AMANUEL MENTAL

NURSING AUDIT CASE

SPECIALIZED
TEAM
HOSPITAL

NURSING PROCESS
NURSING CLINICAL AUDIT TEAM IN
COLLABORATION WITH NURSING DIRECTOR

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 Outline

 Introduction

 Assessment

 Nursing Diagnosis

 Planning

 Implementation

 Evaluation
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 Definition

 The nursing process is a systematic and

dynamic method used by nurses to provide
individualized, holistic care to patients
 It serves as a framework for organizing and
delivering patient care in a structured and
effective manner
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 Purpose of Nursing Process
 Provides an orderly and systematic method of providing care

 Enhances Nursing efficiency by standardizing nursing practice

 Provides a unity of language for the nursing profession

 Provides continuity of care

 Increases quality care through the use of deliberate use of

actions

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 Characteristics
 Interactive, purposeful and systematic
 Client centered
 Dynamic
 The steps are inter-related and depends on
the accuracy of the preceding steps
 Used to identify, diagnose and treat human
responses to health and illness

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 Cont…
 There are five components of the nursing
process—assessment, diagnosis, planning,
implementation, and evaluation—form a
continuous cycle that guides nurses in
delivering comprehensive and individualized
care to patients.

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 Components of Nursing Process

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 ASSESSMENT
 Assessment is the systematic and continuous collection,

organization, validation, and documentation of data

(information).

 During this phase, nurses collect data through various

assessment techniques to understand the patient's

physical, psychological, sociocultural, and spiritual

aspects.
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 Cont..
 Gordon's Functional Health Patterns are
utilized to gather comprehensive data on the
patient's health status across 11 interrelated
categories.
 Nurses gather information about the patient's
past psychiatric diagnoses, treatments,
hospitalizations, and any significant life events
or stressors that may have contributed to their
current mental health condition.

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 Cont…
 Nursing assessments are not duplications of
medical assessments, which target
pathological conditions, instead the human
responses for the illness or potential for the
illness

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 Types of assessment

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 Cont…
 Initial Assessment: Performed within specified time after
admission. To establish a complete database for problem

identification

Example: Gordon's 11 functional patterns, Psychiatry nursing

assessment

 Problem Focused Assessment: To determine the status of a

specific problem identified in an earlier assessment.

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 Cont…
 Emergency Assessment: During emergency
situation to identify any life threatening
situation. Eg: Rapid assessment of an
individual’s airway, breathing status, and
circulation during a cardiac arrest.

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03/18/2024 15
 Assessment Skills

 Observation
 Interviewing (Gordon’s patterns and
psychiatry hx)
 Physical Examination
 Intuition/Insight

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CONT…

DATA COOLLECTION

ORGANIZING DATA

VALIDATING DATA

DOCUMENTATION

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 Cont…
• Symptoms
• Described by the
Subjective patient/Collateral

• Signs
• Information directly
Objective observed/measured by the
healthcare worker

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03/18/2024 19
 Nursing Diagnosis
 Nurses analyze the collected data to identify
actual or potential health problems or nursing
diagnoses. Nursing diagnoses are clinical
judgments about the patient's response to
actual or potential health conditions.
 They provide a common language for nurses
to communicate and plan care.

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 Purpose of the Nursing Diagnosis
 Gives nurses a common language
 Provide direction for nursing care planning
and guide the selection of appropriate
interventions.
 Can provide a standard nursing practice
 Provides a quality improvement base

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 Components of Nursing Diagnosis
 Problem or Diagnostic Label: Describes the
health problem or alteration in the patient's
health status. derived from standardized
nursing taxonomies, such as NANDA-I
 Related or Contributing Factors: Provides
insights into the underlying causes or
conditions that contribute to the identified
problem.

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 Cont…
 Defining Characteristics or Signs and
Symptoms: Observable and measurable cues
or evidence that support the nursing
diagnosis.

