NURSING

PROCESS
NURSING PROCESS -
INTRODUCTION
The term NURSING PROCESS originated in
1955 by Haul.
Johnson (1959), Orlando (1961), and Wiedenbach
(1963) were the first users of the term nursing
process.
The Nursing Process enables the nurse to organize
and deliver nursing care.
NURSING PROCESS - INTRODUCTION
For the successful application of Nursing Process,
◦ the nurse integrates elements of critical thinking to make
judgments

◦ and take actions based on reason.

The nursing process is used to

◦ identify, diagnose and treat human responses to health and
illness.
 Critical
thinking

EVALU
ATING

IMPLEM ASSES
ENTING SMENT

PLAN DIAGN
NING OSING
NURSING PROCESS - INTRODUCTION

It is a dynamic continuous process as the clients

need change.
The use of Nursing Process promotes
individualized nursing care
And assists the nurse in responding to client needs
in a timely and reasonable manner to improve or
maintain the client’s level of health.
Definition
It is a systematic, rational method of
planning and providing nursing care. Its
goal is to identify a client’s health care
status and actual or potential health
problems, to establish plans to meet the
identified needs, and to deliver specific
nursing interventions to address those needs.
The Nursing Process is:

A systematic, rational method of planning and

providing individualized nursing care.

Definition
The nursing process is cyclical, that is, its
components follow a logical sequence, but
more than one component may be involved at
one time. At the end of the first cycle, care
may be terminated if goals are achieved, or
cycle may continue with reassessment or plan
of care may be modified.
It is synonymous with the PROBLEM SOLVING
APPROACH that directs the nurse and the client
to determine the need for nursing care, to plan and
implement the care and evaluate the result.
It is a G O S H approach (goal-oriented,
organized, systematic and humanistic care) for
efficient and effective provision of nursing care.
PURPOSE OF THE NURSING PROCESS

1. Identify a client’s health status and actual or

Potential health problems or needs.

2. To establish plans to meet the identified needs.

3. Deliver specific nursing interventions to meet

those needs.
PURPOSE OF THE NURSING PROCESS

4. To Achieve Scientifically- Based,

Holistic, Individualized Care For
The Client.

5. To Achieve The Opportunity To

Work Collaboratively With
Clients, Others.

6. To Achieve Continuity Of Care.

 Benefits of Nursing Process
1. Provides an orderly & systematic method for planning &
providing care

2. Enhances nursing efficiency by standardizing nursing

practice

3. Facilitates documentation of care

4. Provides a unity of language for the nursing profession

5. Is economical

6. Stresses the independent function of nurses

7. Increases care quality through the use of deliberate actions

 Benefits of using the nursing process

1. Continuity of care

2. Prevention of duplication

3. Individualized care

4. Standards of care

5. Increased client participation

6. Collaboration of care
Characteristics of the Nursing Process
1] Cyclic & dynamic in nature

2] Client centered

3] Focus on problem solving & Decision making

4] Interpersonal & Collaborative style

5] Universal applicability

6] Use of critical thinking.

7] Data from each phase provide input into the next phase.

8]Decision making involved in every phase of nursing

process.
 CHARACTERISTICS:
a. Systematic:
 The nursing process has an ordered sequence of activities
and each activity depends on the accuracy of the activity
that precedes it and influences the activity following it.
b.Dynamic:
 The nursing process has great interaction and
overlapping among the activities and each activity is
fluid and flows into the next activity
c. Interpersonal: The nursing process ensures that nurses
are client-centered rather than task-centered and
encourages them to work to enhance client’s strengths
and meet human needs.
 d. Goal-directed: The nursing process is a means for
nurses and clients to work together to identify specific
goals (wellness promotion, disease and illness
prevention, health restoration, coping and altered
functioning) that are most important to the client, and to
match them with the appropriate nursing actions
e. Universally applicable:
 The nursing process allows nurses to practice nursing
with well or ill people, young or old, in any type of
practice setting
Phases/Steps nursing process
a. Assessing
b. Diagnosing
c. Planning
d. Implementing
e. Evaluating
 1. ASSESSING
a. Collect data
b. Organize data
c. Validate data
d. Analyze data
e. Document data
O 2. DIAGNOSING
a. Analyze data

V b. Identify health problems, risk, and

strengths
c. Formulate diagnostic statements
E 3. PLANNING

R a. Prioritize problems/diagnoses
b. Formulate goals/desired outcome
c. Select nursing interventions
V d. Write nursing orders

