for nursing students

1. . THE NURSING PROCESS
DEFINITION
It isthe systematic,rational methodof planningandprovidingnursingcare
PURPOSE:
TO PROVIDECARE FORCLIENTS THAT IS INDIVIDUALIZED.HOILISTIC,EFFECTIVEANDEFFICIENT
CHARACTERISTICS OF THE NURSING PROCESS
Cyclicand dynamicinnature
Clientcentered
Adaptationof problemsolving
Involvesdecisionmaking
Interpersonal andcollaborative
Universallyapplicable
PHASES OF THE NURSING PROCESS
A – Assessment
D – Diagnosis
P – Planning
I – Implementation
E – Evaluation
1. ASSESSMENT
Systematicandcontinuouscollection,organization,validation,interpretationand
documentationof data
Carriedoutduringall the phasesof the nursingprocess
Types ofAssessment
TYPE
1. Initial
2. Problem-Focused
3. Emergency
4. Time-Lapsed
TIME PERFORMED
Duringadmission
Ongoingprocess
Emergency or crisis situations
Several monthsafterinitial
assessment
PURPOSE
To establishadatabase
To monitorand/oridentifya specific,new
or overlooked problems
To identifylife-threateningproblems
To compare a client’sstatus
overa periodof time

2. ActivitiesDuring Assessment
 Data Collection
 Validationof Data
 Organizationof Data
 Documentationof data
Types ofData
Subjective (covert,symptoms)–feltandexperiencedbythe patient
Objective (overt,signs) –detectedbyanobserver
Sources ofData
1) Primary – client
2) Secondary – familymembers,friends,healthprofessionals,records
MethodsOf Data Collection
1. Observation
2. Interview
3.Physical Examination
DATA VERIFICATION
DATA ARE VALIDATEDWHETHER COMPLETE ANDACCURATE
DATA ORGANIZATION
NURSE ORGANIZESANDCLUSTERS THE INFORMATION TOGETHER IN ORDER TO IDENTIFY AREAS
OF STRENGTH ANDWEAKNESSES.
AssessmentModels
1) Gordon’s11 Functional HealthPatterns
2) Orem’sSelf-Care Model
3) Roy’sAdaptationModel
4) Body System’sModel - Neuman
DATA INTERPRETATION
TRANSLATION OFTHE INFORMATION INTONURSINGDIAGNOSIS
DATA DOCUMENTATION
BASISFOR DETERMINING QUALITY OF CAREAND SHOULD INCLUDE APPROPRIATEDATA TO
SUPPORTIDENTIFIED PROBLEMS
2. DIAGNOSIS
Interpretationof assessmentdataandidentificationof the client’sstrengthsandproblems
DefinitionofTerms
Diagnosis – Science andart of identifyingproblemsorconditions
NursingDiagnosis
– isa clinical judgementaboutindividual,familyorcommunityresponsestoactual or potential
healthproblems/lifeprocesses.
Includesthe DIAGNOSTICLABEL - standardized name.,and problemstatement
plus ETIOLOGY - relationshipbetweenaproblemanditsrelatedorriskfactors

3. NURSING DIAGNOSIS VS. MEDICAL DIAGNOSIS
Nursing Diagnosis Medical Diagnosis
Referstoclient’sresponsestoa disease process Referstodisease processes
Varyamong individuals Fairlyuniforminall patients
Changesas the client’sresponsechanges Remainsthe same foras longas the disease
processispresent
NURSING DIAGNOSIS VS. COLLABORATIVE PROBLEM
NursingDiagnosis Collaborative Problem
Human responsestoadisease process Potential problemsthatmayarise outof a disease
processe.g.complications
Treatmentismainlydependentonthe nurse Treatmentrequiresahealthcare teameffort
Types ofNursing Diagnosis
1) Actual Diagnosis – client’sproblemATPRESENT
Impairedskinintegrityrelatedto prolongedpressure onbonyprominence asmanifestedbyStage II
pressure ulcerovercoccyx,3 cm in diameter
2. RISK NURSING DIAGNOSIS/POTENTIAL PROBLEM
a clinical judgmentthataproblem DOESNOT EXISTbut there ispresence of RISK
FACTORS indicatingthataproblemis LIKELY TO DEVELOP if the nurse will notintervene
Composedof the diagnosticlabel precededbythe phrase “riskfor”withthe specificrisk
factors listed
EXAMPLE: Riskfor impairedskinintegrityrelatedtoinabilitytoturn self fromside toside inbed.
3. POSSIBLE NURSING DIAGNOSIS
Indicatesasituationinwhicha problemcouldarise unlesspreventive actionistaken
A hunchor intuitionbythe nurse thatcannot be confirmedoreliminateduntilmore data have
beencollected
Composedof diagnosticlabelandrelatedfactors
EXAMPLE: Possible Self EsteemDisturbancerelatedtorecentretirementandrelocation
4.WellnessDiagnosis– indicatesthe client’sexpressionof adesire toattaina higherlevel of wellnessin
some area of function
Composedof diagnosticlabelprecededby“potential/readinessforenhanced
Examples:ReadinessforEnhanced SpiritualWell-Being
Potentialforenhanced nutrition

