This module is designed to equip trainees with appropriate knowledge, Attitude and skills required to undertake nursing assessment, diagnosis, planning, implementation and evaluation of patient care.

1. PERFORMING NURSING
PROCESS
By
Gedion Zerihun (BScN, MSc in Adult
Health Nursing Specialty)
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2. Out line of the course
Key terms
Concepts of health and illness
Definition nursing process
Benefits of using nursing process
Purposes nursing process
Characteristics nursing process
Steps nursing process
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3. Definition of terms
Health
Illness
Nursing
Process
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4. Definition of terms
Health is defined as a state of physical, mental
and social well being not merely the absence
of disease or infirmity (WHO, 1948).
Physical health implies a mechanistic
functioning of the body.
Mental health means the ability to think clearly
and coherently and has to do with your
thinking and feeling and how you deal with
your problem.

5. Definition of terms
Illness
 Illness is in ability of an individual’s adaptive response
to maintain physical and emotional balance that
subsequently results in impairment of functional
abilities.
 An unhealthy condition of body or mind ; sickness
Wellness
 Wellness is a condition in which an individual functions
at optimal levels.
 The quality or state of being in good health especially
as an actively sought goal <lifestyles that
promote wellness>
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6. Definition of terms
Nursing is both a science and an art concerned
with the physical, psychological, sociological,
cultural, and spiritual concerns of the
individual.
The science of nursing is based on a broad
theoretical framework;
Its art depends on the caring skills and abilities
of the individual nurse.

7. Definition of terms
Nursing is the protection, promotion and
optimization of health and abilities, prevention
of illness and injury, alleviations of suffering
through the diagnosis and treatment of human
response, and advocacy in the care of
individuals, families, communities, and
populations (ANA, 2003).

8. Nursing Process
Process :- It is a series of planned actions or
operations directed towards a particular result
or goal.
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9. Concept of health and illness
Brain storming questions
What is health?
What is Illness?
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10. HEALTH
Health is defined as a state of physical, mental
and social well being not merely the absence
of disease or infirmity (WHO, 1948).
Physical health implies a mechanistic
functioning of the body.
Mental health means the ability to think clearly
and coherently and has to do with your
thinking and feeling and how you deal with
your problem.

11. Concept of health and illness con……
Illness
 Illness is in ability of an individual’s adaptive response
to maintain physical and emotional balance that
subsequently results in impairment of functional
abilities.
 An unhealthy condition of body or mind ; sickness
Wellness
 Wellness is a condition in which an individual functions
at optimal levels.
 The quality or state of being in good health especially
as an actively sought goal <lifestyles that
promote wellness>
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12. The Illness-Wellness Continuum
The Illness-Wellness Continuum
Wellness is a process, never a static state.
Most of us think of wellness in terms of
illness; we assume that the absence of illness
indicates wellness.
There are actually many degrees of wellness,
just as there are many degrees of illness.
The Illness-Wellness Continuum illustrates the
relationship of the treatment paradigm to the
wellness paradigm.
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13. The Illness-Wellness Continuum
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14. The Illness-Wellness Continuum
 Moving from the center to the left shows a
progressively worsening state of health.
 Moving to the right of center indicates increasing levels
of health and wellbeing.
 The treatment paradigm (drugs, herbs, surgery,
psychotherapy, acupuncture, and so on) can bring you
up to the neutral point, where the symptoms of disease
have been alleviated.
 The wellness paradigm directs you beyond neutral and
encourages you to move as far to the right as possible.
 If you are ill, then treatment is important, but don't stop
at the neutral point. Use the wellness paradigm to move
toward high-level wellness.
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15. The Illness-Wellness Continuum
 Even though people often lack physical symptoms, they
may still be bored, depressed, tense, anxious, or simply
unhappy with their lives. Such emotional states often
set the stage for physical and mental disease.
 Even cancer can be brought on by excessive stress that
weakens the immune system.
 Negative emotional states can also lead to abuse of the
body through smoking, overdrinking alcohol, and
overeating - attempts to substitute for other more basic
human needs such as acknowledgment and respect, a
stimulating and supportive environment, and a sense of
purpose and meaning.
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16. The Illness-Wellness Continuum
High-level wellness involves giving good care to
your physical self, using your mind
constructively, expressing your emotions
effectively, being creatively involved with those
around you, and being concerned about your
physical, psychological, and spiritual
environments.
In fact, it's not so much where you are on the
continuum, but which direction you're facing.
High-level wellness does not preclude periods of
illness and weakness, nor does it attempt to deny
that death is a natural part of life.
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17. Nursing Process
A systematic problem-solving approach used to
identify, prevent and treat actual or potential health
problems and promote wellness
A systematic way to assess, diagnose, plan,
implement and evaluate care for individuals, families,
groups and communities.
Is a systematic, rational method of planning and
providing individualized nursing care.
Is the framework for providing professional, quality
nursing care.
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18. Nursing Process
It directs nursing activities for health promotion,
health protection, and disease prevention and is
used by nurses in every practice setting and
specialty.
 It is an organizational framework for the practice
of nursing, orderly, systematic, Central to all
nursing care, Encompasses all steps taken by the
nurse in caring for a patient

19. Benefits of using the nursing process
Prevention of duplication
Individualized care
Standards of care
Increased client participation
Collaboration of care
Continuity of care
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20. BENEFITS OF THE NURSING PROCESS
For the patient
Access to the quality care
Continuity of the care
Patient participation-reflects respect for the human dignity
Individualized care
For the nurse
Consistent and systematic nursing education and care
provision
Job satisfaction
Professional development
Meeting code of ethics and professional nursing standards
Is economical
Stresses the independent function of nurses
Increases care quality through the use of deliberate actions

21. Purpose of Nursing Process
 To identify a client’s health status, 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.
 It helps nurses in arriving at decisions and in
predicting and evaluating consequences.
 Used for applying a scientific approach or a problem
solving approach to nursing practice.
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22. Purpose of Nursing Process
 To achieve scientifically – based, holistic,
individualized care for the patient.
 To achieve the opportunity to work collaboratively
with the patients and others.
 To establish plans to meet the identified needs.
 It forces the health care to observe and interact with
the patient, and not just the task they are performing
such as administering medication, dressing or bed
bath etc.

