1. Nursing Process

2. Back Ground
The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing.
From her observations she learned that the patient must be the central character.
Nursing care needs to be directed at improving outcomes for the patient, and not about nursing goals.
The nursing process is an essential part of the nursing care plan.

3. Definition of the Nursing Process:
An organized sequence of problem-solving steps used to identify and to manage the health problems of clients
A systematic, rational method of planning and providing individualized nursing care.

4. Purposes of Nursing Process
1- Identify a client health status and actual or potential health care problems and needs.
2- Establish plans to meet the identifying needs.
3- Deliver specific nursing intervention to meet needs.

5. Characteristics a. Systematic b. Dynamic d. Goal-directed
The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it.
b. Dynamic
The nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity
c. Interpersonal
The nursing process ensures that nurses are client-centered rather than task-centered and encourages them to work to enhance client’s strengths and meet human needs
d. Goal-directed
The nursing process is a means for nurses and clients to work together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions
e. Universally applicable
The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting

6. Benefits of Nursing Process
Provides an orderly & systematic method for planning & providing care.
Enhances nursing efficiency by standardizing nursing practice.
Facilitates documentation of care.
Provides a unity of language for the nursing profession.
Stresses the independent function of nurses.
Increases care quality through the use of deliberate actions.

7. 5 Steps of the Nursing Process:
Assessment
Diagnosis
Planning
Implementing
Evaluating

8. Diagnosis
Diagnosis

9. 1st Step of the Nursing Process ASSESSMENT:
1. Objective data-observable and measurable facts (Signs)
Main way to collect objective data:
Physical assessment
Lab and diagnostic testing
Patient record
Is a systematic collection of facts or data
Types of Data

10. Assessment
2. Subjective data-information that only the client feels and can describe (Symptoms)
Primary source - the client’s point of view, Feelings, Perceptions, Concerns
Usually BEST source
Main way to collect subjective data:
Interview with Family & significant others
When patient is a child or impaired adult
Spouses
Consider confidentiality when including friends

11. Subjective VS. objective
Example:
Patient comes to the ER because he cannot move his arm, stating, “it happened about an hour ago when headache got worse. Now I’m nauseated and dizzy”. (Subjective)
The nurse takes his vital signs: T 37.9, P 100, BP 170/95, and observes that he cannot move his left arm and his face is flushed. (objective)

12. Assessment Sources of Data Primary sources Secondary sources Client
Interview
Physical examination & vital signs
Secondary sources
Family members
Other health care providers
Medical records
test results

13. Assessment Step #1 Involves Collecting data (from variety of sources)
Validating the data
Organizing the data Grouping of related information
Organization of assessment data into small groups to be analyzed
Interpreting the data
Documenting the data

14. Assessment Data Collection
4/16/2017
Assessment
Data Collection
Assessment involves taking vital signs (TPR BP & Pain assessment.
Performing a head to toe assessment
Listening to the patient's comments and questions about his health status
Observing his reactions and interactions with others. It involves asking pertinent questions about his signs (observable) and symptoms (Non-observable), and listening carefully to the answers.

15. Data Collection Demographics Medical history Habits
Medications, allergies
Environmental/familial factors
Potential for injury
Ability to participate in plan of care

16. Assessment Types of Assessment: Comprehensive Assessment
Focused Assessment
Ongoing Assessment

17. Types of Assessment 1. Comprehensive assessment “Initial”
Performed on entry to healthcare facility
Information you gather on initial contact with the person to assess all aspects of health status is the Baseline.
Often includes:
Health history
Physical exam and
psychosocial assessment

18. Types of Assessment 2. Focused Assessment
The data you gather to determine the status of a specific condition.
Occurs after initial assessment and period of time.
Limited in scope
Screening for a specific problem
Short stay

19. Types of Assessment 3. Ongoing assessment Follow-up
Monitoring and observation related to specific problems

20. ASSESSMENT Observation Interview Physical Examination
Is a systematic data collection method that uses the senses of sight, hearing, smell, and touch to detect health problems. Four techniques are used: inspection, palpation, percussion, and auscultation
A physical assessment may be carried out before, during, or after the health history, depending on a patient’s physical and emotional status and the immediate priorities of the situation.

