Here it comes the part two section of nursing process.

1. NURSING PROCESS
PART - II
By:
Mrs. Babitha K Devu
Asstt. Professor
SMVDCoN

2. Nursing Diagnosis

4. Introduction to Nursing Diagnosis:
After reviewing and validating a patient’s
assessment, the next step of the nursing
process is to form diagnostic conclusions to
determine the patient’s problems and the
level of care required. A nurse will make
diagnostic conclusion either in the form of a
Nursing diagnosis or a collaborative
problem.
It is the 2nd
step in nursing process.

5. Contin..
The primary organization for defining,
dissemination and integration of standardized
nursing diagnoses worldwide is NANDA-
International
formerly known as the North American Nursing Diag
.
The North American Nursing Diagnosis
Association (NANDA) was established in
1982 with the following purpose: “To develop,
refine, and promote a taxonomy (model) of
nursing diagnostic terms of general use for
professional nurses”.

6. Contin.
Today NANDA – I has developed a model for
organizing nursing diagnoses for
documentation, auditing, and communication
purposes. The model includes 13 domains
(e.g., health promotion, comfort), 47 classes
(e.g., health awareness, physical comfort),
and 188 nursing diagnoses. ----(2009)
New diagnoses are continually developed
through research and is being added.


7. Definition
A nursing diagnosis is a clinical judgment about
individual, family, or community responses to actual and
potential health problems or life processes.
(NANDA International , 2009)
Nursing diagnoses provide the basis for selection of
nursing interventions to achieve outcomes for which
the nurse is accountable.
(Carroll-Johnson, 1990, p. 50)
The nursing diagnoses developed during this phase of the
nursing process provide the basis for client care delivered through
the remaining steps. Client problems are labeled by both medical
and nursing diagnoses. Clients receive both medical and nursing
diagnoses.

8. Contin.
It is the statement that describes a patient’s
actual & potential response to a health
problem that the nurse is licensed and
competent to treat.
Never confuse a medical diagnosis with nursing
diagnosis.

9. Purposes of Nursing Diagnosis
• Provides a means of communicating nursing
requirements of clients to other nurses, other team.
• Facilitates the development of nursing autonomy and
accountability.
• Nursing diagnosis can serve as shorthand for specific
client problems. &Ensures quality nursing care.
• Increases the specificity of nursing interventions for each
client.
• The nursing diagnosis taxonomy will help to bridge the gap
between knowledge and practice and will articulate the
scope of nursing practice.

10. Diagnostic Process/ Activities
• Data Clustering: Organizing all your data into
meaningful and usable keeping in mind the
patient’s response to illness.
• Data Analysis & Interpretation: recognizing
patterns or trends in the clustered data, comparing
them with standards, and then coming to a
reasoned conclusion.
Data Clustering
Data Analysis &
Interpretation
Formulation
of Nursing
Diagnosis

11. Characteristics of Nursing Diagnosis
• It states a clear and concise health problem.
• It is derived from existing evidences about
the client.
• It is potentially amendable to nursing therapy.
• It is the basis for planning and carrying out
nursing care.

12. Types of Nursing Diagnoses
Health Promotion Nursing Diagnosis

15. Health Promotion Nursing Diagnosis:
Is a clinical judgement of a person’s, family’s,
or community’s motivation and desire to
increase well-being and actualize human
health potential as expressed in the
readiness to enhance specific health
behaviours.
An e.g., is Readiness for enhanced comfort.

18. Post trauma syndrome

19. Classification According To Priority
• There are three main types of nursing
diagnosis as per priorities:
High priority
Intermediate priority
Low priority
High priority nursing diagnoses that, if
untreated, result in harm to the patient or
others.
Intermediate priority nursing diagnoses involve
the non emergent, non life threatening
needs of a patient.
Low priority nursing diagnoses are patient
needs that are usually directly related to a
specific illness or prognosis but may affect
the patient’s future well being.

