Nursing

Process
Ns. Nuning Khurotul Af’ida, S.Kep.,M.Kep.
 Objective

• After reading this chapter, the student will

be able to
– Define nursing process
– Identify six steps of the nursing process and
describe nursing action associated with each
– Describe the benefits of using nursing process
 Back Ground

• The nursing process is based on a nursing theory

developed by Ida Jean Orlando. She developed this
theory in the late 1950's as she observed nurses in
action. She saw "good" nursing and "bad" nursing.

• From her observations she learned that the patient

must be the central character.
– Nursing care needs to be directed at improving outcomes
for the patient, and not about nursing goals.
– The nursing process is an essential part of the nursing care
plan.
 The Nursing Process is:
 A systematic, rational method of planning
and providing individualized nursing care.
 An organizational framework for the
practice of nursing
 Orderly, systematic
 Central to all nursing care
 Encompasses all steps taken by the nurse in
caring for a patient
Definition of the Nursing Process
• 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
 Benefits of Nursing Process
• Provides an orderly & systematic method for planning
& providing care
• Enhances nursing efficiency by standardizing nursing
practice
• Facilitates documentation of care
• Provides a unity of language for the nursing profession
• Is economical
• Stresses the independent function of nurses
• Increases care quality through the use of deliberate
actions
Characteristics of the Nursing Process
• Within the legal scope of nursing
• Based on knowledge-requiring critical
thinking
• Planned-organized and systematic
• Client-centered
• Goal-directed
• Prioritized
• Dynamic
Benefits of using the nursing process
• Continuity of care
• Prevention of duplication
• Individualized care
• Standards of care
• Increased client participation
• Collaboration of care
 Holistic
• Physical- Medical Nursing
• Emotional- Diagnosis Diagnosis
Rheumatoid Self-care deficit:
• Psychosocial- Arthritis bathing, related
to joint stiffness
• Developmental-
• Spiritual Being
5 Components of the Nursing Process:
1. Assessment

2. Diagnosis

3. Planning

4. Implementing

5. Evaluating
 1st Component of the Nursing Process-
ASSESSMENT
• The first phase of the nursing process, called
assessment, is the collection of data for nursing
purposes.
• Information is collected using the skills of
observation, interviewing, physical examination,
and intuition
• from many sources, including clients, their family
members or significant others, health records,
other health team members.
 1st Component of the Nursing Process-
ASSESSMENT:
• Data Collection
– Assessment involves taking vital signs
(TPR BP & Pain assessment.

– Performing a head to toe assessment

– Listening to the patient's comments and

questions about his health status

– Observing his reactions and interactions

with others. It involves asking pertinent
questions about his signs (observable)
and symptoms (Non-observable), and
listening carefully to the answers.
 During Assessment, the care
provider:
A. Establishes A Data Base

B. Continuously Updates
The Data Base

C. Validates Data

D. Communicates Data
 Preparing for assessment

Type Aim Time frame

1- Initial assessment Initial identification of normal Within the specified time frame
function, functional status, and after admission to a hospital,
collection of data concerning nursing home, ambulatory
actual or potential dysfunction. healthcare center.
Baseline for reference and
future comparison.

2- Focus assessment Status determination of a Ongoing process, integrated

specific problem identified with nursing care, a few
during previous assessment. minutes to a few hours between
assessments.
3- Time – lapsed reassessment Comparison of client’s current Several months (3,6,9 months
status to baseline obtained or more) between assessment
previously, detection of
changes in all functional health
patterns after an extended
period of time has passed

