The nursing process is based on a nursing theory developed by Ida Jean Orlando.

She developed
this theory in the late 1950's as she observed nurses in action.
●From her observations she learned that the patient must be the central character.
●The nursing process is an essential part of the nursing care plan.

THE NURSING PROCESS

The nursing process is a deliberate, problem-solving approach to meeting the health care and nursing
needs of a patient

THE 5 COMPONENTS OF NURSING

 ASSESSMENT
 DIAGNOSIS
 PLANNING
 IMPLEMENTING
 EVALUATION

Assessing
●Collecting data
●Organizing data
●Validating is the act of “double-checking” or verifying data to confirm that it is accurate and factual.
●Documenting data
●Goal
●Establish a database about the client

TYPES OF ASSESSMENT
Initial
●Performed within a specified time period
●Establishes complete database
●Problem-Focused
●Ongoing process integrated with care
●Determines status of a specific problem
●Emergency
●Performed during physiologic or psychologic crises
●Identifies life-threatening problems

●Time-lapsed
●Occurs several months after initial
●Compares current status to baseline
 Collecting data
 Organizing data
 Validating is the act of “double-checking” or verifying data to confirm that it is accurate and
factual.
 Documenting data
 Goal
 Establish a database about the client
 Initial
 Performed within a specified time period
  Establishes complete database
 Problem-Focused
 Ongoing process integrated with care
 Determines status of a specific problem
 Emergency
 Performed during physiologic or psychologic crises
 Identifies life-threatening problems
 Time-lapsed
 Occurs several months after initial
 Compares current status to baseline

Subjective Data
 Symptoms or covert data
 Apparent only to the person affected
 Can be described only by person affected
 Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health
status and life situations

Objective Data
 Signs or overt data
 Detectable by an observer
 Can be measured or tested against an accepted standard
 Can be seen, heard, felt, or smelled
 Obtained through observation or physical examination

Sources of Data
 Primary Source
 The client
 Secondary Sources
 All other sources of data
 Should be validated, if possible

Methods of Data Collection

 Observing
 Gathering data using the senses
 Used to obtain following types of data:
 Skin color (vision)
 Body or breath odors (smell)
 Lung or heart sounds (hearing)
 Skin temperature (touch)
 Interviewing
 Planned communication or a conversation with a purpose
 Used to:
 Identify problems of mutual concern
 Evaluate change
 Teach
 Provide support
 Provide counseling or therapy
 Examining (physical examination)
 Systematic data-collection method
 Uses observation and inspection, auscultation, palpation, and percussion
 Blood pressure
 Pulses
 Heart and lungs sounds
 Skin temperature and moisture
 Muscle strength

Diagnosing
 Analyzing and synthesizing data
 Goals
 Identify client strengths
 Identify health problems that can be prevented or resolved
 Develop a list of nursing and collaborative problems
 Types of Nursing Diagnosis
 Actual - problem present at the time of the assessment
 Risk - problem does not exist; presence of risk factors
  Wellness - readiness for enhancement
 Possible - Evidence about a health problem incomplete or unclear ; Requires more data
to either support or to refute it
Planning
 Determining how to prevent, reduce, or resolve identified priority client problems
 Determining how to support client strengths
 Determining how to implement nursing interventions in an organized, individualized, and goal-
directed manner
 Goals
 Develop an individualized care plan that specifies client goals/desired outcomes
 Related nursing interventions
Identify activities that occur in the planning process.
 Activities in the Planning Process:
 Prioritizing problems/diagnoses
 Formulating client goals/desired outcomes
 Selecting nursing interventions
 Writing individualized nursing interventions
 Refer to other sources
 Individualize the plan to the client
 Incorporate prevention and health maintenance
 Include discharge and home care plans

Implementing
 Carrying out (or delegating) and documenting planned nursing interventions
 Goals
 Assist the client to meet desired goals/outcomes
 Promote wellness
 Prevent illness and disease
 Restore health
 Facilitate coping with altered functioning
 Types of Nursing Interventions
 Direct- is an intervention performed through interaction with the client.
 Indirect- is an intervention performed away from but on behalf of the client such as
interdisciplinary collaboration or management of the care environment.
 Independent interventions- those activities that nurses are licensed to initiate on the basis of
their knowledge and skills
 Dependent interventions- activities carried out under the doctor's orders or supervision, or
according to specified routines
 Collaborative interventions- actions the nurse carries out in collaboration with other health
team members. The nurse must choose interventions that are most likely to achieve the
goal/desired outcome.

Criteria for Choosing Appropriate Intervention

 Safe and appropriate for the client’s age, health, and condition
 Achievable with the resources available
 Congruent with the client’s values, beliefs, and culture
 Congruent with other therapies
 Based on nursing knowledge and experience or knowledge from relevant sciences
 Within established standards of care

Evaluating
 Measuring the degree to which goals/outcomes have been achieved
 Identifying factors that positively or negatively influence goal achievement
 Goal
 Determine whether to continue, modify, or terminate the plan of care
 Measuring the degree to which goals/outcomes have been achieved
 Identifying factors that positively or negatively influence goal achievement
 Goal
 Determine whether to continue, modify, or terminate the plan of care
 Evaluating and assessing phases overlap
 Evaluating is a planned, ongoing, purposeful activity in which clients and health care
professionals determine the client’s progress toward achievement of goals/ outcomes and
the effectiveness of the nursing care plan.

Nursing Process Discipline

 purpose: meet the patient's immediate need for help.
  3 steps: interaction of 1) the behavior of the patient, 2) the reaction of the nurse and 3) the
nursing actions which are assigned for the patients benefit

Patient behavior
 sets the process in motion
 all pt. behavior must be considered an expression of need for help
 may be verbal or nonverbal
 when pt cannot resolve a need--> sense of helplessness occurs --> distress

Nurse's Reaction
 Comprised of 3 parts:
1. The nurse perceives the behavior through any of her senses
2. The perception leads to automatic thought
3. The thought produces an automatic feeling

Nurse's Action
 done after validating one's reaction to the patient's behavior
 2 types:
1. Automatic
2. Deliberative