NURSING PROCESS

DEFINITION
Nursing process is a critical thinking
process that professional nurses use to
apply the best available evidence to
caregiving and promoting human functions
and responses to health and illness
(American Nurses Association, 2010).
 The nursing process is a systematic
rational method of planning and
providing individualized nursing care.
(KOZIER)
Purposes 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.
Characteristics of Nursing Process
 Systematic / Cyclic
 Dynamic nature,
 Client centered
 Outcome oriented
 Focus on problem solving and decision

making
 Interpersonal and collaborative
 Universal applicability
 Use of critical thinking and clinical reasoning.
Components Of Nursing Process
(Steps / Elements / Phases)
 Assessment (Data Collection)
 Nursing Diagnosis
 Planning
 Implementation
 Evaluation
Definition
Assessment is the systematic and continuous
collection, organization, validation and
documentation of data (Kozier).

Assessment is the deliberate & systematic

collection of data to determine a client’s current
& past health status & functional status & to
determine the client’s present & past coping
patterns (Potter & Perry).
Types of assessment

1. Initial nursing assessment

2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
1. Initial nursing assessment
It is Performed within specified time
(shortly) after admission.
E.g. Nursing admission assessment
PURPOSES
 To determine a complete database for

problem identification ,reference & future

comparison.
2. Problem-focused assessment
Nurses gathers data about a specific
problem which is identified in an
earlier assessment.
E.g. Hourly checking of vital signs of fever
patient , Hourly checking of I/O chart
PURPOSES
To determine the status of a specific
problem
3. Emergency assessment
When a physiological or psychological crisis
is present in patient , the nurse performs an
emergency assessment to identify any life
threatening problem.
E.g. Rapid assessment of an individual’s
circulation , airway & breathing status during
a cardiac arrest.
PURPOSES
 To identify any life threatening problem.
4. Time-lapsed reassessment
It is scheduled to compare a patient’s
current status to baseline data obtained
earlier . It is done several months after
initial assessment.
E.g. Assessment of patient who receive
nursing care over longer period of time
PURPOSES
 Tocompare the client’s current health
status with the data previously obtained
Steps in 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.
Types of Data
Two types: Subjective data and Objective
data.
1. Subjective data /symptoms /covert
data, are perceived & described only by
the affected person.
E.g. Pain, itching, and feelings of worry are
examples of subjective data.
2. Objective data / signs / 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.
E.g. a discoloration of the skin or
assessment of vital signs is objective data.
Sources of Data
Sources of data are primary or
secondary.

1. Primary: It is the direct source of

information. The client is the primary & best
source of data unless the client is infants
or children ,critically ill or confused to
communicate clearly.
2. Secondary: It is the indirect source of
information. All sources other than the client
are considered secondary sources. Family
members or other supporting persons,
health care professionals, records and
reports, laboratory or diagnostic results &
relevant literature are secondary sources.
Methods of data collection
The methods used to collect data are
observation, interview and examination.

 Observation : It is gathering data by

using the senses.
◦Used to obtain following types of data:
 Level of consciousness ,Posture (vision)
 Body or breath odors (smell)
 Breath sound (hearing)
 Skin temperature (touch)
 Interview
An interview is a planned
communication or a conversation with a
purpose. Nursing history is obtained by
interviewing .
There are two approaches to interviewing:
 Directive / Closed ended

 Nondirective / Open ended

• The directive interview is highly
structured and directly ask the questions.
And the nurse controls the interview.

• A nondirective interview, or rapport

building interview and the nurse allows the
client to control the interview.
 Closed Question Open-ended Question

 Directive
 Nondirective
 Specify broad topic to
 Restrictive
discuss
◦ Yes/no
◦ Factual
 Invite longer answers
 Less effort and  Get more information
information from
from client
client
 Response are easily
 Response are difficult
documented to document

Copyright 2008 by Pearson Education, Inc.