4- Emergency assessment Identification of life – AT anytime

threatening situation
Setting and environment

Assessment can take place in any setting

where nurses care for clients and their
family members: in the client’s home, at
a clinic, in a hospital room.
 Assessment skills
1- Observation
 Comprises more than the nurse’s ability to see the
client, nurses also use the senses of smell, hearing,
touch, and, rarely, the sense of taste.
 Observation includes looking, watching, examining.
 Observation begins the moment the nurse meets the
client. It is a conscious, deliberate skill that is
developed through efforts and with an organized
approach.
 Observation has two aspects:
noticing the data and
selecting, organizing, and interpreting the data.
Observation done in the following order:
– Clinical signs of client distress.
– Threats to the client’s safety, real or
anticipated.
– The presence and functioning of
associated equipment.
– The immediate environment, including
the people in it.
2- Interviewing
Is a planned communication or a conversation with
a purpose
for example to get or give information, identify
problems of mutual concern, evaluate change,
teach, provide support.
There are two approaches to interviewing
directive
nondirective.
The directive interview
Is highly structured and elicits specific information.
The nurse establishes the purpose of the interview and
controls the interview.
The client responds to questions but may have limited
opportunities to ask questions or discuss concerns.

The nondirective interview or rapport-building

interview, by contrast the nurse allows the client to
control the purpose, subject matter, and pacing.
3- Physical examination techniques
Is a systematic data collection method that uses the
senses of sight, hearing, smell, and touch to detect
health problems.
Four techniques are used:
Inspection
Palpation
Percussion
Auscultation
1. Inspection
 Is visual examination of the client that is done in a
methodical and deliberate manner.
 The client is observed first from a general point of
view and then with specific attention to detail.
 Effective inspection requires adequate lighting and
exposure of the body parts being observed.
2. Palpation
 Uses the sense of touch to assess texture,
temperature, moisture, organ location and size,
vibrations and pulsations, swelling, masses, and
tenderness.
 Palpation requires a calm, gentle approach and is
used systematically, with light palpation preceding
deep palpation and palpation of tender areas
performed last.
3. Percussion
 Uses short, tapping strokes on the surface of the
skin to create vibrations of underlying organs.
 It is used for assessing the density of structures or
determining the location and the size of organs in
the body.
4. Auscultation
 Involves listening to sounds in the body that are
created by movement of air or fluid.
 Areas most often auscultated include the lungs,
heart, abdomen, and blood vessels.
 Assessment Activities

The activities that make up the assessment are

:the following
Collect data -1
• Data collection, the process of compiling
information about the client, begins with the
first client contact.
• Nurses use observation, interviewing, and
physical examination.
Validate data -2
– Validation, commonly referred to as double –
checking the information at hand, is the process of
confirming the accuracy of assessment data
collected.
– Validation assists in verifying and clarifying cues
and inference.
Organize data -3
 After data collection is completed and information
is validated, the nurse organizes, or clusters, the
information together in order to identify areas of
strengths and weaknesses.
 This process is known as data clustering. How
data are organized depends on the assessment
model used. One of these model is Head – to – Toe
model.
4- Documenting 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.
– To increase accuracy, the nurse records subjective
data in the client’s own words to avoid the chance
of changing the original meaning.
 Types of data:
Subjective data .1
also known as symptoms or covert cues
include the client's feeling and statement
about his or her health problems and are
best recorded as direct quotations from the
client, such as
''.Every time I move, I feel nauseated ''
2. Objective data
also known as signs or overt cues, are observable
and measurable (quantitative) data that are
obtained through observation, standard assessment
techniques performed during the physical
examination, and laboratory and diagnostic testing.
 Sources of data
It can be primary or secondary.
The client is the primary source of data.
Family members or other support persons,
other health professionals, records and
reports, laboratory and diagnostic analyses,
and relevant literatures are secondary or
indirect sources.
2nd Component of the Nursing Process-
NURSING DIAGNOSIS
The second step in the nursing process
involves further analysis (breaking the
whole down into parts that can be
examined) and synthesis (putting data
together in a new way) of the data that have
been collected.
 According to the North American Nursing
Diagnosis Association (NANDA)
 a nursing diagnosis is a clinical judgment about
individual, family, or community responses to
actual or potential health problems/life processes.
 Nursing diagnoses provide the basis for selection
of nursing interventions to achieve outcomes for
which the nurse is accountable. (Carroll-Johnson,
1990, p. 50).
 Purposes of nursing diagnosis

 - Nursing diagnosis is unique in that it focuses

on a client’s response to a health problem,
rather than on the problem itself, and it
provides the structure through which nursing
care can be delivered.
- Nursing diagnosis also provides a means for
effective communication.
- Holistic client, family, and community-
focused care are facilitated with the use of
nursing diagnosis.
- Nursing diagnosis has an important impact
on the health care delivery system
 
 Differentiating Nursing Diagnosis
versus Medical Diagnosis
 
Nursing Diagnosis Medical Diagnosis
- focus on unhealthy responses - identify diseases
to health and illness.

