Nursing Process: Foundation for
Practice
NPN 105
Joyce Smith RN, BSN
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What is the “Nursing Process”?
• It is a systematic method that directs the nurse and
patient in planning patient care, and enables you to
organize and deliver nursing care
• It is patient centered and outcome oriented
• The steps are interrelated and dependent on the
accuracy of each of the preceding steps
• It is used to identify, diagnose, and treat human
responses to health and illness
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Together the nurse and the patient
accomplish the following:
• Assess the patient to determine need for
nursing care
• Determine nursing diagnoses for actual and
potential health problems
• Identify expected out comes and plan care
• Implement care
• Evaluate the results
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Five Steps of the Nursing Process
• Assessment – collection of patient data
• Diagnosis – identifies patients strengths and
potential problems
• Planning – develop the specific holistic desired
goals and nursing interventions to assist the
patient
• Implementation – carry out the plan of care
• Evaluation – determine the effectiveness of the
plan of care
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Assessment: Phase One of the
Nursing Process
• Purpose:
• Establish a baseline of information on the client
and develop a data base
• Determine client’s normal function
• Determine client’s risk for dysfunction
• Determine presence or absence of dysfunction
• Determine client’s strengths
• Provide data for diagnostic phase
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Unique Focus of Nursing
Assessment
• Nursing assessments do not duplicate
medical assessments
• Medical assessments target data pointing to
pathologic conditions
• Nursing assessments focus oh the patient’s
responses to health problems or potential
health problems
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Assessment
• The purpose is to establish a database by:
• Collecting data
• Subjective versus objective
• Interviewing and taking a health history
• Subjective and organized
• Performing a physical examination
• Vital signs, patient’s behavior, diagnostic and
laboratory data, medical records
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Approaches for Data Collection
• Gordon’s 11 Functional Health Patterns
• Uses a series of questions which assist in
formulating a nursing diagnosis
• Problem focused assessment
• Focuses on the patient’s problem and develop
you plan of care around the problem
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Gordon’s Health Patterns
• Health perceptionmanagement
• Nutritional-metabolic
• Elimination
• Activity-exercise
• Sleep-rest
• Cognitive -perceptual
• Self-perception-selfconcept
• Role-relationship
• Sexuality-reproductive
• Coping-stresstolerance
• Value-belief
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Types of Nursing Assessments
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Initial assessment
Focused assessment
Emergency assessment
Time-lapsed assessment
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Types of Data
• Subjective Data
• Information perceived only the affected person
• Cannot be perceived or verified by another
person
• Examples: feeling nervous, nauseated, chilly
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Types of Data
• Objective Data
• Observable and measurable data
• Data that can be see, heard or felt by someone
other than the person experiencing it
• Examples: elevated temperature (>101 F),
moist skin, refusal to eat, vital signs
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Characteristics of Data
• Complete
• Factual and accurate
• Relevant
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Components of Data Collection
• Interview
• Orientation phase
• Working phase
• Termination
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Sources of Data
• Primary
• patient
• Secondary
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Family members
Significant other
Other healthcare professionals
Health records
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Components of Data Collection
• Nursing History
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Biographical information
Reasons for seeking healthcare
Present illness or health concern
Health history
Environmental history
Psychosocial and cultural history
Review of systems or functional health patterns
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Interpreting Assessment Data
• Data interpretation and validation
• Data clustering
• Data documentation
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Diagnosis: Phase 2 of the Nursing
Process
• Data is useless if not used
• An important part of nursing practice is
determining what the client needs
• Developing a nursing diagnosis is the next step in
planning for the care of the patient
• Looking at the data, we can see both problems
treated by nursing (nursing diagnosis) and treated
by other disciplines (collaborative problems).
• Nursing diagnosis are not medical diagnosis
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Purpose of a Nursing Diagnosis
• 1. Identify how and individual, group or
community responds to an actual or
potential health and life processes
• 2. Identify factors that contribute to or cause
health problems (etiology).
