Nursing Process final (1).pdf nursing process phases of nursing

Nursing process

1. Unit: 1 Nursing Process
FON-II, 2nd Semester
BScN Generic 4 Year Degree
Program
By
Rawal Rafiq Leghari
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2. Objectives
1. Define nursing process.
2. Describe the purposes of nursing process.
3. Identify the components of the nursing process
4. Discuss the requirements for effective use of the
nursing process
5. Describe the functional health approach to the
nursing process
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3. Nursing Process
The nursing process is a dynamic & modified form of
scientific method used in nursing profession to
assess client needs and create a course of action to
address and solve patient problems.
OR
An organized sequence of problem-solving steps used
to identify and to manage the health problems of
clients.
It is accepted for clinical practice established by the
American Nurses Association
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4. Purpose Of Nursing Process
•To identify a client’s health status and actual or
potential health care problems or needs.
•To establish plans to meet the identified needs.
•To deliver specific nursing interventions to meet
those needs.
•Purpose is to provide client care that is :
Individualized
Holistic
Effective
Efficient
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5. Components Of Nursing Process
The Nursing Process utilizes the following steps
1.Assessment (data collection),
2.Nursing diagnosis,
3.Planning,
4.Implementation
5.Evaluation.
–Steps remain the same
–Applications and result are different
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6. Components of Nursing Process
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7. Characteristics of Nursing Process
•Cyclic
•Dynamic nature,
•Client centeredness
•Focus on problem solving and decision making
•Interpersonal and collaborative style
•Universal applicability
•Use of critical thinking and clinical reasoning
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8. 1. ASSESSMENT
It involves
•Collection of data
•Organizing the data
•Validating the data
•Documenting the data
Assessment is the systematic and continuous collection,
organization, validation, and documentation of data
(information).
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9. 1. ASSESSMENT
Types of assessment
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
The ultimate Purpose of assessment is data collection
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10. 1. ASSESSMENT
1. Initial nursing assessment:
•Performed within specified time after admission.
•To establish a complete database for problem
identification.
•Eg: Nursing admission assessment
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11. 1. ASSESSMENT
2. Problem-focused assessment :
To determine the status of a specific problem identified
in an earlier assessment. Eg: hourly checking of vital
signs of fever patient
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12. 1. ASSESSMENT
3. Emergency assessment:
During emergency situation to identify any life
threatening situation. Eg: Rapid assessment of an
individual’s airway, breathing status, and circulation
during a cardiac arrest.
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13. 1. ASSESSMENT
4. Time-lapsed reassessment:
Several months after initial assessment. To compare the
client’s current health status with the data previously
obtained
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14. COMPONENTS OF ASSESSMENT
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15. 1. ASSESSMENT
Collection of data
Data collection is the process of gathering information
about a client’s health status. It includes the health
history, physical examination, results of laboratory
and diagnostic tests, and material contributed by
other health personnel.
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16. 1. ASSESSMENT
Types of Data:
1.Subjective data
2.Objective data.
1. Subjective data
Also referred to as symptoms or covert data, are clear
only to the person affected and can be described
only by that person. Itching, pain, and feelings of
worry are examples of subjective data.
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17. 1. ASSESSMENT
2. Objective data
Also referred to as signs or overt data, are detectable
by an observer or can be measured or tested against
an accepted standard. They can be seen, heard, felt,
or smelled, and they are obtained by observation or
physical examination. For example, a discoloration of
the skin or a blood pressure reading is objective data.
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18. 1. ASSESSMENT
Sources of Data
Sources of data are primary or secondary.
1.Primary : It is the direct source of information. The
client is the primary source of data.
2. Secondary: It is the indirect source of information.
All sources other than the client are considered
secondary sources. Family members, health
professionals, records and reports, laboratory and
diagnostic results are secondary sources.
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19. Methods Of Data Collection
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20. 1. ASSESSMENT
Organization of data
The nurse uses a format that organizes the assessment
data systematically. This is often referred to as
nursing health history or nursing assessment form
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21. 1. ASSESSMENT
Validation of data
The information gathered during the assessment is
“double-checked” or verified to confirm that it is
accurate and complete.
