NURSING PROCES

A Lecture Presented by Wasiu

Adebowale Afolabi, RN,RNE, BScN,
PGDE, MScN,
 INTRODUCTION
The nursing process is an internationally
accepted framework for the scientific practice
of nursing care.

Its use gained legitimacy in 1973 when the

phases were included in the American Nurses
Association (ANA) standard of Nursing
practice.
 DEFINITION
The nursing process generally is defined as a
systematic problem-solving approach/framework
toward giving individualized nursing care.
NB. Although, a number of authors have defined it
in various ways.
CRITICAL THINKING IN NURSING PROCESS

It is a reflective reasoning process that guides

a nurse in generating, implementing and
evaluating approaches for dealing with:
i. client care
ii. professional concerns.
Critical thinking is essential to accurate
decision making.
 CRITICAL THINKING IN NURSING PROCESS
CONTINUED
The best attitudes that foster critical thinking
includes:
Independence
Fair mindedness
Insight to egocentricity
Intellectual humility
Intellectual courage to challenge the Status
Quo and Rituals.
 CRITICAL THINKING IN NURSING PROCESS
CONTINUED
Integrity
Perseverance
Confidence
Curiosity
PHASES OF THE NURSING PROCESS
Nursing process is a cyclical process consisting
of the five stages shown in figure 1.1.
• PHASE -1 Assessment
• PHASE -2 Diagnosis
• PHASE -3 Planning
• PHASE -4 Implementation
• PHASE -5 Evaluation
PHASES OF THE NURSING PROCESSCON
ASSESSM
ENT

EVALUATI DIAGNOS
ON IS

IMPLEME PLANNIN
NTION G
 PHASE 1 ASSESSMENT
This is the collation of data or information
necessary to:
• Identify clients problem
• Identify the strength or weakness of client
• Identify the level of knowledge the client has
concerning the health condition or situation.
• Identify required support system.
 ASSESSMENT CONTINUED
Subjective data
Objective data
METHODS OF COLLECTING HEALTH DATA
i. Directive interview
ii. Non directive questions
iii. Leading questions
iv. Neutral questions
v. Open ended questions
vi. Closed question
VII. Physical examination
VII. Laboratory investigation
 PHYSICAL EXAMINATION
A screening examination i.e. a brief review of
essential function of various body parts.
A cephalo- caudal process is best so as not to miss
out any part and information.

• Observation
• Palpation
• Auscultation
• Percussion
 LABORATORY INVESTIGATION
All results should be checked and information
used as guide for care plan
• Scientific imaging results
• Hematology
• Serology
 ASSESSMENT CONTINUED
WHAT TO DO WITH DATA COLLECTED
a) Organize data
b) Validate data
c) Document data
 PHASE 2 –NURSING DIAGNOSIS
• Critically look at the data and Analyze
• Identify and list health problems
• Formulate diagnostic statements
• Nursing diagnosis = problems + its etiology or
cause (if known)
• The Problem. The first element of the nursing
diagnosis is the identified problem that the
patient is experiencing or may experience.
 NURSING DIAGNOSIS CONTINUED
Key components of a nursing diagnosis:
• Is a statement of a client’s problem
• Refers to a health problem
• Is based on objective and subjective assessment
data
• Is a statement of nursing judgement
• Is a short concise statement
• Consists of a two-part or three-part statement
• Is a condition for which a nurse can independently
prescribe care
• Can be validated with the client
 TYPES OF NSG. DIAGNOSES
There are five types of diagnoses/problems.
• Actual diagnosis
• A risk nursing diagnosis
• A wellness diagnosis
• A possible nursing diagnosis
• A syndrome nursing diagnosis
 TYPES OF NSG. DIAGNOSES CONTD.
1. Actual: a problem that is experienced or
perceived by the client, one that is occurring
in the “here and now.” This type of problem is
validated by the presence of defining
characteristics or signs and symptoms.
• Examples: Alteration in nutrition, less than
body requirement.
• Ineffective airway clearance related to
incisional pain
TYPES OF NSG. DIAGNOSES CONTD
2. Risk/High Risk: a problem which may develop in
the future due to the presence of certain risk
factors; and altered state which may occur
unless specific nursing actions are ordered and
implemented.
This type of problem is validated by risk factors.
• Examples: Risk for fluid volume deficit related to
prolonged vomiting.
• Risk for impairment of skin integrity related
immobility.
 TYPES OF NSG. DIAGNOSES CONTD.

3. Possible: a problem which may exist, but

additional data is needed to confirm its
presence; “possible” alerts the nurse the need
for further data collection.
• Example: Possible self-care deficit related to IV
in right hand.
 TYPES OF NSG. DIAGNOSES CONTD.
4. Wellness: is a change from a certain level of
wellness to a higher level of wellness. To have this
type of diagnosis two items should be present:
(1) an increased desire for greater wellness, and
(2) Effective level of function should be present.
• The diagnostic statement will begin with “Potential
for Enhanced” or” Readiness for Enhanced.”
• These diagnoses focus on a client’s healthy
responses or strengths; therefore they do not
include “related to” factors.
• Example: Readiness for Enhanced Family Processes.
 TYPES OF NSG. DIAGNOSES CONTD.
5. Syndrome: this type of diagnosis is a combination
or group of actual or high-risk nursing diagnoses
that all relate to a certain event or situation. This
tells the nurse there is a serious clinical situation
present.
• These diagnoses are usually one-part statements
that actually include the etiology and contributing
factors in the actual diagnostic statement
• Example: Rape Trauma Syndrome
• Disuse Syndrome
 BASIC TWO-PART
PROBLEM RELATED FACTOR ETIOLOGY

constipation Related to Prolonged laxative use

Severe anxiety Related to Threat to physiologic

integrity: cancer or H.I.V
positive confirmation report
 BASIC THREE-PART DIAGNOTIC
STATEMENT
PROBLEM RELATED TO-r/t ETIOLOGY AS MANIFESTED BY- a.
m. B (SIGNS
&SYMPTOMS)

Situational low –Self- r/t Feelings of a. m. b

Esteem rejection by spouse Hypersensitivity to
criticism, refused
positive feedback
 PHASE 3- PLANNING
Planning is determining the approach to be sued in the
assisting the client toward optimal wellness.
It is deciding which actions will be used to help solve,
lessen, or minimize the effects of the identified
problems, or to prevent potential problems.