22. Components (Contin.)
• Diagnostic Label:
Is the name of the nursing diagnosis within the
NANDA-I taxonomy. It describes the essence of a
patient’s response to a health condition in as few
words as possible.
• Related Factor:
Is a condition or etiological factor that appears to
show some type of patterned relationship with the
nursing diagnosis. Related factors include:
 Pathophysiological (biological/psychological)
 Treatment related
 Situational (environmental/personal)
 Maturational

23. Components (Contin.)
• Defining Characteristics:
It is the characteristics of the human response
identified.
Always refer to a definition to assist you in
identifying a patient’s diagnosis.
It is joined to previous parts with AEB
Usually it may be the signs and symptoms shown
by the patient.
e.g., edema, wt gain, decreased urine output,
SOB, abnormal breath sounds,.

24. Components (Contin.)
Sr.
No
Diagno
stic
Label
Related Factor Defining
Characteristics
1. Fatigue Psychological:
anxiety, depression,
stress
Physiological:
anaemia,
malnutrition
Environmental:
humidity, noise
Situational:
occupation, -ve life
events
Lethargic
Drowsy
Inability to maintain
usual level of physical
activity
2. Death
anxiety
Perceived proximity
of death
Anticipating pain
Discussion on topic
of death
Reports deep sadness
Reports worry

27. Formulation of Nursing
Diagnosis

29. Errors In Data Collection
• To avoid errors in data collection be
knowledgeable and skilled in all assessment
techniques. Avoid inaccurate or missing data,
and collect data in an organized way.
• Some TIPS:
 Review your level of comfort & competence
with methods of data collection.
Approach assessment in steps.
Review your clinical assessments in
clinical/classroom settings, giving you a
constructive learning opportunity.
Organize the examinations & prepare well.

30. Errors in Data Clustering
• Errors will result when you cluster data
prematurely, incorrectly, or not at all. Premature
clustering occurs when you make the nursing
diagnosis before grouping all data.
Errors in Interpretation &
Analysis
• After data collection review your data base to
decide if it is accurate and complete. Review
data to validate that measurable, objective
physical findings support subjective data. Be
careful to consider a conflicting cues. It is
important to consider patients 'cultural
background.

31. Correct selection of diagnostic statement

33. Guidelines For Choosing Correct
Diagnostic Statement
• Be sure the etiology portion of the diagnosis is
within the scope of nursing practice.
• Identify the patients response, not the medical
diagnosis.
• Identify a NANDA – I diagnostic statement, not
a symptom.
• Identify a treatable etiology, not a clinical sign or
chronic problem.
• Identify the problem caused by the treatment or
diagnostic study rather than the treatment or
study itself.
• Identify a patient response to equipment rather
than the equipment itself.

34. • Identify patient’s problem rather than your
problems with nursing care.
• Identify patient’s problem rather than your
problems with nursing intervention.
• Identify the patient problem rather than the goal.
• Make professional rather than prejudicial
judgement.
• Avoid legally inadvisable statemnts that imply
blame, negligence, or malpractice.
• Identify the problem and etiology so as to avoid a
circular statement.
• Identify only one patient statement in a diagnostic
statement.
Contin.

38. DocumentationDocumentation
• After identifying a patient’s nursing
diagnoses, list them on the plan of care,
whether this is in the form of computerised
care plans or a problem list.
• When initiating an original care plan,
always place the highest priority nursing
diagnosis first. Date a nursing diagnosis at
the time of entry.

42. 01

43. 02

44. 03

45. Planning

46. Contin.
• Planning is the third step of the
nursing process and includes the
formulation of guidelines that establish
the proposed course of nursing action
in the resolution of nursing diagnoses
and the development of the client’s
plan of care.

47. Purpose
• To determine the goals of care and
the course of actions to be undertaken
during the implementation phase.
• To promote continuity of care.
• To focus charting requirements.
• To allow for delegation of specific
activities.

