NURSING PROCESS AND CARE

PLANFUNDAMENTALS OF NURSING – 1
 NURSING PROCESS

The nursing process is a deliberate, problem-solving

approach to meeting the health care and nursing needs of
patients. It involves assessment (data collection), nursing
diagnosis, planning, implementation, and evaluation, with
subsequent modifications used as feedback mechanisms
that promote the resolution of the nursing diagnoses. The
process as a whole is cyclical, the steps being interrelated,
interdependent, and recurrent.
 NURSING PROCESS

Purpose of the nursing process:

To help nurses manage care, scientifically, holistically, and

creatively.

PROBLEM SOLVING METHODS:

It helps a nurse student to learn with Trial and Error

it is considered to be the best Scientific Method

it builds the Intuitive Problem Solving way in side a nursing student

 COMPONENTS OF NURSING PROCESS

THE 5 STEPS OF THE NURSING PROCESS

1. ASSESSMENT
2. DIAGNOSING
3. PLANNING
4. IMPLEMENTATION
5. EVALUATION
THE NURSING PROCESS ALWAYS FOLLOWS THIS
CYCLE, ALTHOUGH IT TAKES VARYING AMOUNTS OF
TIME TO COMPLETE.
COMPONENTS OF NURSING PROCESS
ASSESSMENT

Collecting data is the process of gathering information about a

client’s health status.

Organizing data is categorizing data systematically using a

specified format.

Validating data is the act of “double-checking” or verifying data

to confirm that it is accurate and factual.

Documenting is accurately and factually recording data.

SUBJECTIVE DATA VS OBJECTIVE DATA
SUBJECTIVE DATA
Symptoms or covert data
Apparent only to the person
affected
Can be described only by person
affected
Includes sensations, feelings,
values, beliefs, attitudes, and
perception of personal health
status and life situations
OBJECTIVE DATA
Signs or overt data
Detectable by an observer
Can be measured or tested against
an accepted standard
Can be seen, heard, felt, or smelled
Obtained through observation or
physical examination
Copyright 2008 by Pearson Education, Inc.
SOURCES OF DATA
Primary Source
The client.

Secondary Sources

All other sources of data

Should be validated, if possible.
Sources of data are primary or secondary. The client is the primary source of data. Family
members or other support persons, other health professionals, records and reports, laboratory
and diagnostic analyses, and relevant literature are secondary or indirect sources. In fact, all
sources other than the client are considered secondary sources. All data from secondary
sources should be validated if possible

Copyright 2008 by Pearson Education, Inc.

METHODS OF DATA COLLECTION

Observing
Gathering data using the senses
Used to obtain following types of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)

Copyright 2008 by Pearson Education, Inc.

METHODS OF DATA COLLECTION

Interviewing
Planned communication or a conversation with a purpose
Used to:
Identify problems of mutual concern
Evaluate change
Teach
Provide support
Provide counseling or therapy

Copyright 2008 by Pearson Education, Inc.

METHODS OF DATA COLLECTION

Examining (physical examination)

Systematic data-collection method
Uses observation and inspection, auscultation, palpation,
and percussion
Blood pressure
Pulses
Heart and lungs sounds
Skin temperature and moisture

Muscle strength

ASSESSMENT TAKES PLACE IN ALL REALMS: PHYSICAL,

MENTAL, EMOTIONAL, CULTURAL, SPIRITUAL AND
SOCIO-ENVIRONMENTAL!!!
Copyright 2008 by Pearson Education, Inc.
EXAMPLES OF QUESTION ASKED DURING
ASSESSMENT
Name, age, gender, admitting diagnosis

Medical/surgical history, chronic illnesses

Laboratory Data/Diagnostic tests

Medications.

Allergies.
SECOND STEP-DIAGNOSIS

DIAGNOSING: USE NANDA (The North American Nursing

Diagnosis Association) as listed in your Taylor, Lillis &
Lemone text pp 263-265 and as described in detail in
your Sparks & Taylor Nsg. Diagnosis Reference Manual.
The Nursing Diagnosis Describes Only Problems That Can Be Handled By
Nurses!!!!!
The nursing diagnosis describes a human response
The nursing diagnosis differs from the medical diagnosis,
but should complement it
COMPONENTS OF A NURSING DIAGNOSIS

