NURSING PROCESS

An overview
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Jane Fatima G.

OBJECTIVES FOR THE DAY

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Define nursing process

Expound on the history of Nursing
process
Identify the phases of nursing
process
Enumerate the steps/tasks to be
done in every phase of nursing
process
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DEFINITION
is the framework for providing
professional, quality nursing care
directs nursing activities for:
health promotion,
health protection, and
Disease prevention
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used by nurses in every practice

setting and specialty
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HISTORY

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1955 - Lydia Hall first referred to

nursing as a process in a journal
article
Referring to the nursing process
as a series of steps, Johnson
(1959), Orlando (1961), and
Wiedenbach (1963) further
developed this description of
nursing
nursing process involved only three4

 1967 - book The Nursing Process,

Yura and Walsh identified four
steps in the nursing process:
Assessing
Planning
Implementing
Evaluating
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 1973 - The Standards of Practice,

American Nurses Association
(ANA), included eight standards.
standards identified each of the
steps, including nursing diagnosis,
that are now included in the nursing
process.
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 Fry (1953) first used the term

nursing diagnosis
1974 - after the first meeting of
the group now called the North
American Nursing Diagnosis
Association (NANDA) - Gebbie and
Lavin added nursing diagnosis
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as a separate and distinct step in the

nursing process.
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 Following publication of the ANA

standards,

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nurse practice acts of many states

were revised to include the steps of
the nursing process specifically.
ANA made revisions to the standards
in 1991 to include outcome
identification as a specific part of the
planning phase.
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 Currently, the steps in the nursing

process are:

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Assessment
Diagnosis
Outcome identification and
planning
Implementation
Evaluation
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 process - is a series of steps or

acts that lead to accomplishment
of some goal or purpose.
The purpose of the nursing
process is to provide care for
clients that is individualized,
holistic, effective, and efficient.
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 The steps of the nursing process

build upon each other, but they
are not linear.
There is overlap of each step with
the previous and subsequent steps

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CHARACTERISTICS
THE NURSING PROCESS IS:
dynamic and requires creativity for
its application
designed to be used with clients
throughout the life span and in any
setting in which a nurse provides
care for clients
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ASSESSMENT
the first step in the nursing process
includes collection, verification,
organization, interpretation, and
documentation of data.
The completeness and correctness of
the information obtained during
assessment are directly related to
the accuracy of thesteps that follow
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STEPS:

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Collecting data from a variety

of sources
Validating the data
Organizing data
Categorizing or identifying
patterns in the data
Making initial inferences or
impressions
Recording or reporting data

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NURSING DIAGNOSIS

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involves further analysis

(breaking the whole down into
parts that can be examined) and
synthesis (putting data together
in a new way) of the data that
have been collected.
Formulation of the list of nursing
diagnoses is the outcome of this
process.
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North
American Nursing Diagnosis Association
(NANDA)

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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.
(Carroll-Johnson, 1990, p. 50)
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Jane
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nursing diagnoses developed during

this phase of the nursing process
provide the basis for client care
delivered through the remaining
steps.
Client problems are labelled by both
medical and nursing diagnoses.
Clients receive both medical and
nursing diagnoses.
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QUESTIONS TO BE ANSWERED
IN THIS STEP:

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Are there problems here?

If so, what are the specific problems?
What are some possible causes for the
problems?
Is there a situation involving risk factors?
What are the risk factors?
Is there a situation in which a problem
can develop if preventive measures are
not taken?
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QUESTIONS TO BE ANSWERED
IN THIS STEP:

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Has the client indicated a desire for a

higher level of wellness in a particular
area of function?
What are the clients strengths?
What data are available to answer these
questions?
Are more data needed to answer the
question?
If so, what are some possible sources of
the data that are needed?
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OUTCOME IDENTIFICATION &

PLANNING

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includes the formulation of guidelines

that establish the proposed course of
nursing action in the resolution of
nursing diagnoses and the
development of the clients plan of
care.
Once the nursing diagnoses have been
developed and client strengths have
been identified, planning can begin.
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TASKS:

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The list of nursing diagnoses is

prioritized.
Client-centered long- and shortterm goals and outcomes are
identified and written.
Specific interventions are
developed
The entire plan of care is recorded
in the clients record.
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IMPLEMENTATION

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involves the execution of the nursing

plan of care derived during the
planning phase.
consists of performing nursing
activities that have been planned to
meet the goals set with the client.
Nurses may delegate some of the
nursing interventions to other persons
assigned to care for the client
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 involves many skills.