There are four essential steps in the planning process:

1. Prioritizing the identified nursing diagnoses.
2. Developing goals/outcome statements.
3. Planning nursing actions.
4. Documentation-the Nursing Care Plan
 PLANNING CONTD.
Prioritizing
After nursing diagnoses have been formulated, they must be
ranked in order of priority.
• Priority nursing diagnoses are the most urgent or
immediate needs of the patient, and may be considered
life-threatening.
• These priorities can be either physical or psychological in
nature.
• Examples: Ineffective breathing pattern related to effects
of anesthesia. (Physical)
• Ineffective coping related to unknown medical diagnosis.
(Psychological)
 PLANNING CONTD
Developing Goal/Outcome Statements
• The second step in the planning phase is to
establish goal/expected outcome statements for
nursing diagnoses and collaborative problems.
• The terms “goal,” “expected outcome,” “desired
outcome,” “predicted outcome,” and “objective”
are used interchangeably to describe a desired
change in the client’s health status or functioning.
• It is the statement of a client behavior that would
demonstrate reduction, resolution, or preventions
of the problem identified in the nursing diagnosis
 PLANNING CONTD.
• Client goals directly measure a client’s progress,
and therefore the effectiveness of the nursing
care plan.
• The goal and the expected outcome(s) are often
connected by the phrase “as evidenced by.”
• Example: The patient will be free of pain by the
fourth postoperative day as evidenced by the
patient states he has no pain.
 PLANNING CONTD.
Planning Nursing Action
• Planning nursing interventions for specific nursing
diagnoses means determining the actions or activities
which will achieve the expected outcome.
• The nursing interventions identify what the nurse is to
do to reduce, resolve, or prevent each of the problems
expressed in the nursing diagnoses.
• The first step in planning nursing interventions is to
examine the second element of the nursing diagnosis
statement. This phrase identifies the etiological
factors: cause, contributing factors, or risk factors.
 Planning Nursing Action Contd.
Examples: Potential impairment of skin integrity related to
prolonged bedrest.
• Once the etiological factors have been identified. You
should proceed to how these are recognized by the nurse,
by stating the “as evidenced by” part of the statement.
This actually identifies the signs and symptoms present,
when there is actual client problem.
• Example: Impaired skin integrity related to prolonged
bedrest as evidenced by red sacral pressure point.
• After the etiological factors have been identified, you
should proceed to determine nursing interventions or
actions which would eliminate the factors or minimize
their effects.
 PLANNING CONTD.
Documentation-the Nursing Care Plan
The Nursing care Plan is a written direction for
action based on the nursing diagnosis, so that
nurses who care for clients can accomplish
care consistently.
The institutional NCP (specifically for use by
nursing students) consists of five columns.
 The Nursing Care Plan contd.
Nursing Objective(s) Nursing orders Scientific Evaluation
Diagnosis principles/Rati
onale
Imbalanced Client will gain -Weigh Client -Weighing will Client gained !
Nutrition:Less 1kg body daily. assist in Kg of body
than body weight within 1 -Give and monitoring weight within 1
requirement week record progress week.
related to sore nutritious diet -Nutritious diet
mouth as given will replace
evidenced by worn out
weight loss of tissues thereby
1kg/week increases
weight
 PHASE 4-IMPLEMENTATION
• This is the clinical practice phase where plan is executed
• Nursing interventions may include any of the following:
1. Directly performing an activity for a client.
2. Assisting the client as he/she performs an activity.
3. Observing or supervising the client as he/she
independently performs an activity.
4. Teaching the client and/or family.
5. Counseling the client (or family).
6. Monitoring or assessing the client for potential
complications of illness..
 PHASE-5 EVALUATION
• Evaluation of the nursing process can be defined
as the planned, systematic comparison of the
client’s health status with the goals/expected
outcomes.
• It is an ongoing activity, done on a day-to-day
basis, which involves the client, the RN, and other
health team members
• Evaluation is a necessary, continuous process that
measures the quality, appropriateness, and
effectiveness of both the plan of care and the care
actually given to the client.
 DOCUMENTATION IN NURSING PROCESS

• When interventions are completed, you must

document the care appropriately, noting the
specific actions along with the client’s response.
• Documentation is essential in monitoring the
client’s progress toward achievement of
goals/expected outcomes, and to assure
continuity of care.
• Documentation of nursing care is a legal
requirement of all health care systems
 REFERENCES
• Berman A, Snyder SJ, Kozier B and Erb Glenora
(2008). Kozier and Erb’s Fundamentals of
Nursing. Concepts, Process and Practice, 8th
Edition, Pearson Prentice hall.

• Carpenito-Moyet, L. J. (2006) Nursing Diagnosis:

Application to Clinical Practice (10th ed.)
Philadelphia, PA: Lippincott, Williams & Wilkins.