The nursing process

OVERVIEW OF THE NURSING PROCESS

What is nursing process

 systematic framework for providing professional, quality nursing care.

 Directs the nursing activities for health promotion, health protection, disease
prevention and is uses in every practice setting and specialty.
 The cognitive pieces of critical thinking ; assumptions, inferences, and
arguments , interface with the steps of nursing process (assessing, planning ,
intervening and evaluating
HISTORICAL PERSPECTIVE

 THE TERM NURSING PROCESSWAS MENTIONED BY DIFFERENT

NURSING THEORIST: HILDEGARD PEPLAU (1955), DOROTHY JOHNSON
(1959), IDA JEAN ORLANDO (1961), ERNESTINE WIEDENBACH (1963).
 DURING THEIR TIME NURSING PROCESS IS CONSIST OF 3 STEPS ;
ASSESSMENT , PLANNING AND EVALUATION
 1967 – THE PROCESS WAS FORMALLY INTRODUCED AS A TOOL FOR
NURSING PRACTICE
 IN THE SAME YEAR 1967, YURA AND WALSH IDENTIFIED 4 STEPS;
ASSESSING PLANNING, IMPLEMENTING AND EVALUATING
HISTORICAL PERSPECTIVE

 1973 – THE ANA PUBLLISHED THE 8 STANDARDS IN NURSING

PRACTICE , THAT INCLUDED EACH STEPS PLUS THE NURSING
DIAGNOSIS.
 1953 – THE TERM NURSING DIAGNOSIS WAS FIRST USED . THE NORTH
AMERICAN NURSING DIAGNOSIS ASSOCIATION. THEY ADDED THE
NURSING DIAGNOSIS AS A NATURAL CONCLUSION AFTER THE
ASSESSMENT PHASE
 1991 – ANA MAKE REVISIONS TO INCLUDE OUTCOME
IDENTIFICATION AS SPECIFIC PART OF PLANNING PHASE
HISTORICAL PERSPECTIVE

 THE DEFINITION OF NURSING PROCESS HAD UNDERGONE

REVISIONS OVER THE YEARS AND NOW GIVE EMPHASIS ON
PROFESSIONAL ACCOUNTABILITY, MULTICULTURISM AND AGING
ISSUES
 ASSESSMENT

EVALUATION DIAGNOSIS

IMPLEMENTATION OUTCOME
IDENTIFICATION
OVERVIEW OF THE NURSING
PROCESS
 NURSING PROCESS IS A SERIES OF STEPS THAT LEAD TO THE PURPOSE OF
PROVIDING INDIVIDUALIZED, HOLISTIC, EFFECTIVE AND EFFICIENT CARE.
 EACH STEP IS BUILD UPON EACH OTHER BUT NIT LINEAR. THERE
OVELAPPING WITH THE PREVIOUS AND SUBSEQUENT STEPS.
 NURSING PROCESS IS DYNAMIC AND REQUIRES CREATIVITY, THE STPES
ARE THE SAME BUT THE APPROACH WILL DIFFERENT IN EACH CLIENT.
 NURSING PROCESS IS DESIGNED TO USE THROUGHOUT THE LIFE SPAN
AND IN VARIED SETTINGS
 NURSES BENEFIT FROM THE PROCESS; BUILD SELF CONFIDENCE , JOB
SATISFACTION, PROFESSIONAL GROWTH
 CLIENT’S BENEFIT POTENTIAL FOR GREATER PARTICIPATION IN THEIR
OWN CARE AND CONTINUITY OF QUALITY CARE.
ASSESSMENT
ASSESSMENT

 THIS IS THE FIRST STEP IN NURSING PROCESS THAT INLCUDE THE

FOLLOWING;
 COLLECTING DATA FROM A VARIETY OF SOURCES
 VALIDATING THE DATA
 ORGANIZING THE DATA
 CATEGORIZING OR IDENTIFYING PATTERNS OF DATA
 MAKING INTIAL INFERENCES OR IMPRESSIONS
 RECORDING AND REPORTING DATA
ASSESSMENT

1. SOURCES OF DATA
 PATIENT, THE PRIMARY SOURCES, THE MAJOR PROVIDER OF
INFORMATION. DONE THROUGH INTERVIEW TECHNIQUE AND
PHYSICAL EXAMINATION
 THE FAMILY, OTHER HEALTH CARE PROVIDE, MEDICAL RECORDS
AND DIAGNOSIC REPORTS
2. TYPES OF INFORMATION; SUBJECTIVE, OBJECITVE
A. SUBJECTIVE ARE DATA COMING FROM THE PATIENT’S POINTS OF
VIEW THAT INCLUDES FEELINGS, PERCEPTIONS, AND CONCERNS. THE
PRIMARY METHOD IS THROUGH INTERVIEW
ASSESSMENT

