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Nursing process

Nursing process is a systematic, rational method of planning and providing nursing care. Its
purpose is to identify a client’s health care status, and actual or potential health problems, to
establish plans to meet the identified needs, and to deliver specific nursing interventions to
address those needs. The nursing process is cyclical; that is, its component follows a logical
sequence, but more than one component may be involved at one time. At the end of the first
cycle, care may be terminated if goals are achieved, or the cycle may continue with
reassessment, or the plan of care may be modified.

Characteristics of Nursing Process

The nursing process has distinctive 5 characteristics that enable the nurse to respond to the
changing health status of the client. These characteristics include its cyclic centeredness; focus
on problem solving and decision making, interpersonal and collaborative style, universal
applicability, and use of critical thinking.

Data from each phase provide input into the next phase. Findings from evaluation feed back
into the assessment. Hence, the nursing process is a regularly repeated event or sequence
of events (a cycle) that is continuously changing (dynamic) rather than staying the same
(static)
The nursing process is client centered. The nurse organizes the plan of care according to
client problems rather than nursing goals. In the assessment phase, the nurse collects data

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to determine the client’s habits, routines, and needs, enabling the nurse to incorporate
client routines into the care plan as much as possible.
The nursing process is an adaptation of problem solving and system theory. It can be
viewed as parallel to but separate from the process used by physicians (the medical model).
Both processes (a) begin with data gathering and analysis, (b) bas action (intervention or
treatment) on a problem statement (nursing diagnosis or medical diagnosis), and (c) include
an evaluate component. However, the medical model focuses on physiological systems and
the disease process, whereas the nursing process is directed toward a client’s responses to
disease illness.
Decision making is involved in every phase of the nursing process. Nurses can be highly
creative in determining when and how to use data to make decisions. They are not bound by
standard responses and may apply their repertoire of skills and knowledge to assists clients.
This facilitates the individualization of the nurse’s plan of care.
The nursing process is interpersonal and collaborative. It requires the nurse to communicate
directly and consistently with clients and families to meet their needs. It also requires that
nurses collaborate, as members of the health care team, in a joint effort to provide quality
client care.

There are 5 phases of nursing process: assessing, diagnosing, planning, implementing, and
evaluating.

Steps of the nursing Process:

1-Assessing (Nursing Assessment)

The nursing assessment (Assessing) is the systematic and continuous collection, organization,
validation, and documentation of data (information). In effect, nursing assessment is a
continuous process carried out during all phases of the nursing process. For example, in the
evaluation phase,nursing assessment is done to determine the outcomes of the nursing
strategies and to evaluate goal achievement. All phases of the nursing process depend on the
accurate and complete collection of data. There are 4 different types of nursing assessments:
initial assessment, problem-focused assessment, emergency assessment, and time-lapsed
reassessment. Assessments vary according to their purpose, timing, time available, and client
status.

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The assessment process involves 4 closely related activities: collecting data, organizing data,
validating data, and documenting data.

– Types of Nursing Assessment

TIME
TYPE PURPOSE EXAMPLE
PERFORMANCE
To establish
a complete
database for
Performed
problem
within specified
identification,
Initial time after Nursing
reference,
Assessment admission to a admission
and future
health care
comparison
agency

Hourly
assessment of
client’s fluid
intake and
urinary
output in an
ICU

To determine
the status of Assessment
Problem- Ongoing process a specific of client’s
focused integrated with problem
Assessment nursing care identified in ability to
an earlier perform self-
assessment
care while
assisting the
client to
bathe

Emergency During any To identify Rapid

Assessment physiologic or life- assessment of
psychologic threatening a person’s
crisis of the problems airway,
client breathing
status and
circulation

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To identify during a
cardiac arrest
new or
overlooked
problems
Assessment
of suicidal
tendencies or
potential for
violence.

Reassessment
of a client’s
functional
To compare health
the client’s patterns in a
Several months current home care or
Time-lapsed
after initial status to outpatient
Reassessment
assessment baseline data setting or, in
previously a hospital, at
obtained shift change

Collecting Data

Data collection is the process of gathering information about a client; it includes the health
theory, physical assessment, primary care provider’s history and physical examination, results
of laboratory and diagnostic tests, and material contributed by the other personnel.

