“The nursing process is a systematic, rational method of planning and providing individualized nursing care.”

1. OVERVIEW OF NURSING PROCESS
AND OVERVIEW OFNANDA
UNIT#1
BY FARIDA FARAZ
PGCN

3. OBJECTIVES
At the end of this session learners will be able to:
 Define Nursing Process (NP).
 Define the purposes of Nursing Process (NP).
 Review the components of the Nursing Process (NP).
 Formulate nursing diagnosis
 Describe the Functional Health approach to nursing process
(NP).
 Develop a concept map-Nursing Care Plan
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4. Nursing Process
 “The nursing process is a systematic, rational
method of planning and providing individualized
nursing care.”
 It is accepted for clinical practice established by the
American Nurses Association
 Pushes nurses to continually examine what they are
doing and to study how it can be done better.
 Consists of five interrelated steps
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5. Purpose of NP
 Is to identify a client’s health status, actual or
potential health care problems or needs.
 Is to establish plans to meet the identified needs.
 Is to deliver specific nursing interventions to meet
those needs.
 It may be an individual, a family, or a group.
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7. Characteristics of Nursing
Process
 Cyclic
 Dynamic nature,
 Client centeredness
 Focus on problem solving and decision making
 Interpersonal and collaborative style
 Universal applicability
 Use of critical thinking and clinical reasoning.

8. ASSESSMENT PROCESS
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9. Assessment
Assessment: is the process of gathering and examining data.
• It is the first step or phase of NP. During this phase, a nurse
collects data from several sources. The collection and
organization of data allow nurse to:
– Determine the patient’s current health status.
– Determine the patient’s strengths and problems.
– Prepare for the second step i.e. diagnosis. (Cox et al, 1993)

10. Types of Assessment
 Initial Assessment:
Performed within specified time after admission to a
health care agency
e.g. initial/admission assessment form.
 Ongoing Assessment:
Ongoing process integrated with nursing care
e.g. hourly assessment if the patient’s fluid intake and
urinary output is altered.

11. Cont….
 Emergency Assessment:
During any psychological crisis of the client e.g.
rapid assessment of person’s airway, breathing
status.
 Time-lapsed Assessment:
Several months after initial assessment e.g.
reassessment of client’s functional health pattern.

12. Types of Data:
 Subjective Data:
 Verbal information given by a patient.
 Data/facts presented by the patient that show his/her
perception, understating, and interpretation of what is
happening. E.g. “The pain begins in my lower back and
runs down my left leg.” or “ I am feeling very weak” or I
can not talk”

13. Objective Data:
Data/facts that are observable and measurable by the
nurse. They are also gathered through diagnostic and
laboratory tests. E.g. Patient’s V/s, blood sugar
levels, medications used, flushed skin etc.

14. Sources of Data
 Collecting Data
 Primary sources
 Secondary sources
 Types of data
 Subjective Data
 Objective Data

15. Sources of Data:
 Primary Source: It is the direct source of
information. The patient is the most valuable source
because the data that are collected are most current
and specific to the patient.
 Secondary Source:It is the indirect source of
information. All sources other than the client are
considered secondary sources. Family
member, health professionals medical records,
laboratory and diagnostic results of patients.

16. Assessment includes
 Observation: To observe together data by using the
senses.
Example
 Clinical sign of client distress, e.g. . Pallor or flushing,
and behavior indicating pain or emotional distress.
 The status of the client i.e. pulse, blood pressure,
respiration etc.

17. Interviewing
 Is the planned communication or a
conversation with a purpose.
 Directive Highly Structured
 Non Directive Encourages to
communicate
by asking close ended questions)
by asking open ended questions)

18. Examining
 The examination includes the assessment of all
body parts and the taking of vital signs , height
and weight.
 To conduct the Physical Examination
 Inspection
 Auscultation
 Palpation
 Percussion

19. Assessment techniques
Inspection:
 Is usual examination that is
assessing using the sense of
sight.
Auscultation:
 Is the process of listening to
sound produced within the
body.

20. Assessment techniques cont…
Percussion:
Is an assessment method in which the body surface
is stuck to elicit sounds that can be heard or
vibration that can be felt.

