this is a powerpoint slide presented to students of GOVT nURSING COLLEGE KOCHI

1. Lt.Col. Mrs Sheela Paul
Lecturer
Dept.of Medical Surgical Nursing
College Of Nursing Govt .Medical
College
Kochi
1

2. “A systematic, rationale method of
planning and providing
individualized nursing care. Its
purpose is to identify client’s health
status, actual or potential healthcare
problems or needs, to establish
plans to meet those needs and to
deliver specific nursing
interventions to meet those needs”.
(Kozier, 2004)
2

3. The set of activities that professional
nurses perform to determine the
needs of the patient and make a
judgment to provide the care that is
needed.
3

4.  CA BRN Standards of Competent
Performance: RN shall be
considered to be competent
when he/ she consistently
demonstrates the ability to
transfer scientific knowledge…in
applying the nursing process:
4

5.  Formulates nursing diagnosis, through
observation and interpretation of
information.
 Formulates a care plan in collaboration with
the client.
 Performs skills essential to the nursing
actions to be taken.
 Delegates tasks to subordinates
 Evaluates the effectiveness of the care plan
 Acts as the client’s advocate.
5

6.  The collection of data is systematic
 Derive nursing diagnosis from data
 Plan nursing care including goals
 Plan includes priorities and nursing
approaches
 Nursing actions provide for client
participation in health promotion,
maintenance, and restoration
 Evaluation of progress or lack of progress
6

7. Priority Setting:
 Determine client health values & beliefs
 Establish priorities from highest to lowest
 Determine urgency or the problem
Problem-Solving:
 Once problem is identified, collect data
 Analyze the data & identify an action-plan
 Implement the plan, observing initial
responses
 Evaluate the results
7

8.  Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation
8

9. Otten/403
9

12.  Subjective Data
- The client states “ . . .”
 Objective Data
- Vital signs
- Physical assessments
- Previous documentation

13.  Temp of 102 degree
 “I feel tired”
 WBC 24,000/mm3
 “I need help to walk”
 B/P 180/96
 “My leg hurts”
 Redness and swelling in R ankle
13

15. A description of the client’s response to a
disease state, process, condition or
situation. It is “a clinical judgment about
an individual, family or community
responses to actual/potential health
problems/life processes. Nursing
diagnoses provide the basis for selection
of nursing interventions to achieve
desired client outcomes”.
(NANDA, 1990)
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16. Nursing Diagnosis
Describes a
response to a disease
process, condition or
situation
Oriented to
individual changes as client
changes
Compliments
medical diagnoses
Teaches client re self-
care
Medical Diagnosis
Describes a
specific disease
process
Oriented to pathology
& remains constant
Well defined
classification system
Teaches clients about
treatments
16

17. Advantages:
 Provides a common language for nurses
 Outcome-oriented
 Efficient, Organized , Systematic, and Goal
Directed
Disadvantages:
 Inconsistently used
 Not always formally recognized (by MDs.)
 Some problems don’t fit diagnostic
statements as outlined by NANDA
17

18. Actual Problems:
Altered Nutrition, less than body
requirements related to poor oral intake
as evidenced by weight loss of 12 lbs. in
two weeks.
Potential Problems:
High risk for infection (Potential for)
related to decreased primary defenses.
18

19. Actual Problem (3 Part Statement)
 Diagnostic Label/Statement (Problem
Statement):
“ Activity Intolerance”“Impaired Physical
Mobility”
(identifies unhealthy responses, what needs
change)
 Etiology (Contributing Factors)
“… related to _______________”
(identifies factors causing undesirable
response)
 Defining Characteristics (Manifestations)
“ … as evidenced by __________” (what you 19

20. Potential Problems (2 Part Statement)
 Diagnostic Label/Statement
 Etiology (Contributing Factors)
20

22.  Goals are broad statements about
the effects of nursing interventions
on the client (overall, non-
measurable statements)
 Outcomes are specific,
measurable criteria used to
evaluate whether goals have been
met based on specific nursing
interventions 22

23.  Outcomes are derived from the
diagnosis
 Outcomes are
measurable/behavioral
 Outcomes are realistic compared to
the client’s self-care abilities
 Outcomes have a time-frame for
completion
 Outcomes provide direction for 23

24.  Interventions should be
developed which are consistent
with the established plan of
care
 Interventions should be
implemented in a safe,
appropriate manner based on
sound nursing theory and 24

25.  Interventions should always
be documented in the
medical record
 Interventions should be
realistic for client, based on
abilities and resources
25