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22. 1. ASSESSMENT
Documentation of data
To complete the assessment phase, the nurse records
client data. Accurate documentation is essential and
should include all data collected about the client’s
health status.
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23. 2. DIAGNOSIS
Diagnosis is the second phase of the nursing process.
In this phase, nurses use critical thinking skills to
interpret assessment data to identify client
problems.
(NANDA) define or refine nursing diagnosis.
The official NANDA definition of a nursing diagnosis is:
“a clinical judgment concerning a human response to
health conditions/life processes, or a vulnerability for
that response, by an individual, family, group, or
community.”
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24. 2. DIAGNOSIS
Diagnosing is to :
1.Analyza data
2. Identify health problems,risks and strengths
3. Formulate diagnostic statement
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25. Status of the Nursing Diagnoses
“Status refers to the actuality or potentiality of the
diagnosis or the categorization of the diagnosis”
(NANDA International, 2009, p. 44).The kinds of
nursing diagnoses according to status are
1.Actual
2.Health promotion
3.Risk
4.Wellness.
5.Possible Nursing Diagnosis
6.Syndrome Nursing diagnosis
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26. 1. Actual Diagnosis
An actual diagnosis is a client peoblem that is present
at the time of Nursing assessment. Examples are
ineffective breathing pattern and anxiety.
It is based on the presence of associated signs and
symptoms
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27. 2.Health Promotion Diagnosis
A health promotion diagnosis relates to
clients’preparedness to implement behaviors
to improve their health condition. These
diagnosis labels begin with the phrase
Readiness for Enhanced, as in Readiness for
Enhanced Nutrition
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28. 3. Risk Nursing Diagnosis
A risk nursing diagnosis is a clinical judgment that a
problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop
unless nurses intervene.
For example, all people admitted to a hospital have some
possibility of acquiring an infection; however, a client with
diabetes or a compromised immune system is at higher risk
than others. Therefore, the nurse would appropriately use the
label Risk for Infection to describe the client’s health status.
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29. 4. Wellness Nursing Diagnosis
It is clinical judgment about an individual, group
or community in transition from a specific
level of wellness to a higher level of wellness.
Eg: Family coping: potential for growth related
to unexpected birth of twins.
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30. 5. Possible Nursing Diagnosis
It describe a suspected problem for which current and
available data are insufficient to validate the
problem. eg: Possible social isolation related to
unknown etiology.
Eg: An elderly widow who lives alone is admitted to the
hospital. The nurse notices that she has no visitors and is
pleased with attention and conversation from the
nursing staff .The nurse may write a nursing diagnosis of
possible social isolation related to unknown etiology.
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31. 6. Syndrome Nursing Diagnosis
It is a cluster of nursing diagnosis that frequently go
together and present a clinical picture.
Eg:
•Chronic Pain syndrome
•Rape Trauma Syndrome
•Disuse syndrome (long term bed riddenpatients)
•Clusters of diagnoses associated with Disuse syndrome
syndrome include Impaired Physical Mobility,Riskfor Impaired
Tissue Integrity, Risk for Activity Intolerance, Risk for
Constipation, Risk for Infection, Risk for Injury, Risk for
Powerlessness, Impaired Gas Exchange, and so on.
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32. Components of a Nursing Diagnosis
A nursing diagnosis has three components:
(1) The problem statement or Diagnostic Lable
(2) The etiology (related factors & risk factors)
(3) Signs & Symptoms or the defining characteristics
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33. 1.Problem Statement (Diagnostic Label)
It Describes the patient health status or response to
health problems for which nursing therapy is given.
The purpose of the diagnostic label is to direct the
formation of client goals and desired outcomes. It
may also suggest some nursing interventions.
Eg: for example, Deficient Knowledge (Medications) or
Deficient Knowledge (Dietary Adjustments).
Similarly., Activity intolerance or Constipation etc
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34. 2. Etiology (Related Factors & Risk Factors)
The etiology component of a nursing diagnosis
identifies causes of the health problem.These are
causative factors that have influenced the clients
actual or potential response to the healthproblem
Eg: Activity intolerance related to generalized weakness
or obesity or sedentary lifestyle. Constipation related
to inadequate fluid intake or inadequate fiber intake.
