Nursing process

Introduction
• A process is a series of step that follow a logical
sequence. The term nursing process is widely
accepted to designate a series of steps that the
nurse take in planning and giving nursing care
• It provides a logical framework on which the
nursing care is based

Definition
Nursing process is a critical thinking
process that professional nurses use to
apply the best available evidence to
caregiving and promoting human functions
and responses to health and illness
(American Nurses Association, 2010).

• Nursing process is a systematic method of
providing care to clients.
• The nursing process is a systematic
method of planning and providing
individualized nursing care.

Purposes of nursing process
• To identify a client’s health status and
actual or potential health care problems or
needs.
• To establish plans to meet the identified
needs.
• To deliver specific nursing interventions to
meet those needs.

Characteristics of Nursing
Process
• Cyclic
• Dynamic nature,
• Client centeredness
• Focus on problem solving and decision
making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking and clinical reasoning.
• It is outcome oriented

Components of nursing process
It involves
1. assessment (data collection),
2. nursing diagnosis,
3. Goal
4. Planning/ Intervention,
5. Rational
6. implementation, and
7. evaluation.

Nursing process
1. • assessment
2. • Nursing Diagnosis
3. • Goal
4. • Planning / intervention
5. • Rational
6. • Implementation
7. • Evaluation

Definition
Assessment is the systematic and continuous
collection, organization, validation, and
documentation of data (information).

Types of assessment
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment

1. Initial nursing assessment: Performed
within specified time after admission. To
establish a complete database for
problem identification.
Eg: Nursing admission assessment
2. Problem-focused assessment : To
determine the status of a specific problem
identified in an earlier assessment.
Eg: hourly checking of vital signs of
fever patient

3. Emergency assessment: During
emergency situation to identify any life
threatening situation.
Eg: Rapid assessment of an individual’s
airway, breathing status, and circulation
during a cardiac arrest.
4. Time-lapsed reassessment: Several
months after initial assessment. To
compare the client’s current health status
with the data previously obtained.

Collection of data
• Data collection is the process of gathering
information about a client’s health status. It
includes the health history, physical examination,
results of laboratory and diagnostic tests, and
material contributed by other health personnel.

Types of Data
Two types: subjective data and objective
data.
1. Subjective data, also referred to as
symptoms or covert data, are clear only
to the person affected and can be
described only by that person.
Itching, pain, and feelings of worry are
examples of subjective data.

2. Objective data, also referred to as signs
or overt data, are detectable by an
observer or can be measured or tested
against an accepted standard. They can
be seen, heard, felt, or smelled, and they
are obtained by observation or physical
examination.
For example, a discoloration of the skin or a
blood pressure reading is objective data.

Sources of Data
Sources of data are primary or secondary.
1. Primary : It is the direct source of
information. The client is the primary source
of data.
2. Secondary: It is the indirect source of
information. All sources other than the client
are considered secondary sources. Family
members, health professionals, records and
reports, laboratory and diagnostic results are
secondary sources.

Methods of data
collection
• The methods used to collect data are
observation, interview and examination.
Observation : It is gathering data by using
the senses. Vision, Smell and Hearing are
used.
Interview : An interview is a planned
communication or a conversation
with a purpose.

• There are two approaches to interviewing:
directive and nondirective.
• The directive interview is highly
structured and directly ask the questions.
And the nurse controls the interview.
• A nondirective interview, or rapport
building interview and the nurse allows the
client to control the interview.

STAGES OF AN INTERVIEW
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing

Examination : The physical examination
is a systematic data collection method to
detect health problems. To conduct the
examination, the nurse uses techniques of
inspection, palpation, percussion and
auscultation.

Organization of data
• The nurse uses a format that organizes the
assessment data systematically. This is often
referred to as nursing health history or nursing
assessment form.

Validation of data
The information gathered during the
assessment is “double-checked” or verified
to confirm that it is accurate and complete.

Documentation of data
To complete the assessment phase,
the nurse records client data. Accurate
documentation is essential and should
include all data collected about the client’s
health status.

Introduction
• Diagnosis is the second phase of the
nursing process. In this phase, nurses use
critical thinking skills to interpret assessment
data to identify client problems.
• North American Nursing Diagnosis
Association (NANDA) define or refine
nursing diagnosis.