26. Independent:
Able to be implemented without a physician’s
order
Dependent:
Must have or obtain physician’s order to
implement this intervention
Collaborative:
Combination of dependent/independent
nursing intervention
26

27.  Independent: functions that are within
scope of nursing practice.
• Assessment - history and physical
• Nursing diagnosis, which require nursing
interventions
• Nursing actions
• Referrals to other health members
• Evaluation of patient’s responses
27

28.  Interdependent: activities that are
carried out in conjunction with other
health team members.
• RN works with a dietician to help a diabetic
patient control blood sugar.
• RN works with PT to help improve patient’s
ambulation.
28

29.  Dependent: activities performed
based on the physician’s orders
• Administration of medication
• Carrying out specific treatments
29

30.  Retakes the B/P; ask the pt what he was
doing.
 Asks the pt. how he is feeling, notes
changes
 Checks B/P with the previous B/P
readings.
 Checks the MD’s order for any related
orders.
 Gives treatments ordered by the MD.
 Monitors effects of medication.
 30

31.  Patient reports, “It feels like my chest
is being crushed”
 Observations show facial grimace,
SOB (shortness of breath), and
diaphoresis (perspiring)
31

32.  Goal of
Medicine: cure,
treat disease,
heal physiologic
being
 Goal of Nursing:
works with the
whole person
32

33.  Medical
interpretation of
pain: diminished
blood flow from
coronary arteries
to myocardium
 Probable
Diagnosis:
Myocardial
Infarction
 Nursing
interpretation:
Pain in the chest
 Probable
Nursing
Diagnosis: chest
pain related to
cardiac disease
33

34.  Medical Plan:
dependent
functions
• Bedrest
• Vital Signs q 15
min.
• Morphine 2mg IV
prn
• NTG 1/200 gr SL
prn
• EKG, O2 at 2L/min
 Nursing Plan:
independent
functions
• Monitor EKG and
dysrhythmia
• Assess chest pain
• Employ comfort
measures, allow
rest
• Alleviate anxiety
34

36.  Require cognitive skills (problem-
solving, creative & critical thinking
skills)
 Require interpersonal skills
(verbal/non-verbal
communication,teaching, caring
etc.)
 Require technical skills (“hands-on”
psychomotor skills, tasks,
36

38. STEP 5
Evaluation—
 determining the
client’s progress
 monitoring the
client’s response
Otten/403
38

39.  Compare the actual to expected outcomes
- Did my client achieve their outcomes?
- If not, determine why outcomes were unmet -
Were the outcomes realistic? Correct problem?
Enough time to achieve outcomes?
 If you determine the outcomes to be
appropriate, assess the interventions
-Were the interventions appropriate? Were they
completed? Does the client require other
nursing interventions?
 If everything looks good, continue with plan of
care, observing for improvement
39

40.  Provides direction & individualizes
client care
 Provides for continuity of care
 Provides direction for follow-up &
documentation
 Provides assistance in assigning
staff
 Provides information for
reimbursement
40

41.  Admitted to the unit with diagnosis of
lung cancer with bone metastases 3 days
ago
 Meds: morphine 180 mg daily;Tylenol
650 mg +Oxycodone 10 mg q6h p.r.n.
 Morning report: Mrs. Huber had been
restless all night
41

42.  Chart review: Has been taking
narcotics for 2 months; spends
most of her days in bed
42

43.  Patient interview:
• Alert and responsive
• “Couldn’t sleep or rest; just couldn’t get into a
comfortable position.” Had trouble describing
her discomfort.
• Reported decreased appetite, ate 3 small
meals/day, one 8 oz can of supplement. Said she
is drinking very little fluids
43

44.  Measurements:
• V.S. were stable
• Had active bowel sounds, abdomen non-tender
to palpation, but noted a firm area in LLQ.
• Said she had not had a BM since admission (3
days ago).
 What nursing diagnosis might be
appropriate for Mrs. Hubert?
44

45. Critical thinking is “making decisions
based on reason, reflection, knowledge
and instinct derived from experience.
Critical thinking helps nurses make
patient-care decisions by helping them
to think creatively, and explore new ideas
and alternative ways of solving problems.
(Catalano, 1996)
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46.  Identify the problem
 Identifying the underlying beliefs (patient,
personal and other healthcare providers)
 Find support for the beliefs (accurate, timely,
consistent literature/research)
 Evaluate the situation for possible solutions
and weigh the solutions against the beliefs
and values
 Present a course of action
46

47. Subjective
Objective
Assessment
Plan
Assessment
Diagnosis
Plan
Implementation
Evaluation