Fund Nursing

COLLEGE OF HEALTH AND MEDICAL
SCIENCE
DEPATMENT OF NURSING
MODULE NAME : FOUNDATION OF NURSING
COURSE TITTLE: FUNDAMENTAL OF
NURSING
prepared by : Dhaba W. 1
Objectives
At the end of this lesson the student will be able to:
Define historical development of nursing process
Define characteristics of nursing process
Differentiate and explain different approaches of nursing
assessment
List and differentiate component of nursing process .
Develops nursing care plan
Definition and historical development
nursing process
Nursing process: is the framework for providing
professional, quality nursing care.
It directs nursing activities for health promotion,
health protection, and disease prevention and is used
by nurses in every practice setting and specialty.
Lydia Hall first referred to nursing as a “process” in a
1955 journal article, yet the term was not widely used
until the late 1960s (Edelman & Mandle, 1997).
Cont…………….
Referring to the “nursing process” as a series of steps,
Johnson (1959), Orlando (1961), and Wiedenbach (1963)
further developed this description of nursing.
At this time, the nursing process involved only three
steps:
Assessment,
Planning, And
Evaluation
In their 1967 book The Nursing Process, Yura and Walsh
identified four steps in the nursing process:
 Assessing
Planning
 Implementing
Evaluating
The Standards of Practice, first published in 1973 by the
American Nurses Association (ANA), included eight
standards.
These standards identified each of the steps, including
nursing diagnosis, that are now included in the nursing
process.
.
Fry (1953) first used the term nursing diagnosis, but it was
not until 1974, after the first meeting of the group now
called the North American Nursing Diagnosis Association
(NANDA), that Gebbie and Lavin added nursing diagnosis
as a separate and distinct step in the nursing process
Prior to this, nursing diagnosis had been included as a
natural conclusion to the first step, assessment.
The ANA made revisions to the standards in 1991 to include
outcome identification as a specific part of the planning
phase.
Currently, the steps in the nursing process are:
1. Assessment
2. Diagnosis
3. Outcome identification and planning
4. Implementation
5. Evaluation
The purpose of the nursing process is to provide care for
clients that is individualized, holistic, effective, and efficient.
The steps of the nursing process build upon each other, but
they are not linear.
There is overlap of each step with the previous and subsequent
steps .
The nursing process is dynamic and requires creativity for its
application.
The steps remain the same, but the application and results
will be different in each client situation.
The nursing process is designed to be used with clients
throughout the life span and in any setting in which a nurse
provides care for clients
Components of Nursing process

Benefits of the Nursing Process
 Speed up diagnosis and treatment of actual and potential
health problems, reducing the incidence of hospital stays
 Has precise documentation that improve communication,
to prevent errors, omissions, and unnecessary repetitions;
 Promotes flexibility and independent thinking;
 Tailors interventions for the individual (not just the
disease);
 Helps nurses to gain satisfaction of getting results.
Comparison of Nursing Process and Medical Process
Assessment
Assessment: is the first step in the nursing process and
includes :
 Collection,
 Verification,
 Organization,
 Interpretation, And
 Documentation Of Data.
The completeness and correctness of the information
obtained during assessment are directly related to the
accuracy of the steps that follow
Assessment involves several steps:
Collecting data from a variety of sources
Validating the data
Organizing data
Categorizing or identifying patterns in the data
Making initial inferences or impressions
Recording or reporting data
Type of assessment:
The information needed for assessment is usually determined by
health care setting and needs of the clients.
Three types of assessment includes:
1. Comprehensive assessment:
 Provide baseline of client data including a complete health
history and current needs assessment.
 Usually completed upon admission to health care agency.
 Changes in the clients health status can be measured against
this database.
 Includes of clients physical and psychological health,
perception of health, presence of health risk factors, and coping
patterns.
2. Focused assessment:
 Is limited to potential health care risks, a particular need,
or health care concern.
 There are not as a detailed as comprehensive assessment.
 Often used when short stays are anticipated (e.g.,
outpatient surgery and emergency departments).
Used in specialty areas such as mental health settings and
delivery.
Used in screening for specific problems or risk factors.
3. Ongoing assessment:
 Follow up , or monitoring of specific problems.
