Nursing Process

NURSING PROCESS

• systematic, rational method of planning and providing

individualized nursing care
• Is a problem-solving framework for planning and delivering
nursing care to patients and their families
NURSING PROCESS
NURSING PROCESS
• A way of thinking as a nurse.
• A framework of interrelated activities resulting in competent
nursing care.
• Dynamic and cyclical in nature.
• A scientific, problem-oriented approach to patient care.
Assessing –
collecting, organizing and communicating / recording
client data
Purpose: to establish data base about
the client’s response to health concerns
or illness and the ability to manage
health care needs
Assessment
Activities:
• Obtain health hx
• Review records, e.g. lab records, other health care records
• Interview support persons
• Validate assessment data
Nursing Process
Assessment

Assessment (Data Collection)

= Observation + Interview +
Examination
Observation
Interview
Examination
Data Collection – process of gathering
information about the client’s health status
TYPES OF DATA :
• Subjective – symptoms or covert data
e.g. – itching pain, feelings of worry
• includes client’s sensations, feelings, values,
beliefs, attitudes and perception of
personal health status and life situations.
Types of Data
•Objective data –signs or overt
data; detectable by an observer
or can be tested against an
accepted standard
•e.g. – discoloration of the skin
• Problem: fever-objective cue :
skin is warm to touch; temp. is
38.9 C/ax
 Objective data
Caput medusae BP reading
 SOURCES OF DATA:

•Primary source -
client (best source of
data)
SOURCES OF DATA:
•Secondary sources –
indirect sources
e.g. – family members,
-support people,
-client records (medical
records, records of
therapies by other health
professionals and
laboratory records),
-health care
professionals,
- literature
METHODS OF DATA COLLECTION:
•Observing  using
the five senses; a
conscious deliberate
skill that is
developed only
through effort and
with an organized
approach
METHODS OF DATA COLLECTION
•Interview  a
planned
communication
or conversation
with a purpose
 Kinds of interview questions:
•Closed questions  • Open-ended
restrictive and questions  lead
generally require or invite clients to
only short answers explore their
giving specific thoughts or
information; often feelings
begin with when,
where, who, what,
do, does, did
NURSING DIAGNOSIS :
• statement of the client’s health status
• clinical judgment about individual, family or
community responses to actual and potential
health problems / life processes.
Purpose: Provides the basis for selections of nursing
interventions to achieve outcomes for w/c the
nurse is accountable
NURSING DIAGNOSIS :

Eg.
• Problem : Fever 
nursing diagnosis :
Alteration in
thermoregulatory
function: or
hyperthermia related to
inflammatory process
TYPES OF NURSING DIAGNOSES:

• Actual Nursing Diagnosis  a judgment about

the client’s response to a health problem is
present at the time of nursing assessment
• Potential Nursing Diagnosis  a judgment that
a client is more vulnerable to develop the
problem in the same / similar situation
• Problem Statement  describes the
client’s health problem or response for
which nursing therapy is given
• Qualifiers  added words to give additional
meaning to the diagnostic statement
• Altered  change from baseline
• Impaired  made worse, weakened,
damaged
• Decreased  smaller in size, amount or
degree
• Ineffective  not producing the desired
effect
• Acute  severe or of short duration
• Chronic  lasting a long time
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1.Using medical diagnosis

–INCORRECT: Self-care deficit related to
stroke
–CORRECT: Self-care deficit related to
neuromuscular impairment
2.Relating the problem to an unchangeable
situation
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES
3. Confusing the etiology or
signs/symptoms for the problem
–INCORRECT: Post-operative lung
congestion related to bed rest
–CORRECT: Ineffective airway
clearance related to general
weakness and immobility
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

4. Use of a procedure instead of a human

response
–INCORRECT: Catheterization related to
urinary retention
–CORRECT: Urinary retention related to
perineal swelling
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES
5. Lack of specificity
• INCORRECT: Constipation related
to nutritional intake
• CORRECT: Constipation related to
inadequate dietary bulk and fluid
intake
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

