NURSING

PROCESS
NURSING DEFINATION
 Florence Nightngale (1820-1910)
defined Nursing as: “Nursing is
putting us in the best possible
condition for nature to restore and
preserve health”
Definition ……..
 Virginia Henderson (1966), defined
Nursing as “The 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
a peaceful death, that he could perform
unaided if he had the necessary strength,
will or knowledge, and to do this in such a
way as to help him gain independence as
rapidly as possible.
DEFINITION…….
 American nurses association (ANA)
(1995) defined nursing as “Nursing
is the diagnosis and treatment of
human responses to actual and
potential health / problems”.
Definition ……

?
Definition of Nursing
Process:
 Nursing process is a systematic
and dynamic method of problem
solving approach
OR
 Method of making clinical
decisions, urden (2002).
DEFINITION……..
 Alfro defines nursing process as an
organized, systemic method of
giving individualized care that
focuses on identifying and treating
unique response of individuals or
groups to actual or potential
alterations in health.
 Sis Steps.
ASSESSMENT
Nursing
Diagnosis
Evaluation Outcome
identification

Planning
Implementation
Summary of the steps.
 Assessment: Gathering of information (data).
 Diagnosis: Analyzing data to identify
problems/nursing diagnosis.
 Expected outcome: Endpoint determination
measure.
 Planning: Making plan of action.
 Implementation / Intervention: Put the
plan into action
 Evaluation: Determine if the plan has
worked.
Six Steps…….
 To remember the steps, remember the first
letter of each of the step (ADEPIE).
 The six steps or phases overlap and build
on each other.
 The steps are interrelated, forming a
continuous circle of thought and actions
that is both dynamic and cyclic.
 Be sure to accurately complete each step
and then build upon the information in that
step to complete the next,
PURPOSE
 Nursing process is central to nursing
actions.

 It is an efficient method of organizing

thought processes for clinical decision
making and problem solving.

 Provides framework within which the

individualized needs of the client, family
and community can be met.
PURPOSE…..
 Ensures that care is planned,
individualized and reviewed over
period of time that patient and the
nurse have a professional
relationship.
WHY DO WE NEED TO
PALN CARE
 Patient has right to expect to receive
complete and high quality care. Gaps
will exist if care planning is not done.
 Care planning and its documentation
provide and promote means of
professional communications.
 Care planning provide a comfort level
for providing ready reference to help
ensure that care is complete.
WHY DO WE NEED EWTO
PLAN CARE……
 Provide a guideline for
documentation and promotes
practice within legally defined
standards.
 Care planning provides legal
protection for the nurse.
 The accreditation status of a health
care agency, can depend on
consistent documentation that
planning of care has been done.
Practice Nursing Roles:
 NURSING: Is a applied science
that employs intellectual,
interpersonal and technical skills
throughout the nursing process to
assist the clients in achieving
maximum health potential.
NURSES ROLES
In nursing practice Nurses roles are-
Independent
Some independent actions are

assessing, analyzing, making

nursing diagnosis, planning,
implementing and evaluating
nursing care.
Practice Nursing Roles
Interdependent
Activities involve coordinating and

planning with health team members.

Dependent
Includes implementation of physicians

orders to administer medications or

treatments.
Nursing process enhances each of the
three roles for clients benefits.
ASSESSMENT
 Nursing theories, frameworks, models
and principles are used as approaches
to data collection with Nursing
process.
 1nurses knowledge of approaches and
the client situation determines the
approach .
 E.g. Nursing model Roy adaptation by
Roy calista.
ASSESSMENT (PHASE ONE)
 Initial step, most crucial and keystone
excellent care.
 Gathering and examining data to
obtain all facts necessary to determine
patients current health status.
 Determine the patients strengths and
problems area both actual and
potential.
ASSESSMENT……
 Prepare for the second step the
Nursing diagnosis.
 Incomplete and inaccurate
assessment lead to inadequate
and inappropriate nursing care.
 Provide baseline information for
planning and implementing
nursing care.
ASSESSMENT
Data collected reflect information
concerning patient/clients.
Biographical status (profile).

Psychological status.

Socio cultural.