23. Purpose of Nursing Process
 The process provides a roadmap that ensures good
nursing care and improves patient outcomes.
 Deliver specific nursing interventions to meet those
needs.
 To achieve continuity of care

24. Characteristics of Nursing Process
 Problem- oriented
 Goal- oriented
 Orderly, planned, systematic
 Open to accepting new information during its
application
 Interpersonal
 Permits creativity among nurses and clients
 Universal

25. Con’t
 Cyclic & dynamic in nature
 Client centered
 Focus on problem solving & Decision making
 Interpersonal & Collaborative style
 Universal applicability
 Use of critical thinking.
 Data from each phase provide input into the next
phase
 Decision making involved in every phase of nursing
process.
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26. Steps in Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
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27. Nursing assessment
Is a continuous process carried out during all
phase of nursing process.
Is systemic and continues collection ,
organization , validation , documentation of
client data.
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28. Purpose of Assessment
To establish baseline information on the client.
To determine the client’s normal function.
To determine the client’s risk for diagnosis function.
To determine presence or absence of diagnosis
function.
To determine client’s strengths.
To provide data for the diagnostic phase.
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29. Types of Nursing Assessment
Initial Assessment /Comprehensive
-Initial identification of normal function, functional
status and collection of data concerning actual and
potential dysfunction.
Eg. nursing admission assessment
Focus Assessment
-Status determine of a specific problem identified
during previous assessment.
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30. Con’t
Time Lapsed Reassessment
-Comparison of client’ current status to baseline
obtained previously, detection of changes in all
functioning health problems after an extended period
of time .
Eg. Follow up for hypertensive patient
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31. Con’t
Emergency Assessment
 Identification of life threatening situation.
 Like Psychiatric / physiologic crisis
 For example rapid assessment of ABC during cardiac
arrest
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32. Types of data
Subjective
Symptoms or covert data
For example Pain experience feeling dizzy anxious
itching pain feeling worry
Objective data
Sign or overt data
Seen felt heard
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33. Source of data
1. Primary
client
2. Secondary
 family
 medical record
 Laboratory record
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34. Formats of health assessment
There are three commonly used formats
1. Systems approach (medical model)
Used to collect and organize data based on body
systems
Used by all clinicians
2. Functional health approach (Gordon approach)
Organize health data in 11 categories
Practiced by nurses and midwives
3. Human response pattern approach
Nowadays out of use
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35. Medical systems
1. Socio demographic data
2. source of referral
3. source of history
4. Previous admission
5. Chief complaint
6. history of present illness
7. history of past illness
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36. Medical systems cont…..
8. Systems review
 GENRAL
 HEENT
 LGS
 RS
 CVS
 GUS
 IS
 MSS
 CNS
9. Personal and social history
10. Family history
11. Physical examination
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37. Functional (Gordon approch)
1. Date
2. Time
3. Identification
4. Source of referral
5. Date of admission
6. Medical diagnosis
7. Condition on admission
8. Vital sign
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38. Functional (Gordon approch) cont…..
9. Assessment of 11 functional health pattern
1. Health perception pattern and management
2. Activity and exercise
3. Nutritional and metabolisms
4. Elimination
5. Sleep and rest
6. Cognitive perception
7. Self perception and self concept
8. Role and relationship
9. Coping and stress tolerance
10. Sexual and reproductive pattern
11. Values and belief
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39. Clinical Skills used in Assessment
Observation
 act of noticing client cues.
 looking, watching, examining, scrutinizing,
surveying, scanning, appraising.
 uses different senses: vision, smell, hearing, touch.
Interviewing – interaction and communication.
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40. Clinical Skills used in Assessment
cont….
Physical Examination
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
 Intuition(insights, instincts or clinical
experiences to make judgment about client
care).
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41. Preparatory
Nurse collects background info from
previous charts.
Ensure environment is conducive.
Arrange seating
3 – 4 ft apart
Interviewer at 45° angle to patient
Allow adequate time.
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42. Introduction
Nurse introduces self
Identifies purpose of interview
Ensure confidentiality of information
Provide for patient needs before
starting
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43. Working
Nurse gathers info for subjective data
Excellent communication skills are
needed
Active listening
Eye contact
Open-ended questions
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44. Termination
Inform patient when nearing end of
interview
Ensure patient knows what will
happen with information
Offer patient chance to add anything
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45. Data base:
A data base is all information about a client.
It includes the nursing health history, physical
assessment, the physician’s history, physical
examination, results of laboratory and
diagnostic tests and material contributed by
other health personnel.
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46. Data Collection
Consider
time
needs of patient
developmental stage
physical surroundings
past and present coping patterns
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47. Data Characteristics
Complete
Factual
Accurate
Relevant
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48. 2.ORGANISING DATA
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Nurses uses a written
or computerized
format for arranging
the data
systematically

49. 3.VALIDATING DATA
 VALIDATING -the act of double checking
Verifies understanding of information
Comparison with another source
 Patient or family member
 Record
 Health team member
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50. 4. DOCUMENTING DATA
Record in permanent record
Use patient’s own words in subjective data –
enclose in “ ___” (quotation marks)
Avoid generalizations – be specific
Don’t make summative statements
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51. Tank you
!!!!!!!!!!!!!!!!
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