1. Fundamentals of Nursing II
Nursing Process
Dr Naiema Gaber

2. Learning objectives Define nursing process.
Detect the importance and purposes of NP
Identify the components of NP
Determine the characteristics of NP
Discuss the five steps of nursing process
Document following the standard criteria

3. Unit1:the Nursing process &critical thinking
Prepared by:
MS/Nawal Gamel Abdulghani

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

5. Medical vs. Nursing Assessments:
Medical assessments
Focus on the client’s disease.
Nursing assessments
Focus on the client’s response to disease.

6. The Purposes of Nursing Process:
To Identify the client’s health status & actual or potential health care problems.
To establish nursing plan to meet the identified health needs.

7. Characteristics of nursing process
1.Open, flexible
2. Humanistic and individualized.
3.Cyclical and ongoing
4.Client centered.
5. Goal directed.
6.Emphasizes feedback and validation

8. To practice universal standards of care to meet client’s health needs
Why do we learn Nursing Process ?
To practice universal standards of care to meet client’s health needs
Practice and improve critical thinking skills

9. Benefits of Nursing Process
Provides a systematic method for providing care.
Increases care quality
Enhances nursing efficiency by standardizing nursing practice.
Facilitates documentation of care.
Provides a unity of language for the nursing profession.
Is economical.
Emphasize the independent function of nurses.

10. Using the nursing process
Being Accountable
Using the nursing process
Using critical thinking before taking actions
Being responsible for your actions
Entering the professional role on the practical areas.
Working at the level of peers

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

12. Nursing process Planning Evaluation Implementation Diagnosis
Assessment

13. Formulate nursing diagnosis
i.D problem
Formulate nursing diagnosis
DIGNOSIS

14. Step 0f the N.P
The First Step
In the N.P

15. Assessment: the first step in NP
it is the process of gathering, verifying and communicating data about a client”.
It describes client’s health problems or response for nursing therapy given.
It starts by wards give additional meaning to the diagnosis as altered, impaired, decreased, ineffective, acute, chronic….

16. Types of Nursing Assessments
Comprehensive initial ( provide baseline client data shortly after admission)
Focused- limited in the scope targets a particular need or health care concern.
Ongoing – systematic monitoring & observation related to specific problem.

17. 2-Confirm the data is accurate
1-Data collection
Assessment Steps
2-Confirm the data is accurate
4-Interpret the data
3-Organize the data

18. 1-Data collection:
Data collection : it is the process of gathering information about a client’s health status.
Type of data collection:
Objective data(signs)
Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
E.g., elevated temperature, skin moisture, vomiting
Subjective data(symptoms)
Information perceived only by the affected person
E.g., pain experience, feeling dizzy, feeling anxious

19. 2-Confirm that data is accurate
1-Patient
2-Family and significant others
5-Nursing and
Other
Healthcare
literature
Sources of Data
3-Patient record
4-Other
Healthcare
professionals

20. 3-Organizing Data Assessment models: Wellness Models
Maslow’s Hierarchy of Needs
Body Systems Model
Neman’s System model.

21. Cues = signs and symptoms
4- Validating Data
Is the act of “double-checking” or verifying data to confirm that they are accurate. How to differentiate the(cues) and (inferences)??
Inference = what you think,
a judgment about the cues
Cues = signs and symptoms
Swollen finger
Misshapen
Reddened
Painful
Broken finger

22. Documenting Data
Enter initial database into computer or record in ink on designated forms the same day patient is admitted.
Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.
Use correct grammar and standard medical abbreviations.
Whenever possible, use patient’s own words.
Avoid non-specific terms, individual interpretation or definition.

23. The Second Step In the N.P
2- Nursing diagnosis
The Second Step
In the N.P
DIAGNOSIS

24. National American Nursing Diagnosis Association-------NANDA
term first used
First national conference of nursing diagnosis
named NANDA
1990 ANA endorsed it as official diagnosis taxonom
….Is incorporated in ANA standards of practice
Meets every two years
Local chapters
148 diagnoses
+ 16 Carpenito

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

26. Steps of Nursing DIAGNOSIS
Sort, cluster, analyze information
Identify potential problems and strengths
Write statement of problem or strength
Example: Risk of infection related to compromised nutrition

