Unit: 1 Nursing Process

By : Ibne Amin
Faculty Institute of Nursing Sciences,
Khyber Medical University , Peshawar
 Nursing Process
The nursing process is a dynamic & 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.
OR
An organized sequence of problem-solving steps used
to identify and to manage the health problems of
clients.
It is accepted for clinical practice established by the
American Nurses Association
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 Purpose Of Nursing Process
• To identify a client’s health status and actual or
potential health care problems or needs.
• To establish plans to meet the identified needs.
• To deliver specific nursing interventions to meet
those needs.
• Purpose is to provide client care that is :
Individualized
Holistic
Effective
Efficient

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 Components Of Nursing Process
The Nursing Process utilizes the following steps
1. Assessment (data collection),
2. Nursing diagnosis,
3. Planning,
4. Implementation
5. Evaluation.

– Steps remain the same

– Applications and result are different

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Components of Nursing Process

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 Characteristics of Nursing Process
• Cyclic
• Dynamic nature,
• Client centeredness
• Focus on problem solving and decision making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking and clinical reasoning

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 1. ASSESSMENT
It involves
• Collection of data
• Organizing the data
• Validating the data
• Documenting the data

Assessment is the systematic and continuous collection,

organization, validation, and documentation of data
(information).

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 1. ASSESSMENT
Types of assessment
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment

The ultimate Purpose of assessment is data collection

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 1. ASSESSMENT

1. Initial nursing assessment:

• Performed within specified time after admission.
• To establish a complete database for problem
identification.
• Eg: Nursing admission assessment

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 1. ASSESSMENT
2. Problem-focused assessment :
To determine the status of a specific problem identified
in an earlier assessment. Eg: hourly checking of vital
signs of fever patient

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 1. ASSESSMENT
3. Emergency assessment:
During emergency situation to identify any life
threatening situation. Eg: Rapid assessment of an
individual’s airway, breathing status, and circulation
during a cardiac arrest.

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 1. ASSESSMENT
4. Time-lapsed reassessment:
Several months after initial assessment. To compare the
client’s current health status with the data previously
obtained

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COMPONENTS OF ASSESSMENT

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 1. ASSESSMENT
Collection of data
Data collection is the process of gathering information
about a client’s health status. It includes the health
history, physical examination, results of laboratory
and diagnostic tests, and material contributed by
other health personnel.

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 1. ASSESSMENT
Types of Data:
1. Subjective data
2. Objective data.

1. Subjective data
Also referred to as symptoms or covert data, are clear
only to the person affected and can be described
only by that person. Itching, pain, and feelings of
worry are examples of subjective data.

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 1. ASSESSMENT
2. Objective data

Also referred to as signs or overt data, are detectable

by an observer or can be measured or tested against
an accepted standard. They can be seen, heard, felt,
or smelled, and they are obtained by observation or
physical examination. For example, a discoloration of
the skin or a blood pressure reading is objective data.

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 1. ASSESSMENT
Sources of Data
Sources of data are primary or secondary.
1. Primary : It is the direct source of information. The
client is the primary source of data.
2. Secondary: It is the indirect source of information.
All sources other than the client are considered
secondary sources. Family members, health
professionals, records and reports, laboratory and
diagnostic results are secondary sources.

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Methods Of Data Collection

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 1. ASSESSMENT
Organization of data
The nurse uses a format that organizes the assessment
data systematically. This is often referred to as
nursing health history or nursing assessment form

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 1. ASSESSMENT
Validation of data
The information gathered during the assessment is
“double-checked” or verified to confirm that it is
accurate and complete.

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 1. ASSESSMENT
Documentation of data
To complete the assessment phase, the nurse records
client data. Accurate documentation is essential and
should include all data collected about the client’s
health status.

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 2. DIAGNOSIS
Diagnosis is the second phase of the nursing process.
In this phase, nurses use critical thinking skills to
interpret assessment data to identify client problems.
(NANDA) define or refine nursing diagnosis.
The official NANDA definition of a nursing diagnosis is:
“a clinical judgment concerning a human response to
health conditions/life processes, or a vulnerability for
that response, by an individual, family, group, or
community.”

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 2. DIAGNOSIS
Diagnosing is to :
1.Analyza data
2. Identify health problems,risks and strengths
3. Formulate diagnostic statement

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 PLANNING
Planning is the third phase of the nursing process, in
which the nurse and client develop client goals/ desired
outcomes and nursing strategies to prevent, reduce or
alleviate the client’s health problems.

It is the process of formulating client goals and designing

the nursing interventions required to prevent, reduce,
or eliminate the client’s health problems.
Planning involves decision making and problem solving.

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 Types Of Planning
1. Initial Planning : Planning which is done after the initial
assessment. The nurse who performs the admission assessment
usually develops the initial comprehensive plan of care.
2. Ongoing Planning : It is a continuous planning. As nurses obtain
new information and evaluate the client’s responses to care,
they can individualize the initial care plan further. It occurs at
the beginning of a shift as the nurse plans the care to be given
that day
3. Discharge Planning :The process of anticipating and planning for
needs after discharge, is a crucial part of a comprehensive
health care and should be addressed in each client’s care plan.

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 Planning Process
It involves
• Prioritize problems/ diagnosis
• Formulate goals/desired outcomes
• Select Nursing intervension
• Write Nursing intervention

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 Planning Process
1. Setting priorities
• The nurse begin planning by deciding which nursing
diagnosis requires attention first, which second, and
so on.
• Nurses frequently use Maslow’s hierarchy of needs
when setting priorities.
• Example: In this physiologic needs such as air, food
and water are basic to life and receive higher priority
than the need for security or activity

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Maslow's Hierarchy of Needs

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 Planning Process
2. Establishing client goals/desired outcomes

After establishing priorities, the nurse set goals for each

nursing diagnosis. Goals may be short term or long
term
Client goals / desired outcomes: It is a specific and
measurable behavior or response that reflects a
clients highest possible level of wellness and
independence in function.

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 Types of Goals
Short Term Goals Long Term Goaals
• It is an objective that is • It is an objective that is
expected to achieved / with expected to believe over a
in a short time, usually less longer time frame, usually
than a week Example: over weeksormonths
Client will achieve comfort Example: Client will adhere
with in 24 hours post to post operative activity
operatively restrict
• Clientwill raise right arm to • Client will regain full use of
shoulder heightby Frida right arm in 6 weeks ions for
one month

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 Planning Process
3. Nursing interventions
A nursing intervention is any treatment, that a nurse
performs to improve patient’s health.
OR
These are the actions that nurses perform to achieve
the clients goals

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 Types Of Nursing Interventions
1. Independent interventions are those activities that
nurses are licensed to initiate on the basis of their
knowledge and skills.
2. Dependent interventions are activities carried out
under the orders or supervision of a licensed
physician.
3. Collaborative interventions are actions the nurse
carries out in collaboration with other health team
members

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 4. IMPLEMENTATION
• In the nursing process, implementing is the action
phase in which the nurse performs the nursing
interventions. Implementing consists of doing and
documenting the activities that are the specific
nursing actions needed to carry out the interventions.
• The nurse performs or delegates the nursing activities
for the interventions that were developed in the
planning step and then concludes the implementing
step by recording nursing activities and the resulting
client responses.

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 EVALUATION
Evaluation is a planned, ongoing, purposeful activity in
which the nurse determines
(a)the client’s progress toward achievement of
goals/outcomes and
(b)the effectiveness of the nursing care plan.

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