Introduction to Nursing

Process(NP)
Presenter :M.Salman Alam
Nursing Instructor, RCN
Acknowledgement: FON team
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 Objectives:
🞇 At the end of the session, learners will be able to:
1. Define nursing process and its components
2. Describe purposes and advantages of NP
3. Perform assessment by utilizing FHP tool
4. List down problem statement, long term and short term
goals and evaluation
5. Integrate five components of NP
6. Begin to use nursing process to deliver safe nursing care
to individual and participate in safe patient care delivery.

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 Nursing Process
Nursing Process define as:
🞇 “The nursing process is a systematic, client centered
method for structuring the delivery of nursing care.
The nursing process entails gathering and analyzing
data in order to identify client strengths and
potential or actual health problems, and developing
and continually reviewing a plan of nursing
interventions to achieve mutually agreed
outcomes”. (Erb & Kozier, 2008)

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 Purposes:

🞇 To identify a client’s health status, actual

or potential health care problems or
needs.
🞇 To establish plans to meet the identified
needs.
🞇 To deliver specific nursing interventions to
meet those needs.
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Components of Nursing
Process

Assessment

Evaluation Nursing
diagnosis

Implementation Planning/
5 NP
Goals
 Represents the cognitive (thinking, reasoning),
psychomotor (physical), and affective
(emotion,
feelings, and values) skills and abilities used by
the nurse to plan care for a patient.
 Works as a cyclic and dynamic process.
 Serves as client-centered framework.
 Permits holistic care delivery.

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 Scenario:
🞇 A 19 years old boy comes in emergency with
complain of vomiting and diarrheas since two
days. Doctors has ordered IV fluids Dextrose
5% immediately , send blood CBC, urine DR
and chest X-ray. Investigations reports reveals
RBS 260 (high) and glucose +1 in urine .
Doctor orders Inj. insulin 2units stat.
1. What should a nurse do in above scenario?
2. What is the rational for nurse intervention?
3. What could be the appropriate action in above
scenario?
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"Critical thinking in nursing practice is a discipline
specific, reflective reasoning process that guides a nurse in
generating, implementing, and evaluating
approaches for dealing with client care and professional
concerns“

Creativity is a major component of critical thinking

9 NP
(National League for Nursing,
2000)
Nurses use critical-thinking skills in a variety
of ways:
Nurses use knowledge from other subjects
and fields in problem solving.
Nurses deal with change in stressful
environments. Nurses make important decisions.
 What is the issue?
What information do I need and how do I get
it? Is my data valid?
What do the data mean, based on the
facts? What should I do?
Are there other questions I should ask?
Is this the best way to deal with the
issue?
Nursing process:

First component:
Assessment

Assessment
  Assessment is the systematic and
continuous collection, organization,
validation, and documentation of data
(information).

 Assessment is done to determine and prioritize

the patients problems, needs and plan nursing
interventions accordingly.

(Erb & Kozier,

2008)
 Data Collection
Data collection is the process of gathering
information about a client's health status.
Types of Data
1.Subjective Data: Subjective data include the
client's sensations, feelings, values, beliefs, attitudes,
and
perception of personal health status and life situation.
This can
be taken from
2.Objective are detectable
client
Data: by an observer or can be
or family member/relatives.
measured or tested. This can be seen, heard, felt, or
smelled, and these can be obtained by observation,
1la4borNaP tory results or physical examination.
3. Organizing Data: This refers to format and
organizes the assessment data systematically
(e.g. Gordon's functional health pattern ).

4.Validating Data : it is the act o f "double-

checking" or verifying data to confirm that it is
accurate and factual.

5. Documenting Data: the nurse records client data.

Accurate documentation is essential and should include all
data collected about the client's health status.
Collecting data
A. History taking
🞇 Principles of history taking:
🞇 Introduction
🞇 Take consent for writing notes or filling form
🞇 Reassurance for privacy and confidentiality of data
🞇 Quiet environment
🞇 Patient should be pain free
🞇 Patient should be facing to wards nurse
🞇 Good light
🞇 Free of distraction
🞇 Proper listening
🞇 Apply principles of Therapeutic communication
Ways of Assessment:

B. Physical Examination:
• General appearance ,height weight ,proper clothing,
orientation with environment

• Head to toe assessment

Ways of Assessment:

