Mrs. L.

Bijayalakshmi Devi
Associate Professor
MKSSBTINE
DEFINITION

 Nursing is “the diagnosis and treatment

of human responses to actual or
potential health problems”. ANA.(1980)
 The statement was updated and entitled
Nursing’s Social Policy Statement (1995)
 The new statement provides four essential features
of today’s contemporary nursing practice:
– 1. attention to the full range of human experiences
and responses to health and illness without
restriction to a problem-focused orientation.
– 2. integration of objective data with knowledge
gained from an understanding of the client’s or
group’s subjective experience
– 3. Application of scientific knowledge to the
processes of diagnosis and treatment
– Provision of a caring relationship that facilitates
health and healing (ANA, 1995)
 “Nursing is the holistic helping of
persons with their self-care activities in
relation to their health. This is an
interactive, interpersonal process that
nurtures strengths to enable
development, release, and channeling
of resources for coping with one’s
circumstances and environment. The
goal is to achieve a state of perceived
optimum health and contentment.”
(Erickson, Tomlin & Swain, 1983)
DEFINITION
 The nursing process is a deliberate problem solving
approach for meeting a person’s health care & nursing
needs.
 The nursing process is a systematic method for taking
independent nursing action.
 The nursing process is a problem-solving method
systematic, goal-directed, flexible, rational approach
which ensures consistent, continuous, quality nursing
care that provides a basis for professional
accountability.
Traditional steps are defined as,
1.ASSESMENT-
The systematic collection of data to
determine the patient’s health status &
identify any actual or political health problem.
Analysis may be included or discuss
separately .
2. DIAGNOSIS –
Identification of the following two types of
patients problems
 a. Nursing diagnosis
Actual or potential health problem that can be
managed by independent nursing intervention.
 b. Collaborative problems
Certain physiologic complication that monitor
to detect onset or changes in status. Nurses
manage collaborative problems
physician prescribed intervention to minimize the
complication of the events. (Carpenito, 1999).
3. PLANNING:
Development of goal & outcome ,as well as a
plan of care designed to assist the patient in
resolving the diagnosed problems &
achieving the identified goal & desired
outcome.
4. IMPLEMENTATION:
Actualization of the plan of care through
nursing intervention.
5. EVALUATION:
Determination of the patient’s responses to
the nursing intervention & the extent to which
the outcome have been achieved.
ASSESSMENT & METHOD OF
DATA COLLECTION:
It is an organized dynamic process involving
three basic activities
Systematically gathering data
Sorting & organizing the data collected
Documenting the data in a retrievable
format.
Data collection
 Patient’s history
 Physical examination
 Laboratory test
 The well defined database for a patient may
begin with admission signs and symptom,
chief complaint or medical diagnosis.
 The assessment data fall into two categories:
– Subjective data (patient and patient relatives)
– Objective data (lab test, physical examination,
health history, documentation)
Nursing diagnosis/need
identification
 The nursing diagnosis is “a clinical
judgement about individual, family or
community responses to actual or
potential health problem/life processes”
by NANDA.
 Time dependent
 Point to remember:
 It is important to remember that nursing diagnosis
are not medical diagnosis
 They are not medical treatment prescribed by the
physician
 They are not diagnostic studies
 They are not the equipment used to implement
medical therapy.
 They are not the problems that the nurse
experiences while caring for the patient.
 They are the patient’s actual or potential health
problems that independent nursing actions can
resolve.
 It is not nursing goal or need.
 Collaborative Problem: Collaborative
problem are certain physiologic
complications that nurses monitor to
detect changes in status or onset of
complications. Nurses manage
collaborative problems using physician-
prescribed and nursing-prescribed
intervention to minimized complication.
(Carpenito, 1999)
ANALYSIS OF DATA
 Arriving at a nursing diagnosis involves
organizing the patient’s history, physical
examination, and lab. Data into cluster and
interpreting what the clusters reveal about
patient's ability to meet basic needs.
 Step of a ethical analysis:
– Assessment for ethical/moral situation of the
problem ( does the situation entail substantive
moral problems?)
– Planning include collecting information about fact,
treatment, values, belief, religious components,
identify ethical issues etc.
– Implement include list of alternative I.e
compare alternative ethical principles and
professional code of ethics.
– Evaluation decide and evaluate decision
( what is the best or morally correct action?
Or give the ethical reasons for your
decision?)
NURSING DIAGNOSIS STATEMENT.

