THE NURSING

PROCESS
ASSESSMENT: 1ST PHASE
• Systematic and continuous data collection .
• Purpose:
To establish a data base
Identify clients actual or potential problems
Types of assessment
1. Comprehensive
Initial assessment on first contact with client or on admission

Purpose
o Is to establish a complete data base
o Base line information
o Problem identification
Types of assessment cont.….
2. Problem focused / episodic
An ongoing process
Limited in scope
Short term
Screening for a specific problem

The purpose
To determine the status of a specific problem identified in an earlier
assessment
To identify new or overlooked problems
Assessment cont.…
3. Emergency – performed during physiologic , psychological or
sociological crises of the client.

Purpose:
to identify life – threatening problems
Assessment cont.….

4.Time- lapsed reassessment .- done several months after initial

assessment

Purpose
To compare the clients current status to baseline data previously
obtained
Activities in assessment
1. Data collection
sources of data
Primary – patient
Secondary – family, significant others, records, labs, etc

Types of data
Subjective – symptoms
Objective

Techniques/methods of colleting data.

Interview
Physical examination
2. Organization
 Clustering data using a frame work
systemic ( head to toe)
Henderson

 Which one do we use here?

Validate data – verifying data for completeness and accuracy

• Clarify statements
• Double check data
• Determine presence of factors that may interfere with accurate
measurements eg crying – R.R ,equipment .
• Check with experts and team members
• Recheck out-liars
• Compare objective and subjective data
Document/ communicate data

 Recording clients data

 Recording in a factual and not as interpreted.
Exercise 1
• Perform an initial assessment .
• Indicate;
Sources of data you have used
The type of data
• Identify with reasons the methods you have used in assessment
• Organize data
• How would you validate the data?
• Document the data obtained
Diagnosis/analysis
• The process of reasoning or the clinical act of …..
• The purpose is to identify health care needs and prepare a nursing
diagnosis.
• To diagnose in nursing – to analyse assessment information and drive
meaning from the analysis

Activities in diagnosis
1. Analyzing data
2. Identifying health problems, risks and strengths
3. Formulating diagnostic statements
Analyzing data
• Compare data against standards e.g. patients blood pressure with normal
parameters
• Cluster cues and making inferences about data –determining the relatedness of
facts e.g. cluster of;
o Vomiting
o Temp=39 degrees centigrade
o Mucous membrane dry ,etc
• Identify gaps and inconsistencies –which could arise from:
o Measurement error
o Unreliable reports
o Expectations
Identifying health problems, risks
and strength
Primarily a decision making process (nurse &patient/client )
• Determine problems – actual & risks
• Determine whether the problem is nursing diagnosis ,medical
diagnosis or collaborative problem.
• Determine strength and establish resources or ability to cope.
Formulating nursing diagnosis
statement (diagnosis)
Nursing diagnosis
 A statement of the client’s potential or actual health problem
resulting from analysis of data
 A statement of the client’s potential or actual changes in his health
status
 A statement that describes a client’s actual or potential health
problems that a nurse can identify and for which she can order
nursing interventions to maintain the health status , to reduce ,
eliminate or prevent alterations/changes
Nursing diagnosis …..
• NANDA clinical judgement about an individual, family or community
responses to actual and potential health problems/life processes .

• It provide the basis for selection of nursing intervention to achieve

outcomes for which nursing s accountable

• Identifies clients strengths and health problems that can be

resolved/preventing by collaborative and independent nursing
interventions.
Characteristics of nursing diagnosis
• It states a clear and concise health problem

• It is derived from existing evidences about the client

• It is potentially amenable to nursing therapy

• It is the basis of planning and carrying out nursing care

Potential (possible) nursing diagnosis- one in which evidence about a
health problem is incomplete or unclear therefore requires more data
to support or reject it ; or the causative factors are unknown but a
problem is only considered possible to occur.

