The Nursing Process

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 The Nursing Process is ...
“A systematic, rationale method of planning
and providing individualized nursing care.
Its purpose is to identify client’s health
status, actual or potential healthcare
problems or needs, to establish plans to
meet those needs and to deliver specific
nursing interventions to meet those needs”.
(Kozier, 2004)

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The Nursing Process is ...
The set of activities that professional nurses
perform to determine the needs of the
patient and make a judgment to provide the
care that is needed.

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Your legal and professional accountability
and the nursing of process

CA BRN Standards of Competent

Performance: RN shall be considered
to be competent when he/ she
consistently demonstrates the ability to
transfer scientific knowledge…in
applying the nursing process:

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Standards of Competent Performance (Board
of Registered Nursing)
Formulates nursing diagnosis, through observation and
interpretation of information.
Formulates a care plan in collaboration with the client.
Performs skills essential to the nursing actions to be
taken.
Delegates tasks to subordinates
Evaluates the effectiveness of the care plan
Acts as the client’s advocate.

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American Nurses Association
Standards of Practice
The collection of data is systematic
Derive nursing diagnosis from data
Plan nursing care including goals
Plan includes priorities and nursing approaches
Nursing actions provide for client participation in
health promotion, maintenance, and restoration
Evaluation of progress or lack of progress

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 Problem-Solving & Priority Setting
Priority Setting:
Determine client health values & beliefs
Establish priorities from highest to lowest
Determine urgency or the problem
Problem-Solving:
Once problem is identified, collect data
Analyze the data & identify an action-plan
Implement the plan, observing initial responses
Evaluate the results

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 Steps of the Nursing Process

Assessment
Diagnosis
Planning
Implementation
Evaluation
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The Nursing Process

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The
Nursing
Process
Assessment
Phase
 Assessment Data

Subjective Data
- The client states “ . . .”

Objective Data
- Vital signs
- Physical assessments
- Previous documentation
Examples of Data
Temp of 102 degree
“I feel tired”
WBC 24,000/mm3
“I need help to walk”
B/P 180/96
“My leg hurts”
Redness and swelling in R ankle

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Diagnosis
Phase
 A Nursing Diagnosis is ...
A description of the client’s response to a disease
state, process, condition or situation. It is “a
clinical judgment about an individual, family or
community responses to actual/potential health
problems/life processes. Nursing diagnoses
provide the basis for selection of nursing
interventions to achieve desired client outcomes”.
(NANDA, 1990)

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 Comparing Nursing & Medical
Diagnoses
Nursing Diagnosis
Describes a response to a
disease process, condition
or situation
Oriented to individual
changes as client changes
Compliments medical
diagnoses
Teaches client re self-care
Medical Diagnosis
Describes a specific disease
process
Oriented to pathology &
remains constant
Well defined classification
system
Teaches clients about
treatments
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Advantages & Disadvantages of Nursing
Diagnoses
Advantages:
Provides a common language for nurses
Outcome-oriented
Efficient, Organized , Systematic, and Goal Directed
Disadvantages:
Inconsistently used
Not always formally recognized (by MDs.)
Some problems don’t fit diagnostic statements as
outlined by NANDA

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 Two Types of Nursing Diagnoses
Actual Problems:
Altered Nutrition, less than body requirements
related to poor oral intake as evidenced by weight
loss of 12 lbs. in two weeks.
Potential Problems:
High risk for infection (Potential for) related to
decreased primary defenses.

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 Components of a Nursing Diagnosis
Actual Problem (3 Part Statement)
Diagnostic Label/Statement (Problem Statement):
“ Activity Intolerance” “Impaired Physical Mobility”
(identifies unhealthy responses, what needs change)
Etiology (Contributing Factors)
“… related to _______________”
(identifies factors causing undesirable response)
Defining Characteristics (Manifestations)
“ … as evidenced by __________” (what you see)

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Components of a Nursing Diagnosis
Potential Problems (2 Part Statement)
 Diagnostic Label/Statement
 Etiology (Contributing Factors)

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Planning
Phase
Daftar diagnosa (klpk III)
1. Ketidak efektifan pola nafas b.d. Kebutuhan O2
yg meningkat
2. Nyeri akut b.d....
3. Gangguan pola tidur b.d....
4. Defisit perawatan diri b.d. ......