By remembering the basic guidelines it

ensures that diagnostic statement is correct:
1.Use proper terminology that reflects the
patients nursing need.
2.Make your statement concise so that it is
easily understood by other health team
members.
3.Use the most precise words possible.
4.Use a problem cause format stating the
problem and its related causes.
5.Use terminology recommended by NANDA
 There are 3 essential components in
nursing diagnosis which are referred as
PES format.
‘P’ Identifies the health problem.
‘E’ represents etiology.
‘S’ describes sign and symptoms
 These 3 parts are combined into one
statement by use of ‘’connecting words’’
hence the diagnosis would be written in this
manner-
problem related to ‘’etiology’’ evidenced by
signs and symptoms.
The problem can be identified as the
human response to actual or potential
health problem as assessed by nurse.
 The etiology may be represented by
past experience,genetic
influence,current environmental factor
pathophysiological changes.
 The defining characteristics describe
what the client says and what the nurse
observes that indicates a particular
problem.
 Problem sensing
 Rule out process
 Synthesizing the data
 Evaluating or confirming the hypothesis
– Re-evaluate the problem list (an actual
need, a risk need, or a resolved need)
– Actual diagnosis: urine retention
– Wellness diagnosis: (more of an
opportunity than a need) e.g. readiness
for enhanced spiritual well-being
 Risk diagnosis refer to human responses to
health condition/life processes that may
developed in a vulnerable individual, family or
community which can be written in two part
statement as there are no s/s. E.g. Risk for
impaired physical immobility.
 Resolved diagnosis are those that no longer
require intervention. Because the need no
longer exist so no diagnostic statement is
needed.
 Other need identification may be help with
medical diagnosis like MI
 Sometime the client or significant may
misunderstand or wrongly percept resulting in
the belief that need exist. So nurse has to
address this to promote optimal well being.
e .g : client believe that after menopause
/hysterectomy sexual disease disappear.
 Reduce the need to basic component in order
to focus intervention on the roots of the
human responses e.g:
Statement writing
 Both the client problem and wellness
issues are being addressed.
 We state as “client diagnostic
statement” not client problem.
 When writing CDS, remember to include
qualifier or quantifier as appropriate
 NANDA has provided some flexibility of
nursing language by creating a multi-
axial taxonomy.
 An axis is defined as dimension of
human response that is considered in
diagnosis processes.
 Axis 1 is diagnosis concept.
 Axis 2 is time
 Axis 3 is unit of care
 Axis 4 is age
 Axis 5 is health status
 Axis 6 is descriptor
 Axis 7 is topology
 E.g: ineffective (descriptor) family (unit of
care) coping (diagnostic concept).
 Sometime specify is mention so it is important
that correct information is provided to make
clear communication.
 E.g: ineffective tissue perfusion (specify), the
modifier to specified is from the topology axis
(e.g: cerebral, renal) but in deficit knowledge
(specify), modifier is actually the topic which
client have deficit like diabetic foot care at
home
Omaha system

 Level 1: domain – health related/social

related
 Level 2: problem classification-
physical/psychological
 Level 3: modifier (individual/family)
 Level 4: sign and symptoms
The following tips and examples should
make the distinction clear:

1.Don’t state a need instead of a problem.

e.g: fluid replacement related to fever.
2.Don’t reverse the two parts of the statements.
e.g: lack of understanding related to non
compliance to DM diet.
3.Don’t identify an untreatable condition instead
of the actual problem it indicates.
e.g: inability to speak related to laryngectomy.
4. Don’t write a legally inadvisable statement.
e.g: red sacrum related to immobility.
5. Don’t identify as unhealthful a response that
would be appropriate or culturally
acceptable.
e.g: anger related to terminal illness.
6.Don’t make a tautological statement
e.g: pain related to alteration in comfort.
7.Don’t identify a nursing problem instead of a
personal problem.
e.g: difficulty suctioning related to thick secretion.
OUTCOME IDENTIFICATION
AND PLANNING.
 The nursing plan of care is a written plan of
action designed to help you deliver quality
patient care.
 It usually forms a permanent part of
patients health record and is used by other
members of health team.
 Should involve client, family to contribute,
participate in and take responsibility for their
own care.
The planning involve the
following stages or phases.