C. Patient's documentation
🞇 Physician notes, physiotherapist notes , dietition notes
🞇 Investigations reports
🞇 Nursing notes
A 24-year-old girl is admitted in the
emergency department for abdominal pain. During
history taking she verbalized “ I have severe pain in
my upper abdomen and said a pain score of 8 (0-10)”.
She is awake and alert, but crying due to pain. On
head to toe assessment nurse found hard abdomen,
pain on palpation and bowel sounds two per minute.
 Subjective Data Objective Data
Patient verbalized “ I have severe 24 years old female admitted
pain in my upper abdomen. to ED with abdominal pain.
Further she rated her pain score Patient was awake and
8 on the pain scale of (0-10) ” alert but crying because
of sharp pain. on head to
toe assessment it was found
that
•Abdomen was hard
•Pain on palpation
•Bowel sounds below
normal (2/min)
Vital signs of patient were
Temp: 36 C,RR : 22,Pulse:
20 NP
102/min, Bp: 123/89
mmHg
Practice time:

🞇 Assessment of patients with different problems

 What is the issue?
What information do I need and how do I get
it? Is my data valid?
What do the data mean, based on the
facts? What should I do?
Are there other questions I should ask?
Is this the best way to deal with the
issue?
It is a statement that describes the client’s actual
or potential response to a health problem that
the nurse is licensed and competent to treat.
 Actual:
An actual nursing diagnosis is a client problem that
is present at the time of the nursing assessment. It
is also based on the presence of associated signs
and symptoms.

E.g. Acute Pain, Ineffective Breathing Pattern, Anxiety etc.

Risk:
Arisk nursing diagnosis is a clinical judgment that problem
a doesn’t , but the presence of risk factors indicates that a
problem is likely to develop unless nurses intervene.

E.g. every patient in hospital has possibility to acquire

infections but a diabetic patient has higher risk. Therefore
the nurse would appropriately use the diagnosis Risk for
Infection.
 Possible:
A possible nursing diagnosis is one in which
evidence about a health problem is incomplete
or unclear.

A possible diagnosis requires more data either to support or

refute it. E.g. an elderly widow who lives alone is admitted to
the hospital .The nurse notices that she has no visitors and
is pleased with attention and conversation from the nursing
staff. Until more data are collected the nurse may write
nursing diagnosis of Possible Social Isolation.
 Syndrome:
A syndrome diagnosis is a diagnosis that is
associated with a cluster of other
diagnosis.

E.g. a long term bedridden patient might have diagnosed as

having Disuse Syndrome i.e. clusters of other associated
diagnosis including Impaired Physical Mobility, Risk for
Infection, Risk for Impaired Skin Integrity etc.
The nursing diagnosis has three
components:
 The Problem (Diagnostic

Label)
 The Etiology (Cause) i.e.

related to
 The Defining Characteristics
 Acute pain
 Hyperthermia
 Constipation
 Impaired urinary elimination
 Ineffective individual coping

(Carpenito, 2002)
A 10 years old boy studying in grade IV,

complained of severe stomach ache while he was studying in

school. His intense facial expressions revealed to his teacher
that he was in severe pain. The school health nurse examined
him and found out that his abdomen was tender and pain was
on scale of 9 out of 10. She also noticed that Furqaan’s
personal hygiene wasn’t proper e.g. he was having unclean
hands and long dirty nails. She called his mother to come
over. During the interview with his mother, she came to know
that Furqaan used to eat junk food which is readily available
outside his school. As his mother was a working lady, she
couldn’t get enough time to make him a lunch box. His
g3e1nera l hygiene practices are poor including bathing and
NP

h a n d washing practices.
7/ 10 /2 018
From the given scenario, you are required
to: Identify the problem.


 Stomach Ache

Explore the cause or etiology of the problem.
 Improper Hygiene practices
 Ingestion of Unhygienic food

List the defining characteristics or sign and
symptoms of the problem.
 Facial Expressions
 Pain scale
32 N Tenderness (pain on touching)
P
 (P) related to (E) as evidenced by
(S)
From case 2:
Acute Pain (i.e. stomach ache) related to ingestion of
unhygienic junk food as evidenced by client’s intense
facial expressions and pain score of 9.

33 NP
 Did the Scenario reflect one problem only?
The answer is NO. The scenario reflected many
other problems responsible for Furqaan’s condition.

