The document discusses the nursing process, which is a systematic, critical thinking process that nurses use to provide individualized care. It includes five main steps: assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data through various methods. Nursing diagnosis involves analyzing the data to identify actual or potential health problems. Planning involves establishing goals and selecting interventions. Implementation is providing the planned care. Evaluation assesses client progress and care plan effectiveness. The nursing process helps nurses apply evidence-based care and problem-solve to promote client health and well-being.

1. NURSING PROCESS
MR.RAMESH MORDI
Assistant Professor,
VM Patil College of Nursing Akluj.

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. 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.

6. STEPS OF NURSING
PROCESS

7. Nursing
process
Assessment
Nursing
diagnosis
Planning
Implementation
Evaluation

8. ASSESSMENT

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

11. 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

12. 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.

13. 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.

14. 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.

15. Types of Data
Two types: subjective data and objective data.
 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.

16. 2. Objective data, also 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.

17. 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.

18. 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.

19. • 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.

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

21.  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.

22. 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.

23. Validation of data
The information gathered during the assessment is
“double-checked” or verified to confirm that it is accurate
and complete.

24. 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.

25. DIAGNOSIS

27. Introduction
• 2nd phase of nursingprocess
• Pivotal step in nursing process
• North American Nursing Diagnosis
Association (NANDA) 1982
Critical
thinking

28. Nursing diagnosis
“A clinical judgment about individual family, or
community responses to actual or potential health
problems / life process”.
 A nursing diagnosis provides the basis for selection
of nursing interventions to achieve outcome for
which the nurse’s accountable.
 Professional nurses are responsible for making nursing
diagnosis.

29. 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.”

30. Characteristics 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.

31. Types of nursing diagnosis …….
Actual nursing diagnosis
Risk nursing diagnosis
Health promotion nursing diagnosis
Possible nursing diagnosis
Syndrome nursing diagnosis

32. Actual nursing diagnosis…….
“A clinical judgment about human experience/responses to
health conditions /life processes that exist in an individual
,family or community.”
 Actual client problem present at the time of assessment.
 It is based on the presence of signs and symptoms
 Eg :
 Ineffective breathing pattern
 Disturbed sleep pattern

33. Risk nursing diagnosis…..
• It is a clinical judgment that a problem doesn't exist but the
presence of risk factors indicates that a problem is likely to
develop unless nurses intervene.
• No subjective or objective cues
• Eg : A client with DM or compromised immune
system is at high risk than others
Risk for infection
Risk for injury

34. Health promotion nursing diagnosis…
• Describes human responses to level of wellness in an
individual, family or community that have a readiness for
enhancement.
• Clinical judgment about a person’s ,families or
communities motivation and desire to increase well
being
• Eg :
 Readiness for enhanced family coping
 Readiness for enhanced self esteem

35. 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 potential risk of constipation as a result of
enforced bed rest

36. 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

37. Components of nursing diagnosis
Nursing
diagnosis
Problem and
its definition
The etiology
Defining
characteristics

38. 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.

39. Steps of diagnostic process…..
1. Analyzing data
2.Identifying
health problems
risks and strengths
3.Formulate
diagnostic
statement

40. Analyzing data………
Compare data against the standard
Cluster cues
Identifies gaps and inconsistencies

41. Identifying health problems…
• The nurse and client can together identify
strengths and problems
• Primarily decision making process
Determine problems
• Medical diagnosis
• Nursing diagnosis
• Collaborative problem
Determine strengths
• Resources
• Ability to cope up

42. Nursing
diagnosis
Two part
statement
One part
statement
Three
part
statement
Formulating diagnostic statement……

43. Basic two parts………..
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 :
 Constipation related to insufficient fluid intake
 Acute pain related to presence of surgical
incision
 Insomnia related to hospitalization

44. Basic three parts…………..
 Also called PES format;
1. Problem
2. Etiology
3. Signs and symptoms (defining characteristics
manifested by the client)
 Actual nursing diagnoses can be documented by
using the three part statement
 Not used for risk diagnosis

45. Basic three parts…………..
• Eg :
– Acute pain r/t surgical incision as evidenced by
verbalization
– Ineffective airway clearance r/t accumulation of
pulmonary secretions as evidenced by crackles on
auscultation
– Hyperthermia r/t underlying infectious process as
evidenced by temperature 100 F

46. 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

47. Qualities of
diagnostic
statement
Correct
format
Accurate
Concise
Specific
Descriptive

48. 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

49. 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.

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

51. PLANNING

53. • 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.

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

55. 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

56. Planning process
Planning includes;
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and
activities
• Writing individualized nursing interventions on care
plans.

57. 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.

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

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

61. 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.

62. 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.

63. IMPLEMENTATION

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

65. The process of implementation includes;
• Implementing the nursing interventions
• Documenting nursing activities

66. EVALUATION

67. • Evaluation is a planned, ongoing, purposeful
activity in which the nurse determines
 The client’s progress toward achievement of
goals/outcomes and,
 The effectiveness of the nursing care plan.

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