6. Combining two nursing diagnosis

• INCORRECT: Anxiety and fear related to
separation from parents
• CORRECT: Anxiety related to change in
environment and unmet needs
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

7. Relating one nursing diagnosis to another

• INCORRECT: Coping, individual
ineffective related to anxiety
• CORRECT: Anxiety, severe related to
change in role functioning and socio-
economic status
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

• Use of judgmental/value-laden language

• Ineffective airway clearance related to bad habit
COMMON ERRORS IN FORMULATING NURSING DIAGNOSES
9. Making assumptions
• INCORRECT: Risk for altered
parenting related to inexperience
• CORRECT: Deficient knowledge
regarding child care issues
related to lack of previous
experience, unfamiliarity with
resources
1.Health – perception – health – management – pattern: Nsg. Dx

• Ineffective health maintenance

• Ineffective therapeutic regimen management
• Ineffective family therapeutic regimen management
• Ineffective community therapeutic regimen
management
1.Health – perception – health – management – pattern:
Nsg. Dx

• Risk for infection

• Risk for injury (trauma)
• Risk for falls
2.Nutritional – metabolic pattern:
Nsg. Dx
• Imbalanced nutrition: more than body requirements
• Risk for imbalanced nutrition: more than body requirements
• Imbalanced nutrition: less than body requirements
TYPOLOGY OF 11 FUNCTIONAL
HEALTH PATTERNS:
3.Elimination – pattern:
• describes pattern of excretory function ( bowel, bladder
and skin)
• Are the person's excretory functions within the normal
range?
• Does the person have any disease of the digestive system,
urinary system or skin?
3.Elimination – pattern:
Nsg. Dx
• Constipation
• Diarrhea
• Risk for constipation
• Bowel incontinence
• Impaired urinary elimination
• Functional urinary incontinence
4. Activity – exercise pattern :
Nsg. Dx
• Activity intolerance
• Risk for activity intolerance
• Fatigue
• Deficient diversonal activity
• Impaired physical mobility
6.Sleep – rest pattern:
Nsg. Dx
• Disturbed sleep pattern
7.Self – perception – self – concept – pattern:
Nsg. Dx
• Fear • Situational low self-esteem
• Anxiety • Risk for situational low self-
• Risk for loneliness esteem
• Hopelessness • Chronic low self-esteem
• Powerlessness • Body image disturbed
• Risk for powerlessness • Disturbed personal identity
• Risk for violence, self-directed
9.Sexuality – reproductive pattern:
Nsg. Dx
• Sexual dysfunction
• Rape-trauma syndrome
10.Coping – stress – tolerance – pattern:
Nsg. Dx.
• Ineffective coping
• Disabled family coping
• Ineffective community coping
• Post-trauma syndrome
• Risk for post-trauma syndrome
• Risk for suicide
10.Writing a Legally Inadvisable Statement
• INCORRECT: Skin integrity related to not being
turned every 2 hours
• CORRECT: Impaired skin integrity related to
pressure and altered circulation
A Nursing Diagnosis
• Is • Is Not
• A medical diagnosis
–A statement of a
• A nursing action
patient problem • A physician order
–Actual or potential • A therapeutic
–Within the scope of treatment
nursing practice
–Directive of nursing
intervention
Medical Dx vs.Nursing Diagnosis
• Myocardial infarction
• Chronic ulcerative colitis
• Chronic ulcerative colitis
• Cancer of the breast
• Cerebral vascular accident
• Fear r/t possible recurrence of
uncertain outcome
• Diarrhea r/t dis. process
• Alteration in nutrition: less than
body requirements r/t altered GI
absorptions
• Risk for(Potential) body image
disturbance if mastectomy is
required
• Self-care deficit: dressing &
grooming r/t right sided
flaccidity
Etiology (Related/ Risk Factors)  the probable
cause of the health problem; may include
client’s behavior, environmental factors or the
interaction of the two;
NANDA-“ related to” to describe the etiology or
likely cause
Example:
• Activity intolerance related to decreased cardiac
output.
• Ineffective breast-feeding related to first-time
experience
• Altered bowel elimination; constipation related
to insufficient fluid intake.
• Medical Diagnosis  made by a
physician refers to a pathophysiologic
responses that are fairly uniform from
one client to another.