Problem
Etiology
Defining characteristics
WRITING THE NURSING DIAGNOSIS: IN 3
STEPS
1. THE PROBLEM STATEMENT(NANDA) ie: Constipation
2. THE ETIOLOGY (CAUSE OF THE PROBLEM)ie:Related to
(R/T) low residue diet and lack of exercise
3. THE EVIDENCE FOR THE
PROBLEM:As evidenced by(AEB)no stool for five days
Putting it all together: Constipation, R/T low
residue diet & lack of exercise AEB no stool for
five days
THIRD STEP -GOAL

GOALS MUST BE REALISTIC (in terms of the client’s potential for

achieving them & the nurse’s ability to help the client achieve
them.)
GOALS SERVE AS GUIDES IN SELECTING NURSING INTERVENTIONS.
Planning is always done on the basis of goals which has to be achieved.
EXPECTED OUTCOMES (GOALS) MUST ALWAYS BE DATED OR TIMED!!!

GOALS ARE ALWAYS STATED BEGINNING WITH “CLIENT WILL”

ie: By Sept. 17, client will state what high fiber foods he prefers
By Sept. 18, client will eat one high fiber food with each meal
By Sept. 17, client will walk length of hall tid with assistance
FOURTH STEP-PLANNING

PLANNING (TO END, HEAL OR OVER-COME

THE PROBLEMS IN THE PROBLEM
STATEMENTS OF THE NURSING DIAGNOSES)
1. Establish priorities (most life threatening
or disturbing first)
2. Select and write down (in cooperation with
the client) in relation to the goals which has to
be achieved.
FIFTH STEP-NURSING INTERVENTION

NURSING INTERVENTIONS (ALSO CALLED IMPLEMENTATIONS)

NURSING INTERVENTIONS MAKE THE CLIENT GOALS COME TRUE!!
NURSING INTERVENTIONS ALWAYS ARE STATED “NURSE WILL”!!
ie: Nurse will consult with the client, dietician, and physician
regarding upgrading client’s diet to a high fiber diet.
Nurse will walk with client, assisting and supporting him, the
length of the hall tid.
IMPLEMENTATION IS THE ACTION PHASE OF THE NURSING PROCESS
(when the nurse does something with, to, or for the client)
FIFTH STEP-NURSING INTERVENTION

All actions (interventions) planned for the client

must be based on scientific principles and rationale.
Interventions are based on the least amount of
discomfort, invasion and risk for the client.
The nurse never does for the client what he can
safely and capably do for himself. (We’re not taking
them to raise; we’re usually trying to return them to
their life.)
THE LAST STEP IN INTERVENTION IS TO ACCURATELY
DOCUMENT IT!!!
FIFTH STEP-NURSING INTERVENTION

Nursing interventions require intellectual,

interpersonal and technical skills.
Intellectual skills required of the nurse include:
problem identification, and problem solving, critical
thinking, and the ability to make sound judgments.
A strong theoretical background is necessary for
these intellectual skills!
FIFTH STEP-NURSING INTERVENTION

Interpersonal skills used during nursing intervention

include: communicating, listening, conveying
interest, compassion, empathy, and
TLC. These skills are invaluable in establishing
rapport and building a therapeutic relationship.
Technical skills refer to the performance of
procedures and the use of equipment and materials
competently and proficiently.
(Practice makes perfect!)
SIXTH STEP-EVALUATION

The last phase of the nursing process is

EVALUATION. Our patient goals and nursing
actions are useless if we are not constantly
evaluating whether or not they are making any
headway in returning the client to health and
functioning.
EVALUATION MEASURES THE DEGREE TO WHICH THE
NURSING PROCESS HAS BEEN SUCCESSFUL.
EVALUATION MEANS WE REASSESS AT EACH STEP TO
ASSURE EFFECTIVENESS AND ACCURACY.
SIXTH STEP-EVALUATION

Common evaluation outcomes:

1. Client responded as expected, problem is
solved, goals effective
2. Client’s problem has not been resolved,
even though expected outcomes were
accomplished.
EXAMPLE

Question:- Sanaa is a 24 year old girl came to emergency room

with complaint of fever, lethargy, nausea and constipation from 5
days. She also mentioned that she is not able to smell or taste
anything since 3 days. On examination Her blood pressure is
100/70 mm hg, temperature is 39.8 degree Celsius ,her pulse is
100.
 EXAMPLE -ASSESSMENT

