it support nursing students

1. Unit one Nursing process
By;degutegegne(bsc,msc)
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2. Objectives
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By the end of this presentation participants
will be able to :
 Define/explain nursing, Nursing process
 Describe purposes ,benefits of nursing
process
 List the characteristics of the Nursing
process
 Develop Nursing Care Plan based on the
nursing Process
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3. INTRODUCTION
Definition:
 It is assisting the individual, sick or well in the
performance of those activities contributing to health
or its recovery (to peaceful death) that he will
perform unaided, if he had the necessary strength,
will or knowledge and to do this in such a way as to
help him gain independence as rapidly as possible
(Virginia Henderson 1960).
 Nursing includes the promotion of health,
prevention of illness, and the care of ill, disabled
and dying people(— International Council of
Nurses).
 Nursing encompasses autonomous and
collaborative care of individuals of all ages, families,
groups and communities, sick or well, and in all
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4. INTRODUCTION
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 The use of clinical judgment in the provision of care to
enable people to improve, maintain, or recover health,
to cope with health problems, and to achieve the best
possible quality of life, whatever their disease or
disability, until death.(— Royal College of Nursing,2003)
 ‘Nursing is a profession that entails the
humanistic blend of scientific knowledge and the
art of holistic practice to address the basic human
need of achieving health and wellness (College of
Registered Nurses of Nova Scotia, 2004)’.
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5. INTRODUCTION…
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 Nursing is the diagnosis and treatment of human
responses to actual or potential health problems
(ANA-2005).
 Nurse: a person who trained and experienced in
nursing profession and interested in care of sick
and well person
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6. HISTORICAL BACKGROUND
 In the early ages, much of the practice of
medicine was integrated with religious
practices.
 Before the development of modern nursing,
women of nomadic tribes performed nursing
duties, such as helping the very young, the
old, and the sick, mothers practiced the
nursing of their time.
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7. HISTORICAL BACKGROUND….
 As human needs expanded, nursing development
broadened; its interest and functions through the
social climates created by religious ideologies,
economics, industrial revolutions, wars, crusades,
and education.
 In this way modern nursing was born.
 The intellectual revolution of the 18th and 19th
centuries led to a scientific revolution.
 The dynamic change in economic and political
situations also influenced every corner of human
development including nursing.
 It was during the time of Florence Nightingale that
modern nursing developed(1859).
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8. HISTORICAL BACKGROUND….
 She greatly modified the tradition of nursing that
existed before her era.
 She " believed the role of the nurse was seen as placing the
client in the best condition for nature to act upon him.”.“
 Since her time modern nursing development has
rapidly occurred in many parts of the world.
 was the first to establish a formal training for nurses.
 Nightingale’s Theory focused on the environment.
 Although Nightingale never specifically used the term
environment in her writing, she did describe in detail
the concepts of ventilation, warmth, light, diet,
cleanliness and noise, which are components of the
environment
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9. HISTORICAL BACKGROUND….
History of Nursing in Ethiopia
 Even though Ethiopia is one of the oldest countries in
the world, introduction of modern medicine was very
late.
 Health care of communities and families was by
Hakim (wogesha or traditional healers).
 Around 1866 missionaries came to Eritrea, (one of the
former provinces of Ethiopia) and started to provide
medical care for very few members of the society.
 In 1908 Minlik II hospital was established in the capital
of Ethiopia.The hospital was equipped and staffed by
Russians.
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10. HISTORICAL BACKGROUND….
 Later hospital building was continued which raised
the need to train health auxiliaries and nurses.
 In 1949 the Ethiopian Red Cross, School of
Nursing was established at Hailesellasie I hospital
in Addis Ababa.
 The training was given for three years.
 In 1954 HailesellasieI Public Health College was
established in Gondar to train health officer,
community health nurses and sanitarians.
 During the regimen of 'Dergue', the former
bedside and community health nursing training
was changed to comprehensive nursing.
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11. HISTORICAL BACKGROUND....
