THE NURSING PROCESS
THE NURSING PROCESS
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“Nursing is the diagnosis and treatment of
human response to actual or potential health
problems” (ANA, 1980). Thus how the client is
responding to a medical problem, treatment
plan and changes in activities of daily living.
“… to assist the individual sick or well in the
performance of those activities contributing to
health or its recovery (or to a peaceful death)
that he would have perform unaided if he had
the necessary strength, will, or knowledge, and
to do this in such a way as to help him gain
independence as rapidly as possible”
(Henderson, 1966)
Process……..?
THE NURSING PROCESS
Hall (1955) originated the term nursing process.
In the 1960s the nursing process emerged and
has become widely accepted to describe the series
of steps that a nurse takes when caring for
his/her patient. Various nurses have described
the process of nursing and organized it in various
phases and in different ways.
 The use of the nursing process gained more
ground and legitimacy in 1973 when the phases
were included in the Standard of Nursing of the
American Nurses Association.
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THE NURSING PROCESS
A systematic and scientifically based model, the
nursing process is used to guide nursing practice
in providing holistic and individualized care to
the client. method used to:
 identify patient’s health problems,
 To specify plans to solve them
 To implement the plans and
 Evaluate the effectiveness of plans in resolving
the problems that were identified (Yura and
Walsh, 1978)
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THE NURSING PROCESS
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The nursing process is the basis of all nursing
actions. Each step of the nursing process builds
on and interacts with the other steps.
The nursing process is patient/family centered,
problem oriented, goal directed and above all
planned with the aim of providing care that is
individualized, holistic, effective and efficient.
THE NURSING PROCESS
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The nursing process runs through five (5)
sequential but interrelated steps which are
cyclical as follows:
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Each step of the nursing process is dependent upon
the accuracy of the preceding step.
THE NURSING PROCESS
ASSESSMENT
EVALUATION
IMPLEMENTATION
NURSING
DIAGNOSIS
PLANNING
THE NURSING PROCESS
Assessment is the first step of the nursing
process. The nurse collects and examine
information to get the necessary facts to
determine the patient’s health status and
describe the strengths and problems. The data
collected is on the patient/family, community’s
health status. Analysis of this data determines
the actual and potential health problems .
 Assessment progresses in stages:
1. Collection of data
2. Organization of data
3. Validation of data
4. Documenting data
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THE NURSING PROCESS
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The purpose of assessment is to obtain
information and to make a decision about a
client’s health status.
Sensitive and continuous nursing assessment by
means of health history and health assessment
helps maintain and awareness of the patient’s
needs and effectiveness of the nursing care
he/she receives.
It also helps identify patient’s strength-skills,
abilities and behaviours the client has that can
be used to promote treatment and recovery. E.g.
family support, coping skill, spiritual beliefs etc.
THE NURSING PROCESS
Data is collected from a variety of sources:
 Primary source (client).
 Secondary source (sources other than the client)
e.g. family members, other health care providers,
medical records and diagnostic reports, literature
review etc.
Data collected may subjective or objective.
 Subjective data refers to symptoms which only
the affected person can describe e.g. itching, pain
and feelings of worry. It includes the client’s
sensation, feelings, values, beliefs, attitudes etc.
The best source of subjective data is from the
patient.
THE NURSING PROCESS
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Objective data (signs) are data that can be
observed, measured or tested against an accepted
standard. This data is collected through
observation or physical examination. Sign
(objective data) can be seen, heard, felt or
smelled. E.g. rashes, sore, hoarseness of voice
blood pressure, results of a test etc.
The nurse obtains objective data to validate
subjective data.
THE NURSING PROCESS
Data collection tools/methods
 Observation-gathering data by using the senses
 Interviewing e.g. health history taking
 Physical examination/physical assessmenta systematic data collection method that uses
observation. It entails inspection, palpation,
auscultation and percussion.
 Data collected is document.
THE NURSING PROCESS
Why nursing assessment?
 To establish database that identify patient’s
health problems, needs and strengths
 To determine client’s immediate responses to
nursing action during the implementation phase
 To evaluate patient’s progress towards desired
outcomes/goals
THE NURSING PROCESS
Nursing Diagnosis
 This is the second phase of the nursing process. It is a
clinical judgement about individual, family, or
community’s response to actual and potential health
problems/life process
During this step, one further analyze and synthesize the
information and come to some specific conclusion;
 Identify areas of positive functioning
 Areas where there may be a risk of problems
developing
 Areas that are problems
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The actual or potential health problems to which
nurses direct their diagnosis and treatment,
then, are the human responses-to the health
challenges encountered in birth, illness, growth
and development and death
THE NURSING PROCESS
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The distinguishing feature of any nursing
diagnosis is that it describes a health condition
primarily resolved by nursing interventions or
therapies.
