CCON The nursing process

Nursing processNursing process
Mr. Ravi kumarMr. Ravi kumar
B.S.C (N)1B.S.C (N)1stst
yearyear
Chirayu college of nursingChirayu college of nursing

Nursing ProcessNursing Process
 The nursing process is a deliberate, problem-solvingThe nursing process is a deliberate, problem-solving
approach to meeting the health care and nursingapproach to meeting the health care and nursing
needs of patients. It involves assessment (dataneeds of patients. It involves assessment (data
collection), nursing diagnosis, planning,collection), nursing diagnosis, planning,
implementation, and evaluation, with subsequentimplementation, and evaluation, with subsequent
modifications used as feedback mechanisms thatmodifications used as feedback mechanisms that
promote the resolution of the nursing diagnoses. Thepromote the resolution of the nursing diagnoses. The
process as a whole is cyclical, the steps beingprocess as a whole is cyclical, the steps being
interrelated, interdependent, and recurrent.interrelated, interdependent, and recurrent.

Copyright 2008 by Pearson Education, Inc.
The Nursing ProcessThe Nursing Process

AssessingAssessing
 Collecting dataCollecting data
 Organizing dataOrganizing data
 Validating is the act of “double-checking” orValidating is the act of “double-checking” or
verifying data to confirm that it is accurate andverifying data to confirm that it is accurate and
factual.factual.
 Documenting dataDocumenting data
 GoalGoal
 Establish a database about the client’s response toEstablish a database about the client’s response to
health concerns or illnesshealth concerns or illness

DiagnosingDiagnosing
 Analyzing and synthesizing dataAnalyzing and synthesizing data
 GoalsGoals
 Identify client strengthsIdentify client strengths
 Identify health problems that can be prevented orIdentify health problems that can be prevented or
resolvedresolved
 Develop a list of nursing and collaborative problemsDevelop a list of nursing and collaborative problems

PlanningPlanning
 Determining how to prevent, reduce, or resolveDetermining how to prevent, reduce, or resolve
identified priority client problemsidentified priority client problems
 Determining how to support client strengthsDetermining how to support client strengths
 Determining how to implement nursing interventionsDetermining how to implement nursing interventions
in an organized, individualized, and goal-directedin an organized, individualized, and goal-directed
mannermanner
 GoalsGoals
 Develop an individualized care plan that specifies clientDevelop an individualized care plan that specifies client
goals/desired outcomesgoals/desired outcomes
 Related nursing interventionsRelated nursing interventions

ImplementingImplementing
 Carrying out (or delegating) and documenting plannedCarrying out (or delegating) and documenting planned
nursing interventionsnursing interventions
 GoalsGoals
 Assist the client to meet desired goals/outcomesAssist the client to meet desired goals/outcomes
 Promote wellnessPromote wellness
 Prevent illness and diseasePrevent illness and disease
 Restore healthRestore health
 Facilitate coping with altered functioningFacilitate coping with altered functioning

EvaluatingEvaluating
 Measuring the degree to which goals/outcomesMeasuring the degree to which goals/outcomes
have been achievedhave been achieved
 Identifying factors that positively or negativelyIdentifying factors that positively or negatively
influence goal achievementinfluence goal achievement
 GoalGoal
 Determine whether to continue, modify, orDetermine whether to continue, modify, or
terminate the plan of careterminate the plan of care

Characteristics of theCharacteristics of the
 Cyclic and dynamic natureCyclic and dynamic nature
 Client centerednessClient centeredness
 Focus on problem-solving and decision-makingFocus on problem-solving and decision-making
 Interpersonal and collaborative styleInterpersonal and collaborative style
 Universal applicabilityUniversal applicability
 Use of critical thinkingUse of critical thinking

Characteristics of theCharacteristics of the

Types of AssessmentsTypes of Assessments
 InitialInitial
 Performed within a specified time periodPerformed within a specified time period
 Establishes complete databaseEstablishes complete database
 Problem-FocusedProblem-Focused
 Ongoing process integrated with careOngoing process integrated with care
 Determines status of a specific problemDetermines status of a specific problem
 EmergencyEmergency
 Performed during physiologic or psychologic crisesPerformed during physiologic or psychologic crises
 Identifies life-threatening problemsIdentifies life-threatening problems
 Identifies new or overlooked problemsIdentifies new or overlooked problems
 Time-lapsedTime-lapsed
 Occurs several months after initialOccurs several months after initial
 Compares current status to baselineCompares current status to baseline