 An additional higher health professional training
institution was also established in 1983 In Jimma.
 After the overthrown of the Dergue, the
transitional government of Ethiopia developed a
health policy that emphasizes health promotion,
diseases prevention, and curative and
rehabilitative health service with priority to the
rural societies.
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12. HISTORICAL BACKGROUND….
 As the result of the policy the training of public
health nursing at the diploma level came in to
existence since 1995.
 Additional public health higher training
institutions were established at Dilla and
Alemaya in 1996.
 The outputs of these training institutions are
providing services all over the country
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13. UNIT ONE
NURSING PROCESS
OUTLINE
 Definition
 Purpose of Nursing process
 Characteristics of Nursing process
 Steps/components of Nursing
process
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14. OBJECTIVES
 At the end of this session, you will be able to:
 Define Nursing process
 Describe the purpose and characteristics of
Nursing process
 Discuss steps/components of Nursing
process
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15. Nursing process
 The nursing process is based on a nursing theory
developed by Ida Jean Orlando (internationally known
psychiatric health nurse, theorist, and researcher)
 Developed this theory in the late 1950's as she observed
nurses in action.
 She saw "good" nursing and "bad" nursing.
 From her observations she learned that the patient must be
the central character.
 Nursing care needs to be directed at improving outcomes
for the patient, and not about nursing goals
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16.  Collecting & Examining Data.
 Analyzing Data to Identify Health Problems &
Strengths.
 Developing the Plan.
 Putting the Plan into Action & Observing
Initial & Responses.
 Determining How Well the Plan has worked
& whether there is still a Problem
Nursing process…
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17. Nursing process…
Purpose of nursing process
 To give scientifically- based, holistic,
individualized care for the patient;
 An opportunity to work collaboratively with
patients and others;
 Achieve continuity of care and;
 Encourages the health care team to observe and
interact with the patient, and not just the task
they are performing such as a administering an
injection, dressing change, or a bed bath.
 The process provides a roadmap that ensures
good nursing care and improves patient
outcomes.
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18. Nursing process…
Characteristics of the Nursing Process
 Within the legal scope of nursing
 Based on knowledge-requiring critical
thinking
 Planned: organized and systematic
 Client-centered
 Goal-directed
 Prioritized
 It is a cyclic
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19. Nursing process…
There are 5 components of nursing process
1. Assessment
2. Nursing diagnosis
3. Planning
4. Implementation
5. Evaluation
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20. Components of the Nursing Process
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21. Nursing process…
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22. Comparison of Nursing Process
and Medical Process
Nursing Process
 Deals with human
response problems and
problems with structure
and function of organs
requiring physician order.
 Uses the five steps
approach
 Consider the whole
person
 Focuses on teaching
individuals and groups
Medical Process
 Deals mostly with
problems with structure
and function of organs or
systems.
 Goals are not clearly
recorded during planning.
 Focuses on teaching
about how diseases and
trauma treated.
 Mostly involved with
individuals and rarely with
groups and families.
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23. First step in the Nursing Process and includes:
 Collection of data
 Nursing History from client as a primary source
 A comprehensive physical examination that helps to identify the
client’s response to disease; to establish an initial data base for
later comparison, and to validate subjective data presented by the
client during the interview- Not toward identification of disease;
 Laboratory;
 Nursing Records
 Relevant Literature
 Input from family and significant others
1.Assessment
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24. 1.Assessment
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 Validation of data
 To make sure that your information is factual and
complete
 If you are not sure about the validity of your information,
obtain more data rather identifying the problem based on
incorrect data.
 Organizing data
 Recording data 2/8/2024

25. purpose of assessment
 To organize a database regarding a client’s
physical,psychosocial, and emotional health.
 To identify health-promoting behaviors and
actual and/or potential health problems.
1.Assessment…
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26. 1.Assessment…
 sources of data
Primary source:
 client or the major provider of information
about a client.
