NURSING PROCESS

Claudette McGregor-
Coombs, MSN, ARNP
Nursing Process

 The nursing process is a framework for

providing professional, quality nursing
Care.
 It directs nursing activities for health
promotion and disease prevention.
NURSING PROCESS

 The nursing process is a series of steps

that lead to accomplishment of goals or
purposes.
 The nursing process is designed to be
used with clients throughout their life
span.
 The nursing process is not linear, but lead
to overlapping steps.
Nursing Process
 The nursing process is a systematic
problem-solving process that guides
nurses in the provision of goal-directed,
client-centered care.
 It consists of six phases:
1.Assessment. 4. Planning interventions
2.Diagnosis 5. Implementation
3.Planning Outcomes 6. Evaluation.
NURSING PROCESS
NURSING PROCESS

 An organized, systematic method of

delivering goal oriented, humanistic care
that is both effective and efficient.

R. Alfaro-Le Fevre
Nursing Process

1. Encountering a problem– data collection

2. Analyzing data
3. Plan of action
4. Putting into action
5. Evaluation
THE NURSING PROCESS

 determines the need for patient care

 allows for planning, implementation

and evaluation
THE NURSING PROCESS IS:

 Purposeful

 Systematic

 Dynamic
THE NURSING PROCESS
IS: (Characteristics)

 Interactive

 Flexible

 Theoretically
based
PURPOSE OF THE
NURSING PROCESS…

 Provide a framework within which the

individual, family & community needs can
be met.
NURSING PROCESS

 Influenced by
the nurse’s:

a. beliefs
b. knowledge
c. skills
NURSING PROCESS IS
BASED ON:

 PRINCIPLES

 RULES
PRINCIPLES AND
RULES
 THE APPLICATION OF THESE PRINCIPLES
PROVIDE NURSES WITH ESSENCIAL
TOOLS NEEDED TO:

assess, identify & solve problems…

NURSING PROCESS

 THE AMERICAN NURSES

ASSOCIATION STANDARDS OF
PRACTICE INCLUDED DIAGNOSING
AS A FUNCTION OF PROFESSIONAL
NURSING. (1973)
Standards of Practice
The American Nurses Association
(ANA,2004) revised practice standards
outlined the steps for the nursing process
as:
1.Assessment.
2.Diagnosis
3.Outcome identification and planning.
4.Implementation
5.Evaluation.
Assessment

Assessment is defined as the use of a

systematic and ongoing process to:
 Collect data.
 Categorize data.
 Validate data.
 Record data.
Assessment

 Methods of assessment:
1.Inspection.
2.Palpation.
3.Auscultation
4.Percussion.
Inspection
Palpation
Auscultation
Percussion
NURSING PROCESS

 Assessment:

1. Objective data

2. Subjective data
Objective Data

 Objective data are observable and

measurable.
 They are obtained through physical
examinations and diagnostic tests.
Subjective Data

 Subjective data is information provided

in relation to a condition by the patient,
spouse, caregiver or paramedics.
ASSESSMENT:

 GATHERING AND

EXAMINING DATA
Assessment

Methods of data collection

 Observation.
 Interview.
 Health History.
 Physical Examination.
Data Organization

 Data is organized into clusters. Clusters

are groups of related signs/symptoms.

 Clusters also can be formed by organizing
data based on strengths and weaknesses.
DIAGNOSING:

 ANALYZING DATA TO IDENTIFY ACTUAL

OR POTENCIAL PROBLEMS
Diagnosis

 Diagnosis is the science or art of

identifying problems or conditions based
on certain features or presentations.
Nursing Diagnosis

 Nursing Diagnosis was formulated by the

North America Nursing Diagnosis
Association ( NANDA).
 The definition of a Nursing Diagnosis
evolved over time.
 In 1994 NANDA revised the nursing
diagnosis and provided a description for
Nursing Diagnosis.
Nursing Diagnosis

 Example:
 Ineffective tissue perfusion ( cardiac) r/t
Coronary ischemia AEB chest pain,
shortness of breath and pain.
Nursing Diagnosis

 A nursing diagnosis is a statement that

describes a clinical judgment about
individual, family and community’s
 ( health-state or actual/potential altered
interaction pattern).
 It provides the basis for selecting
interventions.
Sample Two-Part
Diagnostic Statement
Problem Related to Etiology

Constipation Related to Prolonged laxative use

Severe anxiety Related to Threat to physiologic

integrity; possible cancer
diagnosis.
Nursing Diagnosis ( Two-
Part Statement)

 Component of a Nursing Diagnosis

Diagnostic label or NANDA statement (or
concept) describes the patient’s responses.
Related factor ( Etiology/contributing factor).

Example: Fluid volume deficit related to

frequent watery stools.
Nursing Diagnosis (Three-
Part Statement)
NANDA Related to Etiology Manifestations
STATEMENT
( problem)
Fluid volume Related to Frequent Thirst, dried skin
deficit urination
Nursing Diagnosis (Three-
Part Statement)

 Diagnostic label or NANDA statement ( or

concept).
 Related Factors.
 AEB ( defining characteristics).