4. Well-nessDiagnosis
ReadinessforEnhanced
Effective Breastfeeding
Spiritual Well-Being
HealthSeekingBehavior
AnticipatoryGrieving
Componentsof a NANDA NursingDiagnosis
1) Problem(Diagnostic Label) and Definition – describesthe client’shealthproblemorresponse
2) Etiology (RelatedFactors and Risk Factors) – identifiesone ormore probable causesof the
healthproblem
3) DefiningCharacteristics – clustersof signsand symptomsthatindicatedpresence of a
particulardiagnosticlabel
Acceptable Qualifiersto a Diagnostic Label
1) Deficient – inadequate inamount, quality,ordegree;notsufficient;incomplete
Example:Deficient Knowledge(Medication Administration)
2) Impaired – made worse,weakened,damaged,reduced,deteriorated
Example:Impaired VerbalCommunication
3) Decreased – lesserinsize,amountordegree
Example:Decreased CardiacOutput
Acceptable Qualifiersto a Diagnostic Label
4) Ineffective – not producingthe desiredeffect
Example:IneffectiveAirway Clearance
5) Compromised – to make vulnerable tothreat
Example:Compromised Family Coping
Formulating Diagnostic Statements
1. Basic Two-Part Diagnostic Statement– composedof Problem+ Etiology
Problem Related To Etiology
Constipation related to prolonged laxativeuse
2. Basic Three-PartDiagnostic Statement– composedof Problem+ Etiology+ Signsand Symptoms
Problem RelatedTo Etiology As Manifestedby
Signs and
Symptoms
Constipation related to prolonged
laxativeuse
as manifestedby Hypoactive bowel
sounds

5. 3. One-PartStatement– usedon wellnessdiagnoses andsyndromenursing diagnoses;normally
composedof the ProblemorNANDA label only
Examples:ReadinessforEnhanced PersonalHygiene
ReadinessforEnhanced Breastfeeding
4. Collaborative Problems – shouldbeginwith potential complicationof
Disease/Situation Complication Related to Etiology
Potential complication
of diuretictherapy
arrhythmia related to low serum potassium
Taxonomy Pattern
HEALTH PROMOTION
– HealthAwareness
– HealthManagement
NUTRITION
- Ingestion
- Digestion
- Absorption
- Metabolism
Hydration
ELIMINATION
- Urinary System
- Gastrointestinal
- IntegumentarySystem
- PulmonarySystem
ACTIVITY/ REST
- Sleep/Rest
- Activity/Exercise
- EnergyBalance
- Cardiovascular/PulmonaryResponses
- Self-care
PERCEPTION / COGNITION
- Attention
- Orientation
- Sensation/Perception
- Cognition
- Communication
ROLE RELATIONSHIP
- CaregivingRoles
- FamilyRelationships
- Role Performance
SEXUALITY
- Sexual Identity
- Sexual Function
- Reproduction
COPING/ STRESS TOLERANCE
- Post– Trauma Responses
- CopingResponses
- Neuro– behavioral Stress
LIFE PRINCIPLES
- Values
- Beliefs
- Value /Belief /ActionCongruence
SAFETY / PROTECTION
- Infection
- Physical Injury
- Violence
- Environmental Hazard
- DefensiveProcesses
- Thermoregulation
COMFORT
- Physical Comfort
- Environmental Comfort
- Social Comfort

