EDU

1. Nursing Process
Nursing Process
It is an
It is an organized
organized,
, systematic
systematic
method for
method for providing a
providing a
comprehensive, individualized a
comprehensive, individualized a
quality of patient care that focuses
quality of patient care that focuses
upon identifying the actual and
upon identifying the actual and
potential alteration of health
potential alteration of health
responses (bipsychosocial needs/
responses (bipsychosocial needs/
problems).
problems).

2. Steps of the nursing process
Steps of the nursing process
:
:

Assessment
Assessment
.
.

Nursing diagnosis
Nursing diagnosis
.
.

Planning
Planning
.
.

Implementation
Implementation
.
.

Evaluation
Evaluation
.
.

3. 1
1
.
.
Assessment
Assessment

Assessment is the first step of
Assessment is the first step of
the nursing process
the nursing process
.
.

1
1
-
-
It involves the systematic
It involves the systematic
collection of data about the
collection of data about the
patient’s actual and potential
patient’s actual and potential
health problems and needs
health problems and needs
.
.

2
2
-
-
It provides the scientific basis
It provides the scientific basis
for a nursing diagnosis and a
for a nursing diagnosis and a
complete nursing care plan
complete nursing care plan
.
.

4. Resources for data
Resources for data
collection
collection
:
:

Patient (Primary source)
Patient (Primary source)
.
.

Family / significant others
Family / significant others
.
.

Nursing records
Nursing records
.
.

Medical records
Medical records
.
.

Verbal/written consultation (with
Verbal/written consultation (with
other health care professionals)
other health care professionals)
.
.

Records of diagnostic studies
Records of diagnostic studies
.
.

Relevant literature
Relevant literature
.
.

5. How should data be gathered
How should data be gathered
?
?

Comprehensive data collection occurs
Comprehensive data collection occurs
in 3 phases
in 3 phases

1
1
-
-

-
-
Before the nurse actually see the
Before the nurse actually see the
patient in order to keep an open mind
patient in order to keep an open mind

2
2
-
-

Perform a nursing assessment
Perform a nursing assessment
.
.

3
3
-
-

Review the resources, e.g., medical,
Review the resources, e.g., medical,
nursing, diagnostic records, and others
nursing, diagnostic records, and others
for additional information
for additional information
.
.

6. Steps of assessment:
Steps of assessment:
(I HOPE)
(I HOPE)
:
:

I----------Interview
I----------Interview
.
.

H---------History
H---------History
.
.

O---------Observation
O---------Observation
.
.

P--------- Physical examination
P--------- Physical examination
.
.

E---------- Evaluation
E---------- Evaluation

7. Steps of Interview
Steps of Interview
:
:

1
1
-
-
Preparatory stage
Preparatory stage
:
:

2
2
-
-
Opening stage
Opening stage
.
.

3
3
-
-
Information collection
Information collection
.
.

4
4
-
-
Observation
Observation
.
.

5
5
-
-
Asking questions
Asking questions
.
.

6
6
-
-
Listening
Listening
.
.

7
7
-
-
Speaking
Speaking
.
.

8
8
-
-
Closing stage
Closing stage
.
.

9
9
-
-
Post interviewing stage
Post interviewing stage

8. Types of history
Types of history
:
:

1
1
-
-
Personal history
Personal history
.
.

2
2
-
-
Past history
Past history
.
.

3
3
-
-
Present history
Present history
.
.

9. Observation through
Observation through
:
:

1
1
-
-
Seeing
Seeing
.
.

2
2
-
-
Palpation
Palpation
.
.

3
3
-
-
Auscultation
Auscultation
.
.

4
4
-
-
Percussion
Percussion
.
.

10. Types of problem
Types of problem

Physical
Physical
.
.

Psychological
Psychological
.
.

Social
Social
.
.

Mental
Mental
.
.

11. Nursing diagnosis
Nursing diagnosis

It is an alteration in human health
It is an alteration in human health
response either actual or
response either actual or
potential as regard to needs
potential as regard to needs
.
.

12. Types of Nursing Diagnosis
Types of Nursing Diagnosis
:
:

(
(
1
1
)
)

Actual Nursing diagnosis : Three part
Actual Nursing diagnosis : Three part
statement
statement
:
:

Problem statement +Etiology+ signs
Problem statement +Etiology+ signs
and symptoms
and symptoms

For example
For example
:
:

Self care deficit related to inability to
Self care deficit related to inability to
move both arms as manifested by
move both arms as manifested by
casts on both hands and wrists
casts on both hands and wrists
.
.