Nursing diagnosis provides the basis for selection
of nursing interventions for achieve and outcome
that the nurse is accountable.
THE NURSING PROCESS
Types of Nursing Diagnosis
 Actual diagnosis id a client problem that is
present at the time of the nursing assessment
 Potential/Risk nursing diagnosis is clinical
judgement that though a problem does not exist
presently, the presence of risk factors indicate
that it can develop if certain measures are not
put in place.
 Health promotion diagnosis relates to client’s
preparedness to implement behaviours to
improve their health condition. E.g. Readiness for
enhanced (nutrition)
THE NURSING PROCESS
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Wellness diagnosis describes human response to
levels of wellness in an individual, family or
community. E.g. Readiness for enhanced family
coping.
THE NURSING PROCESS
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The Format
When communicating nursing diagnosis, it is
customary to use a format, that is, the general
arrangement or organization. Formats are
important because they are used in common by
the group adopting them and thus unifying the
group’s approach to communication around
shared understanding and expectations.
The conventional format is the PES format
which indicates the direction of the relationship
between the health problem (P), its etiologic
factors (E), and its defining characteristics/signs
and symptoms (S).
THE NURSING PROCESS
The Problem is a concise statement of the client’s
actual or potential health problem or health state for
which nursing therapy is given. It directs the
formation of client goals and desired outcomes as well
as suggest some of the interventions needed by the
client.
 The problem statement is also called the diagnostic
label; it comes from a list of approved nursing
diagnosis. E.g. Impaired skin integrity, Activity
intolerance. One cannot coin his/ her own
diagnostic label!
 the problem is named using the label that most
closely matches it.
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THE NURSING PROCESS
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Diagnostic labels contain qualifiers (deficient,
impaired, decreased, inefficient compromised
etc.) to give additional meaning to it.
Each diagnostic label approved by NANDA
carries a definition that clarifies its meaning.
Example: Activity intolerance-insufficient
physiological or psychological energy to endure or
complete required or desired daily activities.
NURSING PROCESS
Some Diagnostic Labels
 Activity intolerance
 Ineffective airway clearance
 Anxiety
 Ineffective thermoregulation
 Altered urinary elimination
 Self care deficit
 Altered nutrition
 Impaired mobility
 Knowledge deficit
 Impaired skin integrity
THE NURSING PROCESS
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Etiology-the component of the nursing diagnosis that
identifies the probable causes of the health problem.
Also called the Related Factors or Contributing
Factors, it gives direction to the required nursing
therapy and enables the nurse to individualize the
client’s care. Since the etiology of nursing diagnosis
becomes the focus of intervention in the treatment of
the overall problem, citing medical condition/diagnosis
as etiology inadvisable.
Sign and Symptoms-also known as the Defining
Characteristics are observed, reported or measured
findings that serve as supporting evidence of the
diagnosis.
THE NURSING PROCESS
The word risk for OR potential for is used to
identify the presence of risk factors; thus the
actual problem does not yet exist.
 E.g.
Potential for impaired skin integrity related to
continuous pressure on skin over bony
prominences
Or
 Risk for impaired skin integrity related to
continuous pressure on skin over bony
prominences.
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THE NURSING PROCESS
Formulating Diagnostic Statements
 When communicating the nursing diagnosis, the
various parts (PES) are linked with words that
indicate the direction of the relationship between
the problem, its etiologic factors and the defining
characteristics.
the problem and the etiologic factors are linked
with related to; the defining characteristics are
linked with the indicator as evidenced by or as
manifested by
THE NURSING PROCESS
In the formulation of the nursing diagnosis, one can have;
 Two part statements- this is composed of the
diagnostic label (problem) + contributing factors;
e.g.
Constipation related to prolonged laxative use.
Three part statements-this is composed of the
diagnostic label + contributing factors + signs
and symptoms e.g.
Potential for impaired skin integrity related to
continuous pressure on skin over bony
Prominences as manifested by discolouration of
skin at the buttocks and scapulae.
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When writing statements for nursing diagnosis,
try to express them in such a way that the second
part of the statement (related factors/etiology)
directs the interventions. If this is not possible,
then be sure the problem directs the
intervention.
THE NURSING PROCESS
Nursing diagnosis has the following benefits:
 Assists in organizing, defining and developing
nursing knowledge
 Aids in identifying and describing the domain
and scope of nursing practice
 Focuses nursing care on the client’s response to
problems
 Provides diagnosis-specific nursing interventions
that should increase the effectiveness of nursing
care.
