NURSING PROCESS

Learning objectives
At the end of this unit the students will be able to:

Describe the steps of Nursing care process

Use of nursing process in healthcare provision
Demonstrate critical thinking in provision of nursing
care
Demonstrate ability to apply the nursing process
during patient care.
INTRODUCTION
The term Nursing Process was first used/ mentioned by Lydia

Hall, a nursing theorist, in 1955 wherein she introduced 3

STEPs: observation, administration of care and validation
Johnson (1959), Orlando (1961), and Wiedenbach (1963)

further developed this description of nursing.

3
INTRODUCTION cont’d
Orlando (1961) Explained nursing process as it is
initially had four stages: assessing, implementing,
planning, evaluating,
Yura and Walsh (1967), suggested that nursing process
could be considered the most influential change in
approaches to thinking about nursing care.
It has been described as being a decision‐making
model that focuses on patients’ needs and helps to
solve problems that they may have.
INTRODUCTION cont’d
The nursing process supports professional nursing
practice.
Stonehouse (2017) aptly suggests that in contemporary
practice the nursing process may be better called ‘the
caring process’, involving all members of the
multidisciplinary phase.
The systematic approach to care provision can also be
used for the provision of patient education as well as
health education interventions.
Definition
• A process - a series of steps or acts that lead to
accomplishment of particular goal or purpose.

• The nursing process is a systematic, rational

method of planning and providing individualized
nursing care.

6
THE NURSING
PROCESS (continued)
A series of steps that lead to accomplishing some goal or
purpose.
Its purpose is to identify a client’s health status and actual
or potential health care problems or needs, to establish
plans to meet the identified needs, and to deliver specific
nursing interventions to meet those needs.
A systematic method for providing care to clients.
Provides individualized, holistic, effective and efficient
client care.
• The client may be an individual, a family, a community, or a
group.
Characteristics of nursing
process
The characteristics of nursing process include:
Cyclic and dynamic nature,
Client centeredness,
Focus on problem solving and decision making,
 Interpersonal and collaborative style,
 Universal applicability,
Use of critical thinking
Characteristics of nursing
process cont’d
1.Cyclic and dynamic nature,
The nursing process is a regularly repeated
event or sequence of events (a cycle) that is
continuously changing (dynamic) rather than staying
the same (static).
2. Client centeredness
The nursing process is client centered. The nurse
organizes the plan of care according to client problems
rather than nursing goals.
Characteristics of nursing
process cont’d
3. Focus on problem solving and decision making,
The nursing process is an adaptation of problem
solving
It can be viewed as parallel to but separate from the
process used by physicians (the medical model). Both
processes :
 begin with data gathering and analysis,
 base action (intervention or treatment) on a problem
statement (nursing diagnosis or medical diagnosis),
 include an evaluative component.
Characteristics of nursing
process cont’d
However, the medical model focuses on physiological
systems and the disease process, whereas the nursing
process is directed toward a client’s responses to real or
potential disease and illness.
Decision making is involved in every phase of the
nursing process. Nurses can be highly creative in
determining when and how to use data to make
decisions.
Characteristics of nursing
process cont’d
4. Interpersonal and collaborative style
It requires the nurse to communicate directly and
consistently with clients and families to meet their
needs.
 It also requires that nurses collaborate, as members of
the health care team, in a joint effort to provide quality
client care.
Characteristics of nursing
process cont’d
5. Universal applicability,
• It is used as a framework for nursing care in all types of
health care settings, with clients of all age groups
• 6. Use of critical thinking
• A nurse faces many clinical situations involving
patients, family members, health care staff, and peers.
In each situation it is important to try to see the big
picture and think smart.
• To think smart you have to develop critical thinking
skills to face each new experience and problem
involving a patient’s care with open mindedness,
THE NURSING PROCESS
Includes 5 steps:
1. Assessment
2. Diagnosis
3. Planning and outcome identification
4. Implementation
5. Evaluation
ASSESSMENT
• The first step in the nursing process.
Includes
• Collect data
• Organize data
• Validate data
• Document data
Collect data
Data collection is the process of gathering information
about a client’s health status
It must be both systematic and continuous to prevent
the omission of significant data and reflect a client’s
changing health status
A database contains all the information about a
client; it includes the nursing health history, physical
assessment, primary care provider’s history and
physical examination, results of laboratory and
diagnostic tests, and material contributed by other
health personnel.
 Collect data cont’d
Data can be of subjective or objective and constant
or variable types, and from a primary or secondary source.
Types of Data
Subjective data, also referred to as symptoms
Objective data, also referred to as signs
Sources of Data
 Primary : The client is the primary source of data.
Secondary: Family members or other support persons,
other health professionals, records and reports, laboratory
and diagnostic analyses
Organize data
The nurse uses a written (or electronic) format that
organizes the assessment data systematically. This is
often referred to as a nursing health history, nursing
assessment, or nursing database form.
The format may be modified according to the client’s
physical status
 Data validation
Validation is the act of “double-checking” or verifying data
to confirm that it is accurate and factual.
Validating data helps the nurse complete these tasks:
■ Ensure that assessment information is complete.
■ Ensure that objective and related subjective data agree
■ Obtain additional information that may have been
overlooked.
■ Differentiate between cues and inferences.
Cues are subjective or objective data that can be directly
observed by the nurse; that is, what the client says or what the
nurse can see, hear, feel, smell, or measure.
Data validation cont’d
Inferences are the nurse’s interpretation or
conclusions made based on the cues (e.g., a nurse
observes the cues that an incision is red, hot, and
swollen; the nurse makes the inference that the
incision is infected).

