2. Defines Nursing as:
the diagnosis and treatment of
human responses to actual or
potential health care
problems.

4. a problem solving approach for
gathering data, identifying a
person’s needs, selecting and
implementing approaches for
nursing care and evaluating
outcomes of care given.

5. Steps of Nursing
Process:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

6. RATIONALE FOR USING NURSING PROCESS:
 requirement – national practice standards
 preparation for NCLEX
 promotes critical thinking
 means of communication
 results in an individualized plan of care

7. 7

8. 1. a. Interviewing patient & family
– chief complaint
b. Nursing History:
- support system
- health
- ADL’s
- feelings/concerns
- culture
- occupation
- financial concerns

9. 2. Observation & Measurement:
A 'sixth
sense?' Or
merely
mindful
caution?

10. 3. REVIEW OF THE
RECORDS
1. DOCTOR’S ORDERS
2. PROGRESS NOTE
3. HISTORY/PHYSICAL
4. NURSING NOTES
5. CONSULTATION
6. DIAGNOSTIC STUDIES
7. LAB RESULTS
10

11. 4. Physical Assessment /Examination
GENERAL SURVEY
VITAL SIGNS
HEAD & NECK
UPPER EXTREMITIES
ANTERIOR & POSTERIOR
THORAX
ABDOMEN
LOWER EXTREMITIES
PELVIS & PERINEUM
MOTOR/SENSORY/SPINE
SKIN
11

12. Cluster Data According To Body
Systems
• Visual & Auditory • Question:
• Respiratory After gathering and clustering
• Cardiovascular all your data, in which areas or
systems are you seeing
• Gastrointestinal abnormal findings? These
• Nervous systems become your priority
assessment areas for a
• Musculoskeletal focused assessment or on-
• Urinary going evaluation
• Reproductive
• Hematological
• Endocrine
• Integumentary
12

13. Data Classification:
#1 What are symptoms and signs:
- Sign : aka - objective data –
what you observe
- Symptom: aka – subjective data –
what the person states
#2 Adaptive vs ineffective responses
#3 Identify the causative factors or
etiology
13

14. AKA
PROBLEM
IDENTIFICATION
14

15. CLINICAL JUDGMENT
• IS AN OPINION THAT THE NURSE MAKES BASED ON THE
CLINICAL DATA OBTAINED;
Clinical judgment allows the nurse to identify, associate and interpret
the signs and symptoms of a given condition
NURSING DIAGNOSIS
• IS A CLINICAL JUDGMENT ABOUT AN
INDIVIDUAL’S RESPONSES TO ACTUAL OR
POTENTIAL HEALTH PROBLEMS.

16. CLINICAL JUDGMENT PROCESS – How
to arrive at a Nursing Diagnosis:
Reasoning Critical Nursing
Thinking Diagnosis
/Clinical
Judgment
Knowledge & experience

17. NURSES ARE RESPONSIBLE FOR PROVIDING TREATMENT
FOR IDENTIFIED DIAGNOSES –
…. “actual or potential health problems that nurses by
value of their education and experience are able, licensed
and legally responsible and accountable to treat”.
ANXIETY IMPAIRED MOBILITY

18. TYPES OF NURSING DIAGNOSES
1. ACTUAL
GWC
2. RISK FOR & HIGH RISK FOR
3. POSSIBLE
4. WELLNESS
5. SYNDROME

19. MAKING A NURSING DIAGNOSIS:
A. 1. After gathering data, cluster signs
and symptoms
2. Next identify causative factors
for these signs and symptoms
3. Select a Nursing Diagnosis based
on them
V Klein

20. A 32 year old woman has a fractured leg with
a cast and she does not know how to use her
crutches. She expresses concern that she
“will be confined to bed or a chair and not be
able to get around and care for her 4 year
old son”.
-Fractured leg
- immobilized by a Cast
-Does not know
how to use
Impaired physical mobility
crutches
- Verbalizes concern that
she will be confined and not be able to
care for her 4 year old son
Ineffective Role
Performance
V Klein

21. MAKING A NURSING DIAGNOSIS: cont.
B. Confirm by checking with Carpenito
1. Read the definition
2. Read the defining characteristics –
at least one major

22. MAKING A NURSING DIAGNOSIS: cont.
C. Factors that cause or contribute to the
problem are called Related Factors in
Carpenito – divides them into 4 groups
1. pathophysiological
2. treatment related
3. situational (personal or
environmental)
4. maturational
V Klein

23. Fractured
leg cast
Pathophysiological Treatment
related
Impaired
physical
mobility
Situational Maturational
Lack of none
knowledge

24. MAKING A NURSING DIAGNOSIS: cont.
D. Look at all the causes (aka
related factors) and determine
which is the primary cause of
the problem.
The primary cause or related factor becomes
the second part of the diagnosis which is called
the “related to”
(note: the R/T must be something the
Nurse can treat independently)
V Klein

25. CONNECT THE PROBLEM WITH THE
PRIMARY RELATED FACTOR USING THE
LETTERS R/T:
IMPAIRED PHYSICAL MOBILITY R/T
INSUFFICIENT KNOWLEDGE OF ADAPTIVE
TECHNIQUES IN USE OF CRUTCHES FOR
AMBULATION.

