A simple guide for student nurses

1. H. Deepani
RN, BN, Nursing Tutor
School of Nursing
Colombo
Sri Lanka

2. Objectives
Definition
Characteristics
Benefits
Phases

3. Definition
The nursing process is a modified form
of scientific method used in nursing
profession to
asses client needs and create a course
of action to address and solve patients
problems

4. The nursing process is a systematic,
client centered, goal oriented method
of caring that provides a framework for
nursing practice
It is a systemic, rational method of
planning and providing individualized
nursing care for individuals, families,
groups and communities

5. Benefits of Nursing Process
 Provides an orderly & systematic method for
planning & providing care
 Enhances nursing efficiency by standardizing
nursing practice
 Facilitates documentation of care
 Provides a unity of language for the nursing
profession
 Is economical
 Stresses the independent function of nurses
 Provide continuity of care and prevent
duplication

6. Characteristics of the Nursing
Process
 Systematic
 Dynamic
 Client-centered
 Goal-directed outcome focused
 Universally applicable
 Steps are interrelated and dependant on the
accuracy of each step

7. Phases/Steps
Assesment
Nursing diagnosis
Planning and goal setting
Implementation
Evaluation

8. Steps of nursing process

10. Assesment
 1st step
 Definition -Collecting, organizing,
validating and documenting data
 Gathering information about psychological,
physiological, social and spiritual status
 Data collected through observation,
interview, physical examination, health
records and family members
 Focus on patient response to health
problems

11. Assesment types
 Initial – after admission. Provide baseline data
(vital signs)
 Problem focused- ongoing process to determine
the state of previously identified problem
(hourly UOP of ARF pt)
 Emergency – at life threatening situations
(ABC)
 Time lapsed- after several weeks/ months to
determine the progress of disease and treatment
(clinic follow up)

12. Types of data
Subjective (symptoms)
information perceived only by affected
person
Eg: pain, worry, nausea
Objective (signs)
information perceived by another
person that can be verified by others
Eg: vital signs, reddened skin

13. Sources of data
Client
Support people
Client records and reports
Health care professionals
Health care literature

14. Methods of data collection
1. Observation
conscious and deliberate use of the five senses
 Organized observation (a/c to disease eg.
asthma)
-clinical signs of patient(SOB)
-threats to safety (no side rails)
-associated equipment (IV drip not
functioning)
-immediate environment (slippery floor)
-BHT (Dr’s order, Ix reports, charts, drugs)

15. 2. Interview
planned communication to obtain history
3. Physical assessment
examination of the client for objective data
 Four methods of physical assessment
Inspection
Palpation
Percussion
Auscultation
4. Refer client records and reports
5. consultation

16. Steps of assessment process
Data collection
Validation – double checking for
accuracy
Organizing- head to toe or system wise
Documentation
– subjective (client’s words)
- Objective (medical terms,
abbreviations)

17. Nursing diagnosis
Nursing diagnosis is a clinical
judgment about individual, family or
community response to actual and
potential health problems/life
processes
1990 NANDA definition
North American Nursing Diagnosis
Association

18. Nursing diagnosis
After gathering information about the
client, nurse analyze them and make a
decision about the person’s condition,
strength, problems or needs
It is the judgment that the nurse makes,
which forms the link between
assessment and nursing care plan

19. Components of nursing diagnosis
 Problem statement (derived from NANDA
nursing diagnosis)
-self care deficit
 Etiology/related factor (contributing
factor for the problem)
-R/T paralysis of lower limbs
 Defining characteristics (data that signals
the existence of the problems)
-as evidenced by strong body and urine odor

20. Descriptive words
Acute Chronic
Intermittent Altered
Impaired Increased
Decreased Deficient
Excess Disturbed
Ineffective depleted
dysfunctional

21. Types of nursing diagnosis
 Actual- current/obvious problem
Eg : fluid volume deficit
(decreased intake due to nausea and
vomiting, dry skin, low UOP,
 Potential/risk – problems which may occur
in the future due to current health status
Eg : risk for infection
(surgical incision, discharge on dressing)

22. Wellness – clinical judgment about
the state of wellness
Eg: potential for enhanced spiritual
wellbeing
(practice religious activities, family
provides good support in practices )

23. Medical vs. nursing diagnosis
Medical- identify disease (one)
Nursing - identify unhealthy responses
associated with a disease (several for
signs and symptoms)

24. NANDA - nursing diagnoses
Standard and approved
Keep a copy with you always

25. Guidelines to write nursing
diagnoses
Select problem statement/nursing
diagnosis from NANDA list based on
pt’s assessment
Link the etiology and problem
statement with the phrase “related to”
Do not write medical diagnosis, signs
or symptoms as problem statement

26. Use legally advisable terms
Be sure the problem statement
indicates what is unhealthy
Actual diagnoses must have obvious
relevant data in the assessment column
Use your knowledge, experience and
medical literature to develop risk
diagnoses
 Reread and confirm the diagnoses

27. Prioritizing nursing diagnoses
Ranking of nursing diagnoses in order of
importance
 High priority- if untreated could harm to
client
eg. Ineffective breathing pattern
 Medium – non life threatening
eg. Risk for impaired skin integrity
 Low – not directly related to current illness
or prognosis
Eg. Impaired social interaction