27. Nursing diagnosis
Medical Diagnosis
Identifies situations the
nurse is licensed and
qualified to treat
Identifies conditions the
MD is licensed &qualified
to treat
Focuses on the client’s
responses to actual or
potential health problems
Focuses on the illness,
injury, or disease process
Doesn’t remain constant until a cure is effected
Remains constant until a
cure is effected

28. Types of Nursing Diagnoses
1-Actual nursing diagnosis – a problem exists. Composed of the problem statement, related factors and signs & symptoms 2- Risk nursing diagnosis – indicates the problem doesn’t exist but has special risk factors 3-Wellness nursing diagnosis – indicates the client’s desire to attain a higher level of wellness in some area of function. 4-possible nursing diagnosis. 5- syndrome nursing diagnosis

29. Components of the Nursing Diagnosis
A-Two-part Statement
1. Problem statement – describes the client’s response to an actual or potential health problem (diagnostic label)
2. Etiology – cause of the problem
The diagnostic label & etiology are linked by the terminology Related to (R/T)
Example:
Ineffective breathing pattern R/T neuromuscular
impairment.

30. Development of the Nursing Diagnosis
Two-part Statement: Example:
1. Problem statement: Ineffective breathing pattern
2. Link: R/T (related to)
3. Etiology: neuromuscular impairment.

31. Components of the Nursing Diagnosis cont.
B- Three-part-statement
1. Problem statement – describes the client’s response to an actual or potential health problem (diagnostic label)
2. Etiology – cause of the problem
The diagnostic label & etiology are linked bythe terminology Related to (R/T)
3. Defining characteristics

32. Development of the Nursing Diagnosis
Three-part Statement
Example:
1. Problem statement
Ineffective breathing pattern
2. Link
R/T (related to) R/T (related to)
3. Etiology
neuromuscular impairment.
4. Defining characteristics
(signs & symptoms)
as evidenced by spinal cord injury, poor chest expansion

33. Development of the Nursing Diagnosis
Two-part Statement = (Risk)
Three-part Statement = (actual)
Decreased cardiac output,
related to alterations in rate, rhythm, electrical conduction,
related to alterations in
rate, rhythm, electrical
conduction as evidenced
by diminished peripheral
pulses.
Activity intolerance related to
prolonged bed rest/immobility
prolonged bed rest/immobility as
evidenced by fatigue and
Weakness

34. P E S P = Problem Diagnostic Label = Problem + modifier
ACTUAL DIAGNOSIS An actual diagnosis represents a state that has been clinically validated by identifiable major defining characteristics. Consists of a label, related factors & defining characteristics.
Three Part Statement
P E S
P = Problem
( Precise qualifier / modifiers )
Altered High Risk Ineffective Decreased
Deficit Excess Dysfunctional Disturbance
Chronic Less than More than Anticipatory
Diagnostic Label = Problem + modifier
= Chronic Pain

35. E = Related Factors Actual dx.
Related factors are etiological or other contributing factors
that have influenced the health status change.
Etiology sometimes = Causes or factors of risk
Chronic pain r/t Altered Tissue perfusion
………. secondary to Diabetes
Pathophysiologic Alteration in skin Integrity r/t ( caused by)
Compromised immune system Inadequate circulation
Inadequate peripheral circulation
Treatment-related
Medications
Diagnostic studies Anxiety r/t (caused by) lack of knowledge
Surgery of how to dress his wound
Treatments

36. Etiological Factors Situational Environmental
Home Risk for Injury r/t unsteady gait
Community
Institution
Personal
Life experiences
Roles
Maturational Nutrition Imbalance : Less than Body Requirements r/t
Age related to inadequate sucking

37. Major defining characteristics must be present for
Actual diagnosis.
S = Defining characteristics
S= signs / symptoms
Clinical cues--subjective and objective signs or symptoms that point to the nursing diagnosis
• Are separated into major and minor designations.
• Major defined as critical indicators present of the time.
• Minor are supporting and present 50-79%
Major defining characteristics must be present for
diagnosis to be valid

38. Actual diagnosis A real problem exists !!!!!!!! S P E
Diagnostic Label Related factor
impaired Skin Integrity related to prolonged immobility S
Defining characteristics
as evidenced by a 2 cm sacral lesion
A real problem exists !!!!!!!!

