NURSING PROCESS: SYSTEMATIC METHOD DIRECTING NURSE AND PATIENT TO ACCOMPLISH THE DESIRED GOAL

2. • Presented by: ms pooja nair
I just want to
finish my
work….!!!!!!!!
PRESENTED BY: MS.POOJA NAIR
LECTURER
PD HINDUJA COLLEGE OF NURSING

3. I feel
it’s a
waste of
time…!!!!
Too much
workload..!!
I cant handle
patient…they
buzz a lot…!!
No time to
Eat, Rest or
Void…!!!
I cannot prepare my care plan…!!

5. “ The unique function of a nurse is to assist
the individual Sick or well in performance
of those activities contributing to health or
its recovery or to peaceful death so that he
would perform unaided if he had the
necessary strength , will or knowledge… ”
- Virginia Henderson

8. NURSING PROCESS
Nursing is the Protection, Promotion and Optimization of health and
abilities, Prevention of illness and injury, Alleviation of suffering
through the Diagnosis and Treatment of human responses and
advocacy in the care of individuals, families communities and
population.
Thus Nursing Process is the diagnosis and treatment of human
responses to actual or potential health problems (ANA).

9. Nursing process……..
is the systematic method that directs the
nurse and the patient to accomplish the
desired goal established after assessing and
diagnosing.

10. Nursing process…….
is a systematic, rational
method of planning and
providing nursing care.

11. What is the purpose of NCP…?
To identify a client’s health care status
To identify actual or potential health problems
To establish plans to meet the identified needs
To deliver specific nursing interventions to address those
needs.

14. NURSING ASSESSMENT
Is the systematic and continuous collection, organization,
validation, and documentation of data (information).
It is a continuous process carried out during all phases of the
Nursing process.
Not a Simple Matter of ‘‘Filling in the Blanks’’

15. TYPES OF ASSESSMENT
Initial Assessment
Focused Assessment
Emergency Assessment
Time lapsed Assessment

16. INITIAL ASSESSMENT
Performed within specified time after admission
to a health care agency

17. INITIAL ASSESSMENT….!
53 year old male was apparently alright when he came with c/o pain in
the chest , radiating to back and shoulder since 10am in the morning.
Mr X verbalises it’s the worst pain in the chest “as that of a elephant is
sitting on my chest”, vital parameters s/o tachycardia 120/min,
ECG ST elevation in leads II, III avf…….!!
Lets Review the
case ……!!!!

19. PROBLEM FOCUSED ASSESSMENT
Ongoing process integrated with nursing care
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20. EMERGENCY ASSESSMENT
During any Physiologic or Psychologic crisis of the
client
• Sudden Decrease urine output …… Prerenal failure
• ECG shows Vtach or V-Fibrillation
• Right side hemiparesis Post Thrombolysis.

21. TIME LAPSED ASSESSMENT.
Several months after initial assessment.
During rehabilitation phase…..!!

22. SUBJECTIVE DATA:
Subjective data include the client’s sensations, feelings, values, beliefs,
attitudes, and perception of personal health status and life situation.
For example:
Patients verbatim………………….I am having pain, difficulty breathing,
unable to sleep…

23. OBJECTIVE DATA:
Objective data are obtained by observation or physical
examination.
For example, a discoloration of the skin or a blood pressure reading is
objective data.

24. NURSING DIAGNOSIS
Nursing diagnosis is the second phase of the nursing process.
In this phase, Nurses use critical thinking skills to interpret
assessment data and identify client’s strengths and problems.
Nursing diagnosis is a pivotal step in the nursing process.

25. TYPES OF NURSING DIAGNOSIS
Actual Nursing Diagnosis
Risk Nursing Diagnosis
Wellness Nursing Diagnosis
Possible Nursing Diagnosis
Syndrome Nursing Diagnosis

26. ACTUAL NURSING DIAGNOSIS
An actual nursing diagnosis is a client problem
that is present at the time of the nursing
assessment.
Examples are ineffective breathing pattern and
anxiety.
An actual nursing diagnosis is based on the
presence of associated signs and symptoms.

27. RISK NURSING DIAGNOSIS
 Is a 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.
For example, all people admitted to hospital have some possibility
of acquiring an infection; however, a client with diabetes or a
compromised immune system is at higher risk than others.

28. WELLNESS NURSING DIAGNOSIS
 “Describes human responses to levels of wellness in an
individual, family or community that have a readiness for
enhancement”.
Examples of wellness diagnoses would be readiness for
enhanced spiritual well-being or readiness for enhance family
coping.

29. POSSIBLE NURSING DIAGNOSIS
 Is one in which evidence about a health problem is incomplete or unclear.
Requires more data either to support or to refute it.
For example, an elderly widow who lives alone is admitted to the hospital.
The nurse notices that she has no visitors and is pleased with attention and
conversation from the nursing staff.
Until more data are collected, the nurse may write a nursing diagnosis of
possible social isolation related to unknown etiology.

30. SYNDROME NURSING DIAGNOSIS
 Is a diagnosis in which is associated with a cluster of other diagnoses.
Currently six syndrome diagnoses are on the NANDA international list.
Risk for disuse syndrome, for example, may be experienced by long-term
bedridden clients.
Clusters of diagnoses associated with this syndrome include impaired
physical mobility, risk for impaired tissue integrity, risk for activity
intolerance, risk for constipation, risk for infection, risk for injury, risk for
powerless, impaired gas exchanged, and so on.

