2. “DO NOT LOWER YOUR GOALS
TO THE LEVEL OF YOUR
ABILITIES
INSTEAD RAISE YOUR
ABILITIES TO THE HEIGHT OF
YOUR GOALS”
3. DEFINITION
An orderly, systematic way of
identifying the client’s problems,
making plans to solve them
,initiating the plans or assigning
others to implement it and
evaluating the extent to which the
plan was effective in resolving the
problems identified.
The nursing process is a
systematic, rational method of
planning and providing
individualized nursing care.
4. PURPOSES
To identify a client’s health status.
To identify actual or potential health care
problems/needs.
To establish plans to meet the identified
needs.
To deliver specific nursing interventions
to meet those needs.
To evaluate the outcome of nursing
care.
9. NURSING DIAGNOSIS
• It is a clinical judgement about
individual, family or community
responses to actual or potential health
problems.
10. TYPES
• Actual diagnosis
• Risk diagnosis
• Wellness diagnosis
• Possible diagnosis
• Syndrome diagnosis
11. COMPONENTS
One part
statement
Two part
statement
Three part
statement
Any new
wellness
diagnosis
developed
Problem R/T
Etiology
Problem R/T
Etiology AMB /AEB
signs and symptoms
Readiness for
enhanced
nutrition
Constipation R/T
inadequate intake
of fibre diet
Constipation R/T
inadequate intake of
fibre diet AMB
passing hard stools,
blood in stool
12. AVOIDING AND CORRECTING
ERRORS
• Identify the client’s response not the
medical diagnosis
• Acute pain R/T Myocardial
infarction
Vs
• Acute pain R/T physical exertion
secondary to MI AMB pain scale
score 7,tachycardia
13. Identify a NANDA diagnosis rather
than the symptoms.
• Cough R/T excess mucus
Vs
• Ineffective airway clearance R/T
increased tracheo-bronchial
secretion AMB cough, abnormal
pattern of breathing
15. • Identify only one client problem
in the diagnostic statement.
•pain and anxiety R/T difficulty
in ambulating
Vs
•Impaired physical mobility
R/T pain in the right knee
AMB weakness
•Anxiety R/T difficulty in
ambulating AMB tachycardia
16. Identify the client’s problem
rather than the goal.
•client needs high protein diet
R/T potential alteration in
nutrition
VS
•Imbalanced nutrition :less
than body requirement
anorexia R/T inadequate
nutritional intake AMB
weight loss, poor skin turgor
17. • Identify the client’s response to
the equipment rather than
equipment itself.
Anxiety R/T cardiac monitor
Vs
•Deficient knowledge
regarding cardiac monitor
AMB palpitation, asking
doubts
18. Identify the problem caused by the
treatment or diagnostic study
rather than treatment
• Cardiac catheterization R/T
angina
Vs
Anxiety R/T lack of knowledge
regarding cardiac
catheterization AMB
palpitation, fear
19. Identify the client’s problem
rather than the nursing
interventions.
• Offer bedpan frequently because
of altered elimination pattern
Vs
• Diarrhea R/T food intolerance
AMB watery stools, painful
defecation, dry skin
20. Identify the client’s problem
rather than the nurse’s
problem
Risk for IV complication
R/T poor vascular access
Vs
Risk for infection R/T
presence of IV line.
21. Planning
• It is a deliberate systemic phase of the
nursing process that involves decision
making and problem solving.
28. Activites
• Reassess the client
• Set priorities
• Perform nursing interventions
• Documenting nursing action
29. Evaluation
• It refers to rating ,grading and judging.
• Evaluation is the process of
determining the extent upto which the
goals of nursing care have been
attained.
31. Activities
• Review the client goals and outcome
criteria
• Collection of data
• Measurement of goal attainment
• Documentation
• Revision/modification of plan of care