6. SELF – PERCEPTION
- Self – Concept
- Self – Esteem - BodyImage
GROWTH / DEVELOPMENT
- Growth
- Development
3. PLANNING
the nurse and clientdevelopclientgoals/desiredoutcomesandnursinginterventionsto
prevent,reduce,oralleviate client’shealthproblems
Involvesseveral tasks:
List of nursingdiagnosesisprioritized
Client-centeredlongandshorttermgoalsand outcomesare identifiedandwritten
Specificinterventionsare developed
Entire planof care isrecordedinthe client’srecord
SETTING PRIORITIES
Priority Setting– the processof establishingapreferential sequence foraddressingnursing
diagnosesandinterventions.
Category of SettingPriorities
Highpriority = life –threateningproblems
Mediumpriority = healththreateningproblems
Low priority = arisesfromnormal developmental needsorthatrequiresonlyminimal nursing
support.
TYPES OF PLANNING
1. Initial Planning
 Done by the nurse
 Whendone:
 At specifiedtime uponorafteradmissionof the patient
2. On-goingPlanning
 Who are involved:
 Done by all nurseswhoworkedwiththe patient
 The patienthimself
 The family
 But primarily,the NURSE
4. Discharge Planning
Purpose of Discharge Planning
1) To ensure continuityof care
GOAL
Aim,intentorend
Broad statementsthatdescribe the intendedordesiredchange inthe client’sbehavior
Are specificobjectivesrelatedtothe goals
Usedto evaluate nursinginterventions
Must be measurable,have atime limitandrealistic

7. EstablishingClientGoals/ExpectedOutcomes
Goal – broad statementsaboutthe desiredclient’sstatus
ExpectedOutcomes(Outcome Criteria/Objective) –specific,observable criteriausedto
evaluate whetherthe goalshave beenmet
Examples:
Goal (Broad) : Improved nutritionalstatus
ExpectedOutcome : Gain 5 lbs by April 25
Goal (Broad) : Improved mobility
ExpectedOutcome : (1) Ambulatewith crutchesby end of the week
(2) Stand withoutassistanceby end of the month
GuidelinesforWritingGoalsOrExpectedOutcomes
1. Make sure that it isSMART
– S – Specific
– M – Measurable
– A – Attainable
– R – Realistic
– T – Time bound
2. Write goalsand outcomesintermsof clientresponses,notnurse activities
CORRECT: client will drink 100 cc of water per hour (client behaviour)
INCORRECT:maintain client’s hydration (nursing action)
4. Nursing interventions
The activitythat the nurse will executeforandwiththe clienttoenable
accomplishmentsof goals.
Examples:
Turn, coughand deepbreathe q2h
Teach nipple care whenbreastfeeding
Weighclientbefore breakfast
CompositionofNursing Interventions
DirectCare – interventionperformedthroughinteractionwiththe client
IndirectCare – interventionperformedawayfrombutonbehalf of the client
Types ofNursing Interventions
A. IndependentInterventions –activitiesthatnursesare licensedtoinitiate onthe basisof their
knowledge andskills
Example:providing oralcare
B. DependentInterventions – activitiescarriedoutunderthe physician’sordersorsupervision,or
accordingto specifiedroutines
Example:Check pulsebeforeand afterambulating;deferambulation if pulse >110
C. Collaborative Interventions – actionscarriedout incollaborationwithotherhealthcare team
members
Example:refer patientto social workerforcounselling
Criteria in Choosing the Best Nursing Interventions
Safe and appropriate
Achievable with resources available
Congruent with client’s values, beliefs and culture

