Scientific Workshop

in

Application of Nursing Process

Prepared by
Mr. Ibrahim Ayasreh
RN, MSN
Critical Care Nursing

Mr.Ahmad AlRadi
RN, MSN
Medical Surgical Nursing

Nursing Process
The nursing process is a systematic ,rational method of planning
and providing nursing care.
A process is a series of steps or acts that lead to accomplishment
of some goal or purpose.
The purposes of the nursing process are to identify a client's
healthcare status, and to actual or potential health problems, to
establish plans to meet the identified needs, and to deliver
specific nursing interventions to address those needs.

Steps of Nursing Process

Assessment.
Diagnosis.
Planning.
Implementation.
Evaluation.

Characteristics of Nursing Process

Nursing Process is clients-centered.
Nursing Process is cyclic and dynamic (The steps of the
nursing process build upon each other, but they are not linear.
There is overlap of each step with the previous and subsequent
steps) .
Nursing Process is Universally applicable (is designed to be
used with clients throughout the life span and in any setting in
which a nurse provides care for clients).

Assessment
Assessment is the systematic and continuous
collection, organization, validation, and documentation
of data (information).
Assessment is continuous process carried out during all
phases of nursing process.
All phases of nursing process depend on accurate and
complete collection of data.

Types of assessment
Initial Assessment.
Problem-focused assessment.
Emergency assessment.
Time lapsed assessment.

Initial Assessment
Performed within specified time after admission to a
health care agency.
To establish a complete database for problem
identification, reference and future comparison.
Example: Nursing admission assessment.

Problem Focused Assessment

Ongoing process integrated with nursing care.
To determine the status of a specific problem
identified in a earlier assessment , and to identify new
or overlooked problems.
Example: Hourly assessment of clients fluid intake
and output.

Emergency Assessment
Performed during any physiologic or psychological
crisis of the client.
Its purpose is to identify life-threatening problems.
Example: Rapid assessment of airway, breathing,
circulation during a cardiac arrest.

Time- lapsed reassessment

Performed several months after initial assessment.
Its purpose is to compare the clients current status to
baseline data previously obtained.
Example: Reassessment of the patients in outpatient
setting after being discharged.

Components of Nursing Health History

Biographic data:
Name, Age, Gender, Marital status, Occupation, religion,
Education, Income.
Chief Complaint:
- Is the answer of the patient to question of : What
brought you to the hospital or clinic.
- Should be recorded in patients own words.
- Example :
Patient said: I had sever pain in my chest , I was unable to
breathe since last night

Components of Nursing Health History

History of present illness:
- Onset : When the symptoms started?
- Pattern of onset : Gradual or sudden.
- Setting: Place where the patient was when the symptom
started?
- Severity: Mild, Moderate , Severe.
- Location.
- Quality: characteristics of problem.
- Radiation.
- Duration.
- Palliative and aggravating factors.
- Associated symptoms.

Components of Nursing Health History

Example of History of present illness:
1) Onset: pain started suddenly last night at 3.30 AM.
2) Setting: patient stated that he was in bed at home when pain started.
3) Location: pain is originated in the chest.
4) Quality: pain is like tightness on the chest.
5) Severity: patient said that pain was severe.
6) Radiation: patient stated that the pain is radiated to left arm and back.
7) Duration: patient stated that the pain was continuous.
8) Palliative factors: patient stated that the pain was slightly decreased with rest.
9) Aggravating factors: patient stated that pain was increasing with movement, and
exposure to cold.
10) Associated symptoms: this pain was associated with Dyspnea, and nausea.

Components of Nursing Health History

Past History:
- Childhood illnesses : Chickenpox, Rubella, measles, rheumatic
fever, ..etc.
- Childhood immunizations.
- Allergies to drugs, animals, food, insects.
- Accidents and injuries.
- Previous hospitalizations.

Components of Nursing Health History

Family History:

Components of Nursing Health History

Lifestyle:
- Personal habits: include amount, frequency, and duration of
substance use (Coffee, Tea, cola, Tobacco).
- Diet.
- Sleep.
- Hobbies.
- Daily activities.

Types of data
Subjective data ( Symptoms) : data which is only can be
described and verified by client himself/herself.

Objective data ( Signs): data which can be detected by the

observer or the nurse. They can be seen, heard, smelled, felt,
and they obtained through observation or physical
examination.

Examples of Subjective & Objective Data

Subjective data

Objective Data

I feel pain in my chest.

Blood Pressure: 140/90 mmHg.

I drink 2 cups of tea daily

Skin is pale.

I feel weak when I walk tow steps

forward

Client cried during interview.

Vomited 100 mL green fluid.

Sources of data

Primary source: includes only the client.

