The document discusses the key concepts and steps of the nursing process, including assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting, organizing, validating, and documenting data about the client's health concerns. Nursing diagnosis identifies actual, risk, wellness, possible, or syndrome diagnoses by analyzing data and formulating diagnostic statements. Planning determines how to prevent, reduce, or resolve identified client problems by developing an individualized care plan with goals and nursing interventions.

1. DEPARTMENT= PRE-PHYSICIAN
TOPIC NAME - concepts nurses process
, nurse diagnosis

2. Nursing Process
• The nursing process is a deliberate, problem-
solving approach to meeting the health care and
nursing needs of patients. It involves assessment
(data collection), nursing diagnosis, planning,
implementation, and evaluation, with subsequent
modifications used as feedback mechanisms that
promote the resolution of the nursing diagnoses.
The process as a whole is cyclical, the steps being
interrelated, interdependent, and recurrent.

4. Copyright 2008 by Pearson Education, Inc.
Assessing
• Collecting data
• Organizing data
• Validating is the act of “double-checking” or
verifying data to confirm that it is accurate
and factual.
• Documenting data
• Goal
– Establish a database about the client’s response to
health concerns or illness

5. Copyright 2008 by Pearson Education, Inc.
Planning
• Determining how to prevent, reduce, or resolve
identified priority client problems
• Determining how to support client strengths
• Determining how to implement nursing interventions
in an organized, individualized, and goal-directed
manner
• Goals
– Develop an individualized care plan that specifies client
goals/desired outcomes
– Related nursing interventions

7. • Organizing data is categorizing data
systematically using a specified format.
• Validating data is the act of “double-checking”
or verifying data to confirm that it is accurate
and factual.
• Documenting is accurately and factually
recording data.

8. NURSING DIAGNISIS
Types of Nursing Diagnosis
– Actual
– Risk
– Wellness
– Possible
– Syndrome

9. Actual Diagnosis
– Problem present at the time of the assessment
• Presence of associated signs and symptoms
• (ineffective breathing pattern)
– Risk Diagnosis
– Problem does not exirice
– Presence of risk factors

10. Wellness Diagnosis
• Readiness for enhancement
• describes human responses to levels of
wellness in an individual, family, or
community that have a readiness
enhancement.”
• (readiness for enhanced spiritual well-being
or readiness for enhanced family coping)

11. Possible Diagnosis
– Evidence about a health problem incomplete or
unclear
– Requires more data to either support or to refute
it
– (possible social isolation)

12. Steps in Diagnostic Process
• Analyzing data
– Compare data against standards
– Cluster cues
– Identify gaps and inconsistencies
• Identifying health problems, risks, and
strengths
• Formulating diagnostic statements

13. • Basic three-part statement
– Problem (P)
– Etiology (E)
– Signs and symptoms (S)

14. • The following are guidelines for
writing nursing diagnosis statements:
• Write statements in terms of a problem
instead of a need.
• Word the statement so that it is legally
advisable.
• Use nonjudgmental statements.
• Be sure both elements of the statement do
not say the say thing.

15. Factors to Consider When Setting
Priorities
• Client’s health values and beliefs
• Client’s priorities
• Resources available to the nurse and client
• Urgency of the health problem
• Medical treatment plan

16. Describe the relationship of
goals/desired outcomes to the
nursing diagnoses.
• Goals/Desired Outcomes and Nursing
Diagnosis
• Goals derived from diagnostic label
• Diagnostic label contains the unhealthy
response (problem)
• Goal/desired outcome demonstrates
resolution of the unhealthy response
(problem)

17. Thank you