■ Avoid jumping to conclusions and focusing in the

wrong direction to identify problems
Document 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.
 Data are recorded in a realistic manner and not
interpreted by the nurse.
 Types of assessment
Types Time performed Purpose Examples

Initial Performed within To establish a Nursing admission

assessment specified complete assessment
time after database for
admission to a problem
health care agency identification,
reference, and
future comparison

Problem- Ongoing process To determine the Hourly assessment of client’s

focused integrated status of a specific fluid intake and urinary
assessment with nursing care problem identified output
in an earlier in an ICU
assessment
Assessment of client’s ability
to perform self-care while
assisting a client to bathe
 Types of assessment cont’d
Emergency During any To identify life- Rapid assessment of a
assessment physiological threatening person’s
or problems airway, breathing status,
psychological To identify new or and
crisis of the overlooked circulation during a cardiac
client problems arrest
Assessment of suicidal
tendencies or potential for
violence

Time-lapsed Several To compare the client’s Reassessment of a client’s

reassessment months after current status to baseline functional health patterns
initial data previously obtained in a
assessment home care or outpatient
setting
or, in a hospital, at shift
change
Diagnosis
Second step in the nursing process
The term diagnosing refers to the reasoning process,
whereas the term diagnosis is a statement or
conclusion regarding the nature of a phenomenon.
The standardized NANDA names for the diagnoses are
called diagnostic labels; and the client’s problem
statement, consisting of the diagnostic label plus
etiology (causal relationship between a problem and
its related or risk factors), is called a nursing
diagnosis.
Diagnosis cont’d
This definition is consistent with the following:
Professional nurses (registered nurses) are responsible
for making nursing diagnoses, and may implement
specified nursing care.
A nursing diagnosis is a judgment made only after
thorough, systematic data collection.
 Nursing diagnoses describe a continuum of health
states: deviations from health, presence of risk factors,
and areas of enhanced personal growth
MEDICAL DIAGNOSIS
Clients have both nursing and medical diagnoses.
A medical diagnosis is a clinical judgment by the
physician that identifies or determines a specific disease,
condition, or pathological state.
TYPES OF
NURSING DIAGNOSES
Actual nursing diagnosis–indicates that problem exists.
Risk nursing diagnosis–indicates that specific risk factors
are present.
Wellness nursing diagnosis–client’s statement of desire
to attain a higher level of wellness in some area of
function.
Actual nursing diagnosis
is a client problem that is present at the time of the
nursing assessment.
Examples are Ineffective Breathing Pattern and
Anxiety.
An actual nursing diagnosis is based on the presence
of associated signs and symptoms
Risk nursing diagnosis
It 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.
Wellness diagnosis
It describes human responses to levels of wellness in
an individual, family or community,”
As with health promotion diagnoses, these diagnosis
labels begin with the phrase Readiness for Enhanced.
Examples of wellness diagnoses would be Readiness
for Enhanced Spiritual Well Being or Readiness for
Enhanced Family Coping
Components of a NANDA
Nursing Diagnosis
A nursing diagnosis has three components: (1) the
problem and its definition, (2) the etiology, and (3) the
defining characteristics. Each component serves a
specific purpose
Problem (Diagnostic Label) and
Definition
The problem statement, or diagnostic label, describes
the client’s health problem or response for which
nursing therapy is given.
It describes the client’s health status clearly and
concisely in a few words. The purpose of the diagnostic
label is to direct the formation of client goals and
desired outcomes.
It may also suggest some nursing interventions.
To be clinically useful, diagnostic labels need to be
specific;
Problem (Diagnostic Label) and
Definition cont’d
When the word Specify follows a NANDA label, the
nurse states the area in which the problem occurs, for
example,
Deficient
Knowledge (Medications) or Deficient Knowledge
(Dietary Adjustments).
 Problem (Diagnostic Label) and
Definition cont’d
Qualifiers are words that have been added to some