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Prioritas diagnosa keperawatan
1. Ketidak efektifan pola nafas b.d. Kebutuhan O2
yg meningkat
2. Gangguan pola tidur b.d....
3. Nyeri akut b.d....
l o w
4. Defisit perawatan diri b.d. ...... as
h m
nto
Co

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Dasar memperioritaskan masalah
Kebutuhan dasar menurut maslow
Jenis diagnosa : aktual, resiko dan potensial
Konsep kegawatdaruratan: “Mengancam jiwa”

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 Planning Phase:
Goals & Outcomes
Goals are broad statements about the
effects of nursing interventions on the client
(overall, non-measurable statements)
Outcomes are specific, measurable criteria
used to evaluate whether goals have been
met based on specific nursing interventions

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 Outcome Statements (Criteria)
Outcomes are derived from the diagnosis
Outcomes are measurable/behavioral
Outcomes are realistic compared to the
client’s self-care abilities
Outcomes have a time-frame for completion
Outcomes provide direction for care

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 Planning Phase: Interventions
Interventions should be developed
which are consistent with the
established plan of care

Interventions should be implemented in

a safe, appropriate manner based on
sound nursing theory and judgment
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Planning Phase: Interventions
Interventions should always be
documented in the medical record
Interventions should be realistic for
client, based on abilities and
resources

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 Types of Nursing Interventions
Independent:
Able to be implemented without a physician’s order

Dependent:
Must have or obtain physician’s order to
implement this intervention

Collaborative:
Combination of dependent/independent
nursing intervention

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Types of Nursing Functions
Independent: functions that are within scope of
nursing practice.
Assessment - history and physical
Nursing diagnosis, which require nursing
interventions
Nursing actions
Referrals to other health members
Evaluation of patient’s responses

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Types of Nursing Functions
Interdependent: activities that are carried out in
conjunction with other health team members.
RN works with a dietician to help a diabetic patient
control blood sugar.
RN works with PT to help improve patient’s
ambulation.

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Nursing Functions
Dependent: activities performed
based on the physician’s orders
Administration of medication
Carrying out specific treatments

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Independent? Interdependent? Dependent?
Patient has a B/P of 160/100, the RN
Retakes the B/P; ask the pt what he was doing.
Asks the pt. how he is feeling, notes changes
Checks B/P with the previous B/P readings.
Checks the MD’s order for any related orders.
Gives treatments ordered by the MD.
Monitors effects of medication.
Teaches the pt. relaxation techniques.

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Focus of Patient Care
Medicine and Nursing
Patient reports, “It feels like my chest is
being crushed”
Observations show facial grimace, SOB
(shortness of breath), and diaphoresis
(perspiring)

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Focus of Patient Care
Goal of Medicine: Goal of Nursing:
cure, treat disease, works with the
heal physiologic whole person
being

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Focus of Patient Care
Medical interpretation Nursing
of pain: diminished interpretation: Pain
blood flow from in the chest
coronary arteries to
myocardium Probable Nursing
Probable Diagnosis: Diagnosis: chest
Myocardial Infarction pain related to
cardiac disease
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Focus of Patient Care
Medical Plan: Nursing Plan:
dependent functions independent functions
Bedrest Monitor EKG and
Vital Signs q 15 min. dysrhythmia
Morphine 2mg IV prn Assess chest pain
NTG 1/200 gr SL prn Employ comfort
EKG, O2 at 2L/min measures, allow rest
Alleviate anxiety

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No Diagnosa Tujuan dan kriteria Hasil Rencana tindakan rasional

1 Defisit perawatan Setelah dilakukan Buat rencana Jelaskan alasan

diri berhubungan tindakan keperawsatan tindakan yang masing-masing
dengan selama 3 kali 24 jam dapat mengatasi tindakan yang
keterbatasan pasien diharapkan masalah dilakukan
aktifitas mampu: keperaatan yang
dimanifestasikan -Melaksanakan aktivitas muncul.
dengan : mandiri secara bertahap Didasarkan pada
DS: ..... -Memenuhi kebutuhan diri referensi
secara mandiri dll
DO : .......

