NURSING PROCESS

INTRODUCTION

A process is a series of steps or acts that lead to accomplishment of some goal or purpose. The
purpose of the nursing process is to provide care for clients that is individualized, holistic,
effective, and efficient. The steps of the nursing process build upon each other, but they are not
linear. The nursing process is dynamic and requires creativity for its application. The steps
remain the same, but the application and results will be different in each client situation.

Hall originated the term nursing process in 1955, Johnson(1958),Orlando(1961),and

Weidenbach(1963) were among the first to use it to refer to a series of phases describing the
practice of nursing.

Definition:

The nursing process is defined as a systematic, rational method of planning that guides all
nursing actions in delivering holistic and patient-focused care. The nursing process is a form of
scientific reasoning and requires the nurse’s critical thinking to provide the best care possible to
the client.

Purpose of Nursing process

The following are the purposes of the nursing process:

 To identify the client’s health status and actual or potential health care problems or needs
(through assessment).

 To establish plans to meet the identified needs.

 To deliver specific nursing interventions to meet those needs.

 To apply the best available caregiving evidence and promote human functions and responses
to health and illness (ANA, 2010).
 To protect nurses against legal problems related to nursing care when the standards of the
nursing process are followed correctly.

 To help the nurse perform in a systematically organized way their practice.

 To establish a database about the client’s health status, health concerns, response to illness,
and the ability to manage health care needs.

Characteristics of the nursing process

The following are the unique characteristics of the nursing process:

1. Patient-centered. The unique approach of the nursing process requires care respectful of and
responsive to the individual patient’s needs, preferences, and values. The nurse functions as
a patient advocate by keeping the patient’s right to practice informed decision-making and
maintaining patient-centered engagement in the health care setting.

2. Interpersonal. The nursing process provides the basis for the therapeutic process in which
the nurse and patient respect each other as individuals, both of them learning and growing
due to the interaction. It involves the interaction between the nurse and the patient with a
common goal.

3. Collaborative. The nursing process functions effectively in nursing and inter-professional

teams, promoting open communication, mutual respect, and shared decision-making to
achieve quality patient care.

4. Dynamic and cyclical.The nursing process is a dynamic, cyclical process in which each
phase interacts with and is influenced by the other phases.

5. Requires critical thinking. The use of the nursing process requires critical thinking which is
a vital skill required for nurses in identifying client problems and implementing
interventions to promote effective care outcomes.

Others include;

1. It is goal directed
2. It is systematic

3. It provide individual care

4. Focus on problem solving and decision making

5. Universal applicability

Steps of Nursing Process

The nursing process consists of five stepssteps:

The acronym ADPIE is an easy way to remember the components of the nursing process.

1. Assessment

2. Diagnosis

3. PlanHGning/Outcome identification

4. Implementation

5. Evaluation

1. Assessment:
The first phase of the nursing process is assessment. It involves collecting, organizing,
validating, and documenting the clients’ health status.

Collecting Data

Data collection is the process of gathering information regarding a client’s health status. The
process must be systematic and continuous in collecting data to prevent the omission of
important information concerning the client.The data collected can be subjective or objective.
The source of information can be primary(The client is the only primary source of data and the
only one who can provide subjective data), secondary(if it is provided from someone else other
than the client but within the client’s frame of reference) or tertiary(Sources from outside the
client’s frame of reference example information from textbooks, medical and nursing journals,
drug handbooks, surveys etc).

The methods of data collection are; interview, physical examination, observation etc

Validating Data; Validation is the process of verifying the data to ensure that it is accurate and
factual.

Documenting Data: Once all the information has been collected, data can be recorded and sorted.

2. Nursing Diagnosis

Nursing diagnosis is a clinical judgment concerning a human response to health conditions/life

processes, or a vulnerability to that response, by an individual, family, group, or community. A
nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for
which the nurse has accountability. Nursing diagnoses are developed based on data obtained
during the nursing assessment and enable the nurse to develop the care plan.

Purposes of Nursing Diagnosis

 The purpose of the nursing diagnosis is as follows:

 Nursing diagnoses are developed based on data obtained during the nursing assessment and
enable the nurse to develop the care plan.
 For nursing students, nursing diagnoses are an effective teaching tool to help sharpen their
problem-solving and critical thinking skills.