Broadens the database and allow the nurse to confirm the
validity of data obtained during the initial assessment.
 Systematic monitoring allows the nurse to determine the
clients response to nursing interventions and to identify
any other problems.
Primary Source Of Data:-are the data collected from a the
client (the major provider of information about self).
Secondary Sources Of Data:-Sources of data other than the
client are considered secondary sources and include family
members, other health care providers, and medical records.
Two types of information are collected through the
assessment component:
A. subjective data and
B. Objective data
Subjective data : are data from the client’s point of view
and include feelings, perceptions, and concerns.
The method of collecting subjective information is primarily
the interview.
Examples of subjective information include such statements
as:
“I drink only coffee for breakfast.”
“I have had pains in my legs for three days now.”
“I go to sleep easily each night, but I wake up about two
hours later and cannot go back to sleep until it is time to
get up in the morning
Objective data :- are observable and measurable data
that are obtained through both standard assessment
techniques performed during the physical examination
and diagnostic tests.
The primary method of collecting objective information
is the physical examination, which provides
information about the function of body system
Examples:
 T 98.6°F,
 PR 100,
 RR 12,
 B/P 130/76
 Bowel sounds auscultated in all four quadrants
 Gait slow, shuffling, and unsteady
NB: Assessment does not end with the initial interview and physical
examination.
Assessment is dynamic and continues with each nurse-client
interaction.
Identifying Cues and Making Inferences: Subjective and
Objective data that you have identified act as cues.
Cues are hints, or reminders, that prompt you to suspect a
problem.
Example: Subjective Data
Patient states, “I just started taking penicillin for a tooth abscess
Objective Data :-Fine rash over the trunk
The above data give you cues that may lead you to infer
(suspect) that the person is having an allergic reaction to
penicillin.
How you interpret or perceive a cue is called an inference.
In this case you have made an inference about the rash and
has interpreted as probably having a penicillin allergy.
Cues and correct inferences need :-
Observational Skills,
Nursing Knowledge And
Your Clinical Expertise.
Data should be organized through:
A. Data clustering (admission assessment format): is the
process to putting the data together in order to identify
areas of the client problems and strengths
B. Assessment model: is a framework providing a
systematic way to organize data such as:
1. Hierarchy of needs: proposes that an individual basic
needs (physiological) must be meet before higher level
can be meet.
2. Body system model: organizes data according to tissue
and organ function in the various body systems.
3. Functional health pattern:
cluster information about client habitual pattern and any
change to determine if the clients current response is
functional or dysfunctional.
4. Theory of self care:
based on the client ability to meet self care needs and
identifying existing self care deficits.
2. Diagnosis
It involves further analysis (breaking the whole down into
parts that can be examined) and synthesis (putting data
together in a new way) of the data that have been collected
According to the North American Nursing Diagnosis
Association (NANDA) a nursing diagnosis : is a clinical
judgment about individual, family, or community responses
to actual or potential health problems/life processes.
Client problems are labeled by both medical and
nursing diagnoses.
This process is facilitated by asking questions such as :
 Are there problems here?
 If so, what are the specific problems?
 What are some possible causes for the problems?
 Is there a situation involving risk factors?
 What are the risk factors?
 Is there a situation in which a problem can develop if
preventive measures are not taken?
 Has the client indicated a desire for a higher level of
wellness in a particular area of function?
 What are the client’s strengths?
 What data are available to answer these questions?
 Are more data needed to answer the question?
 If so, what are some possible sources of the data that are
needed?
Cont……………..
The NANDA nursing diagnosis taxonomy is composed of nine
patterns of human response:
1. Exchanging
2. Valuing
3. Perceiving
4. Communicating
5. Choosing
6. Knowing
7. Relating
8. Moving
9. Feeling
Types of Nursing Diagnoses
Analysis of the collected data leads the nurse to make a
diagnosis in one of the following categories:
1. Actual problems
2. Potential problems (including those where risk factors
exist and there are possible problems)
3. Wellness conditions
4. Collaborative problems
A. An actual nursing diagnosis
Indicates that a problem exists, and is composed of :
1. diagnostic label,
2. related factors, and
3. signs and symptoms
E.g. Impaired Skin Integrity related to prolonged pressure on
bony prominence as manifested by stage II pressure ulcer
over coccyx, 3 cm in diameter
B. A risk nursing diagnosis (potential problem)
indicates that a problem does not yet exist, but
special risk factors are present.