The nurse must continue to assess the clients
condition before, during, and after the nursing
intervention.

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Assessment prior to the intervention provides the nurse

with baseline data.
Assessment during and after the intervention allows the
nurse to detect positive or negative responses the client
may have to the intervention.
If negative responses occur during the procedure, the
nurse must take appropriate action.
If positive responses occur, the nurse adds this
information to the database for use in evaluating the
efficacy of the intervention.

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 nurse must also possess psychomotor

skills, interpersonal skills, and critical
thinking skills to perform the nursing
interventions that have been planned.
The nurse uses psychomotor skills
when performing procedures such as:

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giving injections,
changing dressings, and
helping the client perform range-of-motion
(ROM) exercises.
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 Interpersonal skills are necessary as:

the nurse interacts with the client and the
family to collect data,
provide information in teaching sessions, and
offer support in times of anxiety.

Critical thinking skills enable the nurse to:

think through the situation,
ask the appropriate questions, and
make decisions about what needs to be done.
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 involves reporting and

documentation.
Data to be recorded include:

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the clients condition prior to the

intervention,
the specific intervention performed,
the client response to the
intervention,
and client outcomes.
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EVALUATION

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Involves determining whether the

client goals have been met,
partially met, or not met.
If the goal has been met the
nurse must then decide whether
nursing activities will cease or
continue in order for status to be
maintained.
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 If the goal has been partially met

or not been met, the nurse must
reassess the situation.
Data are collected to determine
why the goal has not been
achieved and what modifications
to the plan of care are necessary.
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possible reasons that goals are

not met or are only partially met:

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The initial assessment data were

incomplete.
The goals and expected outcomes
were not realistic.
The time frame was too optimistic.
The goals and/or the nursing
interventions planned were not
appropriate for the client
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 an ongoing process.
Nurses continually evaluate data
in order to make informed
decisions during other phases of
the nursing process

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ASSESSMENT
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ELEMENTS OF ASSESSMENT

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Data
Data
Data
Data
Data

collection
verification
organization
interpretation
documentation

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Jane
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Effective planning of client care

depends on a complete database
and accurate interpretation of
information.
Incomplete or inadequate
assessment may result in
inaccurate conclusions and
incorrect nursing interventions.
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 Proper collection of assessment

data directs decision-making
activities of professional nurses

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GOAL:
the collection and analysis of data
that are used in formulating
nursing diagnoses, identifying
outcomes and planning care, and
developing nursing interventions.

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PURPOSE:
to establish a database concerning
a clients:
physical,
psychosocial, and
emotional health

in order to identify:
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health promoting behaviors as well

as
actual and/or potential health
problems.

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 determines the clients functional abilities

and the absence or presence of
dysfunction.
the clients normal routine for activities of
daily living and lifestyle patterns
Identification of the clients strengths

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provides the nurse and other members of the

treatment team information about the skills,
abilities, and behaviors the client has
available to promote the treatment and
recovery process
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 offers an opportunity for the nurse

to form a therapeutic
interpersonal relationship with the
client.
the client is provided an
opportunity to discuss health care
concerns and goals with the nurse
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TYPES OF ASSESSMENT
type and scope of information
needed for assessment are usually
determined by the health care
setting and needs of the client
comprehensive,
focused, and
ongoing
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COMPREHENSIVE
ASSESSMENT
usually completed upon admission
to a health care agency
includes a complete health history
to determine current needs of the
client.

