The document discusses the nursing process and its five components: assessment, diagnosis, planning, implementation, and evaluation. It focuses on the assessment and diagnosis components. Assessment involves collecting, validating, organizing, interpreting, and documenting client data from various sources. Diagnosis involves analyzing the assessment data to identify client problems or risks, form nursing diagnoses, and determine appropriate nursing interventions. Nursing diagnoses are clinical judgments that describe a client's response to actual or potential health problems and include a label and related factors.

1. By :- Baljinder Singh
M Sc MSN

2. Benefits of using the nursing
process for client
 Continuity of care
 Prevention of duplication
 Individualized care
 Standards of care
 Increased client participation
 Collaboration of care

3. 5 components of the Nursing Process:
1. Assessment
2. Diagnosis
3. Planning
4. Implementing
5. Evaluating

5. 1st Component of the Nursing Process-
ASSESSMENT:
The first step in the
nursing process
involves the following:
 Collecting data.
 Validating data.
 Organizing data.
 Interpreting data.
 Documenting data

6. ASSESSMENT
Assessment is obtain information about a patient
response to health concerns/illness and their ability to
manage these health care issues

7. Purpose of Assessment
To establish a database concerning a client’s
physical, psychosocial, and emotional health.
To identify health-promoting behaviors as well as
actual and/or potential health problems.

8. Types of Assessment
 Comprehensive - Provides baseline data including
complete health history and current needs assessment.
 Focused - Limited in scope in order to focus on a
particular need or concern or potential risk.
 Ongoing - Includes systematic monitoring and
observation related to specific problems.

9. Sources of Data
 Primary Source: The client.
 Secondary Source: The client’s family members,
other health care providers, and medical records.

10. Types of Data
 Subjective: Data from client’s (and sometimes family’s)
point of view. Includes feelings, perceptions, and
concerns. Collected by the interview.
 Objective: Also called signs. Observable and
measurable data obtained through physical
examination and laboratory and diagnostic testing.

11. METHOD OF DATA COLLECTION
 Observation
 Interview that can be Directive or Non directive
 Physical examination:-
->Inspection
->Palpation
->percussion
->Auscultation

13. Validating Data
Validation prevents omissions, misunderstandings,
and incorrect inferences and conclusions.

14. Organizing Data
Collected information must be organized to be
useful.
Data Clustering is a useful tool to identify issues.

15. Interpreting Data
Three critical components:
 Distinguishing between relevant and irrelevant
data
 Determining whether and where there are gaps in
the data
 Identifying patterns of cause and effect

16. Documenting Data
Assessment data must be recorded and reported.
Accurate and complete recording of assessment
data is essential for communicating information to
health care team.

17. NURSING Diagnosis
 A medical diagnosis is a clinical judgment by the
physician that determines a specific disease, condition
or pathological state.
 According to “NANDA” nursing diagnosis is a clinical
judgment about individual, family, or community
responses to actual or potential health problems/life
processes.

18. Diagnostic Analysis
Data
validatio
n
Data
Clustering
Analysis &
Interpretation
of data
Identification
of clients need
Formulation of
Nursing Diagnosis

19. A.Analysis and Interpretation
Of Data:
After completing the
nursing assessment, the nurse proceeds to the
process of forming appropriate nursing diagnosis.
In the assessment phase, data are initially
collected from a variety of source and validated. The
nurse then applies reasoning and begins to look for
patterns in the assessment data.

20. 1. Identify Abnormal Data And Strengths:
Identifying abnormal
findings and strengths requires the nurse to have
and use a knowledge base of anatomy and
physiology, psychology and sociology.

21. 2. Cluster The Data: In this step the nurse looks at
the identified abnormal findings and strengths
for cues that are related. Both abnormal cues and
strength cues should be clustered and a particular
nursing framework should be used as a guide
when possible.

22. B. Draw inferences and
identify the problem
 Nurse will identify the client health problem and
determine what you can treat independently. i.e
something that nurse would intervene and treat
independently. Another purpose of this step is the
referral of identified problems for which the nurse
cannot prescribe the definitive treatment. E.g. diabetic
client who is having trouble with understanding the
exchange diet. Although the nurse has knowledge in
this area so she can advice about diet.

23. C. Propse possible nursing diagnosis:- After
identifying health problem nurse has to
frame nursing diagnosis, nursing diagnosis
may be wellness diagnosis, risk diagnosis or actual
diagnosis.

24. Types of Nursing Diagnosis
 Actual nursing diagnosis: A problem exists; it is
composed of the diagnostic label, related factors, and
signs and symptoms.
 Risk nursing diagnosis: A problem does not yet exist,
but special risk factors are present.
 Wellness nursing diagnosis: Indicates client’s desire to
attain higher level of wellness in some area of function.

25. Nursing Diagnosis is a Two-Part
Statement
 A problem statement or diagnostic label that
describes the client’s response to an actual or
potential health problem or wellness condition.
 And the etiology - the related cause or contributor
to the problem.

26. Nursing Diagnosis
Wellness diagnosis Risk diagnosis Actual diagnosis
•Opportunity to enhance
body image
•Opportunity to enhance
effective breast feeding
•Risk for altered body
image
•Risk for altered family
process
•Altered body image
related to hand wound
that is not healing
•Altered family process
related to hospitalization

27. Nursing Diagnosis Questions
 Are there problems here?
 If so, what are the specific problems?
 What are some possible causes?
 Is there a situation involving risk factors?
 What are the risk factors?
 What are the client’s strengths?
 What data are available to answer these
questions?
 Is more data needed?
 If so, what are the possible sources of further
data?

28. Advantages Of Nursing
Diagnosis
 : Nursing diagnosis is advantageous for both
nurses and clients:-
 1. They facilitate communication among nurse about
the client‘s level of wellness and assist in discharge
planning.
 2. Nursing diagnosis helps in prioritizing the client‘s
needs.

29. Cont…
 3. nursing diagnosis are also used for charting in the
progress notes, writing referrals and providing
effective transition of care from one unit to another,
from one clinic to another or from the hospital to
community.
 4. Nursing diagnosis can also serve as focus for quality
improvement. When focusing the nursing diagnosis
the reviewer can determine whether nursing care was
correct and delivered according to standards of
practice.
 5. Nursing diagnosis is beneficial for the client and
family.