 Facilitates the evaluation of nursing practice
THE NURSING PROCESS
Provides a framework for testing the validity of
nursing interventions
 Provides a standardized vocabulary to enhance intraand interprofessional communication
 Prescribes the content of nursing curricula
 Provides a framework for developing a system to direct
third-party reimbursements for nursing services
 Indicates specific rationales for (client) care based on
nursing assessment
 Leads to more comprehensive and individualized
(client) care.
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THE NURSING PROCESS
Planning
The care plan is a blue print for assisting a client to
resolve the clients health problem. Constructing a
unique plan to guide the delivery of nursing care to
every client requires a wide range of knowledge and
skills.
In developing client care plans, the nurse engages in the
following activities:
 Setting priorities
 Establishing client goals/desired outcomes
 Writing individualized nursing interventions on care
plans
THE NURSING PROCESS
Priority setting is a decision –making process that is
used to rank the urgency or relative importance of
nursing diagnoses, desired outcomes and nursing
implementation. Priorities change as the client’s
condition changes.
 Priority setting is a way of is a way of allocating
resources and, if well done, improves the quality and
efficiency of nursing care.
 Maslow’s hierarchy of needs is one framework that
used in prioritizing care. The client’s beliefs, values
and perception may also influence priority setting as
the resources available for patient care.
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THE NURSING PROCESS
After setting priorities, the nurse and client set goals for
each nursing diagnosis formulated. Goals are derived
directly fro the problems diagnosed. The goals and
desired outcomes(expected outcomes, predicted outcome,
outcome criteria or objective) serve as the yardstick in
evaluating the nursing interventions implemented.
Whiles the goal is a broad statement about the client’s
status, the desire outcome the specific observable
criteria used to evaluate whether the set goals have been
achieved or not.
Goals/objectives set must be SMART:
 Specific
 Measurable
 Achievable
 Realistic and
 Time bound
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THE NURSING PROCESS
In stating the objective/outcome criteria, the goal is
stated and linked with the outcome criteria with the
phrase as evidenced by. E.g.
Ineffective airway clearance related to poor cough effort
secondary to incision pain. (nursing diagnosis)
Patient’s lungs will be clear within 72hours as
evidenced by:
1. Clear lung fields on auscultation
2. Good cough effort
3. Absence of skin pallor.
The goal/desired outcome statement should have the
subject, verb, condition/modifiers and criterion
of desired performance.
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THE NURSING PROCESS
Selecting Nursing Interventions
Nursing interventions and activities are the actions
that a nurse performs to achieve client goals. The
specific interventions chosen should focus on
eliminating or reducing the etiologic factors (the
problems) of the nursing diagnoses.
 If it is not possible to eliminate the etiology, then
the nurse chooses interventions to treat the signs
and symptoms.
 In the case of risk nursing diagnoses, then the
intervention should focus on reducing the client’s
risk factors.
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THE NURSING PROCESS
The interventions may be
 Dependent
 Independent
 Collaborative.
After going through the several intervention
possible interventions identified for each nursing
goal, the nurse must choose and document those
that are most likely to achieve the desired client
outcomes.
THE NURSING PROCESS
Implementation
This is the action phase of the nursing process
where the care as planned is carried
out/performed. It entails performing the actual
nursing activities and documenting them.
The process of implementation includes
 Reassessing the client
 Determining the nurse’s need for assistance
 Implementing the nursing interventions
 Supervising delegated care and
 Documenting nursing activities
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THE NURSING PROCESS
Evaluating
 Evaluation is a systematic comparison of a
client’s health status to standards/outcome
criteria mutually developed by the client and the
nurse. It is a planned, ongoing, purposeful
activity in which clients and health care
professionals determine the effectiveness of the
nursing care plan.
 Evaluation determines whether the nursing
interventions should be continued, change or
terminated.
NURSING PROCESS
During evaluation of nursing care, sharp and objective
outcome criteria are important because they establish
the kind of evaluative data needed to be collected aside
providing the standard or yardstick against which the
data collected is judged.
The components of evaluations phase are:
 Collecting data related to desired outcomes
 Comparing data with desired outcomes
 Relating nursing activities to outcomes
 Drawing conclusions about problems status
 Continuing, modifying or terminating the nursing care
plan
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NURSING PROCESS
Benefits of the Nursing Process
 Promotes individualized/client centred health
care
 Ensures holistic health care delivery
 Promotes flexibility and independent thinking
 Ensures continuity of care
 Avoid duplication of effort and judicious use of
resources.
NURSING PROCESS
Nursing Process
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Deals with two types of health
problems:
Medical Process
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Human response problems (problems
with human functioning that result
from the effect of disease, trauma or
changes in life.
Deals mostly with problem with
structure and function of organs
or systems
Problems with structure and function
organs or systems requiring
physicians’ orders
Considers the whole person ; not only
the organs and systems functions
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Mainly considers organ and
system function
QUESTIONS???