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Nursing Process
Nursing Fundamentals
Introduction

Nursing process
is a systematic method of providing care to
clients
 Allows nurses to communicate plans and
activities to

Clients
 Other health care professionals
 Families

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Encourages orderly thought, analysis,
planning
Overview of the Nursing Process

Process:


“A series of steps or acts that lead to
accomplishment of some goal or purpose”
Purpose is to provide client care that is:
Individualized
 Holistic
 Effective
 Efficient

Overview of the Nursing Process

Consists of 5 steps

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Assessment
Diagnosis
Planning
Implementation
Evaluation
Build on each other
 Not linear

Nursing process is dynamic and requires
creativity in its application
Steps remain the same
 Application and results different


Used throughout the life span in any care
setting
Assessment

Step #
 Collecting data to determine the needs
and health problems of patient.

Involves
Collecting data (from variety of sources)
 Validating the data
 Organizing the data
 Interpreting the data
 Documenting the data

Assessment

Purpose of assessment:


Data collection
Types of assessment:
Comprehensive assessment
 Focused
 Ongoing
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Assessment
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Comprehensive assessment
Baseline
 Physical & psychosocial
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Assessment
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Focused Assessment
Limited in scope
 Screening for a specific problem
 Short stay

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Ongoing assessment
Follow-up
 Monitoring and observation related to
specific problems

Assessment
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Sources of Data
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Primary sources
Client
 Interview
 Physical examination

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Secondary sources
Family members
 Other health care providers
 Medical records
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Types of data
Subjective:(symptoms)
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Data from the client’s point of view
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Feelings, Perceptions, Concerns
(feeling nervous, nauseated, chilly or
experiencing pain)
 Main way to collect subjective data: Interview
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Objective
Observable & measurable data
 Main way to collect objective data:
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Physical assessment &Lab and diagnostic testing
Such as (increase temperature, lab. results,
moist skin, refusal to look at or eat food)
Data Collection Methods
1.
2.
Observation.
Is the conscious and deliberate use of the five
senses to gather data (sighting, smelling,
touching and hearing)
Interview.
Is the planned communication, during the
assessment step of the nursing process to
obtain and establish a successful working
partnership with the patient , then to obtain
the necessary patient data .
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Data Collection Methods (cont’d)
3.
Techniques of Physical Assessment.
Is the examination of the patient for objective
data that may better define the patients
condition and help the nurse in planning care,
include:
inspection , palpation , percussion , and
auscultation .
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Problems Related to Data Collection
1.
2.
3.
4.
5.
Inappropriate organization of the database.
Omission of pertinent data.
Inclusion of irrelevant or duplicate data.
Misinterpreted data.
Failure to establish rapport and partnership.
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Diagnosis

Step 2 in the nursing process
Formulating a nursing diagnosis
 Analysis and synthesis of data
 Health issue that can be prevented,
reduced, resolved, or enhanced
through independent nursing
measures
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Nursing diagnosis:
“A clinical judgment about individual, family
or community responses to actual or
potential heal problems / life processes.
 A nursing diagnosis provides the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is
accountable.”

Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Identifies conditions the Identifies situations the
MD is licensed &
nurse is licensed &
qualified to treat
qualified to treat
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Identifies conditions the Identifies situations the
MD is licensed &
nurse is licensed &
qualified to treat
qualified to treat
Focuses on illness,
injury or disease
processes
Focuses on the clients
responses to actual or
potential health / life
problems
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Remains constant Changes as the clients
until a cure is
response and/or the health
effected
problem changes
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Remains constant Changes as the clients
until a cure is
response and/or the health
effected
problem changes
i.e. Breast cancer
i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
Diangosis
Nursing diagnosis
Medical diagnosis
Breathing patterns,
ineffective
Activity intolerance
Chronic obstructive
pulmonary disease
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Body temperature, risk for
altered
Strep throat
Nursing Diagnosis Categories
1.
2.
3.
4.
5.
Actual.
Risk.
Possible.
Syndrome.
Wellness.
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Diagnostic Statements
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Name of the health-related issue or problem as
identified in the NANDA (North American
Nursing Diagnosis Association) list.
Etiology (its cause)
Signs and Symptoms.
The name of the nursing diagnosis is linked to
the etiology with the phrase “related to,” and
the signs and symptoms are identified with the
phrase “as manifested (or evidenced) by”.
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Purpose of Diagnosis

1.
2.
3.
To identify:
Actual and potential problems.
Factor that contribute the problems
(etiologies)
Strengths the patients can drawn to prevent
or resolve the problems.
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Formulating and Validating Nursing
Diagnosis

1.
2.
3.
Parts of Nursing Dxs.
Problem.
The purpose of the problem statement is to
describe the health state or health problem of
the patient as possible.
Identifies what is unhealthy about the patient,
indicating the need for change
Etiology.
Identifies the factors that are maintaining the
unhealthy state or response (causative factor )
Defining characteristics.
The subjective and objective data that signal
the existence of the problem identify.
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Diagnosis Examples

