The nursing process is a systematic, patient-centered framework for organizing critical thinking and clinical decision-making. It consists of five steps: assessment, nursing diagnosis, planning, implementation, and evaluation. Nursing assessment involves collecting subjective and objective patient data through various means. This data is then analyzed to formulate nursing diagnoses, which are statements describing a patient's response to an actual or potential health problem. Plans of care are developed by setting goals and interventions. Interventions are then implemented and their effectiveness evaluated to determine if goals were met. The nursing process promotes continuity of care and effective communication.

1. Nursing Process
Author: Meredith Scannell RN, MSN, MPH,

2. Nursing Process
• Specific to the nursing profession
• A frame work for critical thinking
• Its purpose is to:
“Diagnosis and treat human responses to actual
or potential health problems.”

3. Nursing Process
• Organized framework to guide practice
• Problem solving method
• Patient focus
• Systematic
• Goal oriented
• Dynamic
• Utilizes critical think process

4. Nursing Process
• Promotes continuity of care
• Promotes more effective communication
• Develops clear plan of action

5. Following the Nursing Process
• Five steps are recognized as the universal
approach to nursing practice.
1. Nursing Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation

6. Nursing Assessment
• Interview patient, primary
source
• Collecting Data
• Health assessment
• Observations
• Signs and Symptoms
• Review medical chart and
records

7. Obstetrical Nursing Assessment
Objective:
Vital Signs: T 98.2 TA HR 72 B/P 116/64 Resp 18
Pain Level: 4 (scale 1/10)
B: Breasts soft, nipples intact.
U: Uterus firm and midline, 1 fb below umbilicus
B: Voiding QS
B: Positive bowel sounds, all four quadrants.LBM: 2/4
L: Moderate amount of lochia serosa
E: REEDA; Abdominal incision: OTA, steri strips in tact.
No redness, no drainage, no echymosis no edema, well
approximated
H: Neg Homan’s sign, trace pedal edema
E: Pt. appears confident in breast feeding

8. Nursing Diagnosis
• Interpret and analyze data
• Formulate nursing Diagnosis
based on NANDA North American Nursing
Diagnosis Association.
• Established in 1973 to identify standards and classify
health problems treated by nurses
• Statement of how the patient is responding to an
actual or potential problem that requires a nursing
intervention.

9. Nursing Diagnosis
• Within the scope of nursing
practice.
• Identify responses to health and
illness.
• Can change from day to day
• Actual problem, risk, wellness
diagnosis

10. Nursing Diagnosis
• 3 Parts:
• Problem statement: response to a
problem.
• Etiology: what’s
causing/contributing to the
problem.
• Defining characteristics: what’s
the evidence.

11. Nursing Diagnosis
Problem( Diagnostic Label)-based on your
assessment of patient…(gathered
information), pick a problem from the
NANDA
Etiology- determine what the problem is
caused by or related to (R/T)
Defining characteristics- then state as
evidenced by (AEB) the specific facts the
problem is based on

12. Example Nursing
Diagnosis
Deficient fluid volume r/t fluid shift from
intravascular to extravascular space
AEB +3 pitting edema on lower
extremities.
Pain: Acute r/t abdominal surgical trauma
AEB pain rated 4/10 while ambulating.

13. Legal ramifications
•A nurse can only identify
problems within the scope of
practice
•A nurse cannot diagnose or treat
medical disease
•A nurse must identify problems
within his/her scope of practice,
abilities and education

14. Planning
• Setting goals of care and desired
outcomes.
• Identifying appropriate nursing
actions.
• Expected outcomes are identified

15. Planning
• Prioritizing list of needs
• Client Specific
• Priorities can change
• Differences in priorities

16. Implementation
• Performing the nursing actions
identified in planning
• Interventions
• Actions designed to assist
patients in moving from the
present level of health to that
which is describe in the goal and
measured with the outcome
criteria.
• Utilizes critical thinking

17. Interventions
• Nurse-Initiated
• Physician initiated
• Collaborative interventions
• Standing orders
• Protocols

18. Evaluation
• Determine if the goals were met.
• Determine if outcomes were
achieved.
• Appropriately revise care plan
based on patient’s response.
• Worsening signs and symptoms or lack of
response require modification.
• Prompt documentation.
• Communicate effectiveness of treatment.

19. The End