39. RISK DIAGNOSIS S E ( related risk factor) No defining characteristics
Is a clinical judgment that an individual, family or
community is more vulnerable to develop the problem than others in the same or similar situation. .
Two part statement P ( problem)
E ( related risk factor)
No defining characteristics S
No signs or symptoms because
No problem yet

40. Risk nursing diagnosis
P E
Diagnostic label Etiological risk factors
Risk for Injury related to lack of awareness of hazards
Factors present a risk situation for
a problem to occur

41. SYNDROME DIAGNOSIS
Comprise a cluster of actual or risk nursing diagnoses that
are predicted to be present because of a certain event or situation.
Nursing Diagnoses Associated with Disuse Syndrome
Risk for Constipation
Risk for Altered Respiratory Function
Risk for Infection
Risk for Thrombosis
Risk for Activity Intolerance
Risk for Injury
Risk for Altered Thought Processes

42. Common Errors In Diagnostic Statements
1. Don’t use medical terms when writing a diagnosis
I‑ Self‑Care Deficit Hygiene r/t Stroke
C- Self-care Deficit: Hygiene r/t weakness secondary to Stroke
2. Don’t write a diagnosis for an unchangeable situation
I‑ Anxiety r/t impending death aeb stating” I am afraid to die”
C- Anxiety r/t fear of dying

43. Common errors
3. Use of procedure / treatment instead of a human response
I- Cauterization r/t urinary retention
C- Risk for Infection Transmission r/t device with contaminated drainage: urinary
4. Don’t write diagnoses that are too general
I- Constipation r/t nutritional intake aeb small hard stools
C- Constipation r/t  dietary roughage and  fluid intake

44. 5. Don’t combine two problems at the same time
Common errors
5. Don’t combine two problems at the same time
I- Pain and Fear r/t to upcoming abdominal surgery
C- Pain r/t tissue trauma secondary to abdominal surgery aeb “ Pain ranked 4/5”
6. Don’t use judgmental/value laden language or make assumptions
I- Spiritual Distress r/t atheism aeb statement “ I don’t believe in God” .
C- Spiritual Distress r/t to feelings of rejection
aeb “ I don’t think God cares about me”

45. Don’t use due to or caused
7. Don’t make statements that are legally inadvisable
I- Tissue Integrity Impaired r/t to infrequent turning aeb 3
cm diameter ankle ulcer
C- Tissue Integrity Impaired r/t immobility secondary to fracture
8. Both parts of a diagnostic statement are the sames
I- Self care deficit : feeding r/t feeding problem aeb unable to bring food to mouth
C- Self Care Deficit: feeding r/t neurological impairment
of rt. hand aeb unable to bring food to mouth
Don’t use due to or caused

46. 3- PLANNING
The Third Step
In the N.P
PLANNING

47. PLANNING
*Definition:
Planning is formulation of the nursing actions in an organized, individualized and goal directed manner“
Should involve decision making and problem solving.
Should be SNART. (specific,
measurable, attainable,
realistic and time bound

48. Types of planning:
Initial
Ongoing
Discharge

49. Initial Planning
Developed by the nurse who performs the nursing history and physical assessment
Addresses each problem listed in the prioritized nursing diagnoses.
Identifies appropriate patient
goals and related nursing care

50. Ongoing Planning Carried out by any nurse who interacts with patient
Keeps the plan up to date
States nursing diagnoses more clearly
Develops new diagnoses,
Makes outcomes more realistic and develops new outcomes as needed
Identifies nursing interventions to accomplish patient goals

51. Discharge Planning
Carried out by the nurse who worked most closely with patient.
Uses teaching and counseling skills effectively to ensure home-care behaviors are performed competency.

52. PLANNING PHASES
An informal nursing care plan : is a strategy for action that exists in the nurse’s mind.
For example : the nurse may think “Mrs.Phan is
very tired. I will need to reinforce her teaching
after she is rested.”
A formal nursing care plan :is a written or computerized guide that organize in formation about the client care.

