nursing tutor kurji college of Nursing,Patna

1. NURSING
PROCESS
Mrs Chinchu Nithin
Nursing tutor
Kurji College of Nursing
Patna

2. DEFINITIONS
NURSING PROCESS
It is a critical thinking process that professional
nurses use to apply the best available evidence to
care giving and promoting human functions and
responses to health and illness. (American
Nurses Association-2010).

3. 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.

4. CHARACTERISTICS
Cyclical and dynamic nature
Systematic and orderly
Client centeredness
It is an adaptation of problem solving and systems
theory
Decision making
Interpersonal and collaborative style
Universally applicable
Use of critical thinking skills

5. PURPOSES OF NURSING PROCESS
To identify a client’s health status and actual or
potential health care problems or needs.
To establish plans to meet the identified needs.
 To deliver specific nursing interventions to meet
those needs.

6. COMPONENTS OF NURSING PROCESS

7. NURSING PROCESS IN ACTION
ASSESSING
• Collect data
• Organize data
• Validate data
• Document data
DIAGNOSIS
• Analyze data
• Identify health problems,risks and
strengths
• Formulate diagnostic statements

8. PLANNING
• Prioritize problems and diagnoses
• Formulate goals and design health
outcome
• Select nursing interventions
• Write nursing interventions
IMPLEMENTING
• Reassess the client
• Determine the nurse’s need for assistance
• Implement the nursing interventions
• Supervise delegate care
• Document nursing activities

9. ASSESSMENT
Assessment is the systematic and continuous
collection, organization,validation and documentation
of data (information).

10. TYPES OF ASSESSMENTS
Initial nursing assessment
Problem focused assessment
 Emergency assessment
Time-lapsed assessment

11. 1. Initial nursing assessment: Performed within
specified time after admission. To establish a
complete database for problem identification.
Eg: Nursing admission assessment
2. Problem-focused assessment : To determine the
status of a specific problem identified in an earlier
assessment.
Eg: hourly checking of vital signs of fever patient

12.  Emergency assessment: During emergency
situation to identify any life threatening situation.
Eg: Rapid assessment of an individual’s airway,
breathing status, and circulation during a cardiac
arrest.
 Time-lapsed reassessment: Several months after
initial assessment. To compare the client’s current
health status with the data previously obtained.

13. ASSESSMENT PROCESS
Collect data
Organize data
Validate data
Document data

14. Data collection is the process of
gathering information about the
client’s health.
COLLECT
DATA

15. Database contains all the information about a
client.
It includes health history , physical assessment,
primary care provider’s history and physical
examination, results of laboratory and diagnostic
tests, and material contributed by other health
personnel.

16. TYPES OF DATA
Subjective data
Objective data

17. SUBJECTIVE DATA
 symptoms or covert data
 Data described or verified
by a person
 Example : Itching, pain,
and feelings of worry

18. OBJECTIVE DATA
 signs or overt data
 Data are detectable by an
observer or can be measured or
tested against an accepted
standard.
 Eg: redness on the hand
BP=100/60mm Hg

20. Constant data-It is information that does not
change over time such as race or blood group.
Variable data can change quickly, frequently, or
rarely and include such data as blood pressure,
level of pain, and age.

21. SOURCES OF DATA
The client is
the primary
source of
data.
Primary
Family members or other
support persons, other
health professionals,
records and and relevant
literature
secondary

22. DATA COLLECTION METHOD
Observation
Interview
Physical Examination
History collection
Lab and diagnostic test

23. OBSERVATION METHOD
It is gathering data by using the senses. Vision, smell
and hearing are used.
Observing occurs whenever the nurse is in contact
with the client or support persons.
Observing has two aspects: (a) noticing the data and
(b) selecting, organizing, and interpreting the data.

24. Nurses observe mainly through sight, most of the
senses are engaged during careful observations.
Observing, involves distinguishing data in a
meaningful manner.
For example, nurses caring for newborns learn to
ignore the usual sounds of machines in the nursery
but respond quickly to an infant’s cry or movement.

25. INTERVIEW METHOD
An interview is a planned communication or a
conversation with a purpose, for example, to get or give
information, identify problems of mutual concern,
evaluate change,or provide counseling or therapy.

26. DEFINTION
It is an interactional communication process which
involves the asking of questions by the interviewer
for the specific purpose of obtaining relevant
information and answering of questions by the
interview.

27. APPROACHES OF INTERVIEW
DIRECTIVE
METHOD
NONDIRECTIVE
METHOD

28. 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.

