 THE NURSING PROCESS

 5 STEPS IN NURSING PROCESS

MODULE 9 

NURSING ASSESSMENT
DEVELOPING THE NURSE-PATIENT RELATIONSHIP FOR DATA COLLECTION
TYPE OF ASSESSMENTS
NURSING AS A SCIENCE: NURSING PROCESS 
 TYPE OF DATA
 SOURCES OF DATA
 THE PATIENT-CENTERED INTERVIW
 INTERVIEW TECHNIUES
 COMPONENTS OF THE NURSING HEALTH HISTORY
 NURSING DIAGNOSIS
 HISTORY OF NURSING DIAGNOSIS
 TYPE OF NURSING DIAGNOSIS
 DATA CLUSTERING
 DATA INTERPRETATION
THE NURSING PROCESS  FORMLATING A NURSING DIAGNOSIS STATEMENT
 CONCEPT MAPPING NURSING DIAGNOSIS
 Definition: The nursing process is a systematic,  SOURCES OF DIADNOSTIC ERROR
problem-solving method used by nurses to assess,  DOCUMENTATION AND INFORATICS
 NURSING DIAGNOSIS:APPLICATION TO CARE PLANNING
diagnose, plan, implement, and evaluate care. It  PLANNING NURSING CARE
ensures personalized care and promotes critical  ESTABLISHING PRIORITIES
thinking.  CRITICAL THINGKING IN SETING GOAL
 ROAL OF THE PATIENT IN GOAL/ OUTCOME SETTING
 SETTING GOALS AND EXPECTED OUCOMES
 WRITIING GOALS AND EXPECTED OUTCOMES
5 STEPS IN THE NURSING PROCESS  TYPE OF INTERVENTION
1. Assessment: Collecting comprehensive data about  SELECTION OF INTERVENTION: FACTORS TO CONSIDER
 NURSING INTERVENTION CLASSIFICATION
the patient’s health status.
 SYSTEM FOR PLANNING NURSING CARE
2. Diagnosis: Analyzing assessment data to identify  HAND-OFF REPORTING
health problems or nursing diagnoses.  STUDENT CARE PLANS
 CONSULTING OTHER HEALTH CARE PROFESSIONALS
3. Planning: Developing a plan of care with goals,  CONCEPT MAPS
outcomes, and interventions.
4. Implementation: Carrying out the interventions and
care plan.
5. Evaluation: Assessing the effectiveness of the interventions and the achievement of outcomes.

NURSING ASSESSMENT
 Purpose: The first step in the nursing process, involving the collection of information to create an accurate picture of the
patient's health status. It includes gathering both subjective and objective data to guide nursing decisions.

DEVELOPING THE NURSE-PATIENT RELATIONSHIP FOR DATA COLLECTION

 Importance: Building trust and rapport with the patient is crucial to gather accurate data. A strong relationship promotes
open communication and effective data collection.

TYPE OF ASSESSMENTS
 Comprehensive Assessment: In-depth review of the patient's health, including a full medical history and physical
examination.
 Focused Assessment: A more specific evaluation based on the patient’s current problems or complaints.
 Ongoing Assessment: Continuous assessments that occur at regular intervals during patient care.
 Emergency Assessment: Rapid assessment to identify life-threatening conditions in urgent situations.

TYPE OF DATA
 Subjective Data: Information provided by the patient, including symptoms, feelings, and perceptions.
 Objective Data: Observable and measurable data, such as vital signs, physical examination findings, and diagnostic test
results.

SOURCES OF DATA
 Primary Source: The patient (most reliable).
 Secondary Sources: Family members, medical records, diagnostic tests, or healthcare providers.

THE PATIENT-CENTERED INTERVIEW

 Definition: A focused conversation with the patient to gather personal, medical, and psychosocial information. The nurse’s
goal is to gain an understanding of the patient’s needs, experiences, and values.
 Phases: Introduction, body, and closing.

INTERVIEW TECHNIQUES
 Open-ended Questions: Allow the patient to express themselves freely (e.g., "How are you feeling today?").

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  Closed-ended Questions: Require specific responses, usually yes or no (e.g., "Do you have any allergies?").
 Clarification: Helps to ensure understanding of the patient’s statements.
 Reflection: Restating what the patient says to demonstrate understanding.

COMPONENTS OF THE NURSING HEALTH HISTORY

 Biographical Information: Name, age, gender, occupation, etc.
 Reason for Seeking Care: The patient’s chief complaint or reason for visit.
 Health History: Past medical conditions, surgeries, and treatments.
 Family History: Health issues within the family that could affect the patient.
 Lifestyle and Health Practices: Diet, exercise, habits, and other lifestyle factors.
 Psychosocial History: Social, emotional, and mental well-being.
 Review of Systems: A systematic review to assess each body system for issues.

NURSING DIAGNOSIS
 Definition: A clinical judgment about an individual’s response to a health condition or problem. It provides a focus for
patient care and guides nursing interventions.
 Components:
o Problem: The health issue.
o Etiology: The cause or contributing factors.
o Symptoms: Observable or measurable evidence.