- describe problems treated by - describe problems for which

nurses within the scope of the physician directs the primary
independent nursing practice. treatment .

- may change from day to day as - remains the same for as long as
the patient’s responses change the disease is present
• Myocardial infarction (heart attack) is a
medical diagnosis.
• Examples of nursing diagnoses for a person
with myocardial infarction include Fear,
Altered Health Maintenance, Knowledge
Deficit, Pain, and Altered Tissue Perfusion.
 Nursing Diagnosis versus
Collaborative Problems

• If such problems require physician – prescribed

and nurse – prescribed action, however, they are
collaborative health problems.
• Collaborative problems refer to actual or potential
physiologic complications that can result from
disease, trauma, treatment, or diagnostic studies
for which nurses intervene in collaboration with
personnel of other disciplines.
 Types of Nursing Diagnoses
1- Actual Nursing Diagnoses
Describe a human response to a health problem
that is being manifested. They are written as three-
part statements: diagnostic label, related factors,
defining characteristics.

Example – Acute pain related to surgical trauma

and inflammation, as evidenced by grimacing and
verbal reports of pain.
Q- Which One is accurate nursing
diagnosis?
1- Impaired physical mobility related to pain
2- Ineffective movement related to arthritis
2- Risk nursing diagnosis
 
As defined by NANDA, ’’describes human
responses to health conditions that may
develop in a vulnerable individual, family, or
community. It is supported by risk factors that
contribute to increased vulnerability’’.
3- Wellness nursing diagnosis
Is a diagnostic statement that describe the
human response to levels of wellness in an
individual, family, or community that have a
potential for enhancement to a higher state
(NANDA, 2005).
 
4- Possible Nursing Diagnoses
Is made when not enough evidence supports
the presence of the problem but the nurse
thinks that is highly probable and wants to
collect more information.
 Validate Diagnosis
For each diagnosis, the nurse should discuss
with the client the significance of the
problem, determine the client’s perception
of the reason for the problem, and ask
whether the client desires help to resolve or
to diminish the problem.
 3rd component of the Nursing Process-
Planning:
• The third step of the nursing process includes the
formulation of guidelines that establish the
proposed course of nursing action in the resolution
of nursing diagnoses and the development of the
client’s plan of care.
• The planning of nursing care occurs in three
phases: initial, ongoing, and discharge. Each type
of planning contributes to the coordination of the
client’s comprehensive plan of care.
Initial planning
 involves development of beginning of care by the
nurse who performs the admission assessment and
gathers the comprehensive admission assessment
data.
 Initial planning is important in addressing each
prioritized problem, identifying appropriate client
goals, and correlating nursing care to hasten
resolution of the client’s problems.
Ongoing planning
entails continuous updating of the client’s plan
of care. Every nurse who cares for the client is
involved in ongoing planning.
 
Discharge planning
involves critical anticipation and planning for
the client’s needs after discharge.
 3rd component of the Nursing Process-
Planning:
• The establishment of client
goals/outcomes
– Working with the client, to prevent, reduce, or
resolve problems

– To determine related nursing interventions

(actions) that are most likely to assist client in
achieving goals

– This is about improving the quality of life for

your patient.

– This is about what your patient needs to do to

improve his health status or better cope with his
illness.
 During Planning, the provider:
• A. Establishes Priorities

• B. Writes Client Goals/Outcomes And

Develops An Evaluative Strategy

• C. Selects Nursing Interventions

• D. Communicates The Plan

 The four critical elements of planning
include:

• Establishing priorities
• Setting goals and developing expected
outcomes (outcome identification)
• Planning nursing interventions (with
collaboration and consultation as needed)
• Documenting
1- Establishing Priorities
The establishment of priorities is the first element
of planning. In establishing priorities, the nurse
examines the client’s nursing diagnoses and ranks
them in order of physiological or psychological
importance.