 Helps identify nursing priorities and helps direct nursing interventions based on identified
priorities.

 Helps the formulation of expected outcomes for quality assurance requirements of third-
party payers.

 Nursing diagnoses help identify how a client or group responds to actual or potential health
and life processes and knowing their available resources of strengths that can be drawn upon
to prevent or resolve problems.

 Provides a common language and forms a basis for communication and understanding
between nursing professionals and the healthcare team.

 Provides a basis of evaluation to determine if nursing care was beneficial to the client and
cost-effective.

Types of Nursing Diagnoses

The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and
Syndrome.

1. Problem-Focused Nursing Diagnosis

A problem-focused diagnosis (also known as actual diagnosis) is a client problem present at the
time of the nursing assessment. These diagnoses are based on the presence of associated signs
and symptoms. Actual nursing diagnosis should not be viewed as more important than risk
diagnoses. There are many instances where a risk diagnosis can be the diagnosis with the highest
priority for a patient.

Problem-focused nursing diagnoses have three components:

(1) nursing diagnosis( the problem and its qualifier )

(2) related factors, and

(3) defining characteristics.

Examples of actual nursing diagnoses are:

Anxiety related to stress as evidenced by increased tension, apprehension, and expression of

concern regarding upcoming surgery

Acute pain related to decreased myocardial flow as evidenced by grimacing, expression of pain,
guarding behavior.

2. Risk Nursing Diagnosis

These are clinical judgments that a problem does not exist, but the presence of risk factors
indicates that a problem is likely to develop unless nurses intervene. A risk diagnosis is based on
the patient’s current health status, past health history, and other risk factors that may increase the
patient’s likelihood of experiencing a health problem.

Components of a risk nursing diagnosis include

(1) risk diagnostic label, and

(2) risk factors.

Examples of risk nursing diagnosis are:

Risk for injury

Risk for infection

Risk for Decreased Cardiac Output related to reduced preload secondary to myocardial
infarction.

3. Health Promotion Diagnosis

Health promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about
motivation and desire to increase well-being. It is a statement that identifies the patient’s
readiness for engaging in activities that promote health and well-being. For example, if a first-
time mother shows interest on how to properly breastfeed her baby, a nurse make make a health
promotion diagnosis of “Readiness for Enhanced Breastfeeding.”

Components of a health promotion diagnosis generally include only the diagnostic label or a one-
part statement.

Examples of health promotion diagnosis:

Readiness for enhanced health literacy

4. Syndrome Diagnosis

A syndrome diagnosis is a clinical judgment concerning a cluster of problem or risk nursing

diagnoses that are predicted to present because of a certain situation or event. They, too, are
written as a one-part statement requiring only the diagnostic label. Examples of a syndrome
nursing diagnosis are:

Chronic Pain Syndrome

 Possible Nursing Diagnosis

A possible nursing diagnosis is not a type of diagnosis as are actual, risk, health promotion, and
syndrome. Possible nursing diagnoses are statements describing a suspected problem for which
additional data are needed to confirm or rule out the suspected problem. It provides the nurse
with the ability to communicate with other nurses that a diagnosis may be present but additional
data collection is indicated to rule out or confirm the diagnosis. Examples include:

Possible chronic low self-esteem

Possible social isolation.

PES Format

Another way of writing nursing diagnostic statements is by using the PES format, which stands
for Problem (diagnostic label), Etiology (related factors), and Signs/Symptoms (defining
characteristics). Diagnostic statements can be one-part, two-part, or three-part using the PES
format.
 One-Part Nursing Diagnosis Statement

Health promotion nursing diagnoses are usually written as one-part statements because related
factors are always the same: motivated to achieve a higher level of wellness through related
factors may be used to improve the chosen diagnosis. Syndrome diagnoses also have no related
factors. Examples of one-part nursing diagnosis statements include:

Readiness for enhanced coping

Rape Trauma Syndrome

 Two-Part Nursing Diagnosis Statement

Risk and possible nursing diagnoses have two-part statements: the first part is the diagnostic
label and the second is the validation for a risk nursing diagnosis or the presence of risk factors.
It’s not possible to have a third part for risk or possible diagnoses because signs and symptoms
do not exist. Examples of two-part nursing diagnosis statements include:

Risk for infection as evidenced by weakened immune system response

Risk for injury as evidenced by unstable hemodynamic profile

“unknown etiology” when the defining characteristics are present but the nurse does not know
the cause or contributing factors. For example, Ineffective Coping related to unknown etiology.