NANDA labels to give additional meaning to the
diagnostic statement; for example:
■ Deficient (inadequate in amount, quality, or degree; not
sufficient; incomplete)
■ Impaired (made worse, weakened, damaged, reduced,
deteriorated)
■ Decreased (lesser in size, amount, or degree)
■ Ineffective (not producing the desired effect)
■ Compromised (to make vulnerable to threat).
Etiology (Related Factors and
Risk Factors)
The etiology component of a nursing diagnosis
identifies one or more probable causes of the health
problem, gives direction to the required nursing
therapy, and enables the nurse to individualize the
client’s care.
Defining characteristics
Defining characteristics are the cluster of signs and
symptoms that indicate the presence of a particular
diagnostic label.
For actual nursing diagnoses, the defining
characteristics are the client’s signs and symptoms. For
risk nursing diagnoses, no subjective and objective
signs are present.
Thus, the factors that cause the client to be more
vulnerable to the problem form the etiology of a risk
nursing diagnosis.
Diagnostic process
The diagnostic process has three steps:

Analyze data
Identify health problems, risks, and strengths
Formulate diagnostic statement
 Analyze data
In the diagnostic process, analyzing involves the following
steps:
1. Compare data against standards (identify significant cues).
2. Cluster the cues (generate tentative hypotheses).
Points to negative or positive change in a client’s health status
or pattern
Varies from norms of the client population
Indicates a developmental delay
3. Identify gaps and inconsistencies: minimizes gaps and
inconsistencies in data.
Data analysis should include a final check to ensure that data
are complete and correct.
 Identify health problems, risks,
and strengths
The nurse and client can together identify strengths and
problem
Determining Problems and Risk
After grouping and clustering the data, the nurse and client
together identify problems that support tentative actual,
risk, and possible diagnoses.
In addition the nurse must determine whether the client’s
problem is a nursing diagnosis, medical diagnosis, or
collaborative problem
Determining Strengths
At this stage, the nurse and client also establish the client’s
strengths, resources, and abilities to cope
Formulate diagnostic statement
Most nursing diagnoses are written as two-part or
three-part statements, but there are variations of these
Formulate diagnostic statement
cont’d
Basic Two-Part Statements
• The basic two-part statement includes the following:
1. Problem (P): statement of the client’s response
(NANDA label)
2. Etiology (E): factors contributing to or probable causes of
the responses.
The two parts are joined by the words related to rather than
due to.
Formulate diagnostic statement
cont’d
Basic Three-Part Statements
The 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): factors contributing to or probable
causes of
the response
3. Signs and symptoms (S): defining characteristics
manifested by the client.
 PLANNING AND
OUTCOME IDENTIFICATION
Third step of the nursing process.
Includes establishing guidelines for the proposed course of
nursing action and developing the client’s plan of care.
Planning is a deliberative, systematic phase of the nursing
process that involves decision making and problem solving.
 In planning, the nurse refers to the client’s assessment data
and diagnostic statements for direction in formulating
client goals and designing the nursing interventions
required to prevent, reduce, or eliminate theclient’s health
problems
PLANNING PHASES
Initial planning–developing a preliminary plan of care.
Ongoing planning–updating the client’s plan of care.
Discharge planning–anticipating and planning for the
client’s needs after discharge.
 Initial Planning
The nurse who performs the admission assessment
usually develops the initial comprehensive plan of care.
Planning should be initiated as soon as possible after the
initial assessment.
Ongoing Planning
Ongoing planning is done by all nurses who work with
the client. As nurses obtain new information and
evaluate the client’s responses to care, they can
individualize the initial care plan further.
Ongoing planning also occurs at the beginning of
a shift as the nurse plans the care to be given that day.
Using ongoing assessment data, the nurse carries out
daily planning for the following purposes:
Ongoing Planning cont’d
Using ongoing assessment data, the nurse carries out
daily planning for the following purposes:

1. To determine whether the client’s health status has

changed
2. To set priorities for the client’s care during the shift
3. To decide which problems to focus on during the shift
4. To coordinate the nurse’s activities so that more than
one
problem can be addressed at each client contact.
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 each client’s
care plan.
Effective discharge planning begins at first client
contact and involves comprehensive and ongoing
assessment to obtain information about the client’s
ongoing needs.
PLANNING INVOLVES …
Prioritizing the nursing diagnoses.
Identifying and writing client-centered long- and short-
term goals and outcomes.
Identifying specific nursing interventions.
Recording the entire nursing care plan in the client’s
record.
Developing Nursing Care Plans
Written guide of strategies to be implemented to help
client achieve optimal health.
Begins on the day of admission and continues until
discharge The end product of the planning phase of the
nursing process is a formal or informal plan of care.
 Informal nursing care plan is a strategy for action
that exists in the nurse’s mind.
Formal nursing care plan is a written or
computerized guide that organizes information about
the client’s care.
The most obvious benefit of a formal
written care plan is that it provides for continuity of
care
A standardized care plan is a formal plan that
specifies the nursing care for groups of clients with
common needs (e.g., all clients with myocardial
infarction).
An individualized care plan is tailored to meet the
unique needs of a specific client—needs that are not
addressed by the standardized plan.
The purposes of the nursing care plan