 Initial assessment is performed within aInitial assessment is performed within a
specified time after admission to a health carespecified time after admission to a health care
agency for the purpose of establishing aagency for the purpose of establishing a
complete database for problem identification,complete database for problem identification,
reference, and future comparison.reference, and future comparison.

 Problem-focused assessment is an ongoingProblem-focused assessment is an ongoing
process integrated with nursing care toprocess integrated with nursing care to
determine the status of a specific problemdetermine the status of a specific problem
identified in an earlier assessment.identified in an earlier assessment.

 Emergency assessment occurs during anyEmergency assessment occurs during any
physiologic or psychologic crisis of the client tophysiologic or psychologic crisis of the client to
identify the life-threatening problems and toidentify the life-threatening problems and to
identify new or overlooked problems.identify new or overlooked problems.

 Time-lapsed (expired)reassessment occursTime-lapsed (expired)reassessment occurs
several months after the initial assessment toseveral months after the initial assessment to
compare the client’s current status to baselinecompare the client’s current status to baseline
data previously obtained.data previously obtained.

Assessment ActivitiesAssessment Activities
 Collecting dataCollecting data
 Organizing dataOrganizing data
 Validating dataValidating data
 Documenting dataDocumenting data

 Collecting dataCollecting data is the process of gatheringis the process of gathering
information about a client’s health status.information about a client’s health status.

 Organizing dataOrganizing data is categorizing datais categorizing data
systematically using a specified format.systematically using a specified format.
 Validating dataValidating data is the act of “double-checking”is the act of “double-checking”
or verifying data to confirm that it is accurateor verifying data to confirm that it is accurate
and factual.and factual.
 DocumentingDocumenting is accurately and factuallyis accurately and factually
recording data.recording data.

Subjective DataSubjective Data
 Symptoms or covert dataSymptoms or covert data
 Apparent only to the person affectedApparent only to the person affected
 Can be described only by person affectedCan be described only by person affected
 Includes sensations, feelings, values,Includes sensations, feelings, values,
beliefs, attitudes, and perception ofbeliefs, attitudes, and perception of
personal health status and life situationspersonal health status and life situations

Objective DataObjective Data
 Signs or overt dataSigns or overt data
 Detectable by an observerDetectable by an observer
 Can be measured or tested against anCan be measured or tested against an
accepted standardaccepted standard
 Can be seen, heard, felt, or smelledCan be seen, heard, felt, or smelled
 Obtained through observation or physicalObtained through observation or physical
examinationexamination

Sources of DataSources of Data
 Primary SourcePrimary Source
 The clientThe client
 Secondary SourcesSecondary Sources
 All other sources of dataAll other sources of data
 Should be validated, if possibleShould be validated, if possible

Methods of Data CollectionMethods of Data Collection
 ObservingObserving
 Gathering data using the sensesGathering data using the senses
 Used to obtain following types of data:Used to obtain following types of data:
 Skin color (vision)Skin color (vision)
 Body or breath odors (smell)Body or breath odors (smell)
 Lung or heart sounds (hearing)Lung or heart sounds (hearing)
 Skin temperature (touch)Skin temperature (touch)

 InterviewingInterviewing
 Planned communication or a conversation with aPlanned communication or a conversation with a
purposepurpose
 Used to:Used to:
 Identify problems of mutual concernIdentify problems of mutual concern
 Evaluate changeEvaluate change
 TeachTeach
 Provide supportProvide support
 Provide counseling or therapyProvide counseling or therapy

 Examining (physical examination)Examining (physical examination)
 Systematic data-collection methodSystematic data-collection method
 Uses observation and inspection, auscultation,Uses observation and inspection, auscultation,
palpation, and percussionpalpation, and percussion
 Blood pressureBlood pressure
 PulsesPulses
 Heart and lungs soundsHeart and lungs sounds
 Skin temperature and moistureSkin temperature and moisture
 Muscle strengthMuscle strength

