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^ An organized sequence of problem-solving

steps used to identify and to manage the health
problems of clients.
^ Steps of the Nursing Process
1. Assessing.
2. Diagnosing.
3. Planning.
4. Implementing.
5. Evaluating.

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^ Assessment: Collecting data to determine the

needs and health problems of patient.

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Dypes of Data:
1. Subjective data (symptoms)
Are information perceived such as (feeling
nervous, nauseated, chilly or experiencing pain)

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2. Objective data (signs)

Are observable and measurable data that can
be seen, heard and felt, and its observed by
one person can be verified by another person
observing the same patients. Such as (increase
temperature, lab. results, moist skin, refusal to
look at or eat food)

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^ Primary source: Client.

^ Secondary source: Client¶s family, reports,
test results, information in current and past
medical records, and discussions with other
health care workers ( physicians , social
workers , dietitians , physiotherapists and
laboratory technicians )

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1. Observation.
Is the conscious and deliberate use of the five
senses to gather data (sighting, smelling and
hearing)
2. Interview.
Is the planned communication, during the
assessment step of the nursing process to
obtain and establish a successful working
partnership with the patient , then to obtain
the necessary patient data .

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3. Dechniques of Physical Assessment.

Is the examination of the patient for objective
data that may better define the patients
condition and help the nurse in planning care,
include:
inspection , palpation , percussion , and
auscultation .

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1. Inappropriate organization of the database.

2. Omission of pertinent data.
3. Inclusion of irrelevant or duplicate data.
4. Misinterpreted data.
5. Failure to establish rapport and partnership.

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^ Mealth issue that can be prevented, reduced,

resolved, or enhanced through independent
nursing measures.

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1. Actual.
2. Risk.
3. Possible.
4. Syndrome.
5. Wellness.

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^ Name of the health-related issue or problem as

identified in the NANDA (North American
Nursing Diagnosis Association) list.
^ Etiology (its cause)
^ Signs and Symptoms.
^ Dhe name of the nursing diagnosis is linked to
the etiology with the phrase ³related to,´ and
the signs and symptoms are identified with the
phrase ³as manifested (or evidenced) by´.

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^ Do identify:
1. Actual and potential problems.
2. Factor that contribute the problems
(etiologies)
3. Strengths the patients can drawn to prevent or
resolve the problems.

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^ Parts of Nursing Dxs.
1. Problem.
Dhe purpose of the problem statement is to
describe the health state or health problem of
the patient as possible.
Identifies what is unhealthy about the patient,
indicating the need for change
2. Etiology.
Identifies the factors that are maintaining the
unhealthy state or response (causative factor )
3. Defining characteristics.
Dhe subjective and objective data that signal
the existence of the problem identify.
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^ Example 1 :
Mygiene self-care deficit ( problem )
related to
fear of falling in the obesity (etiology )
as manifested by
strong body and urine odder (characteristics )

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^ Example 2 :
Chest pain ( problem )
related to
decrease coronary blood flow (etiology)
as manifested by
facial expression (characteristics )

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^ Example 3 :
Ineffective individual coping (problem)
related to
loss of job ( etiology )
as manifested by
increase daily use of alcohol (characteristics )

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^ Dhe process of prioritizing nursing diagnoses and

collaborative problems, identifying measurable
goals or outcomes, selecting appropriate
interventions, and documenting the plan of care.
^ Dhe nurse works in partnership with the patient
and family.

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^ Establishing priorities.
^ Writing goals / outcomes that determine the
evaluative strategy .
^ Selecting appropriate nursing interventions.
^ Communicating the plan of nursing care.


  

 




^ Determine problems that require immediate

action.
^ Maslow¶s Mierarchy of Muman Needs
1. Physiologic needs.
2. Safety.
3. Love and belonging needs.
4. Self-esteem needs.
5. Self- actualization needs.

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^ Short-Derm Goals
Outcomes achievable in a few days or 1 week.
^ Long-Derm Goals
Desirable outcomes that take weeks or months
to accomplish for client¶s with chronic health
problems.


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^ One of the most important consideration in
goal/outcome writing is to encourage the patient
and family to be as involved in goal
development as their abilities and interest
permit .
^ Each patient goal/outcome must have
1- a subject : which is the patient.
2- a verb : which indicates the action.

Dhe patient will perform , and criteria which

describe in observable such as ( define , identify
, list , select , apply , explain , prepare «« etc

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1. Insufficient data collection.

2. Nursing Dxs developed from inaccurate data.
3. Goals /outcomes that are stated too broadly .
4. Goals/outcomes that are derived from poorly
developed nursing Dxs.

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^ Execute the plan of care (action phase)

^ Dhe nurse implements medical orders and
nursing orders.
^ Implementation involves the client and one or
more health care team.
^ Dhe information in the chart shows a correlation
between the plan and the care that has been
provided.
^ Nurses are accountable for carrying out nursing
orders and physician orders.

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1. Dependent nursing action.
Which involve carrying physician ± prescribed
orders.
2. Independent nursing action.
Carrying out nurse- prescribed interventions
written on the nursing plan of care as well as
any other actions that nurses initiate without
the direction of anther health care professional
and that result from their assessment of
patient needs .
3. Interdependent nursing action.
Which performed jointly by nurses and other
members of the health care team .
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^ Evaluate the effectiveness of the plan of care in

terms of patient goal achievements.
^ Dhe nurse and patient together measure how well
the patient has achieved the goals/outcomes
specified in the plan of care , and the purpose of
evaluation is to allow the patients achievement of
expected outcomes to direct future nurse patient
interactions , based on the patients responses to
the plan of care .

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1. Collecting evaluative data.

Dhe data collected to determine whither the
identified health problems have been resolved
through goal achievement.
2. Documenting evaluation.
After the data have been collected the nurse
writes an evaluative statement to summarize
the findings. And the nurse has three decision
options for how goals have been (met «..
Partially met «.. not met...)

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1. Numerous patient:( cognitive , cooperate .etc )

2. Nurse: excellent , frustrate , bored.
3. Mealth care system : inadequate staffing .
relationships«. etc

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^ Documenting care.
Is the written , legal record of all pertinent
interaction with the patient assessing ,
diagnosing , planning , implementing and
evaluation to facilitate patient care .
^ Patient record.
Is a compilation of patients health information

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1. Communication : between health care

professionals
2. Care planning : patient responding to treatment
from day to day .
3. Education : for the manifestations and
treatment
4. Decision analysis.
5. Research .
6. Legal documentation.

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1. Source ± oriented records : one in which each

health care group keeps data on its own
separate form .
2. Problem- oriented medical records:
POMR is organized around a patients problems
rather than a round sources of information .
3. Charting by exception:
Is a shorthand documentation method that
makes use of well-defined standards of practice
4. Computerized records.

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G Face to face meeting.

G Delephone conversation.
G Written message.
G Computer message .

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^ Its procedures in which a group of nurses

visit selected patients individually at each
patient¶s bed side to:
1. Evaluate the nursing care for the patient has
received.
2. Gather information to help plan nursing care.

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DME END

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