NURSING PROCESS
PRESENTED BY AIMAN ALI
VISION COLLEGE OF NURSING
MUZAFFARGARH`````````````````````````````````````
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OBJECTIVES
1. Define nursing process.
2. Describe the purposes of nursing process.
3. Identify the components of the nursing
process
4. Discuss the requirements for effective use of
the nursing process
5. Describe the functional health approach to
the nursing process
2
NURSING PROCESS
The nursing process is a dynamic & modified form of
scientific method used in nursing profession to assess
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client needs and create a course of action to address
and solve patient problems.
OR
An organized sequence of problem-solving steps used to
identify and to manage the health problems of clients.
It is accepted for clinical practice established by the
American Nurses Association
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PURPOSE OF NURSING
PROCESS
To identify a client’s health status and actual or
potential health care problems or needs.
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet
those needs.
Purpose is to provide client care that is :
Individualized
Holistic
Effective
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Efficient
COMPONENTS OF NURSING
PROCESS
The Nursing Process utilizes the following steps
1. Assessment (data collection),
2. Nursing diagnosis,
3. Planning,
4. Implementation
5. Evaluation.
Steps remain the same
Applications and result are different 5
COMPONENTS OF NURSING
PROCESS
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CHARACTERISTICS OF
NURSING PROCESS
Cyclic
Dynamic nature,
Client centeredness
Focus on problem solving and decision
making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking and clinical
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reasoning
1. ASSESSMENT
It involves
Collection of data
Organizing the data
Validating the data
Documenting the data
Assessment is the systematic and continuous
collection, organization, validation, and
documentation of data (information).
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1. ASSESSMENT
Types of assessment
The four different types of assessments are;
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1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
The ultimate Purpose of assessment is
data collection. 9
1. ASSESSMENT
1. Initial nursing assessment:
Performed within specified time after
admission.
To establish a complete database for
problem identification.
Eg: Nursing admission assessment
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1. ASSESSMENT
2. Problem-focused assessment :
To determine the status of a specific
problem identified in an earlier
assessment. Eg: hourly checking of vital
signs of fever patient
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1. ASSESSMENT
3. Emergency assessment:
During emergency situation to identify any
life threatening situation. Eg: Rapid
assessment of an individual’s airway,
breathing status, and circulation during a
cardiac arrest.
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1. ASSESSMENT
4. Time-lapsed reassessment:
Several months after initial assessment. To
compare the client’s current health status
with the data previously obtained
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COMPONENTS OF ASSESSMENT
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1. ASSESSMENT
Collection of data
Data collection is the process of gathering
information about a client’s health status.
It includes the health history, physical
examination, results of laboratory and
diagnostic tests, and material contributed
by other health personnel.
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1. ASSESSMENT
Types of Data:
1. Subjective data
2. Objective data.
1. Subjective data
Also referred to as symptoms or covert
data, are clear only to the person affected
and can be described only by that
person. Itching, pain, and feelings of
worry are examples of subjective data. 16
1. ASSESSMENT
2. 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
example, a discoloration of the skin or a
blood pressure reading is objective data. 17
1. ASSESSMENT
Sources of Data
Sources of data are primary or secondary.
1. Primary : It is the direct source of
information. The client is the primary source of
data.
2. Secondary: It is the indirect source of
information. All sources other than the client
are considered secondary sources. Family
members, health professionals, records and
reports, laboratory and diagnostic results are 18
secondary sources.
METHODS OF DATA
COLLECTION
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1. ASSESSMENT
Organization of data
The nurse uses a format that organizes the
assessment data systematically. This is
often referred to as nursing health history
or nursing assessment form
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1. ASSESSMENT
Validation of data
The information gathered during the
assessment is “double-checked” or
verified to confirm that it is accurate and
complete.
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1. ASSESSMENT
Documentation of data
To complete the assessment phase, the nurse
records client data. Accurate
documentation is essential and should
include all data collected about the client’s
health status.
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2. DIAGNOSIS
Diagnosis is the second phase of the nursing
process. In this phase, nurses use critical
thinking skills to interpret assessment data to
identify client problems.