Example 1 :
Hygiene self-care deficit ( problem )
related to
fear of falling in the obesity (etiology )
as manifested by
strong body and urine odder (characteristics )
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Diagnosis Examples (Cont’d)

Example 2 :
Chest pain ( problem )
related to
decrease coronary blood flow (etiology)
as manifested by
facial expression (characteristics )
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Diagnosis Examples (Cont’d)

Example 3 :
Ineffective individual coping (problem)
related to
loss of job ( etiology )
as manifested by
increase daily use of alcohol (characteristics )
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Planning
Step 3
The process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable
goals or outcomes, selecting appropriate
interventions, and documenting the plan of care.
 The nurse works in partnership with the patient
and family.
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Planning & Outcome identification
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Types of planning
Initial planning
 Ongoing planning
 Discharge planning
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Elements of Planning
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Establishing priorities.
Writing goals / outcomes that determine the
evaluative strategy .
Selecting appropriate nursing interventions.
Communicating the plan of nursing care.
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Priorities of Planning
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1.
2.
3.
4.
5.
Determine problems that require immediate
action.
Maslow’s Hierarchy of Human Needs
Physiologic needs.
Safety.
Love and belonging needs.
Self-esteem needs.
Self- actualization needs.
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Planning & Outcome identification
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Identifying outcomes
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Goals
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Short term goals
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An aim, intent or end.
Hours to days (less than a week)
Long term goals
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Weeks to months
Guidelines For Goal/Outcome Writing
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One of the most important consideration in
goal/outcome writing is to encourage the patient
and family to be as involved in goal
development as their abilities and interest
permit .
Each patient goal/outcome must have
1- a subject : which is the patient.
2- a verb : which indicates the action.
The patient will perform , and criteria which
describe in observable such as ( define , identify
, list , select , apply , explain , prepare …… etc
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Problems Related to Planning
1.
2.
3.
4.
Insufficient data collection.
Nursing Dxs developed from inaccurate data.
Goals /outcomes that are stated too broadly .
Goals/outcomes that are derived from poorly
developed nursing Dxs.
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Implementation (Intervention)
4th step:
 Execute the plan of care (action phase)
 The nurse implements medical orders and
nursing orders.
 Implementation involves the client and one or
more health care team.
 The information in the chart shows a correlation
between the plan and the care that has been
provided.
 Nurses are accountable for carrying out nursing
orders and physician orders.
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Planning & Outcome identification
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Developing specific nursing interventions
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Independent nursing interventions
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No order needed
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Interdependent nursing interventions
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In conjunction with an interdisciplinary team member
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Elevate edematous legs
Assist client with physical therapy exercises
Dependent nursing interventions
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Require an order
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Administering of medications
Carrying Out The Plan of Care

1.
2.
3.
When carrying out the plan of care , nurses use
specialized abilities to
Determine the patients continuing need for nursing
assistance.
Promote self-care .
Assist the patient to achieve health goals.
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Evaluation
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5th step
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Determining
whether the clients
goals have been
met, partially met or
not met.
Evaluation
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Evaluate the effectiveness of the plan of care in
terms of patient goal achievements.
The nurse and patient together measure how well
the patient has achieved the goals/outcomes
specified in the plan of care , and the purpose of
evaluation is to allow the patients achievement of
expected outcomes to direct future nurse patient
interactions , based on the patients responses to
the plan of care .
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Measuring Patient Goal/Outcomes
Achievement
1.
2.
Collecting evaluative data.
The data collected to determine whither the
identified health problems have been resolved
through goal achievement.
Documenting evaluation.
After the data have been collected the nurse
writes an evaluative statement to summarize
the findings. And the nurse has three decision
options for how goals have been (met …..
Partially met ….. not met...)
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Factors That Influence Goal/Outcome
Achievement
1.
2.
3.
Numerous patient:( cognitive , cooperate .etc )
Nurse: excellent , frustrate , bored.
Health care system : inadequate staffing .
relationships…. etc
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Documenting , Reporting and Conferring
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Documenting care.
Is the written , legal record of all pertinent
interaction with the patient assessing ,
diagnosing , planning , implementing and
evaluation to facilitate patient care .
Patient record.
Is a compilation of patients health information
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Purposes of Patient Records
1.
2.
3.
4.
5.
6.
Communication : between health care
professionals
Care planning : patient responding to treatment
from day to day .
Education : for the manifestations and
treatment
Decision analysis.
Research .
Legal documentation.
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Methods of Documentation
1.
2.
3.
4.
Source – oriented records : one in which each
health care group keeps data on its own
separate form .
Problem- oriented medical records:
POMR is organized around a patients problems
rather than a round sources of information .
Charting by exception:
Is a shorthand documentation method that
makes use of well-defined standards of practice
Computerized records.
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Common Methods of Communication
Among Health Care Professionals
 Face to face meeting.
 Telephone conversation.
 Written message.
 Computer message .
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Nursing Care Rounds
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1.
2.
Its procedures in which a group of nurses
visit selected patients individually at each
patient’s bed side to:
Evaluate the nursing care for the patient has
received.
Gather information to help plan nursing care.
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