THE NURSING PROCESS

Nursing Process – is a systematic, rational method of providing individualized nursing care.

 Cornerstone of the Nursing Profession
 Synonymous with the problem-solving approach for discovering the health care and nursing care needs of the
client.
 Elevated nursing from a vocation to profession.

The Nursing Process is:

Organized
Systematic
Goal-oriented Effective and efficient
Patient-centered
Humanistic Care

Purpose of Nursing Process

1. To identify the patient’s health status, actual or potential health care problems or needs.
2. To establish care plan to meet the identified needs of patient.
3. To deliver specific nursing interventions to meet patient’s needs.

Focus of Care
1. Individuals
2. Families
3. Special groups or populations
4. Communities

Phases of the Nursing Process

1. Assessment
 Collecting, validating, organizing, and recording data about the client’s health status.
 Purpose: to establish database
 Activities during assessment:
 Collection of data – gathering information about the client, considering the physical, psychological,
emotional, socio-cultural, and spiritual factors that may affect his/her health status.
1. Types of Data
 Subjective data (symptoms) – can be described by the patient experiencing it (e.g.
pain, nausea, tinnitus)
 Objective data (signs) – can be observed and measured (e.g. pallor, BP readings,
etc.)
2. Methods of Collecting Data
 Interview – planned purposeful conversation
 Observation – use of senses, use of units of measurement, physical examination,
assessment techniques, interpretation of laboratory results.
3. Sources of Data
 Primary: Patient – best source of information
- Patients who are conscious, alert, physically and mentally stable
provide the most accurate information
 Secondary: Family and significant others (primary source for infant and children)
: Health care team
: Medical records
 Verifying/validating data
 Organizing data
 Recording data

2. Diagnosing
 Process which results to diagnostic statement or nursing diagnosis.
 Act of identifying problem statement or diagnostic label (approved by NANDA).
 Analyze assessment information and derive meaning from this analysis.
 Purpose: identify client’s health care needs and to prepare diagnostic statements.
 Nursing Diagnosis
 Is a statement of a client’s actual or potential alteration of health status; uses critical thinking.
 A clinical judgment concerning a human response to health condition/life processes, or vulnerability
for that response by an individual, family, or community that a nurse is licensed and competent to
treat.
  Types of Nursing Diagnosis
1. Problem – focused nursing diagnosis – describes a clinical judgment concerning an
undesirable human response to a health condition/life process that exists in a client. There
are defining characteristics (observable assessment cues such as patient behavior, physical
signs) that support each problem-focused diagnostic judgment.
2. Risk nursing diagnosis - a clinical judgment concerning the vulnerability of a client for
developing an undesirable response to health condition/life process.
3. Health promotion nursing diagnosis - is a clinical judgment concerning a patient's motivation
and desire to increase well-being and actualize human health potential.
 Uses PES format
1. P – problem
2. E – etiology
3. S – signs and symptoms