1. Assigning priorities to nursing

diagnosis and collaborative problems.
2. Specifying expected outcomes.
3. Specifying the immediate,
intermediate, and long term goals of
nursing action.
4. Identify specific nursing interventions
appropriate for attaining the outcomes.
5. Identifying interdependent
interventions.
6. Documenting the nursing diagnosis,
collaborative problems, EOC, nursing
goals and nursing interventions.
7. Communicating to appropriate
personnel about assessment data that
point to health needs that can best be
met by other members.
SETTING PRIORITIES.
 Assigning priorities to nursing diagnosis and
problems is a joint effort of nurse patient or
family member.
 Any disagreement about priorities is resolved
in a way which is mutually acceptable.
 Maslows hierarchy of needs provide a useful
frame work of prioritizing problems.
Establishing expected outcome
/Identification desired outcome
 Expected outcome of the nursing interventions are
stated in terms of patient’s behaviour and time
period as well as special circumstances.
-EOC must be realistic, specific and consider pt.
desires or situation, measurable. And indicate time
frame
-EOC serves as a basis for evaluating the
effectiveness of interventions and for deciding
whether additional nursing care is needed or
whether plan of care to be revised.
 It is written by listing items/behavior that
can be observed and monitor.
 E.g: verbalize understanding of disease
process and potential complication.
 Have to use action verbs like discusses,
states, identifies, administer, explains
and reports. Passive words should be
avoided. Eoc sometime can be ongoing.
ESTABLISHING GOALS.
 The nursing action appropriate for attaining
the goals are identified,
-the patient and his or her family are included in
establishing goals for nursing action.
-immediate goals are those that can be reached
in a short period.
-intermediate and long term require a long time
to be achieved and usually involve preventing
complications and other health problems and
promoting self care and rehabilitation.
Determining Nursing Actions.
• The nurse take into consideration of patient
input and significant others.
• Identifies individualized interventions base on
patients age, circumstances and preferences
that addresses each outcome.
• Interventions should identify the activities
needed and who will carry them out.
• Plan health teaching and return demonstration.
• Planned intervention should be ethical and
appropriate to patient’s culture, age or gender &
promote client strength whenever possible.
Nursing intervention
 It involves the nursing process carrying out
the proposed plan of nursing care
 The plan of nursing care serves as the basis
for implementation:
-the immediate, intermediate and long term
goals are used as a focus for implementation
of nursing interventions.
-revisions are made in plan of care,
 Implementation includes direct or indirect
execution of the planned interventions
 It is focused on solving patients diagnosis
and problems and achieving EOC thus
meeting the patients health needs.
Creating and documenting:
 Date when the intervention is written
 An action verb describing the activity to be
performed
 Qualifier of how? When? Where? Time freq.
& Amount has to be included
 Signature and/ or initial of originating nurse
Point to remember:
 Implementation should be accepted nursing
practice
 Reflecting knowledge of scientific principles
and nursing standards of care and agency
policies.
 Provide safety to client and do no harm
 CDS are supported by client data
 Goals are measurable and achievable
 Arrange in logical sequence
 Demonstrate individualized care
EVALUATION:
EVALUATION.
 It is the final step of nursing process,
allows the nurse to determine the
patients response to the nursing
intervention.
 3 STEP:
– Reassessment
– Modification of Plan of
care
– Termination of service
Through evaluation nurse can answer the
following questions:

1) Were the nursing diagnosis and

collaborative problems accurate?
2) Did the patient achieve the expected
outcome within the critical time period?
3) Have the patient’s nursing diagnosis been
resolved?
4) Have the collaborative problem been
resolved?
5) Have the patients nursing needs been met?
6) Should the nursing intervention be
continued,revised or discontinued?
7) Have any new problems evolved for
which nursing intervention have not
being planned?
8) What factors influenced the
achievement or lack of achievement of
the objectives?
9) Do priorities need to be reassigned?
10) Should changes be made in EOC and
outcome criteria?
DOCUMENTATION OF
OUTCOMES AND REVISION
OF PLAN:
 Outcomes are documented concisely and
objectively.
 Relates to the nursing diagnosis and
collaborative problem.
 Indicates whether the outcomes were met .
 Describe the patients response to
intervention.
 Include any additional pertinent data.