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The Nursing process

Shurouq Qadose


The nursing process generally is defined as a systematic problem- solving approach toward

giving individualized nursing care.

OR The nursing process is a systematic method that directs the nurse and patient as together they accomplish the following:

(1) Assess the patient to determine the need for nursing care; (2) determine nursing diagnoses for actual and potential health problems; (3) identify expected outcomes and plan care; (4) implement the care; and (5) evaluate the results.


The six phases of the nursing process are assessment, diagnosis, out come identification, planning,

implementation, and evaluation.

Nursing Assessment

The first phase of the nursing process, called

assessment, is the collection of data for nursing

purposes. Information is collected using the skills of observation, interviewing, physical examination, and intuition and from many sources, including clients, their family members or significant others, health records, other health team members.

Reasons for doing assessment:-

  • - To establish baseline information on the client

  • - To determine the client’s normal function

  • - To determine the client’s risk for dysfunction

  • - To determine the client’s strengths

  • - To provide data for the diagnosis phase

Preparing for assessment


Time frame

us assessment

Status determination of a specific problem identified during previous assessment.

Ongoing process, integrated wit nursing care, a few minutes to a hours between assessments.

rgency assessment

Identification of life threatening situation

AT anytime

- Setting and environment

Assessment can take place in any setting

where nurses care for clients and their

family members: in the client’s home, at a

clinic, in a hospital room.

Assessment skills

1- Observation

Comprises more than the nurse’s ability to see the

client, nurses also use the senses of smell, hearing,

touch, and, rarely, the sense of taste. Observation includes looking, watching, examining. Observation

begins the moment the nurse meets the client. It is a

conscious, deliberate skill that is developed through efforts and with an organized approach. Observation has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the data.

Observation done in the following order:

Clinical signs of client distress.

Threats to the client’s safety, real or anticipated.

The presence and functioning of associated equipment.

The immediate environment, including the people in it.

2- Interviewing

Is a planned communication or a conversation

with a purpose, for example to get or give

information, identify problems of mutual concern, evaluate change, teach, provide

support. There are two approaches to

interviewing, directive and nondirective.

The directive interview is highly structured and elicits specific information. The nurse

establishes the purpose of the interview and

controls the interview. The client responds to questions but may have limited opportunities

to ask questions or discuss concerns. The nondirective interview or rapport-building interview, by contrast the nurse allows the

client to control the purpose, subject matter,

and pacing.

3- Physical examination techniques

Is a systematic data collection method that uses

the senses of sight, hearing, smell, and touch to detect health problems. Four techniques are

used: inspection, palpation, percussion, and auscultation

- Inspection

Is visual examination of the client that is done in a methodical and deliberate manner. The client

is observed first from a general point of view

and then with specific attention to detail. Effective inspection requires adequate lighting

and exposure of the body parts being observed.

- Palpation

Uses the sense of touch to assess texture, temperature, moisture, organ location and size,

vibrations and pulsations, swelling, masses,

and tenderness. Palpation requires a calm,

gentle approach and is used systematically,

with light palpation preceding deep palpation

and palpation of tender areas performed last.

- Percussion

Uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs.

It is used for assessing the density of structures

or determining the location and the size of organs in the body.

- Auscultation

Involves listening to sounds in the body that are

created by movement of air or fluid. Areas most often auscultated include the lungs, heart, abdomen, and blood vessels.

4- Intuition

Use of insight, instinct, and clinical experience

to make clinical judgments about the client.

Intuition plays a role in the nurse’s ability to

analyze cues rapidly, make clinical decisions, and implement nursing actions even though assessment data may be incomplete or ambiguous.

Assessment Activities

The activities that make up the assessment are the following:

1- Collect data

Data collection, the process of compiling

information about the client, begins with the first client contact. Nurses use observation,

interviewing, and physical examination.

Types of data:

-Subjective data also known as symptoms or covert cues include the client's feeling and

statement about his or her health problems and

are best recorded as direct quotations from the client, such as

'' Every time I move, I feel nauseated.''

- Objective data also known as signs or overt cues, are observable and measurable

(quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.

Sources of data

It can be 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

literatures are secondary or indirect sources.

2- Validate data

Validation, commonly referred to as double checking the information at hand, is the process of confirming the accuracy of assessment data collected. Validation assists in verifying and clarifying cues and inference.

Examples of cues and inferences

Example 1

Group of cues client has

  • - Blurry vision or visual defect

  • - Headache

  • - Tingling and numbness in extremities

  • - Dizziness

Possible inferences

  • - Client has a brain tumor

  • - Client is having warning signals of a stroke

  • - Client may be diabetic

  • - Client is anxious

3- Organize data

After data collection is completed and

information is validated, the nurse organizes, or clusters, the information together in order to

identify areas of strengths and weaknesses.