Secondary source:
 sources of data other than client
 and include family members, other health
care providers, and medical records.
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27. 1.Assessment…
Types of data
 Subjective data (symptoms or covert): data
from client’s point of view, and include
perceptions, feelings, and concerns.
 Collected by interview. e.g.
pain, feeling of worry
 Objective data (signs or overt data ):
observable and measurable, obtained
through both physical
examination and the results of lab and
diagnostic
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28. 1.Assessment…
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EXAMPLE(1)
If the patient states,
"I feel like my heart is racing," and you
observe that his pulse is 140 beats per
minute, your observation verifies that what
he feels is actually happening.
S- S = Subjective data are Stated.
O-O = Objective data are Observable.
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29. 1.Assessment…
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EXAMPLE(2)
Subjective data:
 "I feel sick to my stomach."
 "I have a stabbing pain in my side."
 "I wish I were home."
 "I feel like nobody likes me."
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30. 1.Assessment…
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EXAMPLE (3)
Objective data:
 Blood pressure of 110/70 mmHg.
 Rash on right arm
 Ate all of his breakfast
 Urinated 150 ml clear urine
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31. Assessment…
 Which of the followings are objective data and
which are subjective data.
A. Nausea
B. Vomiting
C. Unsteady gait
D. Anxiety
E. Bruises on the right arms and face
F. Temperature 37.20c
G. Feeling of happiness
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32. Ato Hailu is 51 years old admitted 2 days ago with chest
pain. Ordered the following studies- ECG, and complete
blood studies.He states “ I feel much better today, no
more pain. It is a relief to get rid of discomfort”. You think
he appears a little tired, and seems to be talking slowly
and exhale noisily more often than you think. He denies
being tired. T. 37degree C, PR.74 RR. 20, B/P 140/90.
List subjective and objective data
Practice Session
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33. CASE STUDY
 W/ro Alem Kebede, 28 years of age with Medical
Diagnosis (upon admission) of Acute Gastroenteritis
Subjective: States…
 “I am weak and worried about my condition.”, “My stool is
very watery and frequent” and “I’m feeling very feverish”
Objective:
 Temp = 38.0 C (oral), Pulse = 110 per minute
 Respiration rate = 32 per minute,
 Decreased PA O2 , the nurse observed that the patient
had diarrhea x 2-3 times of ½ cup per bout/expell
following admission
Assessment …Cont’d
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34. 1.Assessment…
Type of assessment
I. Comprehensive (initial assessment)
II. Focus or on going assessment
III. Emergency assessment
IV. Time-lapsed assessment
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35. 1.Assessment…
I. Comprehensive (Initial assessment)
• Performed with specific time after admission to
ahealth care agency
• It includes; history taking, physical examination,
and laboratory test
Purpose: -
– Initial identification of normal function, functional
status, and collection of data concerning actual or
potential dysfunction.
– Baseline for reference and future comparison
E.g. nursing admission assessment
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36. 1.Assessment…
II. Focus or on going assessment
 Is on going process integrated with nursing
care, a
few minutes to a few hours between assessments
Purpose:
– to determine the status of a specific problem
identified in an earlier assessment
– to identify new or over looked problem
E. g- hourly assessment for the client fluid in
take and urinary out put in an ICU
-Assessment of client ability to perform self care.
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37. 1.Assessment…
III. Emergency assessment-
 is assessment during any physiological and
psychological crisis of the client
Purpose:
• to identify life-threatening problem
• E.g. Rapid assessment of the person’s air way,
breathing status and circulations during a
cardiac arrest
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38. 1.Assessment…
IV. Time-lapsed assessment
 Is assessment several months after initial
assessment/re-evaluate how pt react after
treatment plan
Purpose
 to compare the client’s current status to base
line data previously obtained
 E.g. reassessment of the client functional
health
pattern in a home care or out patient setting
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39. Approaches of health assessment
 There are three commonly used formats for
assessment data
Including:-
1. Body system approach
2. Human response pattern approach
3. Functional health pattern approach
1.Body system approach: is the traditional approach in
which the nurse observe and recorded data about each
of the body system
• This format does not usually permit the nurse to collect
all of the information needed to perform a holistic
nursing assessment
• it is difficult to perform nursing diagnose
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40. STRUCTURES OF MEDICAL APPROACH
 Biography
 Chief compliant
 History of present illness
 History of past illness
 Physical examinations
 Medical diagnose
 Deferential diagnose
 Diagnostic test
 Treatment
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41. Approaches…
2.Human response pattern
 This pattern divides a persons human health
status in to nine human response patterns:
exchanging,
communicating, Relating, valuing, choosing,
moving, perceiving, knowing, and feeling.
