Session 4: Utilization of Nursing

Process in Provision of Nursing Care

NMT 04207 APPLICATION OF

NURSING PROCESS&THEORIES
IN NURSING

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 Learning tasks
At the end of this session, Learners are
expected to be able to:
• Assess client’s objective and subjective data
• Formulate nursing diagnosis
• Develop plan of care
• Implement patient/client care
• Evaluate patient/client care

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 Activity: Brainstorming

What are the difference between subjective and

objective data?

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 Assess client’s objective and subjective data

Definition of terms
Subjective data
• This are symptoms or covert data, are apparent only to the
person affected and can be described or verified only by the
person affected
• Examples are: sensations, feelings, values, beliefs, attitudes,
and perception of personal health status and life situations(pain,
nausea, lack of appetite, dizziness)
Objective data
• Referred to signs or overt data detectable by an observer or can
be measured or tested against an accepted standard
• They can be seen, heard, felt, or smelled
• Obtained through observation or physical examination
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•
Assess client’s objective and subjective data

Sources of information:
• Primary source- the client
• Secondary sources- patient’s file, family members,
friends, significant others
Should be validated, if possible
Methods that can be used for data collection
include:
• Observation
• Interview
• Physical examination
• Review of previous records 5
 Assess client’s objective and subjective
data…methods of data collection

1. Observing
• Observing – This is the process of gathering
data using the five senses
• Used to obtain the following data:
– Skin color (vision)
– Body or breath odors (smell)
– Lung or heart sounds (hearing)
– Skin temperature (touch)
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 Assess client’s objective and subjective
data…methods of data collection

2. Interviewing
• Planned communication or a conversation with
a purpose
• Data can be obtained through history taking
• Used to:
– Identify problems of mutual concern
– Evaluate change in patient’s condition

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 Assess client’s objective and subjective
data…methods of data collection

3. Examining (physical examination)

• This is a systematic data-collection method through
comprehensive physical examination from head to
toe including vital signs
• Methods of examination used are inspection,
auscultation, palpation, and percussion
• Used to obtain data such as: vital signs(blood
pressure, pulses respiration and temperature), heart
and lungs sounds, skin moisture, muscle strength,
swelling, discoloration, rashes and paleness 8
 Assess client’s objective and subjective
data…methods of data collection

4. Review of previous records

• Data can be obtained through health records, laboratory tests
and investigation results, patient’s file
• Tools that can be used for data collection include:
• Checklists
• Specific patient care charts e.g. intake and output chart,
observation charts
• Physical examination instruments such as- stethoscope, aural
scope, laryngoscope, and vital sign equipment
• Interview guide
• Laboratory testing facilities 9
 Activity: Group work
Buzz into two participants and brainstorm on the
components of nursing diagnosis, each group
will provide one component of the nursing
diagnosis.

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 Formulate Nursing Diagnosis
Components of the nursing diagnosis
• Problem
• Joining statement
• Etiology or contributing factor

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 Formulate Nursing Diagnosis
Nursing diagnosis can be written as a basic two-
part statement or basic three-part statement
 Basic two-part statement composed of:
• Problem
• Etiology
• E.g. Anxiety related to threat to physiological
integrity
• Anxiety – problem
• Related to – joining statement
• Threat to physiological integrity – aetiology 12
 Formulate Nursing Diagnosis
Basic three part statement composed of:
• Problem
• Etiology
• Signs and symptoms
E.g. Low self-esteem related to feeling of
rejection as manifested by hypersensitivity to
criticism; states “I don’t know if I can manage
by myself”

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 Formulate Nursing Diagnosis…..basic 3
parts problem writing
Problem Joining Statement Etiology Manifestation Signs and Symptom

Situational low self Related to Feeling of rejection As manifested by Hypersensitivity to criticism; states
esteem “I don’t know if I can manage by
myself”

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 Formulate Nursing Diagnosis
Guidelines for writing nursing diagnosis statements
• Write statements in terms of a problem instead of a need
• Word the statement so that it is legally advisable
• Use nonjudgmental statements
• Be sure both elements of the statement do not say the same
thing
• Be sure cause and effect are stated correctly.
• Word diagnosis specifically and precisely.
• Use nursing terminology rather than medical terminology
to describe the client’s response.
• Using nursing terminology rather than medical
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terminology to describe the probable cause of the client’s
 Activity: Group work
• In a group of five participants discuss the
activities involved in the planning process,
each group will present on one activity.

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 Develop Plan of Care

In planning care process, the nurse performs

the following activities:
• Prioritizing problems/diagnoses
• Formulating client goals/desired outcomes
• Selecting nursing interventions
• Writing individualized nursing interventions

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Develop Plan of Care…. Prioritizing problems/diagnoses

Factors to consider when setting priorities

• Client’s health values and beliefs
• Client’s priorities
• Resources available to the nurse and client
• Medical treatment plan
• Urgency of the health problem
• Establishing a preferential sequence for
addressing nursing diagnoses and interventions
– High priority (life-threatening)
– Medium priority (health-threatening)
– Low priority (developmental needs) 19
 Examples of formulated nursing
diagnosis
• Ineffective airway clearance related to various
secretion secondary to fluid deficiency and
inadequate chest expansion secondary to pain and
fatigue – life threatening
• Impaired nutrition; less than body requirement
related to loss of appetite, nausea and increased
metabolism secondary to disease process – health
threatening
• Risk to interrupted family process related to
mother’s illness and potential to unavailability of
father to provide child care – developmental needs20
Develop Plan of Care…. Goal setting

