Nursing process

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Nursing Process:

Nursing Process Mr. Paramathma


Definition “A designated series of actions intended to fulfill the purposes of nursing- to maintain the patient’s wellness- and, if this state changes, to provide the amount and quality of nursing care the situation demands to direct the patient back to wellness, and if wellness can not be achieved, then contribute to the patient’s quality of life, maximizing his resources as long as the life is a reality.” Yuva and Walsh ,1983


Purpose Main - to provide a systematic methodology for nursing practice. Others - It Unifies, standardizes and directs Nursing Practice. Nursing roles and functions are defined. Communication, Collaboration and Synchronization of health team members are enhanced. Health promotion, maintenance and restoration of client health or a peaceful death depending on the client’s situation. Facilitate documentation of data, diagnoses, plans, client responses and evaluation. Evaluate the efficiency and effectiveness of care. Cont…

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Give direction, guidance and meaning to nursing care. Provide continuity of care and to reduce Omissions. Individualize client participation in care. Promote creativity and flexibility in nursing practice. Accountability and Responsibility to clients and Nursing professions care be demonstrated. Economy of time, and money. Enhance professional growth and competence. Increases job satisfaction. Fulfill professional and Legal responsibilities.


Characteristics It is goal-directed toward client entered health care Systematic and provides an organized approach to nursing dynamic by focusing on the changing responses of the client during the ongoing process applicable to individual, families and community groups at any level of health. adaptable to any practice setting or specialization and the components may be used sequentially or concurrently interpersonal and based on the nurse-client relationship useful with any type of model, especially nursing.


Advantage Provides an organized method of giving nursing care. Prevents omissions and Unnecessary reputations Provides for better Communication. Focuses on the individual’s unique human response. Promotes flexibility in giving individualized nursing care. Encourages participation on the part of the patient. Helps nurses gain satisfaction by getting results.


Disadvantage Time consuming Slow process Need expertise


Steps Implementation Planning Diagnosis Assessment Evaluation

Nursing Process in the community:

Nursing Process in the community Promote Prevent Maintain Restore

Assessment :

Assessment Assessment is the deliberate and systematic collection of data to determine a client’s current and past health status and functional status and to determine the client’s present and past coping patterns. (Calpenito 2000


Assessment An organized dynamic process involving three basic activities- Systematically gathering data Organizing data Validating data Documentation




PURPOSE OF ASSESSMENT To determine the clients functional abilities and the presence or absence of dysfunction. To assess clients normal routine for activities of daily living and life style patterns. To identify clients strengths . To offer an opportunity for the nurse to form a therapeutic interpersonal relationship with the client. To provide and opportunity for the client to discuss health care concerns and goals with the nurse


DATA COLLECTION It is the process of gathering information about a clients health status PREPARING FOR DATA COLLECTION Establishing Assessment Priorities Health Orientation Developmental stage Need for Nursing Structuring the Assessment

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TYPES OF DATA : Subjective data Objective data Constant data Variable data CHARACTERISTICS OF DATA : 1. Purposeful 2. Complete 3. Factual and accurate 4. Relevant SOURCES OF DATA : Client Support people Client records Health care professionals Literature Interdisciplinary conferences, rounds and consultations. Results of diagnostic tests



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1. OBSERVATION Observation has two aspects 1 noticing the data 2 selecting, organizing and interpreting the data. 2, INTERVIEW APPROACHES : 1.Directive 2.Non-directive INTERVIEW: STAGES OF INTERVIEW PLANNING THE INTERVIEW AND SETTING INTRODUCTION WORKING PHASE TERMINATION


INTERVIEW PATIENT VARIABLES THAT CAN NEGATIVELY INFLUENCE AN INTERVIEW High Anxiety :- So the patient may speak rapidly or incoherently and may jump from one topic to another Pain :- Patient offers clipped response and “yes” or “no” answers whenever possible Language difficulty :- It occur if the patient not fluent in nurse’s language because patient speaks a different language, has a limited education. Previous negative experiences with nurse or health care delivery system Unrealistic expectations of health care professionals.