Closed and Open-endedClosed and Open-ended
QuestionsQuestions
Closed QuestionClosed Question
 RestrictiveRestrictive
 Yes/noYes/no
 FactualFactual
 Less effort and informationLess effort and information
from clientfrom client
 ““What medications did youWhat medications did you
take?”take?”
 ““Are you having pain now?”Are you having pain now?”
Open-ended QuestionOpen-ended Question
 Specify broad topic toSpecify broad topic to
discussdiscuss
 Invite longer answersInvite longer answers
 Get more informationGet more information
from clientfrom client
 Useful to change topicsUseful to change topics
and elicit attitudesand elicit attitudes
 ““How have you beenHow have you been
feeling lately?”feeling lately?”

 Types of Nursing DiagnosisTypes of Nursing Diagnosis
 ActualActual
 RiskRisk
 WellnessWellness
 PossiblePossible
 SyndromeSyndrome

Actual DiagnosisActual Diagnosis
 Problem present at the time of the assessmentProblem present at the time of the assessment
 Presence of associated signs and symptomsPresence of associated signs and symptoms
 (ineffective breathing pattern)(ineffective breathing pattern)

Risk DiagnosisRisk Diagnosis
 Problem does not existProblem does not exist
 Presence of risk factorsPresence of risk factors

Wellness DiagnosisWellness Diagnosis
 Readiness for enhancementReadiness for enhancement
 describes human responses to levels of wellnessdescribes human responses to levels of wellness
in an individual, family, or community thatin an individual, family, or community that
have a readiness enhancement.”have a readiness enhancement.”
 (readiness for enhanced spiritual well-being or(readiness for enhanced spiritual well-being or
readiness for enhanced family coping)readiness for enhanced family coping)

Possible DiagnosisPossible Diagnosis
 Evidence about a health problem incomplete orEvidence about a health problem incomplete or
unclearunclear
 Requires more data to either support or to refute itRequires more data to either support or to refute it
 (possible social isolation)(possible social isolation)

Syndrome DiagnosisSyndrome Diagnosis
 Associated with a cluster of other diagnosesAssociated with a cluster of other diagnoses
 (risk for disuse syndrome)(risk for disuse syndrome)

Components of a NursingComponents of a Nursing
DiagnosisDiagnosis
 ProblemProblem
 EtiologyEtiology
 Defining characteristicsDefining characteristics

Problem Statement (DiagnosticProblem Statement (Diagnostic
Label)Label)
 Describes the client’s health problem or responseDescribes the client’s health problem or response

 Identifies one or more probable causes of the healthIdentifies one or more probable causes of the health
problemproblem

Defining CharacteristicsDefining Characteristics
 Cluster of signs and symptoms indicating theCluster of signs and symptoms indicating the
presence of a particular diagnostic label (actualpresence of a particular diagnostic label (actual
diagnoses)diagnoses)
 Factors that cause the client to be moreFactors that cause the client to be more
vulnerable to the problem (risk diagnoses)vulnerable to the problem (risk diagnoses)

Steps in Diagnostic ProcessSteps in Diagnostic Process
 Analyzing dataAnalyzing data
 Compare data against standardsCompare data against standards
 Cluster cuesCluster cues
 Identify gaps and inconsistenciesIdentify gaps and inconsistencies
 Identifying health problems, risks, and strengthsIdentifying health problems, risks, and strengths
 Formulating diagnostic statementsFormulating diagnostic statements

 Formats for Writing Nursing DiagnosesFormats for Writing Nursing Diagnoses
 Basic two-part statementBasic two-part statement
 Problem (P)Problem (P)
 Etiology (E)Etiology (E)

 Basic three-part statementBasic three-part statement
 Problem (P)Problem (P)
 Etiology (E)Etiology (E)
 Signs and symptoms (S)Signs and symptoms (S)

 One-part statementOne-part statement
 Wellness (readiness for enhanced)Wellness (readiness for enhanced)
 SyndromeSyndrome