A risk diagnosis is composed of the diagnostic label
preceded by the phrase “risk for,” with the specific
risk factors listed.
Examples : Risk for Impaired Skin Integrity
related to inability to turn self from side to side in
bed.
C. A possible nursing diagnosis: indicates a situation in
which a problem could arise unless preventive action is
taken.
In addition, a possible diagnosis may state a “hunch” or
intuition by the nurse that cannot be confirmed or eliminated
until more data have been collected.
A possible diagnosis is composed of the diagnostic label and
related factors.
Examples:- Possible Self-Esteem Disturbance related to
recent retirement and relocation.
D. wellness nursing diagnosis: indicates the client’s
expression of a desire to attain a higher level of wellness in
some area of function.
It is composed of the diagnostic label preceded by the
phrase “potential for enhanced.
For example a client who is neither overweight nor
underweight tells the nurse that she knows she could
improve her diet in some ways.
She states that she eats only a small number of vegetables
and fruits and thinks that the fat content of her diet is
probably high.
She expresses a desire to know more about how to improve
her diet.
The nurse would make a wellness diagnosis of Potential
for : Enhanced Nutrition
E. Collaborative problems are : defined as physiologic
complications monitored by nurses to assess changes in client
status.
Collaborative problems are managed through the use of
interventions prescribed by other health care practitioners and/or
nurses .
Collaborative problems include those conditions in which the nurse
seeks medical input for treatment of potential medical problems.
Collaborative problems begin with the label Potential
Complication (PC) followed by the situation.
For example, Potential Complication : Hemorrhage.
Avoiding errors in diagnostic statements
Nursing diagnostic statements should not be written in terms
of:
 Cues (e.g., crying, hemoglobin level)
 Inferences (e.g., dyspnea)
 Goals (e.g., should perform own colostomy care)
 Client needs (e.g., needs to walk every shift; needs to
express fears)
 Nursing needs (e.g., change dressing, check blood
pressure)
Nurses should avoid legally inadvisable or judgmental
statements, such as
 Fear related to frequent beatings by husband
 Ineffective Family Coping related to mother-in-law’s
continual harassment of daughter-in-law
 Risk for Impaired Parenting related to low IQ of mother
A nursing diagnosis should not be related to a medical
diagnosis, such as
Disturbed Self-Concept related to multiple sclerosis or Anxiety
related to myocardial infarction.
If the use of a medical diagnosis adds clarity to the diagnosis,
the nurse can link it to the statement with the phrase secondary
to
E.g. Disturbed Self-Concept related to recent losses of role
responsibilities secondary to multiple sclerosis, as evidenced by,
“My mother comes every day to run my house,” or “I can no
longer be the woman in charge of my house.”).
3. Outcome Identification and Planning
Planning : includes the formulation of guidelines that establish
the proposed course of nursing action in the resolution of nursing
diagnoses and the development of the client’s plan of care
The planning phase involves several tasks:
 The list of nursing diagnoses is prioritized.
 Client-centered long- and short-term goals and outcomes are
identified and written.
 Specific interventions are developed.
 The entire plan of care is recorded in the client’s record.
Cont……………..
The four critical elements of planning include:
1. Establishing priorities
2. Setting goals and developing expected outcomes
(outcome identification)
3. Planning nursing interventions (with
collaboration and consultation as needed)
4. Documenting
Cont……………..
The planning of nursing care occurs in three phases:
1. Initial,
2. Ongoing, And
3. Discharge.
Each type of planning contributes to the coordination of
the client’s comprehensive plan of care
OUTCOME IDENTIFICATION AND PLANNING AS A
STANDARD COMPONENT OF CARE
ANA STANDARDS
Standard III.
Outcome Identification
The nurse identifies expected outcomes individualized to the
client.
Guidelines Outcomes should be:
 Based on diagnoses
 Documented in measurable terms
 Developed with the client and health care providers
 Realistic and achievable
Cont……………..
Standard IV.
Planning :-The nurse develops a plan of care that prescribes
interventions to attain expected outcomes.
