Nursing Process

Definition

Nursing process is a critical thinking process that professional nurses use to apply the best
available evidence to care giving and promoting human functions and responses to health and
illness (American Nurses Association, 2010).

Nursing process is a systematic method of providing care to clients. The nursing process is a
systematic method of planning and providing individualized nursing care. This involves a
problem solving approach that enables the nurse to identify client problems and need and
plan, deliver and evaluate nursing care in an orderly scientific manner.

Purposes of nursing process

 To identify a client’s health status and actual or potential health care problems or needs.
 To establish plans to meet the identified needs.
 To deliver specific nursing interventions to meet those needs.

Advantages/Benefits of Nursing Process

 Provides individualized care

 Client is an active participant
 Promotes continuity of care
 Provides more effective communication among nurses and healthcare professionals
 Develops a clear and efficient plan of care
 Provides personal satisfaction as you see client achieve goals
 Professional growth as you evaluate effectiveness of your interventions
 Stresses the independent function of nurses
 Increases care quality through the use of deliberate actions

Benefits of using nursing process

 Continuity care
 Prevention of duplication
 Individualized care
 Standard of care increased client participation collaboration care
 Increased client satisfaction
 Increased nurse satisfaction
 Improves the image of hospital in society
 Being responsible for your actions
Characteristics of Nursing Process

 Cyclic
 Dynamic nature
 Client centered
 Focus on problem solving and decision making
 Interpersonal and collaborative style
 Universal applicability
 Use of critical thinking and clinical reasoning

Steps/Phases of nursing process

 Assessment
 Nursing Diagnosis
 Planning
 Implementation
 Evaluation

Assessment is the first step of nursing process and may be defined as collecting, organizing,
validating and documenting client data. It is the systematic and continuous collection,
organization, validation, and documentation of data (information). It is continuous process
carried out during all phases of nursing process.

During this phase, the nurse gathers information about a patient’s psychological,
physiological, sociological and spiritual status through observation, interviewing, physical
examination, health records and family members.
Types of Assessment

Different types of assessments are:

 Initial nursing assessment

 Problem-focused assessment
 Emergency assessment
 Time-lapsed reassessment

 Initial nursing assessment: Performed within specified time after admission. To

establish a complete database for problem identification. Eg: Nursing admission
assessment
 Problem-focused assessment : To determine the status of a specific problem identified
in an earlier assessment. Eg: hourly checking of vital signs of fever patient
 Emergency assessment: During emergency situation to identify any life threatening
situation. Eg: Rapid assessment of an individual’s airway, breathing status, and
circulation during a cardiac arrest.
 Time-lapsed reassessment: Several months after initial assessment. To compare the
client’s current health status with the data previously obtained.

Collection of data

Data collection is the process of gathering information about a client’s health status. It
includes the health history, physical examination, results of laboratory and diagnostic tests,
and material contributed by other health personnel

Types of Data

 Subjective data, also referred to as symptoms or covert data, are clear only to the
person affected and can be described only by that person. Itching, pain, and feelings of
worry are examples of subjective data.
 Objective data, also referred to as signs or overt data, are detectable by an observer or
can be measured or tested against an accepted standard. They can be seen, heard, felt, or
smelled, and they are obtained by observation or physical examination. For example, a
discoloration of the skin or a blood pressure reading is objective data.

Sources of Data

Sources of data are primary or secondary.

 Primary : It is the direct source of information. The client is the primary source of data.
 Secondary: It is the indirect source of information. All sources other than the client are
considered secondary sources. Family members, health professionals, records and
reports, laboratory and diagnostic results are secondary sources.

Methods of data collection

The methods used to collect data are observation, interview and examination.

 Observation : It is gathering data by using the senses. Vision, Smell and Hearing are
used.
 Interview : An interview is a planned communication or a conversation with a purpose.

Stages of an Interview

An interview has three major stages:

 The opening or introduction

 The body or development
 The closing

Examination

The physical examination

is a systematic data collection method to detect health problems. To conduct the examination,
the nurse uses techniques of inspection, palpation, percussion and auscultation.

Organization of data

The nurse uses a format that organizes the assessment data systematically. This is often
referred to as nursing health history or nursing assessment form.

Validation of data

The information gathered during the assessment is “double-checked” or verified to confirm

that it is accurate and complete

Documentation of data

To complete the assessment phase, the nurse records client data. Accurate documentation is
essential and should include all data collected about the client’s health status.

Nursing Diagnosis
Diagnosis is the second phase of the nursing process. In this phase, nurses use critical
thinking skills to interpret assessment data to identify client problems.

North American Nursing Diagnosis Association (NANDA) define or refine nursing

diagnosis.