Problem Etiology Manifestations

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 Descriptive Words

 By using descriptive words in nursing diagnoses, you

can provide a clearer and more detailed
understanding of the patient's health problems,
 This include words like Risk, Impaired, Acute,
Chronic, Deficient, Disturbed, Depleted, Excessive,
Potential are some of them

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 Types of Nursing Diagnosis

 Actual Nursing Diagnosis

 Potential Nursing Diagnosis
 Wellness Nursing Diagnosis
 Syndrome Nursing Diagnosis

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 Actual Nursing Diagnosis

 This type of nursing diagnosis describes a current

health problem or condition that is present in the
patient.
 It is based on the presence of signs, symptoms, and
supporting data obtained during the assessment
process. It should also include all the 3 components

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 Case Scenario -1
John is a 32-year-old man who has been
diagnosed with schizophrenia. He has a history
of auditory hallucinations, disorganized
speech, and social withdrawal. John lives alone
and has been struggling to maintain his daily
routines and manage his symptoms effectively.
He frequently forgets to take his prescribed
medications and has difficulty attending
therapy sessions due to transportation issues.
He often feels paranoid and believes that
others are plotting against him.
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 Cont…
 Based on the case scenario- Actual nursing diagnosis
 Disturbed Thought Processes related to disorganized
speech and paranoid beliefs as evidenced by
incoherent speech patterns and suspiciousness
towards others.
 Impaired Medication Adherence related to
forgetfulness as evidenced by missed medication
doses
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 Potential Nursing Diagnosis

 Risk nursing diagnoses are used when a patient does

not currently have the identified problem, but is at
risk of developing it
 These diagnoses are based on risk factors or
potential vulnerabilities that increase the likelihood
of a problem occurring. Only Two-part statements

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 Cont…
 Based on the previous case scenario-1, a potential
nursing diagnosis could be made
 Risk for Social Isolation related to social
withdrawal, impaired communication, and paranoid
beliefs

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 Characteristics of Nursing Diagnosis

 Standardized (NANDA)
 Specific
 Individualized
 Dynamic
 Collaborative

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 Commonly found Errors
Category ERRORS

Lack of Specific Nursing Diagnosis Risk for violence directed at self or others
(Two problems at a time )
Risk for others( Only using descriptive )

Incorrect NANDA term Is a concern that an individual may engage

in aggressive or violent behavior towards
others. (Writing the definition )
Writing terms from the older version

Type of nursing diagnosis Writing a potential nursing diagnosis, when

the problem had already manifested.
Example, Writing about Risk for violence
directed at others, when the client had
been exhibiting aggression in the HPI or
chief complaint.

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 Cont…
Lack of individualization Nursing diagnosis made for a client should
have unique Etiology and manifestations

Incomplete Nursing diagnosis If the carried out nursing diagnosis is an

actual one, it should contain all the 3
components , Mostly the third “as
evidenced by” is ignored.

Irrelevant nursing diagnosis Sometimes nursing diagnosis is carried out

for a client that was not identified in the
Assessment phase.

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 Psychiatry Diagnosis Nursing Diagnosis(NANDA) terms

Schizophrenia  Disturbed Thought Process

 Risk for Violence
 Disturbed sensory perception
 Impaired Social Interaction

Major Depressive Disorder  Risk for suicide

 Hopelessness
 Ineffective coping
 Self care deficit

Bipolar I disorder  Risk for injury

 Disturbed Sleep pattern
 Risk for non-compliance
 Impaired Verbal Communication
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 Planning

 Planning is a collaborative process that involves the

active participation of the patient, their family or
support system, and other healthcare professionals
to establish goals, identify priorities, and determine
appropriate interventions
 Goals should be SMART

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 How to write a SMART outcome
 Specific- It should clearly state what is to be
achieved, well-defined and focused. Address
one issue at a time, and should not be
Ambiguous. Should Answer the "Five Ws“
Example. Decrease the frequency of panic
attacks experienced by the client diagnosed
with panic disorder from three times per
week to once per month within three
months.