26. A Nursing Diagnosis is one that nurses can
treat independently and one that does not
require medical intervention
Collaborative problems are certain
physiologic complications that nurses
monitor to detect onset or change in
status; collaborative problems require
nursing and medical intervention

27. Nurses cannot prevent a collaborative problem but they
can detect it early to reduce its seriousness - eg monitoring
a dressing closely for signs of bleeding.
Nurses can prevent certain physiological problems and these
can be identified as Risk for Nursing Diagnoses -egs:
Pressure Ulcers - Risk for Impaired Skin Integrity
Aspiration - Risk for Aspiration
Problems that nurses can treat independently are identified
as Nursing Diagnoses – egs
Ineffective cough - Ineffective Airway Clearing
Stage 1 & 2 pressure ulcers - Impaired Skin Integrity

28. JUST CHECKING TO SEE IF YOU ARE AWAKE 
V Klein

29. 1. When a medical diagnosis is a related
factor, avoid writing it as your R/T
( remember your R/T must be
something you can treat independently
as a nurse)
Eg. Anxiety R/T Cancer
Instead ask what/how has the medical
diagnosis caused or contributed to the
problem V Klein

30. WRITTEN CORRECTLY:
Anxiety R/T perceived/actual
losses secondary to cancer
(Treatment related – loss of hair; financial
etc)
V Klein

31. 2. When writing the R/T avoid using signs
and symptoms – they result from the
problem rather than cause or
contribute.
Eg. Disturbed sleep pattern R/T difficulty
falling asleep.
V Klein

32. CORRECT DIAGNOSIS:
Disturbed sleep pattern R/T environmental
changes due to hospitalization – noise, frequent
interruptions
V Klein

33. 3. Do not use a goal as your R/T.
Impaired parenting R/T parents should
spend more time holding infant
CORRECT DIAGNOSIS:
Impaired parenting R/T a lack of
knowledge regarding infant care and
needs.

34. CORRECTLY WRITTEN ??
Disturbed Body Image R/T Breast Cancer
Disturbed Body Image R/T changes in
appearance secondary to Chemo therapy
Or
Disturbed Body Image R/T a change in
appearance secondary to loss of left breast

35. CORRECTLY WRITTEN ?
Grieving R/T crying and inability to sleep
Grieving R/T losses associated with death of ….
( companionship, financial etc)
V Klein

36. CORRECTLY WRITTEN ?
Ineffective Airway Clearance R/T rhonci bilaterally
Ineffective Airway Clearance R/T inability to maintain an
upright position
OR
Ineffective Airway Clearance R/T thick , tenacious secretions
secondary to inadequate fluid intake.

37. CORRECTLY WRITTEN ?
Imbalanced Nutrition: Less than body requirements R/T
Chemotherapy
Imbalanced Nutrition: Less than body requirements R/T
decreased desire to eat secondary to side effects of chemotherapy
OR
R/T mouth discomfort associated with Chemotherapy
V Klein

38. WHAT IS WRONG WITH THIS DIAGNOSIS??
Risk for Constipation R/T reports of hard dry stool
“ Reports of hard dry stool” is a symptom – therefore it
no longer is a Risk for problem
If the symptom did not exist and the patient had risk
factors :
Risk for constipation R/T side effects of analgesics
Risk for constipation R/T effects of anesthesia and
surgical manipulation.
R/T effects of immobility on peristalsis

39. C. PLANNING – AKA GOAL
SETTING
WHEN WRITING GOALS,THE
FOCUS IS ON CHANGING THE
ABNORMAL SIGNS & SYMPTOMS
Client goals are used to:
1. direct interventions
2. evaluate the effectiveness of
the interventions

40.  S SPECIFIC
 M MEASURABLE
 A ATTAINABLE
 R REALISTIC
 T TIMELY

41. RULES FOR WRITING GOALS:
1. a. Start out with the phrase: The client will
demonstrate….
b. The first part of the goal needs to reflect the
nursing diagnosis
2. This is followed by AEB and 2-3 goal criteria.
a. Goal criteria must reflect desired
changes in the signs and symptoms listed.
b. Criteria must be observable and/or
measureable
3. Always end with one realistic time frame

42. Disturbed sleep pattern R/T environmental
changes due to hospitalization – noise,
frequent interruptions
Symptoms/Subjective Data :
“I can’t fall asleep here and when I do
someone or something always wakes
me up.”
Signs/Objective Data:
Refuses to participate in self-care
measures. Irritable and sarcastic
when talking to family members and
staff

43. Client will demonstrate an improved sleep pattern
AEB:
 Verbalizing that he/she was able to fall and stay
asleep throughout the night
 Participating in morning hygiene – teeth
hair, shower
 Communicating in a pleasant manner with
family members and staff
- within 48 hours

44. D. Implementation- AKA
interventions
Three components:
1. must use an action verb
2. state where, what, how, how much and how
far
3. time element – when, how often and how
long
Types:
Assess, Care, Manage, Teach

45. E. EVALUATION-
results/effects
The final step is to determine if
your patient’s goal has been met.
Look at your goal criteria to do this.
If criteria not met, remember that
the Nursing Process is a circular
process – it begins and ends with
assessment.

46. THE
END
V Klein