• Nursing Diagnosis  describes the

clients’ physical, sociocultural,
psychologic and spiritual responses to
an illness or potential health problems;
vary among individuals.
Nursing diagnosis
Actual nursing diagnoses
PES approach
= Problem + Etiology + S/S
• Impaired verbal communication r/t cultural
differences as manifested by inability to
speak English
 PLANNING
• involves decision making and problem solving
Planning process includes:
A.Setting priorities  establishing a preferential order for
nursing strategies ; the nurse must consider a variety of
factors :
1.Client’s health values and beliefs  a client may
believe that being home with children is more urgent
than a health problem.
2.Client’s priorities  involving the client enhances
cooperation between nurse and client
3.Urgency of health problems  ABC’s of life (airway,
breathing, circulation)
4.Medical treatment plan  must be congruent with
treatment of other health care professionals
 PLANNING
should be S-M-A-R-T (specific, measurable, attainable,
realistic and time-bound)
• Example:
• Problem : Fever  subjective cues : “Mainiting
normal tempreture”
• objective cues : skin is warm to touch; temp. is 38.9 C
•  nursing diagnosis : Alteration in
thermoregulatory function: hyperthermia related to
inflammatory process
 plan : After 4 hours of continuous nursing intervention,
patient’s temperature will decrease from 38.9 C to
37.5C/ ax.
 PLANNING

Planning
= setting priorities + establishing goals + planning
interventions
Components of a goal statement
• PATIENT BEHAVIOR
- an observable activity that the patient will
demonstrate
• (the patient) will void
• Decrease in ( the patient’s) BP
• (the patient) will ambulate
• (the patient) will report
• (the patient) will drink
Components of a goal statement
• TIME FRAME
- a designated time or date when the
patient should be able to achieve the
behavior
–Within the next hour
–By discharge
–At the end of this shift
–By Dec. 25
–In 2 months
Components of a goal statement
• CONDITIONS
- specific aides which will facilitate the patient
performing a behavior at the level in the criteria and
within the specified time frame
• With the help of a walker
• With the use of a wheelchair
• With the help of the family
• With the use of medication
• Using oral analgesics q3-4 hrs
• Using IM Demerol q3-4 hrs
IMPLEMENTATION / INTERVENTION
•  implement the
interventions identified
in the plan of care.
• Cognitive/Intellectual
Skills  include problem
solving, decision making,
critical thinking and
creative thinking
 The process of implementing:
1.Reassessing the client  reassess whether
the intervention is still needed
Note:
even though an order is written on the care
plan, the situation or the client’s condition
may have changed.
The process of implementing:
2.Determining the need for nursing
assistance  the nurse maybe unable
to implement the nursing strategies
safely alone
The process of implementing:
3.Implementing nursing strategies  nursing
activities include caring, communicating, helping,
teaching, counseling, acting as a client advocate
and change agent, leading and managing.
The process of implementing
4.Communicating nursing actions  recording the
interventions along with the client responses in the
nursing progress notes.
• Problem : Fever  subjective cues : “I am feeling hot.”
• objective cues : skin is warm to touch; temp. is 38.9
C
 nursing diagnosis : Alteration in thermoregulatory function:
hyperthermia related to inflammatory process
 plan : After 4 hours of continuous nursing intervention, patient’s
temperature will decrease from 38.9 C to 37.5C.
Intervention
• continuous tepid sponge bath rendered
• tight and thick clothing loosened
• fluid intake increased
• room kept well ventilated
• antipyretics as indicated/ordered administered
 EVALUATION
• The evaluation process has 6 components:
• Identifying the expected outcomes that the nurse will
use to measure client goal achievement
• Collecting data related to the expected outcomes
• Comparing the data with the expected outcomes and
judging whether the goals have been achieved
• Relating nursing actions to client outcomes
• Drawing conclusions about problem status
• Reviewing and modifying the client’s care plan
• determine client’s progress toward goal achievement
and the effectiveness of NCP