29. Directive method means it is highlystructured
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.

30. STAGES OF AN INTERVIEW
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing

31. 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.

32. HISTORY COLLECTION

33. LAB AND DIAGNOSTIC TEST

34. ORGANIZATION OF 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.

35. VALIDATION OF DATA
The information gathered during the assessment is
“double-checked” or verified to confirm that it is
accurate and complete.

36. INTERPRETING DATA
Distinguish relevant and irrelevant data.
Determine whether and where there are gaps in the
data.
Identify patterns of cause and effect.

37. DOCUMENTING DATA
Assessment data must be recorded and
documented.
Accurate and complete record communicates
information to health care workers.

38. NURSING
DIAGNOSIS

39. NURSING DIAGNOSIS
A clinical judgment about the individual family, or
community responses to actual and potential health
problems/life processes.(NANDA International 2009).

40. A nursing diagnosis provides the
basis for selection of nursing
interventions to achieve outcomes
for which the nurse is
accountable.

41. PURPOSE OF NURSING DIAGNOSIS
 Helps to identifies nursing priorities
 Directs nursing interventions to meet the clients
high priority needs
 Provides communication between nursing
professionals and the health care team
 Provides a base of evaluation

42. CHARACTERSTICS OF NURSING
DIAGNOSIS
It states clear and concise health problem.
It derived from existing evidences about the
client.
 It is potentially amenable to nursing therapy.
 It is the basis for planning and carrying out
nursing care.

43. TYPES OF NURSING DIAGNOSIS
Actual
diagnosis
Health
promotion
diagnosis
Syndrome
diagnosis
Risk nursing
diagnosis
Possible
nursing
diagnosis

44. ACTUAL DIAGNOSIS
An actual diagnosis is a client problem that is
present at the time of the nursing assessment.
It is based on the presence of associated signs and
symptoms.
Examples
 Ineffective Breathing
Pattern
 Anxiety

45. HEALTH PROMOTION DIAGNOSIS
It is relates to clients’ preparedness to implement
behaviors to improve their health condition.
These diagnosis labels begin with the phrase
Readiness for Enhanced, as in Readiness for
Enhanced Nutrition.
Eg:Readiness for enhanced family coping

46. RISK NURSING DIAGNOSIS
A risk nursing diagnosis is a clinical judgment that
a problem does not exist,but the presence of risk
factors indicates that a problem may develop if
adequate care is not given.
Example: Risk for infection related to surgery

47. POSSIBLE NURSING DIAGNOSIS
A possible nursing diagnosis is one in which
evidence about a health problem is incomplete or
unclear.
 A possible diagnosis requires more data either to
support or to refuse it.
Eg:Possible social isolation related to unknown etiology

48. SYNDROME NURSING
DIAGNOSIS
A clinical judgment describing a specific cluster of
nursing diagnoses that occurs together and are
best addressed together and through similar
interventions.
Eg: Rape trauma syndrome

49. COMPONENTS OF NANDA NURSING
DIAGNOSIS
(PES FORMAT)
1) The problem and its definition
(2) The etiology
(3) The defining characteristics.

50. Problem statement describes the client’s health
problem.
 The etiology component of a nursing diagnosis
identifies causes of the health problem.
 Defining characteristics are the cluster of signs
and symptoms that indicate the presence of health
problem.

52. Differentiating Nursing Diagnosis
from Medical Diagnosis
Nursing diagnosis Medical diagnosis
A nursing diagnosis is a statement of
nursing judgment that made by
nurse, by their education,
experience, and expertise, are
licensed to treat.
A medical diagnosis is made
by a physician.
Nursing diagnoses describe the
human response to an illness or a
health problem.
Medical diagnoses refer to
disease processes.
Nursing diagnoses may change as
the client’s responses change.
A client’s medical diagnosis
remains the same for as long
as the disease is present.

53. Nursing diagnosis Medical diagnosis
Ineffective breathing
pattern
Asthma
Activity intolerance Cerebrovascular
accident
Acute pain Appendicitis
Disturbed body image Amputation

54. STEPS OF DIAGNOSTIC PROCESS

55. Compare data against
the standard
Cluster cues
Identifies gaps and
inconsistencies
ANALYZING DATA

56. IIDENTIFYING HEALTH PROBLEMS,
RISKS, AND STRENGTHS
The nurse and client can together identify strengths
and problems
 Primarily a decision' making process.