21. Assessment techniques cont…
Palpation:
 Is the examination of the body using the sense of touch.
 Palpation is used to determine texture. e.g:
 Texture of hair.
 Temperature of skin area.
 Distention of urinary bladder
 Presence and rate of peripheral pulse.

22. Organizing Data
 Data collected need to be organized properly in
order to formulate a suitable diagnostic statement.
There are many frameworks available to organize
the data.
 Gordon’s 11 Functional Health Pattern
(FHP)
 Maslow’s Hierarchy .etc

23. Functional Health Approach
1. Health-perception-health management
2. Nutritional metabolic pattern
3. Elimination pattern
4. Activity-Exercise pattern
5. Cognitive perceptual pattern
6. Sleep-rest pattern
7. Self perception-self concept pattern
8. Role relation pattern
9. Sexuality reproductive pattern
10. Coping-stress-tolerance pattern
11. Value-belief pattern

24. 3. VALIDATING DATA
 The information gathered during the assessment phase
must be complete, factual, and accurate because the
nursing diagnosis and interventions are based on this
information.
 Validation is the act of "double-checking" or
verifying data to confirm that it is accurate and factual.
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25. 4. DOCUMENTING DATA
To complete the assessment phase, the nurse
records client data. Accurate documentation is
essential and should include all data collected
about the client’s health status.
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27. Nursing Diagnosis
 Means reaching a definite conclusion regarding the
patient’s strengths and problems.
(Cox et al, 1993)
 Nursing diagnoses are part of a movement in nursing to
standardize terminology which includes standard
descriptions of diagnoses.
 Health issue that can be prevented, reduced, resolved, or
enhanced through independent nursing measures.
 It helps nurses to practice more scientific and evidence
based standers.

29. Conti…
 The purpose of this stage is to identify the patient's
nursing problems.
 Judgment or conclusion about the risk for—or
actual problem of the patient
 NANDA format
 There are five types of nursing diagnosis:
 Actual
 Risk
 Possible
 Syndrome
 Wellness

30. Types of Nursing Diagnosis (Cont…)
 Actual Diagnosis:
An actual nursing diagnosis is a client problem that is
present at the time of the nursing assessment.
E.g. Ineffective Breathing Pattern, Anxiety etc.

31. Risk Diagnosis:
A risk nursing diagnosis is a clinical judgement that a
problem does not exist, but the presence of risk factors
indicates that a problem may develop if adequate care is
not given
. E.g. every patient in hospital has possibility to acquire
infections but a diabetic patient has higher risk. Therefore
the nurse would appropriately use the diagnosis Risk for
Infection.

32. A possible nursing diagnosis is one in which evidence about
a health problem is incomplete or unclear.
A possible diagnosis requires more data either to support or
refute it.
E.g. an elderly widow who lives alone is admitted to the
hospital .The nurse notices that she has no visitors and is
pleased with attention and conversation from the nursing
staff. Until more data are collected the nurse may write
nursing diagnosis of Possible Social Isolation.
Possible Diagnosis

33. A syndrome diagnosis is a diagnosis that is associated
with a cluster of other diagnosis. There are only few
syndrome diagnosis in NANDA list i.e.
Disuse Syndrome, Rape Trauma Syndrome,
Relocation Stress Syndrome, and Impaired
environmental interpretation syndrome.
E.g. a long term bedridden patient might have diagnosed as
having Disuse Syndrome i.e. clusters of other associated
diagnosis including Impaired Physical Mobility, Risk for
Infection, Risk for Impaired Skin Integrity etc.
 Syndrome:

34.  Wellness:
when a healthy client indicates a desire to achieve a
higher level of wellness.
According to NANDA (1990) definition, “A wellness
diagnosis is a clinical judgment about an individual,
family, and community in transition from a specific level
of wellness to a higher level of wellness.”
E.g. a person is identified having strong will to do exercise
to strengthen his cardiovascular system can be diagnosed
as Potential for Enhanced physical Well-being.

