NURSING PROCESS

Mrs.BLESSON THOMAS
Assoc.Prof.
MBCON
 INTRODUCTION
HISTORICAL DEVELOPMENT OF
NURSING PROCESS
The great nursing leader LYDIA HALL coined
the term nursing process in 1955. she
identified three aspect of nursing care as care,
cure and core and the three steps as
obervation, ministration of care and validation.
Then Dorothy Johnson 1959 described nursing
as fostering the behavioral functioning of the
client.
 In the year 1961 Ida Jean Orlando explained 3 steps
in nursing process that is client’s behavior, nurse’s
reaction and nurse’s actions. In 1963 again Ernestine
Wiedenbach describe nursing process in 3 steps.
 Helen Yura and Mary Walsh 1973 along with other
nursing leader decribed nursing process in 4 steps
that is : assessing, planning, implementation, and
evaluating.
 American nurses association in 1973 dearranged the
standard based on 5 steps in nursing process where
diagnosis was used in separate step.
 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.
 The nursing process is defined as an orderly
systematic way of identifying the client’s
problem,makes plans to solve them , initiating the
plans or assigning others to implement it and
evaluating the extent to which the plan was effective
in resolving the problems identified.
 Characteristics of the
Nursing Process
 Cyclic and dynamic nature
 Client centeredness
 Focus on problem-solving and decision-
making
 Interpersonal and collaborative style
 Universal applicability
 Use of critical thinking

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The phases of Nursing Process

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 Assessment
 Collecting data
 Organizing data
 Validating is the act of “double-checking” or verifying
data to confirm that it is accurate and factual.
 Documenting data
 Goal : Establish a database about the client’s
response to health concerns or illness
 Defined as the systematic and continuous
collection, organization, validation and
documentation of data.
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 Diagnosing
 Analyzing and synthesizing data
 Goals
 Identify client strengths
 Identify health problems that can be prevented or resolved
 Develop a list of nursing and collaborative problems
Definition : according to NORTH AMERICAN NURSING
DIAGNOSIS ASSOCIATION (NANDA):
it is a clinical judgement about individual , family, or community
responses to actual and potential health problems/ life process.

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
Planning
Determining how to prevent, reduce, or resolve identified priority
client problems
 Determining how to support client strengths
 Determining how to implement nursing interventions in an organized,
individualized, and goal-directed manner
 Goals
 Develop an individualized care plan that specifies client goals/desired outcomes
 Related nursing interventions

DEFINITION : PLANNING IS A DELIBERATIVE,SYSTEMATIC

PHASE OF THE NURSING PROCESS THAT INVOLVE
DECISION MAKING AND PROBLEM SOLVING

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 Implementing
 Carrying out (or delegating) and documenting planned nursing
interventions (Doing and documentation the activity)
 Goals
 Assist the client to meet desired goals/outcomes
 Promote wellness
 Prevent illness and disease
 Restore health
 Facilitate coping with altered functioning
DEFINITION : IT IS DEFINED AS THE ACTION PHASE IN WHICH
NURSE PERFORMS THE NURSING INTERVENTIONS

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 Evaluating
 Measuring the degree to which goals/outcomes have been achieved
 Identifying factors that positively or negatively influence goal
achievement
 Goal
 Determine whether to continue, modify, or terminate the plan of care
Evaluating is a planned, ongoing, purposeful activity in
which clients and health care professionals determine the
client’s progress toward achievement of goals/ outcomes
and the effectiveness of the nursing care plan. Successful
evaluation depends on the effectiveness of the steps that
precede it.

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 ASSESSMENT
Defined as the systematic and continuous
collection, organization, validation and
documentation of data.
 TYPES OF
ASSESSMENT
TIME
INITIAL LAPSED
ASSESSMENT ASSESSMEN
T

FOCUSED EMERGENCY
ASSESSMEN ASSESSMEN
T T
 Types of Assessments
 Initial
 Performed within a specified time period
 Establishes complete database
 Problem-Focused
 Ongoing process integrated with care
 Determines status of a specific problem
 Emergency
 Performed during physiologic or psychologic crises
 Identifies life-threatening problems
 Identifies new or overlooked problems
 Time-lapsed
 Occurs several months after initial
 Compares current status to baseline
 INITIAL ASSESSMENT

 Initial assessment is performed within a

specified time after admission to a health care
agency for the purpose of establishing a
complete database for problem identification,
reference, and future comparison.
 FOCUSED ASSESSMENT

 Problem-focused assessment is an ongoing

process integrated with nursing care to
determine the status of a specific problem
identified in an earlier assessment.
 Emergency assessment
 Emergency assessment occurs during any
physiologic or psychologic crisis of the client
to identify the life-threatening problems and
to identify new or overlooked problems.
 Time-lapsed assessment
 Time-lapsed (expired)reassessment occurs
several months after the initial assessment to
compare the client’s current status to baseline
data previously obtained.
Assessment Activities

