FUNDAMENTALS OF NURSING

Week 4: The Nursing Process

A. The Nursing Process

a. a systematic, rational method of planning and providing individualized nursing care
b. purposes are to identify a client’s health status and actual or potential health care
problems or needs, to establish plans to meet the identified needs, and to deliver
specific nursing interventions to meet those needs.
c. Phases of the Nursing Process
i. Assessing, Diagnosing, Planning, Implementing and Evaluating
ii. They are not separate entities but overlapping, continuing subprocesses iii.
Each phase of the nursing process affects the others; they are closely interrelated
d. Characteristics of the Nursing Process
i. Cyclic and dynamic nature. Data from each phase provide input into the next
phase. Findings from the evaluation phase feed back into
assessment.
ii. Client centered. The nurse organizes the plan of care according to client
problems rather than nursing goals.
iii. Focus on problem solving and decision making.
iv. Interpersonal and collaborative.
e. Overview
Phase and Description Purpose Activities

ASSESSING To establish a Establish a database:

Collecting, organizing, database about the • Obtain a nursing
validating, client’s health history.
and documenting client data response to health • Conduct a physical
concerns or illness assessment.
and the ability to • Review client records.
manage health care • Review nursing
needs literature. • Consult
support persons. •
Consult health
professionals.
Update data as
needed. Organize
data.
Validate data.
Communicate/document data

DIAGNOSING To identify client Interpret and analyze

Analyzing and strengths and health
synthesizing data problems that can be
prevented
or resolved by
collaborative and
independent nursing
data: • Compare data
against
standards.
• Cluster or group data
(generate tentative
hypotheses).
• Identify gaps and

PLANNING
Determining how to
prevent, reduce, or resolve
the
identified
priority client problems;
how to
support client strengths;
and how
to implement nursing
interventions
in an organized,
individualized, and
goal-directed manner
IMPLEMENTING
Carrying out (or
delegating) and
documenting the
planned nursing
interventions
EVALUATING
Measuring the degree
to which
goals/outcomes have
been achieved
and identifying factors
that positively or
negatively
influence goal
achievement
interventions inconsistencies.
To develop a list of Determine client’s
nursing and strengths, risks, and
collaborative problems problems.
Formulate nursing
diagnoses and collaborative
problem statements.
Document nursing
diagnoses on the care plan.
To develop an Set priorities and
individualized care plan goals/outcomes in
that specifies client collaboration
goals/desired outcomes, with client.
and related nursing Write goals/desired
interventions outcomes.
Select nursing
strategies/interventions.
Consult other health
professionals.
Write nursing
interventions and nursing
care plan.
Communicate care plan
to relevant health care
providers.
To assist the client to Reassess the client to
meet desired goals/ update the database.
outcomes; promote Determine the nurse’s
wellness; prevent need for assistance.
illness and disease; Perform planned
restore health; and nursing interventions.
facilitate coping with Communicate what
altered functioning nursing actions were
implemented:
• Document care and
client responses to care.
• Give verbal reports as
necessary
To determine whether Collaborate with client
to continue, and collect data related to
modify, or terminate the desired outcomes.
plan of care Judge whether
goals/outcomes have
been achieved.
Relate nursing actions
to client
goals/outcomes.
Make decisions about
problem status.
 Review and modify the care

plan as indicated or
terminate nursing care.
Document achievement
of outcomes and
modification of the care plan.

B. Assessing
a. the systematic and continuous collection, organization, validation, and documentation of data
b. a continuous process carried out during all phases of the nursing process. c. All phases
of the nursing process depend on the accurate and complete collection of data.
d. Types of Assessment
i. Initial Assessment - To establish a complete database for problem identification,
reference, and future comparison
ii. Problem-focused Assessment - To determine the status of a specific problem
identified in an earlier assessment
iii. Emergency Assessment - To identify life-threatening problems; To identify new or
overlooked problems
iv. Time-Lapsed Assessment - To compare the client’s current status to baseline data
previously obtained
Data Collection - the process of gathering information about a client’s health status
Types of Data:
a. Subjective Data - symptoms or covert data, can be described or verified only by that
person.
b. Objective Data - signs or overt data, can be seen, heard, felt, or smelled, and they are
obtained by observation or physical examination
Sources of Data:
a. Client - the primary source of data; the best source of data unless the client is too ill,
young or confused to communicate clearly.
b. Support people - Family members, friends, and caregivers who know the client well often can
supplement or verify information provided by the client.
c. Client records - include information documented by various health care professionals;
Types of client records include medical records, records of therapies, and laboratory
records.
d. Health Care Professionals - verbal reports from other health care professionals serve as
other potential sources of information about a client’s health
e. Literature - such as professional journals and reference texts, can provide additional
information for the database

Data Collection Methods

a. Observing - gather data by using the senses. Observing is a conscious, deliberate skill that
is developed through effort and with an organized approach.
 b. Interviewing - a planned communication or a conversation with a purpose c. Examining -
The physical examination or physical assessment is a systematic data collection method that
uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health
problems

