NURSING PROCESS

PREPARED AND PRESENTED BY

MRS.S.ANUKRISHNAN,

VICE PRINCIPAL CUM HOD OBG NURSING,

P.D.BHARATESH COLLEGE OF NURSING,

HALAGA, BELGAUM.

NURSING PROCESS - INTRODUCTIONThe 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

ASSESSMENT

DIAGNOSING

PLANNING

IMPLEMENTING

EVALUATING

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.

NURSING PROCESS - INTRODUCTION

1. 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.

The Nursing Process is:

A systematic, rational method of

planning and

providing individualized nursing care.

DefinitionThe 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.

2. 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.

3. Benefits of Nursing Process1. 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

3. Benefits of 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

4. 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

5. Phases/Steps nursing process

a. Assessing

b. Diagnosing

c. Planning

d. Implementing

e. Evaluating

5. EVALUATIONa. Collect data related to outcomesb. Compare data with outcomesc. Relate nursing actions to client goals/outcomesd. Draw conclusions about problem statuse. Continue, modify, or terminate the client’s care plan

4. IMPLEMENTATIONa. Reassess the clientb. Determine the nurse’s need for

assistancec. Implement the nursing interventionsd. Supervise delegated casee. Document nursing activities

3. PLANNINGa. Prioritize problems/diagnosesb. Formulate goals/desired outcomec. Select nursing interventionsd. Write nursing orders

2. DIAGNOSINGa. Analyze datab. Identify health problems, risk, and

strengthsc. Formulate diagnostic statements

1. ASSESSINGa. Collect datab. Organize datac. Validate datad. Analyze datae. Document data

OVERVIEW

5. a. Assessing - Definition 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.

5. b. 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

5. c. 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 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

2.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

3.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

4.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.

Activities in Assessing phaseActivities:

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

5. d. Description of the assessment phasePhase Description Purpose Activities

i. Assessment Collecting, Organizing, Validating , Analyzing & Documenting 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.

5. d) a. Collecting Data – i. Meaning

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

◦ History of allergic

to penicillin

◦ Past surgical

procedures

◦ Folk healing

practices

◦ Chronic disease

Eg of Current

Problems

◦ pain, nausea, sleep

patterns & religious

practices.

5. d) a. ii.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.

5. d) a. iii.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.

5. d) a. iv. Data Collection Methods

The primary methods of data

collection are

◦I. Observing – Occurs whenever the

nurse is in contact with the client or

support persons.

◦II. Interviewing – is used while taking

the nursing health History

◦III. 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.

5. d) a. iv. I. Observing - Meaningis 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.

i. b. Methods of Observation

◦ 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)

i. c.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.

5. d) a. iv. II. 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 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

1. Used in direct interview,

2. Are restrictive

3. Generally requires yes of No or short factual answers

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

Eg. a. Are you having pain

now?b. What medication did

you take?

1. Associated with nondirective interview

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

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

4. An open ended question begins with what or how?

Eg. a. What brought you to

hospital?b. How did you feel in

that?

1. Is a question the client can answer without direction or pressure from the nurse.

2. Used in non directive that question.

Eg. a. How do you feel

about that?

b. Why do you think you had the operation?

1. Used in directive interview &

2. Thus directs client answer.

Eg.

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

b. 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

5. d) a. iv. III. 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. 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

BODY SYSTEM MODEL 1)THE INTEGUMENTARY SYSTEM

2)THE SKELETAL SYSTEM 3)THE MUSCULAR SYSTEM 4)THE NERVOUS SYSTEM 5)THE ENDOCRINE SYSTEM 6)THE CIRCULATORY SYSTEM 7)THE LYMPHATIC SYSTEM 8)THE RESPIRATORY SYSTEM 9)THE DIGESTIVE SYSTEM 10)THE URINARY SYSTEM 11)THE REPRODUCTIVE SYSTEM

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

c.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

d. Analyze dataCompare 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)