Unit V

Nursing Process in Human

Health and Function
LEARNING OBJECTIVES

 Explain Historical development of nursing process

 Describe the components of the nursing process.
 Discuss the types of skills that nurses must possess in order
to perform the nursing interventions during the
implementation step of the nursing process.
 Relate the nursing process to the problem-solving method
HISTORICAL PERSPECTIVE
 Lydia Hall first referred to nursing as a “process” in a
1955 journal article, yet the term was not widely used
until the late 1960s (Edelman & Mandle, 1997).
 Referring to the “nursing process” as a series of steps,
Johnson (1959), Orlando (1961), and Wiedenbach (1963)
further developed this description of nursing.


A.F(
BSc,
MSc)
HISTORICAL……
 At this time, the nursing process involved only three
steps:
 The Standards of Practice, first published in 1973 by the
American Nurses Association (ANA), included eight
standards.
 These standards identified each of the steps, including
nursing diagnosis, that are now included in the nursing
process.
HISTORICAL……
 Fry (1953) first used the term nursing diagnosis, but it
was not until 1974, after the first meeting of the group
now called the North American Nursing Diagnosis
Association (NANDA), that Gebbie and Lavin added
nursing diagnosis as a separate and distinct step in the
nursing process.
 Prior to this, nursing diagnosis had been included as a
natural conclusion to the first step, assessment.

A.F(
BSc,
MSc)
HISTORICAL……
 The ANA made revisions to the standards in 1991 to
include outcome identification as a specific part of the
planning phase.
 Currently, the steps in the nursing process are:
 Assessment
 Diagnosis
 Outcome identification and planning
 Implementation
 Evaluation

 The American Nurses Association practice standards

address each step of the nursing process. A.F(
BSc,
MSc)
 DEFINITION
Nursing Process
It is a systematic problem solving approach of giving
individualized nursing care.
Nursing process is a deliberate problem-solving approach for
meeting people’s health care and nursing needs.
Central to all nursing care
Encompasses all steps taken by the nurse in caring for a patient
Established by American Nursing Association
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 (time and resources)
CONT…

 Stresses the independent function of nurses

 Increases care quality through the use of
deliberate actions
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
CONT…
 Achieves for the patient : scientifically based , holistic,
and individualized care.
 Prioritized

 Dynamic

 The steps are interrelated and dependent on the

accuracy of each of the preceding steps
CONT…

 It is used to identify, diagnose, and treat human

responses to health and illness
 Allows for collaboration between the patient and the
nurse
 Provides continuity of care
 Prevention of duplication
 MARTHA ROGERS, NURSE THEORIST

“When an apple is cut, others see

seeds in the apple. We, as nurses,
see apples in the seeds.”
 COMPONENTS OF NURSING
PROCESS
Assessment

Diagnosis
Nursing Process &
Critical Thinking
Planning

Implementation

Evaluation

Acronym: “ADPIE” or “ A de-licious PIE”

Assessment

Diagnosis

Planning

Implementation

Evaluation
ASSESSMENT
 It is the first phase of nursing process
 The systematic collection of data to determine the
patient’s health status and any actual or potential
health problems.
 Analysis of data is included as part of the assessment.
 Analysis may also be identified as a separate step of
the nursing process.
CONT…
Assessment skills
 Observation : ability to observe and identify problems

 Interviewing history: the ability to communicate with others.

 Physical examination

 Analysis of bodily function using techniques of –

inspection, palpitation, percussion and auscultation.
Assessment activities
 Collect data:- Compiling information about the patient

 Recording data

 Validate data :- double checking

 Organize data :- use functional health pattern

CONT…
 A physical assessment may be carried out before,
during, or after the health history, depending on a
patient’s physical and emotional status and the
immediate priorities of the situation.
 relevant information should be obtained from the
patient’s family or significant others, from other
members of the health team, and from the patient’s
health record or chart.
TYPES OF ASSESSMENT
 Initial assessment: - Also called – Admonition assessment
 Performed at the time the patient enters the health care facility.
 Very broad and leads us to a center of our diagnosis

Aim – Collection of data concerning actual or potential

dysfunction
 Focus Assessment
 It is concentrated on certain diagnosis and
 It leads us to the general condition of the specific diagnosis.

Aim:- Determine status of a specific problems identified during

previous assessment
TYPES OF ASSESSMENT ……
 Time - Lapsed assessment
 It
is the final assessment done after a period of time
 Assessment is focused type. 

