 Definition 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.
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.
 Assessment is the systematic and continuous
collection, organization, validation, and documentation
of data (information).
Types of assessment
 The four different types of assessments are:
 1. Initial nursing assessment
 2. Problem-focused assessment
 3. Emergency assessment
 4. Time-lapsed reassessment
 1.Initial nursing assessment: Performed within specified time
after admission. To establish a complete database for problem
identification.
 Eg: Nursing admission assessment
 2. 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
 3. 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.
 4. 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
 Two types: subjective data and objective data.
 1. 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.
 2. 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.
 1. Primary : It is the direct source of information. The client is the primary
source of data.
 2. 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.
 There are two approaches to interviewing: directive and
nondirective.
 The directive interview is highly structured and directly ask
the questions. And the nurse controls the interview.
 A nondirective interview, or rapport building interview and the
nurse allows the client to control the interview.
 STAGES OF AN INTERVIEW
 An interview has three major stages:
 1. The opening or introduction
 2. The body or development
 3. 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.
 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 • The official NANDA definition of a nursing diagnosis is: “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
 The status of nursing diagnosis are actual, health promotion and risk.
 1. An actual diagnosis is a client problem that is present at the time
of the nursing assessment.
 2. A health promotion diagnosis relates to clients’ preparedness to
improve their health condition.
 A risk nursing diagnosis is a clinical judgement that a
problem does not exist, but the presence of risk factors
indicates that a problem may develop if adequate care is
not given.

 Components of a NANDA Nursing Diagnosis

 A nursing diagnosis has three components:
 (1) The problem and its definition
 (2) The etiology
 (3) The defining characteristics.
 1. The problem statement describes the client’s health
problem.
 2. The etiology component of a nursing diagnosis identifies
causes of the health problem.
 3. Defining characteristics are the cluster of signs and
symptoms that indicate the presence of health problem.
 Formulating Diagnostic Statements
 The basic three-part nursing diagnosis statement is
called the PES format and includes the following:
 1. Problem (P): statement of the client’s health problem
(NANDA label)
 2. Etiology (E): causes of the health problem
 3. Signs and symptoms (S): defining characteristics
manifested by the client.
 Acute pain related to abdominal surgery as evidenced
by patient discomfort and pain scale.
 Problem - Pain
 Etiology - Surgery of abdomen
 Signs and symptoms - Pain scale and discomfort of patient
 Differentiating Nursing Diagnosis from Medical Diagnosis
 Nursing diagnosis - A nursing diagnosis is a statement of
nursing judgment that made by nurse, by their education,
experience, and expertise, are licensed to treat. Nursing
diagnoses describe the human response to an illness or a health
problem. Nursing diagnoses may change as the client’s
responses change.
 Medical diagnosis - A medical diagnosis is made by a
physician. Medical diagnoses refer to disease processes. A
client’s medical diagnosis remains the same for as long as the
disease is present.
 Nursing diagnosis - Ineffective breathing pattern ; Activity
intolerance; Acute pain;
 Medical Disturbed body image diagnosis Asthma;
Cerebrovascular accident; Appendicitis; Amputation
 Planning involves decision making and problem solving.
 It is the process of formulating client goals and designing the nursing
interventions required to prevent, reduce, or eliminate the client’s health
problems.
 TYPES OF PLANNING
 1. Initial Planning
 2. Ongoing Planning
 3. Discharge Planning

 1. Initial Planning : Planning which is done after the initial assessment.

 2. Ongoing Planning : It is a continuous planning.
 3. Discharge Planning : Planning for needs after discharge
 Planning process
 Planning includes:
 Setting priorities
 Establishing client goals/desired outcomes
 Selecting nursing interventions and activities
 Writing individualized nursing interventions on care plans.

 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.

 Establishing client goals/desired outcomes

 After establishing priorities, the nurse set goals for each nursing diagnosis.
Goals may be short term or long term.
 A nursing intervention is any treatment, that a nurse performs to improve
patient’s health.
 TYPES OF NURSING INTERVENTIONS
 1. Independent interventions are those activities that nurses are licensed to
initiate on the basis of their knowledge and skills.
 2. Dependent interventions are activities carried out under the orders or
supervision of a licensed physician.
 3. Collaborative interventions are actions the nurse carries out in
collaboration with other health team members

 Writing Individualized Nursing Interventions

 After choosing the appropriate nursing interventions, the nurse writes them on the
care plan.
 Nursing care plan is a written or computerized information about the client’s care.
 Implementation consists of doing and
documenting the activities.
 The process of implementation includes:
 Implementing the nursing interventions
 Documenting nursing activities
 Evaluation is a planned, ongoing, purposeful
activity in which the nurse determines
 (a)the client’s progress toward achievement of
goals/outcomes and
 (b)the effectiveness of the nursing care plan.
 The evaluation includes:
 Comparing the data with desired outcomes
 Continuing, modifying, or terminating the
nursing care plan.