57. Cont….
• Medical diagnosis
• Nursing diagnosis
• Collaborative problem
DETERMINE
PROBLEM
• Resources
• Ability to cope up
DETERMINE
STRENGTHS

58. FORMULATING DIAGNOSTIC
STATEMENTS

59. PROBLEM ETIOLOGY SIGNS/SYMPTOMS
hyperthermia
Ineffective airway
clearance
Infectious
process
Upper airway
obstruction
T=100 F
Productive cough
Basic three parts
Hyperthermia related to underlying infectious process as
evidenced by temperature 100 F.
 Ineffective airway clearance related to upper airway
obstruction as evidenced by productive cough.

60. Basic two part
1. Problem :statement of the client responses
2. Etiology :factors contributing to or probable
causes of the responses
 “related to” phrase implies a relation ship
 Eg:Ineffective airway clearance related to
upper airway obstruction
 Acute pain related to presence of surgical
incision
 Insomnia related to hospitalization

61. Basic one part
 The diagnostic label are defined and tend to become
more specific ,the interventions can be derived from the
label itself …… etiology may not be needed.
 Syndrome and wellness diagnosis consist Nanda label
only
Eg : Rape trauma syndrome
 Spiritual well being

62. Cont….

65. North American Nursing Diagnosis
Association (NANDA)
 The purpose of NANDA is to define, refine and
promote a taxonomy of nursing diagnostic
terminology.
 Taxonomy : A taxonomy is a classification system
or set of categories arranged based on a single
principles.
 In 2000, taxonomy 1 revised to taxonomy 2
 Currently, approved,13 domains and 47 classes,
247 nursing diagnosis.

67. EXAMPLE OF NANDA NURSING
DIAGNOSIS
Domain: Nutrition
Class1:Ingestion
Imbalanced nutrition less than body requirement
Readiness for enhanced nutrition
Ineffective breastfeeding
Domain:Activity/rest
Class1:sleep/rest
Insomnia
Sleep deprivation

69. Planning is a deliberative, systematic phase of the
nursing process that involves decision making and
problem solving.
Begins with first client contact
Continues until client (discharge)
 Is multidisciplinary

70. Planning is the third phase of the nursing
process, in which the nurse and client
develop client goals/desired outcomes and
nursing strategies to prevent, reduce or
alleviate the client’s health problem.

71. It also helps to identify nursing interventions that
will assist clients in meeting the goals.
This is the step in which nurse will determine how
to give nursing care in an organized,
individualized, goal -directed manner.

72. TYPES OF PLANNING
Ongoing
planning
Discharge
planning
Initial
Planning

73. 1. Initial Planning : Planning which is done after the
initial assessment.
2. Ongoing Planning : It is a continuous planning.
3. Discharge Planning : Planning for needs
after discharge

74. STEPS OF PLANNING PROCESS
Prioritize problem/diagnoses
select nursing interventions
Formulate goals/desired outcomes
Write nursing interventions/nursing orders

75. 1.Prioritize problem/diagnoses
Priority setting is the ordering of nursing diagnosis
and patient problems using determinations of
urgency and or importance to establish a
preferential order for nursing actions.
(Hendry and Walky 2004)

76. The nurse and client begin planning by deciding
which nursing diagnosis requires attention first,
which second, and so on.
Nurses frequently use Maslow’s hierarchy of
needs when setting priorities.

77. MASLOW’S HIERARCHY OF NEEDS

78. Planning….
Instead of rank-ordering diagnoses, nurses
can group them as
High priority (life-threatening)
Medium priority (health-threatening)
Low priority (developmental needs)

79. Factors to consider
Client's health values and beliefs
Client's priorities
Resources available
Urgency of the health problem
Medical treatment plan

80. 2. Formulate goals/expected outcome
outcomes
Goal- It reflects a patients highest possible
level of wellness and independence in
function.
Short term
Long term

81. 1. Short term goal
For a client who require health care for a short time.
Usually achieved in less than one week.
2.Long term goal
Are often used for clients who have a chronic
health problem.
Usually takes more than one to two weeks to
achieve.

82. Expected outcome- It is a measurable change in a
patient status that is expected to occur in response to
nursing care.
It is the basis for evaluating the effectiveness of the
nursing diagnosis.
Helps in deciding whether additional nursing care
is needed or whether the plan of care needs to be
revised.

83. Purpose of desired goals/outcomes
Provide direction for planning interventions
Serve as criteria for evaluating progress.
Enable the client and the nurse to determine
when the problem has been resolved.
Help motivate the client and nurse by providing a
sense of achievement.