4. IMPLEMENTATION
I a. Reassess the client
b. Determine the nurse’s need for

E assistance
c. Implement the nursing interventions
d. Supervise delegated case
W 5. EVALUATION
e. Document nursing activities

a. Collect data related to outcomes

b. Compare data with outcomes
c. Relate nursing actions to client goals/outcomes
d. Draw conclusions about problem status
e. Continue, modify, or terminate the client’s care plan
Assessing
 It is the systematic and continuous collection, organization,
validation, and documentation of data (information) as
compared to what is standard / norm . 
 It is continuous process carried out during all phases of the
nursing process.
 For Eg. In evaluation phase assessment is done to
determine the outcomes of the nursing strategies and to
evaluate goal achievement.
 All phases of nursing process depend on the accurate and
complete collection of data.
 Purpose of Assessment
1. To establish a data base (all the information
about the client):

2. Nursing health history

3. Physical assessment

4. The physician’s history & physical examination

5. Results of laboratory & diagnostic tests

6. Material from other health personnel

 Types of assessment

There are 4 different types of assessment:-

1] Initial assessment
2] Problem focused assessment
3] Emergency assessment
4] Time lapsed reassessment
 Type Time performed Purpose Example

1.Initial Performed To establish a Nursing

assessment within complete admission
specified time database for assessment
after problem
admission to identification,
a health care reference, and
agency. future
comparison
 Type Time performed Purpose Example

2.Problem- Ongoing To determine Hourly

focused process the status of a assessment of
assessment integrated with specific client’s fluid
nursing care problem intake and
identified in an urinary output
earlier in an ICU
assessment
Assessment of
client’s ability
to perform self
care while
assisting a
client to bathe.
 Type Time performed Purpose Example

3.Emergenc During any To identify life- Rapid

y assessment physiologic or threatening assessment of a
psychologic problems person’s
crisis of the airway,
client breathing
status, and
circulation
during a
cardiac arrest
Assessment of
suicidal
tendencies or
potential for
violence.
 Type Time Purpose Example
performed
4.Time- Several To compare the Reassessment
lapsed months after client’s current of a client’s
reassessment initial status to functional
assessment baseline data health patterns
previously in a home care
obtained. or outpatient
setting or, in a
hospital, at
shift change.
 Assessment varies according to
◦ purpose,
◦ timing,
◦ time available &
◦ client status.
 Nursing assessments focus on a client response to a
health problem.
A Nursing assessment include the clients perceived
needs, health problems, related experience , health
practices, values and life styles.
 Data should be relevant to a particular health problem.
 Activities in Assessing phase
Activities:

a. Collection of data
b. Validation of data
c. Organization of data
d. Analyzing of data
e. Recording/documentation of data
Assessment = Observation of the patient + Interview
of patient, family & Significant Others + examination
of the patient + Review of medical record
 Description of the assessment phase
Phase Description Purpose Activities

Assessment Collecting, To establish Establish a database

Organizing, database about  Obtain a nursing
health history
Validating , the client’s  Conduct a physical
Analyzing & response to health assessment
Documenting concerns or  Review client records
client data. illness and the  Review Nursing
ability to manage literature
 Consult support
health care needs. persons
 Consult health
professionals update
data as needed
organize data validate
data communicate /
document data.
a.Collecting Data
Is the process of gathering information about a
client’s health status.
It must be both systematic & continuous
To prevent the omission of significant data &
reflect a client’s changing health status.
 To collect data clearly both the client & nurse must
actively participate.
 • Client data includes past history as well as
current problems.
 Eg of Past history  Eg of Current Problems
◦ History of allergic to
◦ pain, nausea, sleep
penicillin
patterns & religious
◦ Past surgical
practices.
procedures

◦ Folk healing practices

◦ Chronic disease
 Types of data
Subjective Data Objective data
 Also referred to as symptoms or  Also referred to as signs or overt

covert data data,

 Can be verified described by only  Are detectable by an observer or

the person who affected.  Can be measured or tested against an

 Eg. Itching, pain, feelings of accepted standard.