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 This database provides a baseline

against which changes in the clients
health status can be measured
should include assessment of:

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physical and psychosocial aspects of

the clients health,
the clients perception of health,
the presence of health risk factors, and
the clients coping patterns
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FOCUSED ASSESSMENT
is limited in scope in order to focus on a
particular need or health care problem or
potential health care risks.
not as detailed as comprehensive
assessments
often used in health care agencies:

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in which short stays are anticipated

in specialty areas
in mental health settings
or for purposes of screening for specific
problems or risk factors
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ONGOING ASSESSMENT

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Systematic follow-up is required

when problems are identified
during a comprehensive or focused
assessment.
An ongoing assessment is an
assessment that includes
systematic monitoring and
observation related to specific
problems.
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ONGOING ASSESSMENT

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allows the nurse to broaden the

database or to confirm the validity of
the data obtained during the initial
assessment.
particularly important when problems
have been identified and a plan of care
has been implemented to address these
problems.
Systematic monitoring and observations
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DATA COLLECTION

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nurse must possess strong cognitive,

interpersonal, and technical skills in
order to elicit appropriate information
and make relevant observations
during the data collection process.
Often begins prior to initial contact
between the nurse and the client,
primarily through the nurses review of
biographical data and medical records
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TYPES OF DATA
Subjective data

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are data from the clients point of view

and include feelings, perceptions, and
concerns.
also referred to as symptoms
obtained through interviews with the
client.
rely on the feelings or opinions of the
person experiencing them and cannot
be readily observed by another.
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 Objective data
are observable and measurable (quantitative)
obtained through observation, standard assessment
techniques performed during the physical
examination, and laboratory and diagnostic testing.
also called signs
can be seen, heard, or felt by someone other than
the person experiencing them.

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Assessments that are comprehensive and

accurate include both subjective and objective
data.

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SOURCES
A comprehensive database should
include data from every possible
source
primary source of data - client (the
major provider of information about
self)

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As much information as possible should

be gathered from the client, using both
interview techniques and physical exam
examination skills
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 secondary sources - Sources of

data other than the client,
includes family members, other
health care providers, and medical
records

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METHODS OF DATA
COLLECTION

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observation,
interview,
health history,
Symptom analysis,
physical examination, and
laboratory and diagnostic data

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OBSERVATION
nurse uses the skill of observation to
carefully and attentively note the general
appearance and behavior of the client.
occur whenever there is contact with the
client
include factors such as:

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client mood,
interactions with others,
physical and emotional
responses, and
any safety considerations.
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helps the nurse determine the

clients status, both physical and
mental
nurse can detect nonverbal cues
that indicate a variety of feelings,
including presence of pain,
anxiety, and anger
essential in detecting the early
warning signs of physical changes
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INTERVIEW

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a therapeutic interaction that has

a specific purpose
purpose of the assessment
interview - to collect information
about the clients health history
and current status in order to
make determinations about the
clients health needs
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INTERVIEW

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Effective interviewing depends on

the nurses knowledge and ability
to skillfully elicit information from
the client using appropriate
techniques of communication.
Observation of nonverbal behavior
during the interview is also
essential to effective data
collection.
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Interview Preparation

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includes review of the clients

medical records, conversations
with other health care team
members and research of the
presenting medical diagnosis.
can be useful in obtaining the
clients relevant history and
formulating a current needs
assessment
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Jane
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assessment interview often occurs

at the beginning of a nurse-client
relationship, it is helpful to begin
the process with an orientation
phase.
During this period introductions
are made, rapport is established,
and roles are defined
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Interview Stages
1. Introduction
2. Working
3. Closure

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Introduction
Interview establishes the goals for
the interaction.
Primary goal of the assessment
interview - the collection of data
about the client.
The purpose and use of the data
collection should be discussed.
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Jane
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Adequate time and privacy should

be allowed for the interview so
that the client feels free to share
any information that may be
relevant.
inform the client about the
approximate duration of the
interview.
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 client is more likely to respond

freely if:
the interview environment provides
comfort and privacy and
if rapport exists between the client
and the nurse

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 nurse should sit (if possible), establish

eye contact with the client
listen attentively.
nurses responsibility to note nonverbal
messages that can indicate that the
client is uncomfortable, tired, or
preoccupied with other matters.
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If this situation occurs, it might be

necessary to complete the interview at a
later time
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Working

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Focuses on the details of data collection.

