Nursing process by raj kumar mehta

Nursing Process
 Nursing Process – Objectives
 Benefits of Nursing Process
 Steps of the Nursing process
 Characteristics of the Nursing Process
 Benefits of Using the Nursing process
 What are your responsibilities
 Nursing diagnosis
 Medical Vs nursing diagnosis

 Characteristics of nursing diagnosis
 Format of nursing diagnosis
 Taxonomy of nursing diagnosis
 Outcome identification
 Establish client goals and outcome criteria
 Types of nursing plan of care
 Writing nursing plan of care
Nursing Process…

 A Hospital may be soundly organized,
beautifully situated and well equipped,
but if the
nursing care is not of high quality
the hospital will fail in its’
responsibility.
- Jean Barrett

Nursing process
 Nursing
 Unique function of the nurse is to assist the
individual, sick or well, in the performance of
those activities contributing to health, or its
recovery, (or to peaceful death) that he/she would
have performed unaided if he/she had the
necessary strength, will or knowledge and to do
this in such a way as to help him/her gain
independence as rapidly as possible
-Henderson, 1966, p. 15

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Definition of the Nursing…

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Definition of the Nursing…

Unique function of Nurse…
 In a passage so lovely that it is almost poetry,
Henderson translates this unique function:
 “The nurse is temporarily the consciousness of the
unconscious,
 the love of life for the suicidal,
 the leg of the amputee,
 the eyes of the newly blind,
 a means of locomotion for the infant,
 knowledge and confidence of the young mother, and
 the voice for those too weak or withdrawn to speak”.

 Process:-

Process (Nursing) is not what the nurse does,
but it is the methodby which the
nurse practices.
Nursing process…

Nursing process…
 It is a systematic method by which nurses
plan and provide care for clients.
 This involves a problem solving approach
that enables the nurse to identify client
problems and needs and to plan, deliver,
and evaluate nursing care in an orderly,
scientific manner.

 The framework of the nursing process
enables the nurse to focus on client
needs and to apply the broad Base of
nursing knowledge in an organized
fashion.
Nursing process…

Thus, The Nursing Process…
 An “organizational framework” for the
practice of nursing
 Orderly, systematic
 Central to all nursing care
 Encompasses all steps taken by the nurse
in caring for a patient

Definition of the Nursing Process
 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 and others.

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
 Is economical
 Stresses the independent function of nurses
 Increases care quality through the use of
deliberate actions

The Nursing Process Utilizes The
Following
 Assessment
 Nursing Diagnosis
 Planning
 Implementation
 Evaluation

Characteristics of the Nursing Process
 Within the legal scope of nursing
 Based on knowledge-requiring critical
thinking
 Planned-organized and systematic
 Client-centered
 Goal-directed
 Prioritized
 Dynamic

Benefits of using the nursing process
 Continuity of care
 Prevention of
duplication
 Individualized
care
 Standards of care
 Increased client
participation
 Collaboration of
care

Being Accountable – how ???
 Using critical thinking before taking
actions
 Being responsible for your actions
 Entering the professional role
 Working at the level of your peers
 By Using the nursing process

Something to think about:
 Nurses are responsible for a unique
dimension of healthcare – “ the diagnosis
and treatment of human responses to
actual or potential health problems”

MARTHA ROGERS,
NURSE THEORIST
 “When an apple is cut, others see
seeds in the apple. We, as nurses,
see applesin the seeds.”

What Are Your Responsibilities?
 Recognize health problems.
 Anticipate complications.

Initiate actions to ensure appropriate
and timely treatment.
 Begin to think CRITICALLY !!!!!!

Critical Thinking
 MENTAL OPERATIONS –decision making
& reasoning
 KNOWLEDGE-having the facts &
understanding the reason behind the
knowledge
 ATTITUDES- curious/open-minded/non-
judgmental….

Critical Thinking…
 Critical thinking in nursing is an essential
component of professional
accountability and quality nursing
care.
 Critical thinking is careful, deliberate, and
goal directed.