worry.  They can be seen, heard felt or

 It includes the client’s sensations, smelled and

feelings values, beliefs, attitudes  They are obtained by observation or

and perception of personal health physical examination

status and life situation.  For eg. Discoloration of skin, BP

reading.
 During Physical Examination, the nurse obtains objective
data to validate subjective data.
 Information supplied by family members, significant others
or health professionals are considered subjective if it is not
based on fact.
A complete data base of both subjective & objective data
provides a base line for comparing the client’s responses to
nursing & medical intervention.
 Eg. Of subjective & objective data.
Sl. Subjective Data Objective Data
No.
1 I have fever Body tem – 1000F
Tachycardia – 100 bt/mt
Dull & tired
Dried lips

2 I feel sick to my Vomited 100ml of green tinged fluid

stomach Abdomen firm
Slightly distended
Active bowel sounds in all 4 quadrants

3 I am short of breath RR – 28br/mt

Tachypnoea
Lung sound diminished in ® lower lobe.
 Sources of Data
 Sources of data are primary or secondary.
 The client is the primary source of data.
 Secondary or indirect sources are family members or other
support persons, other health professionals, records &
reports laboratory and diagnostic analyses, and relevant
literature.
 All sources other than the client are considered secondary
sources.
Client
The best source of data
unless the client is to ill, young or
confused to communicate clearly.
The client can provide subjective data that
no one else can offer.
Support people
 Family members, friends and care givers who know the
client well often can supplement or verify information
provided by the client.
◦ They might convey information about the client’s response
to illness
◦ the stresses client was experiencing before the illness,
◦ family attitudes on illness and health,
◦ and the clients home environment.
 Support people data are very important in case of a client
who is very young unconscious or confused. Eg. Mentally ill
 Client Records
 It includes information documented by various health care
professionals.
 Client records also contain data regarding the client’s
occupation, religion, and marital status.
 By reviewing the records the nurse can avoid asking questions
for which answers have already been supplied.
 Medical records (Medical history, physical examination,
operative report, progress notes & consultations by Physicians.)
 Records of therapies – Social workers, nutritionists, dietitians or
physical therapists
Laboratory records and
Health care professionals.
 Data Collection Methods
The primary methods of data collection are
◦ Observing – Occurs whenever the nursing is in
contact with the client or support persons.
◦ Interviewing – is used while taking the nursing
health History
◦ Examining – Major method used in the physical
health assessment.
In reality, the nurse uses all three methods
simultaneously when assessing clients.
for Eg. During the client interview the
nurse observes, listens, asks questions,
and mentally retains information to
explore in the physical examination.
Observing
is to gather data by using the senses.
Observation is a conscious, deliberate skill
that is developed through effort & with an
organized approach.
Eg. Using the senses to observe client data.
◦ Vision :- overall appearance (body size ,
general weight, signs of distress or posture &
grooming) discomfort, facial & body gestures,
skin colour & lesions
◦ Smell: - Body or Breath odors.
◦ Hearing: - lung, heart sounds, bowel sounds,
ability to communicate, language spoken.
◦ Touch :- Skin temperature, moisture, muscle
strength (Hand grip)
 Two aspects of Observation
1] Noticing the data
2] Selecting, organizing & interpreting the data
Eg : - A nurse who observes that a client’s face is
flushed, must relate that observation to body
temperature, activity, environmental temperature,
and blood pressure.
Errors can occur in selecting, organizing &
interpreting data.
 Nursing observations must be organized so that nothing significant

is missed.

 Most nurses develop a particular sequence for observing events,

usually focusing on the client first.

 For Eg. A nurse walks into a client’s room and observes, in the

following order.
1]Clinical signs of client distress (Eg. pallor or flushing, labored breathing, and

behavior indicating pain or emotional distress)

2] Threats to clients safety, real or anticipated (Eg. a lowered side rail)

3]The presence and functioning of associated equipment (Eg. Equipment &

oxygen)

4] The immediate environment, including the people in it.

 Interviewing
An interview is a planned communication or a
conversation with a purpose
for Eg. to get or give information, identify
problems of mutual concern, evaluate change,
teach
Eg. for an Interview is nursing Health history.
There are 2 approaches in interview

Direct Indirect or nondirective

 Direct Indirect or nondirective
Highly structured & elicits Rapport- building interview
specific informations (understanding between two
or more people)
Nurse establishes purpose of Nurse allows the client to
interview and controls the control the purpose, subject
interview matter and pacing