• 3. Identify resources or strengths the
individual, group or community can utilize
to prevent or resolve problems
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Health Problem
• A condition that necessitates intervention to
prevent or resolve the disease or illness or
to promote coping and wellness
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Health Problems for Nursing Focus
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Monitoring for changes in health status
Promoting safety and preventing harm
Identifying and meeting learning needs
Tailoring treatment and medication
regimens for each individual
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Health Problems for Nursing Focus
• Promoting comfort and managing pain
• Promoting health and a sense of well being
• Recognizing and addressing barriers to an
independent, healthy lifestyles
• Determining human responses
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Nursing Diagnosis
• A clinical judgment about individual,
family, or community responses to actual
and potential health problems or life
processes
• The goal of a nursing diagnosis is to
identify actual and potential responses
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Medical Diagnosis
• Identification of a disease condition based
on a specific evaluation of physical signs,
symptoms, history, diagnostic tests, and
procedures
• The goals of a medical diagnosis is to
identify the cause of a illness or injury and
design a treatment plan
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Nursing Diagnosis
• Actual or potential health problems that can
be prevented or resolved by independent
nursing interventions
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Nursing Diagnosis
• Nursing diagnoses provide the basis for
selecting nursing interventions that will
achieve valued patient outcomes for which
the nurse is responsible
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NANDA
• NANDA: North American Nursing
Diagnosis Association
• Established in 1973 to identify standards
and classify health problems treated by
nurses
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NANDA
• NANDA conferences are held every two
years to continue progress in defining,
classifying and describing diagnoses
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NANDAS’ Definition of Nursing
Diagnosis
• Nursing diagnosis is a clinical judgment
about individual, family, or potential health
problems/life processes. Nursing diagnosis
provides the basis for selection of nursing
interventions to achieve outcomes for which
the nurse is accountable
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Nursing Diagnosis
• Clinical judgment about individual, family or
community
• Response to actual or potential health or life
process
• Provides basis for nursing interventions
• Label and action of describing functional
problems
• Identify and synthesize information gathered
during assessment
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Nursing Diagnosis vs. Medical
Diagnosis
• Medical diagnosis
• Identify disease
• Nursing diagnosis
• Focus on unhealthy response to health or illness
• Medical diagnosis
• Physician directs treatment
• Nursing diagnosis
• Nurse treats problem within scope of independent
nursing practice
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Nursing Diagnosis vs. Medical
Diagnosis
• Medical Diagnosis
• Remains the same as long as the disease is
present
• Nursing Diagnosis
• May change from day to day as the patient’s
responses change
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Nursing Diagnosis
• Medical Diagnosis
• Myocardial infarction
• Nursing Diagnosis
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Fear
Altered health maintenance
Knowledge deficit
Pain
Altered tissue perfusion
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Differentiating Nursing Diagnosis versus
Medical Diagnosis
Nursing Diagnosis
Medical Diagnosis
- focus on unhealthy responses to
health and illness.
- identify diseases
- describe problems treated by
nurses within the scope of
independent nursing practice.
- describe problems for which the
physician directs the primary
treatment .
- may change from day to day as - remains the same for as long as
the patient’s responses change
the disease is present
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Myocardial infarction (heart attack) is a
medical diagnosis.
Examples of nursing diagnoses for a person
with myocardial infarction include Fear,
Altered Health Maintenance, Knowledge
Deficit, Pain, and Altered Tissue Perfusion.
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Development of Nursing Diagnosis
• Assess the patient
• Review data and find actual and potential
problems
• Use diagnostic reasoning to identify patient needs
• Arrange data in clusters or defining characteristics
• Use all data available
• Reach conclusions for patient needs
• Determine Nursing Diagnosis according to
NANDA approved diagnoses
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Components of a Nursing Diagnosis
• Diagnostic label – name of the nursing diagnosis with
descriptors
• Related factors – includes factors which contribute to the
problem and are not the cause ,but are associated with it.
THESE ARE NOT MEDICAL DIAGNOSIS.
• Defining characteristics - Assessment data which supports
the nursing diagnosis
• Subjective data – what the patients tells you
• Objective data – what you observe or data obtained
• Risk factors – clues which point to potential problems
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Nursing Diagnosis
• Types of diagnoses
• Actual
• Risk
• Wellness
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Types of Nursing Diagnoses
1- Actual Nursing Diagnoses
Describe a human response to a health problem
that is being manifested. They are written as
three- part statements: diagnostic label, related
factors, defining characteristics.
Example – Acute pain related to surgical trauma
and inflammation, as evidenced by grimacing
and verbal reports of pain.
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2- Risk nursing diagnosis
As defined by NANDA, ’’describes human
responses to health conditions that may
develop in a vulnerable individual, family, or
community. It is supported by risk factors that
contribute to increased vulnerability’’.
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Risk nursing diagnoses are two – part statements
because they do not include defining
characteristics (diagnostic label, risk factors).
