UNIT 5: THE NURSING PROCESS STUDY GUIDE

ASSESSMENT AS THE FIRST STEP OF NURSING PROCESS

Assessment is the first step and involves critical thinking skills and data collection; subjective
and objective. Subjective data involves verbal statements from the patient or caregiver.
Objective data is measurable, tangible data such as vital signs, intake and output, and height
and weight. Data may come from the patient directly or from primary caregivers who may or
may not be direct relation family members. Friends can play a role in data collection.
Electronic health records may populate data in and assist in assessment. Critical thinking
skills are essential to assessment, thus the need for concept-based curriculum changes.
Depending on the patient, the unit that the patient is admitted into and the specialty of the
unit, the nursing assessment could be extremely comprehensive, or it could focus on just one
bodily system or condition. The RN may choose to delegate some of the information-
gathering tasks to a more junior nursing assistant. This could include charting vital signs or
electrocardiograms.
The information that the nurse collates can be collected from various sources. Interaction
with the patient is essential during the assessment phase. The nurse should talk to the patient
and conduct an interview with the patient to ensure their medical history is complete. This
should include family history and past medical events. Nurses should use their core values of
patience and understanding to maximize the likelihood of finding out relevant information.
While the nurse is conducting the interview, this is also a good opportunity to be making
general observations. The nurse may perform a physical examination or reference the exam
as performed by a physician.
The idea underlying this part of the process is to identify what is abnormal compared to what
is normal for the patient. It is easier to treat problems if they are recognized earlier on in the
process. Attention to detail and critical thinking skills are essential skills to use during this
phase as they allow the nurse to identify issues and prioritize the treatments that the patient
requires. This is especially important if the patient has compounded problems with more than
one critical issue that requires an intervention such as medication or other treatment.
TYPES AND SOURCES OF DATA COLLECTION
There are 2 types of data:
 Subjective data:
1. These are the symptoms of a health condition. E.g., stomach pain.
2. These are oblique cues.
3. It contains the client’s thoughts and statements about his health
condition.
4. It is supplied by client in the form of an interview or a written document.
5. Although the nurse attempts to do so by using objective data, it is not
always possible to validate data (e.g., pain, nauseated feeling,
hallucination)
 Objective data:
1. These are the signs regarding a health problem
2. These are obvious hints.
 3. It is gained by the use of senses (vision, touch, hearing, smell) as
well as measurement instruments (thermometers) and laboratory
research. E.g., Blood group or diagnostic procedures like
endoscopy
4. Others can verify or authenticate the data gathered. E.g., body
rashes, heart rates, blood pressure, bowel sounds.
There are two types of sources of data:
 Primary sources:
Client: Unless the client is too unwell or confused to offer objective data, the client is
the finest sources of information. He offers the most up to date information on
healthcare requirements, lifestyle habits, current and previous illness, and symptom
perception.
 Secondary sources:
1. Family and Significant Others: Client information can be given by someone
who spends much time with him or her. Similarly, client information can be
supplemented by someone who knows the client well. For newborns, severly
ill, intellectually impaired, and unconscious clients, they are major source of
knowledge.
2. Health care team: Every member of the healthcare team is a potential
information source. They can recognize and convey data from many sources,
as well as verify information.
3. Records: Medical records (previous health patterns, immunizations), records
of other providers therapies, laboratory records, and other documents offer and
can validate information.
4. A nurse’s review of books and maintaining up to date is critical since it gives
new information.
METHODS OF DATA COLLECTION
Data can be collected by the following 3 methods:
o Observation: The five senses are used to collect data
o Interview: A method of communicating with the client in order to obtain
information, identify problems, and assess changes to instruct, to help, or to
counsel.
o Examination: Systemic data collection, physical examination procedures, and
interpretation of test results are all used to detect health issues. Physical
examination should be carried out in the following order:
 Cephalocaudal approach: head to toe assessment
 Body system approach: examine all the body systems
 Review of system approach: examine only particular area
affected.
DIFFERENCE BETWEEN MEDICAL AND NURSING DIAGNOSIS
MEDICAL DIAGNOSIS NURSING DIAGNOSIS
Focuses on identifying disease It focuses on finding human responses
 E.g., two human beings may have same E.g., Two human beings with the same
disease disease may have different response to the
disease.
It stays the same as long as the disease is It may change from day to day as human
present. response changes from day to day as one
E.g., Patient diagnosed with a case of heart day patient might be diagnosed by nurse as
disease will have same diagnosis throughout “Anxiety related to examination”
hospitalization. Once the examination was over, client
anxiety levels automatically decreased.
Treatable by physicians within scope of Treatable by nurses within scope of nursing
medical practice. practice.
It deals with the actual pathophysiologic It deals with patient’s perception of his own
changes within the body. health state.
Nurses are obliged to carry out physician’s Nursing diagnosis refers to as nurses’
prescribed therapies and treatments. It independent function
means they have dependent function. e.g., Ineffective airway clearance
e.g., pneumonia

STEPS OF NURSING CARE PLAN

Planning is an essential part of the nursing process in which a nurse applies critical thinking
skills and evidence-based practice to outline the appropriate interventions and goals in caring
for patients. Each nursing care plan is tailored to every individual patient, based on their
subjective and objective data. There are different models that can be used to create a nursing
care plan, and one of the most commonly used models is the ADPIE, which stands for:
Assessment, Diagnosis, Planning, Interventions, and Evaluation.
Step 1: Assessment
Assessment is all about collecting and collating all related patient information in order to
create a sound nursing diagnosis. The Assessment phase is divided into two subgroups: the
subjective data and the objective data. The subjective data are dependent on the patient’s
thoughts, actions, and feelings, and are usually composed of:
Patient’s verbalization / chief complaint, e.g. “My stomach is so painful.”
Pain level on a 0 to 10 scale with 10 being the highest, and 0 being the lowest
Behavior, e.g. refusal to eat; guarding sign on the affected area
Feelings, e.g. “I’m stressed with these watery stools.”
Perceptions, e.g. “I think I am not taking the anti-diarrheal drug properly.”
On the other hand, the objective data are based on measurable aspects of the condition of the
patient, such as:
Vital signs and general appearance
Diagnostic test results
Physical examination, e.g. cold, clammy skin, capillary refill of 4 seconds
Assessment tools, e.g. type 6 watery stools based on the Bristol stool chart
It is important to note that all the data that you will put in the Assessment section of your
nursing care plan are precise, brief, and are all able to support your nursing diagnosis.

Step 2: Diagnosis
A nursing diagnosis summarizes all the relevant patient data into one statement that answers
the question, “What is the problem with the patient?”. This directs the nurse to the type and
level of care that the patient requires. The formula of a nursing diagnosis is:
Diagnostic label + Related or secondary factor + Evidence = Nursing Diagnosis
Here’s an example:
Diagnostic Label: “Ineffective Airway Clearance”
Related factor: “related to pneumonia”
Evidence: “as evidenced by productive cough, shortness of breath, oxygen saturation at 91%
on room air”
The North American Nursing Diagnosis Association (NANDA) is an organization that
provides standardized nursing diagnoses widely used in many clinical areas across the globe.

Step 3: Planning

The planning section involves your goals or desired outcomes to resolve the nursing
diagnosis or the patient’s problem. The desired outcomes can be divided into long-term goals
and short-term goals. An example of a long-term goal for Ineffective Airway Clearance is:
“The patient will maintain a patent airway.” One of the short-term goals can be: “Within 4
hours, the patient will have an oxygen saturation of at least 96% on room air.” Each goal
should SMART: short and specific, measurable, achievable, realistic, and time-bound.

Step 4: Intervention

This step involves the nursing actions and rationale, or the reason for doing each nursing
intervention. The nursing interventions include what and when to assess and monitor in terms
of patient’s vital signs and diagnostics, the nursing actions required (e.g. medication,
suctioning, oxygen therapy, dressing changes) fluid and dietary requirements, mobility, as
well as patient education and support. Each nursing intervention should be precise and should
be backed up by a factual rationale to briefly explain why such intervention or action is
needed. For example:
Intervention: Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is
above the target range, or as ordered by the physician.
Rationale: To increase the oxygen level and achieve an SpO2 value within the target range.

