This is a material for English study

1. Nursing Process
Pusat Pengembangan Bahasa (P2B)
Universitas Harapan Bangsa
Purwokerto

2. DEFINITION of NURSING PROCESS
The Nursing Process is a scientific method used
by nurses to ensure the quality of patient care.
All actions taken during the nursing process are documented in
Nursing Care Plan.
Nursing Anesthesia Care Plan is a written guide of strategies for
nurse anesthetist to implement and to help the client achieving
optimal health.
The Objectives are:
1. To promote evidence-based care
2. To promote holistic care (including physical, psychological, soci-
al, and spiritual care)
3. To support methods such as care pathways and care bundles
4. To record care.
5. To measure care.

3. PHASES OF NURSING PROCESS
1.Assessment
2.Diagnosis
3.Planning
4.Implementation
5.Evaluation

4. Assessment
Components of Assessment:
1.Data Collection
2.Chief Complaint
3.History of Present Illness
4.Past Health History (Past Medical
History, immunization, allergies,
drug history, last oral intake,
traveling)
5.Family History

5. Assessment
Types of Data:
1. Subjective Data/ Symptom
Information that is obtained verbally from the
client; it is what the client tells you about him
self or herself either spontaneously or as a
response to direct question (interview).
2. Objective Data/ Sign
Information that is obtained by performing a
physical assessment, taking vital signs, and
noting diagnostic test results.

6. Assessment
Sources of the Data:
1. Primary Source
Patient
2. Secondary Source
Family/Significant other,
Patient Medical Records(Present/Past)
History/Physical Progress Notes
Laboratory Diagnostic Test Result
Medication Lists & Literature

7. Assessment
Methods of Collecting Data:
1. Interview (ask open-ended questions)
2. Observation
3. Physical Examination

8. Diagnosis
1. Medical Diagnosis
Clinical judgment by the physician that identifies
or determines a specific disease, condition or
pathological state.
2. Nursing Diagnosis
A clinical judgment about individual, family, or
community responses to actual or potential
health problems/life process.
Types of Diagnosis:

9. Nursing Diagnosis
Components of Nursing Diagnosis:
1. Problem
A term or phrase which is a name of diagnosed
condition as evidenced by defining characteristics a
nd etiology.
2. Etiology
The related cause or contributor to the problem.
3. Defining Characteristics
Collected data, also known as signs and symptoms,
subjective and objective data, or clinical
manifestations.

10. Planning
There are two steps of planning
a. Planning Expected Outcome
A detailed specific statement describing
the goals to be achieved after implementing
the treatment.
b. Planning Intervention
The methods/actions used to achieve the
goals.

11. Planning Expected Outcome
Types of Planning Expected Outcome:
a. Initial Planning
It involves development of a preliminary plan of
care by the nurse who performs the admission of
assessment data.
b. Ongoing Planning
It updates the client's plan of care. New informa-
tion about the client is collected, evaluated and
revisions are made to the plan of care.
c. Discharge Planning
It involves anticipation of planning for the client's
needs after discharge.

12. Planning Intervention
Types of Intervention:
a. Independent Nursing Intervention
Initiated by the nurse and does not require
direction or order from another health care
professional
b. Interdependent Nursing Intervention
Implemented collaboratively by the nurse in
conjunction with other health care professionals
c. Dependent Nursing Intervention
Require an order from a physician or other
health care professional.

13. IMPLEMENTATION
Definition:
The fourth step is the performance of the
nursing interventions identified during the
planning phase. It involves delegation of
some nursing interventions to staff members.

14. EVALUATION
Definition:
Evaluation determines whether client’s
goals have been met, partially met, or
not met.

15. THANK YOU