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NURSING PROCESS

FGV Jaminit, RN, CNN, MA


Diabetes Care Specialist
HIV/AIDS Counselor
Lecturer, Foundations of Nursing
Pamantasan ng Lungsod ng Pasig

Nursing Process
An

organizational framework for the


practice of nursing
An organized sequence of problemsolving steps used to identify and to
manage the health problems of
clients
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

Nursing Process Devt


It

is a systematic rational method of


planning and providing individualized
nursing care
Lydia Hall, originated the term Nursing
Process in 1955. she introduced 3
steps: Note observation, Administration
of care, Validation
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

Nursing Process Devt


Dorothy

Johnsons 3 steps
Assessment, Decision, Nursing
Action (1959)
Ida Jean Orlando (1961): clients
behavior, nurses reaction, nurses
actions
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

Nursing Process Devt


Walsh

(1967), 4 components:
Assessing , Planning,
Implementing, Evaluating
Knowles (1967), 5 Ds: Discover,
Delve, Decide, Do, Discriminate

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

Nursing Process Devt


ANA

introduced innovations:
Diagnosis distinguished as separate
step (1973)
Diagnosis of actual and potential
health problems delineated as
integral part of the nursing practice
(1980)
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

Assessm
ent

Evaluati
on

Clientel
e

Implementi
ng
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

Diagnosi
ng

Planning
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Characteristics of NP
1.
2.
3.
4.
5.

Problem oriented
Goal oriented
Orderly, planned, step by step, and
systematic
Open in accepting new information
during its application
It is flexible to meet the unique needs of
patient

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

Characteristics of NP
Interpersonal and collaborative
7. Permits creativity among nurses an
patient
8. Cyclical and dynamic
9. Universal
10. Beneficial to the nurse and the client
6.

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

Case

Mr. Lucky Chan, 58 year-old male,


was admitted at Jaminit Medical
Centers Acute and Emergency
Department. He is complaining of
chest pain with pain score of 8/10.
He looks pale and with some DOB
upon Examination, oxygen
saturation was 89%.

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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ASSESSMENT
Collecting, validating organizing, and
recording data about the patients health
status
Its purpose is to establish database
In the collection of data, the nurse does not
make an interference but forces on
establishing a comprehensive database
that reflects the health status of the patient

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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ASSESSMENT
Goal

is to establish baseline
Activity on assessment: Data
Collection

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Types of Data
1.
2.

ASSESSMENT

Subjective
Objective

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Sources of Data
1.
2.

ASSESSMENT

Primary Source
Secondary Source

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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ASSESSMENT

Methods of Collecting Data


1.
2.
3.

Interview
Observation
Physical Assessment

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing
Is

a process which results to a


diagnostic statement or nursing
diagnosis
Clinical act of identifying problems
Analyze assessment information
and derive meaning from this
analysis
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing
Goal

is to identify the clients health


care needs and to prepare
diagnostic statements

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Nursing Diagnosis

Is a statement of clients potential


or actual alteration of health status
It is a clinical judgment about an
individual, family, or community in
response to actual and potential
health problems and life process
(NANDA, 1990)

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Nursing Diagnosis
A

statement of a patients potential or


actual health problems which nurses,
by virtue of their education and
experience are capable and licensed
to treat (Gordon, 1976)

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Activities during diagnosing


Organize

cluster or group data


Compare data against standards
Analyze data after comparing to
standards
Identify gaps and inconsistencies in
data
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Activities during diagnosing


Determine

the clients health


problems, risks, and strengths
Formulate nursing diagnoses
statements (refer to NANDAs list)

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Types of Nursing Diagnoses


1.
2.
3.
4.
5.

Actual nursing diagnosis


Risk nursing diagnosis
Possible nursing diagnosis
Syndrome nursing diagnosis
Wellness nursing diagnosis

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Actual Nursing Diagnosis

Client problem that is present at the


time of the nursing assessment

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Risk Nursing Diagnosis

A clinical judgment that a problem


does not exist, but the presence of
risk factors indicates that a problem
is likely to develop unless nurses
intervene

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Possible Nursing Diagnosis

Evidence about health problem is


unclear or incomplete
It requires more data, either to
support or refute it

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Wellness Nursing Diagnosis

Describes human responses to


levels of wellness in an individual,
family, or community that have a
readiness for enhancement
(NANDA, 2003)

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Wellness Nursing Diagnosis

2 cues must pre present:


1.
2.

A desire for higher level of wellness


An effective present status or function

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Syndrome Nursing Diagnosis

Associated with a cluster of


diagnoses
Comprised a cluster of actual or
risk nursing diagnoses that are
predicted to be resent because of a
certain event or situation

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Wellness Nursing Diagnosis

Diagnostic statement for wellness


diagnoses if one part statement that
contains the label readiness for
enhanced, followed by the desired
higher level wellness
Related factors are not included

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Formula in diagnosing

Actual nursing diagnosis

Risk nursing diagnosis

P+Risk factors

Possible nursing diagnosis

P+E+S

Data but inadequate and with need for further


investigation

Wellness diagnosis

Healthy response, high level of wellness

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Components of a Nursing
Diagnoses
Problem

Deficient,

impaired, decreased,
ineffective, compromised

Etiology

Defining

characteristics

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing
Formulating Diagnostic Statements

One-part statement
Two-part statement
Three-part statement

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Guidelines for setting priorities


1.
2.
3.
4.

Take care of immediate


life-threatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on
the overall picture, the patient as a
whole person, and availability of
time and resources.

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Planning
Involves

determining beforehand the


strategies or course of actions to be
taken before implementation of
nursing care
To be effective, involve the client
and his family in planning.
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Planning
Nursing

plan of care is a written


summary of the care that a client is
to receive
It is the blue print of the nursing
process

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Purposes

Planning

To identify the clients goals and


appropriate nursing interventions
To direct client car activities
To promote continuity of care
To focus charting requirements
To allow delegation of spec. acts.

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Characteristics

Planning

S-M-A-R-T

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Case (Remember Mr. Chan?)


After

assessment, oxygen therapy


was started at 4 LPM via nasal
cannula; Isosorbide dinitrate 10mg SL
was given as stat dose. One hour
after the intervention chest pain was
relieved with pain score of 3/10,O2 sat
of 95% and non-pale looking skin.

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Implementation
Is

putting the nursing care plan into


action
Purpose: carry out planned nursing
interventions to help the client goals
and achieve optimal level of health

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Activities

Implementation

Reassessing
Set priorities
Perform nursing interventions
Record actions

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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Evaluation
Assessing

the clients response to


nursing interventions and then
comparing the response to
predetermined standard or outcome
criteria

Purpose: appraise the extent to w/c goals and


outcome criteria have been achieved
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Activities

Evaluation

Collect data about the clients


response
Compare the clients response to
goals and outcome criteria
Judgment
Analyze reasons of outcome
Modify care plan as needed

NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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NCM 100 - Nursing Process


FGV Jaminit, BSN, RN, CNN, MA

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