Step 5: Evaluation

Evaluation is the final step in the nursing care plan where in you can set parameters to check
if the desired outcomes and goals are fully met, partially met, or unmet. This shows whether
the nursing actions are effective, need modifications, or require to be stopped and changed. If
a goal is partially met or unmet, then it is crucial to re-visit the nursing diagnosis, re-think
about the goals, and change some of the nursing interventions. Here’s an example:
Evaluation: Goal met, as evidenced by patient’s increase of saturation levels from 92% to
96% on room air.

STEPS IN PLANNING
1. SETTING PRIORITIES: Priority is something that takes precedence in position, and
considered the most important among several items. Priority setting is a process of
establishing a preference order for nursing strategies.
Priorities are classified as:
High priorities: The nursing diagnosis if not treated may causse more harm to the
client who has these priorities.
E.g., Ineffective airway clearance related to major abdominal surgery
Intermediate priorities: Nursing diagnosis involves the non-emergent, non-life-
threatening needs of the patient.
e.g., pain related to surgical procedure.
Low priorities: Low priority nursing diagnosis are client’s needs which may not be
directly related to specific illness or prognosis.
e.g., deficit knowledge regarding smoking cessation program.
Maslow’s Hierarchy of Needs: A nurse had been regarded more than just a giver of
health care because, besides her knowledge in medicine, she has high regard for
benevolence providing care for her patients to the best of her ability. And one of every
nurse’s important task is to look after their welfare, attending to both physiological
and psychological needs. As Maslow conceptualized this hierarchy of needs, it had
been in every nurse’s toolbox being regarded as the proper guide in conducting a
physical assessment, attending to emergency care, and in planning nursing
interventions while regarding prioritization and optimum health. Nurses consider this
in pain management as well in which only the patient’s subjective interpretation is the
only basis for how extensive the treatment should be adjusted. Considering the
hierarchy of needs by Maslow as the backbone of patient care priorities, Management
had improved remarkably. It is the only guide that addresses self-actualization, which
may be attained at different levels. It could be as simple as autonomy, independence,
and an increased range of motion after a great trauma or surgery. All of which
alleviates a person’s depressive state into embracing drive, a positive mindset, and
willingness. So, this way, both physiological and psychological aspect’s needs are
met. All in the same way, nurses are helped themselves as they give patient care.
Many times, nurses face a lack of workforce that they had to attend to more than 8
patients per shift. But as Maslow’s Hierarchy of Needs gives them enlightenment in
prioritization, nurses plan better which allows them to manage their time for their
work while imparting quality care. They realize the consequence of not eating on
time, not having adequate rest, and how exhaustion could affect a person’s ability to
do tasks. So, they make sure they find time getting some relaxation and socialization
when they can without feeling guilty, nervous, or exhausted. Maslow had been aiding
all nurses in doing their jobs efficiently. It provides overall clarity in each intervention
they perform and each patient care they provide.
2. Determining goals or expected outcomes: The next step is determining goals and
expected outcomes. Before delivering any form of nursing care, the nurse must decide
what the end point of nursing care should be. Goals are statements of expected
outcomes of nursing interventions.
Purpose of goal:
 Provide directions for planning nursing interventions that will achieve the desired
changes in the client
 Provide a time span for planned activities
 Enable the client and nurse to determine when the problem has been resolved
 Serve as criteria for evaluation of client progress towards derived outcome.
 Help motivate the client and the nurse by providing a sense of achievement.
3. Expected outcomes: Expected outcomes describe the behavior of the patient which is
expected to be achieved. It is the specific step by step objective that serves as criteria
of judging nursing interventions and client progress in the evaluation step. Outcome is
a measurable change of the client’s status in response to the nursing care. Outcome
should be related to the problem. Outcome should reflect the first half of the
diagnostic statement by identifying alternative helpful responses which are desirable
for client. Outcome should be client centered. The outcomes are written to focus on
the behavior of the client.
4. Selecting nursing strategies: Nursing strategies, interventions are the specific
approaches designed for the client to achieve expected outcomes. They are based on
the etiology and the nursing diagnosis statement., the information obtained during
assessment interview and nurses’ interaction with client and family. This involves
selecting measures that involves the person to achieve the outcomes and to resolve the
related factors in the nursing diagnosis. The specific strategies chosen should focus on
eliminating or reducing the etiology of the nursing diagnosis. These selected strategies
and measures are called nursing interventions. Nursing strategies are identified and
written during the planning step of the nursing process. However, they are actually
performed during the implementing step.
5. Developing nursing care plan: A written nursing care plan includes a nursing