Aim:- Comparing the patient’s current status to baseline

obtained previously after an extended period of time

 Emergency assessment
 Assessment done on the life treating situation
 Assessment should be fast, correct, and leading to aggressive
management.
Aim:- identification of life threatening situation
RECORDING THE DATA
 It is a means of communication among members of the
health care team and facilitates coordinated planning and
continuity of care.
The record fulfills other functions as well:
 It serves as the legal and business record
 It serves as a basis for evaluating the quality and
appropriateness of care and for reviewing the effective use
of patient care services.
CONT…
 It provides data that are useful in research, education, and
short- and long-range planning.
Types of data
 Subjective data
 Also know as symptoms or covert include the patients feeling and
statements about his or her health problems
 It should always be taken by the patient words
 E.g I get sharp pain in my chest.”

 Objective data
 Also known as sign or overt cues art observable and measurable
 It is an information witnessed by the examiner
 E.g Vital Signs /BP, RR, To, P etc
CONT…
Source of Data
 Primary sources – the patient
 Secondary sources – family members or significant
others health record laboratory test.
ASSESSMENT SUMMERY

1. Conduct the health history.

2. Perform the physical assessment.

3. Interview the patient’s family or significant others.

4. Study the health record.

5. Organize, analyze, synthesize, and summarize the

collected data.
Assessment

Diagnosis

Planning

Implementation

Evaluation
 NURSING DIAGNOSIS
 The second phase of nursing process
 To diagnose means to analyze assume information and drive
meaning.
 “A clinical judgment about individual family or community
response to the actual or potential health problems”(North
American Nursing Diagnosis Association, NANDA)
Diagnosis: Identification of the following two types of patient problems:
 Nursing diagnoses: Actual or potential health problems that can be
managed by independent nursing interventions
 Collaborative problems: “Certain physiologic complications that nurses
monitor to detect onset or changes in status.
CONT…
 Nurses manage collaborative problems using physician-
prescribed and nurse-prescribed interventions to minimize
the complications of the events”
Diagnosis activities
 Identify pattern - subjective and objective data
 Select the Nursing Dx and validate with the pt.
 Formulate the diagnostic statement

 Nursing diagnoses represent actual or potential health

problems that can be managed by independent nursing
actions.
 WRITING NURSING DIAGNOSIS
 For actual Diagnoses use a three-part statement:

The problem Cause/ Signs and symptoms (defining

(P) Etiology (E) characteristics) (S)

The PES format

THE PES FORMAT
 The PES format describes the problem and its Causes
(etiology), together with data (signs and symptoms) that
validate the chosen diagnosis
 To write the nursing diagnostic statement,
you link: The major signs and
symptoms that validate
The problem Its cause the diagnosis
^ ^
by using:
“as manifested by” or
related to “as evidenced by”
 WRITING NURSING DIAGNOSIS
Examples:

The problem Cause/ Signs and symptoms (defining

(P) Etiology (E) characteristics) (S)

“ineffective related to as manifested by poor cough

airway incisional effort”
clearance pain

“impaired related to as manifested by inability to follow

communicati inability to instructions in Amharic and
on speak verbalisation of requests in
Amharic English”
POTENTIAL NUSRING DIAGNOSES
 If a patient has some high-risk factors that may cause
certain nursing diagnoses, then you have identified a
potential nursing diagnosis

 Two part format:

potential problem “related to” risk factor
link by
E.g.
potential problem “related to” risk factor

You were caring for an elderly woman who was very thin,
immobile, and bedridden. She may have had excellent care at
home, and as a result, has beautiful, healthy-looking skin.

However, Risk factors

You should be aware that her age, weight, immobility, and
confinement to bed can be contributing factors for
Impaired Skin Integrity.

Potential
problem
E.g.
potential problem “related to” risk factor
Potential Impaired Skin related to advanced age,
Integrity immobility, and
confinement to bed

Potential nursing diagnosis: “potential impaired skin integrity

related to advanced age, immobility, and confinement to bed”

 You would then establish a plan of care that would prevent

irritated or broken skin
 e.g. establish a regimen of monitoring for pressure points and
of turning, repositioning, and massaging to promote
circulation to the skin
potential problem “related to” risk factor
Potential Impaired Skin related to advanced age,
Integrity immobility, and
confinement to bed

Statement should provide answer and direct nursing

interventions - “What can I do about this problem”