HISTORY OF NURSING DIAGNOSIS

 1940s-1950s: The concept of nursing diagnosis began to develop.
 1973: The North American Nursing Diagnosis Association (NANDA) was founded, creating a standardized language for
nursing diagnoses.

TYPE OF NURSING DIAGNOSIS

 Problem-focused: Current issues or concerns that need immediate attention.
 Risk diagnosis: Potential problems or health risks that may develop.
 Health Promotion: The patient’s readiness to improve or maintain health.

DATA CLUSTERING
 Definition: Grouping related assessment data together to identify patterns and trends that help in forming a diagnosis.

DATA INTERPRETATION
 Definition: Analyzing collected data to identify health problems or risks and to form nursing diagnoses.

FORMULATING A NURSING DIAGNOSIS STATEMENT

 Structure:
o P: Problem (nursing diagnosis label)
o E: Etiology (cause or contributing factors)
o S: Symptoms (evidence or defining characteristics)
o Example: "Impaired mobility related to pain as evidenced by difficulty walking."

CONCEPT MAPPING NURSING DIAGNOSIS

 Definition: A visual representation that helps connect the patient's nursing diagnoses with appropriate interventions,
facilitating a holistic approach to care.

SOURCES OF DIAGNOSTIC ERROR

 Possible errors:
o Incomplete or inaccurate data collection
o Failure to interpret data correctly
o Bias in diagnosis
 Prevention: Careful and thorough data collection, peer review, and clinical judgment.

DOCUMENTATION AND INFORMATICS

 Importance: Accurate and complete documentation is essential for continuity of care, legal protection, and
communication among healthcare providers. Informatics tools (such as EHRs) facilitate effective documentation.

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 NURSING DIAGNOSIS: APPLICATION TO CARE PLANNING
 Use: Nursing diagnoses serve as the foundation for care planning by identifying the patient’s health needs and forming the
basis for interventions.

PLANNING NURSING CARE

 Definition: The nurse develops a care plan with clear, individualized goals and expected outcomes to guide patient care.
 Components:
o Diagnosis
o Expected Outcomes
o Nursing Interventions
o Evaluation Methods

ESTABLISHING PRIORITIES
 Priority Levels:
o High Priority: Immediate, life-threatening conditions.
o Medium Priority: Conditions that may cause harm if not addressed.
o Low Priority: Conditions that are not life-threatening or urgent.

CRITICAL THINKING IN SETTING GOALS

 SMART Goals:
o Specific
o Measurable
o Attainable
o Realistic
o Time-bound
 Critical thinking helps ensure that the goals are patient-centered and achievable.

ROLE OF THE PATIENT IN GOAL/OUTCOME SETTING

 Involvement: The patient should be actively involved in setting goals to ensure they are meaningful and aligned with their
values, preferences, and capabilities.

SETTING GOALS AND EXPECTED OUTCOMES

 Goal Setting: The nurse and patient work together to create goals that are specific, measurable, and achievable.
 Expected Outcomes: These are the measurable indicators that determine if the goals are met.

WRITING GOALS AND EXPECTED OUTCOMES

 Guidelines: Goals should be written clearly, with a focus on the patient's desired outcomes. Use measurable terms (e.g.,
"Patient will demonstrate improved mobility by the end of the week").

TYPE OF INTERVENTION
 Independent Nursing Interventions: Actions nurses can take without a physician’s order (e.g., patient education).
 Dependent Nursing Interventions: Actions that require a physician’s order (e.g., administering medications).
 Collaborative Interventions: Actions performed in conjunction with other healthcare team members (e.g., physical
therapy).

SELECTION OF INTERVENTION: FACTORS TO CONSIDER

 Patient’s condition: Specific needs and preferences.
 Nurse’s skills and knowledge: What interventions the nurse is capable of performing.
 Available resources: Equipment, medications, personnel.
 Evidence-based practice: Interventions supported by research.

NURSING INTERVENTION CLASSIFICATION (NIC)

 Definition: A standardized system for classifying and categorizing nursing interventions to guide practice.

SYSTEMS FOR PLANNING NURSING CARE

 Nursing Care Plan: Includes all aspects of patient care, including assessments, diagnoses, goals, interventions, and
evaluations.
 Interdisciplinary Care Plan: Involves input from various healthcare professionals to address the patient’s needs holistically.
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 HAND-OFF REPORTING
 Definition: A communication process that occurs when transferring responsibility for patient care from one nurse to
another.
 Effective Communication: Ensures that the next healthcare provider receives all the relevant information to continue
providing quality care.

STUDENT CARE PLANS

 Purpose: Care plans used in educational settings to help students develop critical thinking and clinical skills.
 Features: Often more detailed than clinical care plans, focusing on the educational process and nursing process steps.

CONSULTING OTHER HEALTH CARE PROFESSIONALS

 Definition: Nurses may consult specialists or other healthcare team members to address complex health issues.
 Process: Nurses can refer to specialists, request consultations, or collaborate with other professionals to provide the best
care for patients.

CONCEPT MAPS
 Definition: A visual tool to represent connections between different concepts, such as nursing diagnoses, goals,
interventions, and outcomes. It helps clarify thinking and enhances understanding of complex patient needs.

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