Example - Risk for infection related to surgery
and immunosuppression.
Risk for aspiration related to reduced level of
consciousness
Risk for Impaired Skin Integrity related to
inability to turn self from side to side in bed.
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3- Wellness nursing diagnosis
Is a diagnostic statement that describe the human
response to levels of wellness in an individual,
family, or community that have a potential for
enhancement to a higher state (NANDA,
2005).
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Wellness nursing diagnosis are one part
statement includes diagnostic label.
Example
– Readiness for enhanced spiritual well being
- Readiness for Enhanced Self-Esteem.
Q- Which One is accurate nursing diagnosis?
1- Readiness for Enhanced Family Coping
2- Family coping potential due to desire for
better health
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What a Nursing Diagnosis is Not
• A nursing diagnosis is NOT a medical
diagnosis
• A nursing diagnosis is NOT a statement of
patient need
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Legal Ramifications of Nursing
Diagnosis
• A nurse
• Can only identify problems within the scope of
practice
• Cannot diagnose or treat medical disease
• Must identify problems within his/her scope o
practice, abilities and education
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Nursing Planning
The third step of the nursing process includes the
formulation of guidelines that establish the
proposed course of nursing action in the
resolution of nursing diagnoses and the
development of the client’s plan of care.
The planning of nursing care occurs in three
phases: initial, ongoing, and discharge. Each
type of planning contributes to the coordination
of the client’s comprehensive plan of care.
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- Initial planning involves development of
beginning of care by the nurse who
performs the admission assessment and
gathers the comprehensive admission
assessment data. Initial planning is
important in addressing each prioritized
problem, identifying appropriate client
goals, and correlating nursing care to hasten
resolution of the client’s problems.
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- Ongoing planning entails continuous updating
of the client’s plan of care. Every nurse who
cares for the client is involved in ongoing
planning.
- Discharge planning involves critical
anticipation and planning for the client’s needs
after discharge.
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The four critical elements of planning include:
• Establishing priorities
• Setting goals and developing expected
outcomes (outcome identification)
• Planning nursing interventions (with
collaboration and consultation as needed)
• Documenting
Slide 54
The four critical elements of planning include:
• Establishing priorities
• Setting goals and developing expected
outcomes (outcome identification)
• Planning nursing interventions (with
collaboration and consultation as needed)
• Documenting
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The client’s basic needs, safety, and desires, as
well as anticipation of future diagnoses must
be considered. One of the most common
methods of selecting priorities is the
consideration of Maslow’s hierarchy of needs,
which requires that a life-threatening diagnosis
be given more urgency than a non life
threatening diagnosis.
The client must participate in the identification
of priorities so that the nature of the problem,
as well as the client’s values, are reflected in
the selected course of action.
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3rd Component of the Nursing Process-
Implementing:
• The provider carries out the plan of care
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During Implementing, the care
provider:
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Carries Out The Plan Of Nursing Care or
Setting your plans in motion and
delegating responsibilities for each step.
•
Continues Data Collection And Modifies
The Plan Of Care As Needed
•
Documents Care
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Implementing
Consists of doing and documenting the activities
that are the specific nursing actions needed to
carry out the interventions or nursing orders.
The first three nursing process phasesassessing, diagnosing, and planning-provide
the basis for the nursing actions performed
during the implementing step. In turn, the
implementing phase, provide the actual
nursing activities and client responses that are
examined in the final phase, the evaluating
phase.
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Process of Implementing
• Reassessing the client
• Determining the nurse’s need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
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Documenting Nursing Activities, the nurse
complete the implementing phase by recording the
interventions and client responses in the nursing
process notes. The nurse may record routine or
recurring activities such as mouth care in the client
record at the end of shift, while some actions
recorded in special worksheets according to
agency policy. Immediate recording helps
safeguard the client to prevent double actions.
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During Evaluating, the care provider:
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Measures The Clients Achievement Of
Desired Goals/Outcomes
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Identifies Factors That Contribute To
The
Client’s Success Or Failure
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Modifies The Plan Of Care, If
Indicated
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Process of Evaluating Client Responses
Collecting data related to the desired outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the
nursing care plan.
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When determining whether a goal has been
achieved, the nurse can draw one of the three
possible conclusions:
 The goal was met, that is the client response is
the same as the desired outcomes.
The goal was partially met, that is either a short
term goal was achieved but the long term was
not, or the desired outcome was only partially
attained.
The goal was not met.
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• Thank you….
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