53. Prioritizing the nursing diagnoses Identifying long & short term goals
Planning Steps
Prioritizing the nursing diagnoses
Identifying long & short term goals
Developing nursing interventions
Recording the nursing care plan in the client’s medical record

54. Prioritizing Nursing Diagnoses
Five system variables:
Physiological
Psychological
Socio-cultural
Developmental
Spiritual

55. PLANNING steps
1. Determine priorities and list problems
Which do you think need immediate attention? What does the patient think?
Maslow hierarchy + severity of problem + patient input
Review question: Which of the following problems would you treat first ?
Severe breathing
Diarrhea
Itching

56. Planning steps cont.
2. Establishment of ( goals) OUTCOME and OUTCOME CRITERIA
( What will the patient be able to do?
and in what time frame ? = OUTCOME
And how will I know it was successful? = OUTCOME CRITERIA
Diagnosis Ineffective Airway Clearance
r/t Etiology Weakness secondary to Stroke
EX: Maj. Defining Characteristic (Symptoms)- non productive Ineffective cough
Broad Outcome Effective Airway by 10/4/04 Time frame
aeb Outcome Criteria (symptoms) productive cough

57. Purpose of Outcomes and Criteria
Planning cont.
Purpose of Outcomes and Criteria
Indicators of achievement
was the airway effective?
Did problem ( cough) stay the same,
get  or  , disappear ?
Measuring sticks
Interventions will be directed
toward facilitating a productive
cough
Direct Interventions
Motivating factors
Goal motivates, something to aim for

58.  respiratory rate to 12 to 16  pulse rate to 80 and regular
Ineffective Breathing Patterns
Diagnosis
(P)
(E)
Related to
r/t
Immobility and chest pain
Secondary to abdominal surgery
 in respiratory rate from 12 to 22
pulse rate  88 to 104 and irregular
As evidenced by
(S)
Outcome /goal
Effective Breathing
Date: by 10/22/04
 respiratory rate to 12 to 16
 pulse rate to 80 and regular

59. Establishing client goal/desired outcomes
Goal(broad):improved nutritional status. Desired outcome(specific): gain 5 k by April. Purpose of desired goal/outcomes: 1- provide direction for planning nursing intervention. 2-serve as criteria for evaluation client progress. 3- enable the client and nurse to determine when the problem has been resolved. 4-Help motivate the client and nurse by providing a sense of achievement.

60. Long-Term vs. Short-Term Outcomes
Long-term — requires a longer period to be achieved and may be used as discharge goals.
Short-term — may be accomplished in a specified period of time

61. Components of Outcomes
Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the actions?
Performance criteria: how well is the person to perform the actions?
Target time: by when is the person expected to be able to perform the actions?

62. Common Errors in Writing Patient Outcomes
Expressing patient outcome as nursing intervention.
Using verbs that are not observable or measurable.
Including more than one patient behavior or manifestation in short-term outcomes.
Writing vague outcomes

63. Nursing Care Plan
A written guide, organizing client data into a formal statements of strategies to assist the client have optimal health

64. Nursing care plan design
Date / time
Nursing diagnosis
Client’s goal
Nursing intervention
Outcome criteria and evaluation
A.H
@10:30
Ineffective airway clearance R/T accumulated secretion aeb. Cyanosis & abnormal breathing sound.
Client can be expel the secreation
1-Decrease oxygen consumption by *rest
*setting or semi fowler’s position
2-increase fluid intake
3- B&C exercises .
Has no secretion aeb no cyanosis & normal breathing sound.

65. Documenting the Plan of Care
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.

66. Types of Institutional Plans of Care
Kardex plans of care
Computerized plans of care
Case management plans of care
Clinical pathways, care maps
Student plans of care
Concept map care plan

67. Guidelines for writing nursing care plans
Date and sign the plan
Use category heading.
Use standardized /approved medical or English symbols and key word.
Be specific.
Refer to procedure book or other source information.
Tailor the plan to the unique characteristics of the client by ensuring that the client choice.
Ensure that the nursing plan incorporates preventive and health maintenance aspect as well as restorative one.
Ensure that plan contain intervention for ongoing assessment of the client
Include collaborative and coordination activities in the plan
Include plan for the client’s discharge and home care need.

68. The Fourth Step In the N.P
4- IMPLEMENTAION
The Fourth Step
In the N.P
IMPLEMENTAION

69. Interventions or implementation
* 4th steps in the nursing process.
" Specific nursing activities /actions that a nurse must perform to prevent complications , provide comfort(physical, psychological and spiritual) and promote, maintain and restore health."
Categories
a. Dependent‑implementing M.D. orders-- give Vioxx medication per order
b. Interdependent‑in cooperation with other health team members----follow P.T. plan for exercise
c. Independent‑ performed without M.D. order----turn patient q.2. hrs

70. Process of implementation or intrvetion
Reassessing the client.
Determining the nurse’s need for assistance.
Implementing the nursing interventions.
Supervising the delegated care.
Documenting nursing activities.