Spiritual

Biophysical.
 TYPES OF DATA
 Subjective: facts presented by the
patient that show his or her perception,
understanding and interpretation of what
is happening. E.g. pain begins in my
lower back and runs to down the left leg.
 Objective: The facts that are observable
and measurable. E.g. Blood pressure,
Temperature, weight and height.
SORCES OF DATA
 Primary source _______ patients/client.
 Secondary source __includes
information from:
 Patents family and significant others.
 Health records.
 Professional journals.
 References textbooks.
 Nursing rounds.
 Results of diagnostic tests.
TECHNIQUE USED.
 Interview.
 Physical examination.
 Observations
 Laboratory investgigation.
NURSING DIAGNOSIS
 Nursing diagnosis is an indispensable
and high intellectual skill that is
developed and practiced throughout
Nursing professional life.
 It culminates the assessment phase.
 It is pivotal step in nursing progress,
without it no progress to other stages.
NURSING DIAGNOSIS

 It differs from medical diagnoses in their

focus and specific goals and objectives.

 Medical diagnoses focuses on correction

/ prevention of illness of specific
organs / body systems.
 NURSING DIAGNOSIS
 Nursing responsibility is to diagnose
human responses to health related
issues, concerns and the effects of their
concerns on activities of daily living.
The response include self care
limitations, impaired functioning in
areas of sleep, rest, nutrition,
elimination, pain and deficiencies in
decision making.
 NURSING DIAGNOSIS
 Is define as the judgment or conclusion which
occurs as result of nursing assessment.
 Describes the effects of symptoms and
pathology on clients activities and lifestyle.
 Statement of the patient behavioral response
to condition or situation E.g. anxiety.
 An actual or potential health problem (of
individual, family or group) that nurses can
legally treat independently, initiating the
nursing interventions necessary to prevent,
resolve or reduce the problem.
 NURSING DIAGNOSIS…..
 Nursing diagnosis has three parts:
(1) Human response or problem of the
patent.
(2) Cause of the problem.

(3) Assessed information relating to the

problem. E.g.
(i) Self care deficit related to (ii) muscle
weakness and fatigue as manifested by
(iii) inability to bathe, comb hair or walk
to toilet without assistance.
NURSING DIAGNOSIS…
 Nurses use standardized terms by
(NANDA) as the Nursing diagnosis
to provide basis for selection of
nursing intervention to achieve
outcomes for which they are
accountable.
 A
Impaired skin Impaired gas
integrity exchange
PO2 – 65
2cm decubitus sacrum skin
PCO2 – 54
tears on both anterior legs

Constipation
Fluid volume J.L
74
excess male
No bowel movement for 3
CHF,
interstitial acute
M.I
days
4+ pitting edema in both Ineffective
lower
extremities, hands and face Breathing
crackles up 2/3 of both lung pattern
fields
Ineffective Coping Fluid volume RR – 28
deficit: Cheyne-stokes
Mechanism respiration

Pt crying – unable to
intravascular when sleeping
BP – 90/50 Peripheral
comfort pulses
patient – pt became faint
hysterical HR – 120
Profound thirst
Terms used in nursing
diagnosis.
 Nursing diagnosis is the clients health
concerns expressed as:
 Altered
 Impaired
 Deficit
 High risk for
 Ineffective.
Using Nursing diagnosis
Terminology.
 Do not state nursing diagnosis in
medical terminology. E.g.
Mastectomy related in self concept
related to mastectomy. (correct)
 Do not state nursing diagnosis in
medical diagnosis. Potential
pneumonia (incorrect) ineffective
airway clearance related to poor
cough effort. (correct)
Using Nursing diagnosis
Terminology.
 Do not state nursing diagnosis as
nursing intervention. (incorrect)
offer the bedpan frequently related
to urinary urgency. (correct)
alteration in urinary elimination
related to urinary urgency.
 Do not state two problems at the
same time pain and fear related to
diagnostic procedures.
PLANNING PHASE.
 The act of determining what can be
done to assist the patient to restore,
maintain or and promote health.
Planning includes
 Setting priorities: what problems need