 Three-part Nursing Diagnosis Statement

An actual or problem-focus nursing diagnosis has three-part statements: diagnostic label,

contributing factor (“related to”), and signs and symptoms (“as evidenced by” or “as manifested
by”). The three-part nursing diagnosis statement is also called the PES format which includes the
Problem, Etiology, and Signs and Symptoms. Example of three-part nursing diagnosis statements

Acute pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my
chest "

3. Planning
Is a deliberative,systematic phase of nursing process that involves decision making and problem
solving. In planning the nurse refer to the client assessment and diagnostic statements for
direction in formulating client goals and designing the nursing intervention required to
prevent,reduce or eliminate the client health problem.

TYPES OF PLANNING

1. Initial planning; This is an initial comprehensive plan of care that is perform during admission
procedure.

2. Ongoing planning; its done by all nurses who work with the client. As nurses obtain new
information and evaluate the client responses to care. It can occur at the beginning of the shift as
nurse plan the care to be giving that day.

3. Discharge planning; the process of anticipating and planning for needs after discharge.

DEVELOPING NURSING CARE PLAN

The end product of planning phase of nursing process is a formal or informal plan of care.

Formal nursing care plan; is a written or computerized guide that organizes information about the
client care. It provides for continuity of care.

Informal nursing care plan; is a strategy for action that exist in the nurse mind.

FORMATS FOR NURSING CARE PLANS

1. Nursing diagnosis/Problem

2. Objective/goals or desired outcomes

3. Nursing interventions

4. Scientific rationale(for student care plan)

5. Evaluation

GUIDELINES FOR WRITING NURSING CARE PLANS

1. Date and sign the plan

2. Use category heading

3. Use standardized/approved medical or english symbols and key words rather than complete
sentence.

4. Be specific

5. Refer to procedure book or other source of information rather than including all steps on a
written plan

6. Tailor the plan to the unique characteristics of the client by ensuring that the client choices
such as preferences about times of care and the method used are included.

7. Ensure that the nursing plan incorporate preventive and heath maintenance aspect as well as
restorative ones

8. Ensure that the nursing plan contains ongoing assessment of the client

9. Include collaborative and coordination activities in the plan

10. Include plan for the client discharge and home care needs.

STEPS OF PLANNING PROCESS

• Establishing priorities

• Setting goals and developing expected outcomes (outcome identification)

• Planning nursing interventions (with collaboration and consultation as needed)

• Documenting

4. Implementation

Implementation is the action phase in which the nurse performs the nursing interventions. It
consists of doing and decumenting the activities that are the specific nursing actions needed to
carryout the interventions.
IMPLEMENTATION SKILLS

1. Cognitive skill(intellectual skills)

2. Interpersonal skills

3. Technical skills

Categories of Nursing Interventions

Nursing interventions are classified according to three categories: independent,interdependent,

and dependent.

 Independent nursing interventions are nursing actions initiated by the nurse that do not
require direction or an order from another health care professional.

 Interdependent nursing interventions are those actions that are implemented in a

collaborative manner by the nurse with other health care professionals.

 Dependent nursing interventions are those actions that require an order from another health
care professional. An example of a dependent intervention is administration of a medication.

STEPS OF IMPLEMENTATION PROCESS

1. Reassessing the client

2. Determining the nurses need for assistance

3. Implementing the nursing intervention

4. Supervising the delegated care

5. Documenting nursing action

6. EVALUATION

Evaluating care involves determining the client’s progress toward achievement of expected
outcomes. Effective planning is essential if evaluation is to be effective.

STEPS OF EVALUATION PROCESS

1. Collecting data related to the desired outcomes

2. Comparing the data with desired outcomes

3. Relating nursing activities to outcomes

4. Drawing conclusions about problem status

5. Continuing,modifying or terminating the nursing care plan.