To provide a framework for nursing care

To promote quality, client-centered care
To promote continuity of care
To provide for evaluation of the effectiveness of
nursing care
To promote communication among nursing staff and
other health team members
Documentation
Formats for Nursing Care Plans
 The methods and format vary according to the type of
health care setting and the policies of that institution
 The nursing care plans are often organized into 5
categories (columns):
1. Assessment data
2. Nursing diagnosis
3. Goals / expected outcomes
4. Nursing actions or interventions
5. Evaluation
Student Care Plans
• Student care plans are a learning activity as well as a
plan of care, they may be more lengthy and detailed
than care plans used by working nurses.
• Students care plans is modified by adding “Rationale”
after the nursing interventions.
• A rationale is the evidence-based principle given as
the reason for selecting a particular nursing
intervention.
Nursing Nursing Desired / Interventions Rationale Evaluation
Assessment Diagnoses Expected
Outcomes
Should List List outcomes Discuss the the scientific Evaluation
include: Diagnostic for each of the interventions principle involves
Subjective statements identified necessary for given as assessing or
Data or problems problems. each reason for reflecting on
Objective in terms of They must be: intervention. selecting a how effective
data priority time particular the care plan
Use specified, There should nursing interventions
(List all NANDA realistic, be adequate interventions were in
relevant, statements measurable & interventions (facts, achieving the
appropriate client- to go with evidence) client
areas of centered each nursing goals/expected
assessment (SMART) diagnosis/pro outcomes.
in this blem
column) Evaluate
whether the
outcomes have
been met,
partially or not
met
NURSING INTERVENTIONS
Actions performed by nurse to help client achieve results
specified by goals and expected outcomes.
Refer directly to the related factors or the risk factors in
nursing diagnoses.
Are stated in specific terms.
May change.
CATEGORIES OF
NURSING INTERVENTIONS
Independent–initiated by the nurse and
do not require an order.
Interdependent–implemented in a collaborative manner
by nurse in conjunction with other health care
professionals.
Dependent–requires an order.
IMPLEMENTATION
Fourth step in the nursing process.
The performance of the nursing interventions identified
during the planning phase.
ORDERS FOR INTERVENTIONS
Specific order–for individual client.
Standing order–standardized intervention written,
approved, and signed by a physician, kept on file to be
used in predictable situations.
Protocol–series of standing orders or procedures.
EVALUATION
Fifth step in the nursing process.
Determines whether client goals have been met, partially
met, or not met.
Ongoing evaluation is essential for the nursing process to
be implemented appropriately.
DOCUMENTATION
Any printed or written record of activities.
Recording and reporting are the major ways health care
providers communicate.
The client’s medical record is a legal document of all
activities regarding client care.
PURPOSES OF DOCUMENTATION
Communication
Practice and legal standards
Reimbursement
Education
Research
Nursing audit
COMMUNICATION
Documentation confirms the care provided to the client
and clearly outlines all important information regarding
the client.
PRACTICE AND
LEGAL STANDARDS
The legal aspects of documentation
require:
Writing legible and neat
Spelling and grammar properly used
Authorized abbreviations used
Time-sequenced factual and descriptive entries
PRACTICE
STANDARDS INCLUDE:
State Nursing Practice Acts
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
Confidentiality
Informed consent
Advance Directives
REIMBURSEMENT
The federal government requires monitoring and
evaluation of quality, appropriateness of care provided.
Documentation of intensity of services and severity of
illness reviewed.
Failure to document can result in reimbursement denied.
EDUCATION
Health care students use medical record as tool to learn
about disease processes, nursing diagnoses,
complications and interventions.
Students can enhance critical-thinking skills by
examining the records and following health care team’s
plan of care.
RESEARCH
The client’s medical record is used by researchers to
determine whether a client meets the research criteria
for a study.
Documentation can also indicate a need for research.
NURSING AUDIT
Method of evaluating the quality of care
Includes:
Safety measures
Treatment interventions and responses
Expected outcomes
Client teaching
Discharge planning
Adequate staffing
PRINCIPLES OF EFFECTIVE
DOCUMENTATION
1. Document accurately, completely, and objectively,
including any errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.
PRINCIPLES OF EFFECTIVE
DOCUMENTATION (continued)
7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10. Write on every line.
11. Chart omissions.
12. Sign each entry.
NURSE’S PROGRESS NOTES
Document client’s condition, problems, complaints,
interventions, and client’s response to interventions.
Include MAR, vital signs records, flow sheets, and
intake and output forms.
THE INCIDENT REPORT
• An incident report is an agency record of an accident or
incident.
Whenever a patient is injured or has a potential injury there
exist a possibility of a lawsuit, such a report must be
recorded.
An incidental report may be written for situations involving
a patient, visitors, or employee
THE NURSING
PROCESS
AND CRITICAL
THINKING
 Definitions
Critical thinking is an intentional higher level reasoning
process that is intellectually delineated by one’s worldview,
knowledge, and experience with skills, attitudes, and
standards as a guide for
rational judgment and action.
Critical thinking is the process of purposeful, self-
regulatory judgment.”
Critical thinking is a “purposeful process, self regulatory
judgment which results in interpretations,
analysis, evaluation, and inference, as well as explanation of
the evidential, conceptual, methodological, criteriological or
contextual considerations on which that judgment is base
Definitions cont’d
Critical thinking in nursing practice is a discipline
specific, reflective reasoning process that guides a
nurse in generating, implementing, and evaluating
approaches for dealing with client care and
professional concerns
Nurses use critical thinking skills in a variety of
ways:
Nurses use knowledge from other subjects and fields
Nurses deal with change in stressful environments
Nurses make important decisions
Habit of Mind and critical
thinking skills
Habit of Mind critical thinking skills
Confidence Analyzing
Contextual perspective— Applying standards
Creativity Discriminating
Flexibility Information seeking
Inquisitiveness Logical reasoning
Intellectual integrity Predicting
Intuition Transforming knowledge
Open-mindedness
 Perseverance
Reflection
 Techniques in Critical Thinking
The techniques of critical thinking include critical analysis,
inductive and deductive reasoning, making valid inferences,
differentiating facts from opinions, evaluating the credibility
of information sources, clarifying concepts, and recognizing
assumptions.
ATTITUDES FOR CRITICAL
THINKING
Independence and interdependence
Fair-mindedness
Insight
Intellectual humility
Intellectual courage
Curiosity
Integrity
Perseverance
Confidence
APPLYING CRITICAL THINKING
TO NURSING PRACTICE
Scientific Method. The scientific method is a way to
solve problems using reasoning. It is a systematic,
ordered approach to gathering data and solving
problems used by nurses, physicians, and a variety of
other health care professionals.
The scientific method has five steps:
1. Identifying the problem
2. Collecting data
3. Formulating a question or hypothesis
4. Testing the question or hypothesis
5. Evaluating results of the test or study
 TO NURSING PRACTICE cont’d