Definition of nursing diagnosis

A clinical judgment about individual, family or community responses to the actual or

potential health/life process. Nursing diagnosis provide the basis for selection of nursing
interventions to achieve outcome for which nurse is accountable (NANDA,1997)

Purpose of Nursing Diagnosis

 To identify client strengths and health problems that can be prevented or resolved by
collaborative and independent nursing interventions
 To develop list of nursing collaborative problems

Types of Nursing diagnosis

 Formulating the nursing diagnostic statement involves

 Actual nursing diagnosis
 Risk nursing diagnosis
 Wellness diagnosis
 Possible nursing diagnosis

 An actual diagnosis is a client problem that is present at the time of the nursing
assessment. Eg: Ineffective breathing pattern and Anxiety. An actual nursing diagnosis is
based on the presence of associated signs and symptoms
 A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem may develop if adequate care is not
given. Eg: all people admitted to a hospital have some possibility of acquiring an
infection
 A wellness diagnosis “ Describes human responses to levels of wellness in an
individual, family or community that have a readiness for enhancement”.
 A possible nursing diagnosis is one in which evidence about health problem is
incomplete or unclear. A possible diagnosis requires more data to support or to refute it.

Taxonomy of Nursing Diagnosis

Human Response Pattern(9)

 Exchanging
 Communicating
 Relating
 Valuing
 Choosing
 Moving
 Perceiving
 Knowing
 Feeling
 Exchanging
 Mutual giving / receiving ; physiologic in nature
 Nutrition
 Physical regulations
 Elimination
 Circulation
 Oxygenation

 Physical integrity e.g. break in the skin etc.

 Communicating
 Convey message verbally or nonverbally.
 Impaired verbal communication
 Alteration in non-verbal communication.
 Relating
 Establishing bond or to connect with another thing, person or place.
 Socializing
 Parenting
 Sexuality
 Valuing :Assigning of relative worth; to equate importance
 Spiritual distress
 Risk for spiritual distress
 Potential for enhanced wellbeing
 Choosing: Selection of alternatives; in accordance with inclinations (attitude)
 Coping
 noncompliance
 Moving : Involves activity; ADLs, rest, recreation, feeding, growth and development etc.
 Activity intolerance
 Impaired physical mobility
 Perceiving :Involves the reception of information; to comprehend what is not open.
 Disturbance in body image, self esteem, personal identity.
 Sensory perceptual alterations
 Hopelessness
 Powerlessness
 Knowing :Involves meaning associated with information
 Knowledge deficit information
 Confusion
 Impaired memory
 Altered thought process
 Feeling :Involves subjective awareness of information; fact, event or state,
mental/physical distress.
 Pain
 Grieving
 Post trauma syndrome
 Anxiety
 Fear
Components of a NANDA Nursing Diagnosis

A nursing diagnosis has three components:

 The problem and its definition(P)

 The etiology(E)
 The defining characteristics(S)

Diagnostic Process

 Analyzing Data
 Compare data against standards (identify significant cues)
 Cluster cues(generate tentative hypotheses)
 Identify gaps and inconsistencies
 Formulating Diagnostic Statements

The basic three-part nursing diagnosis statement is called the PES format and includes the
following

• The problem statement/diagnostic label describes the client’s health problem.

• The etiology component of a nursing diagnosis identifies causes of the health
problem.
• Defining characteristics are the cluster of signs and symptoms that indicate the
presence of health problem

Types of Nursing diagnostic statements

• Actual nursing diagnosis

 Three part statement
o Diagnostic label
o Related factors
o Defining characteristics (s/s)
 Stress incontinence related to weak pelvic muscles, obesity, and gravid uterus as
evidenced by urine dribbling when coughing.
 Pain related to surgical trauma and inflammation as evidenced by grimacing and
verbal reports of pain.
 Acute pain related to abdominal surgery as evidenced by patient discomfort and pain
scale.
• Risk nursing diagnosis
 Two part statement
o Diagnostic label
o Risk factors
 Risk for infection related to surgery and immuno suppression.
 o Risk for activity intolerance related to prolonged bed rest.
• Possible nursing diagnosis
 Two part statement
o Diagnostic label
o Related factors (may be unknown)
o Possible self esteem disturbance related to unknown etiology.
o Possible impaired adjustment related to unknown etiology
• Wellness nursing diagnosis
 One part statement
o Diagnostic label
o Potential for enhanced parenting
o Potential for effective breast feeding
o Family coping potential for growth

Difference between Nursing and Medical diagnosis

Nursing diagnosis

o A nursing diagnosis is a statement of nursing judgment that made by nurse, by their

education, experience, and expertise, are licensed to treat.
o Within the scope of nursing practice
o Nursing diagnoses describe the human response to an illness or a health problem.
o Nursing diagnoses may change as the client’s responses change.