Client data should include past history as well as current problems. For example, a history of
an allergic reaction to penicillin is a vital piece of historical data. Past surgical procedures, folk
healing practices, and chronic diseases are also example of historical data. Current data relate
to present circumstances, such as pain, nausea, sleep patterns, and religious practices. To
collect data accurately, both the client and nurse must actively participate. Data can be
subjective or objective and constant or variable types, and from a primary or secondary
source.

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Types of Data

Subjective data:

Subjective data, referred to as symptoms or covert data, are apparent only to the person
affected and can be described or verified only by that person. Itching, pain, and feeling of
worry are examples of subjective data. Subjective data include the client’s sensations, feelings,
values, beliefs, attitudes, and perception of personal health status and life situation.

Objective data:

Objective data , also referred to as signs or overt data, are detectable by an observer or can
be measured or tested against an accepted standard. They can be seen, heard, felt, or
smelted, and they are obtained by observation or physical examination. For example, a
discoloration of the skin or a blood pressure reading is objective data.

Constant data:

Constant data is information that does not change over time such as race or blood type.
Variable data can be change quickly, frequently, or rarely and include such data as blood
pressure, age, and level of pain.

Source of Data

Sources of data are primary and secondary. The client is the primary source of data. Family
member or other support persons, other health professionals, records and reports, laboratory
and diagnostic analyses, and relevant literature are secondary or indirect sources.

Data Collection Methods

The principal methods used to collect data are observing, interviewing, and examining.

Observing

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To observe is to gather data by using the senses. Observation is a conscious, deliberate skill
that is developed through effort and with an organized approach.

Interviewing

An interview is a planned communication or a conversation with a purpose, for example, to get

or give information, identify problems of mutual concern, evaluate change, teach, provide
support, or provide counseling or therapy.

There are two approaches to interviewing: directives and non-directives. The directive
interview is highly structured and elicits specific information. The nurse establishes the
purpose of the interview and controls the interview, at least at the outset. the client
responds to questions but may have limited opportunity to ask questions or discuss
concerns.

During a non-directive interview, or rapport-building interview, by contrast, the nurse

allows the client to control the purpose, the subject matter, and pacing. Rapport is an
understanding between two or more people.

Examining

The physical examination or physical assessment is a systematic data collection method that
uses observation (i.e., the senses of sight, hearing, smell and touch) to detect health
problems. To conduct the examination the nurse uses techniques of inspection, auscultation,
palpation, and percussion.

Organizing Data
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The nurse uses a written (or computerized) format that organizes the assessment data
systematically. This is often referred to as a nursing history, nursing assessment or nursing
data-base form. The format may be modified according to the client’s physical status such as
one focused on musculoskeletal data for orthopedic clients.

Validating Data

The information gathered during the assessment phase must be complete, factual and accurate
because the nursing diagnoses 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.
Validating data helps the nurse to complete these tasks:

Ensure that assessment information is complete

Ensure that objective and related subjective data agree
Obtain additional information that may have been over-looked.
Differentiate between cues and inferences. Cues are subjective or objective data that can be
directly observe by the nurse; that is, what the clients says or what the nurse can see, hear,
smell, or measure. Inference are the nurse’s interpretation or conclusions made based on
the cues (e.g., a nurse observes the cues that an incision is red, hot and swollen; the nurse
makes an inference that the incision is infected).

Avoid jumping to conclusions and focusing in the wrong direction to identify problems.

Documenting Data

To complete the assessment phase, the records client data. Accurate documentation is
essential and should include all data collected about the client’s health status. Data are
recorded in a factual manner and not interpreted by the nurse. For example, the nurse records
the client’s breakfast intake (objective data) as “coffee 240 ml, juice 120 ml, 1 egg, and 1 slice
of toast,” rather than as “appetite good” (a judgment). A judgment or conclusion such as
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“appetite good” or “normal appetite” may have different meanings for different people. To
increase accuracy, the nurse records subjective data in the client’s own words, using quotation
marks. Restating in other words what someone says increase the chance of changing the
original meaning.

