Nursing Process

Shaheen Ghani RN, RM, MPH

OBJECTIVES
Define nursing process
Steps of nursing process
Explain Nursing Assessment
Explain the nursing diagnosis, types, &
Medical Diagnosis Versus Nursing
Diagnosis

Planning, short term goals & long term

goals
Intervention
Evaluation
Decision Making

Nursing
In 1980, the American Nurses Association
(ANA) developed the first Social Policy
Statement defining nursing as the
diagnosis and treatment of human
responses to actual or potential health
problems.

Cont
Nursing is both a science and an art
concerned with the physical, psychological,
sociological, cultural, and spiritual concerns
of the individual.
The science of nursing is based on a broad
theoretical framework; its art depends on
the caring skills and abilities of the
individual nurse.

Nursing Process
Thus, years ago, nursing leaders developed a
problem-solving process consisting of three
steps
assessment, planning, and evaluationpatterned
after the scientific method of observing,
measuring, gathering data, and analyzing findings.
This method, introduced in the 1950s, was called
nursing process.

Cont

Cont

Assessment
Assessment is the first stage of the nursing
process in which the nurse should carry out
a complete and holistic nursing assessment
of every patient's needs, regardless of the
reason for the encounter

Cont
It is a clear picture of clients whole database.

Assessment is an organized dynamic process involving three basic activities:

Systematically gathering data
Sorting and organizing the collected data, and
Documenting the data in a retrievable fashion.

Types of Assessment
Subjective data
is usually documented in the clients own
words. This data includes such things
as previous experiences, and sensations
or emotions that only the client can
describe.

Cot
Objective data
is obtained by the health team, through
observation, physical examination,
or/and diagnostic testing. Objective
data can be seen or measured.

Assessment includes, the "HEALTH

HISTORY" and "physical
assessment".

Nursing Diagnosis/Analyzing
Diagnosis/need identification involves the
analysis of collected data to identify the
clients needs or problems, also known as
the nursing diagnosis.

Cont
The purpose of this step is to draw
conclusions regarding the clients specific
needs or human responses of concern so
that effective care can be planned and
delivered.

North American Nursing Diagnosis

Association
North American Nursing Diagnosis
Association (NANDA)
NANDA-International is recognized as the
leader in development and classification of
nursing diagnoses
[http://www.nanda.org/html/about.html]

Cont
The end product of the client diagnostic
statement that combines the specific client
need with the related factors or risk factors
(etiology), and defining characteristics (or
cues) as appropriate.
[http://www.nanda.org/html/about.html]

Development of the
Nursing Diagnosis

Two-part Statement
Problem statement describes the clients response to an actual or
potential health problem (diagnostic label)

Etiology cause of the problem

The diagnostic label & etiology are linked by the
terminology Related to (R/T)
Nursing diagnosis R/T main cause of problem (focal stimuli).

Nursing Diagnosis

Nursing Diagnosis Versus Medical

Diagnosis

Cont
Medical Diagnosis Nursing Diagnosis
COPD
Breathing Pattern,
Ineffective
CVA
Activity Intolerance
Appendectomy

Pain

Amputation

Body Image
Disturbance
Body Temperature,
Risk for Altered

Strep Throat

Types of Nursing Diagnoses

Actual nursing diagnosis a problem exists.
Composed of the problem statement, related
factors and signs & symptoms.
Example:
Ineffective airway clearance R/T hyperplasia of
the bronchial walls.

Risk nursing diagnosis indicates the

problem doesnt exist but has special risk
factors

Example:
Infection, Risk for R/T prolong stay in the
hospital

Wellness nursing diagnosis indicates the

clients desire to attain a higher level of
wellness in some area of function.

Example:
Effective breast feeding R/T maternal
confidence.

Planning
Planning includes setting priorities,
establishing goals, identifying desired client
outcomes, and determining specific nursing
interventions. These actions are
documented as the plan of care.

Prioritizing Nursing Diagnoses

Cont
The goals may be:
Short-term those that usually must be met
before the client is discharged or moved to a
lesser level of careand/or

Long-term, which may continue even after

discharge.

Short-term and long-term goals:

Goals should be patient-centered,
time-framed, realistic, and measurable.
Use behavioral terms such as;
Pt will demonstrate
Pt will ambulate________
Wound will demonstrate________

Planning & Outcome Identification

Planning is formulation of the actual nursing
actions
Three types of planning:
Initial planning developing the
preliminary plan of care
Ongoing planning updates of care based
on reassessment
Discharge planning anticipation &
planning of client needs after discharge

Planning Phase
Prioritizing the nursing
diagnoses
Identifying long &
short term goals
Developing nursing
interventions
Recording the nursing
care plan in the clients
medical record

Betty Neuman's system Theory

Five system variables:
Physiological
Basic
structure &
Psychological
Energy
Sociocultural
Resources
Developmental
Spiritual
Protected by the lines of defense & resistance to
keep the system stable

Implementation/ Evaluation
4th step in the nursing process
Involves putting the nursing care plan into
action.
Nursing activities (interventions) to meet
the goals set with the client begin.

Cont
The nurse must also be sure that the
interventions are
Consistent with the established plan of
care
Implemented in a safe and appropriate
manner

Evaluated for effectiveness, and

Documented in a timely manner.

Independent nursing interventions nursing

actions that are initiated by the nurse.
Interdependent nursing interventions
actions that are implemented by the nurse in
conjunction with other health care
professionals
Dependant nursing interventions requires
a physician order

Nursing Care Plan

A written guide, organizing client data into a
formal statements of strategies to assist the
client to optimal health

Evaluation
5th step in the nursing process
Determines if client goals are met or not
Determination of continued or cessation of
plan

Decision Making
Recognizing and defining a problem
Gathering relevant information
Generating possible conclusions
Testing possible conclusions
Evaluating Conclusions

Class Activity
Use the steps in nursing process to:
1. Describe how one would decide to purchase new car
2. Describe how one would select a restaurant
3. Describe how one would plan a wedding
4. Describe how one would select a pet
5. Describe how one would select a health insurance
6. Describe how one would select a career

MARTHA ROGERS,
NURSE THEORIST

When an apple is cut,

others see seeds in the apple.
We, as nurses, see apples in
the seeds.

Thank
You