Nursing Process

PREPARED BY :
Mr. Anil H. Mandalia
M.Sc. Nursing
Bhavnagar

Nursing Process
Background

n The nursing process is based

on a nursing theory developed

by Ida Jean Orlando. She
developed this theory in the
late 1950's as she observed
nurses in action. She saw
"good" nursing and "bad"
nursing.
n From her observations she

learned that the patient must be

the central character.

What is Nursing
Process ?

n Nursing process is a

systematic, rational method

of planning and providing
individualized nursing care.
n An organized sequence of

problem-solving steps used

to identify, prevent and treat
actual or potential health
problems and promote
wellness.

What is Nursing
Process ?

n The

nursing process is a
deliberate, problem
solving approach to meet
health care and nursing
needs of clients. It
involves assessment
(data collection) nursing
diagnosis, planning,
implementation and
evaluations.

What is Nursing
Process ?

n Nursing process is defined

as systematic, continuous
and dynamic methods of
providing care to clients. It
comprises series of
sequential phases built
upon the preceding step.
Each phase logically leads
to the next. As one step
leads to the next step it
results into ultimate
achievement of mutually
determined nursing
outcomes/ goals.

Characteristics

n Dynamic
n Client-centered
n Planned
n Goal-directed
n Interpersonal and collaborative
n Universally applicable
n Can focus on problems or
strengths
n Based on knowledge-requiring
critical thinking

Benefits of using the

nursing process
n Continuity of care
n Prevention of duplication

n Individualized care
n Increased client

participation
n Collaboration of care
n Standards of care

Nursing Process
Heart of Nursing
process
Nursing Process
Nursing Process

Nursing process and

critical thinking

Lets Get Started

n Nurse collects background

info from previous charts

n Ensure environment is

conducive
n Arrange seating
n Allow adequate time
n Nurse introduces self
n Identifies purpose of interview
n Ensure confidentiality of

information

n Provide for patient needs

before starting

1. Assessment
1. Assessment
n Assessment

is the
process of collecting,
validating, and
clustering data.

n The

first phase of the

nursing process, called
assessment, is the
collection of data for
nursing purposes.

Assessment
Reasons for doing
assessment:n

To establish baseline
information on the client

To determine the clients

normal function

To determine the clients

risk for dysfunction

To determine the clients

strengths

To provide data for the

diagnosis phase

Assessment
n Systemically collects,

verifies, analyzes and

communicates data
n Two step process-

Collection and Verification of

data & Analysis of data

n Establishes a data base

about client needs, health

problems, responses,
related experiences, health
practices, values. lifestyle, &
expectations

Assessment is
Assessment
n Taking health history
n Physical examination
n Observation
n Auscultation

n Palpation
n Percussion

n Review records and reports

Types of Data
n Objective

dataobservable and
measurable facts (Signs)
n Subjective datainformation that only the
client feels and can
describe (Symptoms)

Lets Exercise
Sources of data

n Primary source: Client

n Secondary source:
n Clients

family

n Reports

& Test results

n Information

in current and past

medical
n Records
n Discussions

with other health

care workers

Taking health history

Data Interpretation

n Data

clustering facilitates
recognition of patterns,
and determination of
further data that are
needed.
n Data interpretation is
necessary for
identification of nursing
diagnoses.

Validation of data

n Validation,

commonly
referred to as double
checking the information at
hand, is the process of
confirming the accuracy of
assessment data collected.
Validation assists in
verifying and clarifying
cues and inference.

Verifying data
n Double check personal

observations
n Double check equipment

n Check with experts and

team members
n Recheck out-liars
n Compare objective and

subjective data
n Clarify statements

2. Nursing Diagnosis
n Statement that describes

the clients actual or

potential response to a
health problem

n Focuses on client-centered

problems
n First introduced in the

1950s
n NANDA established in 1982
n Step of the nursing process

that allows nurse to

individualize care

2. Nursing Diagnosis
n A Nursing diagnosis is a statement
of a patient problem that is arrived
at by making inferences from the
collected data (Mundiger and
Jauron, 1975),

n Nursing diagnosis : A clinical

judgment about individual, family,
or community responses to actual
or potential health problems/life
processes.

n Nursing diagnoses provide the

basis for selection of nursing
interventions to achieve outcomes
for which the nurse is
accountable. (NANDA, March
1990).