51. Guidelines for setting priorities
• Life threatening situations should be
given highest priority.
• Use the principle of CAB.
• Use Maslow’s hierarchy of needs.
• Actual problems takes precedence
over potential concerns.
• Attend the client before equipment.

53. Classification According To
Priority
• There are three main types of nursing diagnosis
as per priorities:
High priority
Intermediate priority
Low priority
High priority nursing diagnoses that, if untreated, result
in harm to the patient or others.
Intermediate priority nursing diagnoses involve the non
emergent, non life threatening needs of a patient.
Low priority nursing diagnoses are patient needs that are
usually directly related to a specific illness or prognosis
but may affect the patient’s future well being.

54. • Definitions:
Goals:
Is a broad statement that describes a
desired change in a patient’s condition or
behaviour. A patient centered goal is a
specific and measureable behaviour or
response that reflects the patient’s highest
possible level of wellness and
independence in function.

55. Characteristics of goal
• A goal is realistic and based on patient needs
and resources.
• A goal represents predicted resolution of a
problem, evidence of progress.
• A goal contains singular behaviours or
responses.
• Each goal is time limited.
• Goals are based on standards of care or clinical
guidelines established for minimal safe
practice.

56. Each goal is time limited and it depends on
the nature of the problem, etiology, overall
condition of the patient, and treatment
settings.

57. Types of goal
• Short-term goal: Is an objective behaviour
or response that you expect the patient to
achieve in a short duration, usually less
than a week. In acute settings it can be
even few hours.
• Long-term goal: Is an objective behaviour
or response that you expect the patient to
achieve over a longer period, usually over
several days, weeks, or months.

59. Expected Outcomes
• Definition:
These are observable effects that are the
result of an intervention.
Achieving outcomes means a goal has been
met. Expected outcomes provide a focus or
direction for nursing care because they are
the desired physical, psychological, social,
emotional, developmental, or spiritual
responses that show resolution of patient’s
health problems.

60. Criteria for outcomes
• Measureable
• Reliable
• Valid
• Suited to the patient
• Sensitive to change

62. 3. Plan Nursing Intervention
• Definition:
These are treatments, based upon clinical
judgement and knowledge, that nurses perform to
enhance patient outcomes.
(Bulechek, Butcher, & Dochterman-2008)
To select interventions you need to be competent in three
areas: 1. Knowing the scientific rationale for intervention
2. Possessing the necessary psychomotor &
interpersonal skills to perform intervention
3. Being able to function within a particular
setting to use the available health care
resources effectively

64. Types of Interventions
 Nurse-initiated Interventions
 Physician-initiated Interventions
 Collaborative Interventions
Nurse-initiatedInterventions
/Independent nursing interventions:
nurse initiate on their own act on a
patient’s behalf. No need of any
order.

65. Contin.
Physician-initiated Interventions/ Dependent
nursing interventions are actions that
requires an order from a physician.
Collaborative Interventions/ interdependent
nursing interventions are therapies that
requires the combined knowledge, skill,
and expertise of multiple health care
professionals.

69. Nursing Kardex
It is a concise method for organising and
recording data about client, making information
readily available to all health care members.
Not a permanent record.

78. Format of Student care Plan
Asses
sment
Nursi
ng
Diagn
osis
Goal/
Outco
me
Interv
entio
ns
Ratio
nale
Imple
menta
tion
Evalu
ation
Subjective
Data
PES
Objective
Data

84. Direct vs Indirect
Implementations
• Direct care Interventions:
Are treatments performed through
interactions with patients. E.g.,
medication administration.
• Indirect Care Interventions:
Are treatments performed away from the
patient but on behalf of the patient or group
of patients. E.g., documentation, patient
environment preparation.

87. Clinical Practice Guidelines
& Protocols
• A clinical guidelines or protocol is a document
that guides decisions and interventions for
specific health care problems or conditions
such as the treatment for a patient who has
had a stroke or the administration of
chemotherapy.
• In acute care settings it is common to find
clinical protocols that outlines independent
nursing interventions for specific conditions.