84. The goal should be
 Measurable and
Observable
 Achievable and time
limited
 Client centred
 Realistic
 Outcome written
 Short

85. Components of Goal or desired health
outcome statement
 Subject
Verb
Conditions or modifiers
Criterion of desired performance

86. Guidelines for writing goals/outcome
Write in terms of client responses
Must be realistic
 Ensure compatibility with therapies of other
professionals
Derive from only one nursing diagnosis
 Use observable, measurable terms
 Make sure client considers goals important

87. NURSING INTERVENTIONS
A nursing intervention is any treatment, that a nurse
performs to improve patient’s health.

88. TYPES OF NURSING INTERVENTIONS
Independent interventions are those activities that
nurses are licensed to initiate on the basis of their
knowledge and skills.
Dependent interventions are activities carried out
under the orders or supervision of a licensed
physician.
Collaborative interventions are actions the nurse
carries out in collaboration with other health team
members.

89. SELECTION OF INTERVENTION
Characteristics of nursing diagnosing
Goals and expected outcome
Feasibility of the intervention
Acceptability of the patient
Own competency
Evidence based for the intervention

90.  Safe and appropriate for the client's
 age, health, and condition
 Achievable with the resources available
 Congruent with the client's values, beliefs, and culture
 Congruent with other therapies
 Based on nursing knowledge and experience or
knowledge from relevant sciences
 Within established standards of care
Criteria for choosing nursing
interventions

92. Writing Individualized Nursing
Interventions
After choosing the appropriate nursing interventions,
the nurse writes them on the care plan.
 Nursing care plan is a written or computerized
information about the client’s care.

93. NURSING CAREPLAN
 Provide a direction for individualized patient care
 Provide continuity of care for the patient with all
hospital departments
 Provide documentation on patient and family needs
 Care plans include the actions nurses must take to
address the nursing diagnoses or client problems and
to produce the desired health outcomes.

94. Cont…
A written guide that organizes data about client’s
care in to a formal statement of the strategies that
will be implemented to help the client achieve
optimal health.
Purposes
Help to identify the nursing actions to be delivered
Identify and coordinate resources to deliver
nursing care
Enhance community care

95. TYPES OF CARE PLAN
Student care plan
Computerized care plan
Multi disciplinary care plan

96. Student care plan
Student care plans are a learning activity as well as
a plan of care, they may be more lengthy and
detailed(five column format).
ASSES
SMENT
Nursing
diagnosis
goal intervention rationale Evaluation

97. Multidisciplinary (Collaborative) Care
Plans
 known as critical pathways Sequence care that must be
given on each day during projected length of stay for
each condition.
 Usually organized with a column for each day listing
interventions and outcomes for that day.
 Includes medical treatments to be performed by other
providers.

98. Computerized care plans
Create and store nursing care plans.
Can be accessed at a centrally located terminal at
nurses' station or in client’s rooms.
 Appropriate diagnoses selected from a menu
suggested by the computer.

99. Guidelines for Writing Nursing Care
Plans
Date and sign the plan
Use category headings
Use standardized/approved medical or english
symbols and key words rather than complete
sentences to communicate your ideas unless agency
policy dictates otherwise
Be specific
Refer to procedure books or other sources of
information

100. Refer to procedure books or other sourceof
information rather than including all the steps on a
written plan.
Tailor the plan to the unique characteristics of the
client by ensuring that the client’s choices, such as
preferences about the times of care and the methods
used, are included.

101. Ensure that the nursing plan incorporates
preventive and health maintenance aspects as
well as restorative ones.
Ensure that the plan contains ongoing assessment
of the client .
Include collaborative and coordination activities
in the plan.

103.  Protocols are preprinted and preplanned to indicate the
actions commonly required for a particular group of clients.
 Policies and procedures are developed to govern the
handling of frequently occurring situations.
 A standing order is a written document about policies,
rules, regulations, or orders regarding client care.
 Standing orders give nurses the authority to carry out
specific actions under certain circumstances, often when a
physician is not immediately available.