diagnosis statement, goals, expected outcomes and specific nursing activities and
interventions. A nursing plan of care documents the problem-solving procedure. The
 plan is a critical element in focusing nursing activity. Nursing care plan is the written
summary of the care that a client is going to receive. It is the blueprint of the nursing
process. It is nursing centered in that the nurse remains in the scope of nursing
practice domain in treating human responses to actual or potential health problems.
Purposes of Nursing care Plan:
 It is a written guidance for client care. Nursing care olan identifies and
organizes resources used to deliver nursing care.
 It enhances the continuity of nursing care between nurses in the hospital and
community.
NURSING DIAGNOSIS
The diagnosing phase involves a nurse making an educated judgment about a potential or
actual health problem with a patient. Multiple diagnoses are sometimes made for a single
patient. These assessments not only include an actual description of the problem (e.g., sleep
deprivation) but also whether or not a patient is at risk of developing further problems. These
diagnoses are also used to determine a patient's readiness for health improvement and
whether or not they may have developed a syndrome. The diagnoses phase is a critical step as
it is used to determine the course of treatment. )A nursing diagnosis is defined as “ a clinical
judgment about an individual, family or community responses to actual and potential health
problems/life processes. Nursing diagnosis provide the basis for selection of nursing
interventions to achieve outcomes for which the nurse is accountable.” (NANDA, 2009)
Purposes of nursing diagnosis:
 To analyze collected data.
 To identify client’s normal level statement.
 To identify the client’s strengths and weaknesses.
 To formulate a diagnostic weakness.
Characteristics of nursing diagnosis:
 States and a clear and concise health problem.
 Derived from existing evidences about the client.
 It is potentially amenable to nursing therapy.
 It is the basis for planning and carrying out nursing care.
TYPES OF NURSING DIAGNOSIS
 Actual diagnosis: It represents a problem that has many defining characteristics. It is
a judgement about a client’s response to a health problem that is present at the time of
nursing assessment. It is based on presence of signs and symptoms.
Examples: Imbalanced nutrition: Less than body requirements related to decreased
appetite nausea.
 High risk diagnosis: It describes a potential problem. It means that client is prone to
develop a problem than other problems if left in similar conditions. It is a clinical
judgement that a problem does not exist therefore no signs and symptoms are present,
but the presence of risk factors indicates that a problem only is likely to develop
unless a nurse intervenes or does something about it. No subjective or objective cues
are present therefore the factors that cause the client to be more vulnerable to the
problem are the etiology of a risk nursing diagnosis
Examples: Risk for impaired skin integrity r/t surgery
 Wellness diagnosis: It is a clinical judgement about an individual family community
in transition from a specific level of wellness to a higher level of wellness
 Example: Potential for growth r/t an unexpected birth of twins.
 Syndrome diagnosis: Cluster of actual or high risk nursing diagnoses that are
predicted to be present because of certain events or situations.
Example: Rape Trauma Syndrome.
NURSING PROCESS
Nursing process is a critical thinking process that professional nurses use to apply the best
available evidence to caregiving 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.
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.
 To promote recovery from illness.
Components of nursing process
• It involves assessment (data collection), nursing diagnosis, planning, implementation, and
evaluation.
Characteristics of Nursing Process
• Cyclic
• Dynamic nature
• Client centeredness
• Focus on problem solving and decision making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking and clinical reasoning.
PURPOSES OF NURSING PROCESS
 To help the patient in maintaining health and to protect client from illness
 To identify client’s health status and to identify actual and potential health problems
 To determine priorities and to initiate or establish plans of care for meeting his needs.
 To deliver the specific nursing interventions to meet those needs and to provide an
individualized, holistic, effective and efficient nursing care.
 To promote recovery from illness and in case of terminal illness, help the client in
dying a peaceful death.
IMPORTANCE OF NURSING PROCESS
o Provides an organized and systematic method of delivering care
o Enhances quality of nursing care by avoiding omissions and duplications
o Active participation of patient and client helps or encourages him to make
decisions.
o It treats the client as a whole person where as medical treatment has focus on
treating the disease.
o Involves both client and nurse into overall plan of care.
NURSING INTERVENTION
The Oxford dictionary defines intervention as “action taken to improve or help a situation”. It
is considered a strategy or planned action to accomplish the desired outcome or goal of a
specific situation. Textbook literature defines intervention as “any treatment based upon
clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes”
(Moorhead, Johnson, Maas, & Swanson, 2018). In the nursing profession, the word
intervention refers to planned activities carried out by a nurse to ensure that a patient
complains is addressed, doctor’s orders are followed, and coordination with other members of
the health care team are in place in order to manage the care of the patient.

