Nursing Process

Chapter 2

MSN. Milad Azar

 Introduction
In the past, nursing practice consisted of actions based mostly on common
sense and the examples set by older, more experienced nurses. The actual
care of clients tended to be limited to the physician’s medical orders.
Although nurses today continue to work interdependently with physicians
and other health care practitioners, they now plan and implement client care
more independently. In even stronger terms, nurses are held responsible and
accountable for providing client care that is safe and appropriate and reflects
currently accepted standards for nursing practice.
 Nursing Process
Process is a set of actions leading to a particular goal. The nursing process is an organized
sequence of problem-solving steps used to identify and to manage the health problems of clients. It
is the accepted standard for clinical practice established by the American Nurses Association
(ANA). The nursing process is the framework for nursing care in all health care settings. When
nursing practice follows the nursing process, clients receive quality care in minimal time with
maximal efficiency.

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.
 The Purpose 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.
• 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 nursing process has seven distinct characteristics:
1. Within the legal scope of nursing.
2. Based on knowledge – Critical thinking.
3. Planned.
4. Client-centered.
5. Goal-directed.
6. Prioritized.
7. Dynamic
8. Collaborative.
 STEPS OF THE NURSING
PROCESS
The steps of the nursing process, each of which is discussed in
detail throughout this chapter, are as follows:
1. Assessment.
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
What is the Different of Nursing type Duties?
 1. Assessment
Assessment, the first step in the nursing process, is the systematic
collection of facts, or data. Assessment begins with the nurse’s first
contact with a client and continues as long as a need for health
care exists. During assessment, the nurse collects information to
determine areas of abnormal function, risk factors that contribute
to health problems, and client strengths.

What are the types of Data?

What are the sources of Data?
 Type of Data
1. Subjective data / symptoms: involve covert information, such as feelings, perceptions, thoughts, sensations, or
concerns that are shared by the patient and can be verified only by the patient, such as nausea, pain, numbness,
pruritus, attitudes, beliefs, values, and perceptions of the health concern and life events.
2. Objective data / sign: are overt, measurable, tangible data collected via the senses, such as sight, touch, smell, or
hearing, and compared to an accepted standard, such as vital signs, intake and output, height and weight, body
temperature, pulse, and respiratory rates, blood pressure, vomiting, distended abdomen, presence of edema, lung
sounds, crying, skin color, and presence of diaphoresis.
3. Verbal data are spoken or written data such as statements made by the client or by a secondary source. Verbal data
requires the listening skills of the nurse to assess difficulties such as slurring, tone of voice, assertiveness, anxiety,
difficulty in finding the desired word, and flight of ideas.
4. Nonverbal data are observable behavior transmitting a message without words, such as the patient’s body language,
general appearance, facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture,
clothing. Nonverbal data obtained can sometimes be more powerful than verbal data, as the client’s body language
may not be congruent with what they really think or feel.
Sources of Data
 Method of Data Collection
1. Health Interview
2. Physical Examination
3. Observation
 Type of Assessment
There are two types of assessments:
1. A data base assessment: initial information about the client’s physical, emotional,
social, and spiritual health, is lengthy and comprehensive. The nurse obtains data base
information during the admission interview and physical examination.
2. A focus assessment: is information that provides more details about specific problems
and expands the original data base. For instance, if during the initial interview the
client tells the nurse that constipation is the rule rather than the exception, more
questions follow. The nurse obtains data about the client’s dietary habits, level of
activity, fluid intake, current medications, frequency of bowel elimination, and stool
characteristics.
 Organization of Data
Why it is important to Organized the Data?
 2. Diagnosis
Diagnosis, the second step in the nursing process, is the identification
of health-related problems. Diagnosis results from analyzing the
collected data and determining whether they suggest normal or
abnormal findings.

Nurses analyze data to identify one or more nursing diagnoses. A

nursing diagnosis is a health issue that can be prevented, reduced,
resolved, or enhanced through independent nursing measures. It is an
exclusive nursing responsibility. Nursing diagnoses are categorized into
five groups: actual, risk, possible, syndrome, and wellness.
 DIAGNOSTIC STATEMENTS.
DIAGNOSTIC STATEMENTS. An actual nursing diagnostic
statement contains three parts:
1. Name of the health-related issue or problem as identified
in the NANDA list.
2. Etiology (its cause)
3. Signs and symptoms
 Collaborative Problems
Collaborative problems are physiologic complications that require both nurse- and
physician-prescribed interventions. They represent an interdependent domain of
nursing practice. The nurse is specifically responsible and accountable for
• Correlating medical diagnoses or medical treatment measures with the risk for
unique complications.
• Documenting the complications for which clients are at risk.
• Making pertinent assessments to detect complications.
• Reporting trends that suggest development of complications.
• Managing the emerging problem with nurse- and physician-prescribed measures.
• Evaluating the outcomes.
 3. Planning
Planning The third step in the nursing process is planning,
or the process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable goals or
outcomes, selecting appropriate interventions, and
documenting the plan of care. Whenever possible, the nurse
consults the client while developing and revising the plan.
 Planning Characteristics
1. Setting Priorities - Prioritization involves ranking from those that
are most serious or immediate to those of lesser importance
2. Establishing Goals: (expected or desired outcome) helps the
nursing team know whether the nursing care has been appropriate
for managing the client’s nursing diagnoses and collaborative
problems. What are types of Goals?
3. Selecting Nursing Interventions.
4. Documenting the Plan of Care.
5. Communicating the Plan of Care.
 Type of Planning
1. Initial planning
2. Ongoing planning
3. Discharge Plaining