71. interventions
Diagnosis  
Broad Outcome
Pt. will experience
wound healing
Altered Skin Integrity
Etiology
INTERVENTIONS
R/t immobility
secondary to fracture  
Defining
Characteristics  
Outcome Criteria
3cm diameter
ankle wound
 diameter to 2cm

72. interventions Characteristics a. consistent b. scientific basis
c. law, professional standards, agency accrediting bodies
Intervention Rationale
Teach client to rotate Repeated use of the same insulin injection sites site may cause fibrosis, and decreased insulin absorption

73. interventions
INDIVIDUALIZED
Donna‑‑17 year old, immobilized by skeletal traction for a FX. Lt. leg due to a motorcycle accident
Betsy‑‑84 year old nursing home resident, slightly dehydrated , confused and confined to bed from a hip fracture
Dx Risk for skin breakdown r/t immobility secondary to
Donna Betsy
Bed trapeze specialized, air mattress
Position cue to turn turn q. 2 hours
Nutrition  protein, zinc etc. tube feeding,  fluids

74. Criteria for choosing nursing intervention
The plan must be:
Safe and appropriate for the individual's age, health, and condition.
Congruent with client’s values, beliefs, and culture.
Congruent with other therapies.
Based on nursing knowledge and experiences.
Within establish standards of care as determined by state laws, professional association and the policies of the institution.

75. interventions Guidelines for Writing a. date and sign
b. list specific activities
Incorrect Correct
Teach colostomy care demonstrate steps us applying colostomy pouch
2. identify equipment needed with colostomy care
3. provide printed instructions and discuss content
4. Have client do return demonstration

76. The Fifth Step
In the N.P
EVALUATION

77. Evaluation 5th step in the nursing process.
Importance of the evaluation:
Determines if client goals are met or not.
Determines of continued or cessation of plan.
Determining outcome achievement.
Identifying the variables affecting
outcome achievement.
Deciding whether to continue, modify
, or terminate the plan

78. 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.

79. Evaluation Process to determine how well the plan worked:
1. Gathering data
2. Compare data with outcome criteria
3. Make judgment
a. outcome achieved
b. outcome not achieved
c. partially achieved
If not----‑check
interventions
human responses
outcomes
related factors

80. Identifying Variable Affecting Outcome Achievement
Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for this particular client?
3. Were changes made in the plan when needed?
4. How does the client feel about the plan?

81. Predict, Prevent, and Manage
Focus on early intervention
Based on research
Predict and anticipate problems
Look for risk factors

82. Documentation

83. Documentation Defined
The interactions between and among health professionals, clients, their families, and health care organizations
The administration of tests, procedures,
treatments, and client education; and
The results of, or client’s response to, diagnostic tests and interventions

84. Purposes of Patient Records
Communication with other healthcare professionals
Record of diagnostic and therapeutic orders
Care planning
Quality of care reviewing
Research
Decision analysis
Education
Legal and historical documentation
Reimbursement

85. Effective Documentation
Follow the nursing process
Date & time, Observation, Intervention &
Evaluation
Use of healthcare facility approved vocabulary and abbreviations.
Signature
Accurate

86. Methods of Documentation
Narrative charting: describes the client’s
status, interventions and treatments in a
story form.
Source-oriented charting: narrative charting by individual disciplines on separate records.
Problem-oriented charting: problem-
oriented medical record (POMR)

87. Methods of Documentation cont.
PIE charting: problem, intervention and
evaluation
FOCUS charting: uses a columnar format to
chart data, action and response (DAR)
Computerized documentation: electronic
medical record

88. Formats for Nursing Documentation
Initial nursing assessment
Kardex and patient care summary
Plan of nursing care
Critical collaborative pathways
Progress notes
Flow sheets
Discharge and transfer summary
Home healthcare documentation
Long term care documentation

89. Types of Flow Sheets Graphic record 24-hour fluid balance record
Medication record
24-hour patient care records and acuity charting forms