Nursing intervention should not be confused with the nursing assessment. Assessment is the
gathering and organizing of data in order to determine what is wrong with the patient.
Assessment activities oftentimes overlap during the intervention phase of the nursing process,
however, it does not completely focus on intervening or helping the patient’s condition. The
words assess, monitor, auscultate, check, and observe allows the nurse to identify whether a
specific patient outcome is achieved. Nonetheless, these actions do not highlight or indicate
how to achieve the outcome. In order to carry out an intervention, an example of the
appropriate words to use are administered, educate, position, and provide (Reising, 2016).
Basic Nursing Interventions
Nursing is considered a stand-alone profession. For so long, nurses have been functioning
under the shadow of doctors and following medical orders. It is still noticeable today and it
cannot be denied that nurses and doctors are still very much the key players in a patient’s
health care. However, nursing leaders are encouraging the medical profession that nurses
should be given the opportunity to work independently, if needed, and not solely depend on
the doctor’s directives.

Without a doctor’s orders, a nurse can still function and contribute to the patient’s
recuperation. In order to this, every nurse should be guided by the basic nursing interventions
that can be done to almost any type of patient in any health care setting.

Communication Skills. Nurses should pay attention to their patient’s clamors and constant
demands. It can be an ordeal sometimes to listen and talk with a patient, especially if they are
always complaining and demanding immediate attention. Then again, only by active listening
and going down to the bottom of the conversation is the only way a nurse can understand the
patient’s problem.

Promote Comfort and Alleviate Pain. Allowing the patient to experience pain is a mortal sin.
There should not be a complaint of pain nor reports that a patient is uncomfortable while he is
receiving medical care. if this happens, the nurse can assess and determine what causes the
pain and provide nursing interventions to counteract this problem. Examples of nursing
interventions include dimming the lights, position changes, offer pillow support, and
diverting the patient’s attention away from the pain sensation.

Fall Prevention. Almost all patients are candidates of fall injuries while in the hospital. In
fact, fall injuries are among the most common incidents reported in the hospital. Therefore,
nurses should always be on the look-out and critical of implementing strategies to prevent fall
injuries. For example, ensuring that the call bell is within the reach of the patient, making use
of non-skid socks if they are up and about, and be mindful of the medications that can cause
drowsiness and confusion. Patients can also benefit from putting the side-rails up for safety.
Promote Fluid Balance. All patients admitted to the hospital can dehydrate if not properly
monitored. It is SOP to initiate intravenous fluid therapy to patients who are critical and
requiring immediate medical intervention. While those who can take oral fluids, nurses
should ensure that they meet the daily requirement of fluid intake to prevent a fluid deficit.
STEPS OF IVALUATION IN NURSING PROCESS
Review direct client goals and outcome criteria: It is very important to measure the
goal attainment. Nurse will judge the attainment of goal by measuring the outcome
criteria for the planning phase.
Collect data: Subjective and objective data is collected systematically to evaluate the
goal attainment and outcome of care, Collection of data is also helpful to determine
the effectiveness of nursing care provided. Sources for collecting the subjective data
are client, family members, nursing personnel, other health care team members etc.
Sources of objective data collection are observation, medical records, physical
assessment and measurement devices etc.
Measure goal attainment: After collecting the data, the nurse forms a picture
regarding client’s behavioral response to the predetermined outcome criteria that is
the nurse compare the client’s action with predetermined goals in planning phase
Revise or modify the plan of care: Revision includes complete reassessment of the
nursing process. In this step, the nurse:
 Gathers data to determine if the new problem has arisen
 Look for all factors affecting goal attainment
 Examine the list of nursing diagnosis and set new priorities
 Reassess the accuracy and appropriateness of the framed diagnosis.
 Make goals realistic and accurate.
 Do reevaluation again
STEPS OF NURSING PROCESS
1. Assessment – It is also called data collection. Assessment is both the most basic and the
most complex nursing skill, which is at the same time both the initial step in the nursing
process and an ongoing component in every other step in the process. In order to assess well,
the five senses are being utilized to identify changes in status and in order for the nurse to
intervene appropriately.
Data collection is composed of observation of the patient, patient interview, family and
support systems, examination of the patient, and the review of medical records. Culture
consideration is given an important venue while assessing a patient and one essential skill of
assessment is the ability of the nurse to collect only relevant data. In assessment, family
relationships, support systems, food preferences, lifestyle habits and activities of daily living,
communication styles, and health care beliefs are all included as its aspects.