 Possible nutritional deficit

 Possible low esteem r/t loss of a job
 Possible altered thought processes r/t unfamiliar surroundings
Components (structure) of nursing
diagnosis (NANDA)
The problem ( diagnostic label)

Definition

Defining characteristics
Problem (diagnosis label)
• Is a concise description of client’s health problem
• Describes client’s health problem or response for which nursing
therapy is given
• Its purpose is to direct the formation of client’s goals and desired
outcomes e.g. activity intolerance
definition
Classifies the meaning. It explains the meaning of the diagnostic label ‘a
state in which an individual has insufficient physiologic energy to
endure or complete required or desired daily activities
Defining characteristics
• The cluster of signs and symptoms that indicate the indicate the
presence of a practical diagnostic label for actual Nursing
diagnosis ,defining characteristics are the signs and symptoms

• Risk nursing diagnosis may not have subjective symptoms but

objective signs are present i.e. the factors that cause the client to be
more than ‘‘normal’’ vulnerable to the problem from the aetiology of
risk progresses
Types of nursing diagnosis
• Actual diagnosis- problem is present at the time of assessment

• It is based on the presence of associated signs and symptoms e.g

ineffective breathing pattern.
Examples …….
• Imbalanced nutrition: less than body requirements r/t decreased
appetite ,nausea
• Disturbed sleep pattern r/t cough ,fever and pain
• Ineffective airway clearance r/t to viscous secretions
• Noncompliance (diabetic diet) r/t unresolved anger about diagnosis
• Acute pain (chest) r/t cough secondary to pneumonia
• Activity intolerance r/t general weakness
• Anxiety r/t difficulty r/t difficulty of breathing & concerns over work
• Risk nursing diagnosis- is a clinical judgement that a problem does not
exist , therefore no S/S are present , but the presence of risk factors
indicate that a problem is likely to develop unless the nurse
intervenes.

• No subjective or objective cues are present.

• Therefore the factors that cause the client to be more vulnerable to

the problem are the aetiology in a risk nursing diagnosis
Examples
• Risk for impaired skin integrity (left ankle) r/t decreased peripheral
perfusion
• Risk for interrupted family processes r/t mother’s & unavailability to
provide child care.
• Risk for constipation r/t inactivity and insufficient fluid intake.
• Risk for infection r/t comprised immune system
• Risk for injury r/t decreased vision after cataract surgery
Cont..
• Pulse –weak, increased rate ,rhythm change ,failure to return to pre
activity level in 3 minutes

Etiology
• Related factors component of nursing diagnosis one or more causes
of the health problem; gives direction to the required nursing therapy
and enables the nurse to individualize the client’s care .
Cont..
• Pathophysiologic :
Cardiac factors – CCF, MI ,Angina
Circulatory – anaemia, arteriosclerosis
Pulmonary –COPD
Treatment related-surgery, medication
Situational –chronic fatigue, pain
Environmental –air pollution
Maturational –old age
Cont..
• Types of defining characteristics

 Major – must be present ; altered physiologic response to activity e.g.

 Respiratory- increased rate.
Shortness of breath

 Minor – may or may not be present e.g. defining characteristics of

activity intolerance
Cont.….
• Classification of diagnosis according to part statements -1 part, 2 parts ,3
parts .most nursing diagnoses are written as 2- or 3- part statement

• Basic 1 part statement

Wellness statement
Syndromes
• Basic 2 part statement
Problem(p)- activity intolerance
Etiology(e)- alterations in oxygen transport
Defining characteristics – signs and symptoms
PLANNING- the third phase
• A deliberate third phase of the nursing process.

• Involves decision making and problem solving.