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35. 3. Defining characteristics (S/S)
Defining characteristics are the cluster of signs and
symptoms that indicate the presence of a particular
diagnostic label or health problem.
e.g Fluid volume deficit related to decreased oral intake
manifested by dry skin and mucus membranes.
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36. The Diagnostic Process
The diagnostic process has three steps:
•Analyzing data
•Identifying health problems, risks, and strengths
•Formulating diagnostic statements.
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37. Formulating Diagnostic statement
Most nursing diagnosis are written as two part or three
parts statements
Basic Two Part Statements: It is also called PE format
Problem (P) –statement of the patients response
Etiology (E) –factors contributing to or probable cause
of the response
Example:Problem(P)relatedtoEtiology(E)
Activity intolerance related to generalized
weaknessorobesity
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38. Formulating Diagnostic statement
Basic Three Part Statements
It is also called as PESformat & includes:
1.Problem (P) –Statement of the patient’s response
2.Etiology (E)
Factors contributing to or probablecausesoftheresponses
3.Signs & Symptoms (S)
Defining characteristicsevidencedbytheclient
Example: Problem related to etiology as evidentced by
signs &symptoms
Activity intolerance related to generalized weakness
evidenced by fatigue
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39. Difference between Nursing Diagnosis
Medical Diagnosis
Nursing Diagnosis
•It is a statement of nursing
judgment and refers to a
condition that nurses are
licensed to treat.
•It is a statement of nursing
judgment.
•It describe a patients
physical, sociocultural,
psychologic and spiritual
responses to an illness or
ahealthproblem
Medical Diagnosis
•It is made by a physician
and refers to a condition
that only a physician cant
reat.
•It is a statement of medical
judgmen.
•Medical diagnoses refer to
disease processes OR It
describes a patient’s
specific pathophysiologic
responses to an illness.
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40. Difference between Nursing Diagnosis
Medical Diagnosis
Nursing Diagnosis
•These responses vary
among individuals
•The patient’s nursing
diagnosis change as the
client’s response change
•Nursing diagnosis relate to
the nurse’s independent
function
•Eg:Tepid sponging for fever
Medical Diagnosis
•These responses are fairly
uniform from one client to
another
•The patient’s medical
diagnosis remains the same
for as long as the disease
process is present
•Nurses are obligated to carry
out physician prescribed
treatment (dependent
function). Eg: Tab. Paracetamol
500mg forfever
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41. Difference between Nursing Diagnosis
Medical Diagnosis
Nursing Diagnosis
•Ineffective breathing
pattern
•Activity intolerance
•Acute pain
•Disturbed body image
Medical Diagnosis
•Asthma
•Cerebrovascular accident
•Appendicitis
•Amputation
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42. PLANNING
Planning is the third phase of the nursing process, in which
the nurse and client develop client goals/ desired
outcomes and nursing strategies to prevent, reduce or
alleviate the client’s health problems.
It is the process of formulating client goals and designing
the nursing interventions required to prevent, reduce, or
eliminate the client’s health problems.
Planning involves decision making and problem solving.
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43. Types Of Planning
1. Initial Planning : Planning which is done after the initial
assessment. The nurse who performs the admission
assessment usually develops the initial comprehensive
plan of care.
2. Ongoing Planning : It is a continuous planning. As nurses
obtain new information and evaluate the client’s
responses to care, they can individualize the initial care
plan further. It occurs at the beginning of a shift as the
nurse plans the care to be given that day
3. Discharge Planning :The process of anticipating and
planning for needs after discharge, is a crucial part of a
comprehensive health care and should be addressed in
each client’s care plan.
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44. Planning Process
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It involves
•Prioritize problems/ diagnosis
•Formulate goals/desired outcomes
•Select Nursing intervension
•Write Nursing intervention
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45. Planning Process
1. Setting priorities
•The nurse begin planning by deciding which nursing
diagnosis requires attention first, which second, and
so on.