(NANDA) define or refine nursing diagnosis.
The official NANDA definition of a nursing
diagnosis is:
“a clinical judgment concerning a human response
to health conditions/life processes, or a
vulnerability for that response, by an individual, 23
family, group, or community.”
2. DIAGNOSIS
Diagnosing is to :
1.Analyza data
2. Identify health problems,risks and
strengths
3. Formulate diagnostic
statement
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STATUS OF THE NURSING
DIAGNOSES
“Status refers to the actuality or potentiality of the
diagnosis or the categorization of the diagnosis”
(NANDA International, 2009, p. 44).The kinds
of nursing diagnoses according to status are
1. Actual
2. Health promotion
3. Risk
4. Wellness.
5. Possible Nursing Diagnosis
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6. Syndrome Nursing diagnosis
1. ACTUAL DIAGNOSIS
An actual diagnosis is a client peoblem that
is present at the time of Nursing
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assessment. Examples are ineffective
breathing pattern and anxiety.
It is based on the presence of associated
signs and symptoms
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2. HEALTH PROMOTION
DIAGNOSIS
A health promotion diagnosis relates to
clients’preparedness to implement
behaviors to improve their health
condition. These diagnosis labels begin
with the phrase Readiness for Enhanced,
as in Readiness for Enhanced Nutrition
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3. RISK NURSING DIAGNOSIS
A risk nursing diagnosis is a clinical judgment that
a problem does not exist, but the presence of risk
factors indicates that a problem is likely to
develop unless nurses intervene.
For example, all people admitted to a hospital have some
possibility of acquiring an infection; however, a client
with diabetes or a compromised immune system is at
higher risk than others. Therefore, the nurse would
appropriately use the label Risk for Infection to describe
the client’s health status. 28
4. WELLNESS NURSING
DIAGNOSIS
It is clinical judgment about an individual,
group or community in transition from a
specific level of wellness to a higher level
of wellness. Eg: Family coping: potential
for growth related to unexpected birth of
twins.
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5. POSSIBLE NURSING
DIAGNOSIS
It describe a suspected problem for which current
and available data are insufficient to validate the
problem. eg: Possible social isolation related to
unknown etiology.
Eg: An elderly widow who lives alone is admitted
to the hospital. The nurse notices that she has no
visitors and is pleased with attention and
conversation from the nursing staff .The nurse
may write a nursing diagnosis of possible social 30
isolation related to unknown etiology.
6. SYNDROME NURSING
DIAGNOSIS
It is a cluster of nursing diagnosis that frequently go
together and present a clinical picture.
Eg:
Chronic Pain syndrome
Rape Trauma Syndrome
Disuse syndrome (long term bed riddenpatients)
Clusters of diagnoses associated with Disuse syndrome
syndrome include Impaired Physical Mobility,Riskfor
Impaired Tissue Integrity, Risk for Activity Intolerance,
Risk for Constipation, Risk for Infection, Risk for Injury, 31
Risk for Powerlessness, Impaired Gas Exchange, and so on .
COMPONENTS OF A NURSING
DIAGNOSIS
A nursing diagnosis has three components:
(1) The problem statement or Diagnostic
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Lable
(2) The etiology (related factors & risk
factors)
(3) Signs & Symptoms or the defining
characteristics
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1.PROBLEM STATEMENT
(DIAGNOSTIC LABEL)
It Describes the patient health status or response to
health problems for which nursing therapy is
given.
The purpose of the diagnostic label is to direct the
formation of client goals and desired outcomes.
It may also suggest some nursing interventions.
Eg: for example, Deficient Knowledge (Medications)
or Deficient Knowledge (Dietary Adjustments).
Similarly., Activity intolerance or Constipation etc 33
2. ETIOLOGY (RELATED
FACTORS & RISK FACTORS)
The etiology component of a nursing diagnosis
identifies causes of the health problem.These are
causative factors that have influenced the clients
actual or potential response to the healthproblem
Eg: Activity intolerance related to generalized
weakness or obesity or sedentary lifestyle.
