By: Omaimah Ali Qadhi
MSN, RN, BSN
King Saud University/School of Nursing

At the end of the class, students will be able to:
• Define the “ Nursing Process” .
•
Successfully understand the meaning of each step in the nursing process:
Assessment, Planning, Implementation, and Evaluation.
• Understand the term “ Nursing Diagnosis”.
• discriminate between nursing diagnosis and medical diagnosis.

At the end the student will be able to:
•
To determine the two types of nursing diagnosis statements and how differentiate between them.
• list the components of the Assessment step.
•
Understand and rationalize the importance of each step in the nursing process .
•
Apply the knowledge and will successfully create at least tow different nursing diagnosis using NANDA (North American Nursing Diagnosis Association).

Assessment
Diagnosis
Evaluation
Implementation
Planning

Definition : SYSTEMIC problem-solving approach to provide the nursing care, based on a theoretical and technical knowledge with a combination of effective communication skills.
Steps of Nursing process:
1.
Assessment.
2. Diagnosis.
3. Planning.
4. Implementation.
5. Evaluation.

.
•
It is DATA collection to determine the patient`s health status.
Data could be obtained from:
 Health history.

Physical assessment or examination.

Analyzing the available data.
 Utilizing the analyzed data to provide the nursing care.

Human`s needs can be assessed in different models.
Maslow`s hierarchy of human needs is one of those models.

Self
Actualization
Morality, personality,
Problem solving
Esteem: Esteem: self-esteem, confidence, achievement, respect of others and by others
Love and belonging: friendship, family, sexual intimacy
Safety: Security of Body, employment, health, family, property, resources
Physiological: breathing, food, water, sleeping, sex, homeostasis, excretion ,


Identify the problem statement or the diagnostic label.
 Identify the etiology.
 Identify the characteristic of the nursing problem.
Types of nursing diagnosis:
According to NANDA ( North American Nursing Diagnosis Association), the nursing diagnosis can be performed under two categories.
1.
Actual diagnosis : the nurse confirms an actual nursing diagnosis.
2.
Potential diagnosis or risk : the predicted complication according to the patient's vulnerability.

Nursing diagnosis
• Focuses on the response to the actual or potential health problem.
Medical diagnosis
• Focus on illness, injury, or disease by the medical physician.

1.
Problem statement or the diagnostic label this includes the actual and the potential health problem.
2.
Etiology of the cause or the influencing factor to the health problem. This can be physiological, situational, congenital, emotional, or as a result of using a medication.
3.
Characteristics of the nursing problem which are described as the signs
(subjective) and the symptoms (objectives). “ as evidenced by”
Characteristic of the problem can be categorized as:
Major
Minor

It has to be made to solving the nursing or health problem
.
•
Priorities: according to the urgency. High, intermediate, or low
•
Expected outcomes: patient`s behavior related, and the period to meet the outcomes.
• Goals: immediate and intermediate, and long term goals.
•
Nursing action: to meet the goals
Examples

= intervention = treatment.
Providing the planned care.

= re-assessment

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