Definition
• The official NANDA definition of a nursing
diagnosis is:
“a clinical judgment concerning a human
response to health conditions/life processes,
or a vulnerability for that response, by an
individual, family, group, or community.”

Status/type of the Nursing
Diagnosis
The status of nursing diagnosis are actual,
health promotion and risk.
1. An actual diagnosis is a client problem
that is present at the time of the nursing
assessment.
2. A health promotion diagnosis relates to
clients’ preparedness to improve their
health condition.

• A risk nursing diagnosis is a clinical
judgement that a problem does not exist,
but the presence of risk factors indicates
that a problem may develop if adequate
care is not given.

Components of a NANDA
Nursing Diagnosis
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.

1. The problem statement describes the
client’s health problem.
2. The etiology component of a nursing
diagnosis identifies causes of the health
problem.
3. Defining characteristics are the cluster
of signs and symptoms that indicate the
presence of health problem.

Formulating Diagnostic
Statements
The basic three-part nursing diagnosis
statement is called the PES format and
includes the following:
1.Problem (P): statement of the client’s
health problem (NANDA label)
2. Etiology (E): causes of the health problem
3.Signs and symptoms (S): defining
characteristics manifested by the client.

Acute pain related
to abdominal
surgery as
evidenced by patient
discomfort and
pain scale.
Problem Etiology Signs and
symptoms
Pain Surgery of
abdomen
Pain scale
and
discomfort of
patient

Differentiating Nursing Diagnosis from
Medical Diagnosis
Nursing diagnosis Medical diagnosis
A nursing diagnosis is a statement of
nursing judgment that made by
nurse, by their education,
experience, and expertise, are
licensed to treat.
A medical diagnosis is made
by a physician.
Nursing diagnoses describe the
human response to an illness or a
health problem.
Medical diagnoses refer to
disease processes.
Nursing diagnoses may change as
the client’s responses change.
A client’s medical diagnosis
remains the same for as long
as the disease is present.

Nursing diagnosis Medical diagnosis
Ineffective breathing pattern Asthma
Activity intolerance Cerebrovascular accident
Acute pain Appendicitis
Disturbed body image Amputation

• Planning involves decision making and
problem solving.
• It is the process of formulating client goals
and designing the nursing interventions
required to prevent, reduce, or eliminate
the client’s health problems.

TYPES OF PLANNING
1. Initial Planning
2. Ongoing Planning
3. Discharge Planning

1. Initial Planning : Planning which is done
after the initial assessment.
2. Ongoing Planning : It is a continuous
planning.
3. Discharge Planning : Planning for needs
after discharge

Planning process
Planning includes;
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and
activities
• Writing individualized nursing interventions
on care plans.

Setting priorities
• The nurse begin planning by deciding
which nursing diagnosis requires attention
first, which second, and so on.
• Nurses frequently use Maslow’s hierarchy
of needs when setting priorities.

Establishing client goals/desired
outcomes
• After establishing priorities, the nurse set
goals for each nursing diagnosis. Goals
may be short term or long term.

Nursing interventions
• A nursing intervention is any treatment,
that a nurse performs to improve patient’s
health.

TYPES OF NURSING INTERVENTIONS
1. Independent interventions are those activities
that nurses are licensed to initiate on the basis
of their knowledge and skills.
2. Dependent interventions are activities carried
out under the orders or supervision of a
licensed physician.
3. Collaborative interventions are actions the
nurse carries out in collaboration with other
health team members

Writing Individualized Nursing
Interventions
• After choosing the appropriate nursing
interventions, the nurse writes them on the
care plan.
• Nursing care plan is a written or
computerized information about the
client’s care.

• Implementation consists of doing and
documenting the activities.

The process of implementation includes;
• Implementing the nursing interventions
• Documenting nursing activities

• Evaluation is a planned, ongoing,
purposeful activity in which the nurse
determines
(a)the client’s progress toward achievement
of goals/outcomes and
(b)the effectiveness of the nursing care plan.

The evaluation includes;
• Comparing the data with desired
outcomes
• Continuing, modifying, or terminating the
nursing care plan.

Nursing process

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