• Consider the following components of

Goal/Desired Outcome Statements
– Subject – client by name
– Action Verb – what patient will be able to
– Condition or modifier – measurement of
performance
– Criterion of desired performance – time/duration
when outcome will be observed

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Develop Plan of Care…. Goal setting

• Guidelines for writing goals/desired

outcomes
• Write in terms of the client responses
• Must be realistic
• Ensure compatibility with the therapies of
other professionals
• Derive from only one nursing diagnosis
• Use observable, measurable terms

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Develop Plan of Care…. Goal setting
Example:
• Mr. Juma (subject) will be able to drink (Action Verb)
2,000 mls of water (condition) within twelve hours
(criterion/time duration)
• Characteristics of an outcome
• S – specific: it must be precisely identify what the
client must achieve
• M – measurable: must use measurable and observable
verbs that can be quantifiable for easy evaluation
• A – achievable: must be realistic for client to achieve
• R – realistic: must be aimed at attaining the set goal
• T – time limited: must be bound by a certain time frame 23
 Nursing interventions
• Process of selecting and choosing nursing
interventions
• Nursing Interventions and activities are
actions a nurse performs to achieve
goals/desired outcomes
• They Focus on eliminating or reducing
etiology of nursing diagnosis or treating
signs/symptoms and defining characteristics

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 Nursing interventions
Criteria for choosing appropriate intervention
• Interventions should be safe and appropriate for
the client’s age, health, and condition
• Must be achievable with the resources available
• Congruent with the client’s values, beliefs, and
culture
• Congruent with other therapies
• Based on nursing knowledge and experience or
knowledge from relevant sciences
• Should be within established standards of care 25
 Nursing interventions
Guidelines for Writing Nursing Care Plans
• Indicate date, time and sign the plan
• Use category headings
• Use standardized/approved terminology and
symbols
• Be specific
• Refer to other sources
• Individualize the plan to the client
• Incorporate prevention and health maintenance
• Include discharge and home care plans 26
 Activity :Group work
In a group of five participants ,discuss the phases
involved in nursing implementation of client’s
goals.
Each group will present on each phases.

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 Nursing implementation
• Implementation is related to actual carrying out
or executing the plan by the nurse and the patient.
• During implementation continues to assess,
validate concerns and modify the plan and
priorities.
• The implementation process comprises of the
following three components:
1. Preparation phase
2. Implementation phase
3. Documentation phase 28
 Nursing implementation
Preparation Phase
• During this phase, prepares yourself and the patient to
carry out the prescribed tasks and strategies of the plan in
order to ascertain whether the plan is still valid and
relevant, priorities have not changed, it is safe to go
ahead, legal and ethical aspects have been taken into
consideration.
• Prepares the patent physically, mentally, socially and
spiritually to enhance patient’s participation in the nursing
process.
• Prepares the equipment and supplies appropriate to the
care which will be given and environment to ensure
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comfort and privacy
 Nursing implementation
Implementation Phase
• This is the actual doing phase.
• Performs and assists the patient to perform
skillfully, efficiently and competently.
• Put emphasis and focus on the patients more
than on the specific procedure or the strategy
that is reaching rather than how to complete a
procedure

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 Nursing implementation
Documentation Phase
• On completion of performance objective, write
the actions which were implemented by the
nurse and the patient; it includes actions which
were not carried out and reasons with focus on
the progress of the patient.
• The recording system will depend on the
respective health care facility.

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Evaluation of patient/client care
• Evaluation is a planned systematic activity of
comparing the current health status of a patient
with the goals and objectives which were put
in place.
• The purposes of evaluation include:
• To determine the patient’s progress
• To judge the effectiveness of the nursing
interventions and strategies

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 Key points
• Subjective data are client’s personal perceptions, often
obtained during nursing health history while objective
data are detectable by the observer
• Nursing diagnosis is a statement that describes the client’s
actual or potential responses to a health problem that the
nurse is licensed and competent to treat.
• Implementation describes a category of nursing behaviors
in which the actions are necessary for achieving the goals
and expected outcomes of nursing care initiated and
completed
• During evaluation the nurse decides if the previous steps
of the nursing process were effective by examining the
client’s response and comparing them with the behaviors 33
 Review questions
• What are guidelines for writing patients’
expected outcome?
• What are the components of nursing
diagnosis?
• What are the purposes of evaluating patients
care?

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 References
• Alexander, M. F., Fawcett, J. N., & Runciman, P. J. (2002).
Nursing practice (2nd ed.).London: Churchill Livingstone.
• Bewes, P. (2003). Surgery: A manual for rural health
workers (2nd ed.). Nairobi: AMREF.
• Black, J. M., & Hawks, J. H. (2009). Medical surgical
nursing (8th ed.). Philadelphia: W. B.Saunders.
• Brunner, L. S., & Suddath, S. D. (2009). Medical surgical
nursing (12th ed.). Philadelphia:Lippincott.
• Bunker Rosdahl, C. (1999). Textbook of basic nursing (7th
ed.). Philadelphia: Lippincott.
• Colmer, M. R. (2005). Moroney’s surgery for nurses (16th
ed.). London: Churchill Livingstone.
• Nettina, S. M. (2001). Lippincott manual of nursing practice
(7th ed.). United States:Lippincott Williams and Wilkins 35
 Assignment # 2
• In a group of two participants ,you are
required to select one patient and apply the
steps of nursing process to provide nursing
care to the selected patient.
• Submit the assignment report ,together with
the nursing care plan.

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