Various guidelines are used in the establishment of

priorities for determining which nursing diagnosis
will be addressed initially.
 The client’s basic needs, safety, and desires, as well as
anticipation of future diagnoses must be considered. One of
the most common methods of selecting priorities is the
consideration of Maslow’s hierarchy of needs, which requires
that a life-threatening diagnosis be given more urgency than a
non life threatening diagnosis.

 The client must participate in the identification of priorities so

that the nature of the problem, as well as the client’s values,
are reflected in the selected course of action.
2- Establishing Goals and Expected Outcomes
The purposes of setting goals and expected
outcomes are to provide guidelines for
individualized nursing interventions and to
establish evaluation criteria to measure the
effectiveness of the nursing care plan.
A goal is an aim, an intent, or an end.
A goal is a broad or globally written
statement describing the intended or desired
change in the client’s behavior, response, or
outcome.
An expected outcome is a detailed,
specific statement that describes the
methods through which the goal will be
achieved.
Goals should be established to meet the
immediate, as well as long-term prevention
and rehabilitation, needs of the client.

A short-term goal is a statement written in

objective format demonstrating an expectation
to be achieved in resolution of the nursing
diagnosis in a short period of time, usually in a
few hours or days.
A long-term goal is a statement written in
objective format demonstrating an
expectation to be achieved in resolution of
the nursing diagnosis over a longer period
of time, usually over weeks or months.
 Guidelines for Writing Outcomes

Written outcomes can be evaluated by seeing

if they conform to the following criteria:
• Each set of outcomes is derived from only one
nursing diagnosis.
• At least one of the outcomes shows a direct
resolution of the problem statement in the nursing
diagnosis.
• Both long-term and short-term outcomes are
identified as necessary.
• Cognitive, psychomotor, and affective outcomes
appropriately signal the type of change needed by the
patient.
• The patient and family value the outcomes.
• Each outcome is brief and specific (clearly describes
one observable, measurable patient
behavior/manifestation), is phrased positively, and
specifies a time line.
• The outcomes are supportive of the total treatment
plan
Example
 
NURSING DIAGNOSIS: Disturbed Sleep
Pattern
Goal: Client will sleep uninterrupted for 6 hours.
EXPECTED OUTCOMES
• Client will request back massage for relaxation.
• Client will set limits to family and significant
other visits.
 
3- Planning Nursing Interventions
Once the goals have been mutually agreed on by
the nurse and client, the nurse should use a
decision-making process to select appropriate
nursing interventions.

Nursing interventions are treatment, based upon

clinical judgment and knowledge that a nurse
performs to enhance patient / client outcomes.
 Writing a client plan of care
Two important concepts guide a client plan of care:
 1- The plan of care is client centered.
 2- The plan of care is a step – by step process.
– Sufficient data are collected to substantiate nursing
diagnoses.
– At least one goal must be stated for each nursing
diagnosis
– Outcome criteria must be identified for each goal
 
• Nursing interventions must be specifically
designed to meet the identified goal.
• Each intervention should be supported by a
scientific rationale.
• Evaluation must address whether each goal
was completely met, partially met, or
completely unmet.
4th Component of the Nursing Process-
Implementing:
• The provider carries out the plan of care
 Implementing

 Consists of doing and documenting the activities that

are the specific nursing actions needed to carry out
the interventions or nursing orders.
 The first three nursing process phases-assessing,
diagnosing, and planning-provide the basis for the
nursing actions performed during the implementing
step.
 In turn, the implementing phase, provide the actual
nursing activities and client responses that are
examined in the final phase, the evaluating phase.
 While implementing nursing orders, the nurse
continues to reassess the client at every contact,
gathering data about the client’s responses to nursing
activities and about any new problems that may
develop.
 To implement the care plan successfully, nurses need
cognitive, interpersonal, and technical skills. These
skills are distinct from one another.
 The cognitive skills (intellectual skills) include problem
solving, decision making, critical thinking, and creativity.