Secondary Source: All sources other than client such
as family members, records and reports, laboratory
and diagnostic findings, and health care providers.

Data collection methods

Observing.
Interviewing.
Examining.

Observing
To observe is to gather data by using the senses.

Sense

Example of client data

Vision

Body size, posture, grooming, skin color.

Smell

Body or breath odors

Hearing

Lung and heart sounds, bowel sounds,

orientation.

Touch

Skin temperature, pulse rate, muscle strength.

Interviewing
Interview: is a planned communication or conversation with
purpose to get or give information.
Types of interview:
- Directive interview: the nurse establishes the purpose of the
interview and control the interview.
- Nondirective interview: the nurse allow the client to control
purposes of the interview.
It is better to use a combination of both directive and nondirective
in interviewing clients.

Types of Interview Questions

Close questions: used in directive interview, and generally
requires only yes or No or short factual
answers.
- Example: What medication did you take?
Are you having pain now?
How old are you?
When did you fall?

Types of Interview Questions

Open questions: used in nondirective interview, ad invites the
client to elaborate, discover, discuss, explore
feelings and thoughts.
- Example: What brought you to the hospital?
Describe the pain you feel in more details?
What would you like to talk about today?

Factors affecting interview planning

Time: nurse need to plan interviews with hospitalized clients when
the clients is physically comfortable, free of pain, minimal
interruptions by friends and family members.
Place: a well-lightened, well-ventilated, moderate sized room, free of
noises.
Distance: must be neither too small nor too great. It is about 8 -12
inches in Arab countries.
Language: The nurse must convert complicated medical terminology
to simple language.

Stages of Interview
The Opening.
The Body.
The Closing.

The opening
In this stage, the nurse introduces her/himself to the client, and
explain the purpose of the interview.
Through thus stage , the rapport between nurse and client is
established.
It can be begin with greeting ( Good morning, Mr. Salem) or
a self introduction ( I am Ibrahim, I am a nursing student),
accompanied by nonverbal gestures such as smile, handshake.

The body

In this stage the client communicates what he/she

thinks, feels, knows, and perceives in responses to
questions of the nurse.

The closing

The nurse terminates the interview when the needed information is obtained.

The closing is important for maintaining rapport and trust and for facilitating
future interactions.

Techniques for closing interview:

- offer to answer questions : do you have any questions?
- conclude by saying: well, thats all I need to know for now?
- Thank the client : thank you for your time and help
- Express concern for person's welfare: take care of yourself
- Plan for next meeting.
- Provide a summary to verify accuracy and agreement.

Organizing data
We use nursing and non-nursing models.
Non-nursing models such as Maslow hierarchy
of needs, and body system models.

body systems model

Integumentary system.
Respiratory system.
Cardiovascular system.
Nervous system.
Musculoskeletal system.
Gastrointestinal system
Genitourinary system.
Reproductive system
Immune system.

Do not forget to document every

thing you assess

Diagnosing
Is the pivotal second phase of the nursing process, in which
the nurse interprets assessment data, identifies clients strengths
and health problems, and formulates diagnostic statements.
According to NANDA : Diagnosis is a clinical judgment
about individual, family, and community response to actual or
potential health problem\ life processes.

Types of Nursing Diagnoses

Actual diagnosis: is a client problem that is present t the time
of assessment.
- Example: Anxiety, Ineffective breathing pattern.
Risk Diagnosis: is a clinical judgment that a problem doesnt
exist, but the presence of risk factors indicates
that the problem is likely to develop.
- Example: Risk for infection.

Types of Nursing Diagnoses

Wellness diagnosis: it describes the human responses to level
of wellness in an individual, family, and
community that have a readiness for
enhancement.
- Example: Readiness for enhanced family coping.
Possible diagnosis: is one in which evidence about a health
problem is incomplete or unclear.

Components of NANDA Nursing Diagnosis

1.

Problem: describe the client health problem or response for

which nursing therapy is given.
- Examples:
* Anxiety.
* Fluid Volume Deficit.
* Ineffective breathing pattern.
* Knowledge deficit.
* Risk for infection.

Components of NANDA Nursing Diagnosis

2. Etiology: identifies one or more probable causes of the health

problem.
- Example:
Constipation related to inactivity and insufficient fluid intake.

Problem

Etiology

Components of NANDA Nursing Diagnosis

3. Defining characteristics: are the cluster of signs and symptoms

that indicate the presence of a
particular problem
- Example:
Problem

Etiology

Anxiety related to breathlessness and medications side effects As manifested by

patient verbalization and facial expressions

Defining characteristics

Examples of nursing diagnosis

Chest pain Related to Increased oxygen demand and decreased
oxygen supply As Manifested By patient verbalizations, facial
expression (furrow eyebrows).
- Problem: Chest pain.
- Etiology: Increased oxygen demand and decreased oxygen supply.
- Defining characteristics: patient verbalizations, facial expression

Components of NANDA Nursing Diagnosis

Risk for Infection related to presence of open surgical wound
in chest and left leg.

