concept of nursing process, data collection, nursing care plan

1. NURSING PROCESSNURSING PROCESS

2. INTRODUCTION
The nursing process provides a useful
description of how nursing should be
performed. Practice of nursing is
caring which is directed by the way
the nurses view the client, the
client’s environment, health and the
purpose of nursing.

3. HISTORY
• First described by Hall in 1955 as a
three step process.
• In 1967, Yura and Walsh added
assessment to the three steps.
• In the mid-1970s an addition of
diagnostic phase resulted into a five
step process.

4. CONCEPT OF NURSING
PROCESS
The basic concepts were:
• Nursing,
• Person,
• Environment
• Health

5. DEFINITION
• Nursing Process (NP) is defined as a
systematic, continuous and dynamic
method of providing care to clients.
It comprises series of sequential
phases built upon the preceding step.
Each phase logically leads to the
next.

6. PHASES
• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation

8. Assessment – The nurse gathers subjective &
objective information from the client & other
sources in order to understand the client’s
situation.
2. Nursing Diagnosis –Organizes (in
collaboration with the client), interprets the
data and makes nursing diagnosis/diagnoses,
which is nursing’s perspective on the
appropriate focus for client nursing care.
3.Planning- Sets, in collaboration with client,
mutually agreed upon goals of care, desired
outcomes strategies to achieve goals of care &
the identification & prioritization of
appropriate nursing actions.

9. 4.Intervention- Perform the
nursing actions identified in
planning.
5.Evaluation- Determine if the
goals are met and outcomes
achieved.

10. PURPOSES/USES
• It makes client and family feel
important and participative
• It is a time saving device
• It avoids unnecessary nursing
actions.

11. Benefits of Nursing
Process
• Provides an orderly & systematic
method for planning & providing
care
• Enhances nursing efficiency by
standardizing nursing practice
• Facilitates documentation of care

12. • 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

13. CHARACTERISTICS
• Dynamic and Cyclic
• Client-centered
• Planned and Goal-directed
• Universally Applicable
• Problem-oriented
• Cognitive Process

14. • Dynamic and Cyclic
The dynamic nature involves continuous
assessment and evaluation of changing
client’s responses to nursing
interventions so as to achieve the
outcomes.
• Client-centered
The plan of care is organized in terms
of client problems rather than nursing
goals. The nurse-client relationship is
shaped around the needs of the client.

15. • Planned and Goal-directed
Interventions are considered according
to the nursing diagnoses and are based
on scientific principles rather than
tradition.
• Universally Applicable
Nursing process can be used with
clients of any age, with any medical
diagnosis, and at any point on the
wellness-illness continuum.

16. • Problem-oriented
Care plans are organized according to
client’s problems. Interventions are
carried out to eliminate the problems
related to any aspect of an individual.
• Cognitive Process
Nursing process involves the use of
intellectual skills in making judgments,
decisions and eliminating client’s
problems.

17. FACTORS AFFECTING
NURISNG PROCESS
• Knowledge
• Skill
• Beliefs

18. Knowledge:
Nursing process is the application of
the nurses’ knowledge. As part of
her/his academic preparation nurse
learns basic concepts of biochemistry,
biophysics, microbiology, anatomy,
physiology, psychology, sociology, and
nutrition. The knowledge of these
sciences enables the nurse to recognize
the problem more clearly and also
determine how the client’s health is
getting disturbed.

19. • Skills:
Nurse uses technical and
interpersonal skills to collect
information about the client. The
effectiveness of the nursing process
depends on the intellectual
(cognitive) skills of the nurse that
she uses in creative and critical
thinking, and decision making.

20. • Beliefs:
The nurse’s personal belief about
nursing, health, the client as an
individual, as a health care consumer
forms the basis of nursing practice.
The nurse is also faced with a moral
and ethical dilemma of providing care
to such a client and his family
members.