C. Diagnosing
a. In this phase, nurses use critical thinking skills to interpret assessment data and identify
client strengths and problems.
b. A nursing diagnosis provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse has accountability
North American Nursing Diagnosis Association (NANDA)
a. to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use
to professional nurses.
b. Taxonomy - a classification system or set of categories arranged based on a single
principle or set of principles
c. Nursing diagnosis - standardized NANDA names for the diagnoses: diagnostic labels +
etiology
d. 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 of the Nursing
Diagnosis
a. Actual diagnosis - a client problem that is present at the time of the nursing assessment b.
Health promotion diagnosis - relates to clients’ preparedness to implement behaviors to
improve their health condition
c. Risk nursing diagnosis - a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to develop unless nurses
intervene
d. Syndrome diagnosis - assigned by a nurse’s clinical judgment to describe a cluster of
nursing diagnoses that have similar interventions
Components of a NANDA Nursing Diagnosis
a. Problem (diagnostic label) and definition - the client’s health problem or response for
which nursing therapy is given.
i. Qualifiers - are words that have been added to some NANDA labels to give
additional meaning to the diagnostic statement, like deficient, impaired,
decreased, ineffective, compromised
b. Etiology (Related Factors and Risk Factors) - identifies one or more probable causes of the
health problem, gives direction to the required nursing therapy, and enables the nurse to
individualize the client’s care
c. Defining Characteristics - the cluster of signs and symptoms that indicate the presence of a
particular diagnostic label
d. Nursing Diagnosis vs Medical Diagnosis vs Collaborative Problems
Nursing Diagnosis Medical Diagnosis Collaborative
Problems
Example Activity Myocardial infarction Potential
Intolerance complication of
related to myocardial
decreased infarction:
cardiac output congestive
heart failure

Description Describe human Describe disease Involve human

responses and pathology; do responses—
to disease process not mainly
or health consider physiological
problem; consist of other human complications of
a one-, responses; disease, tests,
two-, or three- usually consist of or treatments;
part statement, not more than consist of a
usually including three two-part statement
problem and words of situation/
etiology pathophysiology
and the
potential complication

Orientation and Oriented to the Oriented to Oriented to

responsibility for individual; pathology; pathophysiology;
diagnosing nurses physician nurses
responsible for responsible for responsible for
diagnosing diagnosing; diagnosing
diagnosis not
within the scope
of nursing
practice

Nursing focus Treat and prevent Implement Prevent and

medical orders monitor for onset
for or
treatment and status of condition
monitor status of
condition

Nursing actions Independent Dependent (primarily)

actions,
Some
but primarily for
monitoring and
preventing

Duration Can change Remains the Present when

frequently same while disease or
disease is present situation is present
 Classification System Classification
is developed and Well-developed No universally
being used but is classification accepted
not universally system accepted classification system
accepted by the
medical profession

The Diagnostic Process

a. Analyzing Data
i. Comparing data with standards
ii. Cluster the cues
iii. Identify gaps and inconsistencies
b. Identifying health problems, risks and strengths
i. Determining problems and risks
ii. Determining strengths
c. Formulating Diagnostic Statements
i. Basic Two-Part Statements
1. Problem - statement of the client’s response (NANDA label)
2. Etiology -factors contributing to or probable causes of the responses
Example: Constipation (problem) related to prolonged laxative use
(etiology)
Anxiety (problem) related to possible cancer diagnosis (etiology)
ii. Basic Three-Part Statements
1. Problem
2. Etiology
3. Signs and symptoms
Example: Situational Low Self Esteem (problem) related to feeling of
rejection by husband (etiology) as manifested by hypersensitivity to
criticism (signs and symptoms)
iii. One Part Statements
1. Consist of NANDA label only
Example: Impaired physical mobility; Risk for infection
iv. Variations
1. Writing ‘unknown etiology’ - Noncompliance (Medication Regimen) related to
unknown etiology
2. Using the phrase ‘complex factors’ - Chronic Low Self-Esteem related to
complex factors.
3. Using the word ‘possible’ - Possible Low Self-Esteem related to loss of job
and rejection by family
4. Using ‘secondary’ - Risk for Impaired Skin Integrity related to decreased
peripheral circulation secondary to diabetes
5. Adding a second part to the general response or NANDA label - Impaired Skin
Integrity (Left Lateral Ankle) related to decreased peripheral
circulation.

v. Guidelines for writing a nursing diagnostic statement

 1. State in terms of a problem, not a need.
2. Word the statement so that it is legally advisable.
3. Use nonjudgmental statements.
4. Make sure that both elements of the statement do not say the same thing.
5. Be sure that cause and effect are correctly stated.
6. Word the diagnosis specifically and precisely to provide direction for
planning nursing intervention.
7. Use nursing terminology rather than medical terminology to describe the
client’s response.
8. Use nursing terminology rather than medical terminology to describe the
probable cause of the client’s response.

