NURSING PROCESS

AN OVER VIEW

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Dr.Shatha S.M
 :Nursing process

 Definition:
Is a systematic process, rational method
of planning which nurses deliver care
.to individual, families and community

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:Stages of the nursing process

The Nursing process is often remembered by the

acronym ADPIE
 Assessment of patient's needs
 Diagnosis (of human response needs that nursing
can assist with
 Planning (of patient's care
 Implementation of care
 Evaluation (of the success of the implemented care
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 Characteristic of nursing process:
 Provide the framework for care.
 It is client center.
 Adapted of problem solving technique.
 It has planned.
 It is cyclic and dynamic.

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:Assessment

Definition: Is the systematic and continuous

collection, organization, validation,
.documentation of data
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:Type of assessment

 Initial assessment: to establish complete data

base after admission.

 Problem focused assessment: to determine the

status of specific problem integrated with nursing
care.

 Emergency assessment: identify the life-

threatening problem.

 Time lapsed assessment: several month, to

compare the client status. 6
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Data collection:
 Is the process of gathering information about client health
status.
 The collection of patient data is vital steps in nursing
process because the remaining steps depend on these steps.
Characteristic of data:
 Complete.
 Accurate
 Relevant.
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
The data will collect through:

  Nursing history
 physical examination
 Lab results.
 Review records and literature

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 :NURSING HEALTH HISTORY
1. Biographic data:

 Client name, address, age, sex, marital status, occupation,

religious, assurance, Date and time of history.
2. Chief complain:
 The answer given to question "what brought you to the
hospital?
 The chief complain should record in own patient word.
 Ex: my stomach hurts or I have come for my regular check
up.

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 History of present pain:
 Location.
 Radiation.
 frequency
 Timing and duration.
 Quality and quantity.
 Factors aggravated or alleviated.
 Associated symptoms
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 Past History:
 Immunization.
 Childhood illness( measles, mumps, streptococcal
infection and rheumatic fever).
 Allergy ( drug, egg, animals and insect).
 Surgeries
 Hospitalization.
 Medication ( aspirin, laxatives, antihypertensive)

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Family history:
 Risk factor certain disease
 Cancer, hypertension. Angina, bleeding tendency.
Life style:
 Personal habits: tobacco, alcohol, coffee, tea.
 Diet description: high fat diet. High salt.
 sleep pattern.
 Hopis.

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Type of data:
Subjective data: (symptoms, covert data), the client only client
can be described. Such as itching, pain, feeling, I feel weak all
over.

Objective data: referred to as (signs or overt data) are detectable

by observe or can be measured, it can be seen, heard.
 Example Blood pressure reading, pulse, redness, cyanosis.
 Blood pressure: 90/ 50 mmHg.

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Social data
 Family relation ship, friends, support system.
 Level of education.
 Occupation history (number of days are missed, occupied
hazard).
 Economic status, how pay in medical care.
 Home (safety measurement)
psychological data:
 14
Major stressor, usual coping pattern, communication style.
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 Data collection method:
1. Observing: is the conscious use of the five senses to gather information.
 Example: flushed face.
2. Interview:
Is a planned communication or conversation with purpose for example to get
or to give information or to identify problem.

Phases of interview:

Preparatory phase.
Introduction phase.
Working phase.
Termination phase

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Nursing Diagnosis:

A statement that describes actual or

potential health
problems that can be prevented or resolved by independent nursing
intervention

NANDA Definition: (North America Nursing Diagnosis Associate)

 Nursing diagnosis is a clinical judgment about individual,

family, or community responses to actual and potential health
problems/life processes.
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 DIFFERENCE BETWEEN
NURSING AND MEDICAL
DIAGNOSIS
 Nursing Diagnosis- statement used to describe the
client’s actual or potential response to a health problem that a
nurse is licensed and competent to treat i.e.-Impaired skin
integrity, Risk for Infection, etc.
 Medical Diagnosis-physician’s clinical judgment of the
disease- i.e. diabetes mellitus, give insulin, 1800 caloric diet
and moderate exercise.

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 Diagnosis is the second phase of the nursing process.

 Analyze data
 Identify health problem and risk.
 Identify the characteristic of nursing
problem.
 state nursing diagnosis in concise way
and precisely

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It contains three parts:

Problem:
 1) Identifies unhealthy response

 2) Indicates what should change

Etiology:
1) Identifies causative or contributing factors
 suggests nursing interventions

 Sign and symptom: redness, cyanosis, loss of appetite.

It called PES system. 20
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Example:
 problem
 Etiology
 Sign
Ex:  Anxiety related to Fear of death manifested by patient
verbalization.
 
Ex: Activity intolerance related to obesity manifested by body
weight 140 KG.

The words ‘related to’ are used to identify the

cause of the problem.

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 Writing Diagnostic Statements

Problem Etiology Symptom

As
Related Evidence
To d
By
Diagnostic Contribut Signs &
Label ing Symptoms
Factors

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Planning:
Is systematic phase of the nursing process that involves decision making.

Planning process:
 Prioritize problem.
 Formulate goal.
 Select nursing intervention.
 Write nursing order.
.Record and modify 

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:Formula for Writing Goals/Outcomes

Goal statement (long or short term) = patient behavior + criteria + time +

conditions (if needed)

Subject - patient .1
Verb - action/behavior which pt performs .2
Criteria - acceptable performance .3
Within specified time period .4
Condition (if needed) circumstances under which behavior performed .5
:Example
The patient (1) will walk (2) the length of the hall (3) with a walker (5) by the end
.of the shift (4)

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 Implementation:
is the phase in which the nurse puts the nursing care plan
in to action.

Process of implementation:
 Reassessing the client.
 Determine the nurse need for assistance.
 Implementing.
 Supervising.
 Document the action.

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:Evaluation 
 Determine the client progress to ward goals achievement
and effectiveness of

 the nursing care plan.

 Examples:
 The goal met.
 The goal not met.


The goal partially met.

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 Case study:
 Mrs. A 23 years old admitted to the hospital, married, the
temperature is elevated, productive cough, rapid
 respiration with difficulty.

 1) Assessment:
V/S are temperature 39.1C, pulse 92 b/m, respiration rate 28
b/m and blood pressure 122/80 mm/hg. nurse observe that Mrs.
A is dry skin, her cheeks are flushed, she is experience of chill.
 On chest, auscultation reveals respiratory crackles.

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2) Diagnosis:
Ineffective breathing pattern related to accumulation of
secretion as manifested by productive cough, rapid
respiration with difficulty.
3) Planning:
Goal:
The patient (S) will able to breath (V) normally (c) within 8
hours (T).
Restore effective breathing pattern.
Interventions: Deep breathing exercise. Increase fluid intake,
Bronchodilator medications. 28
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4) Implementation:
Mrs. A agree to practice:
Deep breathing exercise q4hrs.
Increase the fluid intake.
Take bronchodilator medications.
5) Evaluation:
(The goal not met) the nurse detects failure of the client to breath
normally, the plan modify to reach normal breathing and
then reevaluation.

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Dr.Shatha Aljabari