STAGES / PHASES OF AN
INTERVIEW
An interview has three major stages:
1. The opening or Orientation phase
2. The body or Working phase
3. The closing or Termination phase

Examination
The physical examination is a
systematic data collection method to
detect health problems. To conduct the
examination, the nurse uses techniques of
inspection, palpation, percussion and
auscultation.
 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.
 Validation of data
The information gathered during the
assessment is “double-checked” or verified
to confirm that it is accurate and complete.
 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.
Diagnosis
It is the second phase of the nursing process.
In this phase, nurses use critical thinking skills
to interpret assessment data to identify client
problems.
Nursing diagnosis is a clinical judgment
about individual, family, group or community
responses to actual & potential health
problems / life processes that the nurse is
licensed & competent to treat.
(NANDA International 2012)
Status (types) of the Nursing
Diagnosis
Actual, risk, health promotion / wellness
and syndrome nursing diagnosis.
1. An actual diagnosis is a client problem
that is present at the time of the nursing
assessment. It is based on the associated
signs & symptoms
2. A risk (possible) nursing diagnosis is a
clinical judgment that a problem does not
exist, but the presence of risk factors
indicates that a problem may develop if
adequate care is not given.
3. A health promotion / wellness nursing
diagnosis prefers to clients’ preparedness
to implement behaviors to improve their
health condition.
4. Syndrome nursing diagnosis comprise
a cluster of actual or risk nursing diagnosis
that are predicted to be present because
of certain event or situation .
Components of a NANDA
Nursing Diagnosis (Parts)
A nursing diagnosis has three components:
(1) The problem (diagnostic label)
(2) The etiology (related factors & risk
factors)
(3) The defining characteristics.
1. The problem (diagnostic label) describes
the client’s health problem or response.

2. The etiology identifies causes or

contributing factor of the health problem.

3. Defining characteristics are the cluster of

signs and symptoms that signal the
existence of health problem.
PROBLEM ETIOLOGY DEFINING
CHARACTERISTICS

Activity intolerance • Generalized  Verbal report of

weakness fatigue / weakness

• Imbalanced  Abnormal heart

between O2 supply rate & BP to activity
& demand
 Extertional
• Immobility discomfort /
dyspnea
• Sedentary life
style
Steps in Nursing Diagnosis
 Analyzing data
Steps in analyzing
 Compare data against standards
 Clustering the cues / Grouping of cues
 Identify gaps & inconsistencies
 Identifying Health Problems ,
Risk & Strength
 Determining problems & risks
 Determining strength
Formulating Diagnostic
Statements
Most of the nursing diagnosis are written
as three - part , two – part , one – part
statement , but there are variations of
these.
Basic three-part nursing diagnosis
statement is called the PES format and
includes the following:
1. Problem (P) : statement of the client’s
response (NANDA label)
2. Etiology (E) : causes of the health
problem / contributing factor
3. Signs and symptoms (S) : defining
characteristics manifested by the client.
Basic two - part nursing diagnosis
statement includes
1. Problem (P) : statement of the client’s
response (NANDA label)
2. Etiology (E) : causes of the health
problem / contributing factor
One – part statement
Health promotion & syndrome nursing
diagnosis consist of a NANDA label only.
More specific interventions can be derived
from the label itself , therefore etiology
may not be needed.
Health promotion nursing diagnosis
(Readiness for enhanced parenting)
Syndrome nursing diagnosis ( Risk for
disuse syndrome)
There are five variations of the basic
formats:
 Writing unknown etiology when the

defining characteristics are present but

the nurse does not know the cause or
contributing factors
 Using the phrase complex factors when

there are too many etiologic factors or

when they are too complex to state in a
brief phrase
 Using the word possible to describe either the
problem or the etiology when the nurse believes
more data are needed about the client’s problem
or the etiology
 Using secondary to divide the etiology into two

parts, thereby making the statement more

descriptive and useful (the part following
secondary to is often a pathophysiologic or
disease process or a medical diagnosis)
 Adding a second part to the general response or