This process is known as data clustering. How data are organized depends on the assessment model used. One of these model is

Head to Toe model.

4- Documenting 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. To increase

accuracy, the nurse records subjective data in

the client’s own words to avoid the chance of

changing the original meaning.

Nursing Diagnosis

The second step in the nursing process involves further analysis (breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected.

According to the North American Nursing Diagnosis Association (NANDA) a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (Carroll-Johnson, 1990, p. 50).

Purposes of nursing diagnosis

- Nursing diagnosis is unique in that it focuses on a client’s response to a health problem, rather than on the problem itself, and it provides the structure through which nursing care can be delivered.

- Nursing diagnosis also provides a means for

effective communication.

- Holistic client, family, and community-focused

care are facilitated with the use of nursing


- Nursing diagnosis has an important impact on the health care delivery system

Components of a nursing


The Two-Part Statement

The components of a nursing diagnosis typically consist of two parts. The first component is a problem statement or diagnostic label. The diagnostic label is the name of the nursing diagnosis as listed in the NANDA. Some examples include stress urinary incontinence, Anxiety.

The second component of a two-part nursing diagnosis is the etiology. The etiology is the related cause or contributor to the problem. The diagnostic label and etiology are linked by the term related to (RT). Examples of nursing diagnoses are Disturbed Body Image RT loss of left lower extremity and Activity Intolerance RT decreased oxygen-carrying capacity of cells.

Descriptive words or terms may be added to clarify specific nursing diagnoses. These

descriptive words are called qualifiers and include Acute, Chronic, Decreased, Deficient,

Depleted, Disturbed, Dysfunctional, Enhanced,

Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, and Risk. These

terms specify a degree of qualification for the

identified nursing diagnosis and are placed (used) before the problem statement.

The Three-Part Statement

The nursing diagnosis can also be expressed as a

three part statement. As in the two-part

statement, the first two components are the diagnostic label and the etiology. The third component consists of defining characteristics (collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations).

In the three-part nursing diagnosis format, the

third part is joined to the first two components

with the connecting phrase ―as evidenced by‖


Differentiating Nursing Diagnosis versus

Medical Diagnosis

Nursing Diagnosis

Medical Diagnosis

- focus on unhealthy responses to health and illness.

- identify diseases

- describe problems treated by nurses within the scope of independent nursing practice.

- describe problems for which the physician directs the primary treatment .

- may change from day to day as the patient’s responses change

- remains the same for as long as the disease is present

Myocardial infarction (heart attack) is a medical


Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Knowledge Deficit, Pain, and Altered Tissue Perfusion.

Nursing Diagnosis versus Collaborative Problems

If such problems require physician prescribed and nurse prescribed action, however, they are collaborative health problems. Collaborative problems refer to actual or potential physiologic

complications that can result from disease, trauma, treatment, or diagnostic studies for which

nurses intervene in collaboration with personnel

of other disciplines.

Example 1

56-year-old mother of seven; 167 lb; ―Whenever I sneeze lately, I dribble urine. This is


Diagnostic statement

Stress Urinary Incontinence related to

degenerative changes in pelvic muscles and

structural supports associated with advanced age, obesity, gravid uterus

Select nursing responses

Teach Kegel exercises to increase muscle tone;

explore patient’s willingness and motivation to

pursue weight reduction and exercise program;

evaluate need for bladder-training program.

Example 2

42-year-old woman; 1 hour after delivery; spinal

anesthesia; 1500 mL fluid infused in past 4 hours without patient voiding; unable to void.

Diagnostic statement

Potential complication: Urinary Retention

related to fluid overload and effects of anesthesia.

Example 2

42-year-old woman; 1 hour after delivery; spinal

anesthesia; 1500 mL fluid infused in past 4 hours without patient voiding; unable to void.

Diagnostic statement

Potential complication: Urinary Retention

related to fluid overload and effects of anesthesia.

Select nursing responses

Monitor for signs of increasing urine retention;

offer bedpan, and encourage voiding with

running water, warm water dripped over perineum, and so forth; if no result, administer

physician-prescribed medication; if no result,

perform physician-prescribed catheterization.

Example 3

―Whenever I have to urinate it burns terribly. I also feel like I have to go all the timereal bad.‖ Small, frequent voidings, cloudy urine;


Diagnostic statement


Select nursing responses

Report signs and symptoms to physician; obtain urine culture; report results to physician; administer appropriate physician-prescribed antibiotic.

Types of Nursing Diagnoses

1- Actual Nursing Diagnoses

Describe a human response to a health problem that is being manifested. They are written as

three- part statements: diagnostic label, related

factors, defining characteristics.

Example Acute pain related to surgical trauma and inflammation, as evidenced by grimacing and verbal reports of pain.

