NURSING PROCESS

Introduction The Nursing Process enables the nurse to

organize and deliver nursing care.

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.

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.

The term Nursing process originated in 1955

by Hall and Johnson (1959),

Orlando (1961) & Wiedenbach (1963) were

the first user with a series of phases

describing the process of nursing.

DefinitionIt 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.

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.

Purposes

1] Identify a client’s health status &

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.

Phases/Steps nursing process

1] Assessing

2] Diagnosing

3] Planning

4] Implementing

5] Evaluating

Characteristics of the Nursing Process1] 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.

Assessing It is the systematic and continuous collection,

organization, validation, and documentation of

data (information). 

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.

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

Initial

assessment

Performed

within

specified time

after

admission to a

health care

agency.

To establish a

complete

database for

problem

identification,

reference, and

future

comparison

Nursing

admission

assessment

Type Time performed Purpose Example

Problem-

focused

assessment

Ongoing

process

integrated with

nursing care

To determine

the status of a

specific

problem

identified in

an earlier

assessment

Hourly assessment of client’s fluid intake and urinary output in an ICU

Assessment of client’s ability to perform self care while assisting a client to bathe.

Type Time performed Purpose Example

Emergency

assessment

During any

physiologic or

psychologic

crisis of the

client

To identify life-

threatening

problems

Rapid assessment of a person’s airway, breathing status, and circulation during a cardiac arrest Assessment of suicidal tendencies or potential for violence.

Type Time performed Purpose Example

Time-lapsed

reassessment

Several

months after

initial

assessment

To compare the

client’s current

status to

baseline data

previously

obtained.

Reassessment of a client’s functional health patterns in a home care 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.

Critical thinking

ASSESSMENT

DIAGNOSING

PLANNING

IMPLEMENTING

EVALUATING

Description of the assessment phasePhase Description Purpose Activities

AssessmentCollecting,

Organizing,

Validating &

Documentin

g client data.

To establish

database about the

client’s response

to health concerns

or illness and the

ability to manage

health care needs.

Establish a database Obtain a nursing health

history Conduct a physical

assessment Review client records Review Nursing

literature Consult support

persons Consult health

professionals update data as needed organize data validate data communicate / document data.

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.

A data base is all the information

about a client; it includes

◦ Nursing health history,

◦ Physical assessment,

◦ The history & physical examination,

◦ Results of laboratory & diagnostic tests,

◦ And material contributed by other health

personnel.

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◦History of

allergic to penicillin

◦Past surgical procedures

◦Folk healing practices

◦Chronic disease

Eg of Current Problems◦pain, nausea,

sleep patterns & religious practices.

Types of data Subjective Data

also referred to as symptoms

or covert data

can be verified described by

only the person who

affected.

Eg. Itching, pain, feelings of

worry.

It includes the client’s

sensations, feelings values,

beliefs, attitudes and

perception of personal health

status and life situation.

Objective data

also referred to as signs or overt

data,

are detectable by an observer or

can be measured or tested

against an accepted standard.

They can be seen, heard felt or

smelled and

they are obtained by observation

or physical examination

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. No.

Subjective Data Objective Data

1 I have fever Body tem – 1000F

Tachycardia – 100 bt/mt

Dull & tired

Dried lips

2 I feel sick to my

stomach

Vomited 100ml of green tinged fluid

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.

InterviewingAn 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 specific informations

Rapport- building interview (understanding between two or more people)

Nurse establishes purpose of interview and controls the interview

Nurse allows the client to control the purpose, subject 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 question

Neutral questions

Leading question

Used in direct interview, Are restrictive

Generally requires yes of No or short factual answers

Often begin with when, where, who, what, do, did or does, or is, are, was.

Eg. Are you having pain now?What medication did you take?

Associated with nondirective interview

Invite clients to discover & explore, elaborate, clarify or illustrate their thoughts or feelings.

It specifies only the broad topic to be discussed & invites longer that one or two words.

An open ended question begins with what or how?Eg. What brought you to hospital?How did you feel in that?

Is a question the client can answer with out direction or pressure from the nurse.

Used in non directive that question.

Eg. How do you feel about that?

Why do you think you had the operation?

Used in directive interview &

Thus directs client answer.

Eg.

You’re stressed about surgery tomorrow, aren’t you?

You’ll take medicine won’t you?

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: - 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

System wise approach

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.

Validating data helps nurse in following

tasks.

1] Ensure that assessment information is

complete.

2] Ensure that objective data & related

subjective data agree.

3] Obtain additional information that may

have been overlooked.

4] Differentiate between cues &

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

(Eg. cues nurse observes incision is red,

hot & swollen. nurse makes the inference

that the incision is infected

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)