3, METHODS OF DATA COLLECTION HEALTH HISTORY Demographic Information Reason for seeking Health care Perception of Health status Previous illnesses, Hospitalizations and surgeries Client and Family Medical History Immunizations and Exposure to Communicable Disease Allergies

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8. Current Medications 9. Developmental Level 10. Psychosocial History 11. Socio cultural History 12. Activities of Daily Living


METHODS OF DATA COLLECTON 4.PHYSICAL EXAMINATION Assessment Techniques Inspection. Palpation Percussion Auscultation 5. LABORATORY AND DIAGNOSTIC DATA


ORGANIZING (CLUSTSERING DATA) ASSESSMENT MODELS Holistic 1. Hierarchy of Human Needs 2. Functional Health Patterns 3. Human response patterns Medical Body system model

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3. Validating data To make sure that the information gather is factual and complete. To avoid missing of pertinent information, misunderstanding situation and jumping in to the situation.

4. Documenting:

4. Documenting Document immediately after the assessment focus on abnormal data mention significant findings. Purpose – To ensure diagnosis Keep others accountable & Help in learning

Definition of Nursing Diagnosis:

Definition of Nursing Diagnosis A clinical judgment about individual, family, or community responses to actual or potential health/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

Definition of Nursing Diagnsis:

Definition of Nursing Diagnsis A nursing diagnosis is a statement of the high risk or actual problems in the client’s health status that the nurse is licensed and competent to treat

Nursing Diagnostic Statement:

Nursing Diagnostic Statement Derived from actual or potential problems Derived from physiological, sociocultural, developmental, and spiritual dimensions of client Focus: Helping client to achieve a maximal level of wellness and highest level of independence

Benefits of Nursing Diagnosis:

Benefits of Nursing Diagnosis Gives nurses a common language Promotes identification of appropriate expected outcomes Provides acuity information Can create a standard for nursing practice Provide a quality improvement base

NDX VS Medical Diagnosis:

NDX VS Medical Diagnosis Nursing Diagnosis Made by the nurse Describes clients response Responses vary between individuals Changes as client responses change Nurse orders interventions Medical Diagnosis Made by a physician Refers to the disease process Somewhat uniform between clients Remains same during disease process Physician orders interventions

Diagnostic Analysis:

Diagnostic Analysis Data validation Data Clustering Analysis & Interpretation of data Identification of clients need Formulation of Nursing Diagnosis

Components of Analysis Phase:

Components of Analysis Phase 3 major components of analysis phase: Analysis and interpretation of data Validation of data Clustering of data Identification of problems/health care needs Formulation of nursing diagnosis statement

Advantages of Nursing Diagnosis:

Advantages of Nursing Diagnosis For client- individualization of care, appropriate selection of interventions, establishment of goals For nursing- facilitates communication, documentation, and continuity of care among health care providers

Sources of error:

Sources of error Errors in data collection Errors in data analysis Clustering errors Incorrect diagnostic statement Common error, however, if correct steps are followed this will not occur

Nursing Diagnostic Statement Diagram:

Nursing Diagnostic Statement Diagram #___ ___________ r/t __________ e/b _____________ Priority Patient’s this is the cause these are signs/ symptoms needs/problem (etiology) that come from the assess- ment (what you see that supports the problem) r/t= related to e/b or m/b= evidenced by or manifested by Patient’s needs/problem= NANDA approved statement found in book

Example Statements:

Example Statements #1 Pain r/t tissue damage e/b patient complains of pain at level of 7 out of 10 #2 Constipation r/t poor fiber intake e/b no bowel movement for 3 days and abdominal distention #3 Risk for injury r/t generalized weakness

Parts of Nursing Diagnostic Statement:

Parts of Nursing Diagnostic Statement Problem Actual- firm diagnosis supported by nurse’s findings (validated) High risk- has risk factors but does not have signs and symptoms, more vulnerable to develop problems Possible- tenative- additional data needed to confirm or rule out problem

Parts of Nursing Diagnostic Statement:

Parts of Nursing Diagnostic Statement Qualifiers/ Modifiers Impaired Altered Decreased Possible Ineffective High risk