 This approach is commented by experts for
creating confusion because nursing diagnoses
are also expressed in terms of human response
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42. Approaches…
3. Functional health pattern
 The format developed by Marjory Gordon
 Organizes data in to 11 categories of
information
which describes the sequence of behavior over
time rather than isolated events.
 It permits the nurse to identify functional
pattern
(client Strength ) and dysfunctional patterns or
nursing diagnose
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43. Functional health pattern
 Dysfunctional health patterns result in
nursing diagnosis, and identify risk conditions
for problems.
 It assess the following area
Approaches…
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44. Structure of Gordon’s
approach
1. Health perception and health management
pattern
2. Nutritional metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest patterns
6. Self perception and self concept pattern
7. Cognitive and perceptual pattern
8. Role relation ship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value belief pattern
Approaches…
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45. approach…
Structure of Gordon’s
1.Health perception and health management
pattern
• Description of health, how client define health, client
health concern; preventive measure uses or methods
used to maintain health, how he/she view its situation
now
Purpose
▪ determines how the client perceives and maintains
his/her health.
▪ Describe client’s perceived of health and wellbeing and
how health is managed
▪ Compliance with current and past nursing and medical
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46. 1.Health perception and health
management pattern…
➢ Subjective data
• Client perception of health
• Client perception of illness
• Health management habit
• Compliance with prescribed medication and
treatment
➢ Objective data
• Vital sign measurement
• Pt exercise at regular bases
• Pt use salt free diet
• Pt use driving belt
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47. 2.Nutritional metabolic pattern
• Describes patterns of food and fluid
consumption relative to metabolic need and
pattern indications of local nutrient supply
 Purpose
– To determine the client dietary habits and
metabolic needs
– To determine the conditions of hair, skin,
nails,teeth and mucous membrane
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48. 2.Nutritional metabolic pattern…
➢ Subjective data include
• Hx of dietary and fluid intake (24 hour recall)
• Conditions of skin, hair and metabolism
➢ Objective data
• Assess the patient weight and
height(Anthropometric measurement)
• Assessment of the skin, hair, nails, mouth, or
pharynx, nose and sinus
• Lab. Diagnosis (hgb, serum albumin, urine
specific gravity)
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49. 3.Elimination pattern
• Describe patterns of excretory function
(bowel,bladder, and skin)
Purpose
– To determine the adequacy of the client bowel and
bladder for elimination
– To determine client’s bowel and urinary routine
and habit
– To determine any bowel or urinary problem and
use of urinary or bowel eliminations device are
examined
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50. 3.Elimination pattern…
➢ Subjective data
• Bowel habit frequency, color, consistency
• Bladder habit frequency, color, and problem
during urinations
➢ Objective data
• Abdominal assessment and rectal assessment
• Lab. & diagnostic tests
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51. 4.Activity-exercise pattern
• Determines the client’s activities of daily living,
including routines of exercise, leisure, and
recreation.
Purpose
– To determine client’s activities of daily living
including routine of exercise, leisure, and
recreations, this include activities necessary for
personal hygiene, cooking, shopping, eating, ---
– To assess any factors that affect or interfere with
the client routine activities of daily living
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52. 4.Activity-exercise pattern…
➢ Subjective data
• Activities of daily living
• Leisure activities
• Occupational activities
➢ Objective data
• Thoracic and lung assessment
• Cardiac assessment
• Musculoskeletal assessment
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53. 5.Sleep-rest patterns
• Determine the client’s perceptions of the quality
of his/her sleep relaxation and energy level.