If risk factor cannot be

prevented, use the Risk factors
problem to directs the directs
intervention interventions
COLLABORATIVE PROBLEMS
 Nursing practice involves certain situations and
interventions that do not fall within the definition of
nursing diagnoses.
 These activities pertain to potential problems or
complications that are medical in origin and require
collaborative interventions with the physician and
other members of the health care team are called
collaborative problems
 MEDICAL VS NURSING DIAGNOSIS
Medical Nursing

Identifies conditions the MD is Identifies situations the nurse is

licensed & qualified to treat licensed & qualified to treat

Focuses on illness, injury or Focuses on the clients responses

disease processes to actual or potential health / life
problems

Remains constant until a cure is Changes as the clients response

effected and/or the health problem changes

Breast cancer Knowledge deficit, Powerlessness

Grieving, anticipatory Body image
disturbance, Individual coping,
ineffective
 CONT…
Medical Diagnosis Nursing diagnosis
Chronic obstructive pulmonary Breathing patterns, ineffective
disease airway...

Cerebrovascular accident Activity intolerance

Appendectomy Pain

Amputation Body image disturbance

pneumonia Ineffective Airway clearance

R/o tracheae-bronchial
secretion
Assessment

Diagnosis

Planning

Implementation

Evaluation
PURPOSES OF PLAN OF CARE :
 Facilitating communication between care givers

 Directing care and documentation

 Providing a record that can later be used for evaluation

and research
PLANNING INCLUDES
Establishing goals
and expected out-
comes
Setting priorities

Determining Recording the

nursing plan of care

interventions
SETTING PRIORITIES
 Setting priorities helps getting organized

 To set priorities, look at the identified problems and ask

some key questions:
 What problems need immediate attention (e.g. Life
threatening problems, pain, discomfort)?
 What problems have simple solutions?
 What problems must be referred?
 What problems must be recorded on the plan of care?
 PRINCIPLES OF SETTING PRIORITIES
Priority Example
1 Life threatening problems and Problems with respiration, circulation,
those interfering with nutrition, hydration, elimination,
physiologic needs. temperature regulation, physical
comfort
2 Problems interfering with Environmental hazards, fear
safety and security
3 Problems interfering with Isolation or loss of a loved one
love and belonging
4 Problems interfering with self Inability to wash hair, perform normal
esteem activities) creat
ed
5 Problems interfering with the by
Davi
ability to achieve personal d
goals. Cont
eh &
Rex
Won
 EXERCISE - SETTING PRIORITIES

A nurse is formulating a plan of care for a client receiving

enteral feedings. Which nursing diagnosis is of the highest
priority?
a. Altered nutrition, less than body requirements

b. High risk for aspiration

c. High risk for fluid volume deficit

d. Diarrhea
 EXERCISE - SETTING PRIORITIES -
ANSWER

Which of the following problems should be treated

immediately? Correct answer is?

a. Altered nutrition, less than body requirements

b. High risk for aspiration
c. High risk for fluid volume deficit
d. Diarrhea
PLANNING INCLUDES
Establishing Goals
and expected out-
comes
Setting priorities

Determining Recording the

nursing plan of care

interventions
WHY WRITING AN OUTCOME?
 It describes the evidence that tells you the problems have been:
 Prevented
 corrected or
 controlled

 It helps determining:
 specificinterventions
 evaluating care
CLIENT CENTERED GOALS (OUTCOMES)

This is more effective because client-centered goals

Client-centered
focus on the desired result of the plan
goals
of care,
Nursing goalswhich
what is
that thetheclient the nurse
  aims to
(what client benefit
is from nursing care.
achieve
expected to achieve)

Effectiveness
 Client-centered Goal has 2 parts:

Broad goal “as evidenced by” The outcome

The client should be the linked by

(Describes the specific data
subject of a client- that tell you the broad
centered goal goal has been achieved
Example:

Broad goal “as evidenced by” The outcome

Hailu will demonstrate the ability to clear lungs

effective airway as evidenced by by coughing every 2
clearance hours.

creat
Will demonstrate knowledge of medication regimen as ed
by
evidenced by ability of list drug names, actions, doses, Davi
d
and side effects. Cont
eh &
Rex
Won
SHORT TERM AND LONG TERM GOALS
Short term Long term
Can be met relatively quickly, Are to be achieved over a longer
often in less than a week period of time, often weeks or
months
Often set a few short term goals Usually are on going,
in order to reach a long term accomplished or maintain every
goal day
e.g. “Tigist will demonstrate e.g.“Sara will dress herself
how to hold the baby by every morning”
tomorrow”
“Ato Hailu will turn and e.g. “Ato Daniel will maintain a
reposition himself from side to fluid intake of 2000ml a day.”
side every 2 hours”
GOALS VS OUTCOME
Objectives Outcomes
often used
interchangeably
Goals
they are all statements of what is expected to be
accomplished by a certain time.