VariationsVariations
 Unknown etiologyUnknown etiology
 Complex factorsComplex factors
 PossiblePossible
 SecondarySecondary
 Other additions for precisionsOther additions for precisions

There are five variations of theThere are five variations of the
basic formats:basic formats:
 WritingWriting unknown etiologyunknown etiology when the definingwhen the defining
characteristics are present but the nurse doescharacteristics are present but the nurse does
not know the cause or contributing factorsnot know the cause or contributing factors
 Using the phraseUsing the phrase complex factorscomplex factors when there arewhen there are
too many etiologic factors or when they are tootoo many etiologic factors or when they are too
complex to state in a brief phrasecomplex to state in a brief phrase

 Using the wordUsing the word possiblepossible to describe either theto describe either the
problem or the etiology when the nurse believesproblem or the etiology when the nurse believes
more data are needed about the client’s problemmore data are needed about the client’s problem
or the etiologyor the etiology

 UsingUsing secondarysecondary to divide the etiology into twoto divide the etiology into two
parts, thereby making the statement moreparts, thereby making the statement more
descriptive and useful (the part followingdescriptive and useful (the part following
secondary tosecondary to is often a pathophysiologic or diseaseis often a pathophysiologic or disease
process or a medical diagnosis)process or a medical diagnosis)
 Adding a second part to the general response orAdding a second part to the general response or
NANDA label to make it more preciseNANDA label to make it more precise

 The following are guidelines forThe following are guidelines for
writing nursing diagnosis statements:writing nursing diagnosis statements:
 Write statements in terms of a problem insteadWrite statements in terms of a problem instead
of a need.of a need.
 Word the statement so that it is legally advisable.Word the statement so that it is legally advisable.
 Use nonjudgmental statements.Use nonjudgmental statements.
 Be sure both elements of the statement do notBe sure both elements of the statement do not
say the say thing.say the say thing.

 Be sure cause and effect are stated correctly.Be sure cause and effect are stated correctly.
 Word diagnosis specifically and precisely.Word diagnosis specifically and precisely.
 Use nursing terminology rather than medicalUse nursing terminology rather than medical
terminology to describe the client’s response.terminology to describe the client’s response.
 Using nursing terminology rather than medicalUsing nursing terminology rather than medical
terminology to describe the probable cause ofterminology to describe the probable cause of
the client’s response.the client’s response.

 . To improve diagnostic reasoning and avoid. To improve diagnostic reasoning and avoid
diagnostic reasoning errors, the nurse should dodiagnostic reasoning errors, the nurse should do
the following: verify diagnoses by talking withthe following: verify diagnoses by talking with
the client and family, build a good knowledgethe client and family, build a good knowledge
base and acquire clinical experience, have abase and acquire clinical experience, have a
working knowledge of what is normal, consultworking knowledge of what is normal, consult
resources, base diagnoses on patterns (that is,resources, base diagnoses on patterns (that is,
behavior over time) rather than an isolatedbehavior over time) rather than an isolated
incident, and improve critical-thinking skills.incident, and improve critical-thinking skills.

 Advantages of a Taxonomy of NursingAdvantages of a Taxonomy of Nursing
DiagnosesDiagnoses
 Development of a standardized nursing languageDevelopment of a standardized nursing language
 Nursing minimum data setNursing minimum data set

Identify activities that occur in theIdentify activities that occur in the
planning process.planning process.
 Activities in the Planning ProcessActivities in the Planning Process
 Prioritizing problems/diagnosesPrioritizing problems/diagnoses
 Formulating client goals/desired outcomesFormulating client goals/desired outcomes
 Selecting nursing interventionsSelecting nursing interventions
 Writing individualized nursing interventionsWriting individualized nursing interventions

Identify essential guidelines forIdentify essential guidelines for
writing nursing care plans.writing nursing care plans.
 Guidelines for Writing NursingGuidelines for Writing Nursing
Care PlansCare Plans
 Date and sign the planDate and sign the plan
 Use category headingsUse category headings
 Use standardized/approved terminology and symbolsUse standardized/approved terminology and symbols
 Be specificBe specific