Constipation related to inadequate fluid intake or
inadequate fiber intake.
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3. DEFINING CHARACTERISTICS
(S/S)
Defining characteristics are the cluster of signs
and symptoms that indicate the presence of a
particular diagnostic label or health problem.
e.g Fluid volume deficit related to decreased oral
intake manifested by dry skin and mucus
membranes.
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THE DIAGNOSTIC PROCESS
The diagnostic process has three steps:
Analyzing data
Identifying health problems, risks, and
strengths
Formulating diagnostic statements.
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FORMULATING DIAGNOSTIC
STATEMENT
Most nursing diagnosis are written as two part or
three parts statements
Basic Two Part Statements: It is also called PE
format
Problem (P) – statement of the patients response
Etiology (E) – factors contributing to or probable
cause of the response
Example:Problem(P)relatedtoEtiology(E)
Activity intolerance related to generalized
weaknessorobesity 37
FORMULATING DIAGNOSTIC
STATEMENT
Basic Three Part Statements
It is also called as PES format & includes:
1.Problem (P) – Statement of the patient’s response
2.Etiology (E)
Factors contributing to or probable causes of the responses.
3.Signs & Symptoms (S)
Defining characteristics evidenced by the client
Example: Problem related to etiology as evidenced by
signs &symptoms
Activity intolerance related to generalized weakness
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evidenced by fatigue
DIFFERENCE BETWEEN NURSING
DIAGNOSIS MEDICAL DIAGNOSIS
Nursing Diagnosis Medical Diagnosis
It is a statement of nursing It is made by a physician
judgment and refers to a and refers to a condition
condition that nurses are that only a physician can
licensed to treat. treat.
It is a statement of nursing It is a statement of medical
judgment. judgment.
It describe a patients Medical diagnoses refer to
physical, sociocultural, disease processes OR It
psychologic and spiritual describes a patient’s
responses to an illness or a specific pathophysiologic
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health problem. responses to an illness.
DIFFERENCE BETWEEN
NURSING DIAGNOSIS MEDICAL
DIAGNOSIS
Nursing Diagnosis Medical Diagnosis
The patient’s nursing The patient’s medical
diagnosis change as the diagnosis remains the same
client’s response change for as long as the disease
process is present
Nursing diagnosis relate
Nurses are obligated to
to the nurse’s independent carry out physician
function prescribed treatment
Eg:Tepid sponging for (dependent function).
fever Eg: Tab. Paracetamol
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500mg for fever
DIFFERENCE BETWEEN
NURSING DIAGNOSIS MEDICAL
DIAGNOSIS
Nursing Diagnosis Medical Diagnosis
Ineffective breathing Asthma
pattern
Activity intolerance Cerebrovascular accident
Acute pain Appendicitis
Disturbed body image
Amputation 41
PLANNING
Planning is the third phase of the nursing process,
in which the nurse and client develop client
goals/ desired outcomes and nursing strategies to
prevent, reduce or alleviate the client’s health
problems.
It is the process of formulating client goals and
designing the nursing interventions required to
prevent, reduce, or eliminate the client’s health
problems.
Planning involves decision making and problem 42
solving.
TYPES OF PLANNING
1. Initial Planning : Planning which is done after the
initial assessment. The nurse who performs the
admission assessment usually develops the initial
comprehensive plan of care.
2. Ongoing Planning : It is a continuous planning. As
nurses obtain new information and evaluate the client’s
responses to care, they can individualize the initial care
plan further. It occurs at the beginning of a shift as the
nurse plans the care to be given that day
3. Discharge Planning :The process of anticipating and
planning for needs after discharge, is a crucial part of a
comprehensive health care and should be addressed in 43
each client’s care plan.
PLANNING PROCESS
It involves
Prioritize problems/ diagnosis
Formulate goals/desired outcomes
Select Nursing intervension
Write Nursing intervention
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PLANNING PROCESS
1. Setting priorities
The nurse begin planning by deciding which
nursing diagnosis requires attention first, which
second, and so on.
