1. Concepts of Nursing NUR 212
The Nursing Process

2. 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

3. Purpose 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.

4. 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

5. 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.

6. Steps of the Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation

7. Diagnosis
Diagnosis

8. The nursing process

9. Assessment Types of Data Systematic collection of facts or data
Objective data-observable and measurable facts (Signs)
Subjective data-information that only the client feels and can describe (Symptoms)
Types of Data

10. Sources of Data Primary source: Client
Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers.

11. Types of Assessments Data base assessment
Comprehensive information you gather on initial contact with the person to assess all aspects of health status.
Focus assessment
The data you gather to determine the status of a specific condition.

12. Organization of Data Grouping of related information
Organization of assessment data into small groups to be analyzed

13. The data will collect through:
Nursing history.
Physical examination & vital signs.
Lab results.
Review records and literature.

14. Nursing Diagnosis
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 .
Nursing Diagnosis Categories:
-Actual
-Potential

15. It contains three parts:
Problem: Name of the health-related issue or problem as identified in the NANDA list
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”

16. Writing Diagnostic Statements
Problem
Related To
Etiology As
manifested By
Signs &
Symptoms
Diagnostic
Label
Contributing Factors

17. Nursing Diagnosis
Prioritize the problems
Not a medical diagnosis

18. Difference Between Nursing and Medical Diagnosis
Nursing Diagnosis- 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.
Medical Diagnosis- physician "clinical judgment of the disease- i.e. diabetes mellitus.

19. 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

20. Short-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

21. Long-Term Goals
Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems

22. 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).

23. 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

24. Selecting Nursing Implementation
Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking.
Nursing interventions are directed at eliminating the etiologies.
The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects.
Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.

25. 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.

26. Nursing Implementation
Carrying out the plan of care
The nurse implements medical orders and nursing orders
Implementation involves the client and one or more health care team
The information in the chart shows a correlation between the plan and the care that has been provided.
Nurses are accountable for carrying out nursing orders and physician orders.

27. Evaluation
The way nurses determine whether a client has reached a goal.
It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care.
Examples:
The goal met.
The goal not met.
The goal partially met.

28. Process of evaluating client responses:
1- Identify the desired out comes.
2- Collecting data related to desired out comes.
3- Compare the data with desired out comes
4- Relate nursing actions to client goals/desired outcomes.
5- Draw conclusions about problem status.
6- Continue to modify or terminate the clients care plan.

29. Take home message Nursing process:
is a tool for identifying patient's problems and an organized method for meeting patient's needs.

30. Thank you