Q- Which One is accurate nursing diagnosis?

1- Impaired physical mobility related to pain

2- Ineffective movement related to arthritis

2- Risk nursing diagnosis

As defined by NANDA, ’’describes human

responses to health conditions that may

develop in a vulnerable individual, family, or community. It is supported by risk factors that

contribute to increased vulnerability’’.

Risk nursing diagnoses are two part statements because they do not include defining

characteristics (diagnostic label, risk factors).

Example - Risk for infection related to surgery and immunosuppression.

Risk for aspiration related to reduced level of consciousness

Risk for Impaired Skin Integrity related to

inability to turn self from side to side in bed.

3- Wellness nursing diagnosis Is a diagnostic statement that describe the human

response to levels of wellness in an individual,

family, or community that have a potential for enhancement to a higher state (NANDA,


Wellness nursing diagnosis are one part statement includes diagnostic label.


Readiness for enhanced spiritual well being

  • - Readiness for Enhanced Self-Esteem.

Q- Which One is accurate nursing diagnosis?

1- Readiness for Enhanced Family Coping

2- Family coping potential due to desire for

better health

4- Possible Nursing Diagnoses

Is made when not enough evidence supports the presence of the problem but the nurse thinks that is highly probable and wants to collect

more information.

Possible Nursing Diagnoses are two part

statement includes diagnostic label, related factors (unknown).

Example- Possible self esteem disturbance related to unknown etiology

Q- Which One is accurate nursing diagnosis?

Adjustment impaired, possibly due to recent car

accident that resulted in quadriplegia

Possible impaired adjustment related to unknown etiology

Validate Diagnosis

For each diagnosis, the nurse should discuss with

the client the significance of the problem,

determine the client’s perception of the reason

for the problem, and ask whether the client desires help to resolve or to diminish the problem.

Nursing Planning

The third step of the nursing process includes

the formulation of guidelines that establish the

proposed course of nursing action in the resolution of nursing diagnoses and the

development of the client’s plan of care.

The planning of nursing care occurs in three phases: initial, ongoing, and discharge. Each

type of planning contributes to the

coordination of the client’s comprehensive

plan of care.

- Initial planning involves development of

beginning of care by the nurse who performs

the admission assessment and gathers the comprehensive admission assessment data. Initial planning is important in addressing each prioritized problem, identifying appropriate client goals, and correlating nursing care to

hasten resolution of the client’s problems.

  • - Ongoing planning entails continuous updating of the client’s plan of care. Every nurse who

cares for the client is involved in ongoing


  • - Discharge planning involves critical

anticipation and planning for the client’s needs

after discharge.

The four critical elements of planning include:

Establishing priorities

Setting goals and developing expected outcomes (outcome identification)

Planning nursing interventions (with collaboration and consultation as needed)


1- Establishing Priorities

The establishment of priorities is the first element of planning. In establishing priorities,

the nurse examines the client’s nursing

diagnoses and ranks them in order of physiological or psychological importance.

Various guidelines are used in the establishment

of priorities for determining which nursing diagnosis will be addressed initially.

The client’s basic needs, safety, and desires, as

well as anticipation of future diagnoses must

be considered. One of the most common

methods of selecting priorities is the

consideration of Maslow’s hierarchy of needs,

which requires that a life-threatening diagnosis

be given more urgency than a non life

threatening diagnosis.

The client must participate in the identification

of priorities so that the nature of the problem,

as well as the client’s values, are reflected in

the selected course of action.

2- Establishing Goals and Expected Outcomes

The purposes of setting goals and expected outcomes are to provide guidelines for individualized nursing interventions and to establish evaluation criteria to measure the effectiveness of the nursing care plan. A goal is an aim, an intent, or an end.

A goal is a broad or globally written statement

describing the intended or desired change in the client’s behavior, response, or outcome. An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved.

Goals should be established to meet the

immediate, as well as long-term prevention

and rehabilitation, needs of the client.

A short-term goal is a statement written in objective format demonstrating an expectation

to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a

few hours or days.

A long-term goal is a statement written in objective format demonstrating an expectation

to be achieved in resolution of the nursing diagnosis over a longer period of time, usually over weeks or months.

Guidelines for Writing Outcomes

Written outcomes can be evaluated by seeing if they conform to the following criteria:

• Each set of outcomes is derived from only one

nursing diagnosis.

• At least one of the outcomes shows a direct

resolution of the problem statement in the

nursing diagnosis.

• Both long-term and short-term outcomes are identified as necessary.

• Cognitive, psychomotor, and affective

outcomes appropriately signal the type of

change needed by the patient.

• The patient and family value the outcomes.

• Each outcome is brief and specific (clearly

describes one observable, measurable patient

behavior/manifestation), is phrased positively,

and specifies a time line.