 USING THERAPEUTIC INTERVIEWING TECHNIQUES

SAMPE SUBJECTIVE INFORMATION
 “ I DRINK COFFEE FOR BREAKFAST”
 “ I HAVE HAD PAINS IN MY LEGS FOR 3 DAYS NOW.’
 “ I GO TO SLEEP EASILY EACH NIGHT , BUT I WAKE UP ABOUT 2
HOURS LATER AND CANNOT GO BACK TO SLEEP UNTIL TO GET UP IN
THE MORNING.”
B. OBJECTIVE DATA – THESE ARE OBSERVABLE AND MEASURABLE AND
OBTAINED THROUGH STANDARD ASSESSMENT DURING PHYSICAL
EXAMINATION AND DIAGNOSTIC TEST. THE PRIMARY METHOD IS PE, TO
GET INFORMATION ABOUT THE FUNCTION OF THE BODY SYSTEMS
ASSESSMENT

EX. OF OBJECTIVE INFORMATION

 T – 36.5 C, P – 100 bpm, R – 12 cpm, B/P 130/76
 BOWEL SOUNDS AUSCULTATED IN ALL4 QUADRANTS
 GAIT SLOW, HUFFLING, AND UNSTEADY
 OBJECTIVE SYMPTOMS MAY ADD TO OR VALIDATE SUBJECTIVE
INFORMATION . VALIDATION IS IMPORTANT TO AVOID OMMISSIONS AND
PREVENT MISUNDERSTANDINGS AND INCORRECT INFERENCES AND
CONCLUSION
 COLLECTING DATA FORM OTHER SOURCES MAY HELP ORGANIZE THE
INFORMATION .
 CLUSTERING DATA BY USING GORDON’S FUNCTIONAL HEALTH PATTERNS .
ASSESSMENT

 AFTER CLUSTERING ;
 THE NURSE CAN DISTINGUISH BETWEEN WHAT IS RELEVANT AND IRRELEVANT DATA
 DETERMINE IF THERE ARE GAPS IN THE DATA
 IDENTIFY THE PATTERNS OF CAUSE AND EFFECT
 USING CRITICAL THINKING , THE NURSE CAN BEGIN TO DEVELOP IMPRESSIONS OR
INFERENCES
 DATA ASSESSED MUST BE RECORDED AND REPORTED. DISTINGUISH WHICH DATA
NEEDED TO BE REPORTED IMMEDIATELY AND WHICH IS NEEDED TO BE RECORDED
ONLY.
 DATA THAT ARE DEVIATING SEVERELY FROM NORMAL NEED TO REPORTED AND
RECORDED ( RAPID HEART BEAT, DOB, HIGH LEVEL OF ANXIETY)
 ASSESSMENT DOES NOT END WITH INITIAL INTERVIEW , IT IS DYNAMIC AND
CONTINOUS
NURSING DIAGNOSIS
NURSING DIAGNOSIS

THE SECOND PHASE OF NURSING PROCESS, THAT INVOLVES FURTHER

1. ANALYSIS
(BREAKING THE WHOLE DOWN INTO PARTS THAT CAN BE EXAMINE)
2. SYNTHESIS – PUTTIN TOGETHER IN A NEW WAY
 ANA DEFINITION OF NURSING DIAGNOSIS- A CLINICAL JUDGMENT
ABOUT INDIVIDUAL , FAMILY , OR COMMUNITY RESPONSES TO
ACTUAL OR POTENTIAL HELATH PROBLEM.
 THE NURSING DX DEVELOPED PROVIDE BASIS FOR CLIENT CARE
THROUHG OUT THE REMAINING PHASE
TABLE SHOWING COMPARISON OF MEDICAL AND NURSING
DIAGNOSIS
MEDICAL DIAGNOSIS NURSING DIAGNOSIS
FOCUS IS ON THE ILLNESS , INJURY, FOCUSES ON THE REPONSES TO
OR DISEASES PROCESS ACTUAL POTENTIAL HEALTH
PROBLEM OR LIFE PROCESS
REMAIN CONSTANT UNTIL A CURE CHANGES AS THE CLIENT
IS AFFECTEC RESPONSE AND/OR THE HEALTH
PROBLEM CHANGES
IDENTIFIES CONDITIONS THE IDENTIFIES SITUATIONS IN WHICH
HEALTH CARE PRACTITIONER IS THE NURSE IS LICENSED AND
LICENSED AND QUALIFIED TO QUALIFIED TO INTERVENE.
TREAT
TYPES OF NURSING DIAGNOSIS

 ACTUAL NURSING DIAGNOSIS

 RISK NURSING DIAGNOSIS
 POSSIBLE NURSING DIAGNOSIS
 WELLNESS DIAGNOSIS
 COLLABORATIVE PROBLEM
NURSING DIAGNOSIS

 ACTUAL NURSING DIAGNOSIS- A PROBLEMS EXIST AND COMPOSED

OF THE DIAGNOSTIC LABEL , RELATED FACTOR AND SIGNS AND
SYMPTOMS.
Ex.
Impaired Skin Integrity Related to prolonged pressure on body prominences as
manifested by stage II pressure ulcer, 3cm in diameter

