3. 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).
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
It involves assessment (data collection), nursing diagnosis, planning,
implementation, and evaluation
6. 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.
8. Types of Assessment
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
9. Assessment
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.
10. Collection of data
Definition
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.
Types of Data
1. Subjective data and
2. Objective data.
11. Types of data
1. Subjective data = symptoms or covert data,
Are clear only to the person affected and can be described only by that
person.
E.g. Itching, pain, and feelings of worry
2. Objective data = 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.
E.g. a discoloration of the skin or a blood pressure reading
12. Sources of Data
Can be 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.
E.g Family members, health professionals, records and reports,
laboratory and diagnostic results
13. Methods of data collection
Include observation, interview and examination.
1. Observation : It is gathering data by using the senses. Vision, Smell
and Hearing are used.
2. Interview : An interview is a planned communication or a conversation
with a purpose. There are two approaches to interviewing:
i. The directive interview is highly structured and directly ask the
questions. And the nurse controls the interview.
ii. A nondirective interview, or rapport building interview and the nurse
allows the client to control the interview.
14. Stages of an interview
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing
15. The techniques of skilled interviewing
Active listening
Adaptive questioning
Nonverbal communication
Facilitation
Echoing
16. The techniques of skilled interviewing
Empathic responses
Validation
Reassurance
Summarization
Highlighting transitions
17. Data Collection: Examination
The physical examination is a systematic data collection method to detect
health problems.
To conduct the examination, the nurse uses techniques of
i. inspection,
ii. palpation,
iii. percussion and
iv. auscultation.
18. Data collection
Organization of data; The nurse uses a format that organizes the
assessment data systematically e.g. nursing health history or nursing
assessment form.
Validation of data; The information gathered during the assessment is
“double-checked” or verified to confirm that it is accurate and complete.
Documentation of data; the nurse records client data. Accurate
documentation is essential and should include all data collected about the
client’s health status. This complete the assessment phase,
20. DIAGNOSIS
This is the second phase of the nursing process.
Here, nurses use critical thinking skills to interpret assessment data to
identify client problems.
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.”
NANDA* North American Nursing Diagnosis Association.
22. 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.
3. 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.
23. Components of a NANDA Nursing
Diagnosis
A nursing diagnosis has three components:
1. The problem and its definition; describes the client’s health problem
2. The etiology; identifies causes of the health problem
3. The defining characteristics; These are the cluster of signs and
symptoms that indicate the presence of health problem.
24. Formulating Diagnostic Statements
The basic three-part nursing diagnosis statement is called the PES format
and includes the following: 1. Problem (P): (NANDA label), 2. Etiology
(E) and 3. Signs and symptoms (S):
E.g. Acute pain related to abdominal surgery as evidenced by patient
discomfort and pain scale.
1. Problem: Pain
2. Etiology: Surgery of abdomen
3. Signs and symptoms: Pain scale and discomfort of patient
26. Nursing Diagnosis Vs 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
27. Nursing diagnosis Medical diagnosis
Ineffective breathing pattern Asthma
Activity intolerance Cerebrovascular accident
Acute pain Appendicitis
Disturbed body image Amputation
29. Planning
This 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.
30. Types of planning
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
31. Planning process
Planning includes;
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and activities
• Writing individualized nursing interventions on care plans.
32. 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.
34. Nursing interventions
A nursing intervention is any treatment, that a nurse performs to improve
patient’s health.
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
35. 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.
36. Implementation
Implementation consists of doing and documenting the activities.
The process includes;
Implementing the nursing interventions
Documenting nursing activities
37. Evaluation
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.
It includes;
Comparing the data with desired outcomes
Continuing, modifying, or terminating the nursing care plan.
READ ABOUT CONCEPT MAP CARE PLANS