For example:
Unhygienic practices which may cause
potential
alteration in Furqaan’s health in a long
run.
34 aAltered
ttentio Family Processes i.e. lack of
NP

nmotherly
Ms. Maria admitted with the complain of urinary
retention. while history taking, she verbalized to
the nurse that she is experiencing difficulty in
passing urine and her normal urinary elimination
pattern was not normal as before. On examination
nurse found distention of lower abdomen.
Ultrasound of whole abdomen showed calculi in
urinary tract.
 (P) related to (E) as evidenced by
(S)
From case 3:
Impaired urinary elimination (i.e. urinary retention)
related to obstruction (stones) in the urinary tract
evidenced by lower abdominal distention and
patient verbalization of difficulty in passing urine
 Planning is the process of designing
nursing strategies to prevent, reduce, or
eliminate a client’s health problems.
 Goals/ Expected outcomes (interchangeably
used)and is a desired out come or change in
clients behavior

 Goals (broad): Nutritional status will improve


Expected outcome (specific): will gain 5 lb. by
September 25, 2016.

 Goals:
1. Short term
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2. Long term
NP
 Long-Term Goals:
Is one that will take time to achieve (weeks to
months). Long-term goals are often used for
clients who live at home or have chronic health
problems, for clients in nursing homes,
extended care facilities, and rehabilitation
centers. E.g.
“Client will regain full use of right arm in
6 weeks.”
 Short-Term Goal:
Is one that can be achieved relatively quickly
(usually within a week or two). Short-term goals
are useful for clients who require health care for
a short time and who are frustrated by long-term
goals that seem difficult to achieve. E.g. “Client
will raise right arm to shoulder height by Friday.”
Essentials of outcome measures
Short Term Goal:
By the end of my clinical hours Patients pain score
will be 2 from 9 on the pain scale of 0-10.

Long Term Goal:

By the end of two weeks patient will be pain free/ or
pain will be 0.
Definition:
Doing and documenting activities that are
specific nursing interventions.

(Erb & Kozier, 2008)

Intervention could be of three types:
Independent Interventions (e.g.
back massage, deep breathing
exercise).
Dependent Interventions (e.g.
Administering painkillers)
Collaborative/Interdependent
Interventions (e.g. other departments
involved like nutritionist, pharmacy
or physiotherapist).
Evaluating is a planned, ongoing, purposeful
activity, in which clients and health care
professionals determine

1) the client’s progress toward goal achievement

2) the effectiveness of the nursing care plan

(Erb & Kozier,2008)

45 NP
 Ongoing Evaluation (on every contact with
patient,
e.g. after intervention)

 Intermittent Evaluation (on a specific time period,

e.g. "Will rate pain as <3 on 1-10scale within 1
hour after medication." )

 Terminal Evaluation (at the end of discharge)


The nursing care plan (NCP) is a written guide
that organizes information about a client’s care into
a meaningful whole. The purpose of written care
plan is to:
Provide direction for individualized care.
 Provide continuity of care.
 Provide direction about what needs to be documented on
the client’s progress notes.
Serve as a guide for assigning staff to care for the client.
Nursing Care Plan with Components of Nursing
Process
Assessment Diagnosis Expected Implementation Evaluation
outcome /nursing
intervention
Subjective Data: Acute Pain Short term • Assess By the end of
Patient (stomach ache) goal: pain on my shift patients
verbalized that related to By the end the pain scale pain was reduced
“he was in ingestion of of my shift from 9 to 2 on the
severe pain”. He unhygienic junk “Patients pain • Take vital pain scale of 0-
further told a pain food as score will be signs of 10.
score of 9 on the evidenced by 2 from 9 on patients
pain scale of client’s intense the pain scale
(0-10) facial expressions of 0-10. • Give
Objective Data: and pain score of Long Term medication as
10 years old boy 9 (0-10). Goal: prescribed
complained of By the end of by doctor
severe stomach two weeks
ache. Nurse patient will be • Massage
observes intense pain free (0). therapy
facial expressions.
Abdom4e8n waNsP • Guided
imagery
 Health-perception-health management
 Nutritional metabolic pattern
 Elimination pattern Activity-
 Exercise pattern Cognitive
 perceptual pattern Sleep-rest
 pattern
 Self perception-self concept pattern
 Role relation pattern
 Sexuality reproductive pattern
 Coping-stress-tolerance pattern
 Value-belief pattern
 Erb, G., & Kozier, B. (2008). Fundamentals of
nursing: Concepts, process and practice. (8th
ed.). Addison – Wesley.
 Carpenito, J. L. (2002). Handbook of
nursing diagnosis. (9th ed.).Lippincott.
 Yildirim, B., & Ozkahraman, S. (2011). Critical
thinking in nursing process and education.
International Journal of Humanities and
Social Science, 1(13), 257-262.
Enjoy Your Weekend