NANDA label to make it more precise

Guidelines for writing nursing
diagnosis statement
 State terms of a problem , not a need.
 Word the statement so that it is legally
advisable.
 Use nonjudgemental statements.
 Make sure that both elements of the
statement do not say the same thing
 Be sure that cause & effects are correctly
stated.
 Word the diagnosis specifically & precisely
to provide direction for planning nursing
intervention .
 Use nursing terminology rather than
medical terminology to describe the
client’s response
To improve diagnostic reasoning and
avoid diagnostic reasoning errors, the
nurse should do the following
 verify diagnoses by talking with the client and
family, build a good knowledge base and acquire
clinical experience, have a working knowledge of
what is normal, consult resources, base
diagnoses on patterns (that is, behavior over time)
rather than an isolated incident, and improve
critical-thinking skills.
Taxonomy
It is the practice and science of
categorization and classification.
Taxonomy of Nursing Diagnoses is helping
for the development of a standardized
nursing language
 The NANDA-I taxonomy currently includes
206 nursing diagnoses that are grouped
(classified) within 13 domains (categories)
of nursing practice: Health Promotion;
Nutrition; Elimination and Exchange;
Activity/Rest; Perception/Cognition; Self-
Perception; Role Relationships; Sexuality;
Coping/Stress Tolerance; Life Principles;
Safety/Protection; Comfort;
Growth/Development .
PLANNING
• It is a deliberative, systematic phase of the
nursing process that involves decision
making and problem solving.
• It is the process of formulating client goals
and designing the nursing interventions
required to prevent, reduce, or eliminate
the client’s health problems.
TYPES (STAGES) OF PLANNING

1. Initial Planning
2. Ongoing Planning
3. Discharge Planning
1. Initial Planning : Planning which is done
after the initial assessment. This
comprehensive plan addresses each
problem listed in the prioritized nursing
diagnoses & identifies appropriate patient
goal & related nursing care.
2. Ongoing Planning : It is a continuous
planning. It is to keep the plan up to date
to facilitate the resolution of health
problems, manage risk factors & promote
function.
3. Discharge Planning : It is the process of
anticipating & planning for needs after
discharge. It is a crucial part of
comprehensive health care plan & should
be address in each client’s care plan.
 Activities of (Steps) Planning
process
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and activities
• Writing individualized nursing interventions
on care plans.
 Setting priorities
• The nurse & client begin planning by deciding
which nursing diagnosis requires attention first,
which second, and so on.
• Identify factors that the nurse must consider
when setting priorities.
Establish a preferential sequence for addressing
nursing diagnoses and interventions
◦High priority (life-threatening)
◦Medium priority (health-threatening)
◦Low priority (developmental needs)
 Consider the following factors
 Client’s health values and beliefs
 Client’s priorities
 Resources available to the nurse and
client
 Urgency of the health problem
 Medical treatment plan
 Nurses
frequently use Maslow’s hierarchy of
human needs when setting priorities.
Establishing client goals/desired Outcomes
 • After establishing priorities, the nurse set
goals for each nursing diagnosis. Goals may
be short term or long term
 short term goal– It is useful for client who
require health care for a short time
 long term goal – Achieved by 6 weeks or more

.
Relationship of goals/desired outcomes
to the nursing diagnoses.
 Goals derived from the client’s Nursing
Diagnosis – primarily from diagnostic label
 Diagnostic label contains the unhealthy
response (problem)
 Goal/desired outcome demonstrates
resolution of the unhealthy response
(problem)
Components of goals/desired outcome
statement.
 Subject
 Verb
 Condition or modifier
 Criterion of desired performance
Guidelines for Writing Goal/Outcome
Statements
 Write in terms of the client responses
 Must be realistic
 Ensure compatibility with the therapies of

other professionals
 Derive from only one nursing diagnosis
 Use observable, measurable terms
 Selecting nursing interventions
and activities
Nursing interventions
A nursing intervention is any treatment, that a
nurse performs to improve patient’s health.
Purposes
 To reduce / eliminate contributing factors of the

