Nursing Process: A Clinical Guide Molly Sam
Activity and exercise 87
nursing diagnoses under sleep and rest pattern 88
activity intolerance—high- risk/actual 88
altered growth and development 95
decreased tissue perfusion 100
fatigue 89
impaired gas exchange 102
impaired home maintenance management 103
impaired physical mobility 91
ineffective airway clearance 96
ineffective breathing pattern 98
self-care deficit 93
Approved nursing diagnoses— NANDA, 1990 12
Assessment guidelines 126
activity/rest reports 128
circulation 128
ego integrity 129
elimination 130
food/fluid 130
hygiene 131
medical/surgical assessment tool 127
neurosensory 132
pain/comfort 133
respiration 133
safety 134
sexuality 134
social interaction 135
teaching/learning 136
Body temperature 31
Bowel incontinence 31, 82
Cognition and perception 109
anxiety 119
expected outcomes 121
related clinical concerns 120
fear 123
clinical concerns 123
expected outcomes 123
related factors 123
nursing diagnosis 109
altered thought process 118
knowledge deficit 116
sensory perceptual alteration 112
Comparison of nursing models for data collection 5
Data collection and nursing diagnoses 11
cognition, reception and self- concept 21
NANDA approved nursing diagnosis according to human response patterns categories 14
NANDA list of nursing diagnoses organized according to Gordon's functional health patterns 17
nursing diagnoses classified under body systems 22
cardiovascular system 22
endocrine system 25
gastrointestinal system 23
genitourinary system 24
integumentary system 25
intensive cares 26
musculoskeletal system 24
nervous system 23
oncology 26
postoperative 26
preoperative 25
respiratory system 22
patterns and nursing diagnoses 20
activity-exercise sleep rest 21
elimination 21
health perception-health pattern management 20
nutrition metabolism 20
Elimination 78
nursing diagnosis 78
altered urinary elimination: incontinence 83
bowel incontinence 82
diarrhea 80
urinary retention 85
Fluid volume access 35
Fluid volume deficit – actual 34
Fluid volume deficit – potential 34
Gas exchange, impaired 35
Growth and development, altered 35
Health perception—health management pattern 50
Impaired swallowing 68
Impaired tissue/skin integrity-high risk for/actual 74
Infection potential for 38
Injury potential for 40
Knowledge deficit 40
Medical/surgical assessment tool 127
Mobility, impaired physical 38
Musculoskeletal system 24
Nursing care plan 138
Nursing diagnoses of health perception 50
altered health maintenance 50
clinical conditions 51
expected outcome 51
possibly evidenced 51
altered protection 57
clinical problems 58
possibly evidenced by 58
high-risk for infection 52
clinical conditions 53
expected outcome 53
high-risk for injury 55
clinical problems 56
expected outcome 56
possibly evidenced 56
in effective management of therapeutic regime 54
clinical concerns 54
expected outcome 54
Nursing diagnoses with defining characteristics and contributing factors 28
activity intolerance 28
activity intolerance potential 29
airway clearance, ineffective 29
anxiety 29
aspiration, potential for 30
body temperature, potential altered 31
bowel incontinence 31
breathing pattern, ineffective 31
constipation 32
diarrhea 32
fatigue 33
fluid volume deficit, actual 34
fluid volume deficit, potential 34
fluid volume excess 35
gas exchange, impaired 35
growth and development, altered 35
health maintenance, altered 36
home maintenance management impaired 37
infection, potential for 38
injury potential for 40
knowledge deficit 40
mobility, impaired physical 38
nutrition, altered: less than body requirements 39
nutrition, altered; more than body requirements actual and potential 41
pain 42
pain, chronic 42
self-care deficit, bathing/hygiene 42
self-care deficit, dressing/ grooming 43
self-care deficit, feeding 43
self-care deficit, toileting 44
sensory/perceptual alterations (specify): visual, auditory, kinesthetic gustatory, tactile, olfactory 40
skin integrity, impaired 44
skin integrity, potential impaired 44
sleep pattern disturbances 45
swallowing, impaired 45
tissue integrity, impaired 46
tissue perfusion, altered (specify) 47
trauma, potential for 46
urinary elimination, altered 48
urinary incontinence 48, 49
urinary retention 49
Nursing process 1
benefits 2
steps 3
assessment 3
diagnosis 7
expected outcome 9
implementation 8
planning 7
Nursing process and conceptual framework 2
Nutrition metabolism 60
nursing diagnoses 61
altered body temperature 75
altered nutrition—less than body requirement 61
fluid volume deficit: actual or high-risk for 70
fluid volume excess 72
high-risk for/or potential for aspiration 66
impaired swallowing 68
impaired tissue/skin integrity- high-risk for/actual 74
Oncology 26
Place of nursing process in nursing education 2
Related clinical concerns 120
Respiratory system 22
Sleep-rest 106
sleep pattern disturbance 106
clinical conditions 106
expected outcome 107
possibly evidenced 106
Teaching/learning 136
Tissue integrity 46
Tissue perfusion 47
Trauma, potential for 46
Urinary retention 85
Chapter Notes

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Nursing ProcessCHAPTER 1

Nursing process is an organized systematic method of giving individualized nursing care that focuses on identifying and treating unique responses.