31. How to formulate Nursing Diagnosis…..???
Basic Two-Part Statements
•The basic two-part statement includes the
following:
•Problem (P): statement of the client’s response
•Etiology (E): factors contributing to or probable
causes of the responses.

32. Take home message…..!!!!
P+R+E

33. Basic Three-Part Statements
The basic three-part nursing diagnosis statement is called the PES
format and includes the following:
Problem (P): statement of the client’s response
Etiology (E): factors contributing to or probable causes of the response
Signs and Symptoms (S): defining the characteristics manifested by the
client.

34. Take home message…..!!!!
P+R+E+S

35. PLANNING
Is a deliberative, systematic phase of the nursing process that involves
decision making and problem solving.
In planning, the nurse refers to the client’s assessment data and
diagnostic statements for direction in formulating client goals and
designing the nursing interventions required to prevent, reduce, or
eliminate the client’s health problems.

36. NURSING INTERVENTION
A Nursing intervention is “any treatment, based upon clinical judgment
and knowledge that a nurse performs to enhance patient/client
outcomes”.
End product of the planning phase is a client care plan.
Nursing Intervention: Nursing Orders
First: Independent intervention then Collaborative Intervention

37. INITIAL PLANNING
The nurse who performs the admission assessment usually
develops the initial comprehensive plan of care.
Planning should be initiated as soon as possible after the initial
assessment.

38. ONGOING PLANNING
Ongoing planning occurs at the beginning of a shift as the nurse plans the care
to be given that day. Using ongoing assessment data, the nurse carries out daily
planning :
to determine whether the client’s health status has changed
to set priorities for the client’s care during the shift
to decide which problems to focus on during the shift
to coordinate the nurse’s activities so that more than one problem can be
addressed at each client contact.

39. DISCHARGE PLANNING
Discharge planning, the process of anticipating and planning for needs
after discharge, is a crucial part of comprehensive health care and
should be addressed in each client’s care plan.

40. IMPLEMENTING
In the nursing process, implementing is the action phase in which the
Nurse performs the nursing interventions.
Nurse performs or delegates the nursing activities for the intervention
that were developed in the planning step and then concludes the
implementing step by recording nursing activities and the reviewing
client responses.

41. Skills required…..
To implement the care plan successfully, nurses need cognitive, interpersonal
and technical skills.
ForExample:___________________________________________________
________________________________________________________
When inserting a urinary catheter the nurse needs cognitive knowledge of the
principles and steps of the procedure, interpersonal skills to inform and reassure
the client. And technical skill in draping the client and manipulating the
equipment.

42. Impaired gas exchanged related to obstruction of pulmonary
arterial blood flow by the embolus as evidence by dyspnea,
positive d-dimmer for Pulmonary Embolism, and abnormal
pulse oximetry.
NURSING DIAGNOSIS:

43. EVALUATION
Evaluating is the fifth and last phase of the nursing process.
Evaluation is a planned, ongoing, purposely activity in which
clients and health care professionals determine :
(a) the client’s progress toward achievement of goals/outcomes
(b) the effectiveness of the nursing care plan.

44. https://www.scribd.com/doc/286840614/Nanda-2015-2017-Nursing-Diagnosis

45. What do you think is priority Nursing
diagnosis…???
A patient was rushed to the emergency room because he was found in the
men’s public toilet sprawled on the floor, unconscious. ECG results show
an inverted T wave, an abnormal Q wave, and ST segment elevation.
Upon waking up, the patient narrated that he fell unconscious because of
the unexplainable pain in the chest that he felt. ER doctors diagnosed
him with myocardial infarction.
__________________________________________________________
__________________________________________________________
__________________________________________________________

46. Ineffective cardiac tissue perfusion related to reduced coronary blood
flow.
Acute pain related to reduced coronary blood flow
Risk for ineffective peripheral tissue perfusion related to decrease
cardiac output from left ventricular dysfunction.
Deficient knowledge related to post-MI self-care.

47. A 65 year old female presents to your floor from the ER.
The patient is admitted for dyspnea.
You note that the patient presents with extreme dyspnea on activity, especially during
ambulation.
O2 saturation drops during activity to 82% on room air.
While resting the patient oxygen saturation is 88-89%. You place the patient on 2L nasal
cannula.
Patient’s history includes: Breast Cancer 2000, double mastectomy 2001, Appendectomy
1983, Rhinoplasty 1999.
VS: HR 105, BP 115/82, O2 Saturation 93% 2L nasal cannula, Temp. 98.6, RR 21, pain
2 on 1-10 scale. D-Dimer 920, Troponin 0.01.
Pt had a CT scan with PE protocol performed before arrival to your floor and the results
showed positive for Pulmonary Embolism. Pt is started on Lovenox 1mg/kg BID subq
and Coumadin 5mg PO daily. Current INR 1.2.

49. PatienceIntrospection
Self awareness
Respect
your patient
Quick
Prompt in
your action
It’s not about being a superwomen/men but a superb human being, NURSE