UNIT 2

NURSING PROCESS

Mrs. Asha Russel

Asst. Science Tutor ‘A’
PAIN ASSESSMENT TOOL
 Diagnosis
Nursing diagnosis Medical diagnosis

Breathing patterns, ineffective Asthma

Activity intolerance Congestive Heart Failure

Pain Appendicitis

Body image disturbance Amputation

Body temperature, risk for Tuberculosis

altered
 Parts of Nursing Diagnostic Statement
Qualifiers/ Modifiers – (Problem)
Altered Change from baseline
Impaired Made worse, weakened, damaged
Decreased Smaller in size, amount or
degree
Ineffective Not producing the desired effect
Acute Severe or of short duration
Chronic Lasting a long time
Parts of Nursing Diagnostic Statement
Related to (r/t) – (Etiology)
Educated guess as to what factors are contributing to or
causing the problem
Placed between problem and signs & symptoms to
indicate relationship between them
Cannot be a medical diagnosis
Must be modifiable by nursing interventions
 Must be able to do something about it
Will be in one of five categories:
 Environmental, situational, psychological, pathophysi0logical,
and maturational
Parts of Nursing Diagnostic Statement
Evidenced by (e/b) or Manifested by (m/b):
Signs and symptoms (assessment data) that led to
your nursing diagnosis.
Examples:
 SOB while walking
 Client stating food intake is poor

 Client states he is in pain

 Client states that he hasn’t had bowel movements since 3 days

 Client has open wound on buttocks

edema.
Eg : Readiness for enhanced nutrition,
Readiness for enhanced family coping,
Readiness for enhanced body image, etc….
 Prioritizing the nursing diagnosis

Maslow’s hierarchy of needs

Maslow’s Hierarchy of Needs
 Planning
It is the third step of the nursing process.

It is a category of nursing behaviours in which the

nurse sets:
Client centered goals
Expected outcomes
And plans nursing interventions
Steps in planning
 Goals
Goals should be established to meet the
immediate, as well as long-term
prevention and rehabilitation, needs of
the client.
 Goals
Client Goals can be short or long term goals

Short-Term Goal- objective is to be attained

within a short time i.e.: few hours to a week.
 Ex: client will achieve comfort within 24 hours post surgery

Long-Term Goal- achieve over a longer period of

time i.e.: weeks or months.
 Ex: client will follow post-op activity restriction for 1 month
Characteristics of Goals
 Expected Outcomes (Outcome criteria)
Expected Outcomes are developed on the basis of
the nursing diagnoses and client goals.

Also known as evaluative criteria

Desired behaviours or responses that the nurse

plans and the client expects to occur as a result of
the interventions taken by the nurse

Enable the nurse and client evaluate whether the

plan of care has been successful in meeting the
goal(s)
 Goal Outcome

The aim or object Something that follows

towards which an from an action; result;
endeavour is directed consequence
 PLANNING NURSING INTERVENTIONS

Interventions are selected to solve the client’s

health needs and to attain goals and
outcomes.

Decision-making and problem solving skills

are required
PLANNING NURSING INTERVENTIONS
Planning of nursing interventions require:
 review of the literature
 collaborates with client, family and other health
team members
 Nursing Interventions
Nursing interventions are decided after goals and
expected outcomes are confirmed.

Assist the client to move form his/her present

state of health to that which is identified in the
goal and outcomes.
 Interventions should:
 Monitor, prevent & manage health problems/
concerns & risk factors

 Promote optimum function, independence & sense

of wellbeing

 All interventions should be accompanied by

appropriate rationale or scientific explanations.

 Achieve expected outcomes

 Selecting Nursing Interventions

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.
 Selecting an intervention
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.
 Communicating The Plan

The nurse shares the plan of care with nursing

team members, the client, and client’s family.

The plan is a permanent part of the record.

 EVALUATION
Evaluation of client goals and client
outcomes - were they met, partially
met, or unmet, why & the present
health status of the client at evaluation
stage.
 EVALUATION
Evaluation of care involves tracking
the client’s progress toward
achievement of expected outcomes.