nursing diagnosis
 Promote higher level wellness
 Prevent problem
 Monitor & evaluate status
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
Criteria for Choosing Appropriate
Intervention
 Safe and appropriate for the client’s age, health
and condition
 Achievable with the resources available
 Congruent with the client’s values, beliefs, and
culture
 Congruent with other therapies
 Based on nursing knowledge and experience
or knowledge from relevant sciences
 Within established standards of care
 Writing individualized nursing
interventions on care plans.
• After choosing the appropriate nursing
interventions, the nurse writes them on the care
plan.
• Nursing care plan is the end product of
planning phase of the nursing process.
Nursing care plan
Nursing care plan may be formal or
informal.
Formal Nursing care plan
It is a written or computerized information
about the client’s care.
Informal Nursing care plan
It is a strategy of action that exists in the
nurse’s mind.
Standardized care plan
It is a formal plan that specifies the
nursing care (action) for groups of clients
with common needs . They are written
from the perspective of what care the
client can expect .
E.g. Care plan for all clients with myocardial
infarction
Individualized care plan
It is tailored to meet the unique needs of
a specific client – needs that are not
addressed by the standardized care plan .
The nurse must decide which of the
client’s problem need individualized care
plan & which need standardized care plan.
Protocols
These are predeveloped to indicate the
actions commonly required for a particular
group of clients. It may include both
primary care provider’s order & nursing
interventions.
E.g. care for a client receiving continuous
epidural analgesia
Policies & procedures
These are developed to govern the
handling of frequently occurring situations
E.g. hospital may have a policy specifying
the number of visitors a client may have.
Some polices & procedures are similar to
protocols & specify what is to be done
E.g. in case of cardiac arrest
Standing order
It is a written document about policies,
rules, regulations or order regarding client
care. Standing orders give nurses
authority to carry out specific actions
under certain circumstances, often when a
primary care provider is not immediately
available.
Format for nursing care plan
 Student care plans
The nursing care plan helps the students to
apply knowledge gained from the literature & the
classroom to a practice situation. The care plan
that students are required to develop are often
more detailed than those used in practice setting.
They may also modify the plan by adding
‘Rationale’ after the nursing interventions.
Rationale is the evidence based principle given
as the reason for selecting a particular nursing
intervention.
Institutional care plans
It become the part of a client’s legal
medical record. Many hospital use a
kardex nursing care plan. Kardex is a
trade name for a card – filling system that
allows quick reference to the needs of the
client for certain aspects of nursing care.
 Computerized care plans
Nurses now often use computerized
plans of nursing care as part of the
electronic medical record. The computer
can generate both standardized &
individualized care plans. Nurses access
the client’s stored care plans from a
centrally located terminals at the nurses
station or from terminals in client rooms.
 Community based care plan
The client / family unit must be able to
independently provide the majority of
health care. So design a plan to educate
the client / family about the necessary
care techniques & precautions .
 Multidisciplinary (Collaborative)
care plans
These are tools used in case
management to communicate the
standardized, interdisciplinary plan of care for
the client. It outlines the care required for
clients with common, predictable usually
medical conditions. It also referred to as
critical pathways / clinical pathways / care
maps , are sequence the care that must be
given on each day during the projected length
of stay for the specific type of condition.
 Concept map
It is a visual tool in which ideas or data
are enclosed in circles or boxes of some
shape & relationship between these are
indicated by connecting lines or arrows . It
is a diagram of patient problem &
interventions.
Guidelines for Writing Nursing Care Plans
 Date and sign the plan
 Use category headings
 Use standardized/approved terminology and

symbols
 Be specific
 Include collaborative & coordination activities
 Refer to other sources
 Individualize the plan to the client
 Incorporate prevention and health maintenance
 Include discharge and home care plans
Implementation
It consists of doing and documenting the
activities that are specific nursing actions
needed to carry out the interventions.
Implementing skills
 Cognitive skills
 Interpersonal skills
 Technical skills
The process of implementation
includes;
• Reassessing the client
• Determining the nurse’s needs for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
Evaluation
It is a planned, ongoing, purposeful activity in
which the nurse determines the client’s
progress toward achievement of goals/
outcomes and the effectiveness of the nursing
care plan.
Components of evaluation phase
 Collectingdata related to the desired outcome
 Comparing the data with desired outcomes
 Relating nursing activities to outcomes
 Drawing conclusion about problem status
 Continuing, modifying, or terminating the

nursing care plan.