Nursing Process

● framework or guideline that defines the way how we manages nursing problems
● is basically a modification of the scientific process (the reason why nursing is science ,
because we utilize the scientific process)
● scientific process (input:data , data process: throughput, output:results)
● nursing process is adaptation of scientific process in a nursing situation

characteristic

- multifaceted (made up of different phases)

- the different phases but are interrelated
- the phases is progressive
- also cyclical (the end of processes, can be also the start of a process)

history of nursing process

● the first term nursing process was made, because of Ida Jean Orlando

assessment

diagnosing

planning

implementation

evaluation

6 phases

assessment

● data dependent
● 4 majors activities:
○ data collection
○ data sources: primary DS (patient)
○ secondary DS (sources other than your patient)
○ types /classification of data
■ objective
■ manifestation what you senses can see
■ overt data
■ also call signs
■ subjective
 ■ manifestation that is perceived the one who can experience the
pain
■ covert data
■ also call symptoms
■ methods
■ 4 general methods
■ observation (senses)
■ interview ( define as purposive communication)
■ phases of interview
■ pre-orientation
■ orientation (consent)
■ working (carry out the interview)
■ closed ended ( answerable by yes or
no)
■ open ended (to express , ideally)
■ termination
■ physical examination
■ Inspection (sight and touch)
■ Palpitation (touch)
■ Percussion (sound)
■ auscultation
■ directly
■ indirectly
■ Maneuver
■ olfaction
■ intuition
■ previous experience
■ primary source of action
○ data validation
■ whenever you collect data , you should always validate
○ data organizing
■ cluster the data , at your own volition
■ data analysis comes in
○ data documentation
■ in the patient’s chart

assessment is a data dependent