Clients who responds may

have limited opportunity to
ask question or Discuss
concerns
 Types of interview questions
There are 4 types of interview questions
Closed question
Open ended question
Neutral questions
Leading question
 Closed question Open ended Neutral questions Leading question
question
1. Used in direct 1. Associated with 1. Is a question the 1. Used in directive
interview, nondirective client can answer interview &
interview without direction or
2. Are restrictive 2. Invite clients to pressure from the 2. Thus directs client
discover & nurse. answer.
3. Generally requires explore, elaborate,
yes of No or short clarify or illustrate Eg.
factual answers their thoughts or 2. Used in non
feelings. directive that
question. a. You’re stressed
4. Often begin with about surgery
3. It specifies only the
when, where, who, tomorrow, aren’t
broad topic to be Eg.
what, do, did or you?
discussed & invites a. How do you feel
does, or is, are,
longer that one or about that?
was. b. You’ll take medicine
two words.
Eg. won’t you?
a. Are you having pain 4. An open ended b. Why do you think
now? question begins you had the
b. What medication did with what or how? operation?
you take? Eg.
a. What brought you to
hospital?
b. How did you feel in
that?
 Planning the interview and setting

Before beginning an interview, the nurse

reviews available information.
Eg. Operative report, information about the
current illness.
Each interview is influenced by time, place,
seating arrangement or distance, and
language.
 Time: -
Nurse need to plan for an interview with hospitalized clients
◦ physically comfortable,
◦ free of pain,
◦ when interruptions by friends, family, and other health
professionals are minimal.

The client should be made to feel comfortable & unhurried.

 Place: - Well lighted, well ventilated, moderate sized
room, free of nurse, movements, interruptions encourages
the communication.
 Seating arrangements: -
 Distance:-
Stages of an interview
 Opening or introduction 2 steps
1] establish rapport
2] orientation
Body or development – closing
Examining
Physical examination or physical
assessment is a systematic data collection
method that uses observation to detect
health problems.
To conduct examination the nurse uses
techniques of 1) Inspection 2) auscultation,
3) palpation, 4) percussion.
Inspection
Palpation
Auscultation
Percussion
Inspection: - Process of checking that things
are in the correct condition.
Auscultation: - Examining the internal organs
by listening to the sounds that they give out
Palpation: - Examination of organ by touches
or pressure of the hand over the part.
Percussion: - Tapping with the fingers or with
a light hammer upon any part of the body.
 The physical examination is carried our
systematically.
 It may be organized according to the examiner’s
preference,
 Head to toe approach (Cephalo caudal approach)
 System wise approach – examine all the body system
 Review of system approach – examine only particular
area affected
b.Validating Data
The information gathered during assessment
phase must be complete, factual, and
accurate because the nursing diagnoses and
interventions are based on this information.
Validation is double checking or verifying
the data is accurate and factual.
 Purposes of data validation
1. Ensure that data collection is complete
2. Ensure that objective and subjective data agree
3. Obtain additional data that may have been
overlooked
4. Avoid jumping to conclusion
5. Differentiate cues and inferences
 Cues - subjective and objective data that can be directly
observed by the nurse.

(What client can say, what the nurse can see, hear, feel, smell
or measure)
 Inferences - Nurses interpretation or conclusions made
based on the cues

Example:

1. Red, swollen wound = infected wound

2. Dry skin = dehydrated

c. Organization of data
 Uses a written or computerized format that organizes
assessment data systematically.
 Maslow’s basic needs
 Body system model
 Gordon’s functional health patterns
Gordon’s Functional Health Patterns:
i. Health perception-health management pattern.

ii. Nutritional-metabolic pattern

iii. Elimination pattern

iv. Activity-exercise pattern

v. Sleep-rest pattern

vi. Cognitive-perceptual pattern

vii. Self-perception-concept pattern

viii. Role-relationship pattern

ix. Sexuality-reproductive pattern

x. Coping-stress tolerance pattern

xi. Value-belief pattern

 d. Analyze data
 Compare data against standard and identify significant
cues.
 Standard/norm are generally accepted measurements,
model, pattern:

Ex:

1. Normal vital signs,

2. Standard weight and height,

3. Normal laboratory/diagnostic values,

4. Normal growth and development pattern

 e. Documenting data
 To complete the assessment phase, the nurse records client data.
 record in a factual manner
 It includes all data collected about client status.
 Eg. Data in factual manner Wrong manner
 Slice of toast – I Appetite is good”
 Egg - I “normal appetite”
 Juice - 250ml.
 Coffee- 240ml.

- Record subjective data in client’s own words (more accuracy)