ASSESSMENT DIAGNOSIS GOAL PLANNING INTERVENTION EVALUATION

SUBJECTIVE: -lethargy
Nausea, constipation from 5
days No smell and no taste
from 3 days OBJECTIVE: -
Blood pressure: -100/70
Temperature: -39.8 Pulse -
100
 EXAMPLE -DIAGNOSIS

ASSESSMENT DIAGNOSIS GOAL PLANNING INTERVENTION EVALUATION

SUBJECTIVE: -
lethargy Nausea,
constipation from 5
days No smell and
no taste from 3 days
OBJECTIVE: - Alteration in
Blood pressure: - comfort
100/70 related to
Temperature: -39.8 hyperthermia
Pulse -100
 EXAMPLE - GOAL

ASSESSMENT DIAGNOSIS GOAL PLANNING INTERVENTION EVALUATION

SUBJECTIVE: -
lethargy Nausea,
constipation from 5
days No smell and
no taste from 3 days
Alteration in
OBJECTIVE: -
Blood pressure: - comfort related Reduce body
100/70 to temperature
Temperature: -39.8 hyperthermia
Pulse -100
 EXAMPLE -PLANNING

ASSESSMENT DIAGNOSIS GOAL PLANNING INTERVENTION EVALUATION

SUBJECTIVE: -
lethargy Nausea,
constipation from 5
days No smell and Remove excessive
no taste from 3 Alteration in clothes
days Urine and blood
comfort Reduce body
OBJECTIVE: - analysis
related to temperature Give sponge bath
Blood pressure: -
100/70 hyperthermia Antipyretic
Temperature: -39.8 medicine
Pulse -100
 EXAMPLE- INTERVENTION

ASSESSMENT DIAGNOSIS GOAL PLANNING INTERVENTION EVALUATION

ASSESSMEN DIAGNOSIS GOAL PLANNING INTERVENT EVALUAT

T ION ION
SUBJECTIVE: - SUBJECTIV
lethargy Nausea, E: -lethargy
constipation from 5Nausea, Excessive clothes
Excessive
clothesand
andblankets are
days No smell and constipation
no taste from 3 Remove
Remove excessive removed
blankets are After
from the4
from 5 days removed from
clothes patient hour
days smell and Alteration
NoAlteration in
Reduce
excessive
the patient
in comfort Urine and blood PatientPatient
clothes istemperat
admitted,
OBJECTIVE: - nocomforttaste from Reduce body is
body Urine and
analysis urine
admitted, and blood
urine
Blood pressure: - 3 days
related to related to ure
temperature to is
blood analysis
temperat Give sponge bathand blood
sample sent
100/70 OBJECTIVE
hyperthermiahyperther
Give sponge
Antipyretic sent to decreas
samplelaboratory
Temperature: -39.8: - Blood ure bath
medicine laboratory
Patient is given
mia Antipyretic
Patient is given ed to
Pulse -100 pressure: -
spongesponge bath
medicine
100/70
bath 37.6
PatientPatient
is givenis given adol
Temperature: adol
-39.8 Pulse -
100
 EXAMPLE- INTERVENTION

ASSESSMENT DIAGNOSIS GOAL PLANNING INTERVENTION EVALUATION

ASSESSMEN DIAGNOSIS GOAL PLANNING INTERVENT EVALUAT

T ION ION
SUBJECTIVE: - SUBJECTIV
lethargy Nausea, E: -lethargy
constipation from 5Nausea, Excessive clothes
Excessive
clothesand
andblankets are
days No smell and constipation
no taste from 3 Remove
Remove excessive removed
blankets are After
from the4
from 5 days removed from
clothes patient hour
days smell and Alteration
NoAlteration in
Reduce
excessive
the patient
After 4 hour
Urine and blood PatientPatient
clothes istemperat
admitted,
OBJECTIVE: - nocomforttaste from in comfort
Reduce body is temperature
body Urine and
analysis urine
admitted, and blood
urine
Blood pressure: - 3 days
related to related to ure
temperature to is is decreased
blood analysis
temperat Give sponge bathand blood
sample sent
100/70 OBJECTIVE
hyperthermiahyperther
Give sponge
Antipyretic sent to decreas to 37.6
samplelaboratory
Temperature: -39.8: - Blood ure bath
medicine laboratory
Patient is given
mia Antipyretic
Patient is given ed to
Pulse -100 pressure: -
spongesponge bath
medicine
100/70
bath 37.6
PatientPatient
is givenis given adol
Temperature: adol
-39.8 Pulse -
100
THANK YOU SO MUCH FOR LISTENING