21. Components of Nursing Process
1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation

22. Assessment
Assessment is the deliberate and
systemic collection of data to
determine client current and past
health status and copping pattern

23. Components of Assessment:
1. Collection of data
2. Verification of data
3. Organization of data
4. Recording of data

24. Types of Data
1.Subjective Data:
These are client’s perception about
their health problem. e.g. pain
2.Objective Data:
These data are observable and
measurable by data collector e.g. Vital
signs

25. Sources of data:
1.Primary Sources:
Client
2. Secondary sources:
– Family & significant others
– Health care team members
– Medical records
– Other records
– Literature review
– Nurses experience

26. Method of data collection
1. Observation
2. Interview technique
It is a organized conversation with the client
or family members to obtain the current
health information regarding patient.
3. Physical examination
4. Laboratory tests
5. Review of the records, books & related
literature

27. Interview technique
It is a organized conversation with the
client or family members to obtain the
current health information regarding
patient.
Phases of Interview:
1. Orientation phase
2. Working phase
3. Termination phase

28. 1. Orientation phase
It begins with the nurse’s introduction
with client which includes the nurse’s
name, position and explanation of
purpose of the interview. The nurse
client relationship is enhanced by the
professionalism and competence
conveyed by the nurse’s attitude,
manner & appearance

29. 2.Working phase
During the working phase of the
interview the nurse gather information
about the client’s health status. Nurse
use variety of communication
strategies such as listening,
paraphrasing, focusing, summarizing &
clarifying to facilitate communication
and ensure that nurse & client clearly
understood each other.

30. 3. Termination phase
• This phase also require skill on the part of
the interview . The client should be given
a clue that the interview is coming to an
end.
e.g. There are just two more questions or
We will be finished within 5 to 6 minutes
• This approach also gives the client an
opportunity to ask questions.
• The interview terminated in a friendly
manner

31. Elements for effective interview:
• Clear goal
• Aware about background of the client
• Self introduction
• Choose strategy
• Maintain rapport
• Confidentiality
• Recovery
• Closure

32. Types of Interview Technique:
1.Open ended questions:
It prompts clients to describe a situation in
more that one or two words. This questions
give chance to client to speak freely.
e.g.What do you know about your
condition?
How do you feel in hospital?

33. 2. Close ended questions:
It prompts client to give answer in only
one or more words
e.g. Do you have pain?
How many time you go for
toilet?

34. Validation of Data
• Data validation to be done to ensure its
accuracy
• Validation of collected data involves
comparing the data with other sources

35. Organization of data
• Clustering of data & arrangement in a
systematic and logical order which gives
clue for nursing diagnosis
e.g. Anger is a cue for the diagnosis
for anxiety, fear

36. Recording of data
• Documentation should be concise,
thorough and accurate
• Documentation depends upon the
institutional policy
• It is descriptive in nature

37. INTRODUCTION:
Nursing Process
Nursing
Diagnosis

38. INTRODUCTION
From Assessment to Diagnosis
athering Data
alidating Data
rganizing Data
entify Data
eporting &
ecording Data
ANALYSIS AND
SYNTHESIS OF DATA
DIAGNOSIS

39. Nurses are Responsible
“Nurse are responsible and accountable for
diagnosing actual and potential health
problem and initiating action to ensure
appropriate and finely treatment”

40. What Is Nursing Diagnosis (Dx)?
Has two related meanings:
• Nursing diagnosis is an action: the
process of analyzing assessment data
to arrive at a….nursing diagnosis!
• Nursing diagnosis is a label that
describes the patient’s response to an
actual or potential health problem

41. Medical Diagnosis Nursing
Diagnosis
• Describes a disease or
pathology
• Conditions MD treats
• MD cares for a pt with
Congestive Heart Failure
(CHF) – treats
pathology with meds,
oxygen, diet & fluid
restriction
• Describes pt’s response
to a health problem
• Situations RNs can treat
• Nursing dx describe pt’s
response to CHF: such
as:
Anxiety
Activity
Intolerance, Impaired
Peripheral Tissue
Perfusion,
Powerlessness

42. Nursing Diagnosis: The Action
• RN reviews assessment data to
identify patterns
• Subjective & objective “cues” are
organized into groups that seem to fit
together & indicate actual or potential
client problems (nursing dx)
• RN makes an educated hunch about
which nursing diagnoses might fit the
cue cluster
• Review the selected nursing diagnoses
to decide which is most accurate

43. Nursing Diagnosis: The Label
• North American Nursing Diagnosis Association
(NANDA): official organization responsible for
developing system of naming & classifying nursing
diagnoses
• Diagnostic label is often called a “NANDA”
• Each NANDA describes the essence
of the problem in as few words as
possible.