- Problem : Risk for infection.

- Etiology: Presence of open surgical wound in chest and
leg.

Example

Patient said:" I feel chest pain radiated to my back and left arm lasted for
about 20minutes".
Patient stated that pain severity is about 8 on scale.
Patient stated that pain was slightly decreased but not relieved by rest.
Facial expressions: furrow eyebrows, no smile.
Patients heart rate was 123 b/m.

Severe chest pain Related to Increased oxygen demand and decreased oxygen supply As
Manifested By patient verbalizations, facial expression (furrow eyebrows, absence of smile),
tachycardia, patient is anxious.

Planning
Planning is the third phase in which the nurse and the client
develop goal\desired outcomes, and nursing interventions to
prevent, reduce, or alleviate a client health problem.
Nursing Intervention: is any treatment, based upon clinical
judgment and knowledge, that the nurse perform to enhance
patient or client outcomes.

Types of planning
Initial Planning: is planning which performed by the nurse
after admission assessment.
Ongoing Planning: is performed by all nurses who work with
the client. Also ongoing planning may
performed before each shift as the nurse
plans the care given at that day.
Discharge Planning: is the process of anticipatin and planning
for needs after discharge.

Care Plans
Informal nursing care plan : is a strategy of action that exists
in the nurses mind.
Formal nursing care plan : is a written or computerized
guide that organizes information about the
clients care.
Standardized care plan: a formal plan that specifies the nursing
care for groups of clients with common needs.
Individualized care plan: a formal plan that specifies the nursing
care for individual with unique needs.

The Planning Process

Setting priorities.
Establishing client goal / desired outcomes.
Selecting nursing interventions.
Writing nursing orders.

Setting priorities
Setting priority : is the process of establishing a preferential
sequence for addressing nursing diagnoses and nursing
interventions.
Nurses frequently use Maslow hierarchy of needs when setting
priorities.
For example : Ineffective airway clearance take higher
priority over Anxiety.

Establishing Client Goals/Desired Outcomes

On care plan, Goal/Desired Outcomes describes what the

nurse hopes to achieve by implementing the nursing
interventions.
Goal : is a broad statement about the clients status.
Desired outcomes: specific statements used to evaluate
whether goal have been met or not.

Example of Goal and Desired Outcomes

Nursing diagnosis : Altered nutrition: less than body requirements.

Goal: To improve nutritional status of the client.
Desired outcome: Patient will gain 10 kg within 1 month.

Types of Goals
Short term goal : is the goal that needs shorter time to be
achieved ( usually lesser than 6 weeks).
- Example : Client will reports decrease in anxiety
level within 6 hours.
Long- term goal: is the goal that needs longer time to be
achieved ( usually more than 6 weeks).
- Example : Client will regain full use of right arm
within 6 weeks .

Components of Goal/Desired Outcomes

Subject: is the noun, or any part of clients name, or some
attribute of the client.
Verb: specifies the action that the client is to perform.
Condition: added to verb to explain circumstances under
which the behavior is t be performed. They explain what,
where, when , and how.
Criterion of desired performance: specifies the time or speed,
accuracy, distance, and quality.

How to Write Desired Outcome

Client will drink 100 mL of water per hour

Subject

Verb

Condition

Criterion

Examples of Desired Outcome

Client will perform leg range of motion exercises as taught every 8 hours.

Subject

Verb

Condition

Criterion

Client will list three signs and symptoms of diabetes before discharge.

Subject

Verb

Condition

Criterion

Examples of Action Verbs

Apply.
Breathe.
Choose.
Compare.
Define.
Demonstrate.
Describe.
Discuss.

Drink.
Explain.
Identify.
Inject.
List.
Move.
Name.
Report.

Select.
Share.
Sit.
Sleep.
State.
Talk.
Transfer.
Verbalize.

Selecting Nursing Interventions

Nursing interventions: are the activities that the nurse perform to
achieve client goals.
Types of nursing interventions:
- Independent nursing intervention: are those activities that nurses
are licensed to initiate on the basis of their knowledge and
skills.
- Dependent nursing intervention: are those activities that carried
out by the nurses under the physician's order or supervision.

Writing Nursing orders

4/4/2011 : Administer prescribed analgesics every 12 hours / I.R.A

Date

Action Verb

Content Area

Time element

Signature