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Nursing Process

Nursing Fundamentals

Didik S. S.Kep, Ns

Introduction
Nursing process
is a systematic method of providing care to clients
Allows nurses to communicate plans and activities
to
Clients
Other health care professionals
Families

Encourages orderly thought, analysis, planning

Overview of the Nursing Process


Process:
A series of steps or acts that lead to
accomplishment of some goal or purpose

Purpose is to provide client care that is:

Individualized
Holistic
Effective
Efficient

Purpose of the nursing process:


To Achieve ScientificallyBased, Holistic, Individualized
Care For The Client
To Achieve The Opportunity To
Work Collaboratively With
Clients, Others
To Achieve Continuity Of Care

Overview of the Nursing Process


Consists of 5 steps

Assessment
Diagnosis
Planning
Implementation
Evaluation

Build on each other


Not linear

Nursing process is dynamic and requires


creativity in its application
Steps remain the same
Application and results different

Used throughout the life span in any care setting

Small group questions:


1.
2.
3.
4.

How many steps are in the nursing process?


What are the names of each of the steps?
What is the purpose of the nursing process?
In what clinical setting is the nursing process
used?

Assessment
Step #1
Involves

Collecting data (from variety of sources)


Validating the data
Organizing the data
Interpreting the data
Documenting the data

Resources

Client
Other individuals
Previous records
Consultations
Diagnostics studies
Relevant literature

Assessment
Purpose of assessment:
Data collection

Types of assessment:
Comprehensive assessment
Focused
Ongoing

Assessment
Comprehensive assessment
Baseline
Physical & psychosocial

Assessment
Focused Assessment
Limited in scope
Screening for a specific problem
Short stay

Ongoing assessment
Follow-up
Monitoring and observation related to specific
problems

Assessment
Sources of Data
Primary sources
Client
Interview
Physical examination

Secondary sources
Family members
Other health care providers
Medical records

Assessment
Types of data
Subjective
Data from the clients point of view
Feelings, Perceptions, Concerns

Main way to collect subjective data:


Interview

Objective
Observable & measurable data
Main way to collect objective data:
Physical assessment
Lab and diagnostic testing

Assessment
Validating the Data
Organizing the Data
Interpreting the Data
Relevant vs. irrelevant
Gaps?
Identify patterns

Document the Data

Verifying Data

Essential in critical thinking!!!!!


Measurable data
Double check personal observations
Double check equipment
Check with experts and team members
Recheck out-liers
Compare objective and subjective data
Clarify statements

Small group questions:


1. Baby Jane a 2 month infant goes into the
doctor for her initial immunization and well
baby check-up. What type of assessment
should the nurse perform?
A. Comprehensive
B. Focused
C. Ongoing

Small Group Questions


2. Which of the following are objective data and
which are subjective data.
A. Nausea
B. Vomiting
C. Unsteady gait
D. Anxiety
E. Bruises on the right arms and face
F. Temperature 101 F

Diagnosis
Step 2 in the nursing process
Formulating a nursing diagnosis
Analysis and synthesis of data

Nursing diagnosis:
A clinical judgment about individual, family or
community responses to actual or potential heal
problems / life processes.
A nursing diagnosis provides the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is accountable.

Medical vs. Nursing diagnosis


Medical diagnosis

Nursing diagnosis

Identifies conditions the


MD is licensed &
qualified to treat

Identifies situations the


nurse is licensed &
qualified to treat

Medical vs. Nursing diagnosis


Medical diagnosis

Nursing diagnosis

Identifies conditions the


MD is licensed &
qualified to treat

Identifies situations the


nurse is licensed &
qualified to treat

Focuses on illness,
injury or disease
processes

Focuses on the clients


responses to actual or
potential health / life
problems

Medical vs. Nursing diagnosis


Medical diagnosis

Nursing diagnosis

Remains constant
until a cure is
effected

Changes as the clients


response and/or the health
problem changes

Medical vs. Nursing diagnosis


Medical diagnosis

Nursing diagnosis

Remains constant
until a cure is
effected

Changes as the clients


response and/or the health
problem changes

i.e. Breast cancer

i.e. Knowledge deficit


Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective

Nursing diagnosis
Diagnosis

Medical diagnosis

Breathing patterns,
ineffective

Chronic obstructive
pulmonary disease

Activity intolerance

Cerebrovascular accident

Pain

Appendectomy

Body image disturbance

Amputation

Body temperature, risk for


altered

Strep throat

Planning & Outcome identification


Step 3
Types of planning
Initial planning
Ongoing planning
Discharge planning

Planning & Outcome identification


Identifying outcomes
Goals
An aim, intent or end.

Short term goals


Hours to days (less than a week)

Long term goals


Weeks to months

Planning & Outcome identification


Developing specific nursing interventions
Independent nursing interventions
No order needed
Elevate edematous legs

Interdependent nursing interventions


In conjunction with an interdisciplinary team member
Assist client with physical therapy exercises

Dependent nursing interventions


Require an order
Administering of medications

Prioritizing the nursing diagnosis


Maslows hierarchy of needs

Maslows Hierarchy of Needs

General Guidelines for Setting Priorities


1. Take care of immediate
lifethreatening issues.
2. Safety issues.
3. Patient-identified issues.
4. Nurse-identified priorities based on the overall
picture, the patient as a whole person, and
availability of time and resources.

Nurse Identified Priorities


Composite of all patients strengths and health
concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.

Identifying Client-centered Outcomes


State what the patient will do
or
experience at the completion
of care.
Give direction to the patients
overall
care.
Patient behaviors not nurse behaviors!!
The patient will

Nursing Interventions

1.
2.
3.
4.
5.

Road maps directing the best ways to provide


nursing care.
Evidence based nursing.
Monitor health status.
Minimize risks.
Resolve or control a problem.
Assist with ADLs.
Promote optimum health and independence.

Interventions
Direct interventions: actions performed
through interaction with clients.
Indirect interventions: actions performed
away from the client, on behalf of a client or
group of clients.

Implementation
4th step:
Execution of the nursing care plan
Delegation

DO IT
DO IT RIGHT
DO IT RIGHT NOW!

Evaluation
5th step
Determining
whether the clients
goals have been
met, partially met or
not met.

Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting outcome
achievement
3. Deciding whether to continue, modify, or
terminate the plan

Determining Outcome Achievement

Must be aware of outcomes set for the client.


Must be sure patient is ready for evaluation.
Is patient able to meet outcome criteria?
Is it:
Completely met?
Partially met?
Not met at all?
Record in progress in notes.
Update care plan.

Predict, Prevent, and Manage

Focus on early intervention


Based on research
Predict and anticipate problems
Look for risk factors

Documenting the Plan of Care

1.
2.
3.

To ensure continuity of care, the plan must be


written and shared with all health care personnel
caring for the client.
Consists of:
Prioritized nursing diagnostic statements.
Outcomes.
Interventions.

Documentation
Clear and concise
Appropriate terminology
Usually on a designated form

Physical assessment
Usually by Review of Systems

Overview of symptoms
Diet
Each body system

THANK YOU..
KEEP PRACTISING!!!