8. Base on nursing knowledge and experience or knowledge from relevant sciences
Within the established standards of care
Format of Written Interventions
Verb + Condition and Modifiers + time element
Correct: Explain (to the client) the actions of insulin.
Incorrect: Teach (the client) about insulin
Correct: Measure and record ankle circumference daily at 9 am
Incorrect: Assess edema of the left ankle daily
IMPLEMENTATION
Carryingout the plannednursinginterventions
IMPLEMENTING SKILLS
Cognitive Skills (Intellectual Skills)
- problem solving, critical thinking, creativity
Interpersonal Skills
- all of the activities, verbal and non-verbal people use when interacting directly with
one another.
Technical Skills
– purposeful “hands -on” skills. Tasks, procedures, psychomotor skills.
Activities in the Implementation Phase
database
Determine the need for nursing assistance
Perform planned nursing interventions
Supervise the delegated care
Document nursing activities
5. EVALUATION
Measuring the degree to which goals/outcomes have been achieved and identifying
factors that influence goal achievement
Activities in the Evaluation Phase
1) Collect data related to expected outcomes
2) Compare data with outcomes
3) Related nursing activities to outcomes
4) Draw conclusions about problem status
5) Continuing, modifying, or terminating the nursing care plan
Components of an Evaluation Statement
1. Conclusion – a statement that the goal/expected outcome has been:
 Met
 Partially met
 Not met
Components of an Evaluation Statement
2. Supporting Data – list of client responses that support the conclusion

9. Example:
Conclusion Supporting Data
Goal met Oral intake of 300 ML more than output;
good skin turgor; moist mucous membranes
Components of a Nursing Care Plan
Assessment Nursing
Diagnosis
Goals and
Objectives
Interventions Evaluation
Subjective Cues:
Objective Cues:
Problem +
Etiology
Goal:
Desired
Outcomes:
First Format
Independent:
Dependent:
Collaborative
Second Format
Observation
Prevention
Intervention
Treatments
Health
Promotion
Interventions
Met
Partially Met
Not Met
Recording, Charting or Documenting
- Process of making an entry on a client record
Chart or client record
- a formal, legal document that provides evidence of a client’s care.
Ethical and legal consideration
“ the nurse has the duty to maintain confidentiality of all patient information”
Client’s record is legally protected as a private record
GUIDELINES ON DOCUMENTATION
 Timing
Document patient care as soon as possible
 Observe confidentiality
 Observe permanence
Use non-erasable ink
Do not use sign pen
 Signature
Sign full name and append R.N.
 Accuracy

10. Ensure that data is correct
Avoid biases
Avoid ambiguous terms
 Appropriateness
Write only appropriate information
 Completeness
 Use standard terminology
 Brevity
Make it concise yet meaningful
 Legal Awareness
Cross out erroneous entry
Write “Error”
Countersign
Purposes of client record:
Planning client care
Auditing health agency
Research
Education
Reimbursement
Legal documentation
Health care analysis
DOCUMENTATION SYSTEM
Source-Oriented Clinical Record
Problem-Oriented Clinical Record
SOURCE-ORIENTED CLINICAL RECORD
Classification of information is based on SOURCE
Each person or department maintains a different section on chart
COMPONENTS OF A SOURCE-ORIENTED CLINICAL RECORD
Face Sheet
Medical History and Physical Examination Sheet
Diagnostic Findings Sheet
TPR Graphic Sheet
Doctor’s Treatment and Order Sheet
Therapeutic Sheet
PROBLEM-ORIENTED MEDICAL RECORD
Same as Problem Oriented Medical Record
Entry of data is based on CLIENT’S PROBLEM
– Example:
Problem No. 1: constipation
– Increase fluid intake: doctor

11. – Diatabs: pharmacist
– NPO:
FOUR BASIC COMPONENTS OF PROBLEM-ORIENTED CLINICAL RECORD
1. Baseline Data
– All information gathered from a patient when he first entered the agency
2. Problem List
– Contains only ACTIVE problems (and relevant information about the problem)
– No potential problems (these are contained only in the progress notes)
3. Initial list of orders or Care Plans
4. Progress Notes
Chart entry made by all health professionals involved in a client’s care
Example is SOAP/SOAPIER
– Includes:
Nurses’ narrative notes (SOAPIE)
Flow sheets
Discharge Notes and Referral Summaries
Focus Charting
Intended to make the client and client concerns and strengths the focus of care
3 columns
Date and time
Focus
Progress notes
Charting by exception
Only abnormal or significant findings or exception to norms are recorded
3 elements:
Flow sheets
Standards of nursing care
Bedside access to chart forms
Flow sheets
Graphic record
Fluid balance record
Client teaching record
Client discharge record
Skin assessment record
PURPOSES OF THE KARDEX
To make valuable information readily available
Allergies are written in red ink
It is a reminder
It is not a record