44. NANDA Definitions
Each NANDA-approved nursing diagnosis is
accompanied by a definition that describes its
characteristics:
– NANDA: Impaired Physical Mobility
– NANDA Definition: state in which a person
experiences or is at risk of experiencing
limitation of physical movement but is not
immobile

45. Types of Nursing Diagnoses
• Actual nursing diagnoses: patient has problem
• Risk diagnoses: patient is at risk for developing
the problem (Either begins with “Risk for” or
the definition will include “is at risk for”)
• Wellness diagnoses: patient functioning
effectively but desires higher level of wellness
• Others that you do not need to know:
– Possible diagnoses
– Syndrome diagnoses
– Collaborative problems:

46. Parts of a Nursing Diagnosis:
Defining Characteristics
• These are the signs & symptoms that validate that an
actual nursing diagnosis is present.
Major: at least one must be present to use the
nursing diagnosis
Minor: may not be present, but if it is, helps to
validate selecting the nursing diagnosis
• Defining characteristics are not present in ‘Risk’dx
because signs & symptoms don’t exist if the problem
hasn’t happened
.

47. Parts of a Nursing Diagnosis:
Related Factors or Risk Factors
• Related Factors: factors that contributed to the
development of
patient’s problem (nursing dx)
• Risk Factors: factors that increase the possibility of the
patient developing a problem
• Is a relationship rather than direct cause & effect (is
‘related to’ rather than ‘caused by’)
• Only one of these factors (risk or related) needs to be
present to justify use of the nursing dx

48. Nursing Diagnosis Action Revisited
• Make a hunch about which diagnosis might fit
• Read the diagnosis definition to see if it fits
• Check out the defining characteristics
•Major: one must be present
•Minor: if present may help confirm hunch
• Rule out any diagnosis for which your patient
does not meeting the defining characteristics

49. Formulating the Diagnostic Statement
• After identifying the best NANDA to describe
your patient’s problem...
• You need to formulate a “diagnostic statement”
– An actual diagnosis has a three-part
statement
– A risk diagnosis has a two part statement
– A wellness diagnosis has a one part statement

50. Actual Diagnostic Statement Three-Part Format
Three parts:
1 NANDA label
2 Related factors (follows NANDA & linked
by the words “related to”)
3 Defining characteristics (follows related
factors & linked by the words “as
manifested
by”)

51. Actual Diagnostic Statement Example
1 Impaired Physical Mobility
2 related to (r/t) decreased motor ability and
muscle weakness
3 as manifested by limited ROM
“Impaired Physical Mobility r/t
muscle weakness AMB limited ROM”

52. Risk Diagnostic Statement Two-Part
Format
Two parts:
• 1 NANDA label
• 2 Risk factors (follows NANDA label
and is
linked by the words related to)

53. Risk Diagnostic Statement Example
1 Risk for Impaired Physical Mobility
2 related to (r/t) full leg cast
“Risk for Impaired Physical Mobility
r/t full leg cast”

54. Clarifying the Related Factors
Part of the Diagnostic Statement
• You will often need to add words to the ‘related
to’ portion of an actual or a risk diagnostic
statement to clarify the origin of the problem
• These words always follow the ‘related to’ and
are linked with the words ‘secondary to’ (2°)
• NOTE: This is the only way a medical diagnosis
can ever be inserted into a nursing dx
statement

55. Examples: Adding a Secondary Factor to the
‘related to’ part of a Diagnostic Statement
for Clarity
• Impaired Physical Mobility r/t muscle rigidity
and tremors secondary to (2°) Parkinson’s
Disease AMB limited ROM and compromised
ability to move purposefully
• Risk for Impaired Skin Integrity r/t immobility
2° fractured hip

