The Nursing Process

Bryan M. Espiritu MAN, RN

Nursing Process
• The nursing process is a modified form of scientific method
used in nursing profession to assess client needs and create a
course of action to address and solve patient problems.
• Nursing process is a rational problem solving framework on
which professional nursing practice is based. It provides an
organized, systematic approach to nursing care thereby
improving the probability of positive outcomes for individuals
and groups.
Nursing Process=Scientific Method
• ASSESSMENT • Ask Question

• DIAGNOSIS • Identify the problem

• PLANNING • Hypothesis

• IMPLEMENTATION • Experiment

• EVALUATION • Analyze/Conclusion
Benefits of Nursing Process
• 1. Provides an orderly & systematic method for planning &
providing care
• 2. Enhances nursing efficiency by standardizing nursing practice
• 3. Facilitates documentation of care
• 4. Provides a unity of language for the nursing profession
• 5. Nursing Process is economical
• 6. Stresses the independent function of nurses
• 7. Increases care quality through the use of deliberate actions
• 8. Provide continuity of care and prevent duplication
Characteristics Of Nursing Process
• 1. Interactive, Purposeful and Systematic (organized)
• 2. Client-centered
• 3. Goal-directed, outcome focused
• 4. Within the legal scope of nursing
• 5. Prioritizing the needs
• 6. The steps are interrelated and dependent on the accuracy of
each of the preceding steps
• 7. It is used to identify, diagnose, and treat human responses to
health and illness
Assessment
• Assessment is the first step of nursing process and may be
defined as collecting, organizing, validating and documenting
client data
• During this phase, the nurse gathers information about a
patient's psychological, physiological, sociological, and
spiritual status through observation, interviewing, physical
examination, health records and family members.
• Nursing assessments do not duplicate medical assessments
(which target to pathologic conditions) but focus on the
patient’s responses to health problems or potential health
problems
Types of Assessment
• 1. Initial assessment: Also known as triage, is performed
within a specified time after admission to establish a complete
database for problem identification, reference, and future
comparison.
• 2. Problem-focused assessment: is an on-going process
integrated with nursing care to determine the status of a
specific problem identified in an earlier assessment.
• 3. Emergency assessment: occurs during any physiologic or
psychological crisis of the client to identify the life-threatening
problems and to identify new or overlooked problems.
• 4. Time-lapsed assessment: occurs several months after the
initial assessment to compare the client’s current status to
baseline data previously obtained.
Purpose Of Assessment
• 1. To establish baseline information on the client
• 2. To determine the client’s normal function
• 3. To determine the client’s risk for dysfunction
• 4. To determine the client’s strengths
• 5. To provide data for the diagnosis phase
Assessment Skills
• 1. Observation
• 2. Interview: a conversation with purpose to get or give
information, to teach and provide support.
• 3. Physical Examination: a systematic data collection method
by inspection, palpation, percussion and auscultation.
• 4. Intuition (Insight): Use of insight, instinct, and clinical
experience to make clinical judgments about the client.
Assessment Activities
Activities or action performed during assessment are:
1. Collect Data
2. Validate Data: Double checking the data to confirm accuracy
3. Organize Data : Grouping the data using Head to Toe model,
Systemic Review etc.
4. Document Data: Documents subjective data in client own
words and objective using medical terms, key, abbreviations
etc.
Collect Data
The process of gathering information about the client that begin with
the first client contact, using method/skills of assessment
(Observation, PE, Interview etc). Two type of data to be collected:
- Subjective Data: including symptoms, client's feeling and statement
about his/her health problems which should be recorded as direct
quotations from the client, such as '' Every time I move, I feel pain.'‘
- Objective data: including signs or observable and measurable data
that are obtained through observation, physical examination, and
laboratory testing.
Subjective Samples
• “I feel weak all over when I exert myself.”
• Client states he has a cramping pain in his abdomen. States,
“I feel sick to my stomach.”
• “I’m short of breath.”
• Wife states: “He doesn’t seem so sad today.” (This is
subjective and secondary source data.)
• “I would like to see the chaplain before surgery.”
Objective Samples
• Blood pressure 90/50 mmHg
• Apical pulse 104 beats/min
• Skin pale and diaphoretic
• Vomited 100 mL green-tinged fluid
• Abdomen firm and slightly distended
• Active bowel sounds during auscultation
• Client cried during interview
Sources of data
A. Primary
• The client is the primary source of data. Secondary
B. Secondary
• Family members or other supporting persons,
• Health professionals
• Health records and reports
• Laboratory and diagnostic analyses
Nursing Diagnosis
• Nursing Diagnosis is a clinical judgment about individual,
family, or community responses to actual or potential health
problems/life processes.
• Nursing diagnoses provide the basis for selection of nursing
interventions to achieve outcomes for which the nurse is
accountable.
Benefits Of Nursing Diagnosis
• Gives Nurses a Common Language.
• Promotes identification of appropriate goals or correct choice.
• Can create a standard for nursing practice.
• Provides a quality improvement base.
Components of Nursing Diagnosis
A typical nursing diagnosis statement has two or three
parts/statements.
• in two parts nursing diagnosis, the first component is a
