Nursing Process

By
Dr. Rasha Elauoty
Outlines:

 Introduction.

 Definition of Nursing process.

 Advantages of Nursing Process.

 Characteristics of the Nursing Process.

 Steps of Nursing Process.

Definition

• Nursing process is a deliberate

problem-solving approach for
meeting people’s health care and
nursing needs.
The common components of the
nursing process are assessment,
diagnosis, planning,
implementation, and evaluation.
Advantages 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
Steps of the Nursing Process:

 Assessment.

 Diagnosis.

 Planning.

 Implementation.

 Evaluation.
1. Assessment: (data collection)

• Assessment is systematic collection of data to

determine patient’s health status and any actual or

potential health problems.

• Assessment data are gathered through health history

and physical examination.

Type of Assessment

1. Initial assessment
• Initial assessment is performed within a specified time
after admission to a health care agency for the
purpose of establishing a complete database for
problem identification, and future comparison.
2. Problem-Focused
• Problem-focused assessment is an ongoing process
integrated with nursing care to determine the status of
a specific problem.
3. Emergency assessment
Occurs during any physiologic or psychologic crisis of the
client to identify the life-threatening problems.
4. Time-lapsed
Occurs several months after the initial assessment to
compare the client’s current status to baseline data
previously obtained.
5. Ongoing or partial/shift assessment:
Partial assessment is performed at the commencement
of every shift on every patient and the collected data is
used to develop a plan of care.
Phases of Assessment Process

 Collecting data.

 Validating (verifying) data.

 Organizing data.

 Analyze the data.

 Documenting data
1. Collecting Data:

• Data collection is "the process of gathering

information about a client’s health status “ It must be
both systematic and continuous to prevent the
omission of significant data and reflect a client‘s
changing health status
Types of data:
1. Subjective data:
• Symptoms or covert data
• Can be described only by person affected
• Includes pain, anxiety, sensations, feelings, values, beliefs, and
attitudes.
2. The objective data:
• Signs or overt data.
• Detectable by an observer.
• Can be seen, heard, felt, or smelled.
• Obtained through observation or physical examination
Methods of data collection:
1. Interviewing: Planned communication or a conversation to:
- Take a history.
- Identify problems.
- Teach patient.
- Provide support or counseling
2. Observing: Gathering data using the senses.
- Skin color (vision).
- Body or breath odors (smell).
- Lung or heart sounds (hearing).
- Skin temperature (touch).
3. Examining: ( Physical Examination)
It uses observation ,inspection, auscultation, palpation, and
percussion
Assessment techniques:
1. Inspection
• " a systematic visual examination of the patient done in a
deliberate manner".
• or "The use of sight to gather data". - Inspection should begin
with general observation of the patient progressing to specific
body areas.
2. Palpation
• Use hands to touch body parts.
• Use different parts of hands to distinguish texture, temperature
& movement.
• Hands should be warm, fingernails should be short.
• Start with light palpation and end with deep palpation.
Types of Palpation

• Light palpation.

• Deep palpation

• Bimanual Palpation
3. Percussion

• Tap body with fingertips to produce

a vibration.
• Sound determines location, size, and
density of structures.
Types of percussion
• Direct percussion.
• Indirect or mediate percussion.
• blunt percussion.
Types of sounds heard when using percussion:

 Flat – soft: e.g., thigh area.

 Dull –medium: e.g., liver.

 Resonance –loud: e.g., normal lung.

 Hyperresonance -very loud: e.g., emphysematous

lung.

 Tympany – loud: e.g. abdomen, or puffed-out cheek

4. Auscultation:

• Involves listening to sounds.

• Learn normal sounds first before identifying

abnormal or variations.

• Requires a good stethoscope, concentration and

practice.
2. Validating Data:
• Validation is "the act of ―double-checking or verifying
data to confirm that it is accurate and factual".

3. Organizing Data:
• The assessor should record data throughout the
assessment followed by formal documentation in an
organized framework using a written or computerized
format that organizes the assessment data.
 4. Analyzing Data:

• Compare data against standard and identify significant cues.

• Standard e.g. normal vital signs, standard weight and height,

normal laboratory/diagnostic values, normal growth and
development pattern.