Parts of Nursing Diagnostic Statement:

Parts of Nursing Diagnostic Statement Related to (r/t) Educated guess as to what factors are contributing to or causing the problem Placed between problem and etiology to indicate relationship between them Can not be a medical diagnosis Must be modifiable by nursing interventions Must be able to do something about it Will be in one of five categories: Environmental, situational, psychological, pathophysical, and maturational

Parts of Nursing Diagnostic Statement:

Parts of Nursing Diagnostic Statement Evidenced by (e/b) or Manifested by (m/b): Signs and symptoms (assessment data) that led to your nursing diagnosis. Examples: SOB while walking Client stating food intake is poor Client states they are in pain Client hasn’t had bowel movement in 3 days Client has open wound on buttocks

Setting Priorities:

Setting Priorities Criteria for setting priorities – Frequency with which the problem occurs prevalence Seriousness of the problem for individuals & society Urgency of the problem Feasibility of susceptibility to control the problem within the financial resource limitation i.e. Affordable, accessible, acceptable, practicable, cost-effectiveness. Cont…

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Eg. Prev Seriousness Urgency Feasibility Total Dental Problem +++ + ++ ++ 8 Leprosy + ++ +++ + 7 Diarheal disease ++ ++++ ++++ ++++ 14

Setting the goals:

Setting the goals Immediate Intermediate & Long term


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.

Planning for Nursing Care:

Planning for Nursing Care Client-centered goals and expected outcomes are established Priorities are set relating to unmet needs Maslow’s Hierarchy of Needs is a useful method for setting priorities Priorities are classifies as high, intermediate, or low

Planning – Begin by prioritizing client problems:

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

Planning-select interventions:

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.

Implementing :

Implementing Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. The first three nursing process phases-assessing, diagnosing, and planning-provide the basis for the nursing actions performed during the implementing step. In turn, the implementing phase, provide the actual nursing activities and client responses that are examined in the final phase, the evaluating phase.

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While implementing nursing orders, the nurse continues to reassess the client at every contact, gathering data about the client’s responses to nursing activities and about any new problems that may develop. To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. These skills are distinct from one another. The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity.

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Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another, this depends on the ability of the nurse to communicate effectively with others. It is necessary for all nursing activities, caring, comforting, advocating, referring, counseling, and supporting others. Technical skills are hands-on skills such as manipulating equipments, giving injections and bandaging, moving lifting, and repositioning clients. These are called procedures, tasks, or psychomotor skills.

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Process of Implementing 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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Reassess the Client, to make sure the intervention is still needed. Even though an order is written on the care plan, the client’s condition may have changed. The nurse also provides supportive communication to help alleviate the client’s stress.

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Determining the Nurse’s Need for Assistance, for one of the following reasons: The nurse is unable to implement the nursing activities safely alone Assistance would reduce stress on the client The nurse lacks the knowledge or skills to implement a particular nursing activities

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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 outcome is. Ensure client privacy, coordinate client care, and involve scheduling client contacts with other departments.

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When implementing interventions, nurses should follow these guidelines: Base nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible. Clearly understand the order to be implemented and question any that are not understood. Adapt activities to the individual client, a client’s beliefs, values; age, health status, and environment are factors that can affect the success of a nursing action.

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Implement safe care Provide teaching, support and comfort to enhance the effectiveness of nursing care plans. Be holistic; view the client as a whole. Respect the dignity of the client and enhance the client’s self- esteem Encourage client to participate actively in implementing the nursing interventions.

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Supervising Delegating Care, if care has been delegated to other health care personnel, the nurse responsible for all the client’s care must ensure that the activities have been implemented according to the care plan.

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Documenting Nursing Activities, the nurse complete the implementing phase by recording the interventions and client responses in the nursing process notes. The nurse may record routine or recurring activities such as mouth care in the client record at the end of shift, while some actions recorded in special worksheets according to agency policy. Immediate recording helps safeguard the client to prevent double actions.