Nursing Diagnosis
process

Differentiating Nursing
Diagnosis versus Medical
Diagnosis

Nur. Diagnosis / Med.

Diagnosis

Types of Nursing
Diagnoses
n Actual nursing diagnoses:
patient has problem
n Risk diagnoses: patient is at risk
for developing the problem
(Either begins with Risk for or
the definition will include is at
risk for)

n Wellness diagnoses: patient

functioning effectively but
desires higher level of wellness
n Others that you do not need to
know:
n Possible diagnoses
n Syndrome diagnoses
n Collaborative problems

How to write Nursing

diagnosis ?
n It is written

in a format
called PES by NANDA
(North American Nursing
Diagnosis Association1982)

n Three

parts:

nP

= Problem

nE

= Etiology

nS

= Signs and Symptoms

P = Problem
nP

stands for the Problem

is clear, concise
statement of clients
existing or potential
health problem or
unhealthful response.

n The

statement of
problem provides a clear
indication of what needs
to change.

E = Etiology
nE

stands for etiology

explaining the factors
believed to be related to
or contributing to the
health problem.

n The

related factors are

the socio-cultural,
environmental,
physiological,
psychological and
spiritual factors.

S = Signs and
symptoms
nS

refers to the signs and

symptoms identified
during assessment.

n These

signs and
symptoms form the basis
for nursing inferences
and subsequent nursing
diagnoses.
n They are recorded in the
database.

Actual diagnosis
statement
Three parts:
1 NANDA label (Problem)
2 Related factors (follows
NANDA & linked

by the words related to)

(Etiology)
3 Defining characteristics
(follows related
factors & linked by the words
as manifested
by) (Signs and Symptoms)

Nursing Diagnosis
Example :1
n Ineffective

Airway
Clearance related to
fatigue as evidenced by
dyspnea at rest

= Problem
= Etiology
= Signs and symptoms

Nursing Diagnosis
Example :2
n Acute

pain related to
surgical trauma and
inflammation, as
evidenced by grimacing
and verbal reports of
pain.
= Problem

= Etiology
= Signs and symptoms

Nursing Diagnosis
Example :3
n Impaired

Physical
Mobility r/t muscle
weakness AMB limited
ROM
= Problem
= Etiology
= Signs and symptoms

NURSING CARE
PLAN
3. Planning
n Planning is the third phase

of nursing process. This

phase begins after the
formulation of the diagnostic
statement and concludes
with actual documentation
of the plan of care.

n The

planning of nursing
care occurs in three
phases: initial, ongoing,
and discharge.
n Each type of planning
contributes to the
coordination of the
clients comprehensive
plan of care.

Initial planning

n Initial planning involves

development of beginning of
care by the nurse who
performs the admission
assessment and gathers the
comprehensive admission
assessment data. Initial
planning is important in
addressing each prioritized
problem, identifying
appropriate client goals, and
correlating nursing care to
hasten resolution of the
clients problems.

Ongoing
planning
n Ongoing

planning
entails (means)
continuous updating of
the clients plan of
care. Every nurse who
cares for the client is
involved in ongoing
planning.

Discharge
planning
n

Discharge
planning involves
critical anticipation
and planning for
the clients needs
after discharge.

