Nursing process

By Getachew N. (MSc)

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 NURSING PROCESS
• Nursing process is an assertive, problem solving approach to the
identification and treatment of patient problems.

• The nursing process is goal-oriented method of caring that provides a

framework to nursing care.

• It involves five major steps (six steps for some scholars).

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 History of the Nursing Process
1950s
Patient should be
Some bad
the centre of care
nursing
practice

Nursing to be directed by
improving outcomes and
goals
What is her name?

Ida Jean Orlando

(Deliberative nursing process)
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 Purpose of Nursing Process

To Provide scientific-based, holistic, individualized patient care.

To Work collaboratively with patients and others.

To Achieve continuity of care and

To Encourage the health care team to observe and interact with patient (not just

performing a task e.g. administering injection, dressing change, or bed bath)

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 Nursing Process is also…

 The cornerstone of the Nursing profession.

 An opportunity for nurses to build their own scientific body of knowledge.

 Elevating Nursing from a vocation into a profession.

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 Characteristics of nursing process

 Cyclic, dynamic and ongoing process (end at any stage if the problem is solved)

 Exists for every problem that the individual/family/community has.

 Goal directed, problem oriented and client centered

 Interpersonal and collaborative

 Universally applicable
 Systematic

 Permits creativity among Nurses and clients

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 Benefits of the Nursing Process
To patients

 Access to quality nursing care

 Continuity of care
 Patient participation reflects respect for human
dignity.
 Reduces incidence of hospital stay.

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 Benefits of the Nursing Process
To nurses

♣ Speed up diagnosis and treatment of actual and potential

health problems.
♣ Promotes flexibility & independent thinking.
♣ Professional development..
♣ Avoid legal action.
♣ Improves communication through documentation;
professional nursing standards.
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 Comparison of
Medical Process Nursing Process
 Deals mostly with problems with  Deals with human response to
structure and function of organs problems and problems with
structure and function of organs
or systems. requiring Collaboration with
physician.
 Goals are not clearly recorded  Uses the five steps approach and
during planning. strict rule.
 Focuses on teaching about how  Consider the whole person and
diseases and trauma treated. system function and response.
 Mostly involved with individuals  Focuses on teaching individuals
and rarely with groups and families. and groups.
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 Components of Nursing process

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 1. Nursing assessment
• A systematic, dynamic process by which the nurse collects and analyzes data
about the client, through interaction with the client, significant others, and
health care providers.
• Assessment is broader than observing and data gathering.

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There are two types of data
• Subjective data: gathered through history taking and in-depth interview with patients
or significant others.
e.g., "I'm tired”
• Objective data: obtained through physical examination which includes the four
technique, inspection, palpation, percussion, auscultation
– vital signs
– laboratory studies
– changes in physical appearance
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 EXAMPLES
Subjective data (covert data):
 “I feel sick to my stomach."
 "I have a stabbing pain in my side."
 "I wish I were home."
 "I feel like nobody likes me.“
 Itching, feelings of worry

07/05/2023 set by: Kirubel.E 13

EXAMPLES…
Objective data (overt data); Can be measured or tested against an
accepted standard.
 Blood pressure of 110/70 mmHg
 Rash on right arm
 Walks with a limp
 Discoloration of the skin
 Ate all of his breakfast
 Urinated 150 ml clear urine
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 Sources of data

 primary source of data

Information gathered from the client
Interview techniques and physical examination skills are used.
 secondary sources
Sources of data other than the client are considered and include family
members, other health care providers, and medical records.

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 Cont…

• Organizing data is categorizing data systematically using a specified format.

• Validating data is the act of “double-checking” or verifying data to confirm
that it is accurate and factual.
• Documenting is accurately and factually recording data.

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 TYPES OF HEALTH ASSESSMENT
The four basic types of assessment are:
i. Initial comprehensive assessment

ii. Ongoing or partial assessment

iii. Focused or problem-oriented assessment

iv. Emergency assessment

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 Cont..

 Initial Comprehensive Assessment (admission assessment): involves

collection of subjective data about the client’s perception of his or her health

of all body parts or systems

 Focused Assessment is limited to potential health care risks, a particular

need, or health care concern.