Guidelines Planning should:
 Be individualized to the client’s needs and status
 Be developed with the client, significant others, and
health care providers
 Be documented
 Promote continuity of care
Establishing Priorities
In establishing priorities, the nurse examines the client’s
nursing diagnoses and ranks them in order of
physiological or psychological importance.
This method organizes a client’s nursing diagnoses into
an operational format for the planning of nursing care
Cont……………..
When an individual client has more than one diagnosis, the
nurse and client need to establish priorities to identify which
nursing diagnosis will be addressed initially in the plan of
care .
One of the most common methods of selecting priorities is
the consideration of Maslow’s hierarchy of needs, which
requires that a life-threatening diagnosis be given more
urgency than a non–life threatening diagnosis.
Cont……………..
Once the basic physiological needs (e.g., respiration,
nutrition, hydration, elimination) are met to some
degree, the nurse may consider needs on the next level
of the hierarchy (e.g., safe environment, stable living
condition) and so on up the hierarchy until all the
client’s nursing diagnoses have been prioritized.
Fundamental Principles of Setting Priorities
(Maslow, 1943, Smeltzer 2003 and Cherry, 2011)
Priority 1 - Life threatening problems and those interfering
with physiological needs.
Priority 2 - Problems interfering with safety and security..

Priority 3 - Problems interfering with love and belonging..
Priority 4 - Problems interfering with self esteem. activities.
Priority 5 - Problems interfering with the ability to achieve

personal goals.
Cont……………..
Cont……………..
Nursing diagnoses of low and moderate priorities often
involve the prevention of anticipated potential or risk
diagnoses.
After assessing the client, formulating nursing diagnoses, and
establishing priorities, the nurse sets goals and identifies and
establishes expected outcomes for each nursing diagnosis.
The purposes of setting goals and expected outcomes are to
provide guidelines for individualized nursing interventions
and to establish evaluation criteria to measure the
effectiveness of the nursing care plan.
Cont……………..
A goal is an aim, an intent, or an end.
A goal is a broad or globally written statement describing
the intended or desired change in the client’s behavior,
response, or outcome.
An expected outcome is a detailed, specific statement that
describes the methods through which the goal will be
achieved.
It includes aspects such as direct nursing care and client
teaching.
Cont……………..
Goals should be established to meet the immediate, as well
as long-term prevention and rehabilitation, needs of the
client.
The essential component is the criteria of a goal.
 A time limit
 Amount of activity
 Important characteristics of accurate performance
 Description of the performance to be followed
Writing Goals and Expected Outcomes
Characteristics of Goal and Expected outcome:
The SMART acronym
Specific
Measurable
Attainable
Realistic
Timed
Types of Interventions
There are three categories of nursing interventions:
1. Nurse-initiated,
2. Health Care Provider-initiated, And
3. Collaborative Interventions
Nurse-initiated interventions: are the independent
nursing interventions or actions that a nurse initiates
without supervision or direction from others.
Cont……………..
Health care provider–initiated : interventions are
dependent nursing interventions, or actions that require an
order from a health care provider
Collaborative interventions, or interdependent
interventions: are therapies that require the combined
knowledge, skill, and expertise of multiple health care
providers.
4. Implementation
It involves completion of nursing activities to accomplish
predetermined goals and to make progress toward
achievement of specific outcomes.
Nursing implementation activities include:
 Ongoing assessment
 Establishment of priorities
 Allocation of resources
 Initiation of nursing interventions
 Documentation of interventions and client response
5. EVALUATION
Evaluation : is the measurement of the degree to which
objectives are achieved.
Therefore, evaluating the care provided to clients is an
essential part of professional nursing.
Evaluation is a planned, systematic process that compares
the client’s health status with the desired expected outcomes.
Cont……………..
Evaluation must:
 Be performed as a systemic process
 Occur on an ongoing basis
 Lead to revision of the plan of care when needed
 Involve the client, significant others, and other members
of the health care team
 Be documented
TYPES OF EVALUATION
Evaluation can be classified according to what is being
evaluated: the structure, the process, or the outcome.
Structure evaluation: is a determination of the health
care agency’s ability to provide the services offered to
its client population.
This type of evaluation focuses on assessing the systems
by which nursing care is delivered
Cont……………..