88. Standing Orders
• It is a pre-printed document containing orders
for the conduct of routine therapies,
monitoring guidelines, and/or diagnostic
procedures for the specific patients with
identified clinical problems. The orders direct
the conduct of patient care in various clinical
settings. Licensed, prescribing physician or
nurse practitioners responsible for a patient’s
care at the time of implementation approve
and sign standing order.

89. NIC Interventions
• The Nursing Intervention
Classification Intervention system
developed by the University of Lowa
helps to differentiate nursing practice
from that of other health care
professional by offering a language
that nurses can use to describe sets
of actions in delivering nursing care.

95. Organizing Resources
& Care Delivery
• Equipment: Most nursing procedures
require some equipment or supplies. Decide
what supplies are necessary and determine
their availability before you start
implementation.
• Personnel: Nursing care delivery models
vary among facilities. The model by which
nursing is organized determines how nursing
personnel deliver patient care. E.g., A RN
accountability vary in a team nursing model
from those in a primary nursing model.

96. Contin..
• Environment: A patient care environment
need to be safe and conducive for
implementing therapies. Patient safety is
your first concern.
• Patient: Before you deliver interventions,
be sure the patient is as physically and
psychologically comfortable as possible.

98. Contin..
• Identifying areas of assistance:
Certain nursing situations require
you to obtain assistance by seeking
additional personnel, knowledge,
and/or nursing skills. Before beginning
care, review the plan for the need for
such assistance.

99. Controlling for adverse
reactions
Preventive Measures

107. The Evaluation Process

108. Thus evaluation is most effective when you
know what to observe or measure. Proper
evaluation allows you to determine
whether each patient reaches a level of
wellness or recovery that is reflected in the
goals of care.

109. • The intend of assessment is to identify
what if any problem exists.

116. Conclusion
• The nursing process is an organized method of
planning and delivering nursing care.
• The nursing process is composed of five steps:
assessment, diagnosis, outcome identification and
planning, implementation, and evaluation.
• Assessment is the first step in the nursing process and
involves collecting, validating, organizing, categorizing,
and recording data.
• Both subjective data (information given by the client)
and objective data (information collected by the health
care provider using the senses) are collected during
the assessment process.

117. Contin..
• The second step in the nursing process involves
further analysis and synthesis of the data and
results in a list of nursing diagnoses.
• Types of nursing diagnoses include: actual,
potential (including risk and possible), and
wellness.
• Planning, the third step in the nursing process,
involves prioritizing nursing diagnoses, identifying
and writing goals and client outcomes, developing
nursing interventions, and recording the plan of
care in the client’s record.

118. Contin..
• Implementation, the fourth step in the nursing process,
involves performing or delegating nursing activities.
• The nurse uses psychomotor skills, interpersonal skills, and
cognitive skills when performing nursing activities.
• Evaluation, the fifth step in the nursing process, involves
deciding whether the client goals have been met, been
partially met, or not been met.
• The steps in the nursing process are similar to those in the
problem-solving method in that problems are identified,
information is gathered, a specific problem is named, a plan
for solving the problem is developed, the plan is put into
action, and the results of the plan are evaluated.

121. Case Study: Mrs. Lendo
• Let’s suppose that your patient, Martha Lendo, a 65-
year-old married woman, presents with a lower
extremity wound, obtained during a minor vehicular
accident 15 days ago, that does not show signs of
healing. She has 3+ edema in her lower extremities,
significantly diminished bilateral peripheral pulses,
and a lower extremity capillary refill time of 5
seconds. She is a moderate smoker who is
overweight, and she has diabetes mellitus. She
describes her life as extremely sedentary, and she
states, “Even if I wanted to exercise, I couldn’t – my
legs hurt so badly when I walk almost any distance
at all.”

122. • After completing your assessment
and Formulate a Nursing Care Plan
for Mrs. Lindo and submit on
20/08/2016.