immediate attention? What problems

must be addressed on care plan? What
problems must be referred? And what
order do you plan to do all this.
CONT
 Establishing Goals: Exactly what must
be accomplished and by when?
 Determined Nursing Interventions:
What nursing actions/patient activities will
help to achieve the goals that nurse and
the patient have set.
 Documenting Nursing care plan: Other
nurses need to know the plan of care you
prescribed and goals you except to
achieve.
Care plan.
 Care Plan: A written plan of nursing
action that describes specific client
problems, expected outcomes,
nursing orders and client progress.
 Nursing order: A statement written
by the nurse that specifies nursing
interventions that all nurses caring
for that specific patent should follow.
Documenting the Plan of
Nursing Care.
 Writing nursing care plan is the
final step in the planning process.
 If you fail to document your plan,
you waste all your effort you have
given to determining an
individualized care plan.
 No one will know the work that has
been done.
Proposes of Documentation
 To validate that there has been a
thorough plan of care formulated
for each patient.
 To serve as a record that can later
be studied to evaluate patient care.
 To communicate to other nurses
the specific problems, goals, and
interventions that have been
identified for the patient.
Implementation /
Intervention.
 Collaborative actions are those
activities that involve mutual
decision making between two or
more health practitioners.
 Nursing actions guide both actual
patient care and proper
documentation, therefore must be
detailed and exact.
 Nursing action.
 A complete written nursing action plan
incorporates at least following five
components according to Bolander.
 Date the action was initially written.
 Specific action verb that tells what the nurse is
to do. E.g. “Assist”. “Supervise”
 A prescribed activity e.g. ambulation
 Specific time units e.g. (For 25 minutes at
least 4 times a day).
 Signature of the nurse who writes the initial
action order. (i.e. accepting legal and
accountability).
 Nursing interventions
include
 Directly performing an activity for a client.
 Assisting client to perform an activity
himself.
 Supervising the client while performs an
activity himself.
 Teaching client about the health care.
 Monitoring the client for potential
complications of illness.
 Counseling the client in making choices
about seeking and utilizing appropriate
health care resources
 Pre-printed form of care
plan
Name …………….…….……. Reg No.
…….Ward…….. Patient diagnosis …………….
……………………….…….
Dat Assessme Nursing Goal Nursing Evaluatio sig
e nt diagnos expecte interventi n n
Date is d on
statement statement
 Implementation/
Intervention.
 This is the action phase or nursing
process and hence the term “Nursing
Action” used .
 Two important steps are involved in
implementation.
 Determining the specific nursing actions.
 Documenting the care administered.
 Nursing Action is defined as nursing
behavior that serves to help the patent
achieve the expected outcome.
 Implementation/
Intervention.
 Nursing actions include both
independent and collaborative
activities.
 Independent actions are those actions
nurse performs using his/her own
discretionary judgment and require no
validation or guidelines from any other
health care practitioner e.g. deciding on
noninvasive technique to use for pain
control.
Evaluation.
 Means assessing what progress
has been made toward meeting
expected outcomes.
 Is the feedback and control part of
nursing process.
 It require continuous assessment
that begun in assessment phase.
 Data collected in this phase
measure patient progress.
Action following data
collection
 Simply means making a nursing judgment of what
modifications in the plan of care are needed.
There three judgments
 Resolved: Means that evaluative data indicate

the health problem reflected in nursing diagnosis

no longer exist e.g. expected outcome of Mr. Y.
will have decrease in number of requests for
analgesics by 20/4. in the assessment the nurse
finds that Mr. Y has requested only one analgesic
for the last 24 hours and none win the 12 hours.
One the chart 20/4 data – 1 analgesic in past 24
hours, none in past 12 hours. State having no
pain declared.
 Revise.
Indicate two actions.
First, initial diagnosis not correct so it

is revised.
Second, while collecting evaluation

data for one diagnosis and outcome,

she finds factors that show another
problem has risen. Revise the plan to
include new nursing diagnosis.
Continue
 Indicate that the expected
outcome has not been met so
continue with care.
Recommendations
 Nursing process committees are
require to coordinate, oversee,
monitor and evaluate the use and
effectiveness of nursing process in
every health facility providing nursing
care.
 Nursing process is more largely
theoretical than practical.
 Challenge is ours of putting standard
care in place for all Kenyans.
References.
 Emergency Nurses Association (ENA)
(2000) EMERGENCY Nursing Core
Curriculum 4th edition.
 Urden and et al (1998) Thelan’s
Critical care Nursing 4th M Mosby.
 Carpenito L.J (1991) Nursing Care
Plans and documentation J.P Lippincot.
 Griffin and et al 1982 Nursing process,
application of theories. Framework
and models.
END
 Thank you