104. IMPLEMENTATION
The fourth step of nursing process involves
execution of nursing care plan derived during the
planning phase.
Implementation consists of doing and documenting
the activities.
Intervention
Direct care Indirect care

105. Interpersonal
skill

106. Skills……
Interpersonal
skills
 Verbal non verbal
communication
 Therapeutic
communication
Technical skills
 Manipulating
equipment
 Giving injections
 Bandaging
Cognitive skill
 Problem solving
 Decision making
 Critical thinking

107. IMPLEMENTATION PROCESS
1. Reassessing the client
2. Determining the nurse’s need for assistance
3. Implementing the nursing interventions
4. Supervising the delegated care
5. Communicating nursing activities

108. 1.Reassess the client
Before implement the nurse must reassess. It helps
to identify the proposed nursing actions are still
appropriate for the level of wellness.

109. 2.Determining the nurse’s need for
assistance
When implementing some nursing strategies, the nurse may
require assistance for one of the following reasons:
 The nurse is unable to safely implement the nursing strategies
alone (e.g., turning a heavy client in bed).
 Assistance would reduce stress on the client (e.g., turning a
person who experiences acute pain when moved).
 The nurse lacks the knowledge or skills to implement a
particular nursing activity (e.g., a nurse who is not familiar with
a particular model of oxygen mask).

110. 3. Implementing the nursing interventions
Provide nursing care or actions to the client
Based on priority of client’s need.
The nurses actions may be dependent or independent
 It is important to explain to the client what
intervention will be done
 Ensure client privacy

111. When implementing interventions, nurses should
follow these guidelines:
 Base nursing interventions on scientific knowledge,
nursing research, evidence-informed practice, and
professional standards of care when these exist.
 Clearly understand the interventions to be implemented
and question any that are not understood.

112. Adapt activities to the individual client.
Implement safe care.
Provide teaching, support, and comfort.
Use a holistic approach.
Respect the dignity of the client and enhance the
client’s self esteem.
Encourage clients to participate actively in
implementing the nursing interventions.

113. 4.Supervising delegated care
While developing and writing nursing
interventions on the client’s care plan, the nurse
must also determine who should actually perform
the activity.
Ensure that the activities have been implemented
according to the care plan.

114. 5. Communicating the nursing actions
Report and record the nursing activities and
client responses in the client record.
Report client status at a change of shift and on a
client’s discharge to another unit or health care
agency in person, via a voice recording, or in
writing.

115. EVALUATION

116. EVALUATION
Evaluation is defined as the judgment of the
effectiveness of nursing care to meet client’s goal; in this
phase the nurse compare the behavioural responses with
predetermined client goals and outcomes.
(CRAVEN 1996)

117. Evaluation is a planned, ongoing, purposeful activity
in which clients and health care professionals
determine
a) The client’s progress toward goal achievement
and
b) The effectiveness of the nursing care plan.

118. PURPOSES OF EVALUATION
Determine client’s behavioural responses.
Compare client response with outcome criteria.
Appraise the extent to which client’s goals.
Assess the collaboration of client and health team.
Identifies the errors in the plan of care.
Monitor the quality of nursing care.

119. PROCESS OF EVALUATION
Collect data Compare data
Relating
nursing
activities
Draw conclusion
Continue,modify
&terminate
careplan

120. 1.Collecting the date related to the desired
outcomes
Using clearly stated ,precise and measurable desired
outcomes as a guide.
Conclusions can be drawn about whether goals have
been met.
Collect both subjective and objective data.
Data must be recorded concisely and accurately to
facilitate the next part of the evaluating process.

121. 2.Comparing data with outcomes
 Both the nurse and client play an active role in comparing
the clients actual responses with the desired outcome.
Three possible conclusions,
The goal was met
The goal was partially met
The goals was not met
 After determining whether the goal met , the nurse write an
evaluative statement.
Evaluation statement
 Consist of two pats a conclusion and supportive data

122. 3.Relating nursing activities with
outcomes
 Determining whether nursing activities had any relation to
the outcome.
 It is important to establish the relationship for the nursing
actions to the client responses.
NURSING
ACTION
GOAL

123. 4.Drawing conclusions about problem
status
The nurses uses the judgments about goal achievement to
determine whether the care plan was effective in resolving ,
reducing or preventing client problem
 Conclusions
When goals met ,
The actual problem stated in the nursing diagnoses has been
resolved
The potential problem is being prevented
The actual problem still exists even though some goals are
being met

124. Cont…
When goals partially met or not met
The care plan may need to be revised, since the
problem is only partially resolved.
The care plan does more not need revise ,
because the client merely need more time to achieve
previously established goals.

125. 5.Continuing, modifying, terminating
the nursing care plan
After drawing the conclusion about the status of
the clients problem , the nurse modifies the care
plan as indicated.