• The outcomes are supportive of the total

treatment plan


NURSING DIAGNOSIS: Disturbed Sleep Pattern

Goal: Client will sleep uninterrupted for 6 hours.


• Client will request back massage for relaxation.

• Client will set limits to family and significant

other visits.

NURSING DIAGNOSIS: Ineffective Tissue Perfusion: Peripheral

Goal: Client will have palpable peripheral pulses

in 1 week.


• Client will identify three factors to improve

peripheral circulation.

• Client’s feet will be warm to touch.

3- Planning Nursing Interventions

Once the goals have been mutually agreed on by the nurse and client, the nurse should use a decision-making process to select appropriate nursing interventions.

Nursing interventions are treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient / client


Writing a client plan of care

Two important concepts guide a client plan of


1- The plan of care is client centered. 2- The plan of care is a step by step process. Sufficient data are collected to substantiate nursing diagnoses.

At least one goal must be stated for each nursing diagnosis

Outcome criteria must be identified for each goal

Nursing interventions must be specifically designed to meet the identified goal.

Each intervention should be supported by a scientific rationale.

Evaluation must address whether each goal was completely met, partially met, or

completely unmet.


Consists of doing and documenting the activities

that are the specific nursing actions needed to

carry out the interventions or nursing orders. The first three nursing process phases-

assessing, diagnosing, and planning-provide

the basis for the nursing actions performed during the implementing step. In turn, the

implementing phase, provide the actual

nursing activities and client responses that are examined in the final phase, the evaluating


While implementing nursing orders, the nurse

continues to reassess the client at every

contact, gathering data about the client’s

responses to nursing activities and about any new problems that may develop. To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. These skills are distinct from one another. The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity.

Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting

directly with one another, this depends on the

ability of the nurse to communicate effectively with others. It is necessary for all nursing

activities, caring, comforting, advocating, referring, counseling, and supporting others. Technical skills are hands-on skills such as manipulating equipments, giving injections and

bandaging, moving lifting, and repositioning clients. These are called procedures, tasks, or

psychomotor skills.

Process of Implementing Reassessing the client Determining the nurse’s need for assistance Implementing the nursing interventions Supervising the delegated care Documenting nursing activities

Reassess the Client, to make sure the intervention is still needed. Even though an

order is written on the care plan, the client’s

condition may have changed. The nurse also provides supportive communication to help

alleviate the client’s stress.

Determining the Nurse’s Need for Assistance,

for one of the following reasons:

The nurse is unable to implement the nursing activities safely alone

Assistance would reduce stress on the client

The nurse lacks the knowledge or skills to implement a particular nursing activities

Implementing the nursing Interventions, it is important to explain to the client what

interventions will be done, what sensations to expect, what the client is expected to do, and

what the outcome is. Ensure client privacy,

coordinate client care, and involve scheduling client contacts with other departments.

When implementing interventions, nurses should follow these guidelines:

Base nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible.

Clearly understand the order to be implemented and question any that are not understood.

Adapt activities to the individual client, a client’s beliefs, values; age, health status, and

environment are factors that can affect the

success of a nursing action.

Implement safe care Provide teaching, support and comfort to enhance the effectiveness of nursing care plans. Be holistic; view the client as a whole.

Respect the dignity of the client and enhance the client’s self- esteem

Encourage client to participate actively in implementing the nursing interventions.

Supervising Delegating Care, if care has been delegated to other health care personnel, the

nurse responsible for all the client’s care must

ensure that the activities have been implemented according to the care plan.

Documenting Nursing Activities, the nurse complete the implementing phase by recording the

interventions and client responses in the nursing process notes. The nurse may record routine or

recurring activities such as mouth care in the client

record at the end of shift, while some actions

recorded in special worksheets according to agency policy. Immediate recording helps safeguard the client to prevent double actions.


The last phase of the nursing process, follows

implementation of the plan of care, it’s the

judgment of the effectiveness of nursing care

to meet client goals based on the client’s

behavioral responses.

Process of Evaluating Client Responses

Collecting data related to the desired outcomes

Comparing the data with outcomes

Relating nursing activities to outcomes

Drawing conclusions about problem status

Continuing, modifying, or terminating the nursing care plan.

When determining whether a goal has been achieved, the nurse can draw one of the three

possible conclusions:

The goal was met, that is the client response is the same as the desired outcomes.

The goal was partially met, that is either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained.

The goal was not met.

Relationship of Evaluation to Nursing Process

Relationship of Evaluation to Nursing Process

―When goals have been partially met or when

goals have not been met, two conclusions may be drawn:

The care plan may need to be revised, since the problem is only partially resolved


The care plan does not need revision, because the client merely needs more time to achieve the previously established goals.

So the nurse must reassess why the goals

are not being partially achieved.