systematic method for planning & providing care 2. Enhances nursing efficiency by standardizing nursing practice 3. Facilitates documentation of care 4. Provides a unity of language for the nursing profession 5. Nursing Process is economical 6. Stresses the independent function of nurses 7. Increases care quality through the use of deliberate actions 8. Provide continuity of care and prevent duplication 9/27/2013 7
  • 8. Characteristics Of Nursing Process 1. Interactive, Purposeful and Systematic (organized) 2. Client-centered 3. Goal-directed, outcome focused 4. Within the legal scope of nursing 5. Prioritizing the needs 6. The steps are interrelated and dependent on the accuracy of each of the preceding steps 7. It is used to identify, diagnose, and treat human responses to health and illness 9/27/2013 8
  • 10. Assessment  Assessment is the first step of nursing process and may be defined as collecting, organizing, validating and documenting client data  During this phase, the nurse gathers information about a patient's psychological, physiological, sociological, and spiritual status through observation, interviewing, physical examination, health records and family members.9/27/2013 10
  • 11. Assessment (cont….)  Nursing assessments do not duplicate medical assessments (which target to pathologic conditions) but focus on the patient’s responses to health problems or potential health problems 9/27/2013 11
  • 12. Types of Assessment 1. Initial assessment: Also known as triage, is performed within a specified time after admission to establish a complete database for problem identification, reference, and future comparison. 2. Problem-focused assessment: is an ongoing process integrated with nursing care to determine the status of a specific problem identified in an earlier assessment. 3. Emergency assessment: occurs during any physiologic or psychological crisis of the client to identify the life-threatening problems and to identify new or overlooked problems. 4. Time-lapsed assessment: occurs several months after the initial assessment to compare the client’s current status to baseline data previously obtained. 9/27/2013 12
  • 13. Purpose Of Assessment 1. To establish baseline information on the client 2. To determine the client’s normal function 3. To determine the client’s risk for dysfunction 4. To determine the client’s strengths 5. To provide data for the diagnosis phase 9/27/2013 13
  • 14. Assessment Skills 1. Observation 2. Interview:  a conversation with purpose to get or give information, to teach and provide support. 3. Physical Examination:  a systematic data collection method by inspection, palpation, percussion and auscultation. 4. Intuition (Insight):  Use of insight, instinct, and clinical experience to make clinical judgments about the client. 9/27/2013 14
  • 15. Assessment Activities  Activities or action performed during assessment are: 1. Collect Data 2. Validate Data: Double checking the data to confirm accuracy 3. Organize Data : Grouping the data using Head to Toe model, Systemic Review etc 4. Document Data: Documents subjective data in client own words and objective using medical terms, key, abbreviations etc. 9/27/2013 15
  • 16. Collect Data  The process of gathering information about the client that begin with the first client contact, using method/skills of assessment (Observation, PE, Interview etc). Two type of data to be collected:  Subjective Data: including symptoms, client's feeling and statement about his/her health problems which should be recorded as direct quotations from the client, such as '' Every time I move, I feel pain.'‘  Objective data: including signs or observable and measurable data that are obtained through observation, physical examination, and laboratory testing. 9/27/2013 16
  • 17. Sources of data  Primary  The client is the primary source of data.  Secondary  Family members or other supporting persons,  Health professionals,  Health records and reports,  Laboratory and diagnostic analyses, 9/27/2013 17
  • 19.  Nursing Diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.  Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Nursing Diagnosis 9/27/2013 19
  • 20. Benefits Of Nursing Diagnosis  Gives Nurses a Common Language.  Promotes identification of appropriate goals or correct choice.  Can create a standard for nursing practice.  Provides a quality improvement base. 9/27/2013 20
  • 21. Components of Nursing Diagnosis  A typical nursing diagnosis statement has two or three parts/statements.  In two parts nursing diagnosis, the first component is a problem statement or diagnostic label (as listed in NANDA), while second component is the etiology. Both of these parts are linked by the term related to (RT). E.g. Disturbed Body Image RT loss of left lower extremity  The three part nursing diagnosis statement consists Problem, Etiology and Sign, Symptoms (defining characteristics) joined to the first two component by connecting phrase “as evidence by” (AEB). E.g. “ineffective Airway clearance RT fatigue AEB dyspnea at rest” 9/27/2013 21