Evaluation Evaluation includes determining whether the desired outcomes have been met This in an on going process that determines how well the plan of care is working and if the plan of care needs to be modified

A Time for reassessment:

A Time for reassessment Evaluation requires continued reassessment of the client’s condition, and determines Appropriateness of nursing actions Need to revise interventions Development of new client problems/needs Need to rearrange priorities to meet changing demands

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Purposes: To facilitate additional decision making Helps to conclude what had been done, what could not have been done to reach to goal To identify the alterations that are needed in the plan of care to make effectively reach the desired out comes To know, the cost effectiveness in terms of money, time and other resources.

How do you evaluate?:

How do you evaluate? Direct observation Client interview Review of records Progress notes, flow sheets, nursing notes

Components of evaluation expected outcomes:

Components of evaluation expected outcomes Identification of expected outcomes Collect data related to expected outcomes Relate nursing actions to expected outcomes Draw conclusions about problem status Resolved Revised continue

Expected outcomes are either::

Expected outcomes are either: Met Not met Partially met

EO: Met:

EO: Met Document what client assessment findings show that the expected outcome is met How do you know as a nurse that this expected outcome is met? What has happened to prove the problem is resolved Which intervention can be terminated? How easily where the outcomes achieved? Can timelines be shortened

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Actual problem resolved Nursing diagnosis is discontinued High risk problem resolved Risk factors no longer exist Nursing diagnosis is discontinues Problem still exists Revise interventions

EO: Partially Met:

EO: Partially Met Document the assessment findings that indicate that progress has been made, but there is still work to do. How do you know that progress has been made? What needs to be done to make continued progress?

EO: Not met:

EO: Not met Document what has been done that hasn’t worked so other HCP will be aware. How do you know that the client has not met the EO? What are the assessment findings that support this? What are you ideas for change?

If EO is not met ask these questions:

If EO is not met ask these questions Were the outcomes realistic and appropriate? Was the client involved in setting the outcomes? Does the client believe the outcomes were important? Does the client know why the outcomes have not been met?

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Have all of the interventions that were planned been carried out and in the timeframe specified? If not, why not? Were they too vague or misinterpreted? What variables may have affected achievement of the outcomes? Were new problems and adverse client responses detected early enough to make appropriate changes in the plan of care?

Modification of the plan of care:

Modification of the plan of care When evaluation indicates a change in the plan of care is needed, “back up” through the nursing process to see where areas for change lie

How to write evaluations:

How to write evaluations EO was met, partially met, or not met. Any new or additional data Any changes that were made in the intervention as a result of ongoing assessment How the interventions helped achieve the goal

ANA Standard VI:

ANA Standard VI Evaluation: The nurse evaluates the client’s progress toward attainment of outcomes 1. Evaluation is systematic ongoing, and criterion-based. 2. The client, family, and other healthcare providers are involved in the evaluation process as appropriate.

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3. Ongoing assessment data are used to revise diagnosis, outcomes, and the plan of care, as needed. 4. Revision in diagnoses, outcomes, and the plan of care are documented. 5. The effectiveness of interventions is evaluated in relation to outcomes. 6. The patient’s responses to interventions are documented.

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Steps: 1. Determine what is to be evaluated Structure Process Out come 2. Establish standards and criteria 3. Plan the methodology to be applied 4. Gather information 5. Analyze the results 6. Take action 7. Re-evaluate

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Elements: Relevance Adequacy Accessibility Acceptability Effectiveness Efficiency Impact

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Evaluation Process

Evaluation in community health Nursing:

Evaluation in community health Nursing Importance The degree to which objectives and targets are fulfilled and quality of the result obtained The productivity of available resources in achieving clearly defined objectives How much out put or cost effectiveness is achieved Makes possible the reallocation of priorities and of resources on the basis of changing health needs.

Multilevel intervention evaluation: :

Multilevel intervention evaluation: Individual changes Community subsystem changes Community inter relationship changes Total community changes Methods for evaluation: Case study Surveys Programme monitoring Experimental evaluation Cost-effectiveness evaluation


Conclusion: Nursing process is continuous process with five steps. Health care providers have the responsibility to ensure the objectives of each steps and carry out activities for the success of the individual, family as well as community care following these steps during their day to day practice.

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Thank You

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