THE NURSING PROCESS
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A critical thinking process that professional
nurses use to apply the best available evidence
to caregiving and promoting human functions
and responses to health and illness (American
Nurses Association, 2010).
NURSING PROCESS
- A problem-solving framework for planning and
delivering nursing care to patients and their
families
- Nursing process is a systematic method of
providing care to clients.
- The nursing process is a systematic method of
planning and providing individualized nursing
care.
- A way of thinking of the nurse
- A framework of interrelated activities resulting
in competent nursing care
- A dynamic and cyclical in nature, requiring
repeated review
- A scientific, problem-oriented approach to
patient care
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Allows nurses to communicate plans and
activities to
 Clients
 Other health care professionals
 Families
Encourages orderly thought, analysis, planning
Process:
- “A series of steps or acts that lead to
accomplishment of some goal or purpose”
Purpose is to provide client care that is:
- Individualized
- Holistic
- Effective
- Efficient
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To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet
those needs.
CHARACTERISTICS OF NURSING PROCESS
Cyclic
Dynamic nature
Client centeredness
Focus on problem solving and decision making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking and clinical reasoning.
Consists of 5 steps
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation
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Build on each other
Not linear
During the process a written NURSING CARE
PLAN is developed
THE NURSING PROCESS
ASSESSMENT
ASSESSMENT- DATA COLLECTION
Involves
- Collecting
- Validating the data
- Organizing the data
- Interpreting the data
- Documenting the data
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Assessment is the systematic and continuous
collection, organization, validation, and
documentation of data (information) for the
purpose of identifying the actual or potential
patient health problems which the professional
nurse is licensed to treat
The initial nursing assessment is the basis of the
patient care plan and later assessments
contribute to revisions and updates in the plan
as the patient’s condition changes.
Nursing process is dynamic and requires
creativity in its application
 Steps remain the same
 Application and results different
Used throughout the life span in any care
setting
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PURPOSES OF NURSING PROCESS
To identify a client’s health status and actual or
potential health care problems or needs.
1. Initial nursing assessment: Performed within
specified time after admission. To establish a
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complete database for problem identification.
E.g.: Nursing admission assessment
2. Problem-focused assessment: To determine
the status of a specific problem identified in an
earlier assessment.
E.g.: hourly checking of vital signs of fever
patient
3. Emergency assessment: During emergency
situation to identify any life-threatening
situation. E.g.: Rapid assessment of an
individual’s airway, breathing status, and
circulation during a cardiac arrest.
4. Time-lapsed reassessment: Several months
after initial assessment. To compare the client’s
current health status with the data previously
obtained.
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Data collection is the process of gathering
information about a client’s health status. It
includes the health history, physical
examination, results of laboratory and
diagnostic tests, and material contributed by
other health personnel.
Sources of Data
1. Primary: It is the direct source of information.
The client is the primary source of data.
 Client
 Interview
 Physical Examination
2. Secondary: It is the indirect source of
information. All sources other than the client
are considered secondary sources. Family
members, health professionals, records and
reports, laboratory and diagnostic results are
secondary sources.
 Family members
 Other health care providers
 Medical records
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2. Objective data
- also referred to as signs or overt data, are
detectable by an observer or can be measured
or tested against an accepted standard.
- They can be seen, heard, felt, or smelled, and
they are obtained by observation or physical
examination.
- For example, a discoloration of the skin or a
blood pressure reading is objective data.
- Observable and measurable data
- Main way to collect objective data
 Physical assessment
 Lab and diagnostic testing
Activities in Assessment
Validating the Data
- The information gathered during the
assessment is “double-checked” or verified to
confirm that it is accurate and complete
Organizing the Data
- The nurse uses a format that organizes the
assessment data systematically
- This is often referred to as nursing health
history or nursing assessment form
Interpreting the Data
Document the 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.
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Types of Data
1. Subjective data
- also referred to as symptoms or covert data, are
clear only to the person affected and can be
described only by that person.
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Itching, pain, dizziness and feelings of worry
Data from the client’s point of view
 Feelings, perceptions, concerns
Main way to collect subjective data:
 Interview
METHODS OF DATA COLLECTION
Observation: It is gathering data by using the
senses. Vision, Smell and Hearing are used.
Interview: An interview is a planned
communication or a conversation with a
purpose.
Physical Examination
Assessment= Observation + Interview +
Examination
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APPROACHES TO INTERVIEWING
- The directive interview is highly structured and
directly ask the questions. And the nurse
controls the interview.
- A nondirective interview, or rapport building
interview and the nurse allows the client to
control the interview.
Stages of an Interview
1. The opening or introduction
2. The body or development
3. The closing
EXAMINATION
- The physical examination is a systematic data
collection method to detect health problems.
- To conduct the examination, the nurse uses
techniques of inspection, palpation, percussion
and auscultation.
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