Mandiri,
observasional/monitori
ng kolaborasi,penkes
SMART
OH
NT Tidak tahu, tidak
CO
mampu dan tidak mau

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Implementation
Phase
 Implementation Skills (3)
Require cognitive skills (problem-solving,
creative & critical thinking skills)
Require interpersonal skills (verbal/non-
verbal communication,teaching, caring etc.)
Require technical skills (“hands-on”
psychomotor skills, tasks, procedures)

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Minimal format implementasi
N Hari/ Diagnosa Tindakan (hasil Parat/
o tanggal/jam Keperawatan dan respon) tandatanga
n
1 28 Maret 2015 Dx 1 Melaksanakan observasi
Jam 10.00 tanda-tanda vita:
H : TD 110/70 mmHg, N:
76x/menit, RR : 20
x/mnt, S: 38,5oC

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Evaluation
Phase
The Nursing Process
STEP 5
Evaluation—
determining the
client’s progress

monitoring the
client’s response

Otten/403 43
 Evaluation Process
Compare the actual to expected outcomes
- Did my client achieve their outcomes?
- If not, determine why outcomes were unmet - Were the
outcomes realistic? Correct problem? Enough time to
achieve outcomes?
If you determine the outcomes to be appropriate, assess
the interventions
-Were the interventions appropriate? Were they completed?
Does the client require other nursing interventions?
If everything looks good, continue with plan of care,
observing for improvement

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 Purposes of a Written Care Plan
Provides direction & individualizes client
care
Provides for continuity of care
Provides direction for follow-up &
documentation
Provides assistance in assigning staff
Provides information for reimbursement
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Mrs. Ida Hubert, 67 y.o.
Admitted to the unit with diagnosis of lung
cancer with bone metastases 3 days ago
Meds: morphine 180 mg daily; Tylenol 650 mg
+Oxycodone 10 mg q6h p.r.n.
Morning report: Mrs. Huber had been restless all
night

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What assessments would you want to make
in your preparation for her care?

Chart review: Has been taking

narcotics for 2 months; spends
most of her days in bed

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Assessment of Mrs. Hubert
Patient interview:
Alert and responsive
“Couldn’t sleep or rest; just couldn’t get into a
comfortable position.” Had trouble describing her
discomfort.
Reported decreased appetite, ate 3 small meals/day,
one 8 oz can of supplement. Said she is drinking
very little fluids

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Assessment of Mrs. Hubert
Measurements:
V.S. were stable
Had active bowel sounds, abdomen non-tender to
palpation, but noted a firm area in LLQ.
Said she had not had a BM since admission (3 days
ago).
What nursing diagnosis might be appropriate for
Mrs. Hubert?

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 Critical Thinking: What is it?
Critical thinking is “making decisions based on
reason, reflection, knowledge and instinct
derived from experience. Critical thinking helps
nurses make patient-care decisions by helping
them to think creatively, and explore new ideas
and alternative ways of solving problems.
(Catalano, 1996)

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 The Critical Thinking Process
Identify the problem
Identifying the underlying beliefs (patient, personal and
other healthcare providers)
Find support for the beliefs (accurate, timely, consistent
literature/research)
Evaluate the situation for possible solutions and weigh
the solutions against the beliefs and values
Present a course of action

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Comparison of SOAP & Nursing Process Steps

Subjective Assessment

Objective Diagnosis

Plan
Assessment
Implementation
Plan
Evaluation