Structure evaluation examines the physical facilities,
resources, equipment, staffing patterns, organizational
patterns, and the agency’s qualifications for staff.
Process evaluation: is the measurement of nursing actions
by examination of each phase of the nursing process.
This type of evaluation is done to determine whether
nursing care was adequate, appropriate, effective, and
efficient.
Nursing interventions are judged to be effective when use
of the action results in the desired outcome.
Cont……………..
Outcome evaluation : is the process of comparing the client’s
current status with the expected outcomes.
This type of evaluation examines all direct care activities that
affect the client’s health status.
Outcome evaluation focuses on changes in the client’s health
status.
A basic question to ask when evaluating the outcome is:
Has the expected change occurred?
Such changes may include “modifications of symptoms; signs;
knowledge; attitudes; satisfaction; skill; and compliance with
treatment regimen
Cont……………..
The purposes of evaluation include:
 To determine the client’s progress or lack of progress
toward achievement of expected outcomes
 To determine the effectiveness of nursing care in helping
clients achieve the expected outcomes
 To determine the overall quality of care provided
 To promote nursing accountability
Cont……………..
Evaluation is not an end to the nursing process, but rather an
ongoing mechanism that assures quality interventions.
Effective evaluation is done periodically, not just prior to
termination of care
Cont……………..
Prior to implementation, it is necessary to determine exactly:
 What is to be done
 How it is to be done
 When it should be done
 Who will do it
 How long it should be done
Nursing Audit
A nursing audit is the process of collecting and analyzing
data to evaluate the effectiveness of nursing interventions.
A nursing audit can focus on implementation of the nursing
process, client outcomes, or both in order to evaluate the
quality of care provided.
Cont……………..
Nursing audits examine data related to:
 Safety measures
 Treatment interventions and client responses to the
interventions
 Pre-established outcomes used as basis for interventions
 Discharge planning
 Client teaching
 Adequacy of staffing patterns
Gordon’s model of 11 functional health patterns
Gordon’s system of functional health patterns provides an
excellent, relevant format for nursing data collection to
determine an individual’s or group’s health status and
functioning (1994).
A comprehensive assessment moves from the general to the
specific.
You begin to see patterns of behavior and physiological
responses that relate to a functional health category
Ultimately your assessment identifies functional (patient
strengths) and dysfunctional (nursing diagnoses) patterns
that help you develop the nursing care plan
11 Functional Health Patterns
1. Health perception–health management pattern:
Describes patient’s self-report of health and well-being,
how patient manages health knowledge of preventive
health practices .
It include
 Perceived pattern of health, well-being
 Knowledge of lifestyle and relationship to health
 Knowledge of preventive health practices
 Adherence to medical, nursing prescriptions
Examples of Nursing diagnosis
 Risk for Individual Contamination
 Risk for Delayed Failure to Thrive,
 Risk for Disproportionate
 Ineffective Immunization Status,
 Readiness for Enhanced Injury,
 Risk for Aspiration,
 Risk for Falls,
 Risk for Perioperative Positioning Injury,
 Risk for Poisoning,
 Risk for Suffocation
Cont…………..
2. Nutritional-metabolic pattern:
Describes patient’s daily/weekly pattern of food and fluid
intake (e.g., food preferences or restrictions, special diet,
appetite), actual weight, weight loss or gain.
 Usual pattern of food and fluid intake
 Types of food and fluid intake
Actual weight, weight loss or gain
 Appetite, preferences
Ineffective Breastfeeding,
Readiness for Enhanced Breast Milk,
 Risk for Fluid Balance,
Readiness for Enhanced Fluid Volume,
Deficient Fluid Volume,
Excess Fluid Volume
Cont…………..
3. Elimination pattern:
Describes patterns of excretory function (bowel, bladder,
and skin)
Bowel elimination pattern, changes
 Bladder elimination pattern, changes
 Control problems
Use of assistive devices
 Use of medications
Dysfunctional Gastrointestinal Motility,
Risk for Dysfunctional
Impaired Continuous Urinary Incontinence
Stress Urinary Incontinence
Urge Urinary Incontinence
Bowel Incontinence
Constipation
Diarrhea
Cont……………..