D. Planning
a. a deliberative, systematic phase of the nursing process that involves decision making and
problem solving
b. The end product of the planning phase is a client care plan.
c. Nurses do not plan for the client, but encourage the client to participate actively to the
extent possible
Types of Planning
a. Initial planning
b. Ongoing planning
c. Discharge planning
Developing Nursing Care Plans
- An informal nursing care plan is a strategy for action that exists in the nurse’s mind - A formal
nursing care plan is a written or computerized guide that organizes information about the
client’s care
- A standardized care plan is a formal plan that specifies the nursing care for groups of
clients with common needs
- An individualized care plan is tailored to meet the unique needs of a specific client
The Planning Process
a. Setting Priorities
i. Life threatening problems - high priority
ii. Health threatening problems - medium priority
iii. Normal developmental needs - low priority
b. Establishing Client Goals/Desired Outcomes
Purpose: to provide direction for planning nursing interventions, serve as criteria for
evaluating client progress, enable the client and nurse to determine when the problem has
been resolved, help motivate the client and nurse by providing a sense of achievement
i. Short term goals
ii. Long term goals
c. Components of Goal/Desired Outcome Statements
i. Subject
ii. Verb
iii. Conditions or modifiers
iv. Criterion of desired performance
d. Selecting Nursing interventions and Activities
Types of Nursing Interventions
a. Independent interventions - activities that nurses are licensed to initiate on the
basis of their knowledge and skills
b. Dependent interventions - activities carried out under the orders or supervision of a
licensed physician or other health care provider authorized to write orders to nurses
c. Collaborative interventions - actions the nurse carries out in collaboration with
other health team members, such as physical therapists, social workers,
dietitians, and primary care providers
e. Writing Individualized Nursing Interventions
i. Verb
ii. Conditions or modifiers
 iii. Time element

E. Implementing
a. the action phase in which the nurse performs the nursing interventions. b. consists of
doing and documenting the activities that are the specific nursing actions needed to carry
out the interventions
c. While implementing nursing care, the nurse continues to reassess the client at every
contact, gathering data about the client’s responses to the nursing activities and about
any new problems that may develop
Implementing Skills
a. Cognitive Skills - include problem solving, decision making, critical thinking, clinical
reasoning, and creativity. They are crucial to safe, intelligent nursing care b. Interpersonal
Skills - all of the activities, verbal and nonverbal, people use when interacting directly with
one another
c. Technical Skills - purposeful “hands-on” skills such as manipulating equipment, giving
injections, bandaging, moving, lifting, and repositioning clients. These skills are also
called tasks, procedures, or psychomotor skills
The Implementing Process
a. Reassessing the client
b. Determining the nurse’s need for assistance
c. Implementing the nursing interventions
d. Supervising the delegated care
e. Documenting nursing activities.

F. Evaluating
a. a planned, ongoing, purposeful activity in which clients and health care professionals
determine (a) the client’s progress toward achievement of goals/outcomes and (b) the
effectiveness of the nursing care plan
b. conclusions drawn from the evaluation determine whether the nursing interventions
should be terminated, continued, or changed
c. It is continuous
d. It is done while or immediately after implementing a nursing order enables the nurse to
make on the-spot modifications in an intervention
The Evaluating Process
a. Collecting data
b. Comparing data with desired outcomes - evaluation statement: conclusion + supporting data
i. The goal was met
ii. The goal was partially met
iii. The goal was not met
c. Continuing, modifying or terminating the nursing care plan

G. Documenting
a. Report - oral, written, or computer-based communication intended to convey information to
others
b. Record - a chart or client record, is a formal, legal document that provides evidence of a
client’s care and can be written or computer based
c. Recording, Charting or Documenting- the process of making an entry on a client record
Purposes of Client Records
a. Communication
b. Planning Client Care
c. Auditing health agencies
d. Research
e. Education
f. Reimbursement
g. Legal Documentation
h. Health care analysis
Documentation Systems
a. Source-Oriented Record - Each person or department makes notations in a separate
section or sections of the client’s chart; information about a particular problem is
distributed throughout the record
b. Problem-Oriented Medical Record - the data are arranged according to the problems the
client has rather than the source of the information
c. Focus Charting - intended to make the client and client concerns and strengths the focus of
care; Three columns for recording are usually used: date and time, focus, and progress
notes; (D) data, (A) action and (R) response
Documenting Nursing Activities
a. Admission nursing assessment
b. Nursing care plans
c. Kardexes
d. Flow sheets - graphic record, intake and output record, medication administration
record, skin assessment record
e. Progress notes
f. Nursing Discharge/Referral summaries
General Guidelines for Documentation/Recording
a. Date and time
b. Timing
c. Legibility
d. Permanence
e. Accepted terminology
f. Correct spelling
g. Signature
h. Accuracy
i. Sequence
j. Appropriateness
k. Completeness
l. Conciseness
m. Legal prudence

H. Reporting - to communicate specific information to a person or group of people. a.

Change of shift reports
b. Telephone reports
c. Telephone orders
d. Care plan conference
e. Nursing rounds