The Nursing process provides organization of care in every clinical setting. It helps in resolving health problems.
Lydia Hall was one of the first nurses to use term nursing process in the early 1950. Since then nursing process has been used to describe the accepted method of delivering nurse care.
Nursing process provides a frame work with which individualized needs of the patient/family/community can be met. It is an efficient method of organizing thought process for clinical decision making and problem solving. It provides the framework to utilize in working with the patient. It begins at the time the patient needs assistance with health care, of individuals or groups to actual or potential alteration in health through the time the patient no longer needs assistance to meet health care maintenance.
The north American Nursing Diagnosis Association (NANDA) has developed and classified nursing diagnosis. NANDA helps in identifying a communication pattern among the nurses. It also gives a clear distinction between nursing diagnosis and medical diagnosis. It also gives clear direction 2for care. Nursing diagnosis focuses on patient response and medical diagnosis focuses on disease process.
Nursing education emphasizes on critical thinking and clinical judgment on the part of the student nurse to make diagnostic and therapeutic judgment. Nursing process has served to make nursing more visible in its contribution to health care in western countries. NANDA is still not precise, consistent or fully descriptive of the unique aspects of nursing. But the available categories should be used and researched to evolve the profession as a unique one.
Many professionals interact in care delivery and each has to appreciate others focus on practice. We may encounter clinical situations for which a problem has not been described or labeled by NANDA. The implementation of nursing diagnosis in practice requires nurses to sharpen their diagnostic judgments skills and assume responsibility and accountability for their action. A good nursing care is the result of thoughtful analysis. Using diagnostic language greatly facilitates practice and clarifies what nurses has to offer to the patients.
NANDA is the organization responsible for development, review and approval of nursing diagnoses. Nursing Diagnosis made by professional nurses describe actual or potential problems which nurses by virtue of their education and experience are capable and licensed to treat.
Nursing process is the action phase of nursing models. Models guide the use of nursing process.
  1. Nurse gets to plan individualized care which helps her to develop a professional relationship.3
  2. It involves the patient actively in all phases, so the nurse and patient derives satisfaction.
  3. It gives the nurse a framework to use in patient care.
  4. It makes the nurse to be aware of the skills and abilities used by her in patient's care.
There are five steps/stages. Each step cannot be separated from each other and they may overlap one another. But with practice it is possible to accurately complete each step and use it for the next stage. They are:
  • Assessment
  • Nursing Diagnosis
  • Planning
  • Implementation
  • Expected outcome
These five steps are performed by the nurse to achieve the ultimate goal of nursing. They are:
  1. To promote, maintain/restore health, or to assist patient to achieve a peaceful death, when their condition is terminal.
  2. To enable patient/family/community to manage their own health care to the best of their ability.
Collecting health data. Assessment is possible only when human needs are understood. Concepts that contribute to understanding these needs are basic human needs, the teaching learning process, therapeutic communication, and developmental theory. Knowledge of anatomy, physiology, pathophysiology, asepsis, nutrition, accountability, group dynamics and group process and mental health concepts are basic to nursing process and helps in data collection. In this 4stage data is collected from several sources. The collection and organization should give the following:
  1. Patient's current health status
  2. Patient's strength and problem areas (Actual or potential)
Assessment requires the use of the skills of interviewing, physical assessment and observation. Data collection can be classified under subjective and objective.
Subjective are the facts presented by the patient in her or his perception.
