Nursing process

IMPORTANT PPT OF NURSING PROCESS

1. Nursing Process
Presented by:
MR VIJAYREDDY VANDALI
ASSOCIATE PROF CUM VICE-
PRINCIPAL
SCHOOL OF NURSING
P P SAVANI UNIVERSITY
GUJARAT

2. NURSING PROCESS
•Specific to the nursing profession
•A framework for critical thinking
•It’s purpose is to:
“Diagnose and treat human responses to actual or potential
health problems”

3. Nsg Dx vs MD Dx
•Within the scope of
nursing practice
•Identify responses to
health and illness
•Can change from day
to day
•Within the scope of
medical practice
•Focuses on curing
pathology
•Stays the same as long
as the disease is present

4. Nursing Process
•Organized framework to guide practice
•Problem solving method - client focused
•Systematic- sequential steps
•Goal oriented- outcome criteria
•Dynamic-always changing, flexible
•Utilizes critical thinking processes

5. Scientific Method of problem
solving
•ID problem
•Collect data
•Form hypothesis
•Plan of action
•Hypothesis testing
•Interpret results
•Evaluate findings

6. Advantages of Nursing Process
•Provides individualized
care
•Client is an active
participant
•Promotes continuity of
care
•Provides more effective
communication among
nurses and healthcare
professionals
•Develops a clear and
efficient plan of care
•Provides personal
satisfaction as you see
client achieve goals
•Professional growth as
you evaluate
effectiveness of your
interventions

7. 5 Steps in the Nursing Process
•Assessment
•Nursing Diagnosis
•Planning
•Implementing
•Evaluating

9. Assessment
•First step of the Nursing Process
•Gather Information/Collect Data
•Primary Source - Client / Family
•Secondary Source - physical exam, nursing history, team members, lab
reports, diagnostic tests…..
• Subjective -from the client (symptom)
•“I have a headache”
•Objective - observable data (sign)
•Blood Pressure 130/80

10. ASSESSMENT-COLLECTING
DATA
•Nursing Interview (history)
•Health Assessment -Review of Systems
•Physical Exam
•Inspection
•Palpation
•Percussion
•Auscultation

11. ASSESSMENT-COLLECTING
DATA
•Make sure information is complete &
accurate
•Validate prn
•Interpret and analyze data
Compare to “standard norms”
•Organize and cluster data

12. Example of Assessment
•Obtain info from nursing assessment, history and physical
(H&P) etc…...
•Client diagnosed with hypertension
•B/P 160/90
•2 Gm Na diet and antihypertensive medications were
prescribed
•Client statement “ I really don’t watch my salt” “ It’s hard to
do and I just don’t get it”

13. Nursing Diagnosis
•Second step of the Nursing Process
•Interpret & analyze clustered data
•Identify client’s problems and strengths
•Formulate Nursing Diagnosis (NANDA : North American
Nursing Diagnosis Association)-Statement of how the client is
RESPONDING to an actual or potential problem that requires
nursing intervention

14. Formulating a Nursing Diagnosis
•Composed of 3 parts:
•Problem statement- the client’s response to a problem
•Etiology- what’s causing/contributing to the client’s problem
•Defining Characteristics- what’s the evidence of the
problem

15. Nursing Diagnosis
•Problem( Diagnostic Label)-based on your assessment of
client…(gathered information), pick a problem from the
NANDA list...
•Etiology- determine what the problem is caused by or
related to (R/T)...
•Defining characteristics- then state as evidenced by (AEB)
the specific facts the problem is based on...

16. Example of Nursing Dx
•Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack
of knowledge
AEB B/P= 160/90, dietary sodium restrictions not
being observed, and client statements of “ I don’t
watch my salt” “It’s hard to do and I just don’t get
it”.

17. Types of Nursing Diagnoses
•Actual
Imbalanced nutrition; less than body requirements
RT chronic diarrhea, nausea, and pain AEB height
5’5” weight 105 lbs.
•Risk
Risk for falls RT altered gait and generalized
weakness
•Wellness
Family coping: potential for growth RT unexpected
birth of twins.

18. Collaborative Problems
•Require both nursing interventions and medical interventions
EXAMPLE: Client admitted with medical dx of pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy

19. Planning
Third step of the Nursing Process
•This is when the nurse organizes a nursing care plan based on the
nursing diagnoses.
•Nurse and client formulate goals to help the client with their
problems
•Expected outcomes are identified
•Interventions (nursing orders) are selected to aid the client reach
these goals.

20. Planning – Begin by prioritizing client
problems
•Prioritize list of client’s nursing
diagnoses using Maslow
•Rank as high, intermediate or
low
•Client specific
•Priorities can change

21. Planning
Developing a goal and outcome statement
•Goal and outcome
statements are client
focused.
•Worded positively
•Measurable, specific
observable, time-limited,
and realistic
•Goal = broad statement
•Expected outcome =
objective criterion for
measurement of goal
•Utilize NOC as standard
EXAMPLE
•Goal:
Client will achieve therapeutic
management of disease
process….
•Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of understanding
importance of dietary sodium
restrictions by day of
discharge.

22. Planning- Types of goals
•Short term goals
•Long term goals
•Cognitive goals
•Psychomotor goals
•Affective goals

23. Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)

24. PLANNING-SELECT INTERVENTIONS
•Interventions are selected and written.
•The nurse uses clinical judgment and professional knowledge
to select appropriate interventions that will aid the client in
reaching their goal.
•Interventions should be examined for feasibility and
acceptability to the client
•Interventions should be written clearly and specifically.

25. INTERVENTIONS – 3 types
•Independent ( Nurse initiated )- any action the nurse can
initiate without direct supervision
•Dependent ( Physician initiated )-nursing actions requiring
MD orders
•Collaborative- nursing actions performed jointly with other
health care team members

26. IMPLEMENTATION
•The fourth step in the Nursing Process
•This is the “Doing” step
•Carrying out nursing interventions (orders) selected during
the planning step
•This includes monitoring, teaching, further assessing,
reviewing NCP, incorporating physicians orders and
monitoring cost effectiveness of interventions
•Utilize NIC as standard

27. Implementing- “Doing”
•Monitor VS q4h
•Maintain prescribed diet (2
Gm Na)
•Teach client amount of
sodium restriction, foods
high in sodium, use of
nutrition labels, food
preparation and sodium
substitutes
•Teach potential
complications of
hypertension to instill
importance of
maintaining Na
restrictions
•Assess for cultural
factors affecting dietary
regime

28. Implementing – “Doing”
•Teach the client-
hypertension can’t
be cured but it can
be controlled.
•Remind the client to
continue medication
even though no S/S
are present.
•Teach client importance
of life style changes:
(weight reduction,
smoking cessation,
increasing activity)
•Stress the importance of
ongoing follow-up care
even though the patient
feels well.

29. EVALUATION- To determine
effectiveness of NCP
•Final step of the Nursing Process but
also done concurrently throughout client care
•A comparison of client behavior and/or response to
the established outcome criteria
•Continuous review of the nursing care plan
•Examines if nursing interventions are working
•Determines changes needed to help client reach
stated goals.

30. EVALUATION
•Outcome criteria met? Problem resolved!
•Outcome criteria not fully met? Continue plan of
care- ongoing.
•Outcome criteria unobtainable- review each previous
step of NCP and determine if modification of the
NCP is needed.
•Were the nsg interventions appropriate/effective?

31. EVALUATION
Factors that impede goal attainment:
•Incomplete database
•Unrealistic client outcomes
•Nonspecific nsg interventions
•Inadequate time for clients to achieve outcomes.

34. THANK YOU