NURSING PROCESS

BY: S.Ali
Lecturer
KMU
NURSING PROCESS
What is Nursing Process?

• It is a systematic method that directs the nurse and

patient as they together accomplish the following;
Cont….
 NURSING PROCESS
• 1. Assess the patient to determine the need for
nursing care,

• 2. Determine nursing diagnoses,

• 3. Plan care

• 4. Implement the care, and

• 5. Evaluate the results.

 NURSING PROCESS
• The process provides a framework that enables
the nurse and patient to accomplish the
following:

• Systematically collect patient data (assessing)

• Clearly identify patient strengths and problems

(diagnosing) Cont..
 NURSING PROCESS
• Develop a holistic plan of individualized care
that specifies the desired patient goals and
related outcomes and the nursing interventions
most likely to assist the patient to meet those
expected outcomes (planning).

• Execute the plan of care (implementing)

Cont….
NURSING PROCESS

• Evaluate the effectiveness of the plan of care in

terms of patient goal achievement (evaluating)
COMPONENT OF NURSING PROCESS
• Components

Assessing

Implementing Diagnosing

Evaluating Planning
 COMPONENT OF NURSING PROCESS

Component Description Purpose

Assessing Collection, Make a judgment about the

validation, and patient’s health status, ability
communication to manage his or her own
of patient data. health manage his or her own
health care, and need for
nursing. Plan individualized
holistic care that draws on
patient strengths and its
responsive to changes in the
patient’s conditions.
NURSING PROCESS
• Assessment

Subjective data Objective data

Are information perceived only Are observable and measurable

by the affected person; these data that can be seen, hear, or
data cannot be perceived or felt by someone other than the
verified by another person. person experiencing them.
COMPONENTS OF NURSING PROCESS
Diagnosing Analysis of patient data to Develop a prioritized list of
identify patient strengths and nursing diagnoses.
health problems that
independent nursing
intervention can prevent or
resolve.

Planning Specification of (1) patient Develop an individualized

goals/outcomes to prevent, plan of nursing care
reduce, or resolve the problems
identified in the nursing
diagnoses; and (2) related
nursing intervention.
 COMPONENT OF NURSING PROCESS
Implementing Carrying out the plan of Assist patients to
care. achieve desired goals-
promote wellness,
prevent disease and
illness, restore health,
facilitate coping with
altered functioning.

Evaluating Measuring the extent to Continue, modify, or

which the patient has terminate nursing
achieved the goals specified care.
in the plan of care;
identifying factors that
positively or negatively
influenced goal
achievement; revising the
plan of care if necessary
DIAGNOSIS
• Nursing diagnosis are derived from health status data
• Nursing diagnosis ---------- analyzing,
• Validate data
• Sort and group data
• Label data with diagnostic statements
 Different between Nursing Diagnosis and Medical Diagnosis

Nursing Diagnosis Medical Diagnosis

1. Focus on unhealthy 1. Identify disease

responses to health and
illness.
2. Describe problems treated
by nurses within the scope
of independent nursing
practice.
3. May change from day to day
as the patient’s responses
change.
2. Describe problems for which
the physician directs the
primary treatment
3. Remains the same for as
long as the disease is
present
 Different between Nursing Diagnosis and Medical Diagnosis

• EXAMPLES
• Myocardial Infarction is a medical diagnosis. Examples of
nursing diagnoses for a person with myocardial infarction
include Fear, Altered Health Maintenance, Knowledge Deficit,
Pain and Altered Tissue Perfusion.
PLANNING
• The act of determining what can be done to assist the
client in restoring, maintaining or promoting health.
• Judging priorities
• Establishing goals
• Developing objectives
• Identifying strategies & techniques for
implementation
PLANNING
• GOALS/OUTCOMES

• A goal statement is a patient behavior that is expected

to reduce or alleviate the problem identified through
actions.

Goals are written in terms of patient outcomes not

nursing action.
PLANNING
• TYPES OF GOAL

• 1. LONG TERM
• Optimum health level the patient can realistically
achieve after an illness or hospitalization.
• 2. SHORT TERM
• What you want the patient to accomplish day to day.
PLANNING

• Goal should be;

• Realistic & Reasonable (RUMBA)
• Understandable
• Measurable
• Behaviorable
• Achievable
NURSING PROCESS

• Characteristics of the Nursing Process

Systematic
Dynamic
Interpersonal
Goal oriented
Universally applicable
NURSING DIAGNOSIS
1. Definition
2. Defining characteristics
Major (Must be present)
Minor (May be present)
3. Related factors
• Pathophysiological
• Treatment related
• Situational (Personal, Environmental)
• Maturational
1. Outcome Criteria