• Describe patterns of sleep, rest, and relaxation
Purpose
– To determine client’s perceptions of the
qualities of his or her sleep, relaxations, and
energy level
– To determine methods used to promote
relaxation and sleep
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54. 5.Sleep-rest patterns…
➢ Subjective data
• Sleep habit
• Disturbance of sleep due to illness
➢ Objective data
• Observe appearance
• Puffy eye with dark circles
• Yawning
• drowsy during day
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55. 6.Self perception and self concept
pattern
▪ Describe self concept pattern and perception
of
self e.g body, comfort, body image, and feeling
state
purpose
• to determine the client perception of his or her
identity, ability, body image, and self worth
• the client behavior, attitude, and emotional
patterns are also assessed
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56. 6.Self perception and self concept pattern…
➢ Subjective data
• perception of identity
• perception of body image
➢ Objective data
• Observe appearance, behavior, mental status
assessment
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57. 7.Cognitive and perceptual pattern
• Describe sensory-perceptual and cognitive
pattern
Purpose
– To determine the functional status of the five
senses:vision, hearing, touch, taste, and smell
– Device and method used to assist the client with
deficits in any of these five sense assessed
– To determine the client’s ability to understand,
communicate, remember, and make decisions
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58. 7.Cognitive and perceptual
pattern…
➢ Subjective data
• Perception of sense: ability to see, hear, feel,
taste,
and smell
• Ability to understand
• Ability to communicate
• Ability to remember
• Ability to make decisions
➢ Objective data
• Assessment of nose, eye, ear, cranial nerve,
and
tongue
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59. 8.Role-relationship pattern
• Describes patterns of role engagement and
relation ship in family and community
Purpose
– To determine the client’s perceptions of
responsibilities and role in the family, at work
and in social life.
– Difficulties in the client relation ships and
interactions with other are examined
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60. 8.Role-relationship pattern…
➢ Subjective data
• Perception of major role and responsibilities in
family and societies
• perceptions of major role and relation ship at
work
• perception of major social roles and
responsibilities
➢ Objective data
• Observe your client family member how do
they communicate with each other
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61. 9.Sexuality-reproductive pattern
• Describe client’s patterns of satisfaction and
dissatisfaction with sexuality, describe
reproduction pattern
Purpose
• To describe the client’s fulfillments of sexual
needs and perceived level of satisfaction
• To assess perceived problem related to sexual
activities, relation ship and self concept
• The physical and psychological effect of the
client
current health status on his or her sexuality or
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62. 9.Sexuality-reproductive pattern…
➢ Subjective data
• Female menstrual history and obstetric history
• Female/male perception of sexual activities and
concern related to illness
➢ Objective data
• Breast assessment
• Abdominal assessment
• Genitourinary-reproductive assessment
• Contraception
• any sexual transmitted disease, effect or concern
of illness, surgery on sexuality, and details of
obstetric history should be assessed
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63. 10.Coping-stress tolerance pattern
• Determine the amount of stress in a client’s
life and the effectiveness of coping method
used to deal with it.
• Availability and use of support system such as
family,friends, and religious beliefs are
assessed
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64. 10.Coping-stress tolerance
pattern…
➢ Subjective data
• Perception of stress and problem in life
• Coping methods and support system
➢ Objective data
• Mental status assessment
Orientation to PPT,Attention and
concentration, Memory,Verbal and
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65. 11.Value belief pattern
 This pattern is also called spiritual
assessment
because it focus on the spiritual dimensions of
life.
 determine the client’s value, goals, and
beliefs.