 Collecting data
 Organizing data
 Validating data
 Documenting data
 Collecting data
 Collecting data is the process of gathering
information about a client’s health status.
TYPES OF DATA COLLECTION
1. SUBJECTIVE DATA
2. OBJECTIVE DATA
SOURCES OF DATA
3. PRIMARY SOURCE
4. SECONDARY SOURCE: family members,
health care team, records, review of literature
 Organizing data is categorizing data
systematically using a specified format.
Example: 1 . gordon’s typology of 11 nursing
functional health pattern
2. Roy’s adaptation model
 Validating data is the act of “double-checking”
or verifying data to confirm that it is accurate
and factual.
 Documenting or recording data is accurately
and factually recording 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

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 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
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 Sources of Data
 Primary Source
 The client
 Secondary Sources
 Allother sources of data
 Should be validated, if possible

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 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)

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 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

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 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

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 Closed and Open-ended
Questions
Closed Question Open-ended Question
 Restrictive  Specify broad topic to
 Yes/no discuss
 Factual
 Invite longer answers
 Less effort and information  Get more information
from client
from client
 “What medications did you
 Useful to change topics
take?”
and elicit attitudes
 “Are you having pain now?”
 “How have you been
feeling lately?”

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 Nursing Diagnosis
 Statement that describes the client’s actual or
potential response to a health problem
 Focuses on client-centered problems
 First introduced in the 1950’s
 NANDA established in 1982
 Step of the nursing process that allows nurse to
individualize care
 Types of Nursing Diagnosis

 Actual
 Risk
 Wellness
 Possible
 Syndrome
 Actual Diagnosis

 Problem present at the time of the assessment

 Presence of associated signs and symptoms
 (ineffective breathing pattern)
 Risk Diagnosis

 Problem does not exist

 Presence of risk factors
 Wellness Diagnosis

 Readiness for enhancement

 describes human responses to levels of
wellness in an individual, family, or
community that have a readiness
enhancement.”
 (readiness for enhanced spiritual well-being
or readiness for enhanced family coping)
 Possible Diagnosis

 Evidence about a health problem incomplete or

unclear
 Requires more data to either support or to refute it

 (possible social isolation)

 Syndrome Diagnosis

 Associated with a cluster of other diagnoses

 (risk for disuse syndrome)
 Components of a Nursing
 Problem
Diagnosis
 Etiology
 Defining characteristics
 Defining Characteristics

 Cluster of signs and symptoms indicating the

presence of a particular diagnostic label (actual
diagnoses)
 Factors that cause the client to be more
vulnerable to the problem (risk diagnoses)
 Steps in Diagnostic Process
 Analyzing data
 Compare data against standards
 Cluster cues

 Identify gaps and inconsistencies

 Identifying health problems, risks, and

strengths
 Formulating diagnostic statements
 Formats for Writing Nursing
Diagnoses

 Basic two-part statement

 Problem (P)
 Etiology (E)
Example
 Basic three-part statement
 Problem (P)
 Etiology (E)

 Signs and symptoms (S)

 One-part statement
 Wellness (readiness for enhanced)
 Syndrome
 Using secondary to divide the etiology into
two parts, thereby making the statement more
descriptive and useful (the part following
secondary to is often a pathophysiologic or
disease process or a medical diagnosis)
 Adding a second part to the general response
or NANDA label to make it more precise
The following are guidelines for writing
nursing diagnosis statements:
 Write statements in terms of a problem instead of a
need.
 Word the statement so that it is legally advisable.
 Use nonjudgmental statements.
 Be sure both elements of the statement do not say
the say thing.
 Be sure cause and effect are stated correctly.
 Word diagnosis specifically and precisely.
 Use nursing terminology rather than medical
terminology to describe the client’s response.
 Using nursing terminology rather than medical
terminology to describe the probable cause of
the client’s response.
 . To improve diagnostic reasoning and avoid
diagnostic reasoning errors, the nurse should
do the following: verify diagnoses by talking
with the client and family, build a good
knowledge base and acquire clinical
experience, have a working knowledge of
what is normal, consult resources, base
diagnoses on patterns (that is, behavior over
time) rather than an isolated incident, and
improve critical-thinking skills.
 Advantages of a Taxonomy of
Nursing Diagnoses
 Development of a standardized nursing
language
 Nursing minimum data set
 Identify essential guidelines for
writing nursing care plans.