 Interpersonal skills are all of the activities, verbal and

nonverbal, people use when interacting directly with one
another, this depends on the ability of the nurse to
communicate effectively with others. It is necessary for all
nursing activities, caring, comforting, advocating, referring,
counseling, and supporting others.

 Technical skills are hands-on skills such as manipulating

equipments, giving injections and bandaging, moving lifting,
and repositioning clients. These are called procedures, tasks, or
psychomotor skills.
 Process of Implementing

• Reassessing the client

• Determining the nurse’s need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
 Reassess the Client, to make sure the
intervention is still needed.
 Even though an order is written on the care
plan, the client’s condition may have
changed.
 The nurse also provides supportive
communication to help alleviate the client’s
stress.
Determining the Nurse’s Need for Assistance, for
one of the following reasons:

• The nurse is unable to implement the

nursing activities safely alone
• Assistance would reduce stress on the client
• The nurse lacks the knowledge or skills to
implement a particular nursing activities
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 outcome is.

Ensure client privacy, coordinate client care,

and involve scheduling client contacts with
other departments.
 When implementing interventions, nurses
should follow these guidelines:

• Base nursing interventions on scientific

knowledge, nursing research, and professional
standards of care whenever possible.
• Clearly understand the order to be implemented
and question any that are not understood.
• Adapt activities to the individual client, a client’s
beliefs, values; age, health status, and environment
are factors that can affect the success of a nursing
action.
• Implement safe care
• Provide teaching, support and comfort to enhance the
effectiveness of nursing care plans.
• Be holistic; view the client as a whole.
• Respect the dignity of the client and enhance the
client’s self- esteem
• Encourage client to participate actively in
implementing the nursing interventions.
Supervising Delegating Care, if care has
been delegated to other health care
personnel, the nurse responsible for all the
client’s care must ensure that the activities
have been implemented according to the
care plan.
Documenting Nursing Activities, the nurse
complete the implementing phase by recording the
interventions and client responses in the nursing
process notes.
 The nurse may record routine or recurring activities
such as mouth care in the client record at the end of
shift, while some actions recorded in special
worksheets according to agency policy.
 Immediate recording helps safeguard the client to
prevent double actions.
 During Implementing, the care
provider:
• Carries Out The Plan Of Nursing Care or
Setting your plans in motion and
delegating responsibilities for each step.

• Continues Data Collection And Modifies

The Plan Of Care As Needed

• Documents Care
 5th Component of the Nursing Process-
Evaluating:

The last phase of the nursing process,

follows implementation of the plan of care,
it’s the judgment of the effectiveness of
nursing care to meet client goals based on
the client’s behavioral responses.
 5th Component of the Nursing Process-
Evaluating:
• The measuring of the extent to which
client goals have been met

• Evaluation involves not only

analyzing the success of the goals and
interventions, but examining the need
for adjustments and changes as well.

• The evaluation incorporates all input

from the entire health care team,
including the patient.
Process of Evaluating Client Responses

Collecting data related to the desired

outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the
nursing care plan.
When determining whether a goal has been
achieved, the nurse can draw one of the three
possible conclusions:
– The goal was met, that is the client response is the
same as the desired outcomes.
– The goal was partially met, that is either a short
term goal was achieved but the long term was not,
or the desired outcome was only partially attained.
– The goal was not met.
Relationship of Evaluation to Nursing Process
 
 During Evaluating, the care provider:
• Measures The Clients Achievement Of
Desired Goals/Outcomes

• Identifies Factors That Contribute To

The Client’s Success Or Failure

• Modifies The Plan Of Care, If

Indicated
 Purpose of the nursing process:

• To Achieve Scientifically-
Based, Holistic, Individualized
Care For The Client

• To Achieve The Opportunity To

Work Collaboratively With
Clients, Others

• To Achieve Continuity Of Care

 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