56. Wellness Diagnostic Statement
• Used when pt doesn’t have a health problem
but can attain higher level of health
• Is a one part statement consisting only of the
NANDA:
– Readiness for Enhanced Parenting
– Readiness for Enhanced Family Processes
– Readiness for Enhanced Spiritual Well- Being

57. MCQs – 7/09/2015
1. The nursing process was first
described by ……………… in 1955.
a. yura
b. Walsh
c. Hall
d. Florence

58. 2. Following are the basic concept of
nursing process except :
a. health
b. illness
c. nurse
d. patient

59. 3. Nursing Process (NP) is defined as a
……………, continuous and dynamic
method of providing care to clients.
a. systemic
b. rhythmic
c. cumulative
d. judgement

60. 4. Nursing process having mainly ………
components/phases.
a. 2
b. 3
c. 4
d. 5

61. 5. After the analysis of data next
phase of nursing process is ………… .
a. planning
b. formulate nursing diagnosis
c. implementing
d. evaluation

62. Answers
1. - c
2. – b
3. – a
4. - d
5. - b

63. MCQs – /09/2015
1. Nursing process is …………… centered.
a. nurse
b. doctor
c. family
d. patient

64. 2. In ………… phase of nursing process,
nurse has to set outcomes strategies
to achieve goals of care.
a. assessment
b. planning
c. implementation
d. evaluation

65. 3. Nursing process is the application of
the nurses’ ………… .
a. judgment
b. knowledge
c. belief
d. skill

66. 4. …………… data are observable and
measurable by nurse.
a. subjective
b. past
c. objective
d. present

67. 5. Primary data is directly collected
from …………… .
a. medical records
b. family members
c. nurse’s experiences
d. client/ patient

69. • Nursing assessment includes two steps:
1. Collection of information from a primary
source (the patient) and secondary sources
(e.g., family members, health professionals,
and medical record)
2. The interpretation and validation of data to
ensure a complete database

70. PROBLEM
AND
ASSOCIATED
FACTORS
QUESTIONS PHYSICAL
ASSESSMENT
Nature of pain Describe your pain for me.
Place your hand over the
area that hurts or is
uncomfortable.
Observe nonverbal cues.
Observe where patient
points to pain; note if it
radiates or is localized.
Precipitating
factors
Do you notice if pain
worsens during any
activities or specific
time of day?
Is pain associated with
movement?
Observe if patient
demonstrates
nonverbal signs of pain
during movement,
positioning,
swallowing.
Severity Rate your pain on a scale
of 0 to 10.
Inspect area of
discomfort; palpate for
tenderness.

75. 1. The nurse asks a patient, “Describe for me
your typical diet over a 24-hour day. What
foods do you prefer? Have you noticed a
change in your weight recently?” This series of
questions would likely occur during which phase
of a patient centered interview?
a. Setting the stage
b. Gathering information about the patient’s chief
concerns
c. Collecting the assessment
d. Termination

76. 2. During the review of systems in a nursing history,
a nurse learns that the patient has been coughing
mucus. Which of the following nursing assessments
would be best for the nurse to use to confirm a lung
problem?
a. Family report
b. Chest x-ray film
c. Physical examination with auscultation of the
lungs
d. Medical record summary of x-ray film findings

77. 3. What type of interview techniques does
the nurse use when asking these questions,
“Do you have pain or cramping?” “Does the
pain get worse when you walk?” (Select all
that apply.)
a.Active listening
b.Open-ended questioning
c. Closed-ended questioning
d.Problem-oriented questioning

78. 4. What technique(s) best encourage(s) a
patient to tell his or her full story except
one :
1.Active listening
2.Back channeling
3.Validating
4.Use of open-ended questions

79. 5. A 58-year-old patient with nerve deafness has come to
his doctor’s office for a routine examination. The patient
wears two hearing aids. The advanced practice nurse who
is conducting the assessment uses which of the following
approaches while conducting the interview with this
patient? (Select all that apply.)
•Maintain a neutral facial expression
•Lean forward when interacting with the patient
•Acknowledge the patient’s answers through head nodding
•Limit direct eye contact

80. 1 - c
2 – c,d
3 - c
4 - c
5 – b,c