NILOFAR LOLADIYA MSN: OBGY The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care One of the most important tools a nurse can use in practice is the nursing process. Although nursing schools teach first-year students about the nursing process, some nurses fail to grasp the impact its proper use can have on patient care. In this article, I will share information about the nursing process, its history, its purpose, its main characteristics, and the 5 steps involved in carrying out the nursing process. • Establishes plans to meet patient needs • Guides nurses in the delivery of high-quality evidence-based care • Protects nurses against potential legal problems • Promotes a systematic approach to patient care that all members of the nursing team can follow The nursing process consists of five steps which encompass the care provided. The five nursing process steps are: 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

1. NURSING
PROCESS
-Mrs Nilofar Loladiya

3. WHAT is Nursing?

4. North American Nursing
Diagnosis Association
International
(NANDA-I)
WHAT is Nursing Process?

5. WHAT is Nursing Process?
Systematic, rational method of planning
and providing individualized nursing care
It is Systematic method that directs the nurse
and the patient to accomplish the desired goal
established after assessing and diagnosing.

6. WHY Nursing Process?
• Identify nursing priorities
• Helps direct nursing interventions
• Expected outcomes for quality
assurance
• Identify responses to actual or
potential health and life processes
• Identify available resources
• Common basis for communication
• Evaluation to determine if nursing
care was beneficial
• Sharpens problem-solving and
critical thinking skills

7.  Cyclic and dynamic rather than static
 Client centered
 Problem-solving
 Decision making
 Interpersonal and collaborative
 Universal applicability
 Critical thinking and Clinical reasoning skills
Characteristics of Nursing Process

10. MRS. NILOFAR: CNE ON NURSING PROCESS

11. ASSESSMENT
COLLECT DATA
INITIAL
COMPREHENSIVE
ASSESSMENT
(Database)
ONGOING
ASSESSMENT
(patient Progress)
HISTORY
(subjective Data)
PHYSICAL
EXAMINATION
(Objective Data)
• Patient History
• Biographic data
• History of illness
• Present Function
• Expectation
• Stress/Coping
• V/S
• Measurements
Interview Examination
observation
VALIDATE
ORGANIZE RECORD

12. ASSESSMENT
DATA TYPES
SUBJECTIVE DATA OBJECTIVE DATA
• “ My throat hurts to swallow “
• White patches noted at back of throat
• Tonsillar area reddened and swollen
SUBJECTIVE DATA OBJECTIVE DATA
MRS. NILOFAR: CNE ON NURSING PROCESS

13. ASSESSMENT
DATA SOURCES
PRIMARY SOURCE
(client) SECONDARY
SOURCES
(everything else)
• Pulse rate: 100 b/m
• Shortness of breath
• WBC count from client record
• Surgical dressing dry- transfer report
MRS. NILOFAR: CNE ON NURSING PROCESS

14. CRITICAL THINKING
NANDA Definition
A Nursing diagnosis is a clinical judgment concerning a human response to health
conditions/life processes, or a vulnerability to that response, by an individual, family,
group, or community.
Nursing diagnoses are developed based on data obtained during the nursing
assessment and enable the nurse to develop the care plan.

15. Nursing diagnosis V/S Medical diagnosis
• Second step in the nursing process, diagnosis.
• Nursing diagnosis is focused on care.
• Classification system established and approved by NANDA
• A nursing diagnosis is based upon the patient’s response to the medical condition.
• Associated with what nurses have the autonomy to take action about
• Anything that is a physical, mental, and spiritual type of response

16. Nursing diagnosis V/S Medical diagnosis

17. • Diagnosing: Refers to the reasoning process
• Diagnosis: A statement or conclusion regarding the nature of
phenomenon
• Diagnostic labels: Standardized NANDA names for diagnoses
• Etiology: Causal relationship between ad problem and its related
factors
• Nursing diagnosis: Problem statement consisting of diagnostic
label plus etiology
Common Terminologies

19. Problem (diagnostic label) and definition
Describes the client's health problem or response
May require specification
Qualifiers added to give additional meaning
Deficient, (Inadequate in amount, quality; insufficient)
Impaired, (Made worse, weakened, damaged, deteriorated)
Decreased, (less in size, amount)
Ineffective, (Not producing desired effect)
Compromised (vulnerable, threat)

20. Qualifier Focus of the Diagnosis
Deficient Fluid volume
Imbalanced Nutrition: Less Than Body Requirements
Impaired Gas Exchange
Ineffective Tissue Perfusion
Risk for Injury

21. Etiology (related factors and risk factors)
Identifies one or more probable causes of the health problem
Gives direction to the required nursing therapy
Enables the nurse to individualize the client's care

22. Defining characteristics
Cluster of existing signs and symptoms indicates actual diagnosis
Clients have signs and symptoms.

24. Problem-focused diagnosis
• Also known as actual diagnosis
• It is a client problem present at the time of the nursing assessment.
• These diagnoses are based on the presence of associated signs and
symptoms.