Nurses frequently use Maslow’s hierarchy of
needs when setting priorities.
Example: In this physiologic needs such as air,
food and water are basic to life and receive
higher priority than the need for security or
activity 45
Maslow's Hierarchy of Needs
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PLANNING PROCESS
2. Establishing client goals/desired outcomes
After establishing priorities, the nurse set goals
for each nursing diagnosis. Goals may be
short term or long term
Client goals / desired outcomes: It is a specific
and measurable behavior or response that
reflects a clients highest possible level of
wellness and independence in function.
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TYPES OF GOALS
Short Term Goals Long Term Goaals
It is an objective that is It is an objective that is
expected to achieved / expected to believe over a
with in a short time, longer time frame, usually
usually less than a week. over weeks or months .
Example: Client will Example: Client will
achieve comfort with in adhere to post operative
24 hours post operatively activity restrict
Clientwill raise right arm Client will regain full use
to shoulder height by of right arm in 6 weeks
Friday ions for one month 48
PLANNING PROCESS
3. Nursing interventions
A nursing intervention is any treatment, that
a nurse performs to improve patient’s
health.
OR
These are the actions that nurses perform to
achieve the clients goals
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TYPES OF NURSING
INTERVENTIONS
1. Independent interventions are those activities
that nurses are licensed to initiate on the basis
of their knowledge and skills.
2. Dependent interventions are activities carried
out under the orders or supervision of a
licensed physician.
3. Collaborative interventions are actions the nurse
carries out in collaboration with other health
team members
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4. IMPLEMENTATION
In the nursing process, implementing is the action
phase in which the nurse performs the nursing
interventions. Implementing consists of doing and
documenting the activities that are the specific
nursing actions needed to carry out the
interventions.
The nurse performs or delegates the nursing
activities for the interventions that were developed
in the planning step and then concludes the
implementing step by recording nursing activities 51
and the resulting client responses.
PROCESS OF IMPLEMENTING
The process of implementing normally
includes the following:
Reassessing the client
Determining the nurse’s need for
assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities.
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PROCESS OF IMPLEMENTING
1. Reassessing the Client
Just before implementing an intervention, the nurse must reassess the
client to make sure the intervention is still needed.
2. Determining the Nurse’s Need for Assistance
When implementing some nursing interventions, the nurse may require
assistance for one or more of the following reasons:
The nurse is unable to implement the nursing activity safely or
efficiently alone (e.g., ambulating an unsteady obese client).
Assistance would reduce stress on the client (e.g., turning a person
who experiences acute pain when moved).
The nurse lacks the knowledge or skills to implement a particular
nursing activity (e.g., a nurse who is not familiar with a particular
model of traction equipment needs assistance the first time it is 53
applied).
PROCESS OF IMPLEMENTING
3. Implementing the Nursing Interventions
It is important to explain to the client what
interventions will be done, what sensations
to expect, what the client is expected to do,
and what the expected outcome is.
For many nursing activities, it is also
important to ensure the client’s privacy, for
example by closing doors, pulling curtains,
or draping the client. 54
PROCESS OF IMPLEMENTING
4. Supervising Delegated Care
If care has been delegated to other health care personnel, the
nurse responsible for the client’s overall care must ensure
that the activities have been implemented according to the
care plan.
Other caregivers may be required to communicate their
activities to the nurse by documenting them on the client
record, reporting verbally, or filling out a written form.
The nurse validates and responds to any adverse findings or
client responses. This may involve modifying the nursing
care plan.
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PROCESS OF IMPLEMENTING
5. Documenting nursing activities.
After carrying out the nursing activities, the
nurse completes the implementing phase
by recording the interventions and client
responses in the nursing progress notes.
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EVALUATION
Evaluation is a planned, ongoing,
purposeful activity in which the nurse
determines
(A) the client’s progress toward
achievement of goals/outcomes and
(B) the effectiveness of the nursing care
plan.
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REFERENCES
kozier & Erb’s Fundamental of Nursing ,8 th
edition(Audrey Berman ,Shirlee J.
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Synder).
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