• Nurses don’t plan alone or for the clients but with the clients
PLANNING
Types of planning
Initial planning – comprehensive plan for admission ,assessment done by
admitting nurse.
Ongoing planning –includes new information on clients response to care.
Purpose for daily planning is to :
Set priorities for a client during a shift
Decide problems to focus on.
Co-ordinate nurses activities and respond to client’s needs
Discharge planning starts on admission.
Cont.…
Activities in planning process
1. Selecting priorities
2. Formulating goals
3. Selecting nursing interventions
4. Writing nursing orders
5. Develop a nursing care plan
Cont.…
Selecting priorities
The process of establishing a preference order for nursing diagnosis and intervention
Diagnosis are grouped as – high, medium, low
Considerations
o Client’s health values and beliefs. What clients consider important
o Client’s priorities – educate clients appropriately when there is conflict on client’s
perception of what is important
o Resources available
o Urgency of the health problem, life threatening situation must be of high priority
o Medical treatment plan – harmonize with other health professions establishing
priority.
Cont..
Formulating goals
• Set with client where appropriate
• Goals describe observable and measurable client
responses/behaviour
• Goals contain desire outcome (specific expected level acceptable e.g.
improvement nutritional status –goal gain weight 1 kg by 5 weeks)
• Long term goals for long stay patients or home care agencies
• Goals are derived from nursing diagnosis
Cont..
• Purpose for desire outcomes/ goals
• Provides direction for planning nursing care
• Serves as a criteria for evaluating client progress
• Enable the client and the nurse to determine when the problem is
resolved
• Motivation for nurse and client as a sense of achievement is provided
Cont.….
Components of goal desired outcomes
 Subject : client though generally not written as it is assumed client is the subject
 Action verb : specifies an action a client is to perform e.g.
demonstrate ,verbalize etc.
 Conditions : circumstances under which action is performed .explains what,
when, where, or how.eg.
Walks with the help of crutches(how)
After attending two education sessions(when)
When at home(where)
Discuss signs of hypoglycaemia(what)
Cont..
Criterion:
Standard of desire or acceptable performance. Specifies time, speed,
distance and quantity e.g.
• Weighs 75 kgs. by Feb (time)
• Lists 5 out of 7 ( accuracy)
• Walks one stair per day(time and distance)
• Administers insulin using aseptic technique(quality )
Cont.…
Guidelines for writing goals :
o Write in terms of client responses not activities
o Desired outcomes must be realistic
o Compatibility with goals of other professionals
o Each goal is derived from only one nursing diagnosis
o Have 4 components
o Client considers goals as important and values them
Cont.…
Selecting priorities
The process of establishing a preference order for nursing diagnosis and
interventions
Diagnoses are grouped as –high, medium, low
 Problems that threaten life, dignity or integrity of the client.
 Problems that destructively destroy the client
 Problems that affect normal growth and development
 Priorities change as client’s responses, problems and therapies
change.
Cont.…
Criteria for the best nursing activities/ strategies
 Safe and appropriate
 Achievable with available resources
 Consistent with client’s values
 Based o scientific knowledge and experience
 Within established standards of care according to hospitals /or NCK
policies
Cont.….
Considerations made when assigning priorities
 Client’s health values and beliefs. What clients consider important
 Resources available
 Urgency of health problem, life threatening situation must be of high
priority.
 Medical treatment plan –harmonious with other health professions
establishing priority
Cont.….
Writing nursing orders
Nursing orders: specific instructions for specific activities performed by
the nurse to help the client meet established health goals.
Components of a nursing order
• Date
• Action
• Content area(where and what of the order)
• time
• Signature
Cont.….
After receiving a report from an night nurse , which of the following
patient should be nurse see first
• A 40 year old man with left sided weakness asking for assistance to
the bedside commode
• A 53 year old woman complaining of fever and is scheduled for open
reduction of a fracture
• A 65 year old man with an NG tube who had a bowel resection the
previous day
• A 31 year old woman with COPD complained of persistent cough
most of the night
Cont.…
From the arranged diagnoses above;
• Formulate goals /desired outcomes
• Select nursing interventions
• Write nursing orders
• Develop a nursing care plan
 present care plan for marking, presentation should follow laid dwon
protocol
IMPELEMETATION
• Execution of the nursing care plan
• Consists of doing ,delegation and rewarding
• Implementing steps provides the actual nursing activity and client
responses that are evaluated in the final step (evaluation)
Implementation skills
• Cognitive/intellectual : include problem solving, decision making,
critical thinking and creative thinking
• Interpersonal : verbal and non verbal skills for communication
• Technical : psychomotor for manipulations of equipment
Activities in implementation
• Reassessment of the patient-done just before carrying out the
procedure to determine if action is still relevant or if other more
urgent issues have cropped up.
• Determining need for assistance – nurse may be unable to perform
alone, assistance may reduce client’s stress ,nurse may lack the
required KAS
• Implementing nursing orders –patient preparation , actual observance
of procedure guidelines ,scheduling clients contacts ,serving as liaison
Activities in implementation…..
• Delegating and supervising
Determines who to carry out what actions
Ensures actions are in accordance with the policy guidelines