2- Diagnosing (Nursing Diagnosis)

Nursing diagnosis (Diagnosing) is the second phase of the nursing process. In this phase,
nurses use critical thinking skills to interpret assessment data and identify client’s strengths
and problems. Nursing diagnosis is a pivotal step in the nursing process. Activities preceding
this phase are directed toward formulating the nursing diagnoses; the care-planning activities
following this phase are based on the nursing diagnoses.

Types of nursing diagnoses

The five types of nursing diagnoses are actual, risk, wellness, possible, and syndrome.

1. An actual nursing diagnosis is a client problem that is present at the time of the nursing
assessment. Examples are ineffective breathing pattern and anxiety. An actual nursing
diagnosis is based on the presence of associated signs and symptoms.
2. A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
For example, all people admitted to hospital have some possibility of acquiring an infection;
however, a client with diabetes or a compromised immune system is at higher risk than
others. Therefore, the nurse would appropriately use the label risk for infection to describe
the clients health status.
3. A wellness nursing diagnosis “describes human responses to levels of wellness in an
individual, family or community that have a readiness for enhancement”. Examples of
wellness diagnoses would be readiness for enhanced spiritual well-being or readiness for
enhance family coping.
4. 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 to refute
it. Fro example, an elderly widow who lives alone is admitted to the hospital. The nurse

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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 a nursing diagnosis of
possible social isolation related to unknown etiology.
5. A syndrome nursing diagnosis is a diagnosis in which is associated with a cluster of other
diagnoses. Currently six syndrome diagnoses are on the NANDA international list. Risk for
disuse syndrome, for example, may be experienced by long-term bedridden clients. Clusters
of diagnoses associated with this syndrome include impaired physical mobility, risk for
impaired tissue integrity, risk for activity intolerance, risk for constipation, risk for infection,
risk for injury, risk for powerless, impaired gas exchanged, and so on.

Analyzing Data

In the diagnostic process, analyzing involves the following steps:

1. Compare date against standards (identify significant cues).

2. Cluster cues (generate tentative hypothesis).
3. Identify gaps and inconsistencies.

For experienced nurses, these activities occur continuously rather than sequentially.

Comparing data with Standards

Nurses draw a knowledge and experience to compare client data to standards and norms and
identify significant and relevant cues. A standard or norm is generally accepted measure, rule,
model, or pattern. The nurse uses a wide range of standards, such as growth and
developmental patterns, normal vital signs, and laboratory values.

Clustering Cues

Data Clustering or grouping cues is a process of determining the relatedness of facts and
determining whether any patterns are present, whether the data represent isolated incidents,

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and whether the data are significant. This is the beginning of synthesis.

Identifying Gaps and Inconsistencies

Skillful assessment minimizes gaps and inconsistencies in data. However, data analysis should
include a final check to ensure that the data are complete and concrete.

Inconsistencies are conflicting data. Possible sources of conflicting data include measurement
error, expectations, and inconsistent or unreliable reports. For example, the nurse may learn
from the nursing history that the client reports not having seen a doctor in 15 years, yet during
the physical health examination, he states, “My doctor takes my blood pressure every year.”
All inconsistencies must be clarified before a valid pattern can be established.

Identifying Health Problems, Risks, and Strengths

After data are analyzed, the nurse and client can together identify strengths and problems.
This is primarily a decision-making process.

Determining Problem and Risks

After grouping and clustering the data, the nurse and client together identify problems that
support tentative actual, risk, and possible diagnosis. In addition, the nurse must determine
whether the client’s problem is a nursing diagnosis, medical diagnosis or collaborative problem.

Determining Strengths

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At this stage, the nurse and client’s strengths, resources, and abilities to cope. Most people
have a clearer perception of their problems or weaknesses than of their strengths and assets,
which they often take for granted. By taking inventory strengths, the client can develop a
better-rounded self concept and self image. Strengths can be an aid to immobilizing health and
regenerative processes.

Formulating Diagnostic Statements

Most nursing diagnoses are written as two-part or three-part statements, but there are
variations of these.

Basic Two-Part Statements

The basic two-part statement includes the following:

1. Problem (P): statement of the client’s response

2. Etiology (E): factors contributing to or probable causes of the responses.

The two-parts are joined by the words related to rather than due to. The phrase due to implies
that one part causes or is responsible for the other part. By contrast, the phrase related
tomerely implies a relationship.