 Refer to other sourcesRefer to other sources
 Individualize the plan to the clientIndividualize the plan to the client
 Incorporate prevention and health maintenanceIncorporate prevention and health maintenance
 Include discharge and home care plansInclude discharge and home care plans

Identify factors that the nurse mustIdentify factors that the nurse must
consider when setting priorities.consider when setting priorities.
 Setting PrioritiesSetting Priorities
 Establishing a preferential sequence forEstablishing a preferential sequence for
addressing nursing diagnoses and interventionsaddressing nursing diagnoses and interventions
 High priority (life-threatening)High priority (life-threatening)
 Medium priority (health-threatening)Medium priority (health-threatening)
 Low priority (developmental needs)Low priority (developmental needs)

Factors to Consider When SettingFactors to Consider When Setting
PrioritiesPriorities
 Client’s health values and beliefsClient’s health values and beliefs
 Client’s prioritiesClient’s priorities
 Resources available to the nurse and clientResources available to the nurse and client
 Urgency of the health problemUrgency of the health problem
 Medical treatment planMedical treatment plan

Describe the relationship ofDescribe the relationship of
goals/desired outcomes to thegoals/desired outcomes to the
nursing diagnoses.nursing diagnoses.
 Goals/Desired Outcomes and NursingGoals/Desired Outcomes and Nursing
DiagnosisDiagnosis
 Goals derived from diagnostic labelGoals derived from diagnostic label
 Diagnostic label contains the unhealthy responseDiagnostic label contains the unhealthy response
(problem)(problem)
 Goal/desired outcome demonstrates resolutionGoal/desired outcome demonstrates resolution
of the unhealthy response (problem)of the unhealthy response (problem)

 Identify guidelines for writing goals/desiredIdentify guidelines for writing goals/desired
outcomes.outcomes.
 Components of Goal/Desired OutcomeComponents of Goal/Desired Outcome
StatementsStatements
 SubjectSubject
 VerbVerb
 Condition or modifierCondition or modifier
 Criterion of desired performanceCriterion of desired performance

Guidelines for WritingGuidelines for Writing
Goal/Outcome StatementsGoal/Outcome Statements
 Write in terms of the client responsesWrite in terms of the client responses
 Must be realisticMust be realistic
 Ensure compatibility with the therapies ofEnsure compatibility with the therapies of
other professionalsother professionals
 Derive from only one nursing diagnosisDerive from only one nursing diagnosis
 Use observable, measurable termsUse observable, measurable terms

Describe the process of selectingDescribe the process of selecting
and choosing nursing interventions.and choosing nursing interventions.
 Nursing Interventions and ActivitiesNursing Interventions and Activities
 Actions nurse performs to achieve goals/desiredActions nurse performs to achieve goals/desired
outcomesoutcomes
 Focus on eliminating or reducing etiology ofFocus on eliminating or reducing etiology of
nursing diagnosisnursing diagnosis
 Treat signs/symptoms and definingTreat signs/symptoms and defining
characteristicscharacteristics

 Types of Nursing InterventionsTypes of Nursing Interventions
 DirectDirect
 IndirectIndirect
 Independent interventionsIndependent interventions
 Dependent interventionsDependent interventions
 Collaborative interventionsCollaborative interventions

 Direct care is an intervention performedDirect care is an intervention performed
through interaction with the client.through interaction with the client.
 Indirect care is an intervention performed awayIndirect care is an intervention performed away
from but on behalf of the client such asfrom but on behalf of the client such as
interdisciplinary collaboration or management ofinterdisciplinary collaboration or management of
the care environment.the care environment.

 independent interventionsindependent interventions, those activities, those activities
that nurses are licensed to initiate on the basis ofthat nurses are licensed to initiate on the basis of
their knowledge and skills;their knowledge and skills;
 dependent interventionsdependent interventions, activities carried out, activities carried out
under the primary care provider’s orders orunder the primary care provider’s orders or
supervision, or according to specified routines;supervision, or according to specified routines;
 collaborative interventionscollaborative interventions, actions the nurse, actions the nurse
carries out in collaboration with other healthcarries out in collaboration with other health
team members. The nurse must chooseteam members. The nurse must choose
interventions that are most likely to achieve theinterventions that are most likely to achieve the
goal/desired outcome.goal/desired outcome.