5. Documenting Data (Reporting & Recording):

• Documentation is an important step of assessment because
it forms the database for the entire nursing process and
provides data for all the members of the health care team.
2. Diagnosis
• Diagnosis is identification of the following two types of patient
problems:

– Nursing diagnoses: Actual or potential health problems that

can be managed by independent nursing interventions

– Collaborative problems: Certain physiologic complications

that nurse monitor to detect onset or changes in status.

• After completion of the health history and physical assessment,

nurses organize, analyze, synthesize, and summarize the data
collected and determine the patient’s need for nursing care.
Cont’

• Actual Diagnosis

- Problem present at the time of the assessment

- Presence of associated signs and symptoms

- Ex.: (ineffective breathing pattern).

• Risk Diagnosis
- Problem does not exist and presence of risk factors
Cont’
Components of a Nursing Diagnosis
- Problem
- Etiology
- Signs and symptoms (Defining characteristics)
Problem Statement (Diagnostic Label):
- Describes the client’s health problem or response.
• Etiology (Related Factors and Risk Factors):
- Identifies one or more probable causes of the health problem
Defining Characteristics:
- Cluster of signs and symptoms indicating the presence of a
particular diagnostic label (actual diagnoses).
 3. Planning
• Once the nursing diagnoses have been
identified, the planning component of the
nursing process begins.
• This phase involves the following steps:

1. Setting priorities to the nursing diagnoses

• most critical problems receiving the highest
priority.
• Maslow hierarchy of needs provides one
framework for prioritizing problems, with
importance being given first to physical
needs
2. Specifying expected outcomes, immediate, intermediate, and
long term goals of nursing action.

• Determine goals (immediate, intermediate, and long-term).

Goals are patient-centered and (SMART): Specific,
Measurable, Attainable, Relevant, Time Bound.

 Immediate goals are those that can be attained within a short

period. Intermediate and long-term goals require a longer time
to be achieved and involve preventing complications and other
health problems and promoting self-care and rehabilitation.
For example:
Nursing diagnosis of
• Impaired physical mobility related to pain and edema
following total knee replacement may be stated as
follows:
• Immediate goal: Stands at bedside for 5 minutes 6 to 12
hours after surgery.
• Intermediate goal: Ambulates with walker or crutches in
hospital and home.
• Long-term goal: Ambulates independently each day
3. Identifying specific nursing interventions
appropriate for attaining outcomes.

• Interventions should identify the activities needed and who will

implement them. Determination of interdisciplinary
(interdependent) activities is made in collaboration with other
health care providers as needed.

• The nurse identifies patient teaching as needed to assist patient

in learning certain self-care activities.
4. Documenting

Nursing diagnoses, collaborative problems, expected

outcomes, nursing goals, and nursing interventions on
the plan of nursing care.

5. Communicating to appropriate personnel any

assessment data that point to health care needs that
can best be met by other members of the health care
team.
4. Implementation

• Is actualization of plan of care through nursing interventions

• Nurse assumes responsibility for implementation and

coordinates activities of all those involved in implementation,
including patient and family, and other members of health care
team, so that the schedule of activities facilitates the patient’s
recovery.

• While implementing nursing care, nurse continually assesses

patient and his or her response to nursing care.
Examples of nursing interventions

• Promoting physical and psychological comfort.

• Supporting respiratory and elimination functions.

• Facilitating ingestion of food, fluids, and nutrients.

• Managing patient’s immediate surroundings; providing

health teaching.

• Promoting a therapeutic relationship.

• Carrying out a variety of therapeutic nursing activities.

5. Evaluation

• Evaluation, the final step of the nursing process, allows nurse

to determine patient’s response to nursing interventions and
the extent to which the outcomes have been achieved. The
plan of nursing care is the basis for evaluation.

• The nursing diagnoses, collaborative problems, priorities,

nursing interventions, and expected outcomes provide the
specific guidelines that dictate the focus of the evaluation.
 Example of Nursing Care Plane:
PT Problem PT Outcom Nursing Rational Evaluation
intervention
Problem: Patient will be  Assess pt  To evaluate The pt be come
Comfort free from pain health status the pt status free from pain
alteration (chest & level of
pain)related to pain.
chest infection  Divert pt
Subjective data: attention
Pt verbalize about pain.
suffering from  Assure the pt
pain about his pain
Objective data:
Change in vital
signs
Facial expression
Thank you

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