ADVANCE CONCEPTS IN

NURSING
INTRODUCTION TO
NURSING PROCESS
 LEARNING OUTCOMES
 Discuss the concepts and theories that underpin the process of
nursing.
 Formulate nursing diagnosis on actual and potential patient’s
problems.
 Plan and document appropriate patient’s goals and interventions
with the collaboration of patient, family and the multidisciplinary
team.
 Implement the Nursing Care Plan.
 Evaluate and reassess each component of the Nursing Care Plan
appropriately.
 Educate patients and their families during their stay at hospital
and at the time of discharge.
 Demonstrate appropriate communication skills and interaction
skills with patients, families and colleagues.
 THE NURSING PROCESS IS:

 A systematic, rational method of planning and providing

individualized nursing care.
 An organized, systematic method of giving individualized
nursing care that focuses on identifying and treating unique
responses of individuals or groups to actual-(Alfaro)
 Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment
of human responses, and advocacy in the care of individuals,
families, communities, and populations. (ANA)
 CHARACTERISTICS OF NP

• A problem-solving method

• Systematic, goal-directed, flexible, rational approach

• Ensures consistent, continuous, quality nursing care

• Provides a basis for professional accountability

• Utilizes critical thinking processes

 CHARACTERISTICS:
a) Systematic
 The nursing process has an ordered sequence of activities and each
activity depends on the accuracy of the activity that precedes it and
influences the activity following it.
b) Dynamic
 The nursing process has great interaction and overlapping among the
activities and each activity is fluid and flows into the next activity
c) Interpersonal
 The nursing process ensures that nurses are client-centered rather than
task-centered and encourages them to work to enhance client’s
strengths and meet human needs
d) Goal-directed
 The nursing process is a means for nurses and clients to work together
to identify specific goals (wellness promotion, disease and illness
prevention, health restoration, coping and altered functioning) that are
most important to the client, and to match them with the appropriate
nursing actions
e) Universally applicable
 The nursing process allows nurses to practice nursing with well or ill
people, young or old, in any type of practice setting
BACK
GROUND

 Thenursing process is based on a nursing theory

developed by Ida Jean Orlando.
 She developed this theory in the late 1950's as she
observed nurses in action.
 She saw "good" nursing and "bad" nursing.
 Fromher observations she learned that the patient
must be the central character.
 Nursing care needs to be directed at improving outcomes for
the patient, and not about nursing goals.
 The nursing process is an essential part of the nursing care
plan.
BACK GROUND OF NURSING PROCESS
 The original concept of the nursing process was introduced in the
1950s as a three-step process of
 Assessment, Planning, and Evaluation
 Based on the scientific method of
 Observing, Measuring, Gathering data, and Analyzing the findings.
 Over time, became part of the;
 Conceptual framework of all nursing curricula and
 Included in the legal definition of nursing in the nurse practice acts
of most states.
 After years of study, use, and refinement, the three step process
was expanded into five steps.
 ADVANTAGES OF NURSING PROCESS
 Provides individualized care  Develops a clear and
 Client is an active participant efficient plan of care
 Promotes continuity of care  Provides personal
 Provides more effective satisfaction as you see
communication among client achieve goals
 Professional growth as you
nurses and healthcare
professionals evaluate effectiveness of
your interventions
5 STEPS IN THE NURSING
PROCESS
Assessment
Nursing
Diagnosis
Planning
Implementing
Evaluating
 1ST COMPONENT OF THE NURSING
PROCESS- ASSESSMENT:
 The first step, or phase, of the nursing process is assessment.
 During this phase, you are collecting data (factual information)
from several sources.
 The collection and organization of these data allow to:

 Determine the patient’s current health status.

 Determine the patient’s strengths and problem areas (both

actual and potential).
 Prepare for the second step of the process—diagnosis.
 1ST COMPONENT OF THE NURSING
PROCESS- ASSESSMENT:
 Data Collection
 Assessment involves taking vital signs (TPR
BP & Pain assessment).

 Performing a head to toe assessment

 Listening to the patient's comments and

questions about his health status

 Observing his reactions and interactions with

others. It involves asking pertinent questions
about his signs (observable) and symptoms
(Non-observable), and listening carefully to
the answers.
DURING ASSESSMENT, THE CARE
PROVIDER

A. Establishes A Data Base

B. Continuously Updates
The Data Base

C. Validates Data

D. Communicates Data
ASSESSMENT
 Firststep of the Nursing Process
 Gather Information/Collect Data
Primary Source - Client / Family
Secondary Source - physical exam, nursing
history, team members, lab reports, diagnostic
tests…..
 Subjective -from the client (symptom)
 “I have a headache”
Objective - observable data (sign)
 Blood Pressure 130/80
ASSESSMENT-
COLLECTING DATA
 Nursing Interview (history)
 Health Assessment -Review of Systems
 Physical Exam
Inspection
Palpation
Percussion
Auscultation
EXAMPLE OF
ASSESSMENT
 Obtain info from nursing assessment, history and physical
(H&P) etc…...