Potential OR possible nursing diagnosis
Potential OR possible nursing diagnosis
:
:

13. (
(
2
2
)
)
Potential OR possible nursing
Potential OR possible nursing
diagnosis
diagnosis
:
:

Potential OR possible nursing
Potential OR possible nursing
diagnosis
diagnosis
:
:

Problem statement +Etiology
Problem statement +Etiology

For example
For example
:
:

Potential ineffective airway
Potential ineffective airway
clearance related to smoking
clearance related to smoking

14. (
(
3
3
)
)
Collaborative nursing
Collaborative nursing
diagnosis
diagnosis
:
:

Problem statement Etiology
Problem statement Etiology

For example
For example
:
:

Potential impaired skin integrity
Potential impaired skin integrity
(phlebitis) related to intravenous
(phlebitis) related to intravenous
therapy
therapy
.
.

15. 2
2
.
.
Planning
Planning

It is the third steps of the nursing
It is the third steps of the nursing
process
process
.
.

Steps of planning
Steps of planning
:
:

Setting priorities
Setting priorities
.
.

Establishing goals
Establishing goals
.
.

Determining nursing interventions
Determining nursing interventions
.
.

Documenting the plan of care
Documenting the plan of care
.
.

Setting priorities
Setting priorities
:
:

Determining life threatening problems
Determining life threatening problems
and taking immediate appropriate
and taking immediate appropriate
action
action
.
.

16. 4
4
.
.
Implementation
Implementation

It is the fourth stage of the nursing
It is the fourth stage of the nursing
process
process
.
.

It is putting the nursing care into action
It is putting the nursing care into action
.
.

During the implementation stage the
During the implementation stage the
nurse continues to
nurse continues to
:
:

Continuing data collection
Continuing data collection
.
.

Setting priorities
Setting priorities
.
.

Performing nursing interventions
Performing nursing interventions
.
.

Documenting nursing care (charting)
Documenting nursing care (charting)
.
.

Giving verbal nursing reports
Giving verbal nursing reports
.
.

Maintating a current plan of care
Maintating a current plan of care
.
.

17. 5
5
.
.
Evaluation
Evaluation

It is measuring the expected outcomes
It is measuring the expected outcomes
.
.

Assessment
Assessment
:
:

Performing an assessment to identify health status
Performing an assessment to identify health status
tody and to make sure you have all the data
tody and to make sure you have all the data
.
.

Nursing diagnosis
Nursing diagnosis
:
:

Making sure your list of diagnosis is accurate and
Making sure your list of diagnosis is accurate and
complete
complete
.
.

Planning
Planning
:
:

Checking whether the goals and interventions were
Checking whether the goals and interventions were
appropriate and how well goals were achieved
appropriate and how well goals were achieved
.
.

Implementation
Implementation
:
:

Determining whether the plan was implemented as
Determining whether the plan was implemented as
prescribed and identifying factors that helped or
prescribed and identifying factors that helped or
hindered progress
hindered progress
.
.

18. 
Communication
Communication
:
:

Impaired verbal communication
Impaired verbal communication
.
.

Anxiety
Anxiety
.
.

Fear
Fear
.
.

Avoid danger
Avoid danger
:
:

High risk for /potential for
High risk for /potential for
:
:

Infection
Infection
.
.

Injury
Injury
.
.

Suffocation
Suffocation
.
.

Poisoning
Poisoning
.
.

Trauma
Trauma
.
.

Aspiration
Aspiration
.
.

Altered protection
Altered protection
.
.

19. 
Worshipping
Worshipping
:
:

Spiritual distress
Spiritual distress
.
.

Perceiving
Perceiving
:
:

Body image disturbance
Body image disturbance
.
.

Self-esteem disturbance
Self-esteem disturbance
.
.

Chronic low self esteem
Chronic low self esteem
.
.

Situational identity disturbance
Situational identity disturbance
.
.

Unilateral neglect
Unilateral neglect
.
.

Hopelessness
Hopelessness
.
.

Powerlessness
Powerlessness
.
.

Ineffective denial
Ineffective denial
.
.