Nursing Process

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 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

Assessment

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.

It is a clear picture of clients whole database.

Cont

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

Strep Throat Body Temperature,

Risk for Altered

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 includes setting priorities,

establishing goals, identifying desired client

outcomes, and determining specific nursing

interventions. These actions are

documented as the plan of care.

Planning

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

Five system variables:

Physiological

Psychological

Sociocultural

Developmental

Spiritual

Protected by the lines of defense & resistance to

keep the system stable

Basic

structure &

Energy

Resources

Betty Neuman's system Theory

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

When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.

MARTHA ROGERS,

NURSE THEORIST

Thank

You