Steps of the Nursing process
1.
Assessment
1.
Assessment
Data collection
History and
physical examination
Assessment

2.
Diagnosis
2.
Diagnosis
-analysis of data
(nursing
perspective)
- Formal
statements of
client’s (actual &
potential health
problems)
Steps of the Nursing process…

3.
Planning
3.
Planning
4.
Implementat
ion
4.
Implementat
ion
5.
Evaluation
5.
Evaluation
Steps of the Nursing process…

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

Nursing Diagnosis
 Terminology used by professional nurses that
identifies actual, risk or wellness responses to a
health state, problem or condition
 Terminology used by professional nurses that
identifies a person’s, family’s, or community’s
motivation and desire to increase wellbeing and
actualize human health potential

Comparisons
 Medical Diagnoses
 Chronic obstructive
pulmonary disease
 Cerebrovascular attack
 Amputation
 Nursing Diagnoses
 Ineffective breathing pattern
 Activity intolerance
 Disturbed body image
 Readiness for enhanced
coping

Nursing Diagnosis: Definition
 The NANDA definition of a nursing diagnosis
was adapted from a national, Delphi study by
Dr. Joyce Shoemaker (1984)
 Nursing diagnosis is a clinical judgment about
individual, family, or community responses to
actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection
of nursing interventions to achieve outcomes for
which the nurse is accountable (NANDA, 1997).

Suggested Revision to Definition of
Nursing Diagnosis (2008)
 A nursing diagnosis is a clinical judgment that
nurses make about individual, family and
community responses to conditions/life
processes. Based on that judgment, the nurse
is responsible for monitoring of client
responses, decision-making culminating in a
plan of care, and implementing interventions,
including interdisciplinary collaboration and
referral as needed. The nurse is wholly or
partially accountable for the achievement of the
desired outcomes.

Medical Vs. Nursing Diagnosis
 Medical diagnosis describes a disease or
pathology of specific organs or systems
that treatment focuses on correcting or
preventing.
 Nursing diagnosis is actual, possible, or
wellness of human response to a health
problem that nurses are responsible for
treating independently.

 Nursing diagnosis describes client’s
response to disease process,
developmental stage or life process and
provide a way to communicate nursing
interventions.
Medical Vs. Nursing Diagnosis..

Medical Diagnosis
 Terminology used by physicians and
advanced practice nurses (nurse
practitioners) for a clinical judgment that
identifies or determines a specific disease,
condition, or pathological state

Characteristics of Nursing Diagnosis
 Nursing diagnosis provide a means for
communicating nursing requirements for
client care to other nurses, the health care
team, and public.
 Nursing diagnostic labels can serve as short
hand for specific client problems.
 Making accurate nursing diagnosis helps to
ensure that individual get quality nursing
care.

 Nursing diagnosis increases the specificity of
nursing interventions for the receiver of care.
 A cluster interpretation is synthesis of clue
clusters.
 Diagnostic validation occurs in two stages:
 Comparing the cluster with norms
 Evaluating the specific nursing diagnosis for its
particular research base.
Characteristics of Nursing Dx…

 Formulating the nursing diagnostic
statements involves the
 actual,
 risk,
 wellness, or

possible nursing diagnosis.
Characteristics of Nursing Dx…

Format of Nursing Diagnosis
Human response pattern
(there are 9 patterns)
Statement of diagnostic pattern
(there are 4 patterns)
Statement of nursing diagnosis
RATIONALE
Outcome identification and planning
Implementation and evaluation

Taxonomy of nursing diagnosis
 Exchanging
 Communicating
 Relating
 Valuing
 Choosing
 Moving
 Perceiving
 Knowing
 Feeling
Human response pattern

Exchanging
 Mutual giving / receiving ; physiologic in
nature
 Nutrition
 Physical regulations
 Elimination
 Circulation
 Oxygenation
 Physical integrity e.g. break in the skin etc.

Communicating
 Convey message verbally or
nonverbally.
 Impaired verbal communication
 Alteration in non-verbal communication.