Basic Three-Part Statements

The basic three-part nursing diagnosis statement is called the PES format and includes the
following:

1. Problem (P): statement of the client’s response

2. Etiology (E): factors contributing to or probable causes of the response
3. Signs and Symptoms (S): defining the characteristics manifested by the client.

Actual nursing diagnoses can be documented by using the three-part statement because the
signs and symptoms have been identified. This format cannot be used for risk diagnoses

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because the client does not have signs and symptoms of the diagnosis.

The PES format is especially recommended for beginning diagnosticians because the signs
and symptoms validate why the diagnosis was chosen and make the problem statement more
descriptive.

One-Part Statement

Some diagnostic statements, such as wellness, diagnoses and syndrome nursing diagnoses,
consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more
specific, so that nursing interventions can be derived from the label itself. Therefore, an
etiology may not be needed. For example, adding an etiology to the label Rape-Trauma
Syndrome does not make the label any more descriptive or useful.

Evaluating the Quality of the Diagnostic Statement

In addition, to using the correct format, nurse must consider the content of their diagnostic
statements. The statements should, for example, be accurate, concise, descriptive, and
specific. The nurse must always validate the diagnostic statements with the client and compare
the client’s signs and symptoms to the NANDA defining characteristics. For risk problems, the
nurse compares the client’s risk factors to NANDA risk factors.

3- Planning
Planning is a deliberative, systematic phase of the nursing process that involves decision
making and problem solving. In planning, the nurse refers to the client’s assessment data and
diagnostic statements for direction in formulating client goals and designing the nursing
interventions required to prevent, reduce, or eliminate the client’s health problems. A Nursing
intervention is “any treatment, based upon clinical judgment and knowledge that a nurse
performs to enhance patient/client outcomes”. The end product of the planning phase is a
client care plan.

Although planning is basically the nurse’s responsibility, input from the client and support
persons is essential if a plan is to be effective. Nurses do not plan for the client, but encourage
the client to participate actively to the extent possible. In a home setting, the client’s support
people and caregivers are the one’s who implement the plan of care; thus, its effectiveness
depends largely on them.
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Types of planning

Planning begins with first client contact and continues until the nurse-client relationship ends,
usually when the client is discharge from the health care agency. All planning is
multidisciplinary (involves all health care providers interacting with the client) and includes the
client and family to the fullest extent possible in every step.

Initial planning

The nurse who performs the admission assessment usually develops the initial comprehensive
plan of care. This nurse has the benefit of the client’s body language as well as some intuitive
kinds of information that are not available solely from the written database. Planning should be
initiated as soon as possible after the initial assessment, especially because of the trend
toward shorter hospital stays.

Ongoing planning

Ongoing planning is done by all nurses who work with the client. As nurses obtain new
information and evaluate the client’s responses to care, they can individualize the initial care
plan further. Ongoing planning also occurs at the beginning of a shift as the nurse plans the
care to be given that day. Using ongoing assessment data, the nurse carries out daily planning
for the following purposes:

1. to determine whether the client’s health status has changed

2. to set priorities for the client’s care during the shift
3. to decide which problems to focus on during the shift
4. to coordinate the nurse’s activities so that more than one problem can be addressed at each
client contact.

Discharge planning

Discharge planning, the process of anticipating and planning for needs after discharge, is a
crucial part of comprehensive health care and should be addressed in each client’s care plan.
Because the average stay of clients in acute care hospitals has become shorter, people are
sometimes discharge still needing care. Although many clients are discharge to other agencies

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(e.g. long-term care facilities), such care is increasingly being delivered in the home. Effective
discharge planning begins at first client contact and involves comprehensive and ongoing
assessment to obtain information about the client’s ongoing needs.

Developing a nursing care plan

The end product of the planning phase of the nursing process is a formal or informal plan of
care. An informal nursing care plan is a strategy for action that exists in the nurse’s mind. For
example, the nurse may think, “Mrs. Pham is very tired. I will need to reinforce her teaching
after she is rested.” A formal nursing care plan is a written or computerized guide that
organizes information about the client’s care. The most obvious benefit of formal written care
plan is that it provides for continuity of care.

A standardized care plan is a formal plan that specifies the nursing care for groups of clients
with common needs. An individualized care plan is tailored to meet the unique needs of specific
client-needs that are not addressed by the standardized plan.