Criteria for Choosing AppropriateCriteria for Choosing Appropriate
InterventionIntervention
 Safe and appropriate for the client’s age, health, andSafe and appropriate for the client’s age, health, and
conditioncondition
 Achievable with the resources availableAchievable with the resources available
 Congruent with the client’s values, beliefs, and cultureCongruent with the client’s values, beliefs, and culture
 Congruent with other therapiesCongruent with other therapies
 Based on nursing knowledge and experience orBased on nursing knowledge and experience or
knowledge from relevant sciencesknowledge from relevant sciences
 Within established standards of careWithin established standards of care

 Discuss the five activities of theDiscuss the five activities of the
implementing phase.implementing phase.
 Five Activities of the Implementing PhaseFive Activities of the Implementing Phase
 Reassessing the clientReassessing the client
 Determining the nurse’s need for assistanceDetermining the nurse’s need for assistance
 Implementing nursing interventionsImplementing nursing interventions
 Supervising delegated careSupervising delegated care

Explain how evaluating relates to otherExplain how evaluating relates to other
phases of the nursing process.phases of the nursing process.
 Nursing Process—EvaluatingNursing Process—Evaluating
 Depends on the effectiveness of phases thatDepends on the effectiveness of phases that
precedeprecede
 Assessing and nursing diagnosis must beAssessing and nursing diagnosis must be
accurateaccurate
 Goals/desired outcomes must be statedGoals/desired outcomes must be stated
behaviorally to be useful for evaluatingbehaviorally to be useful for evaluating

 Without implementing phase, there would beWithout implementing phase, there would be
nothing to evaluatenothing to evaluate

 Evaluating and assessing phases overlapEvaluating and assessing phases overlap
 1.1. Evaluating is a planned, ongoing, purposefulEvaluating is a planned, ongoing, purposeful
activity in which clients and health careactivity in which clients and health care
professionals determine the client’s progressprofessionals determine the client’s progress
toward achievement of goals/ outcomes and thetoward achievement of goals/ outcomes and the
effectiveness of the nursing care plan. Successfuleffectiveness of the nursing care plan. Successful
evaluation depends on the effectiveness of theevaluation depends on the effectiveness of the
steps that precede it.steps that precede it.

 Assessment data must be accurate and completeAssessment data must be accurate and complete
so the nurse can formulate appropriate nursingso the nurse can formulate appropriate nursing
diagnoses and goals/desired outcomes. Thediagnoses and goals/desired outcomes. The
goals/desired outcomes must be statedgoals/desired outcomes must be stated
concretely in behavioral terms to be useful forconcretely in behavioral terms to be useful for
evaluating client responses. Without theevaluating client responses. Without the
implementing phase in which the plan is put intoimplementing phase in which the plan is put into
action, there would be nothing to evaluate. Theaction, there would be nothing to evaluate. The
evaluating and assessing phases overlap.evaluating and assessing phases overlap.

 During the assessment phase the nurse collectsDuring the assessment phase the nurse collects
data for the purpose of making diagnoses.data for the purpose of making diagnoses.
During the evaluation step the nurse collectsDuring the evaluation step the nurse collects
data for the purpose of comparing the data todata for the purpose of comparing the data to
preselected goals and judging the effectivenesspreselected goals and judging the effectiveness
of the nursing care. The act of assessing (dataof the nursing care. The act of assessing (data
collection) is the same. The differences lie incollection) is the same. The differences lie in
when the data are collected and how the data arewhen the data are collected and how the data are
used.used.

Components of the EvaluationComponents of the Evaluation
ProcessProcess
 Collecting data related to the desired outcomesCollecting data related to the desired outcomes
( nursing outcomes classifications NOC indicators)( nursing outcomes classifications NOC indicators)
 Comparing the data with outcomesComparing the data with outcomes
 Relating nursing activities to outcomesRelating nursing activities to outcomes
 Drawing conclusions about problem statusDrawing conclusions about problem status
 Continuing, modifying, or terminating theContinuing, modifying, or terminating the
nursing care plannursing care plan

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