Relating
 Establishing bond or to connect with
another thing, person or place.
 Socializing
 Parenting
 Sexuality

Valuing
 Assigning of relative worth; to equate
importance
 Spiritual distress
 Risk for spiritual distress
 Potential for enhanced wellbeing

Choosing
 Selection of alternatives; in accordance
with inclinations (attitude)
 Coping
 noncompliance

Moving
 Involves activity; ADLs, rest, recreation,
feeding, growth and development etc.
 Activity intolerance
 Impaired physical mobility

Perceiving
 Involves the reception of information; to
comprehend what is not open.
 Disturbance in body image, self esteem,
personal identity.
 Sensory perceptual alterations
 Hopelessness
 Powerlessness

Knowing
 Involves meaning associated with
information
 Knowledge deficit information
 Confusion
 Impaired memory
 Altered thought process

Feeling
 Involves subjective awareness of
information; fact, event or state,
mental/physical distress.
 Pain
 Grieving
 Post trauma syndrome
 Anxiety
 fear

Types of nursing dxtic statements
 Actual nursing diagnosis
 Three part statement
 Risk nursing diagnosis
 Two part statement
 Possible nursing diagnosis
 Two part statement
 Wellness nursing diagnosis
 One part statement

Nursing dx : Statement-1
 Actual nursing dx:
 Diagnostic label
 Related factors
 Defining characteristics (s/s)
 Stress incontinence related to weak pelvic
muscles, obesity, and gravid uterus as
evidenced by urine dribbling when coughing.
 Pain related to surgical trauma and
inflammation as evidenced by grimacing and
verbal reports of pain.

 Risk nursing dx:
 Risk factors
 Risk for infection related to surgery and immuno
suppression.
 Risk for activity intolerance related to prolonged bed
rest.

 Possible nursing dx:
 Related factors (may be unknown)
 Possible self esteem disturbance related to
unknown etiology.
 Possible impaired adjustment related to
unknown etiology

 Wellness nursing dx:
 Potential for enhanced parenting
 Potential for effective breast feeding
 Family coping potential for growth

Nursing diagnosis : Key points
 Collection of data provides basis for
identifying nursing dx.
 Only registered nurse (RN) will make nursing
diagnosis
 It is a clinical judgment about individual,
family, or community responses to actual or
potential health/life processes. Accountable

 Activities include pattern identification,
diagnostic evaluation, and formulation of
nursing dx
 Nursing diagnosis are organized as per the
human response pattern
Nursing diagnosis : Key points…

 Nursing diagnosis must be within scope of
education of nurse and the nurse must be
able to intervene legally and independent
of physician prescribed actions.
 Nurse is accountable to identify and treat
collaborative problems.

 Nursing dx consists of diagnostic label
definition, defining characteristics, risk
factors, related factors and qualifiers.
 A clue is a piece of information
(objective/subjective) collected during
information system
 A cluster interpretation is synthesis of clue
clusters.

 Diagnostic validation occurs in 2 – stages;
 1-comparing the cluster with norms,
 2-evaluating the specific nursing dx for its
particular research base.
 Formulating the nsg dxtic statements involves
the actual, risk, wellness or possible nsg dx.

Outcome identification
 Purposes:-
 Provide individualized care
 Promote client participation
 Plan care that is realistic and measurable
 Allow for involvement of support people

 Activities:-
 Establish priorities
 Establish client goals & outcome criteria
Outcome identification…

 Establish priorities:-
 High priority – transportation to O.T., inform
surgeon / O.T.
 Medium priority – quick history
 Low priority – blood
E.g. ER case –placenta previa pt.
(wheels within wheel)

 High priority:-
 Life threatening situations
 Difficulty in breathing
 Consent before test
 Something that needs immediate attention
 Preparation for a test
 Impending discharge
 Something that is very important to the client
 Anxiety
 Pain
(e.g., I want to see my child – you should arrange
it – Higher priority)

 Medium priority:-
 Problem that could result in unhealthy
consequences
 Physical / emotional impairment but not likely to
threaten life
 Fatigue
 Stress incontinence
 Dysfunctional grieving
 Priority to be assigned as per the significance
from assessment data

 Low priority:-
 Problems that could be resolved easily with
minimal interventions
 Have little potential to cause significant
dysfunction for the client
 High likely hood for being resolved
 Post-operative pain, client refusing to ambulate
 Ambulation is priority for nurse, where as pain is priority
for client.
 Therefore, care to be given after discussion with
client.

Establish Client Goals & Outcome
Criteria
 Client goals:-
 Goal is a educated guess (on the basis of some
facts) of what the clients state will be after the
nursing intervention is carried out.
 It is directly addresses the problem stated in
nursing diagnosis.
 Goal has action verb and the qualifier (level of
performance)

 Qualifier:-
 Within 5 min……….↓
 If not achieved set other objective &
immediately act.
 Goal : client demonstrates correct skin
care procedure.
Establish Client Goals & Outcome
Criteria…

Outcome criteria
 Are specific measurable, realistic statements of goal
attainment.
 Subject:- Who will achieve the goal?
 Verb:- What actions will be taken to achieve the
goal?
 Condition:- Under what circumstances the action
will be performed.
 Criteria:- How well the action will be performed?
 Specific time:- When the action is to be
performed?

