By.

Hesti Agustina Widyastuti, BN

English In Nursing Sciences 2
Introduction
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Assessment
 Determine current health status
 Determine problem area (actual and potential)
 Data source and types
 Subjective data
 Objective data
 Historitical data
 Current data

 Essential skill
 Interviewing technic
 Physical assessment

 Data grouping
 Maslow hierarchy
 Roy’s adaptation models
 NANDA-I Taxonomy
Cont’..................
 Data source and types
 Subjective data
Fact presented by the patient that show his/her perception,
understanding of what is happening.
Ex : Pain
 Objective data
Facts that are observable and measureble by nurse
 Historitical data
Health events that happenend prior to last data.
 Current data
Fact specifically related to this admission or health problem episode.
Cont’...........
 Essential skill
 Interviewing Technic
Gathering data for the nursing history. Ask
 Physical Assessment
Inspection, Palpation, Percution, Auscultation
o Head-to-toe approach

o Body system appoach

o Functional health pattern

Cont’.........
 Data grouping
 Maslow hierarchy
Basic human’s need
 Roy’s adaptation models
 NANDA-I Taxonomy
what NANDA_I stand
for...........????
Diagnosis
 Coclusion regarding the patient’s strengths and human
responses.
 Nursing Diagnosis
Indentify the human’s responses to actual or potential health problem
 Diagnosis Statements
 Identify the unhealthy response
 Identify the probable cause of unhealthy
 Use the phrasse : related to, secondary to, due to

 Example :
Acute Pain related to tissue demage
Planning
 Setting Priority
 Identify problem that may can solve in 1 – 3 day
hospitalize
 Priority based on life threat
 Expected Outcomes
 Expected outcomes are clearly stated in patient behavior
 Realistic, observable, achievable, safe, acceptable
 Using NOC (Nursing Outcomes Clasification)
 Patient centered
 Establishing Target Data
 Writing the target date at the end of the expected
outcomes
Example......
A. Understand how to self-administer insulin
B. Accurately return demonstrades self administration
of insulin

Find the right sentence of Outcome.................!!!!

Implementation
The action phase of nursing process
 Nursing action
Nursing behavior to serve the patient problem based on
expected outcomes
 Independent activities

 Collaborative activities
Evalution............
 Assesing what progress has been made toward
meeting the expected outcome.
Benefits of using the nursing process
 Continuity of care

 Prevention of duplication

 Individualized care

 Increased client participation

 Collaboration of care

 Standards of care
 NANDA – North American Nursing
Diagnosis Association
 Identifies nursing functions
 Creates classification system
 Establishes diagnostic labels

 Risk of infection related to compromised nutritional

state
 Potential complication of seizure disorder related to
medication compliance
 Creating Nursing Diagnosis Statements

 State the person’s response or diagnostic

label

 Identify related factors contributing to or

causing the problem

 Signs and symptoms

Qualities For Application Of The Nursing
Process
 Intellectual skills
 Critical thinking
 Decision-making
 Interpersonal skills
 Technical skills
 Creativity
 Adaptability