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• Nursing Process


  A systematic, rational method of planning and providing individualized nursing care. It is a deliberate way of thinking by the nurses using an organized, systematic framework (or structure) of interrelated activities that is a scientific problem-solving approach towards individualized dynamic and continuing interpersonal care for clients changing responses and needs.
• Process


  A series of steps or acts that lead to accomplishment of some goal or purpose
• Characteristics of the Nursing Process

  • Open and Flexible
  • Cyclic and dynamic
  • Client Centered
  • Individualized to meet the client's needs
  • Interpersonal and Collaborative
  • Planned
  • Goal-directed
  • Permits creativity
  • Emphasizes Feedback
  • Universally accepted
• ANA's Standards of Clinical Nursing

  • Assessment
  • Diagnosis
  • Outcome Identification
  • Planning
  • Implementation
  • Evaluation
• Assessment


  1. Collect data

  2. Organize data

  3. Validate data

  4. Document data
• Diagnosing


  1. Analyze data

  2. Identify health problems, risks and strengths

  3. Formulate diagnostic statement
• Planning


  1. Prioritize problem/Nursing Diagnoses

  2. Formulate goals/ desired outcomes

  3. Select nursing interventions

  4. Write nursing interventions
• Implementing


  1. Reassess the client

  2. Determine the nurse's need for assistance

  3. Implement the nursing interventions

  4. Supervise delegated care

  5. Document nursing activities
• Evaluating


  1. Collect data related to outcomes

  2. Compare data with outcomes

  3. Relate nursing actions to client goals or outcomes

  4. Draw conclusions about problem status

  5. Continue, modify or terminate client's care plan
• Subjective Data


  Data elicited and verified by the client
• Objective Data


  Data directly or indirectly observed through measurement
• Sources of Data


  • Client
  • Family and significant others
  • Client record
  • Other health care professional
• Methods of Data Collection

  • Interview
  • Observation
• Types of Nursing Diagnoses


  • Actual Diagnosis
  • Health Promotion Diagnosis
  • Risk Nursing Diagnosis
  • Syndrome Diagnosis
• Nursing Diagnosis


  A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes
• Formulating Diagnostic Statements


  • Basic two-part statement: Problem (P) and Etiology (E)
  • Basic three-part statement: Problem (P), Etiology (E), and Signs and Symptoms (S)
• Characteristics of a Well-Stated Outcome Criteria

  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time-framed
• Types of Nursing Interventions

  • Independent or Nurse-Initiated Interventions
  • Dependent or Physician-Initiated Interventions
  • Interdependent or Collaborative Interventions
• Criteria for Choosing Appropriate Intervention

  • Safe and appropriate for the client's age, health, and condition
  • 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
  • Within established standards of care
• Requirements of Implementation


  • Knowledge
  • Technical Skills
  • Communication Skills
  • Therapeutic Use of self
• Evaluation


  1. Collect data about the client's response

  2. Compare the client's response to goals and outcome criteria

  3. Analyze the reasons for the outcomes

  4. Modify care plan as needed
• Documentation


  Something that is not written is considered as not done
• Factors Affecting Respiratory Function

  • Age
  • Changes compromised by infection, physical or emotional stress, surgery, anesthesia, or other procedures
  • Chest wall, airways more rigid and less elastic
  • Drier mucous membranes
  • Increased risk of aspiration from GERD
• Environmental Factors Affecting Respiratory Function

  • Partial pressure of oxygen in the atmosphere
  • Heat- increase environmental temperature is accompanied by vasodilatation increases O2 demand
  • Pollutants
• Lifestyle Factors Affecting Respiratory Function

  • Cigarette smoking
  • Occupation
  • Sedentary life style
• Body Position


  • Upright position allows greatest ease of lung expansion
  • Lying position causes the greatest difficulty of expansion
• Activity and Exercise


  Strenuous exercise increases oxygen demand by the body and carbon dioxide production which results in increase depth and rate of respiration
• Pregnancy


  • During the last trimester of pregnancy, the pregnant uterus is large enough to displace the diaphragm upward
  • Excess weight during pregnancy increases oxygen demand and CO2 production
• Body Weight


  Protuberant abdomen displaces the diaphragm upward
• Eupnea


  Normal, effortless, noiseless breathing
• Hypoxia


  Insufficient oxygenation of tissues
• Early Signs of Hypoxia

  • Tachycardia
  • Increased rate and depth or respiration
  • Slight increase in systolic BP
• Late Signs of Hypoxia

  • Bradycardia
  • Dyspnea
  • Decreased systolic BP
  • Cough
  • Hemoptysis
• Altered Breathing Patterns


  • Rate: Tachypnea, Bradypnea, Apnea
  • Volume: Hyperventilation, Hypoventilation
  • Rhythm: Cheyne-Stokes, Kussmaul's, Apneustic, Biot's
  • Ease of Effort: Dyspnea, Orthopnea
• Hypoxemia


  Reduced oxygen level in blood
• Signs and Symptoms of Hypoxia

  • Flaring of nares
  • Substernal or intercostal retractions
  • Cyanosis
• Conditions Affecting Oxygen Transport

  • Decreased cardiac output: Congestive heart failure, Hypovolemia
• Nursing Assessment


  • Nursing history
  • Physical examination
  • Diagnostic studies
• Nursing Diagnoses


  • Ineffective Airway Clearance
  • Ineffective Breathing Pattern
  • Impaired Gas Exchange
  • Activity Intolerance
• Etiology of Other Nursing Diagnoses

  • Anxiety
  • Fatigue
  • Fear
  • Powerlessness
  • Insomnia
  • Social Isolation