25. • Ineffective Breathing Pattern related to pain as evidenced by pursed-lip breathing, reports of pain
during inhalation, use of accessory muscles to breathe
• Anxiety related to Pre-operative status as evidenced by body language, apprehension, and
expression of concern regarding upcoming Surgery
• Acute Pain related to decreased myocardial flow as evidenced by grimacing, expression of pain,
guarding behavior.
• Impaired Skin Integrity related to pressure over bony prominence as evidenced by pain, bleeding,
redness, wound drainage.
Problem-focused diagnosis

27. Risk nursing diagnosis
• Clinical problem does not exist,
• Presence of risk factors indicates that a problem is likely to develop unless nurses
intervene.
• The individual (or group) is more susceptible to developing the problem than others in the
same or a similar situation because of risk factors.

28. For example, an elderly client with diabetes and vertigo who has
difficulty walking refuses to ask for assistance during ambulation
 Risk for Injury.
 Risk for fall
Risk nursing diagnosis

29. Health promotion diagnosis
• Also known as wellness diagnosis
• It is a clinical judgment about motivation and desire to increase well-being.
• Concerned with the individual, family, or community transition from a specific
level of wellness to a higher level of wellness.
• Components of a health promotion diagnosis generally include only the
diagnostic label or a one-part statement.

30. Health promotion diagnosis
Examples of health promotion diagnosis:
Readiness for Enhanced Spiritual Well Being
Readiness for Enhanced Family Coping
Readiness for Enhanced Parenting

31. Syndrome diagnosis
• A clinical judgment concerning a cluster of problem or risk nursing
diagnoses that are predicted to present because of a certain situation or
event.
• written as a one-part statement requiring only the diagnostic label.

32. Syndrome diagnosis
Chronic Pain Syndrome
Post-trauma Syndrome
Frail Elderly Syndrome

33. • Using “secondary to” to make the diagnostic statement more descriptive and useful.
Following the “secondary to” is often a pathophysiologic or disease process or a medical
diagnosis.
For example, Risk for Decreased Cardiac Output related to reduced preload secondary
to myocardial infarction.
• Specifying a second part of the general response or NANDA label to make it more precise.
e.g. Impaired Skin Integrity (Right Anterior Chest) related to disruption of skin surface
secondary to burn injury.

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36. GOAL SETTING
WHAT YOU WANT TO ACHIEVE THROUGH YOUR NURSING ACTIVITIES.
Clients need to be able participate in setting goals; unless goals are set mutually and there is a clear plan for action,
clients may not follow the plan of care.
• SHORT TERM
Are those you expect the patient to achieve within few hours or days
• LONG TERM
Changes in health status to be achieved over a longer period, a week, a month or more
They describe the optimum level of functioning you expect the patient to achieve, given health status and available
resources.
MRS. NILOFAR: CNE ON NURSING PROCESS

37. Previously Goals and expected outcomes are same but now they have
been defined separately.
GOAL EXPECTED OUTCOMES
Decision Making • Patient participates in discussion about own care
• Chooses between two or more alternatives
Relief Constipation • Bowel will be soft and having bowel movement within 24 hours
MRS. NILOFAR: CNE ON NURSING PROCESS

38. EXPECTED OUTCOMES:
• They are specific client behaviours or physiological responses that the registered nurse and
the client set to achieve. (Potter & Perry, 2010).
Client admitted for a total joint replacement could be;
• Client’s self report of pain will be 3 or less on a scale of 0 to 10.
• Client will be able to mobilize with minimal discomfort within 2 days of care.
MRS. NILOFAR: CNE ON NURSING PROCESS

39. INTERVENTIONS
Action based on clinical judgement and nursing knowledge that nurses perform to achieve
client outcomes.
• DIRECT CARE:
• INDIRECT CARE:
• INDEPENDENT/AUTONOMOUS
• DEPENDENT
• COLLABORATIVE
MRS. NILOFAR: CNE ON NURSING PROCESS

40. INTERVENTIONS FLOW FROM NURSING DIAGNOSIS
PROBLEM
CONSTIPATION
STANDARDISED CARE
INTERVENTION:
• Administer prescribed stool softner and
laxatives -HS
• Encourage fluid intake
ETIOLOGY
r/t immobility and decreased GI Mobility Secondary
to narcotic analgesics
INDIVIDUALIZED CARE
INTERVENTION:
• Encourage high fibre diet
• Use Non-Pharamacological measures
MRS. NILOFAR: CNE ON NURSING PROCESS

41. EVALUATION
• COMPLETE
• PARTIAL
• INCOMPLETE
• Needs assessment
• Outcome evaluation
MRS. NILOFAR: CNE ON NURSING PROCESS

42. CASE STUDY
A 46 YEAR OLD FEMALE NEWLY DIAGNOSED WITH ASTHMA HAS COME TO YOUR
CLINIC FOR THE FIRST TIME. SHE IS A SMOKER AND HAS HAD ASTMATIC
SYMPTOMS FOR THE LAST 36 HOURS .SHE HAS BEEN PRESCRIBED A SHORT
ACTING BRONCHODIATOR VIA INLAHER AND LONG ACTING MEDICATION .
MRS. NILOFAR: CNE ON NURSING PROCESS

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