 Client diagnosed with hypertension

 B/P 160/90
 2 Gm Na diet and antihypertensive medications were
prescribed
 Client statement “ I really don’t watch my salt” “ It’s hard
to do and I just don’t get it”
 2ND COMPONENT OF THE NURSING
PROCESS- DIAGNOSIS:
 Diagnosis means reaching a definite conclusion
regarding the patient’s strengths and human
responses.
 This diagnostic process is complex and utilizes
aspects of intelligence, thinking, and critical
thinking.
 The diagnosis of human responses is a complex
process involving the interpretation of human
behavior related to health.
NURSING DIAGNOSIS
 Second step of the Nursing Process

 Interpret & analyze clustered data

 Identify client’s problems and strengths

 Formulate Nursing Diagnosis (NANDA : North American

Nursing Diagnosis Association)-Statement of how the client is
RESPONDING to an actual or potential problem that requires
nursing intervention
 NSG DX VS MD DX
 Within the scope  Within the scope
of nursing practice of medical
 Identify responses practice
to health and  Focuses on curing
illness pathology
 Can change from  Stays the same as
day to day long as the disease
is present
FORMULATING A NURSING DIAGNOSIS

 Composed of 3 parts:
 Problem statement- the client’s response to a problem

 Etiology- what’s causing/contributing to the client’s

problem
 Defining Characteristics- what’s the evidence of the
problem
NURSING DIAGNOSIS
 Problem( Diagnostic Label)-based on your assessment of
client…(gathered information), pick a problem from the
NANDA list...
 Etiology- determine what the problem is caused by or
related to (R/T)...
 Defining characteristics- then state as evidenced by
(AEB) the specific facts the problem is based on...
EXAMPLE OF NURSING DX
 Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack of
knowledge
AEB B/P= 160/90, dietary sodium restrictions not being
observed, and client statements of “ I don’t watch my
salt” “It’s hard to do and I just don’t get it”.
TYPES OF NURSING DIAGNOSES

 Actual
Imbalanced nutrition; less than body requirements
RT chronic diarrhea, nausea, and pain AEB height
5’5” weight 105 lbs.
 Risk/Potential
Risk for falls RT altered gait and generalized
weakness
 Wellness
Family coping: potential for growth RT
unexpected birth of twins.
 COLLABORATIVE PROBLEMS

Require both nursing interventions and medical interventions

EXAMPLE: Client admitted with medical dx of pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy
3RD COMPONENT OF THE NURSING
PROCESS- PLANNING:
The establishment of client goals/outcomes
Working with the client, to prevent, reduce, or
resolve problems

 To determine related nursing interventions (actions)

that are most likely to assist client in achieving goals

This is about improving the quality of life for your

patient.

This is about what your patient needs to do to

improve his health status or better cope with his
illness.
DURING PLANNING, THE PROVIDER:
 A. Establishes Priorities

 B.Writes Client Goals/Outcomes And

Develops An Evaluative Strategy

 C. Selects Nursing Interventions

 D. Communicates The Plan

 PLANNING
Third step of the Nursing Process
 This is when the nurse organizes a nursing care plan based on the
nursing diagnoses.
 Nurse and client formulate goals to help the client with their
problems
 Expected outcomes are identified

 Interventions (nursing orders) are selected to aid the client reach

these goals.
PRIORITIZING CLIENT
PROBLEMS

 Prioritize list of client’s

nursing diagnoses
using Maslow
 Rank as high,
intermediate or low
 Client specific
 Priorities can change
PLANNING- TYPES OF
GOALS
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals
GOALS ARE PATIENT-CENTERED
AND
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt)
3RD COMPONENT OF THE NURSING
PROCESS- IMPLEMENTING:
 The provider carries out the plan of care
DURING IMPLEMENTING, THE CARE
PROVIDER:
 Carries Out The Plan Of Nursing Care or Setting your
plans in motion and delegating responsibilities for
each step.

 Continues Data Collection And Modifies The Plan Of

Care As Needed

 Documents Care
IMPLEMENTION
“Doing” step

 Carrying out nursing intervention

 s

 This includes monitoring, teaching, further assessing,

reviewing NCP, incorporating physicians orders and
monitoring cost effectiveness of interventions
PLANNING-SELECT INTERVENTIONS
 Interventions are selected and written.
 The nurse uses clinical judgment and professional
knowledge to select appropriate interventions that will aid
the client in reaching their goal.
 Interventions should be examined for feasibility and
acceptability to the client
 Interventions should be written clearly and specifically.
INTERVENTIONS –
 Independent ( Nurse initiated )- any action the nurse can
initiate without direct supervision
 Dependent ( Physician initiated )-nursing actions
requiring MD orders
 Collaborative- nursing actions performed jointly with
other health care team members
4TH COMPONENT OF THE NURSING
PROCESS- EVALUATING:
 The measuring of the extent to which
client goals have been met

 Evaluation involves not only analyzing

the success of the goals and
interventions, but examining the need
for adjustments and changes as well.

 The evaluation incorporates all input

from the entire health care team,
including the patient.
DURING EVALUATING, THE CARE
PROVIDER:
 Measures The Clients Achievement
Of Desired Goals/Outcomes

 Identifies Factors That Contribute To

The Client’s Success Or Failure

 Modifies The Plan Of Care, If

Indicated
EVALUATION-

 A comparison of client behavior and/or response to

the established outcome criteria
 Continuous review of the nursing care plan

 Examines if nursing interventions are working

EVALUATION ERRORS
Factors that impede goal attainment:

 Incomplete database
 Unrealistic client outcomes

 Nonspecific nsg interventions

 Inadequate time for clients to achieve outcomes.

 PURPOSE OF THE NURSING PROCESS:

 To AchieveScientifically-
Based, Holistic, Individualized
Care For The Client

 To Achieve The Opportunity To

Work Collaboratively With
Clients, Others

 To Achieve Continuity Of Care

THE WHOLE PATIENT
 The nursing process involves looking at the whole
patient at all times. It personalizes the patient. He is
not "the CVA in 214B."

 Italso forces the health care team to observe and

interact with the patient, and not just the task they are
performing such as a dressing change, or a bed bath.
The process provides a roadmap that ensures good
nursing care and improves patient outcomes.
HOLISTIC
 Physical- Medical Nursing
 Emotional- Diagnosis Diagnosis
Rheumatoid Arthritis Self-care deficit:
 Psychosocial-
bathing, related to
 Developmental- joint stiffness
 Spiritual Being