Medical diagnosis

o A medical diagnosis is made by a physician.

o Within the scope of medical practice
o Medical diagnoses refer to disease processes
o Stays the same as long as the disease is present

Diagnostic errors

Error can occur at any point in the diagnostic process:

o Data collection
o Data interpretation
o Data clustering
o Labeling
Avoiding Errors in Diagnostic reasoning

o Verify
o Build a good knowledge based and acquired clinical experience
o Have a working knowledge of what is normal
o Consult resources
o Improve critical thinking skill
o Avoid legally inadvisable statement
o Identify the problem and etiology
o Identify only one client problem in the diagnostic problem
o Make professional rather than prejudicial judgment

Planning

o Planning is a deliberate, systematic phase of the nursing process that involves

decision making and problem solving.
o Formulating clients goals and designing the nursing interventions required to prevent,
reduce or eliminate the client’s health problems.

Types of Planning

o Initial Planning: Planning which is done after the initial assessment.

o Ongoing Planning: It is a continuous planning.
 o Discharge Planning: Planning for needs after discharge

Planning includes:

o Setting priorities
o Establishing client goals/desired outcomes
o Selecting nursing interventions and activities
o Writing individualized nursing interventions on care plans.

o Setting priorities: The nurse begin planning by deciding which nursing diagnosis
requires attention first, which second, and so on. Nurses frequently use Maslow’s
hierarchy of needs when setting priorities. Priorities change as the client’s responses,
problems and therapies change. The nurse must consider a variety of factors when
assigning priorities.

o Client health values and beliefs

o Client’s priorities
o Resources available to the nurse and client
o Urgency of health problem
o Medical treatment plan
o Establishing client goals/desired outcomes: After establishing priorities, the nurse
set goals for each nursing diagnosis. Goals may be short term or long term. The terms
 goal and desire outcome are used interchangeably in the text except when discussing
and using standard language. The term goal is a broad statement about the client’s
status and desire outcome as a more specific.

Goal(broad): Improve mobility

Desired outcome(specific): Ambulate with crutches by end of the week

Purpose of desire goal/ Outcomes

o Provide direction for nursing intervention

o Serve as criteria for evaluating client progress
o Enable the client and nurse to determine when the problem has been resolve
o Help motivate the client and nurse by providing a sense of achievement

Type of goal

o Short term goal

o Long term goal

Goal are patient centered and SMART

o Specific
o Measurable
o Attainable
o Relevant
o Time Bound

Selecting Nursing intervention and activities

Three types of nursing intervention

o Independent nursing intervention (Nurse initiate)

o Dependent nursing intervention (Physician initiate)
o Interdependent or Collaborative intervention

Independent interventions are those activities that nurses are licensed to initiate on the
basis of their knowledge and skills.

Dependent interventions are activities carried out under the orders or supervision of
licensed physician.

Collaborative interventions are actions the nurse carries out in collaboration with other
health team members
Component of goal/Expected outcome

o Subject: who will achieve the goal(client)

o Verb: What action will be taken to achieve the goal(drink, sleep, verbalize, report,
identify)
o Condition or modifiers: Under what circumstanced the action will be performed

(1500ml of fluid, correct insulin dose)

Criteria of desired performance: Daily

Client drink 1500ml of fluid daily

Implementation

Implementation consists of doing and documenting the activities.

The process of implementation includes;

o Implementing the nursing interventions

o Documenting nursing activities

Implementation skill

o Cognitive skill(intellectual skills: educational or thinking process and supervisory)

o Interpersonal skills (coordinating, supportive and psychological)
o Technical skills(manipulating equipment, giving injection lifting repositioning

Process of implementation

o Reassessing the client

o Determining the nurse’s need for assistance
o Implementing the nursing intervention
o Supervising the delegated care
o Documenting nursing activities

Method of care

o Direct care method

o Indirect care method

Evaluation

Evaluation is the final step of the nursing process, is crucial to determine whether , after
application of the nursing process, the client’s condition or well-being improves. It is a
planned, ongoing, purposeful activity in which the nurse determines the client’s progress
toward achievement of goals/outcomes and the effectiveness of the nursing care plan.

The nurse applies all that is known about a client and the client’s condition, as well as
experience with previous clients, to evaluate whether nursing care was effective. The nurse
conducts evaluation measures to determine if expected outcomes are met, not the nursing
interventions.

The evaluation includes:

o Comparing the data with desired outcomes

o Continuing, modifying, or terminating the nursing care plan

Evaluation skills
 Knowledge of standards of care
  Knowledge of normal client response
 Knowledge of conceptual models & theories
 Ability to monitor effectiveness of nursing interventions
 Awareness of clinical research (match your practice at present )

Types of evaluation
 Structure evaluation – facilities
 Process evaluation – injection given but unsterile
 Outcome evaluation – activities done but patient’s behaviour not changed