The scope of the assessment interview
depends on the type of assessment to be
conducted
may be structured and formal (used in
situations when a large amount of
information needs to be obtained)
or unstructured and informal (used in
interactions that focus on a specific area
of concern to the client).
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 The nurse should be familiar with

the specific assessment format
used by the health care agency so
that attention can be focused
toward the client rather than the
form itself.
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 generally begins with questions

about biographical and other
nonthreatening information
The clients reason for seeking
health care is also addressed early
in the working phase
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 Information is usually gathered

from the general to the specific,
with details about intimate or
potentially embarrassing topics
reserved until later

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Types of questions

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A comprehensive interview that

seeks to identify problems and
concerns is facilitated by openended questions,
while an interview that focuses on
specific details about a presenting
problem will be facilitated by
direct, closed questions.
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 Open-ended questions are

questions that encourage the
client to elaborate about a
particular concern or problem.
Closed questions are questions
that can be answered briefly or
with one-word responses.
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Closure
is established in the introduction phase
when approximate time parameters are set.
As the interview session is concluding, the
nurse should indicate this fact by stating
that almost all the information needed has
been obtained or that the time for the
interview is almost over.

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This action allows the client an opportunity to

present any other relevant information and it
avoids surprises when the interview terminates.

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Jane
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the nurse summarizes what was

covered or accomplished during the
interview
requests validation of perceptions with
the client.
If the nurse or the client feels that
additional time is needed for further
exploration of specific points discussed
during this session, plans can be made
for future interviews.
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HEALTH HISTORY

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primary focus of the data

collection interview
health history is a review of the
clients functional health patterns
prior to the current contact with a
health care agency
medical history concentrates on
symptoms and the progression of
disease
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 focuses on the clients functional

health patterns, responses to
changes in health status, and
alterations in lifestyle.
also used in developing the plan of
care and formulating nursing
interventions.
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PHYSICAL
EXAMINATION
purpose of the physical examination
is to:
make direct observations of any
deviations from normal and
To validate subjective data gathered
through the interview

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Baseline measurements are obtained,

and physical examination techniques
are used to gather objective data
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LABORATORY AND
DIAGNOSTIC DATA
Results can be useful objective
data
these values often serve as
defining characteristics for various
altered health states
these can also be helpful in ruling
out certain suspected problems.
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LABORATORY AND
DIAGNOSTIC DATA

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Results can be useful objective data

The pattern of these types of
variations is useful in determining a
plan of care.
In addition, the effectiveness of
nursing and medical interventions and
progress toward health restoration are
often monitored through laboratory
and diagnostic test data.
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DATA VERIFICATION

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the process through which data are

validated as being complete and
accurate.
Once the nurse completes the
initial data collection, the data are
reviewed for inconsistencies or
omissions.
particularly important if data
sources are considered unreliable.
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done by examining the congruence

between subjective and objective
data.
The nurse would need to consider
possible reasons for this
discrepancy in findings and collect
more information before
formulating conclusions or
planning care.
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 Findings should also be compared

with norms.
Any grossly abnormal findings
should be rechecked and
confirmed

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DATA ORGANIZATION
DATA CLUSTERING - the nurse
organizes, or clusters, the
information together in order to
identify areas of strengths and
weaknesses
How data are organized depends
on the assessment model used
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NURSING MODELS

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Functional Health Patterns

(Marjory Gordon) 11
Functional Health Patterns
Human Response Pattern (NANDA)
9 human response pattern
Theory of Self-Care (Orem) Roy Adaptation Model
adaptive behaviors
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NONNURSING MODELS
Body systems models organ and
tissue function
Hierarchy of needs 5 basic needs

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DATA INTERPRETATION
Data clustering facilitates
recognition of patterns, and
determination of further data that
are needed.
Data interpretation is necessary
for identification of nursing
diagnoses
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DATA DOCUMENTATION

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Accurate and complete recording

of assessment data are essential
for communicating information to
other health care team members.
documentation is the basis for
determining quality of care and
should include appropriate data to
support identified problems.
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