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 Cont…
 Measurable: An outcome should be measurable so that
progress can be tracked and evaluated. If the problem is
quantifiable, use numeric's, percentages, if not use
sign/symptoms
 You should have assessment tools, it could be It could
include standardized scales, observations or equipments
 Establish a starting point or baseline measurement to
compare against as progress is tracked
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 Cont…
 Example. For a client with a BMI of 16.1 Kg/m2 , a measurable
outcome would be,

 “The client will have improved appetite in 1 week”̀is

incorrect

 The client will be able to increase his BMI from 16.1 Kg/m2 to

18.6 Kg/2 within 4 weeks of nursing intervention or

 By utilizing percentages it could be the client will be able to

have an increase with 9.1 % of his previous weight within 4

weeks of nursing intervention

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 Cont…
 For problems which can not be quantifiable, like Disturbed
thought process (suspiciousness) a measurable outcome could
be
 “The client will have improved thought process in 3 weeks “
is incorrect
 The client will be able to minimize the frequency of paranoid
thoughts and suspicious behaviors from daily occurrences to
no more than once per week within 3 weeks of nursing
intervention
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 Cont…
 Achievable: The outcome written should be realistic and
attainable within the given resources, time, and constraints
and it should consider the clients capabilities as well as the
nurses scope of practice

 “The client will be able to increase his BMI from 16.1 to 24

Kg/m2 within 2 weeks of nursing intervention” is incorrect

 The client will be able to have gained 5Kg of weights

within 2 weeks of nursing intervention
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 Cont…
 Relevant: An outcome should be relevant and
meaningful to the patient's overall well-being
and the desired nursing interventions
 It should be in line with the identified
problems during the assessment phase
 For a client presented with suspiciousness,
disturbed sleep pattern and BMI of 16Kg/m2
 “The client will be have desire to engage in
ADLs and regularly shower within 1 week of
nursing intervention” is incorrect
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 Cont…
 Time Bound: An outcome should have a
specific timeframe or deadline for completion,
Time-bound outcomes ensure that progress is
monitored and appropriate interventions are
implemented within the specified timeframe
 “The client will be able to fall asleep within
30 minutes and sleep 6-8 hours a day” is
incorrect
 “The client will be able to engage in a calm
and serene manner with others” is incorrect
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 Cont…
 Instead write

 “The client will be able to fall asleep within 30

minutes and sleep 6-8 hours a day within 1 week
of nursing intervention ”

 “The client will be able to engage in a calm and

serene manner with others within 10 days of
nursing intervention”
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 Clear indicators, it could be
Clear and concise, One
scales, sign/symptoms,
problem at a time
quantifiable data

Take into the clients abilities Should be directly related to

and commitment, the identified health
resources, time problems and clients needs

Specific timeframe to
achieve the desired
outcomes

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 Cont…
 Based on the above case scenario, a SMART
would be
 Over the course of 3 weeks the client will
demonstrate trusting relationship by
engaging in open conversation with others
and exhibit decreased vigilance or paranoia
during interactions

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 Prioritization
 Problems related to patient safety and immediate
risk should always be the highest priority. These may
include situations involving self-harm, harm to
others, or acute psychiatric crises
 Next, prioritize problems related to the patient's
basic physiological needs, such as nutrition,
hydration, sleep, and medication management
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 Cont…

 Address problems associated with distressing or

disabling symptoms that significantly impact the
patient's quality of life or functioning
 Prioritize problems related to critical medication
management, such as medication adherence,
adverse effects, or drug interactions

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 Implementation

 The implementation phase in the nursing process is

where the planned interventions are put into action
 It involves carrying out the nursing activities and
providing the necessary care to the patient

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 Cont…
 Nurses take action by performing tasks,
procedures, and activities that are part of the
care plan
 This can include administering medications,
providing treatments, assisting with activities
of daily living, offering emotional support, and
implementing therapeutic interventions

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 Evaluation
 The final step of the nursing process, but not the end
of the cycle involves determining the effectiveness of
the nursing interventions and evaluating the patient's
progress toward achieving the desired outcomes
 The nurse compares the patient's actual response to
the expected outcomes and revises the care plan as
needed
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 Cont…

 It is a planned ongoing activity where the

nurse determines the clients progress towards
the previously established outcomes
 It should always be in line with nursing
outcome/patient manifestations

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