IMPORTANT PPT OF NURSING PROCESS

1. Nursing Process
Presented by:
MR VIJAYREDDY VANDALI
ASSOCIATE PROF CUM VICE-
PRINCIPAL
SCHOOL OF NURSING
P P SAVANI UNIVERSITY
GUJARAT

2. NURSING PROCESS
• Specific to the nursing profession
• A framework for critical thinking
• It’s purpose is to:
“Diagnose and treat human responses to actual or potential
health problems”

3. Nsg Dx vs MD Dx
• Within the scope of
nursing practice
• Identify responses to
health and illness
• Can change from day
to day
• Within the scope of
medical practice
• Focuses on curing
pathology
• Stays the same as long
as the disease is present

4. Nursing Process
• Organized framework to guide practice
• Problem solving method - client focused
• Systematic- sequential steps
• Goal oriented- outcome criteria
• Dynamic-always changing, flexible
• Utilizes critical thinking processes

5. Scientific Method of problem
solving
• ID problem
• Collect data
• Form hypothesis
• Plan of action
• Hypothesis testing
• Interpret results
• Evaluate findings

6. Advantages of Nursing Process
• Provides individualized
care
• Client is an active
participant
• Promotes continuity of
care
• Provides more effective
communication among
nurses and healthcare
professionals
• Develops a clear and
efficient plan of care
• Provides personal
satisfaction as you see
client achieve goals
• Professional growth as
you evaluate
effectiveness of your
interventions

7. 5 Steps in the Nursing Process
• Assessment
• Nursing Diagnosis
• Planning
• Implementing
• Evaluating

9. Assessment
• First step of the Nursing Process
• Gather Information/Collect Data
• Primary Source - Client / Family
• Secondary Source - physical exam, nursing history, team members, lab
reports, diagnostic tests…..
• Subjective -from the client (symptom)
• “I have a headache”
• Objective - observable data (sign)
• Blood Pressure 130/80

10. ASSESSMENT-COLLECTING
DATA
• Nursing Interview (history)
• Health Assessment -Review of Systems
• Physical Exam
• Inspection
• Palpation
• Percussion
• Auscultation

11. ASSESSMENT-COLLECTING
DATA
• Make sure information is complete &
accurate
• Validate prn
• Interpret and analyze data
Compare to “standard norms”
• Organize and cluster data

12. Example of Assessment
• Obtain info from nursing assessment, history and physical
(H&P) etc…...
• Client diagnosed with hypertension
• B/P 160/90
• 2 Gm Na diet and antihypertensive medications were
prescribed
• Client statement “ I really don’t watch my salt” “ It’s hard to
do and I just don’t get it”

13. Nursing Diagnosis
• Second step of the Nursing Process
• Interpret & analyze clustered data
• Identify client’s problems and strengths
• Formulate Nursing Diagnosis (NANDA : North American
Nursing Diagnosis Association)-Statement of how the client is
RESPONDING to an actual or potential problem that requires
nursing intervention

14. Formulating a Nursing Diagnosis
• Composed of 3 parts:
• Problem statement- the client’s response to a problem
• Etiology- what’s causing/contributing to the client’s problem
• Defining Characteristics- what’s the evidence of the
problem

15. Nursing Diagnosis
• Problem( Diagnostic Label)-based on your assessment of
client…(gathered information), pick a problem from the
NANDA list...
• Etiology- determine what the problem is caused by or
related to (R/T)...
• Defining characteristics- then state as evidenced by (AEB)
the specific facts the problem is based on...

16. Example of Nursing Dx
• Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack
of knowledge
AEB B/P= 160/90, dietary sodium restrictions not
being observed, and client statements of “ I don’t
watch my salt” “It’s hard to do and I just don’t get
it”.

17. Types of Nursing Diagnoses
• Actual
Imbalanced nutrition; less than body requirements
RT chronic diarrhea, nausea, and pain AEB height
5’5” weight 105 lbs.
• Risk
Risk for falls RT altered gait and generalized
weakness
• Wellness
Family coping: potential for growth RT unexpected
birth of twins.

18. Collaborative Problems
• Require both nursing interventions and medical interventions
EXAMPLE: Client admitted with medical dx of pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy

19. Planning
Third step of the Nursing Process
• This is when the nurse organizes a nursing care plan based on the
nursing diagnoses.
• Nurse and client formulate goals to help the client with their
problems
• Expected outcomes are identified
• Interventions (nursing orders) are selected to aid the client reach
these goals.

20. Planning – Begin by prioritizing client
problems
• Prioritize list of client’s nursing
diagnoses using Maslow
• Rank as high, intermediate or
low
• Client specific
• Priorities can change

21. Planning
Developing a goal and outcome statement
• Goal and outcome
statements are client
focused.
• Worded positively
• Measurable, specific
observable, time-limited,
and realistic
• Goal = broad statement
• Expected outcome =
objective criterion for
measurement of goal
• Utilize NOC as standard
EXAMPLE
• Goal:
Client will achieve therapeutic
management of disease
process….
• Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of understanding
importance of dietary sodium
restrictions by day of
discharge.

22. Planning- Types of goals
• Short term goals
• Long term goals
• Cognitive goals
• Psychomotor goals
• Affective goals

23. Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)

24. PLANNING-SELECT INTERVENTIONS
• Interventions are selected and written.
• The nurse uses clinical judgment and professional knowledge
to select appropriate interventions that will aid the client in
reaching their goal.
• Interventions should be examined for feasibility and
acceptability to the client
• Interventions should be written clearly and specifically.

25. INTERVENTIONS – 3 types
• Independent ( Nurse initiated )- any action the nurse can
initiate without direct supervision
• Dependent ( Physician initiated )-nursing actions requiring
MD orders
• Collaborative- nursing actions performed jointly with other
health care team members

26. IMPLEMENTATION
• The fourth step in the Nursing Process
• This is the “Doing” step
• Carrying out nursing interventions (orders) selected during
the planning step
• This includes monitoring, teaching, further assessing,
reviewing NCP, incorporating physicians orders and
monitoring cost effectiveness of interventions
• Utilize NIC as standard

27. Implementing- “Doing”
• Monitor VS q4h
• Maintain prescribed diet (2
Gm Na)
• Teach client amount of
sodium restriction, foods
high in sodium, use of
nutrition labels, food
preparation and sodium
substitutes
• Teach potential
complications of
hypertension to instill
importance of
maintaining Na
restrictions
• Assess for cultural
factors affecting dietary
regime

28. Implementing – “Doing”
• Teach the client-
hypertension can’t
be cured but it can
be controlled.
• Remind the client to
continue medication
even though no S/S
are present.
• Teach client importance
of life style changes:
(weight reduction,
smoking cessation,
increasing activity)
• Stress the importance of
ongoing follow-up care
even though the patient
feels well.

29. EVALUATION- To determine
effectiveness of NCP
• Final step of the Nursing Process but
also done concurrently throughout client care
• A comparison of client behavior and/or response to
the established outcome criteria
• Continuous review of the nursing care plan
• Examines if nursing interventions are working
• Determines changes needed to help client reach
stated goals.

30. EVALUATION
• Outcome criteria met? Problem resolved!
• Outcome criteria not fully met? Continue plan of
care- ongoing.
• Outcome criteria unobtainable- review each previous
step of NCP and determine if modification of the
NCP is needed.
• Were the nsg interventions appropriate/effective?

31. EVALUATION
Factors that impede goal attainment:
• Incomplete database
• Unrealistic client outcomes
• Nonspecific nsg interventions
• Inadequate time for clients to achieve outcomes.

34. THANK YOU