Objective are facts which are observable and measurable. This data gathered through physical assessment, interviews and observation by using the five senses. Also diagnostic examinations and organizing the information is by clustering data in a concise way.
There are many ways of clustering data. They are:
  1. Clustering data according to body systems.
  2. Clustering data according to human needs (Maslows)
  3. Clustering data according to a nursing theory
  4. Clustering data according to functional health pattern based on a theory.
In this book the last method—clustering according to functional health pattern is used.
zoom view
Organizing the data using a nursing framework will assist in focusing the attention and in choosing a specific nursing diagnoses label.5
Comparison of nursing models for data collection
Diagnostic divisions (Doenges and, 1993)
Functional health patterns (Gordon, 1993)
Human response patterns (Fitzpatrick, 1991)
Activity/rest: Ability to engage in necessary/desired activities of life (work and leisure) and to obtain adequate sleep/rest.
Circulation: Ability to transport oxygen and nutrients necessary to meet cellular needs.
Ego Integrity: Ability to develop and use skills and behaviors/integrate and manage life experiences.
Elimination: Ability to excrete waste products,
Food/fluid: Ability to maintain intake of and use nutrients and liquids to meet physiologic needs.
Hygiene: Ability to perform activities of daily living (ADL).
Neurosensory: Ability to perceive, integrate, and respond to internal and external cues.
Pain/discomfort: Ability to control internal/external environment to maintain comfort.
Respiration: Ability to provide and use oxygen to meet physiologic needs.
Safety: Ability to provide safe, growth promoting environment.
Sexuality: (Component of Ego Integrity and
Health perception/health management: Client's perception of general health status and well-being. Adherence to preventive health practices.
Nutritional-Metabolic: Patterns of food, and fluid intake, fluid and electrolyte balance, general ability to heal.
Elimination: Patterns of excretory function (bowel, bladder and skin), and client's perception.
Activity/exercise: Pattern of exercise, activity, leisure, recreation, and ADL; factors that interfere with desired or expected individual pattern.
Cognitive-perceptual: Adequacy of sensory modes, such as vision, hearing taste, touch, smell, pain perception, cognitive functional abilities.
Sleep/rest: Patterns of sleep and rest-relaxation periods during 24 hour day as well as quality and quantity.
Self-perception/self-concept: Individual's attitudes about self, perception of abilities, body image, identity, general sense of worth and emotional patterns,
Choosing: To select between alternatives, the action of selecting or exercising preference in regard to a matter in which one is a free agent; to determine in favor of a course; to decide in accordance with inclinations,
Communicating: To converse; to impart, confer, or transmit thoughts, feelings, or information internally or externally, verbally or nonverbally.
Exchanging: To give, relinquish or lose something while receiving something in return, the substitution of one element for another; the reciprocal act of giving and receiving,
Feeling: To experience, a consciousness, sensation, apprehension or sense; to be consciously or emotionally affected by a fact, event or state.
Knowing: To recognize or acknowledge a thing or a person; to be familiar with by experience or through information or report; to be cognizant of something through observation, inquiry or information; to be conversant with a body of facts, principles, or methods of action; to understand.
Moving: To change the place or position of a body
Social (Interaction) Ability to meet requirements/characteristics of male/female role.
Social Interaction: Ability to establish and maintain relationships.
Teaching/learning: Ability to incorporate and use information to achieve healthy lifestyle/optimal wellness.
Role/relationship: Client's perception of major roles and responsibilities in current life situation.
Sexuality/reproductive: Client's perceived satisfaction or dissatisfaction with sexuality. Reproductive stage and pattern.
Coping/stress tolerance: General coping pattern, stress tole-ranee, support systems, and perceived ability to control and manage situations.
Value Belief: Values, goals, choices and decision.
or any part of the body; to put and/or keep in motion; to provoke an excretion or discharge; the urge to action or to do something; to take action,
Perceiving: To apprehend with the mind; to become aware of by the senses; to apprehend what is not open or present to observation; to take fully or adequately,
Relating: To connect, to establish a link between, to stand in some association to another thing, person or place.
Valuing: To be concerned about; to care, the worth or worthiness, usefulness, importance, ones opinion of liking or a person or thing, to equate in importance.
Gorden has brought out the method of collection of data by using “functional health pattern” for assessment which allows identification of three major types of data which is very useful and easy to collect data.