4. Activity-exercise pattern:
Describes patterns of exercise, activity, leisure, and
recreation; ability to perform activities of daily living
 Pattern of exercise, activity, leisure, recreation
 Ability to perform activities of daily living (self-care,
home maintenance, work, eating, shopping, cooking
 Activity Intolerance
 Activity Planning,
 Ineffective Activity Planning,
 Risk for Ineffective Bleeding,
 Decreased Disuse Syndrome,
 Deficient Home Maintenance,
 Impaired Infant Behavior,
 Risk for Disorganized Infant Behavior,
 Readiness for Enhanced Organized Intracranial
 Risk for Impaired Mobility,
 Impaired Physical
Cont…………..
5. Sleep-rest pattern:
Describes:-
 Patterns of sleep, rest
 Perception of quality, quantity
 patterns relaxation
 Readiness for Enhanced Sleep Pattern,
 Disturbed Insomnia
 Sleep Deprivation
Cont…………..
6. Cognitive-perceptual pattern:
Describes sensory-perceptual patterns:-
• learning,
• taste,
• touch,
• smell
• Language adequacy
• memory,
• decision-making ability
 Acute Pain,
 Chronic Comfort
 Readiness for Enhanced Confusion,
 Acute Confusion,
 Chronic Decisional Conflict
 Readiness for Enhanced
 Risk for Autonomic
 Environmental Interpretation Syndrome,
 Impaired Knowledge
Cont…………..
7. Self-perception–self-concept pattern:
Describes patient’s self-concept pattern and perceptions of
self
 Attitudes about self, sense of worth
 Perception of abilities
 Emotional patterns
 Body image, identity
Anxiety
Disturbed Body Image,
Disturbed Personal Identity,
Risk for Disturbed Self-Esteem,
Chronic Low Self-Esteem,
Risk for Chronic Low Self-Esteem,
Disturbed Self-Esteem,
Situational Low Self-Esteem,
Risk for Situational Low Self-Concept,
Cont……………..
8. Role-relationship pattern:
Describes patient’s patterns of role engagements and
relationships
 Patterns of relationships
 Role responsibilities
 Satisfaction with relationships and responsibilities
 Ineffective Childbearing Process
 Impaired Communication,
 Impaired Verbal Communication
 Enhanced Family Processes,
 Interrupted Family Processes
 Readiness for Enhanced Grieving
 Conflict Parenting,
 Impaired Parent–Infant Attachment,
Cont…………..
9. Sexuality-reproductive pattern:
Describes patient’s patterns of satisfaction and
dissatisfaction with sexuality pattern, patient’s reproductive
patterns, premenopausal and postmenopausal problems
 Menstrual, reproductive history
 Satisfaction with sexual relationships, sexual identity
 Premenopausal or postmenopausal problems
 Accuracy of sex education
Childbearing Process,
Readiness for Enhanced Maternal/Fetal Dyad,
Risk for Disturbed Sexuality Pattern,
Ineffective Sexual
Dysfunction
Cont…………..
10. Coping–stress tolerance pattern:
Describes patient’s ability to :-
 previous coping responses
 effectiveness of coping patterns in terms of stress
tolerance
 Ability to manage stress
 Knowledge of stress tolerance
 Sources of support
 Number of stressful life events in last year
Compromised Family Coping,
Disabled Family Coping,
Ineffective Coping,
Defensive Coping,
Readiness for Enhanced Denial,
Ineffective Impulse Control
Risk for Suicide,
Risk for Stress,
Risk for Self-Directed Violence,
Cont…………..
11. Value-belief pattern:
Describes patterns of values, beliefs (including spiritual
practices), and goals that guide patient’s choices or decisions
 Values, goals, beliefs
 Spiritual practices
 Perceived conflicts in values
Moral Distress
Risk for Religiosity,
Readiness for Enhanced
Spiritual Distress
Impaired Religiosity,
Risk for Impaired Spiritual Distress,
Risk for Spiritual Well-Being,
THANK YOU FOR YOUR ATTENTION
THE END

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COLLEGE OF HEALTH AND MEDICAL

Components of Nursing process

Priority 2 - Problems interfering with safety and security..

Priority 5 - Problems interfering with the ability to achieve

prepared by : Dhaba W. 103

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