The document defines and discusses the nursing process. The nursing process is a systematic method for solving patient problems through five steps: assessment, diagnosis, planning, implementation, and evaluation. It is cyclic and dynamic, focuses on the client, and uses problem-solving and critical thinking. The benefits of the nursing process include identifying patient problems to simplify nursing interventions and foster decision making. The steps are used to continuously assess, diagnose, plan, implement interventions for, and evaluate the care of the patient.

1. DOCUMENTATION
Nursing Process
K. CHAONA

2. Learning Objectives
By the end of the lesson the student should be
able to review the following:
- the definition nursing process
-the characteristics of a nursing process
- the benefits of the nursing process
-the steps used in nursing process in details
- Application of the nursing process in Acute
Adult Nursing using the ABC concept

3. DEFINITION OF NURSING
PROCESS
• A nursing process is defined as a way for
solving patient problems with a guide of steps
in improving nursing care.

4. THE NURSING PROCESS CT…
It is a basis of bringing together different
midwives who work in varied areas as :
Forms an important practice for a midwife to
deliver holistic, patient-focused care.
Formulates a measure for nurse’s scope of
practice as it fosters accountability and
responsibility in nursing.

5. Characteristics of the
Nursing Process
 Cyclic and dynamic nature
 Client centeredness
 Focus on problem-solving and decision-
making
 Interpersonal and collaborative style
 Universal applicability
 Use of critical thinking

6. BENEFITS OF USING THE NURSING
PROCESS
o Identifies the client’s actual or potential
problems hence simplifying the nursing
interventions.
o For easy planning as it fosters decision making
problems are put in order of priority (critical
thinking) .
o Addresses the specific interventions to client
problems.

7. STEP OF NURSING PROCESS
There five steps of nursing process :
1 . Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

9. STEPS OF NURSING PROCESS
1. Assessment
 uses a systematic, dynamic way to collect and
analyze data about a client (subjective and
objective) to establish a database about the
client’s response to health concerns or illness.
includes physiological, psychological,
sociocultural, spiritual, economic, data and
life-style factors in an organized manner.

10. Steps of Nursing Process ct…
2.Diagnosis
It is the nurse’s clinical judgment about the
client’s response to actual or potential health
conditions or needs.
It is the basis for the nurse’s care plan.
Take note that nursing diagnosis is different
from medical diagnosis.

11. Planning
The nurse sets measurable and achievable short-
and long-range goals for this patient (SMART)
Specific
Measurable
Action –oriented
Realistic
Time bound

12. Implementation
• Nursing care is implemented according to the
care plan’s diagnosis.
• It is used for continuity of care for the patient
during hospitalization and in preparation for
discharge needs to be assured.
• Care is documented in the patient’s record.

13. Implementation
• It is essential to use judgment, critical thinking
,and good decision making skills
• It is uses interdependent and dependent
function of the nurse.

14. Evaluation/Outcomes
Both the patient’s status and the effectiveness
of the nursing care must be continuously
evaluated through:
• Comparing the data with outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem status
Continuing or modifying or terminating the
nursing care plan as needed.