Outcome criteria…
The client (who)
verbalizes (What action)
three dietary modifications of a low salt diet to his wife
(under what
circumstances)accurately (how well)
after the teaching session (When)

Types of Nursing Plan of Care
 Instructional nursing plan of care
 Giving instruction to other
 Other have to give care e.g., position to be
changed instead change of position
 Clinical nursing plan of care
 Individualized plan of care
 Standardized plan of care
 Generic plan of care
 Computerized plan of care
 Collaborative care plan: critical pathways

Implementation of nursing plan of care
 Implementation skills
 Intellectual skills
 Interpersonal skills
 Technical skills
 Implementation activities
 Reassess
 Set priority
 Perform nursing intervention

Implementation Activities
 Not a easy job
 Cognitive intervention
 Educational (thinking process)
 Supervisory
 Interpersonal Intervention
 Coordinating
 Supportive
 Psychosocial
 Technical Intervention (Dealing with machinery)
 Surveillance
 Maintenance

Evaluation
 Evaluation skills:-
 Knowledge of standards of care
 Knowledge of normal client response
 Knowledge of conceptual models & theories
 Ability to monitor effectiveness of nursing
interventions
 Awareness of clinical research (match your
practice at present )

Types of evaluation
 Structure evaluation – facilities
 Process evaluation – injection given
but unsterile
 Outcome evaluation – activities done
but pts behaviour not changed

Writing Nursing Plan of Care
 Planning Nursing Intervention
 Writing Nursing Plan of Care

Planning Nursing Interventions
 Any treatment based upon clinical
judgment and knowledge, that a nurse
performs to enhance client outcomes.

 Purposes:-
 Direct client care activities
 Promote continuity of care
 Focus charting requirements
 Allow for delegation of specific activities
Planning Nursing Interventions…

Taxonomy of Nursing Interventions
 Six domains:
 Physiologic : Basic – hygiene, comfort,
positioning
 Physiologic : Complex – O2
 Behavioural
 Safety
 Family
 Health systems

Types of Nursing Interventions
 Psychomotor
 Positioning, inserting, applying
 Psychosocial
 Supporting, exploring, encouraging
 Educational
 Demonstrating, teaching, observing, return
demonstration

 Maintenance
 Skin care, hygiene
 Surveillance
 Detecting changes
 Supervisory
 Other health care providers
 Socio-cultural
 Spending time, incorporating cultural differences
in care regimens.
Types of Nursing Interventions…

Writing Nursing Plan of Care…
 Plan of care is nursing centered
 Plan of care is step by step process
 Sufficient data are collected to substantiate
nursing diagnosis
 At least one goal must be stated for each
nursing diagnosis
 Outcome criteria must be identified for each
goal

 Each intervention must be specially deigned
to meet the identified goal.
 Each intervention must be supported by
scientific rationale.
 Evaluation must address whether each goal
was completely/partially met or unmet or not
at all.
Writing Nursing Plan of Care…

Types of Plans
 Narrative
 SOAP : Subjective data – Objective data
Assessment – Plan
 SOAPIE : Subjective/Objective/Assessment/Nursing
Diagnosis/Plan/Goals/Intervention/Rationales/Evalu
ation
 PIE : Problem – Intervention – Evaluation
 FOCUS : Data – Action – Response
 CBE : Charting By Exception

CBE—What is it?
 Charting by exception (CBE) is a shorthand
method of documenting normal findings,
based on clearly defined normals, standards
of practice, and predetermined criteria for
assessments and interventions. Significant
findings or exceptions to the predefined
norms are documented in detail.
 Murphy and Burke, 1990

Benefits of CBE
 Standards allow for consistent quality of care
and documentation within organization
 Abnormal findings are highlighted
 Repetitive documentation of routine care is
eliminated through use of standards
  documentation time

What are your views on Nursing/
Nursing Process ?
Is it an art ? science?or

The Future Face of
Nursing Education &
Practice

Nursing process by raj kumar mehta

Nursing process by raj kumar mehta

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