NURSING PROCESS

by
KUSWANTORO RUSCA PUTRA

Initial
Ongoing
Examination/Observation
comprehensive
assessment assessment

Collect data

Validate Data
Organize Data
Record Data

Overview of assessment

NANDA Component in Diagnostic

Statement
Diagnostic Statement Components
Problem
Etiology
A.M.B
Actual
Label
Related
Defining
Diagnoses
factors
characteris
tic
Risk/Potent Label
ial
Diagnosis

Risk
factors

None

Actual Nursing Diagnosis

Problem
Symptoms

(r/t)

(NANDA label) (r/t)

(Defining

Etiology

(A.M.B)

(Related factors)

(A.M.B)

characteristics)

Gas Exchange,
Impaired

Alveolar-capillary
(r/t) membrane changes (A.M.B)
Ventilation-perfusion
imbalance

Dyspnea
Visual
Disturbance
Abnormal
arterial
blood gases
Diaphoresis
Tachycardia

Risk Nursing Diagnosis

Problem
Symptoms

(r/t)

(NANDA label) (r/t)

Etiology

(Risk factors)

v
v

Infection,
Risk for

Inadequate primary
defenses
(r/t)

Malnutrition
Trauma

(A.M.B)

Prioritizing Diagnoses
Preservation of Life
Maslows Hierarchy
Patient Preference

Goals/Desired Outcomes
Type of Problem

Actual Nursing
Diagnosis

Risk Nursing
Diagnosis

Patient
Response
Demonstrates
Resolution or
reduction of
problem

Nursing Focuses
on
Resolution or
reduction of
problem

Prevention of
complication
Problem has not Prevention and
developed
detection of
problem

Components of Goal/Expected Outcome

Statements
Subject

Verb

Special
Conditions

Performance
Criteria

Target Time

Client

Will
walk

(using
walker)

To bathroom and
back without
shortness of
breath

Within 3 day

Patients
lungs

Will be

Clear to
auscultation

Within 24
hours

Types of Nursing Order in Relation to

Diagnoses
Actual Nursing
Diagnosis
Observation
for improvement or
complications
Prevention
of further
complications
Treatment
Remove causal and
contributing factors
Relieve symptoms

Risk Nursing Diagnosis

Observation
For change to actual
status
Prevention
Remove or reduce risk
factors

Nursing Interventions
1.
2.
3.
4.

Observation
Prevention
Treatment
Health Promotion

Nursing Skills Used in

Implementation

Cognitive Skills
Interpersonal Skills
Psychomotor (Technical Skills)

Guidelines for Successful

Implementation
Prepare the Nurse
1. Determine whether you need help to perform
the action safely and minimize stress to the
client
2. Be sure you know the rationale for action, as
well as any potential side effects or
complications.
3. Question any actions you do not understand
or that seem inappropriate or potentially
unsafe
4. Determine feedback points and assess the
clients response during the activity

Guidelines for Successful

Implementation
Prepare the Nurse
5. Schedule activities to allow adequate
time for completion
6. Delegate tasks to other team members
in order to use your time efficiently
7. Improve your knowledge base by
continually seeking new knowledge

Guidelines for Successful

Implementation
Prepare the Client
8. Reassess for changes in patient status
9. Determine that the action is still
needed and appropriate
10.Assess client readiness
11.Inform the client of what to expect and
that what is expected of him
12.Provide for privacy and comfort

Guidelines for Successful

Implementation
Prepare Supplies and Equipment
13.Gather and organize all necessary supplies
During Implementation
14.Observe the patients initial response to the
intervention
15.Continue to observe response as you
implement
16.Adapt activities to the clients age, value,
culture, and health status. Remain flexible
and make creative modifications as your work

Guidelines for Successful

Implementation
During Implementation
17.Encourage the client to participate
actively
18.Perform
actions
according
to
professional standards of care and
agency policies & procedures
19.Perform
actions
carefully
and
accurately
20.Supervise and evaluate delegates
activities

Process for Evaluating Client

Progress
1. Review the desires outcomes
(indicators)
2. Collect evaluation data
3. Compare patient status with
desire outcomes, and draw a
conclusion
4. Write the evaluative statement
5. Relate nursing interventions to
outcomes

Recording
Nursing documentation in the permanent
record is found on the following forms:
1. The initial, comprehensive nursing
assessment
2. The individualized nursing care plan
3. Nursing progress notes
4. Flow sheets (e.g, graphic sheets,
medication records)
5. The client discharge summary

Documentation Method

Narrative, chronological charting

SOAP Charting
PIE and PART Charting
DAR

Reference
Wilkinson, J.M (2005) Nursing
Diagnosis Handbook with NIC
Interventions and NOC Outcomes.
New Jersey: Pearson Education
Wilkinson, J.M (2007) Nursing Process
and Critical Thinking 4th Edition. New
Jersey: Pearson Education