21. Physical Assessment Techniques
1. Inspection – critical observation “to see”
Take time to “observe” with eyes, ears, nose
Use appropriate lighting
Look at color, shape, symmetry, position
Odors from skin, breath, wound
Provide privacy for client
Expose body areas adequately
Use instruments when appropriate, i.e. otoscope, ophthalmoscope, penlight
Inspection is done alone and in combination with other assessment techniques

22. Physical Assessment Techniques
2. Palpation - light and deep touch
Uses the sense of touch
Back of hand to assess skin temperature
Fingers to assess texture, moisture, areas of tenderness
Assess organ location, size, shape, and consistency of lesions, swelling, masses, and tenderness.
Palpation requires a calm, gentle approach and is used systematically, with light palpation preceding deep palpation and palpation of tender areas performed last.

23. Physical Assessment Techniques
3- Percussion – to tap
Uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. It is used for assessing the density of structures or determining the location and the size of organs in the body.

24. Percuss – to tap
Percussion Sounds - elicits 4 percussion notes on selected body surfaces
Flatness (thigh muscle) elicit and describe sound
Dullness (liver) elicit and describe sound
Resonance (normal lung) elicit and describe sound.
Tympani (gastric air bubble) elicit and describe sound

25. Physical Assessment Techniques
4- Auscultation - listening to sounds produced by the body that are created by movement of air or fluid.
Direct auscultation – sounds are audible without stethoscope
Indirect auscultation – uses stethoscope

26. Assessment techniques - Cont. Auscultation
Instrument: stethoscope (to skin)
Diaphragm –high pitched sounds
Heart
Lungs
Abdomen
Bell – low pitched sounds
- Blood vessels

27. Nursing Diagnosis Step 2 in the nursing process
The purpose of this stage is to identify the patient's nursing problem
Nursing diagnosis: actual or potential health problems that can be managed by independent nursing interventions .

28. It contains three parts:
Problem: Name of the health-related issue or problem
Etiology: (its cause)
Sign and symptom
It called PES system.
The name of the nursing diagnosis is linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by”

29. Writing Diagnostic Statements
Problem
Related To
Etiology As
manifested By
Signs &
Symptoms
Diagnostic
Label
Contributin g Factors
Nursing Diagnosis
Prioritize the problems
Not a medical diagnosis

30. Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
physician "clinical judgment of the disease- i.e. diabetes mellitus.
statement used to describe the client's actual or potential response to a health problem that a nurse is licensed and competent to treat i.e.-Impaired skin integrity, Risk for Infection, etc.
Focuses on illness, injury or disease processes
Focuses on the clients responses to actual or potential health / life problems

31. 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

32. Examples of Diagnosis Nursing diagnosis Medical diagnosis
Breathing patterns, ineffective
Chronic obstructive pulmonary disease
Activity intolerance
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Self-care deficit: bathing, related to joint stiffness
Rheumatoid Arthritis

33. Planning & Outcome identification
Step 3
Types of planning
Initial planning
Ongoing planning
Discharge planning

34. Planning
The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care.
The nurse consults with the client while developing and revising the plan.
Determine problems that require immediate action

35. Short-Term Goals Long-Term Goals
Outcomes achievable in a few days or 1 week
Developed from the problem portion of the diagnostic statement
Client-centered
Measurable
Realistic
Accompanied by a target date
Long-Term Goals
Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems

36. Formula for Writing Goals/Outcomes:
Goal statement (long or short term) = patient behavior + criteria + time + conditions (if needed)
1. Subject -patient
2. Verb -action/behavior which pt performs
3. Criteria -acceptable performance
4. Within specified time period
5. Condition (if needed) circumstances under which behavior performed
Example:
The patient (1) will walk (2) the length of the hall (3) with a walker (5) by the end of the shift (4).

37. Prioritizing the nursing diagnosis
Maslow’s hierarchy of needs

38. Priorities are classified:
High: nursing diagnosis that if untreated, could result in harm to the client or others have the highest priority
Intermediate: nursing diagnosis involves the non-emergency, non-life threatening needs of the clients
Low: nursing diagnosis are client’s needs that may not be directly to a specific illness or prognosis

40. Implementation DO IT DO IT RIGHT DO IT RIGHT NOW!
4th step of Nursing Process:
Put the plan of nursing care into action
DO IT
DO IT RIGHT
DO IT RIGHT NOW!

41. Nursing Implementation
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.

42. Evaluation 5th and final step
It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care.
Determining whether the clients goals have been met, partially met or not met.

43. Example:
NURSING DIAGNOSIS: Disturbed Sleep Pattern
Goal: Client will sleep uninterrupted for 6 hours.
EXPECTED OUTCOMES
• Client will request back massage for relaxation.
• Client will set limits to family and significant other visits.