 To determine the client life values and goals,
philosophical beliefs, religious beliefs, and
spiritual beliefs that influence his or her
choice and decision
 Conflicts between these value, goal, belief
and expectation that are related to health
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66. 11.Value belief pattern…
➢ Subjective data
• Sense of personal fulfillment
• Sense of peace with the self & world
• Ability to discover & articulate a basic purpose
in life
➢ Objective data
• Pt asks to discover religious leaders
• Presence of religious articles with him
• Praying
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67. 2.Nursing diagnosis
 Second step in the nursing process.
 Soon after the completion of the health
history and the physical assessment, the
nurse organizes, analyzes, synthesizes, and
summarizes the data collected
 determines the patient’s need for nursing
care.
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68. 2.Nursing diagnosis…
 Is the process of making clinical judgments
about individual, family, or community
responses to potential or actual problem
 Is the process of identification of actual or
potential health problem of the patient.
 Is problem identification & gives meaning to
the data
 Provides the basis for client care through the
remaining steps.
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69. Types of Nursing diagnosis
▪ Problem-focused diagnosis (Actual diagnosis)
• Is a client problem that is present at the time of the
nursing assessment.
These diagnoses are based on the presence of
associated signs and symptoms
• Three-part nursing diagnosis statement is also
called the PES format which includes the Problem,
Etiology, and Signs and Symptoms.
e.g “ineffective airway clearance related to
incisional pain as manifested by poor cough
effort”
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70. Types of Nursing diagnosis…
▪ Potential or risk nursing diagnosis
• These are clinical judgment that a problem
does not exist, but the presence of risk factors
indicates that a problem is likely to develop
unless nurses intervene.
• Components of a risk nursing diagnosis
include:
(1) risk diagnostic label, and (2) risk factors.
Examples of risk nursing diagnosis are:
• Risk for Falls
• Risk for Injury
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71. Types of Nursing diagnosis…
▪ Health promotion diagnosis (Wellness
diagnosis)
• Is a clinical judgment about motivation and desire
to increase well-being.
• Components of a health promotion diagnosis
generally
include only the diagnostic label or a one-part-
statement.
Examples of health promotion diagnosis:
• Readiness for Enhanced Spiritual Well Being
• Readiness for Enhanced Family Coping
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72. Types of Nursing diagnosis…
• Possible nursing diagnosis eg-possible chronic
low self estem
• Syndrome nursing diagnosis e.g-rape
NOTE…
• A Problem statement or diagnostic label usually has
two
parts: Qualifier and focus of the diagnosis. Qualifiers
(also
called modifiers) are words that have been added to
some
diagnostic labels to give additional meaning, limit or
specify the diagnostic statement.
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73. Types of Nursing diagnosis…
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74. Types of Nursing diagnosis…
One-Part Nursing Diagnosis Statement
• Health promotion nursing diagnoses are usually written as
one part statements because related factors are always the
same:
 motivated to achieve a higher level. Syndrome diagnoses
also have no related factors.
Two-Part Nursing Diagnosis Statement
• Risk nursing diagnoses have two-part statements: the first
part is
the diagnostic label and the second is the validation for a risk
nursing diagnosis or the presence of risk factors
Three-part Nursing Diagnosis Statement
• An actual or problem focused nursing diagnosis have three-
part
 statements: PES format
e.g Impaired Skin Integrity related to prolonged pressure
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75. Types of Nursing diagnosis…
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76. NANDA-I Approved Nursing
Diagnoses (only some)
Activity Intolerance
• Activity Intolerance, Risk for
• Anxiety,
• Aspiration, Risk for
• Attachment,
Parent/Infant/Child,
Risk for
• Autonomic Dysreflexia
• Autonomic Dysreflexia, Risk
for
• Blood Glucose, Risk for
Unstable
• Body Image, Disturbed
Bowel Incontinence
• Breastfeeding, Effective
• Breastfeeding, Ineffective
• Breathing Pattern,
Ineffective
• Cardiac Output, Decreased
• Coping: Community,
Readiness
for Enhanced
• Coping, Defensive
• Airway Clearance,
Ineffective
• Imbalanced,
 •
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77. Avoiding errors when writing
Diagnostic Statements
 Don’t state the nursing diagnoses using the
medical terminology; focus on the person’s
response to the medical problems;
e.g. osteomylitis related to open #
e.g. hyperthermia related to pneumonia
 Don’t state two problems at the same time;
e.g. anxiety and pain

78. 2.Nursing diagnosis…
PHYSICIAN vs. NURSING DIAGNOSIS
▪ Physician diagnosis is disease focused,
for e.g.