problem statement or diagnostic label (as listed in NANDA),
while second component is the etiology. Both of these parts
are linked by the term related to (RT). E.g. Disturbed Body
Image RT loss of left lower extremity
• The three part nursing diagnosis statement consists Problem,
Etiology and Sign, Symptoms (defining characteristics) joined
to the first two component by connecting phrase “as evidence
by” (AEB). E.g. “ineffective Airway clearance RT fatigue AEB
dyspnea at rest”
Descriptive Words
• To clarify nursing diagnosis, descriptive words or terms may be
added before or after the problem statement. These words
include: Acute, Chronic, Decreased, Deficient, Depleted,
Disturbed, Dysfunctional, Enhanced, Excessive, Impaired,
Increased, Ineffective, Intermittent, Potential, and Risk for.
Types Of Nursing Diagnosis
• Actual nursing diagnosis
• Risk nursing diagnosis
• Wellness nursing diagnosis
Actual Diagnosis
• An actual nursing diagnosis is the diagnosis about current
problem that is present at the time of the nursing assessment,
based on the presence of signs and symptoms.
Examples of an actual nursing diagnosis are: anxiety
characterized by fear, panic, apprehension and sleep
disturbances, or an ineffective airway clearance characterized by
an ineffective cough, abnormal breathing or a fever.
Risk Nursing Diagnosis
• Risk nursing diagnosis describes human responses to health
conditions that may develop in a vulnerable individual, family,
or community.
• Risk nursing diagnoses are two – part statements, do not
include defining characteristics.
• Examples – Risk for infection related to surgery or
immunosuppression.
Risk for aspiration related to reduced level of
consciousness
Wellness nursing diagnosis
• A clinical judgment about a person’s, family’s or community’s
motivation and desire to increase wellbeing as expressed in
the readiness to enhance specific health behaviors, and can be
used in any health state.
• Wellness nursing diagnosis are one part statement includes
diagnostic label.
• Example -Readiness for enhanced spiritual well being
Readiness for Enhanced Self-Esteem.
Difference b/w Medical & Nursing Diagnosis
Nursing Diagnosis Medical Diagnosis
• Clinical judgment • Identification of a
about individual, disease condition
family, or community based on a specific
responses to actual evaluation of physical
and potential health signs, symptoms,
problems or life history, diagnostic
processes tests, and procedures
• The goal of a nursing • The goals of a medical
diagnosis is to identify diagnosis is to identify
actual and potential the cause of a illness or
responses injury and design a
treatment plan
• Nurse treats • Physician directs
problem within treatment for
scope of medical diagnosis
independent nursing
practice • Remains the same as
• May change from day long as the disease is
to day as the present
patient’s responses
change
Nursing diagnosis for Medical
diagnosis
Planning
Planning
• Planning is to formulate the way to manage the problem.
• The third step of the nursing process includes the formulation
of guidelines that establish the proposed course of nursing
action in the resolution of nursing diagnoses and the
development of the client’s plan of care.
Planning consists three stage:
1. Initial Planning
2. On-going planning
3. Discharge planning
Steps Of Planning
1. Initial Planning
Done by the nurse who perform admission assessment in
order to prioritize problems, identify goals and correlate nursing
care to resolve the problems.
2. On-going planning
Involves continuous updating of the client’s plan of care.
Every nurse who cares for the client is involved in on-going
planning.
3. Discharge planning
involves anticipation and planning for the client’s needs
after discharge.
Elements Of Planning
1. Prioritizing the problems/nursing diagnosis
2. Formulate goals/desired outcomes
Short Term (to resolve in few hours or days)
Long Term (to resolve over weeks or months)
3. Select nursing interventions
4. Write nursing interventions
Implementation
• Implementing phase, provide the actual nursing activities and
client responses. Implementation consists of doing and
documenting the activities that are the specific nursing actions
needed to carry out the interventions or nursing orders.
Nursing Skills during
Implementation
To implement nursing care plan successfully , nurse need to have
following skills
1. Cognitive Skills= Including problem solving and decision
making
2. Interpersonal Skills = Include verbal and non-verbal
response, communication
3. Technical Skills= Includes hand on skills need to perform
procedures such as administrating injection, drugs, lifting,
moving
Evaluation
• The last phase of the nursing process which include the
judgment of the effectiveness of nursing care to meet client
goals based on the client’s behavioral responses.
• This step determine the success/effectiveness of the whole
nursing process and the decision either to continue, modify or
repeat the process is depend on evaluation.
While documenting evaluation phase, the nurse can draw one of
the three possible conclusions: 1. The goal was met= The client
response is the same as the desired outcomes.
2. The goal was partially met= Either a short term goal was
achieved but the long term was not, or the desired outcome was
only partially attained.
3. The goal was not met
Practice Problem
Ms. Maroo Puk is a 33-year-old nursing student. She is married
and has a 13-year-old daughter and 5-year-old son. She is
admitted to the hospital with an elevated temperature, a
productive cough, and rapid, labored respirations. While taking
a nursing history, Ms. Massmaru Pok, RN, finds that Ms. Maroo
Puk has had a “chest cold” for 2 weeks and has been
experiencing shortness of breath upon exertion. Yesterday she
developed an elevated temperature and began to experience
“pain” in her “lungs.”