Not all decisions require in-depth crucial thinking

Small decisions are may be resolved with minimal thinking
involved.
A nurse often employs critical thinking when setting
priorities for the day and working with groups and dealing
with situations or critical incidents.
Critical thinking is applied in the following conditions:
Problem Solving
The nurse obtains information that clarifies the nature of the
problem and suggests possible solutions.
Decision making
Decision making is a critical-thinking process for choosing
the best actions to meet a desired goal.
CRITICAL THINKING COMPETENCIES
Kataoka-Yahiro and Saylor (1994) describe critical
thinking competencies as the cognitive processes a
nurse uses to make judgments about the clinical care
of patients.
These include general critical thinking, specific
critical thinking in clinical situations, and specific
critical thinking in nursing.
DEVELOPING CRITICAL THINKING
SKILLS
Critical thinking is not easy.
Solving problems, identifying and harnessing
strengths and making decisions are risky.
Everyone can improve their critical-thinking skills to
become an effective problem solver and decision
maker.
The ways of developing critical thinking:
 DEVELOPING CRITICAL
THINKING SKILLS cont’d
Self-assessment: Reflection at every step of critical thinking
and nursing care helps the nurse examine the ways in which
they gather and analyse data, make decisions and determine
the effectiveness
of interventions.
Reflection requires the nurse to assess their
beliefs, knowledge, values, attitudes and abilities in the
particular situation at hand.
The purpose of this reflection is to determine if the current
course of action is the best one and to
improve future actions.
DEVELOPING CRITICAL THINKING
SKILLS cont’d
Tolerance
The nurse needs to take deliberate efforts to cultivate critical
thinking attitudes
Nurses should increase their tolerance for ideas that
contradict previously held beliefs and they should practise
suspending judgment until ambiguity is explored, evidence
properly examined and a solution proposed on that basis.
DEVELOPING CRITICAL
THINKING SKILLS cont’d
Creating supportive environments
Nurses in leadership positions must be particularly
aware of the climate for thinking that they establish,
and they mustactively create a stimulating
environment that encourages differences of opinion
and fair examination of ideas, evidence and options.
Nurses must embrace exploration of the perspectives
of people from different ages, cultures, religions,
socioeconomic levels and family structures.
References
Kozier and ERB’S. 2018 fundamentals of nursing
Concepts, Process and Practice. 4th edition Volume 1-3
Pp 193- 219
IAN PeAte, OBe, FRCN, 2020 Fundamentals of
Assessment and Care Planning for Nurses first
edition,
THANK YOU FOR YOUR
KIND ATTENTION