 Guidelines for Writing Nursing

Care Plans
 Date and sign the plan
 Use category headings
 Use standardized/approved terminology and symbols
 Be specific
 Refer to other sources
 Individualize the plan to the client
 Incorporate prevention and health maintenance
 Include discharge and home care plans
 PLANNING
 Planning is the 3rd step in nursing process
 It is the determination of what is to be
done ,when is to be done, where is to be done
and who will do and also how to evaluate the
result.
 DEFINITIONS:

KOZIER (1975): planning is deliberative

systematic phase of the nursing process that
involves decision making and problem
solving.
 Potter and perry (2001) : planning is a
category of nursing behavior in which client
centered goals are established and
interventions are designed to achieve stated
goals.
 PURPOSES

Give direction to the client care activities

Enhance the continuity of care
Permit the delegation of specific activity
 Types
1. Initial planning : planning done immediately
after the initial assessment is known as initial
planning
Planning must be started early because of the
trend towards shorter stay in the hospital.
2. Ongoing planning : in this the nurse plan
during her nursing care this is done daily.
3. Discharge planning : it is done during the
discharge of the patient and it required to plan
the needs ,dos and don’ts after the patient goes
homes after the hospital stay.
 Phases of planning
 Setting priorities
 Determining the goals or expected outcomes
 Selecting the nursing strategies
 Developing nursing care plan
 Setting priorities : it is to determine the order
in which patient’s problem is approached
Priorities are classified into :
High priorities : immediate attention if care not
given it can harm the client
Intermediate priorities : it involves non emergent
,non life threatening needs of the client
Low priorities : client’s needwhich may not be
directly related to specific illness or prognosis.
Maslaw’s hierarchy
Self
of needs
act
uali
sati
on
Self esteem

Love and belongingness

Safety and security

Physiological needs like air water, food etc.

Determining goals and expected
outcome
 Goal : they are the statements of dxpected
outcomes of nursing
 Purpose : to evaluate client’s progress,
To evaluate the effectiveness of nursing
intervention
 Types of goals : short term and long term goal
 Factors to Consider When
Setting Priorities
 Client’s health values and beliefs
 Client’s priorities
 Resources available to the nurse and client
 Urgency of the health problem
 Medical treatment plan
 Guidelines for Writing
Goal/Outcome Statements
 Write in terms of the client responses
 Must be realistic
 Ensure compatibility with the therapies of
other professionals
 Derive from only one nursing diagnosis
 Use observable, measurable terms
 Describe the process of selecting
and choosing nursing interventions.
 Nursing Interventions and Activities
 Actions nurse performs to achieve
goals/desired outcomes
 Focus on eliminating or reducing etiology of
nursing diagnosis
 Treat signs/symptoms and defining
characteristics
 Types of Nursing Interventions
 Direct
 Indirect
 Independent interventions
 Dependent interventions
 Collaborative interventions
 Types of Interventions
 Nurse-Initiated

 Physician-Initiated

 Collaborative
Interventions
 Direct care is an intervention performed
through interaction with the client.
 Indirect care is an intervention performed
away from but on behalf of the client such as
interdisciplinary collaboration or management
of the care environment.
 independent interventions, those activities
that nurses are licensed to initiate on the basis
of their knowledge and skills;
 dependent interventions, activities carried
out under the primary care provider’s orders or
supervision, or according to specified routines;
 collaborative interventions, actions the nurse
carries out in collaboration with other health
team members. The nurse must choose
interventions that are most likely to achieve
the goal/desired outcome.
 Criteria for Choosing
Appropriate Intervention
 Safe and appropriate for the client’s age, health, and
condition
 Achievable with the resources available
 Congruent with the client’s values, beliefs, and
culture
 Congruent with other therapies
 Based on nursing knowledge and experience or
knowledge from relevant sciences
 Within established standards of care
 IMPLEMENATION
 According to Campbell(1990)
A nursing intervention is a single action
treatment, procedure or activity- designed to
achieve an outcome to a diagnosis- nursing or
medical for which the nurse is accountable.
 Gordon (1994) : “ nursing intervention is an
action taken by the nurse to help the client
move from a present health state to the health
state described in expected outcomes.
 Purpose
 To provide technical nursing care
 To provide therapeutic nursing care
 To help client to achieve optimum level of
health
 activities
 Reassess
 Setting priorities
 Organizing resources
 Performing nursing intervention
 Recording
 Setting priorities:
Client’s condition
New information from reassessment
Time and resources available
Feedback from client/family/health care staff
Nurse’s knowledge and experience in setting
priority
 Organizing resources :
Equipment
Personnel
Environment
Client
 Performing nursing intervention:

Directly perform
Assisting
Supervising
Teaching and monitoring
 Recording
 IMPLEMENTATION SKILL

 Cognitive skill

 Interpersonal skill

 Psychomotor skill

 Technical skill
 EVALUATION
 Evaluation is the fifth step in nursing process

 DEFINITION:
Craven (1996) the judgement of the
effectiveness of the nursing care to meet client
goals. In this phase nurse compares the client
in behavioral responses with the
predetermined client goals and outcome
criteria
 Purposes
 Collect data for making judgements about nursing
care delivered.
 Determine client’s behavioural response to nursing
intervention.
 Compare the client’s response with predetermined
outcome criteria.
 Appraise the extent to which client’s goals were
attained.
 Appraise / appreciate the involvement of client/
family member in health care decision.
 Assess the collaboration of client and health
care team members
 Identify the errors in the plan of care
 Monitor the quality of nursing care.
EVALUATION PROCESS