  • 22. Descriptive Words  To clarify nursing diagnosis, descriptive words or terms may be added before or after the problem statement. These words include Acute, Chronic, Decreased, Deficient, Depleted, Distu rbed, Dysfunctional, Enhanced, Excessive, Impaired, I ncreased, Ineffective, Intermittent, Potential, and Risk for. 9/27/2013 22
  • 24. Types Of Nursing Diagnosis  Actual nursing diagnosis  Risk nursing diagnosis  Wellness nursing diagnosis  Syndrome nursing diagnosis 9/27/2013 24
  • 25. Actual  An actual nursing diagnosis is the diagnosis about current problem that is present at the time of the nursing assessment, based on the presence of signs and symptoms.  Examples of an actual nursing diagnosis are anxiety characterized by fear, panic, apprehension and sleep disturbances, or an ineffective airway clearance characterized by an ineffective cough, abnormal breathing or a fever. 9/27/2013 25
  • 26. Risk Nursing Diagnosis  Risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community.  Risk nursing diagnoses are two – part statements, do not include defining characteristics.  Examples –  Risk for infection related to surgery or immunosuppression.  Risk for aspiration related to reduced level of consciousness 9/27/2013 26
  • 27. Wellness nursing diagnosis  A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.  Wellness nursing diagnosis are one part statement includes diagnostic label.  Example  Readiness for enhanced spiritual well being  Readiness for Enhanced Self-Esteem. 9/27/2013 27
  • 28. Syndrome Nursing Diagnosis  A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.“  An example of a syndrome diagnosis is: Relocation stress syndrome. 9/27/2013 28
  • 29. Difference b/w Medical & Nursing Diagnosis Nursing Diagnosis Medical Diagnosis Clinical judgment about individual, family, or community responses to actual and potential health problems or life processes Identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures The goal of a nursing diagnosis is to identify actual and potential responses The goals of a medical diagnosis is to identify the cause of a illness or injury and design a treatment plan Nurse treats problem within scope of independent nursing practice Physician directs treatment for medical diagnosis May change from day to day as the patient’s responses change Remains the same as long as the disease is present 9/27/2013 29
  • 30. Nursing diagnosis for Medical diagnosis 9/27/2013 30
  • 32. Planning  Planning is to formulate the way to manage the problem.  The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.  Planning consists three stage:  Initial Planning  On-going planning  Discharge planning 9/27/2013 32
  • 33. Steps Of Planning  Initial Planning  Done by the nurse who perform admission assessment in order to prioritize problems, identify goals and correlate nursing care to resolve the problems.  Ongoing planning  Involves continuous updating of the client’s plan of care. Every nurse who cares for the client is involved in ongoing planning.  Discharge planning  involves anticipation and planning for the client’s needs after discharge. 9/27/2013 33
  • 34. Elements Of Planning  Prioritizing the problems/nursing diagnosis  Formulate goals/desired outcomes  Short Term (to resolve in few hours or days)  Long Term (to resolve over weeks or months)  Select nursing interventions  Write nursing interventions 9/27/2013 34
  • 37. Implementation  Implementing phase, provide the actual nursing activities and client responses. Implementation consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. 9/27/2013 37
  • 38. Nursing Skills during Implementation  To implement nursing care plan successfully , nurse need to have following skills  Cognitive Skills  Including problem solving and decision making  Interpersonal Skills  Include verbal and non-verbal response, communication,  Technical Skills  Includes hand on skills need to perform procedures such as administrating injection, drugs, lifting, moving 9/27/2013 38
  • 40. Evaluation  The last phase of the nursing process which include the judgment of the effectiveness of nursing care to meet client goals based on the client’s behavioral responses.  This step determine the success/effectiveness of the whole nursing process and the decision either to continue, modify or repeat the process is depend on evaluation. 9/27/2013 40
  • 41. Evaluation  While documenting evaluation phase, the nurse can draw one of the three possible conclusions:  The goal was met,  The client response is the same as the desired outcomes.  The goal was partially met,  Either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained.  The goal was not met 9/27/2013 41
  • 42. Relationship of Evaluation to Nursing Process 9/27/2013 42

Editor's Notes

  1. NANDA = North American Nursing Diagnosis Association