3. Planning
 Involves determining beforehand the strategies or course of actions to be taken before the implementation
of nursing care.
 The nurse collaborates with a patient and family (as appropriate) and the rest of the health care team to
determine the urgency of the identified problems and prioritizes patient needs
 Planning requires critical thinking applied through deliberate decision making and problem solving.
 A plan of care is dynamic and changes as a patient's needs change.
 Purpose:
 To establish client’s goal and expected outcome
 To identify appropriate nursing interventions
 To direct client care activities and allow delegation of specific care activities
 To promote continuity of care
 To focus charting requirements
 Allow involvement of support people
 Establishing priorities
 Priority setting – is the ordering of nursing diagnoses or patient problems using notions of urgency
and importance to establish a preferential order for nursing interventions.
─ is a decision-making process that ranks the order of nursing diagnoses in terms of
importance to the patient.
 Establishing priorities includes the following:
1. Life – threatening situation should be given highest priority.
2. Using the principle of ABC’s (airway, breathing, circulation)
3. Consider something that is very important to the client.
4. Client with unstable condition should be given highest priority over clients with stable conditions.
5. Consider the amount of time, materials, equipment required to care for clients.
6. Actual problems take precedence over potential problems.
7. Attend to clean first before equipment.
 Setting goals and expected outcomes
 Goal – may be short-term or long-term, an educated guess, made as broad statement, about what
the client’s state will be after nursing interventions is carried out.
 Expected outcome – is the measurable change (patient behavior, physical state, or perception) that
must be achieved to reach a goal.
─ written in manner that they answer the questions who, what actions, under
what circumstances, how well, and when.
 Characteristics of a well – stated goals and expected outcomes
1. Specific. Each goal and outcome addresses only one behavior, perception, or physiological
response.
2. Measurable. Goals and expected outcomes are the standards against which to measure or
observe a patient's response to nursing care. Terms describing quality, quantity, frequency,
length, or weight allow you to evaluate outcomes precisely
3. Attainable. A goal and an outcome likely are attainable when mutually set with the patient.
This ensures that a patient and nurse agree on the direction and time limits of care
4. Realistic. To establish realistic goals, assess the resources of a patient, health care facility,
and family. Be aware of the patient's physiological, emotional, cognitive, sociocultural
potential, and the economic cost and resources available to reach expected outcomes in a
timely manner.
 5. Timed. Each goal and outcome is time limited so the health care team has a common time
frame for problem resolution. The time frame depends on the nature of the problem,
etiology, overall condition of the patient, and treatment setting.
 A short-term goal is an objective behavior or response that you expect a patient to
achieve in a short time, usually less than a week. In an acute care setting you often
set goals for over a course of just a few hours.
 A long-term goal is an objective behavior or response that you expect a patient to
achieve over a longer period, usually over several days, weeks, or months.
 Types of Interventions
 Independent Nursing interventions. Actions that a nurse initiates without supervision or direction
from others.
 Dependent Nursing Intervention. Actions that require an order from a health care provider.
 Interdependent or Collaborative Intervention. Are therapies that require the combined knowledge,
skill, and expertise of multiple health care providers

4. Implementation
 Putting the nursing care plan into action.
 Purpose: Carry out planned nursing interventions to help the client attain goals and expected outcomes and
achieve optimal level of health.
 Activities: reassessing patient, setting priorities, perform nursing interventions, record actions.
 A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to
enhance patient outcomes. Nursing interventions include direct and indirect care measures aimed at
individuals, families, and/or the community.
 Direct care interventions are treatments performed through interactions with patients. For
example, a patient receives direct intervention in the form of medication administration, insertion of
a urinary catheter, discharge instruction, or counseling during a time of grief.
 Indirect care interventions are treatments performed away from a patient but on behalf of the
patient or group of patients (e.g., managing a patient's environment [e.g., safety and infection
control]), documentation, and interdisciplinary collaboration
 Implementation requirements:
 Knowledge
 Technical skills
 Communication skills
 Therapeutic use of self

5. Evaluation
 Assessing the client’s response to nursing interventions and comparing the response to predetermined
standards or outcome criteria.
 Purpose: appraise the extent to which the goals and expected outcome of nursing care have been achieved.
 The possible patient outcomes are generally explained under three terms:
 The patient’s condition improved,
 The patient’s condition stabilized, and
 The patient’s condition worsened.
 Accordingly, evaluation is the last, but if goals were not sufficed, the nursing process begins again from the
first step.

Benefit of Nursing Process for Clients

1. Quality client care
2. Continuity of care
3. Client’s participation in health care plan

Benefit of Nursing Process for the Nurse

1. Consistent and systematic nursing education
2. Job satisfaction
3. Professional growth
4. Avoidance of legal action
5. Meeting professional nursing standards
6. Meeting standard of accredited hospitals

Access the link for supplemental idea on Nursing Process.

https://nurseslabs.com/nursing-diagnosis/