•Nurses frequently use Maslow’s hierarchy of needs
when setting priorities.
•Example: In this physiologic needs such as air, food
and water are basic to life and receive higher priority
than the need for security or activity
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46. 46
Maslow's Hierarchy of Needs
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47. Planning Process
2. Establishing client goals/desired outcomes
After establishing priorities, the nurse set goals for each
nursing diagnosis. Goals may be short term or long
term
Client goals / desired outcomes: It is a specific and
measurable behavior or response that reflects a
clients highest possible level of wellness and
independence in function.
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48. Types of Goals
Short Term Goals
•It is an objective that is
expected to achieved / with
in a short time, usually less
than a week Example:
Client will achieve comfort
with in 24 hours post
operatively
•Clientwill raise right arm to
shoulder heightby Frida
Long Term Goaals
•It is an objective that is
expected to believe over a
longer time frame, usually
over weeksormonths
Example: Client will adhere
to post operative activity
restrict
•Client will regain full use of
right arm in 6 weeks ions for
one month
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49. Planning Process
3. Nursing interventions
A nursing intervention is any treatment, that a nurse
performs to improve patient’s health.
OR
These are the actions that nurses perform to achieve
the clients goals
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50. Types Of Nursing Interventions
1.Independent interventions are those activities that
nurses are licensed to initiate on the basis of their
knowledge and skills.
2. Dependent interventions are activities carried out
under the orders or supervision of a licensed
physician.
3. Collaborative interventions are actions the nurse
carries out in collaboration with other health team
members
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51. 4. IMPLEMENTATION
•In the nursing process, implementing is the action
phase in which the nurse performs the nursing
interventions. Implementing consists of doing and
documenting the activities that are the specific nursing
actions needed to carry out the interventions.
•The nurse performs or delegates the nursing activities
for the interventions that were developed in the
planning step and then concludes the implementing
step by recording nursing activities and the resulting
client responses.
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52. Process of Implementing
•The process of implementing normally includes the
following:
•Reassessing the client
•Determining the nurse’s need for assistance
•Implementing the nursing interventions
•Supervising the delegated care
•Documenting nursing activities.
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53. Process of Implementing
1. Reassessing the Client
Just before implementing an intervention, the nurse must reassess the
client to make sure the intervention is still needed.
2. Determining the Nurse’s Need for Assistance
When implementing some nursing interventions, the nurse may
require assistance for one or more of the following reasons:
•The nurse is unable to implement the nursing activity safely or efficiently alone
(e.g., ambulating an unsteady obese client).
•Assistance would reduce stress on the client (e.g., turning a person who
experiences acute pain when moved).
•The nurse lacks the knowledge or skills to implement a particular nursing activity
(e.g., a nurse who is not familiar with a particular model of traction equipment
needs assistance the first time it is applied).
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54. Process of Implementing
3. Implementing the Nursing Interventions
It is important to explain to the client what
interventions will be done, what sensations to
expect, what the client is expected to do, and what
the expected outcome is.
For many nursing activities, it is also important to
ensure the client’s privacy, for example by closing
doors, pulling curtains, or draping the client.
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55. Process of Implementing
4. Supervising Delegated Care
•If care has been delegated to other health care
personnel, the nurse responsible for the client’s overall
care must ensure that the activities have been
implemented according to the care plan.
•Other caregivers may be required to communicate their
activities to the nurse by documenting them on the client
record, reporting verbally, or filling out a written form.
•The nurse validates and responds to any adverse findings
or client responses. This may involve modifying the
nursing care plan.
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56. Process of Implementing
5. Documenting nursing activities.
After carrying out the nursing activities, the nurse
completes the implementing phase by recording the
interventions and client responses in the nursing
progress notes.
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57. EVALUATION
Evaluation is a planned, ongoing, purposeful activity in
which the nurse determines
(a)the client’s progress toward achievement of
goals/outcomes and
(b)the effectiveness of the nursing care plan.
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58. References
kozier & Erb’s Fundamental of Nursing ,8
th
edition( Audrey Berman ,Shirlee J. Synder).
www.slideshare.com
www.google.com
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59. 02/08/2021 59