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 Cont…
• Ongoing Assessment: When problems are identified during a comprehensive
or focused assessment, follow-up is required.
– Determine the client’s response to nursing interventions and to identify any
other problems
• An emergency assessment is a very rapid assessment performed in life-
threatening situations

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 Functional Health Patterns (Gordon’s approach)
It provides a framework for data collection
The 11 patterns are:
1. Health perception/health management pattern
2. Nutritional/metabolic pattern
3. Elimination pattern
4. Activity/exercise pattern
5. Cognitive/perceptual pattern
6. Sleep/rest pattern
7. Self-perception/self-concept pattern
8. Role/relationship pattern
9. Sexuality/reproductive pattern
10. Coping/stress-tolerance pattern
11. Value/belief pattern
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 2. Nursing diagnosis

• A nursing diagnosis is “a clinical judgment about individual, family, or

community responses to actual or potential health problems / life processes.

• Nursing diagnosis provides the basis for selection of nursing interventions to

achieve outcomes for which the nurse has accountability.

– Ex. A person in pain may demonstrate the potential for poor nutrition,

anxiety, and/or decreased mobility

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 Types of nursing diagnosis

Actual nursing diagnosis

• An actual nursing diagnosis represents a problem that has been validated by

the presence of major defining characteristics.

• An actual nursing diagnosis has three parts; problem, etiology and defining

characteristics.

E.g. impaired mobility related to (r/t) prolonged bed stay as evidenced by

inability to maintain normal gait.

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 Risk and high risk (potential) nursing diagnoses

• A risk or high risk diagnoses (also called potential dx) is defined as “a

clinical judgment that an individual, family, or community is more vulnerable
to develop the problem than others in the same or similar situation.
• It is diagnoses by the presence of risk factors rather than defining
characteristics (It has only problem and etiology, no defining characteristics).
“Problem r/t risk factors”.
Ex. Risk for complication of Hyperglycemia r/t Steroid therapy

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 Possible nursing diagnosis

• Possible nursing diagnoses are statements that describe a suspected problem

requiring additional data
• It can also be thought of as a tentative position similar to the “rule-out”
statement health care provider’s use.
• Problem r/t data that leads the nurse to suspect the diagnosis

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Wellness nursing diagnosis

• A wellness diagnoses is described as “a clinical judgment about an

individual, group, or community in transition from a specific level of

wellness to a higher level of wellness

• Wellness diagnoses are especially useful for healthy clients.

• Do not contain related factors, but rather contain the label only

• Ex. Readiness for enhanced nutrition'

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 Syndrome nursing diagnose

• The Syndrome diagnoses “comprise a cluster of predicted actual or high risk

nursing diagnoses related to a certain event of situation.”
• This type of diagnostic statements only contain the label (no related to)
• NANDA has ff syndrome diagnoses: Rape Trauma Syndrome, Disuse
Syndrome, Post-Trauma Syndrome, and Impaired Environmental
Interpretation Syndrome.

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 3. Planning
• In agreement with the client, the nurse addresses each of the problems identified in the
diagnosing phase.
• When there are multiple nursing diagnoses to be addressed, the nurse prioritizes which
diagnoses will receive the most attention first according to their severity and potential for
causing more serious harm.
• Revise the plan when the needs of the person significantly change (i.e., new diagnoses, new
medications, changes in condition).
• For each goal/outcome, the nurse selects nursing interventions that will help achieve the
goal/outcome
• The result of this phase is a nursing care plan.
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 4. Implementation

• The nurse implements the nursing care plan, performing the determined
interventions that were selected to help meet the goals/outcomes that were
established.
• Delegated tasks and the monitoring of them is included here as well.

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 Cont..

Activities ..
• Pre-assessment of the client-done before just carrying out implementation to
determine if it is relevant.
• Determine need for assistance
• Implementation of nursing orders
• Delegating and supervising-determines who to carry out what action.

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 6. Evaluation

• The nurse evaluates the progress toward the goals/outcomes identified in the
previous phases.
• If progress towards the goal is slow, or if regression has occurred, the nurse must
change the plan of care accordingly.
• Conversely, if the goal has been achieved then the care can cease.

• New problems may be identified at this stage, and thus the process will start all over
again.

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 Assignment (15 pts)

1. The 11 functional health patterns (Gordon’s approach)

2. Systemic approach
3. Human response pattern

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