Basic Nursing: Foundations of

Skills & Concepts

Chapter 9

NURSING
PROCESS
The Nursing Process

 A systematic method of providing care

to clients.
The 5-Step Nursing Process

 Assessment.
 Diagnosis.
 Planning and outcome identification.
 Implementation.
 Evaluation.
Assessment or Data Collection

 The first step in the nursing process

involves the following:
 Collecting data.
 Validating data.
 Organizing data.
 Interpreting data.
 Documenting data
Purpose of Assessment

 To establish a database concerning a

client’s physical, psychosocial, and
emotional health.

 To identify health-promoting behaviors

as well as actual and/or potential health
problems.
Types of Assessment

 Comprehensive - Provides baseline data including

complete health history and current needs
assessment.

 Focused - Limited in scope in order to focus on a

particular need or concern or potential risk.

 Ongoing - Includes systematic monitoring and

observation related to specific problems.
Sources of Data

 Primary Source: The client.

 Secondary Source: The client’s family

members, other health care providers,
and medical records.
Types of Data

 Subjective: Data from client’s (and sometimes

family’s) point of view. Includes feelings, perceptions,
and concerns. Collected by the interview.

 Objective: Also called signs. Observable and

measurable data obtained through physical
examination and laboratory and diagnostic testing.
Validating Data

 Validation prevents omissions,

misunderstandings, and incorrect
inferences and conclusions.
Organizing Data

 Collected information must be

organized to be useful.

 Data Clustering is a useful tool to

identify issues.
Interpreting Data

Three critical components:

 Distinguishing between relevant and
irrelevant data
 Determining whether and where there
are gaps in the data
 Identifying patterns of cause and effect
Documenting Data

 Assessment data must be recorded and

reported.

 Accurate and complete recording of

assessment data is essential for
communicating information to health
care team.
Diagnosis

 A medical diagnosis is a clinical judgment by the

physician that determines a specific disease,
condition or pathological state.

 A nursing diagnosis is a clinical judgment about

individual, family, or community responses to actual
or potential health problems/life processes.
Nursing Diagnosis Questions

 Are there problems here?

 If so, what are the specific problems?
 What are some possible causes?
 Is there a situation involving risk factors?
 What are the risk factors?
 What are the client’s strengths?
 What data are available to answer these questions?
 Is more data needed?
 If so, what are the possible sources of further data?
Nursing Diagnosis is a Two-Part
Statement

 A problem statement or diagnostic label

that describes the client’s response to
an actual or potential health problem or
wellness condition.

 And the etiology - the related cause or

contributor to the problem.
Nursing Diagnosis is a Three-
Part Statement

 Includes first two parts of Two-Part

Statement: the diagnostic label and the
etiology.

 Also includes defining characteristics,

the collected data, also known as signs
and symptoms, subjective and objective
data, and clinical manifestations.
Types of Nursing Diagnosis

 Actual nursing diagnosis: A problem exists; it is

composed of the diagnostic label, related factors,
and signs and symptoms.

 Risk nursing diagnosis: A problem does not yet exist,

but special risk factors are present.

 Wellness nursing diagnosis: Indicates client’s desire

to attain higher level of wellness in some area of
function.
Planning and Outcome
Identification

 Planning combines with outcome

identification to comprise the third step
of the nursing process.
Three Phases of Planning

 Initial Planning: developing a preliminary plan of care

by the nurse who performs the admission
assessment.

 Ongoing Planning: continuous updating of client’s

plan of care.

 Discharge Planning: Involves critical anticipation and

planning for client’s needs after discharge.
Tasks Involved with Planning

 Prioritizing list of nursing diagnoses.

 Identifying and writing client-centered long- and

short-term goals and outcomes.

 Developing specific nursing interventions.

 Recording entire nursing plan in client’s record.

Intervention

 A nursing intervention is an action

performed by the nurse that helps the
client achieve the results specified by
the goals and expected outcomes.
Categories of Nursing
Interventions

 Independent: Actions initiated by nurse that do not

require direction or an order from another health care
professional

 Interdependent: Actions implemented in collaborative

manner by nurse in conjunction with other health
care professionals

 Dependent: Actions that require an order from a

physician or other health care professional.
Types of Nursing Interventions

 Specific order - written by physician or nurse

especially for an individual client.

 Standing order - A standardized intervention written,

approved and signed by a physician that is kept on
file to be used in predictable situations or in
circumstances requiring immediate attention.

 Protocol - A series of standing orders or procedures.

Types of Nursing Interventions
 Specific order: written by physician or nurse
especially for an individual client
 Standing order: A standardized intervention
written, approved and signed by a physician
that is kept on file to be used in predictable
situations or in circumstances requiring
immediate attention.
 Protocol: A series of standing orders or
procedures
The Nursing Care Plan

 A written guide that organizes data

about a client’s care into a formal
statement of the strategies that will be
implemented to help the client achieve
optimal health.
Implementation

 This fourth step of the nursing process

involves the execution of the nursing
care plan derived during the Planning
phase.
Evaluation

 This fifth step of the nursing process,

determining whether client goals have
been met, partially met, or not met.
Nursing Audit

 The process of collecting and analyzing

data to evaluate the effectiveness of
nursing interventions.
The Nursing Process
is Critical Thinking

 Critical thinking, problem-solving, and

decision-making are important in the
use of the nursing process.

 These skills can be learned!