nursing process is an art of doing patient care in an routine manner.

1. NURSING PROCESS

2. DEFINITION
Nursing process is 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)

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. 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.

5. Components of nursing process
• Assessment (data collection)
• Nursing diagnosis
• Planning
• Implementation
• Evaluation.

6. FIVE STEPS OF NURSNG PROCESS
Assessment
Gather
information about
the patients
condition
Diagnosis
Identify the
patients
problems
Planning
Setting a goals of care
and desired outcome
and identify
appropriate nursing
action
Implementation
Perform a nursing
action identified in a
planning
Evaluation
Determine if goals
and expected
outcomes are
achieved

7. ASSESSMENT

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

10. TYPES OF ASSESSMENT
The four different types of assessments
are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment

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. 3. 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.
4. Time-lapsed reassessment: Several
months after initial assessment. To
compare the client’s current health
status with the data previously
obtained.

13. COLLECTION OF DATA
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.

14. TYPES OF DATA
Two types: Subjective data and
Objective 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. Itching,
pain, and feelings of worry are
examples of subjective data.

15. 2. Objective data- 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.

16. SOURCES OF DATA
Sources of data are primary or secondary.
1. Primary: It is the direct source of
information. The client is the primary
source of data.
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.

17. METHODS OF DATA
COLLECTION
The methods used to collect data are
observation, interview and examination.
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.

18. • There are two approaches to
interviewing:
Directive and Nondirective.
• 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.

19. 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
auscultation and olfaction.

20. 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.

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

22. DOCUMENTATION OF 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.

23. DIAGNOSIS

25. • Diagnosis is the second phase of the
nursing process. In this phase, nurses
use critical thinking skills to interpret
assessment data to identify client
problems.
• North American Nursing
Diagnosis Association (NANDA)
define or refine nursing diagnosis.

26. Definition
The official NANDA definition of a
nursing diagnosis is:
“A clinical judgment concerning a
human response to health
conditions/life processes, or a
vulnerability for that response, by an
individual, family, group, or community.”

27. Status of the Nursing Diagnosis
The status of nursing diagnosis are
actual, health promotion and risk.
1. An actual diagnosis is a client
problem that is present at the time of
the nursing assessment.
2. A health promotion diagnosis relates
to clients’ preparedness to improve
their health condition.

28. A risk nursing diagnosis is a clinical
judgement that a problem does not exist,
but the presence of risk factors indicates
that a problem may develop if adequate
care is not given.

29. Components of a NANDA
Nursing Diagnosis
A nursing diagnosis has three
components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.

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

31. Formulating Diagnostic
Statements
The basic three-part nursing
diagnosis statement is called the PES
format and includes the following:
1.Problem (P): Statement of the client’s
health problem (NANDA label)
2. Etiology (E): causes of the health problem
3.Signs and symptoms (S): defining
characteristics manifested by the
client.

32. Acute pain related to abdominal
surgery as evidenced by patient
discomfort and pain scale.
Problem Etiology Signs and
symptoms
Pain Surgery of
abdomen
Pain scale
and
discomfort of
patient

33. NANDA nursing diagnosis

61. 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 diagnosis describe
the human response to an
illness or a health problem.
Medical diagnosis
refer to disease
processes.
Nursing diagnosis may
change as the client’s
responses change.
A client’s medical
diagnosis remains the
same for as long as the
disease is present.

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

63. PLANNING

65. • Planning involves decision making
and problem solving.
• It is the process of formulating client
goals and designing the nursing
interventions required to prevent,
reduce, or eliminate the client’s health
problems.

66. TYPES OF PLANNING
1. Initial Planning
2. Ongoing Planning
3. Discharge Planning

67. 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

68. PLANNING PROCESS
Planning includes:
• Setting priorities
• Establishing client goals/desired
outcomes
• Selecting nursing interventions
and activities
• Writing individualized nursing
interventions on care plans.

69. Setting priorities
• The nurse 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.

71. Establishing client goals/desired
outcomes
After establishing priorities, the
nurse set goals for each nursing
diagnosis. Goals may be short term
or long term.

72. Nursing interventions
A nursing intervention is any treatment,
that a nurse performs to improve patient’s
health.

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

74. 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.

75. IMPLEMENTATION

76. • Implementation consists of doing and
documenting the activities.

77. The process of implementation includes:
• Implementing the nursing interventions
• Documenting nursing activities

78. EVALUATION

79. Evaluation is a planned, ongoing,
purposeful activity in which the
nurse determines:
(a)The client’s progress toward
achievement of goals/outcomes and
(b)The effectiveness of the nursing care
plan.

80. The evaluation includes:
• Comparing the data with desired
outcomes
• Continuing, modifying, or terminating
the nursing care plan.

81. Caring
For
Life