  1. Functional pattern: Functional pattern are patient's strengths on which nursing actions can be built.
  2. Dysfunctional pattern: Helps to identify problem areas for which interventions from nurse is needed.
  3. Potential dysfunctional patterns: are high risk conditions which alerts nurses to use her clinical judgment to minimize these problem to eliminate it.
The advantage of functional health model is that it uses a Nursing model rather than a medical model, thus differentiating between areas of independent nursing 7interventions which can be done by nurse, and areas requiring collaboration with other health professional or referrals to other agencies.
Analysis of the assessment data in determining nursing diagnosis. Diagnoses means reaching at a definite conclusion regarding the patient's strengths and problems. The problems are primary focus and the strengths help in implementing the care.
While stating the nursing diagnosis, a human response and an indication of the factor contributing to the response is stated. These two parts of the nursing diagnosis are connected using the:
  • related to;
  • secondary to;
  • due to.
Stating the nursing diagnosis clarifies the logical relationship that exist between the patient's problem and proposed plan of care.
High-risk and potential states are conditions that are predicted but has not occurred. Documentation of care plans enhances communication and continuity of care, thus reducing omissions and duplication of nursing care.
Planning provides consistency of care. Nurse develops plan of care that prescribes intervention to attain the expected outcome. It includes setting priorities and establishing target dates, nursing actions and evaluations by setting standards. There are many ways of setting priorities like maslows hierarchy of needs, priorities based on life threat posed by a problem: e.g., Ineffective breathing pattern is more important 8than many other problems from the nurses point of view. But the best way to set priorities is to ask the patient which problem he or she would like to be given priority. Another method is to combine your skills of communication and coming to a consensus with the patient.
The steps of planning are:
  1. Setting priorities: The problems which need.immediate attention are taken care first.
  2. Establishing goals: This is what the nurse and patient expect to accomplish in a particular time framework.
  3. Determining nursing interventions: The activities the nurse and patient will do to achieve the desired goals.
  4. Recording care plan: Other nurses need to know the plan of care that you have prescribed and the goals you expect to achieve.
Implements the intervention identified in the plan of care. It is the action phase of the nursing process. Nursing actions are behavior that serves to help the patient to achieve the expected outcome. It includes both independent and collaborative actions.
Independent actions: These activities are performed by the nurse using her own judgment. These activities do not require guidelines or orders from other health professionals, e.g., giving nail care.
Collaborative actions: Those activities that involves, mutual decision with the doctors, and other health care professionals, e.g., giving medications.
Nursing interventions are specific nursing activities or actions that a nurse must perform to prevent complications, provide comfort (physical, psychological and spiritual) to promote, maintain and restore health.9
The activities and interventions that are to be undertaken by a nurse are:
  1. Performing nursing assessment to identify new and existing problems.
  2. Patient teaching to help patient to gain new knowledge concerning health.
  3. Counseling patient to make their own decisions regarding health.
  4. Consulting/referring with other health care professional for holistic care.
  5. Performing specific treatment actions to remove/reduce/or resolve health problems.
  6. Assisting patient to perform activities themselves.
So the nurses role is assessing, teaching, counseling, consulting and specific nursing interventions which she is authorized to do by her profession.
To carry out these aspects of nursing process, the nurse should be aware of the facilities and resources available with the patient/family/hospital/community. Patient teaching and discharge planning should not be left for the day of discharge and should be initiated from the time of admission.
Putting Plan into Action
The planning can be put into implementation when the following activities are kept in mind.
  1. Continuing data collection and assessment,
  2. Setting daily priorities,
  3. Performing nursing interventions,
  4. Documenting nursing care,
  5. Giving verbal nursing reports,
  6. Maintaining a current care plan.
Expected Outcome
Evaluates the patients progress towards attainment of outcome. Objectives, goals and evaluation almost mean the 10same and are used interchangingly. It assesses/measures progress. It provides feedback regarding the nursing care given, gives opportunities for evaluating quality of nursing care.
Steps in Evaluating an Outcome
  1. List the goals to the patient which you have set forth.
  2. Assess what the patient is able to do.
  3. Compare your goals in relation to patient's ability.
  4. Discuss the goals with the patient. Allow him to verbalize his feeling and if he feels the goals were achieved.
If goals are all not achieved, try to find out where it has gone wrong. Record your findings. Write an evaluation statement that includes how well goals have been achieved.