• communicating nursing action

Documentation –interventions and client responses
o Avoid duplication of activities especially in unconscious patients
o Communication of other members of the team.
o Legal documents
EVALUATION
• Evaluation includes determining whether the desired outcomes have
been met

• This is an ongoing process that determines how well the plan of care
is working and if the plan of care needs to be modified
A Time for reassessment
Evaluation requires continued reassessment of the client’s condition,
and determines
Appropriateness of nursing actions
Need to revise interventions
Development of new client problems /needs
Need to rearrange priorities to meet changing demands
How do you evaluate ?
• Direct observation

• Client interview

• Review of records ; progress notes, flow sheets, nursing notes

Components of evaluation
Expected outcomes
 Identification of expected outcomes.
 Collect data related to expected outcomes
 Draw conclusions about problem status ;
Resolved
Revised
Continue
Expected outcomes are either :

• Met
• Not met
• Partially met
EO: Met
Document what client assessment findings show that the expected
outcome is met
 How do you know as a nurse that this expected outcome is met?
 What has happened to prove the problem is solved
 Which intervention can be terminated?
 How easily were the outcomes achieved?
 Can timelines be shortened
• Actual problem resolved
Nursing diagnosis is discontinued
• High risk problem resolved
Risk factors no longer exist
Nursing diagnosis is discontinues
• Problem still exists
Revise interventions
EO: partially met
• Document the assessment findings that indicate that progress has
been made, but there is still work to do.

How do you know that progress has been made?

What needs to be done to make continued progress?

EO: Not met
• Document what has been done that hasn’t worked so other HCP will
be aware.
 How do you know that the clients has not met the EO?

 What are the assessment findings that support this?

 What are your ideas for change?

If EO is not met ask these questions
• Were the outcomes realistic and appropriate?

• Was the client involved in setting the outcomes?

• Does the client believe the outcomes were important?

• Does the client know why the outcomes have not been met?
• Has all the interventions planned been carried out and in the
timeframe specified?

• If not, why not? Were they too vague or misinterpreted?

• What variables may have affected achievements of the outcomes?

• Were new problems and adverse client responses detected early

enough to make appropriate changes in the plan of care?
Modification of the plan of care

When evaluation indicates a change in the plan of care is needed ,’’back

up’’ through the nursing process to see where areas for change lie .
How to write evaluation

• EO was met, partially met, or not met.

• Any new or additional data
• Any changes that were made in the intervention as a result of ongoing
assessment
• How the interventions helped achieve the goal
ANA Standard VI
• Evaluation : the nurse evaluates the client’s progress toward attainment of
outcomes
• 1. Evaluation is systematic ongoing ,and criterion-based
• 2. The client, family, and other healthcare providers are involved in the
evaluation process as appropriate.
• 3. Ongoing assessment data are used to revise diagnosis, outcomes, and
the plan of care, as needed.
• 4. Revision in diagnoses, outcomes, and the plan of care are documented
• 5. The effectiveness of interventions is evaluated in relation to outcomes.
• 6. The patients responses to interventions are documented
Documentation and reporting
• Process of making an entry on a client’s record
• Legal documents that provides evidence for client’s care