Critical elements of
planning
n Establishing

priorities

n Setting

goals and
developing expected
outcomes (outcome
identification)

n Planning

nursing
interventions (with
collaboration and
consultation as needed)

n Documenting

Establishing
priorities

n The

establishment of
priorities is the first
element of planning. In
establishing priorities,
the nurse examines the
clients nursing
diagnoses and ranks
them in order of
physiological or
psychological
importance.

n Maslows Hierarchy of

Needs is a useful method

for setting priorities

n Priorities are classifies as

high, intermediate, or low

2. Establishing Goals
and Expected
Outcomes

n The

purposes of setting
goals and expected
outcomes are to provide
guidelines for
individualized nursing
interventions and to
establish evaluation
criteria to measure the
effectiveness of the
nursing care plan. A goal
is an aim, an intent, or an
end.

n A goal

is a broad or
globally written
statement describing the
intended or desired
change in the clients
behavior, response, or
outcome.
n An expected outcome is
a detailed, specific
statement that describes
the methods through
which the goal will be
achieved.

n Goals should be established

to meet the immediate, as

well as long-term prevention
and rehabilitation, needs of
the client.
n A short-term goal is a

statement written in
objective format
demonstrating an
expectation to be achieved
in resolution of the nursing
diagnosis in a short period
of time, usually in a few
hours or days.

nA

long-term goal is a
statement written in
objective format
demonstrating an
expectation to be
achieved in resolution
of the nursing
diagnosis over a
longer period of time,
usually over weeks or
months.

Characteristics
of goals
Client-centered
n Measurable
n Realistic
n Accompanied by a
target date
n

Example 1

n NURSING DIAGNOSIS:

Disturbed Sleep Pattern

Goal: Client will sleep
uninterrupted for 6 hours.
n EXPECTED OUTCOMES

Client will request back

massage for relaxation.
Client will set limits to
family and
significant
other visits.

INTERVENTION
n Interventions are selected after
goals and outcomes are
determined

n Actions designed to assist client

in moving from the present level
of health to that which is
described in the goal and
measured with outcome criteria
n Utilizes critical thinking by
applying attitudes and standards
and synthesizing data

Example 2
n NURSING DIAGNOSIS:

Ineffective Tissue Perfusion:

Peripheral
Goal: Client will have
palpable peripheral
pulses in 1 week.

n EXPECTED OUTCOMES

Client will identify three

factors to
improve
peripheral circulation.
Clients feet will be warm
to touch.

n Nursing

interventions
are treatment, based
upon clinical judgment
and knowledge that a
nurse performs to
enhance patient /
client outcomes.
3. Planning Nursing
Interventions

n Once

the goals have

been mutually agreed
on by the nurse and
client, the nurse
should use a decisionmaking process to
select appropriate
nursing interventions.

Implementation
(Doing .)
n The fourth step in the

Nursing Process

n This is the Doing step

n Carrying out nursing

interventions (orders)
selected during the planning
step
n This includes monitoring,

teaching, further assessing,

reviewing NCP,
incorporating physicians
orders and monitoring cost
effectiveness of
interventions
n Utilize NIC as standard

Types of Interventions

n Nurse-Initiated
n Physician-Initiated
n Collaborative Interventions

OR we can say.
n Independent ( Nurse

initiated )- any action the

nurse can initiate without
direct supervision
n Dependent ( Physician

initiated )-nursing actions

requiring MD orders

n Collaborative- nursing

actions performed jointly

with other health care team
members

EVALUATION
n Evaluation is the measurement
of the degree to which
objectives are achieved.
n Evaluation is done primarily to
determine whether a client is
progressingthat is,
experiencing an improvement in
health status.

n Evaluation is not an end to the

nursing process, but rather an
ongoing mechanism that
ensures quality interventions.

PURPOSES OF
EVALUATION
n To determine the clients
progress or lack of progress
toward achievement of expected
outcomes
n To determine the effectiveness
of nursing care in helping clients
achieve the expected outcomes
n To determine the overall quality
of care provided

n To promote nursing
accountability

METHOD OF
EVALUATION
n Establishing standards

(goals)
n Collecting data
n Determining goal

achievement
n Relating nursing actions to

client status
n Reassessing the clients

status
n Modifying the plan of care

SUMMERIZATION
n Process evaluation

measures nursing actions

by examining each phase of
the nursing process to
determine the effectiveness
of the actions in helping
clients meet expected
outcomes and goals.