Deficient fluid volume related to nauseas and vomiting as manifested by dry skin
and mucous membranes and decreased oral intake
NURSING DIAGNOSIS

 RISK NURSING DIAGNOSIS – (POTENTIAL Problem)- indications that a

problem might come up even though it is not yet seen and observed. The
diagnosis level of risk for precede.
Ex. Risk for impaired skin integrity related to inability to turn self from side to side
Risk for infection related to presences of invasive lines (IV lines or indwelling
catheters)
NURSING DIAGNOSIS

 Possible nursing diagnosis – a situation where in a problem could possibly arise

unless prevention action is taken.
Ex.
Possible self-esteem disturbance related to recent retirement and relocation
Possible imbalances nutrition less than the body requirement s related to insufficient
oral intake
NURSING DIAGNOSIS

 wellness diagnosis- the client’s expression of the desire to attain a higher level of
wellness in some areas of functioning. The statement of the diagnosis is preceded
by potential for enhanced ..
Ex.
Potential for enhanced nutrition
Readiness for enhanced spiritual well-being
 Collaborative problem- physical complications assessed by the nurse
Ex.
Potential complication (PC); increased intracranial pressure
Potential complication ; hemorrage
NURSING DIAGNOSIS

 THE FOLLOWING ARE NURSING DIAGNOSIS THAT ARE LISTED

ACCORDING TO PRIORITY
 INEFFECTIVE AIRWAY CLEARANCE RELATED TO EXCESSIVE AND
THICK SECRETIONS AND PAIN SECONDARY TO SURGERY AND
INABILITY TO COUGH EFFECTIVELY; RR- 25, SHALLOW , WHEEZING.
 RISK FOR INJURY (FALLS) RELATED TO USTEADY GAIT
 IMBALANCE NUTRITION LESS THAN THE BODY REQUIREMENTS
RELATED TO NAUSEA AND VOMITING
OUTCOME IDENTIFICATION
/PLANNING
 GOAL SETTING AND PLANNING- THE THIRD STEP OF THE NURSING
PROCESS, AFTER NURSING DIAGNOSIS HAD BEEN DEVELOPED AND
CLIENT STRENGTH HAD BEEN IDENTIFIED. IT INVOLVE THE FF.
TASKS
 THE LIST OF NURSING DIAGNOSIS IS PRIORITIZES
 CLIENT CENTERED;LONG AND SHORT TEM GOALS AND OUTCOMES
ARE IDENTIFIED AND WRITTEN AND SHOULD BE DONE IN
COLLABORATION WITH THE CLIENT
 SPECIFIC INTERVETIONS ARE DEVELOPED
 THE ENTIRE PLAN IS RECORDED IN THE CLIENT’S RECORD
OUTCOME IDENTIFICATION
/PLANNING
 EXPECTED OUTCOMES ARE SPECIFIC OBJECTIVES RELATED TO THE
GOAL AND ARE USED TP EVALUATE THE NURSING INTERVENTION
(SMART)
NURSING INTERVENTION

 THE ACITIVITY THAT THE NURSE EXECUTE FOR AND WITH THE
CLIENT TO ACCOMPLISH THE GOALS
 THE NURSING INTERVENTION IS RELATED TO ACTUAL NURSING
DIAGNOSIS AND RISK FACTORS.
 NURSING INTERVETIONS CAN DEPEDNDENT AND INDEPENDENT
 NURSING INTERVENTIONS ARE INDIVIDUALIZED
EX. TURN TO SIDES, ENOCURAGE DEEP BREATHING EVERY 2 HOURS AT
0800 , 2/10
-TEACH NIPPLE CARE WHEN BREAST FEEDING AT 1000 2/11
-WEIGH CLIENT EACH VISIT
IMPLEMENTATION

 THE EXECUTION OF THE NURSING CARE PLAN

 THE NURSE MUST CONTINOUSLY ASSESS THAT CLIENT’S CONDITION
BEFORE, DURING, AND AFTER NURSING INTERVENTION
 THE NURSE MUST POSSESS PSYCHOMOTOR SKILLS, INTERPERSONAL
SKILLS, AND CRITICAL THINKING SKILLS IN PERORMING NURSING
INTERVENTION
 IT INVOLVES RECORDING AND REPORTING OF DATA
EVALUATION

 DETERMINING WHEHTER THE GOLAS HAD BEEN MET, PARTIALLY OR

COMPLETELY
 POSSIBLE REASOSN FOR NOT MEETING THE GOALS;
 DATA ON INITIAL ASSESSMENT WERE INCOMPLETE
 THE GOALS AND EXPECTED OUTCOMES ARE NOT REALISTIC
 THE TIME FRAME WAS TOO OPTIMISTIC
 THE NURSING INTERVENTIONS WERE NOT APPROPRIATE WITH THE
CLIENT