• Ato Yidnek has pain and swelling in all joints.
Diagnostic
studies indicate that he has rheumatoid arthritis”
▪ Nursing diagnosis is holistic, considering both the
problem
and its effect on the patient and family,
for e.g.
• Ato Yidnek has pain and swelling in all joints, making
it
difficult to feed and dress himself.
• He has expressed that it's difficult to feel worthwhile
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79. 3.Planning
• Is 3rd step of the nursing process
• Involves a series of steps in which the nurse and
the
client set priorities, goals, expected out come and
formulating intervention
• During this step you identify a set of diagnoses,
set pt centered goals & prescribe nursing
interventions
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80. 3.Planning …
Includes the following activities
1. Setting priorities:-establishing a preferential
order
for nursing strategies
2. Establishing client goal/expected out come
3. Selecting nursing strategies/interventions
4. Developing nursing care plan
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81. 3.Planning …
1. Setting priorities…
The nurse establishes the priorities of the nursing
diagnoses by ranking them in order of importance
to meet the client’s immediate needs
Setting priorities
• What problems need immediate attention?
• What problems have simple solutions?
• What problems must be referred?
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82. 3.Planning …
 Prioritize nursing diagnoses???
__Incontinence
__Sexuality patterns, altered
__Ineffective airway clearance
__risk for impaired skin integrity
__Situational low self esteem
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83. 3.Planning …
2- Establishing client goal & desired/expected outcome
Client goals are stated in terms of the patient behavior
and
time period in which they are to be achieved.
✓ These goals must be realistic, measurable, and spec
indicate a definite time frame for achievement and
consider patients desired and resources.
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84. 3.Planning …
85
▪ Examples of measurable verbs: state that,
report that,
demonstrate, perform, identifies, adapt,
increase, decrease
– Patient will ambulate using cane within 48hrs
after surgery
– Patient will identifies nutritional needs within
36hrs
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85. 3.Planning …
3. Selecting nursing strategies(intervention or action)
- Selecting nursing intervention and activities are actions that
nurse performs to achieve client goals.
- The specific strategies chosen should focus on eliminating
or
reducing the etiology.
Types of Nursing Intervention:
1- Independent intervention: are those activities that nurses
are licensed to initiate on the basis of their knowledge and
skills.
2- Dependent intervention: are activities carried out under the
physician orders.
3- Collaborative intervention: are actions the nurse carries
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86. 3.Planning …
Criteria for choosing nursing strategies
1- Safe and appropriate for patient.
2- An achievable with the resources available
3- Congruent with other strategies
4- Determined by state law
4- Writing Nursing Orders:
The component of nursing order:
1- Date
2- Action verb
3- Content area
4- Time element
5- Signature
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87. 4.Implementation
• Is putting the nursing care plan in to action
• During implementation phase the nurse carries out
the
prescribed nursing activities
Nursing Interventions are activities performed by the
nurse:
– Monitor Heath Status.
– Teach, Counsel, and Consult with, or referring to the
appropriate H-C professionals.
– Prevent, Resolve, or Control a Problem
– Assist with Activities of Daily Living [ADL]
– Promote Optimum Health and Independence
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88. 5.Evaluation
• The last phase of the nursing process
• Determines whether client goals have been
met,
partially met, or not met.
• Is assessing the client response to the goal or
out
come criteria written in the planning phase
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89. Nursing care Plan
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90. 91
ANY QUESTION?
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