2. Diagnosis – It is the second step in the nursing process, and it is the phase by which the
nurse analyzes the data gathered and identifies the problem for the patient. It is the process of
data analysis, problem identification, and the formulation of nursing diagnosis.
A nursing diagnosis is a clinical judgment about the patient’s response to actual or potential
health conditions or needs. There are three types of nursing diagnoses: actual, risk, and
possible nursing diagnoses. When writing the nursing diagnosis, the nurse usually uses the
words “related to,” abbreviated as “r/t”?
Planning – The nurse develops a plan of care that prescribes interventions to attain expected
outcomes. Nursing interventions are considered activities that are planned and implemented
to help patients achieve identified outcomes. Nursing interventions are often given nursing
rationale to prove that those interventions are based on principles and knowledge integrated
from nursing education and experience as well as from behavioral and physical sciences.
Nursing interventions should be safe for the patient, be congruent with other therapies,
realistic, and consider meeting the lower level of survival needs before higher-level needs. It
is imperative too that nursing interventions meet the patient’s personal goals and values.

Implementation – It is the fifth phase in the nursing process and is consists of validating the
care plan, documenting the care plan, giving and documenting the nursing care, and
continuing data collection. It is primarily focused on working with the patient and the family
to carry out the plan of care.
This is done not only to know how the patient responds to the nursing interventions but also
to provide increased information for revising the care plan as the status of the patient
changes. The patient is an active participant in care as they are given the right to refuse or
request interventions. On the other hand, the nurse is flexible and should be open to
suggestions in changing patient and family priorities, but still committed to help promote
health, reduce and eliminate, or prevent problems.

Evaluation – It should be done continuously while care is being given and as the nurse
evaluates progress from intermediate outcomes up to discharge outcomes. Evaluating is
composed of documenting responses to interventions, evaluating the effectiveness of
interventions, evaluating outcome achievement, and reviewing the nursing care plan.
When deciding how well an outcome was met, there are three alternatives: met, partially met,
and not met. When written, an outcome evaluation statement includes if met, partially met, or
not met and actual patient behavior as evidence.
CHARACTERESTICS OF NURSING PROCESS
It is a framework that enables a nurse to give nursing care to individuals, families and
communities.
It is systematic and orderly. Each nursing activity is part of an ordered sequence of activities.
The nursing process directs each step of nursing care in a sequentially ordered manner.
It is dynamic. Each step in the nursing process flows on to the next step. In some nursing
situations, all the stages occur almost simultaneously.
It is interpersonal. Human being is always the heart of nursing. In this nurse are client-centred
and not task oriented.
The nursing process encourages nurses to work together to help clients to use their strengths
to meet all human needs. This also helps nurses to explore their own strengths and limitations
and to grow personally and professionally.
It is outcome-oriented. The client benefit from continuity of care and each nurse’s care moves
the clients closer to outcome achievement.
This process is universally applicable in all nursing situations and This can be used
throughout the life span.