The Nursing Process:
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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:
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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
The Nursing Process Utilizes The Following:
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Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Characteristics of the Nursing Process:
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Within the legal scope of nursing
Based on knowledge-requiring critical thinking
Planned-organized and systematic
Client-centered
Goal-directed
Prioritized
Dynamic
Assessment of Well-Being:
 According to the World Health Organization is well-being in these domains:
 Emotional
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 Physical
 Social
 Spiritual
Tools of assessment:
 Observation
 Interview
 Types of questions
 Environment (physical and emotional) Spiritual considerations
 Examination
Types of Data To Collect:
 Objective data-observable and measurable facts (Signs)
 Subjective data-information that only the client feels and can describe
(Symptoms)
Sources of Data:
 Primary source: Client
 Secondary source: Client’s family, reports, test results, information in current and
past medical records, and discussions with other health care workers
Disease Prevention:
 Primary prevention – protection from a disease while still in a healthy state.
 Secondary prevention – early detection and treatment of disease.
 Tertiary prevention – prevent complications and to maintain health once the
disease process has occurred.
Planning:
 Establish the goals, interventions and outcomes
General Guidelines for Setting Priorities:
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Take care of immediate life-threatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on the overall picture, the patient as a whole person,
and availability of time and resources.
Nurse Identified Priorities:
 Composite of all patient’s strengths and health concerns.
 Moral and ethical issues.
 Time, resources, and setting.
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 Hierarchy of needs.
 Interdisciplinary planning.
DIAGNOSIS:
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Sort, cluster, analyze information
Identify potential problems and strengths
Write statement of problem or strength
Risk of infection related to compromised nutrition
Components of Outcomes:
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Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the actions?
Performance criteria: how well is the person to perform the actions?
Target time: by when is the person expected to be able to perform the actions?
Nursing Interventions:
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Road maps directing the best ways to provide nursing care.
Evidence based nursing.
Monitor health status.
Minimize risks.
Resolve or control a problem.
Assist with ADLs.
Promote optimum health and independence.
Interventions:
 Direct interventions: actions performed through interaction with clients.
 Indirect interventions: actions performed away from the client, on behalf of a
client or group of clients.
Documentation:
 Clear and concise
 Appropriate terminology
 Usually on a designated form
 Physical assessment
 Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system
Evaluation:
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1. Determining outcome achievement
2. Identifying the variables affecting outcome achievement
3. Deciding whether to continue, modify, or terminate the plan
NANDA – North American Nursing Diagnosis Association
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Identifies nursing functions
Creates classification system
Establishes diagnostic labels
Risk of infection related to compromised nutritional state
Potential complication of seizure disorder related to medication compliance
Community as Client:
• A community-wide group of people as the focus of nursing service
– The community directly influences the health of individuals, families,
groups, subpopulations, and populations who are a part of it.
– Provision of most health services occurs at the community level.
Dimensions of Community as Client:
• One perspective:
– Status: morbidity & mortality data identifying physical, emotional, and
social determinants of health
– Structure: services and resources
– Process: ability to function effectively
• Another perspective:
– Location (community boundaries, location of health services, geographic
features, climate, flora, fauna, human-made environment)
– Population (size, density, composition, rate of growth or decline, cultural
characteristics, social class and educational level, mobility)
– Social system (variables, health care delivery system)
Nursing Process Characteristics & Community:
• Problem-solving process; management process; process for implementing change
• Characteristics:
– Deliberative; adaptable; cyclic
– Client-focused; need-oriented
– Interaction with community (communication, reciprocal interaction,
paving way for helping relationship, aggregate application)
– Forming of partnerships and building of coalitions
Community Needs Assessment:
• Process of determining real or perceived needs of a defined community
• Types
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Windshield survey (familiarization assessment)
Problem-oriented assessment
Community subsystem assessment
Comprehensive assessment (key informants)
Community assets assessment
Community Assessment Methods:
Surveys
Descriptive epidemiologic studies
Community forums/town hall meetings
Focus groups
Sources of Community Data:
• Primary: gathered by talking to the people
• Secondary: records produced by people who know the community well
• International
• National
• State
• Local
Community Diagnoses:
• Portray a community focus
• Include community response and related factors that have potential for change via
CHN; logically consistent; response and factors logically linked
• Include statements narrow enough to guide interventions
• Use a community response instead of a risk, goal, or need statement
• Include factors within the domain of community health nursing intervention
• Deficit and wellness diagnoses (include maintenance or potential change
responses due to growth and development) when no deficit is present
Planning to Meet Community Health Needs; Implementing Plans:
• Planning
– Tools for assistance: operational definitions of objectives and activities, conceptual
frameworks and models; systematic approach
– Health planning process
• Implementing
– Preparation
– Activities or actions
Evaluating Implemented Community Health Plan:
• Measuring or judging effectiveness of goal or outcome attainment
• Types of evaluation
– Formative: focus on process during actual interventions; development of performance
standards
– Summative: focus on the outcomes of interventions; effect; impact
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