Documenting nursing activities

• Client record should describe client’s ongoing status and reflect full
range of the nursing process
• Admission nursing assessment ( initial data base)
Purpose of records
• Communication
• Planning client care
• Auditing for quality management
• Research
• Education
• Reimbursement
• Legal document
• Health care systems
Cont.….
Where do we document?
o Nursing care plans
o Kardex –series of cards kept in portable index file
o Flow sheets-fluid intake charts, medication records, vital signs charts.
o Nursing discharge/referral summaries
Guidelines for recording
• Date and time
• Timing-as soon as an action is performed
• Legibility
• Performance
• Accepted technology
• Correct spelling-consider:
o ‘’light’’ for light
o ‘’was’’ for wash
Cont.…
• Signature
• Accuracy
• Sequence
• Appropriateness
• Completeness
• Conciseness
• Report must be both written and verbal
Reports are given during:
• Change of shift
• Telephone- must be documented
• Telephone orders
• Nursing conferences
• Nursing rounds
Key elements of change of shift
report
• Orderliness
• Client’s identification & physical location in the ward.
• Diagnosis
• Duration of stay
• Date of admission
• Reasons for admission
• Significant previous health history
• Current health status
Cont.…
• Investigations done & findings
• Treatment and nursing interventions in the last 24 hours & response.
• Include patient’s progress since admission
• Client’s special needs e.g. emotional support
• Current treatment being given/to be given
• State priorities of care due in the new shift
• Comprehensiveness
• Concise
Example of nursing diagnoses
1. After receiving the report, patient X doing 2nd day post admission
with a diagnosis of gastritis reports abdominal pain. The patient
rates his pain at 5 in a scale of 1 to 10. using nursing process plan
for the care of patient X.
Assessment
Patient reporting/ verbalizes abdominal pain,
Appears restless
Pain rated at 5 in a scale of 1 to 10.
Nursing diagnosis
Acute pain related to inflammation of the gastric and intestinal mucusa
as evidenced by the patient verbalizing pain, rated at 5/10.

Expected outcome/ goal

The patient will have a pain relief to a rate of 1/10 and be calm within
45 minutes
Nursing interventions
reassure the patient
Position the patient on lateral positions
Monitor vital signs
Administer analgesics as prescribed
Implementation
Patient reassured
Patient positioned on right lateral position
Vital observations monitored
Intravenous paracetamol 1000mg administered

Evaluation
Patient calm, reports pain relief and rates the pain at 1/10 after 45
minutes
2. During a routine check on patients, nurse June finds patient Y
covering himself fully and asks for more blankets, the patients reports
to be feeling cold. Upon checking the body temperature, it reads
38.7◦C. the patient is being managed for malaria. Using the nursing
process plan for the care of patient Y for the next 12 hours.

Assessment
Patient reports to be feeling cold
Core body temperature of 38.7
Nursing diagnosis
Hyperthermia related to inflammatory process aimed at eliminating an
infectious agent as evidenced by the patient feeling cold and a body
temperature of 38.7

Goal / expected outcome

To allay anxiety
The body temperature to be within normal ranges within one hour
To increase patient’s comfort throughout the shift.
Intervention
Reassure the patient
Reduce the number of the blankets the patient is using
Check the vitals at the moment
Administer an antipyretic medication as prescribed e.g. paracetamol
Implementation
Patient reassured
Patient exposed to facilitate heat loss
Windows opened to allow flow of air currents in the room to facilitate heat
loss.
Paracetamol 1 gram intravenous administered; works by blocking the
production of prostaglandins that mediate the elevation of body
temperature through inflammatory process.

Evaluation
Patient should start feeling comfortable after 30 minutes; onset of drug
effects
Temperature to be between 36.5 and 37.7 degrees centigrade
3. Nurse George working in the casualty of a facility receives a 38 year
old patient presenting with complaints of three episodes of diarrhea
and five episodes of vomiting. Using nursing process, describe the plan
of care for the patient

Nursing diagnosis
Risk for fluid and electrolyte imbalance related to increased
gastrointestinal motility hindering water and electrolyte absorption in
the colon
Goal/ expected outcome
Reduce gastrointestinal motility to enhance absorption of water and
electrolytes
Replace the lost electrolyte and fluids
Increase comfort of the patient
Intervention
Monitor blood pressure
Position the patient in a couch, establish an intravenous access using a
large bore canular.
Infuse lactated ringers alternating with normal saline 0.9%.
Administer analgesia, most preferably loperamide 4mg stat and 2 mg
with every motion.
Provide intravenous dextrose.
Reassure the patient/ the accompanying family members
Implementation
Patient position the patient in the most comfortable.
I.V access acquired and fluid resuscitation started. NS/RL.
Dextrose infusion

Evaluation
Assess dehydration, skin turgor
Monitor blood pressure
Monitor blood sugar
Keep fluid input output for the first 48 hours
Assignment
1. State four differences between medical and nursing diagnoses
2. Familiarize with the NANDA list of nursing diagnoses and formulate
at least two nursing diagnoses in each domain based on the
assessment.
The end