 Example: Fluid volume deficit related to

frequent urination AEB thirst, dry skin.
Nursing Diagnosis

 In order to formulate nursing diagnoses,

subjective cues and objective cues must be
organized in clusters.
 Clue clusters are groups of conditions or
manifestations that represent known health
problem or situation.
 For example: A sneeze, runny nose and a
cough usually indicate respiratory disorder.
Examples of clue Clusters.
Condition/ NANDA Clue clusters Clue Clusters
(Objective) ( Subjective)
Possible dehydration Dried, pale mucus Daughter states , “my
membrane, dry skin, mother is always
poor skin turgor, thirsty.”
decreased urine output Patient states, “ I am
drinking a lot.”
Fluid volume deficit Frequent loss stools, Patient states, “ I am
decreased urine output. urinating every 30-60
minutes
PLANNING:

 SETTING GOALS
 PLAN OF ACTION.
IMPLEMENTATION:
 PUTTING THE PLAN
INTO ACTION AND
OBSERVING INITIAL
RESPONSES.
EVALUATION:

 DETERMINING IF THE PLAN HAS

WORKED, MAKING NECESSARY

CHANGES.
STEP 1 : ASSESSMENT
 ESTABLISHES THE HEALTH CARE
DATA BASE: CONSULTATIONS
CONTINIOUS UPDATE
NURSING HISTORY OF DATA BASE
PHYSICAL DATA VALIDATION
ASSESSMENT COMMUNICATION
REVIEW OF CLIENT
RECORD
ASSESSMENT TOOLS
 COMMUNICATION

 INTERVIEW

 SCIENTIFIC
KNOWLEDGE
ASSESSMENT TOOLS
 MEDICAL/SOCIAL
KNOWLEDGE
 NURSING
KNOWLEDGE
 PHYSICAL
ASSESSMENT SKILLS
 APPLICATION OF THE
NURSING PROCESS
ASSESSMENT
TECHNIQUES
 INSPECTION

 PALPATION

 AUSCLUTATION

 PERCUSSION
TIPS
 3 S’s : Size, shape,
symmetry

 3 C‘s: Color,
Contour, consistency
REVIEW: Steps of the
Nursing Process
1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation
Assessment
 Nursing assessment is a two-step process.
It includes:
 Collection and verification of data from a
primary source (a client) and secondary
sources ( family, caregivers and health
professionals).
 The analysis of all data is a source for
developing nursing diagnoses, identifying
collaborative problems and develop a plan of
care. ( Carpenito-Moyet, 2005).
Nursing Diagnosis

 The Nursing Diagnosis provides the basis

for selection of nursing interventions to
achieve outcomes.
 Nursing Diagnoses are a clinical
judgments about an individual, family or
community actual or potential health
problem.
Planning Nursing Care

 Nursing care is provided based on priority.

 Prioritizing nursing care is accomplished
through arranging actual/potential health
problems in the order of severity or
physiological importance.
Implementation

 Implementation is the initiation of

activities that will cause a positive change,
or desired outcome in the identified
nursing problem.
 An example of implementation is
administering an antipyretic to reduce
fever.
Evaluation

 Evaluation is determining if nursing goals

are attained, based on the care
implemented. The main question, “are the
expected outcomes achieved?
 Evaluation in nursing is a continuous
process.
Identify Phases of Nursing
Process:

1. Analyzing & interpreting data

2. Initiating nursing interventions

3. Performing a physical examination

4. Determining outcomes with patient

Cont.

5. Revising plan of care

6. Interviewing the client

7. Writing a nursing diagnosis

8. Outcomes achieved?
Cont.

9. Developing interventions to achieve

outcomes

10. Recording care

11. Developing a plan of care

Critical Thinking Example
 Ms X is brought to the emergency department be her
daughter. The daughter states, “ my mother is
having diarrhea x 3 days, she is weak and has a
fever. Upon assessment the nurse finds that the
patient has:
 T 102, P122, R22, BP 92/56, dry skin and dry
mucosa.

 1. What could be the problem?

 2. What do you assess?
 3. What are your interventions?
Format of the Critical
Thinking Exercise

 I. What are the possible problems based

on a given scenario.

 11. What would you assess ( based on

the patient’s clinical presentation in the
scenario).
 III. What would you do. What are your
priority interventions.
Nursing Care Plan
Scenario

 Ms X is brought to the emergency

department be her daughter. The
daughter states, “ my mother is having
diarrhea x 3 days, she is weak and has a
fever. Upon assessment the nurse finds
that the patient has:
 T 102, P122, R22, BP 92/56, dry skin and
dry mucosa.
Format of the Nursing Care
Plan Exercise
 Assessment:
 1. Subjective Data.
 2. Objective Data.
Nursing Diagnosis
a.Two-part – Dehydration r/t excessive fluid
loss.
Or
b. Three-part – Dehydration r/t excessive fluid
loss AEB dried mucosa, dried skin and
decreased urine output.
Format of the Nursing Care
Plan Exercise (cont’d)

 Expected Outcomes. ( Statement

starting with patient will….. This
statement must be measurable, feasible
and timed).
Format of the Nursing Care
Plan Exercise ( cont’d).

 Interventions:
 1. What would you assess.
 2. What would you do. ( Prioritize)
 3. What would you teach.