R. NusLab
 4. Implementation – Intervention
Implementation, the fourth step in the nursing process, means carrying out
the plan of care. The nurse implements medical orders as well as nursing
orders, which should complement each other. Implementing the plan
involves the client and one or more members of the health care team.
A wide circle of care providers with assorted roles may be called on to
participate, either directly or indirectly, in carrying out one client’s plan of
care.
 Nursing Interventions Classification
What to change and How to change
1. Behavioral Nursing Interventions – exercise
2. Community Nursing Interventions – physical activities– environment
3. Family Nursing Interventions – Family center approached
4. Health System Nursing Interventions – life style of eating
5. Physiological Nursing Interventions - Eating
6. Safety Nursing Interventions -
 Skills Used in Implementing Nursing Care
When implementing care, nurses need cognitive, interpersonal, and technical skills to perform the
care plan successfully.
1. Cognitive Skills are also known as Intellectual Skills are skills involve learning and understanding
fundamental knowledge including basic sciences, nursing procedures, and their underlying rationale
before caring for clients. Cognitive skills also include problem-solving, decision-making, critical
thinking, clinical reasoning, and creativity.
2. Interpersonal Skills are skills that involve believing, behaving, and relating to others. The
effectiveness of a nursing action usually leans mainly on the nurse’s ability to communicate with the
patient and the members of the health care team.
3. Technical Skills are purposeful “hands-on” skills such as changing a sterile dressing,
administering an injection, manipulating equipment, bandaging, moving, lifting, and repositioning
clients. All of these activities require safe and competent performance.
 Charting
• The medical record is legal evidence that the plan of care
has been more than just a paper trail.

Why ?
 5. Evaluation
Evaluation, the fifth and final step in the nursing process, is
the way by which nurses determine whether a client has
reached a goal. Although this is considered the last step, the
entire process is ongoing. By analyzing the client’s
response, evaluation helps to determine the effectiveness of
nursing care.
 Discharge Nursing Care Plan
A discharge plan includes specific components of client teaching with documentation such as:
• Equipment needed at home. Coordinate home-based care and special equipment needed.
• Dietary needs or special diet. Discuss what the patient can or cannot eat at home.
• Medications to be taken at home. List the patient’s medications and discuss the purpose of each medicine, how much to
take, how to take it, and potential side effects.
• Resources such as contact numbers and addresses of important people. Write down the name and contact information of
someone to call if there is a problem.
• Emergency response: Danger signs. Identify and educate patients and families about warning signs or potential problems.
• Home care activities. Educate patient on what activities to do or avoid at home.
• Summary. Discuss with the patient and family about the patient’s condition, the discharge process, and follow-up checkups.
 Using of Nursing Process
Use of the nursing process is the standard for clinical
nursing practice. Nurse practice acts hold nurses
accountable for demonstrating all the steps in the nursing
process when caring for clients. To do less implies
negligence.

When to use it ?
 Concept Mapping
Concept mapping (also known as care mapping) is a method of organizing
information in graphic or pictorial form. This strategy promotes learning by
having the student gather data from the client and medical record or a
written case study, select significant information, and organize related
concepts on a one or two-page working document.
Various formats used include a spider diagram with a central theme such as
the client’s medical diagnosis, a hierarchy moving from general to specific,
or a linear flow chart. With additional knowledge, students draw lines or
arrows to link or correlate relationships within the map. Organizing the data
then facilitates identifying nursing diagnoses, setting goals and expected
outcomes, and evaluating the results of the care provided.
 Using Concept mapping needs
Those who use concept mapping report that the technique:
• Allows students to integrate previous knowledge with newly acquired information.
• Enables students to organize and visualize relationships between their current academic learning and new,
unique client assignments.
• Increases critical thinking and clinical reasoning skills.
• Enhances retention of knowledge.
• Correlates theoretical knowledge with nursing practice.
• Helps students recognize information that they must review or learn to promote safe, appropriate client care.
• Promotes better time management for beginning students otherwise focused on the composition
requirements of nursing care plans rather than use of the nursing process itself.
Nursing Care Plan – example
Table 2. Nursing Care Plan
Assessment Nursing Diagnosis Planning Implementation Evaluative
(Short- and
long-term Goals)
Actions Rational
(Why)
Subjective: Patient Say According to NANDA My goal will 1. 1. Met
meet during 2. 2. Not met
Ongoing

Period of

Objective: Nurse Observe

Thank you