28. Guides for prioritizing nursing
diagnoses
Maslow’s hierarchy
Virginia Henderson’s guide for needs
Client preference
Anticipation of future problems

29. Planning
In this phase Nurse and client work
together to
1. develop client goals if achieved which
solve the client problem in nursing
diagnosis
2. identify the nursing interventions
which are most likely assist the client in
achieving those goals

30. Types
1- Initial planning:
the nurse who performs the admission
usually develops the initial
comprehensive plan of care.
2- Ongoing planning:
- Is done by all nurses who work
with the client.
3- Discharge planning:
The process of anticipating and
planning for needs after discharge.
30

31. Planning Process:
1- Setting priorities.
2- Establishing client goals/desired out
comes.
3- Selecting nursing
strategies./interventions
4- Writing nursing orders.
31

32. Planning Process:
1-Setting priorities:
As you learned above
32

33. Planning Process:
Formulating Goal/ objective/
expected outcome
* Purpose of Goals:
a- provide direction for planning nursing
interventions
b- Serve as criteria for evaluating client
progress.
c- Enable the client and the nurse to
determine when the problem has been
resolved.
33

34. Formulating goals
- derived from the problem statement of
nursing diagnosis
-for each diagnosis at least one goal
-consider client’s preference
-find the descriptive term of the
diagnosis
-find the opposite term of descriptive
term
-write the goal as “To +verb stem”

35. Example
 problem statement-impaired skin
integrity
Descriptive term-Impaired
Opposite of impaired- improved
Verb stem- improve
Goal- To improve skin integrity

36. SMART goals
S - Specific
M - Measurable
A - Achievable
R - Realistic
T - Time bound

37. SMART goal example
Nursing diagnosis- Fluid volume
deficit r/t frequent passage of stools
Goal
S- Mr. Sirisena
M- will drink
A- 60ml fluid
R-while awake
T- every hour

38. Types of Goals:
a- Short Term Goals:
For a client who require health care
for a short time.
usually achieved in less than one week
b- Long Term Goals:
Are often used for clients who have
a chronic health problem
usually takes more than one to two
weeks to achieve
38

39. Nursing strategies/ interventions
Derived from nursing diagnosis
Based on causative factors for the
problem
Identify several options
Simple to complex

40. Selecting nursing interventions
Types of Nursing Intervention:
1- Independent intervention: 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 out in collaboration with other
health team member.
40

41. Writing nursing orders
Write as orders
-provide back care 2hly
-change the dressing
Clear
brief
Simple to complex
Use abbreviations

42. Implementation
Putting the planned care into action
Prerequisite nursing skills
Intellectual
Interpersonal
technical
42

43. Process of implementation
 Determine the need for assistance
(basic human needs)
 Promote self care, teaching and counseling
(active participation of client and family)
 Assisting to meet health goals
(carry out the planned actions)
 Ongoing data collection
 Communicating care
(documentation –only about carried out actions
past tense)

44. Evaluation
 Planned, ongoing, purposeful
activity in which clients and health
care professionals determine:
- The clients progress toward goals
an achievement.
- The effectiveness of the nursing
care plan.
44

45. Evaluation
Process of evaluating client responses:
1- Identify the desired out comes.
2- Collecting data related to desired out
comes.
3- Relate nursing actions to client
goals/desired outcomes.
4- Draw conclusions about problem
status.
5- Continue to modify or terminate the
clients care plan.
45

46. Documenting evaluation
Goal met
Partially met
Not met
with brief relevant description

47. Writing care plans
Use institutional format
Date/time/assessment/nursing
diagnosis/planning/implementation/
evaluation
Assessment- include significant data
about basic human needs, signs and
symptoms, feelings,Ix reports, special
medical care, vital signs etc. Avoid too
long descriptions

48.  Nursing diagnoses- use NANDA problem
statement +related factor
 Planning-goals and plans to achieve goal
write as orders
 Implementation- about carried out actions
write in past tense
 Evaluation- mention about goals met or not
with brief description.
 Use accepted abbreviations and symbols of
your agency
 Kardex-mostly used care plan

49. Important !important!!
Important!!!
 Every client is unique
 They have unique problems
 Develop ability to identify unique problems of each
client
 Unique ,clear assessment helps to provide unique care
for each client
 NEVER COPY AND PASTE from web sources for study
purposes

50. Questions?

51. Thank you!

52. Case study
52 years old Mr. Perera is a clerk. He was
admitted to your ward with a history of
difficulty in breathing, difficulty in
swallowing, mild chest pain and
hoarseness of voice. He has lost 5kg of
weight within last two months. Today
is the second day after admission. Still
he has all the symptoms he had on
admission.

53. He looks ill and complains generalized body
weakness. he is on liquid diet , but he
refuses his meals saying “no appetite”. His
urinary and bowel elimination normal. He
has not slept last night due to unfamiliar
environment. Today he is waiting for his
endoscopic biopsy report. He worries about
the uncertain results of the report. He wants
to know the reason for his physical changes.
His last Hb report is 9.2g/dl. His vital signs
are normal.

54.  Underline client’s problems
 Write those in a separate paper
 Write possible problems which may occur in
the future
 Select problem statement for each problem
from NANDA diagnoses list
 Select etiology from assessment and
literature
 Write two part nursing diagnosis for each
problem.
 Formulate goals
 Plan actions to achieve goals