35. Components of a Nursing Diagnosis
 Problem Statement
 diagnostic label
 describes the clients health problem
 Etiology
 related factor
 the probable cause of the health problem
 Defining Characteristic
 a cluster of signs and symptoms
(S & S)

36. Example
 Ineffective airway clearance related to the
presence of tracheo-bronchial secretion as
manifested by thick sputum upon expectoration.
 Problem (Ineffective airway clearance) +
 Etiology (related to) +
 Defining Characteristics (as manifested by)

37. cont….
 Ineffective airway clearance R/t accumulation of
secretions in the airway as evidence by abnormal breath
sounds.
 Altered nutrition less then body requirements R/t
decreased desire to eat
 High risk for impaired skin integrity related to bed rest

40. 3. Planning
 Involves a series of steps in which the nurse and the
client set priorities and goals to resolve or minimizing the
identical problems of the client.
 In the planning nurses establish the:
 Goals (SMART)
 Interventions
 Outcomes
 Prioritization

45. Setting Priorities
1. Take care of immediate
life-threatening issues.
2. Safety issues.
3. Nurse-identified priorities based on the
overall picture, the patient as a whole
person, and availability of time and
resources.

47. Short-Term Goals
 Outcomes achievable in a few days or 1 week
 Developed from the problem portion of the diagnostic
statement
 Client-centered
 Measurable
 Realistic
 Time frame
 Long-Term Goals
Desirable outcomes that take weeks or months to
accomplish for client’s with chronic health problems.

48. Nursing Interventions
 Road maps directing the best ways to provide
nursing care.
 Evidence based nursing.
 Monitor health status.
 Minimize risks.
 Resolve or control a problem.
 Promote optimum health and independence.

51. Implementation
 Is putting the nursing care plan into action.
 e.g.
 Assess respiratory rate, rhythm and depth every
2/hourly.
 Encourage deep breathing and coughing exercise.

52. Evaluation
 The way nurses determine whether a client has reached a
goal.
 It is the analysis of the client’s response, evaluation helps
to determine the effectiveness of nursing care plan.
 Ongoing part of the nursing process
 Determining the status of the goals and outcomes of care
e.g.
 Respiratory rate is within normal range.
 Patient’ airway is clear.

53. Determining Outcome Achievement
 Must be aware of outcomes set for the client.
 Is it:
Completely met?
Partially met?
Not met at all?
 Record in progress in notes.
 Deciding whether to continue, modify, or terminate the
plan
 Update care plan according to the need of the patient

54. Communicating the plan
 The nurse shares the plan of care with nursing team
members, the client, and client’s family.
 The plan is a permanent part of the record.

55. Assessment
Diagnoses
Planning
Implementation
Evaluation
Collect, validate, organize, and record data
Analyze data, Formulate a diagnosis, Validate the
diagnosis
Prioritize problems/diagnoses, Formulate expected
outcomes, choose nursing strategies, develop a care plan.
Putting NCP into action, Reassess need for
intervention continuation, Document nursing
intervention and client responses
Evaluating expected outcomes/goal achievement,
Terminate care for goal achieved/problems resolved, or
revise care plan if needed
Summarization of the steps
of Nursing Process
Gulzar Habibullah

56. NCP
Assessment Diagnosis Goals Intervention Rational Evaluation
Subjective
data: Pt stated
that
“----------”
Objective data:
Nursing
diagnosis as
per NANDA
SMART
goals
Scientifically
proven (EBP)
What will
occur
after this
interventio
n
Evaluation of
goals
Subjective
data: Pt stated
that
“----------”
Objective data:

57. REFERENCE
Cox, C , Helen. (2007) : Clinical Application of Nursing
Diagnosis ( 7th ed.). Mosby.
Fuller, J, Schaller – Ayers, J, (2000) Health Assessment A
nursing approach (3rd ed.) Philadelphia
Harkreader, H. & Hogan, M. A. (2004) Fundamental of
nursing: caring and clinical Judgment (2nd ed.). Sunders
Lough, M.E., et al. (2002). Thelan’s Critical Care Nursing:
Diagnosis and Management. St. Louis: Mosby. 57

58. Gulzar Habibullah
58