more general more specific

 GOALS VS OUTCOME…
Broad goals or objectives Specific outcomes

Outcome statement that can clearly describe what will

be observed in the patient when the goal is achieved

E.g. list exactly what you expect

“will demonstrate
to observe or hear that will
effective airway
tell you the person is able
clearance,”
to clear her airway.

created by David Conteh

& Rex Wong
PLANNING INCLUDES
Establishing Goals
and expected out-
comes
Setting priorities

Determining Recording the

nursing plan of care

interventions
 DETERMINING NURSING
INTERVENTIONS
Nursing Interventions are activities performed by the nurse to:
 Monitor health status
 Prevent, resolve or control problems
 Assist with activities of daily living (bathing and so forth)
 Promote optimum health and independence

Nursing interventions could be carried out through assessing,

teaching, counseling, consulting, and determining problem
specific interventions
PLANNING INCLUDES
Establishing Goals
and expected out-
comes
Setting priorities

Determining Recording the

nursing plan of care

interventions
RECORDING THE PLAN OF CARE
 Documenting the nursing diagnoses, collaborative problems,
expected outcomes, nursing goals, and nursing interventions
on the plan of nursing care
 Communicating to appropriate personnel any assessment data
that point to health care needs that can best be met by other
members of the health care team
Assessment

Diagnosis

Planning

Implementation

Evaluation
 IMPLEMENTATION
 It is the action phase of the nursing process in which
nursing care is provided.
 It involves carrying out the proposed plan of nursing care.
 The nurse assumes responsibility for the implementation and
coordinates the activities of all those involved in
implementation
 The schedule of activities facilitates the patient’s recovery.
CONT…

 The plan of nursing care serves as the basis for

implementation of:
 The immediate, intermediate, and long-term goals are used
as a focus for the implementation of the designated nursing
interventions.
 While implementing nursing care, the nurse continually
assesses the patient and his or her response to the nursing
care.
CONT…

 Revisions are made in the plan of care as the

patient’s condition, problems, and responses
change and when reordering of priorities is
required.
TYPES OF NURSING INTERVENTIONS
Nurses function during Intervention-

 Independent Interventions
 Dependent Interventions

 Collaborative or Interdependent Interventions

 EXAMPLES OF NURSING INTERVENTIONS:

 Assisting with hygiene care

 Promoting physical and psychological comfort
 Supporting respiratory and elimination functions;
 Facilitating the ingestion of food, fluids, and nutrients;
 Managing the patient’s immediate surroundings;
 Providing health teaching; promoting a therapeutic
relationship; and
 Carrying out a variety of therapeutic nursing activities.
SUMMERY

Implementation

1. Put the plan of nursing care into action.

2. Coordinate the activities of the patient, family or significant

others, nursing team members, and other health team
members.

3. Record the patient’s responses to the nursing actions.

4. The implementation phase of the nursing process ends

when the nursing interventions have been completed.
Assessment

Diagnosis

Planning

Implementation
creat
Evaluation ed
by
Davi
d
Cont
eh &
Rex
Won
EVALUATION
 The plan of nursing care is the basis for evaluation.
 Through evaluation, the nurse can answer the following
questions:
 Were the nursing diagnoses and collaborative problems
accurate?
 Did the patient achieve the expected outcomes within the
critical time periods?
 Have the patient’s nursing diagnoses been resolved?
CONT…
 Have the collaborative problems been resolved?
 Do priorities need to be reordered?
 Have the patient’s nursing needs been met?
 Should the nursing interventions be continued, revised, or
discontinued?
 Have new problems evolved for which nursing interventions
have not been planned or implemented?
CONT…

 What factors influenced the achievement or lack of

achievement of the objectives?
 Should changes be made in the expected outcomes
and outcome criteria?
 DOCUMENTATION OF OUTCOMES
AND REVISION OF PLAN
 Outcomes are documented concisely and objectively.
 Documentation should relate outcomes to the nursing
diagnoses and collaborative problems
 Describe the patient’s responses to the interventions
 Indicate whether the outcomes were met, and include
any additional pertinent data.
SUMMERY OF EVALUATION

Decide and evaluate the decision.

A. What is the best or morally correct action?

B. Give the ethical reasons for your decision.

C. What are the ethical reasons against your decision?

D. How do you respond to the reasons against your decision?

THANKS