The nursing process provides a framework for delivering nursing care. It involves assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting subjective and objective data about a patient's health status and history through various methods like observation, interviews, physical exams, and record reviews. This collected data is then organized, validated, and recorded to identify nursing diagnoses and develop a care plan to address any issues. The nursing process aims to improve the quality of patient care through a systematic, individualized approach.

1. NURSING PROCESS
RATHEESH R L

2. INTRODUCTION
The nursing process provides a useful description
of how nursing should be performed. Practice of
nursing is caring which is directed by the way the
nurses view the client, the client’s environment,
health and the purpose of nursing.

3. DEFINITION
 The nursing process is a professional nurses
approach to identify, diagnose, and treat human
response to health and illness.
American Nurses Association

4.  Nursing process is a systematic, rational method of
planning and providing individualized nursing care.

5.  The nursing process is a series of organized steps
designed for nurses to provide excellent care.

6. THE PURPOSE OF NURSING PROCESS
 To identify client’s health status, actual or potential
healthcare problems or need.
 To establish plans to meet the identified needs and to
deliver specific interventions to meet those needs.
 It provides a framework in which to practice nursing.

7. BENEFITS OF NURSING PROCESS
 Improves the quality of care that the client receives
 Ensures a high level of client participation together with
continuous evaluation designed to meet the client’s
unique needs
 Enables nurses to use time and resources efficiently to
both their own and their client’s benefit.

8. CHARACTERISTICS OF A NURSING PROCESS:
 Dynamic and cyclic
 Patient centered
 Goal directed
 Open and Flexible
 Problem Oriented
 Planned
 Universally accepted
 Interpersonal and collaborative
 Holistic
 Systematic

9. Dynamic and Cyclic
The dynamic nature involves continuous
assessment and evaluation of changing
client’s responses to nursing interventions
so as to achieve the outcomes.
Client-centered
The plan of care is organized in terms of
client problems rather than nursing goals.
The nurse-client relationship is shaped
around the needs of the client.

10. Planned and Goal-directed
Interventions are considered according to
the nursing diagnoses and are based on
scientific principles rather than tradition.
Universally Applicable
Nursing process can be used with clients
of any age, with any medical diagnosis,
and at any point on the wellness-illness
continuum.

11. Problem-oriented
Care plans are organized according to
client’s problems. Interventions are carried
out to eliminate the problems related to
any aspect of an individual.
Cognitive Process
Nursing process involves the use of
intellectual skills in making judgments,
decisions and eliminating client’s
problems.

12. FACTORS AFFECTING NURISNG
PROCESS
 Knowledge
 Skill
 Beliefs

13. Knowledge:
Nursing process is the application of the
nurses knowledge. As part of her/his
academic preparation nurse learns basic
concepts of biochemistry, biophysics,
microbiology, anatomy, physiology,
psychology, sociology, and nutrition.

14.  The knowledge of these sciences enables the
nurse to recognize the problem more clearly and
also determine how the client’s health is getting
disturbed.

15.  Skills:
Nurse uses technical and interpersonal skills to
collect information about the client. The effectiveness
of the nursing process depends on the intellectual
(cognitive) skills of the nurse that she uses in creative
and critical thinking, and decision making.

16.  Beliefs:
The nurse’s personal belief about nursing, health, the
client as an individual, as a health care consumer
forms the basis of nursing practice.
The nurse is also faced with a moral and ethical
dilemma of providing care to such a client and his
family members.

17. Components of Nursing Process
1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation

18. STEPS OF THE NURSING PROCESS

19. ASSESSMENT
“Let me look at that.”
“Tell me about it.”

20. Assessment
Assessment is the deliberate and systemic collection
of data to determine client current and past health
status and copping pattern

21. ASSESSMENT
Assessment (Data
Collection)
= Observation +
Interview + Examination

22. Components of Assessment:
1. Collection of data
2. Verification of data
3. Organization of data
4. Recording of data

23. Types of Data
1. Subjective Data:
These are client’s perception about their health
problem. e.g. pain
2. Objective Data:
These data are observable and measurable by data
collector e.g. Vital signs

24. PRIMARY SOURCES
 Primary sources are usually defined as first
hand information or data that is generated by
witnesses or participants in past events.

25. SECONDARY DATA
 Secondary data is the data that have been already
collected by and readily available from other
sources.

26. Sources of data:
1. Primary Sources:
Client
2. Secondary sources:
 Family & significant others
 Health care team members
 Medical records
 Other records
 Literature review
 Nurses experience

27. METHOD OF DATA COLLECTION
1. Observation
2. Interview technique
It is a organized conversation with the client or
family members to obtain the current health
information regarding patient.
3. Physical examination
4. Laboratory tests
5. Review of the records, books & related
literature

28. OBSERVATION
 It is the action or process of closely observing or
monitoring something or someone.

29. Interview technique
It is a organized conversation with the client or family
members to obtain the current health information
regarding patient.
Phases of Interview:
1. Orientation phase
2. Working phase
3. Termination phase

30. 1. Orientation phase
It begins with the nurse’s introduction with
client which includes the nurse’s name,
position and explanation of purpose of the
interview. The nurse client relationship is
enhanced by the professionalism and
competence conveyed by the nurse’s
attitude, manner & appearance

31. 2. Working phase
During the working phase of the
interview the nurse gather information
about the client’s health status. Nurse use
variety of communication strategies such
as listening, paraphrasing, focusing,
summarizing & clarifying to facilitate
communication and ensure that nurse &
client clearly understood each other.

32. 3. Termination phase
 This phase also require skill on the part of
the interview . The client should be given a
clue that the interview is coming to an end.
e.g. There are just two more questions or
We will be finished within 5 to 6 minutes
 This approach also gives the client an
opportunity to ask questions.
 The interview terminated in a friendly
manner

33. Elements for effective interview:
 Clear goal
 Aware about background of the client
 Self introduction
 Choose strategy
 Maintain rapport
 Confidentiality
 Recovery
 Closure

34. Types of Interview Technique:
1. Open ended questions:
It prompts clients to describe a situation in more
that one or two words. This questions give
chance to client to speak freely.
e.g. What do you know about your
condition?
How do you feel in hospital?

35. 2. Close ended questions:
It prompts client to give answer in only one or more
words
e.g. Do you have pain?
How many time you go for toilet?

36. PHYSICAL EXAMINATION
 It is a medical examination to determine a person's
bodily fitness.

37. VALIDATION OF DATA
 Data validation to be done to ensure its accuracy
 Validation of collected data involves comparing the data
with other sources

38. ORGANIZATION OF DATA
 Clustering of data & arrangement in a systematic and
logical order which gives clue for nursing diagnosis
e.g. Anger is a cue for the diagnosis
for anxiety, fear

39. RECORDING/ DOCUMENTATION OF DATA
 Documentation should be concise, thorough and
accurate
 Documentation depends upon the institutional policy
 It is descriptive in nature