NURSING

PROCESS
Presented by: Dalia Al Habashi
 1 Introduction 4 Step by step
List Process

of 2 Background 5 Summary
Contents
3 Purpose and 6 References
Characteristics
 Introduction
The Nursing Process is a critical thinking model based on a
systematic approach to patient-centered care and treatment that
nurses use to perform clinical reasoning and make clinical
judgments when providing patient care.
 Background
In 1958, Ida Jean Orlando started the nursing process still evident in
nursing care today. According to Orlando’s theory, the patient’s
behavior sets the nursing process in motion. Through the nurse‘s
knowledge to analyze and diagnose the behavior to determine the
patient’s needs. Holistic and evidenced-based practice
recommendations are integrated to provide the basis for
compassionate, quality-based care.
 Purpose of the Nursing Process
To identify the client’s health status and
To apply the best available caregiving evidence
actual or potential health care problems
and promote human functions and responses
or needs (through assessment).
to health and illness (ANA, 2010).

To establish plans to meet the identified To protect nurses against legal problems related to
needs. nursing care when the standards of the nursing process
are followed correctly.
To deliver specific nursing interventions
to meet those needs.
To establish a database about the client’s health
status, health concerns, response to illness, and
the ability to manage health care needs.
To help the nurse perform in a
systematically organized way their practice.
 The
Nursing
Process
ADPIE
The first phase of the nursing process is ASSESSMENT.
It involves collecting, organizing, validating and
documenting the client’s health status.

Collecting Data
Sources of Data
Methods of Collection
Documenting Data
 Collecting Data
types of data
Objective Data that are overt and you can observe using the senses, such as

Data / sight, touch, smell, or hearing, and compared to an accepted

standard, such as vital signs (example: I&O, Ht and Wt, Temp., PR,

Signs RR, Blood Pressure, Abdominal and liung sounds, Skin color)

Subjective Data that involve covert information, verbalized by the patient or the
significant others., such as feelings, perceptions, thoughts,
Data / sensations, or concerns by the patient (example: nausea, pain,
numbness, pruritus, attitudes, beliefs, values, and perceptions of the
Symptoms health concern and life events.
 Collecting Data
sources of data
The client is the only primary source of data and the only one who can
Primary provide subjective data. Anything the client says or reports to the
Source members of the healthcare team is considered primary.

If the data is provided by someone else other than the client but within
Secondary the client’s frame of reference. (Example: Client’s family).
Source Additionally, the client’s records and assessment data from other
nurses or other members of the healthcare team are also an example.

Sources from outside the client’s frame of reference are considered

Tertiary tertiary sources of data. (Examples information from textbooks,
Source medical and nursing journals, drug handbooks, surveys, and policy and
procedural manuals)
 Collecting Data
methods of collection
An interview is an intended communication or a conversation with a
Health purpose to obtain or provide information, identify problems of mutual
Interview concern, evaluate change, teach, provide support, or provide counseling

Physical This is done by a comprehensive physical assessment to the patient

Examination referencing a patient’s health history and patient’s family history.

Observation is an assessment tool that depends on the senses (sight,

touch, hearing, smell, and taste). This information relates to
Observation characteristics of the client’s appearance, functioning, primary
relationships, and environment.
 Collecting Data
documenting data

Once all the information has been collected, data can be

recorded and sorted. Excellent record-keeping is fundamental
so that all the data gathered is documented and explained in a
way that is accessible to the whole health care team and can
be referenced during evaluation.
 The data gathered is analyzed to
formulate a diagnosis. A nursing
diagnosis is the nurse’s clinical judgment
about the client’s response to actual or
potential health conditions or needs.

Nursing Diagnosis is
different from the
Medical diagnosis
 The North American Nursing
Diagnosis Association (NANDA)

s
ed
Ne
This is a book provides nurses with an up-to-date list of

by
of
nursing diagnoses. A nursing diagnosis, according to

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hy
NANDA, is defined as a clinical judgment about responses

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to actual or potential health problems on the part of the

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patient, family, or community.

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ow

ow
Basic physiological

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needs must be met

Ma
A nursing diagnosis
before higher needs encompasses Maslow's
can be achieved such Hierarchy of Needs and helps to
as self-esteem and prioritize and plan care based
self-actualization. on patient-centered outcomes.
Examples!
Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway
(suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs),
sleep, sex, shelter, and exercise.
Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide
precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust
and safety (therapeutic relationship), patient education (modifiable risk factors for stroke,
heart disease).
Love and Belonging: Foster supportive relationships, methods to avoid social isolation
(bullying), employ active listening techniques, therapeutic communication, and sexual
intimacy.
Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of
control or empowerment, accepting one's physical appearance or body habitus.
Self-Actualization: Empowering environment, spiritual growth, ability to recognize the
point of view of others, reaching one's maximum potential.
 The planning phase is where goals and outcomes are
formulated that directly impact patient care based on
evidence-based practice (EBP) guidelines. These
patient-specific goals and the attainment of such assist
in ensuring a positive outcome.

Nursing Care plans is a personalized care made to an

individual’s unique needs. Overall condition and
comorbid conditions play a role in the construction of a
care plan. It enhances communication, documentation
and continuity of care across the healthcare team.
Nursing Care Plan (NCP)
a formal process that correctly identifies existing needs and
recognizes potential needs or risks. Care plans provide
Goals should be:
communication among nurses, their patients, and other
Specific
healthcare providers to achieve health care outcomes. Measurable or Meaningful
Attainable or Action-
Oriented
Realistic or Results-
Oriented
Timely or Time-Oriented
Implementation is the step that involves action or doing
and the actual carrying out of nursing interventions
outlined in the plan of care. This phase requires nursing
interventions such as applying a cardiac monitor or
oxygen, direct or indirect care, medication
administration, standard treatment protocols, and EDP
standards
 Nursing Intervention
categories
independent nursing dependent nursing interdependent
interventions interventions nursing interventions

-action that can be performed -actions that cannot be

on their own without the help performed alone. Some actions -nurse performs as part of
or assistance from other require guidance or supervision collaborative or interdependent
medical personnel from a physician or other interventions that involve team
routine nursing tasks medical professional members across disciplines.
such as checking vital prescribing new medication physical therapist
signs inserting and removing a dietitian
educating a patient on the urinary catheter occupational therapist
importance of their providing diet
medication so they can Implementing wound or
administer it as bladder irrigations
prescribed
 This final step of the nursing process is vital to a
positive patient outcome. Reassessment may frequently
be needed depending upon overall patient condition to
know if the interventions are working. The plan of care
may be changed based on new assessment data.

Did the intervention worked?

YES: continue the care plan

NO: revise the care plan

 summary systematic approach to

Nursing Process
patient-centered care and
treatment used by nurses to
provide patient care.
gather data
reassessment -primary source: patient
did the plan worked? -secondary source: family
continue the care -tertiary source: books
plan
revise the care plan

The formulate a nursing

diagnosis based on the data

Nursing gathered
Basic needs should be
carrying out of nursing
interventions outlined in the
Process fulfilled first

plan of care
independent: can do alone ADPIE formulate a plan of care
dependent: needs physician’s
order for the patient
interdependent: collaborate goal must be SMART
with healthcare team
Thank You