Guidelines for writing nursing care plan

The nurse should use the following guidelines when writing nursing care plans:

1. Date and sign the plan.

2. Use category headings.
3. Use standardized/approved medical or English symbols and key words rather than complete
sentences to communicate your ideas unless the agency policy dictates otherwise.
4. Be specific.
5. Refer to procedure books or other sources of information rather than including all the steps
on a written plan.
6. Tailor the plan to the unique characteristics of the client by ensuring that the client’s
choices, such as preferences about the times of care and the methods used.
7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as
well as restorative ones.
8. Ensure that the plan contains interventions for ongoing assessment of the client.
9. Include collaborative and coordination activities in the plan.
10. Include plans for the client’s discharge and home care needs.

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4- Implementing
In the nursing process, implementing is the action phase in which the nurse performs the
nursing interventions. Using NIC terminology, implementing consists of doing and documenting
the activities that are the specific nursing actions needed to carry out interventions. The nurse
performs or delegates the nursing activities for the intervention that were developed in the
planning step and then concludes the implementing step by recording nursing activities and
the resulting client responses.

Implementing Skills

To implement the care plan successfully, nurses need cognitive, interpersonal and technical
skills. These skills are distinct from one another; in practice, however, nurses use them in
various combinations and with different emphasis, depending on the activity. For instance,
when inserting a urinary catheter the nurse needs cognitive knowledge of the principles and
steps of the procedure, interpersonal skills to inform and reassure the client. And technical skill
in draping the client and manipulating the equipment.

The cognitive skills (intellectual skills) include problem solving, decision making, critical
thinking, and creativity. They are crucial to safe, intelligent nursing care.

Interpersonal skills are all of the activities, verbal and non-verbal people use when
interacting directly with one another. The effectiveness of a nursing action often depends
largely on the nurse’s ability to communicate with others. The nurse uses therapeutic
communication to understand the client and in turn be understood. A nurse also needs to
work effectively with others as a member of the health care team

Technical skills are purposely “hands-on” skills such as manipulating equipment, giving
injections, bandaging, moving, lifting and repositioning the clients. These skills are also

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called tasks, procedures or psychomotor skills. The term psychomotor refers to physical
actions that are controlled by the mind, not reflexive.

Process of implementing

The process of implementing normally includes the following:

Reassessing the client

Determining the nurse’s need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities

5- Evaluating
To evaluate is to judge or to appraise. Evaluating is the fifth and last phase of the nursing
process. In this context, evaluating is a planned, ongoing, purposely activity in which clients
and health care professionals determine (a) the client’s progress toward achievement of
goals/outcomes and (b) the effectiveness of the nursing care plan. Evaluation is an important
aspect of the nursing process because conclusions drawn from the evaluation determine
whether the nursing interventions should be terminated, continued or changed.

Evaluation is continuous. Evaluation done while or immediately after implementing a nursing

order enables the nurse to make on-the-spot modifications in an intervention. Evaluation
performed at specified intervals (e.g. once a week for the home care client) shows the extent
of progress toward goal achievement and enables the nurse to correct any deficiencies and
modify the care plan as needed. Evaluation continuous until the client achieves the health
goals or is discharged from nursing care. Evaluation at discharge includes the status of goal
achievement and the client’s self-care abilities with regard to follow-up care. Most agencies
have a special discharge record for this evaluation.

Through evaluating, nurses demonstrates responsibility and accountability for their actions,
indicate interest in the results of the nursing activities, and demonstrates a desire not to
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perpetuate ineffective actions but to adopt more effective ones.

Process of evaluating client response

Before evaluation, the nurse identifies the desired outcomes (indicators) that will be used to
measure client goal achievement. (This is done in the planning step). Desired outcomes serve
twp purposes: They establish the kind of evaluative data that need to be collected and provide
a standard against which the data are judged. For example, given the following expected
outcomes, any nurse caring for the client would know what data to collect.

Daily fluid intake will not be less than 2500ml.

Urinary output will balance with fluid intake.
Residual urine will be less than 100ml.

The evaluation process has 5 components

Collecting data related to the desired outcome (NOC indicators)

Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the nursing care plan

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