The Nursing Process
I.
Historical Development:
ANA defines nursing as “the diagnosis
and treatment of human responses to
actual or potential health problems”.
1960’s:
1955:
1950 & early 60’s:
1970’s
1973
1973
1982
Nsg educators began to ID and describe what nurses did to help
students understand the intellectual process of nsg.
Nsg process first used as a term by Lydia Hall
1959 Dorothy Johnson
1961 Ida Orlando
1963 Ernestine Wiedenbach
1967 Lois Knowles – 5 D’s
Discover, Delve, Decide, Do, discriminate
1967 WICHE (Western Interstate Commission of Higher
Education) & Catholic University:
Assessment, Planning, Intervention, Evaluation
Conferences on Nursing Diagnoses began
North American Nursing Diagnosis Association (NANDA)
 Developed the first list of approved nsg dx.
 Holds national conferences every 2 years to revise the list.
ANA used the nsg process as a guide to develop “Standards of
Nursing Practice”. The 5 Step Process began.
NCLEX (professional state board licensing exam) included the nsg
process as one of the concepts for competent nsg practice.
II. Definition:
Systematic problem-solving method for providing individualized care for individuals, families,
and communities in all states of health and illness.
Purpose is to develop a holistic plan of individualized care to help the client meet goals.
III.
Steps: Assessment, Nsg dx, Planning, Implementation, Evaluation

Purpose: The written plan of care provides for continuity between nurses as they
change shifts and on different days. Changes in the plan must be passed on from shift
to shift.
A.
Assessment:
Subjective:
Objective:
Physical Exam: Inspection, Palpation, Percussion, and Auscultation
B.
Nursing Diagnosis
The statement of actual or potential (Risk for) problems that can be resolved, diminished, or in some way changed
by nursing intervention.
ANA defines nsg diagnosis:
“A clinical judgment about individual, family, or community responses to actual or potential health problems or
to life processes”.
1.
2.
Nursing dx has three parts:
 Problem Statement: From NANDA list.

Etiology: Related to…. This cannot be the medical diagnosis. It must be
something that you can work to improve. Ideally this can be resolved through
independent nsg interventions.

Signs & Symptoms: Assessment findings that validate the presence of the
problem.
Types of Nsg Dx
Actual:
Response that the client is currently experiencing as a result of the health
problems or life processes.
Risk for:
Recognition of risk factors that could contribute to an actual problem.
Possible:
When the nurse thinks that a client may have a certain dx, but more data is needed
for confirmation.
Collaborative:
Nonnursing dx that result as a complication of the altered health state. These
problems require nsg and medical interventions for dx and tx.
3.
Prioritization:
B. Planning
Development of goals.
Note that the goal statement is composed of three parts:
 an introduction (that states the overall goal),
 time frame for completion,
 measurable outcome criteria.
The outcomes need to be:
 very specific,
 measurable,
 appro. & realistic,
 Developed with the client &/or family.
C. Interventions
Use action verbs:
No passive words:
walk, assist, and demonstrate
encourage, try, etc.
1.
Specifications:
 Need to be appro for the client’s health status, his age, developmental
level.
 Include a mix of independent, interdependent, and dependent nsg
actions.
 Very specific re: time, action, frequency, quantity, method. Note that
ea should be written such that another nurse would implement it
exactly as you would.
2.
Types of Interventions:
Independent:
May be complete without a MD order. Based on the nurse’s independent
judgement.
Interdependent:
Need MD order to institute requires nsg action to carry out. May require
nurse’s independent judgement as to when to carry out.
Dependent:
Need MD order to institute and carry out.
3.
Categorize the interventions:
Develop interventions appro to Assessment, Treat, Teach. Write down a
header and list all appro interventions for ea.
4.
Address ea outcome criteria of the goal statements:
Implementation: Carry out the nsg care plan. Cont. assessment of the client to ensure that
his status has not changed.
D. Evaluation: