NURSING PROCESS AND ITS STEPS .pptx

NURSING PROCESS MS. POOJA SEN
NURSING LECTURER (MHN)

INTRODUCTION
• It is a systematic method of providing nursing care.
• It provide the framework for planning and
implementation of nursing care.
• This involves a problem-solving approach that enables
the nurse to identified pt. problems and potential risk
needs or problems and to plan ,deliver and evaluate
nursing care in an orderly scientific manner
MS. POOJA SEN

HISTORY
 The idea the nursing is a process rather than a set of separate
actions started to emerge in the united state in the 1950s.
 Lydia Hall first described or created the nursing process in
1955.
 It revised in 1958 Ida jean Orlando .
 In 1967 Yura & Walsh published the first comprehensive
book on nursing process.
 1973 ANA published standard of nursing practice (5steps)
 1974 NANDA ( NORTH AMERICAN NURSING DIGNOSIS
ASSOCIATION) added the nursing diagnosis in nursing
process.
MS. POOJA SEN

HISTORY
 Gebbie and Lavin (1974) made nursing diagnosis a separate
steps in the process. This leads to the development of 5 steps
in nursing process commonly used today, Assessment, Nursing
Diagnosis, Planning, Implementation and Evaluation.
 1980 the nursing process added in the curriculum in India.
 1991 published standard of clinical nursing practice.
 The six steps of nursing process – Assessment ,Diagnosis,
Goal, Intervention/Implementation, Rational, Evaluation .
 In 1996 JCAHO ( JOINT COMMISSION ON THE
ACCREDIATION OF HEALTH CARE ORGANIZATION )
mandatory each client nursing care based or identified
nursing diagnosis on client care need.
MS. POOJA SEN

DEFINITION
It is a systematic method or rational method
of planning and providing individualized
nursing care.
 Nursing process can be said to be systematic
& goal directed set of activities which are
interrelated & dynamic used by the nurse to
determine plan and implement
individualized nursing care.
MS. POOJA SEN

DEFINITION
According to American nurses' association (2010)-
Nursing process is a critical thinking process that
professional nurse use to apply the best available
evidence to caregiving & promoting human
function and response to health and illness.
According to NANDA (1990) – Nursing process is
a 5-part systematic decision-making method
focusing on identifying and treating response of
individual or groups to actual or potential
alterations in health. MS. POOJA SEN

OBJECTIVE
OBJECTIVES OF NURSING PROCESS: The steps of the nursing
process are not separated items, but rather are parts of whole used to ;
- Identify needs of the patient.
- To establish priorities of care.
- To maximize strengths.
- To resolve actual & or potential patient problem.
- To apply health promotion to possible for each patient.
MS. POOJA SEN

CHARACTERISTICS
 The nursing process is a cyclical and ongoing process
that can end at any stage if the problem is solved.
 The nursing process exists for every problem that the
individual/family/community has. The nursing
process not only focuses on ways to improve physical
needs, but also on social and emotional needs as well.
 Systematic Process
 Cyclic and dynamic
MS. POOJA SEN

CHARACTERISTICS
 Cyclic and dynamic
 Goal directed and client centered
 Interpersonal and collaborative
 Universally applicable
 Outcome Oriented
 Use of critical thinking
MS. POOJA SEN

PURPOSES
• To identify a client 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.
MS. POOJA SEN

COMPONENTS
MS. POOJA SEN

MS. POOJA SEN

INTRODUCTION
Assessment involves data collection and analysis of data. It begin with
the nurses' first encounter with the patients . Assessment is the first
steps of the nursing process.
The immediate purpose of assessment is to collect information about
the patients' needs or problems, construct a database and identify
problems or nursing care needs of the patients.
The entire care is based on the data you collected during this phase
and make every effort to ensure that your information is correct.
MS. POOJA SEN

DEFINITION
Assessment is the systematic and continuous collection and
analysis of information about a client.
Assessment is a continuous & systematic collection, analysis ,
validation and communication of patient data or information.
Nursing assessment is the gathering of information about a
patients physiological, psychological, sociological & spiritual
status by licensed registered nurse. MS. POOJA SEN

DEFINITION
Assessment is the systematic and continuous collection,
organization, validation and documentation of data.
Assessing is the systematic and continuous collection,
organization, validation and documentation of data.
MS. POOJA SEN

PURPOSES
 To collect the baseline data about patients.
Assess need of nursing care.
 Monitor the effectiveness of provided nursing care.
 Determine the patients normal & abnormal functions.
 To enhance the investigations.
MS. POOJA SEN

PURPOSES
 Identify the strength & weakness of the patients.
 Identify the need of health teaching.
 It is route of whole nursing.
 To build up the rapport with the patients & his family.
 Pinpoint of actual problems of patient.
 Identify the actual health problems.
MS. POOJA SEN

TYPES
1. INITIAL ASSESSMENT
2. PROBLEM FOCUSED
ASSESSMENT
3. EMERGENCY
ASSESSMENT
4.TIME LAPSED
ASSESSMENT
TYPES OF
ASSESSMENT
MS. POOJA SEN

TYPES
 Initial Assessment –It is performed with
in specified time after admission to
health care agency.
Purpose - This assessment is to collect a
complete data base for problem
identification, reference and future
comparison.
Example – identification data collection
during admission. MS. POOJA SEN

TYPES
Problem Focused Assessment – Ongoing
process integrated with nursing care to
determine specific problem identified new or
overlooked problems.
Purpose - To determine the status of a specific
problem identified in an earlier assessment
and to identified new or overlooked problems.
Example – Hourly checking of vital signs of
fever patients.
Hourly assessment of client fluid intake and
output chart.
MS. POOJA SEN

TYPES
Emergency Assessment – Done during
psychiatric or physiological crisis of the
client to identify life threatening problems.
Purpose - To identify the life-threatening
problems.
Example – Rapid assessment of person’s
airway breathing status and circulation during
a cardiac arrest.
Assessment of suicidal tendencies or
potential for violence.
MS. POOJA SEN

TYPES
Time Lapsed Assessment – Done
several month after initial assessment
to compare the client status to
baseline data previously obtained.
Purpose - to compare the client
status to baseline data previously
obtained.
Example –Reassessment of a client
functional health pattern in a home
care. MS. POOJA SEN

METHODS OF ASSESSMENT
The primary methods used to assess clients' care.
1.
• OBSERVATION
2.
• INTERVIEW
3.
• EXAMINATION
MS. POOJA SEN

1. OBSERVATION – Observation is a
conscious deliberate skill that is
developed only through and with
an organized approach .
It is not just seeing the client act of
noticing client uses such as
looking ,watching ,examine, scanning
uses different senses vision, smell,
hearing, touch.
Example – Client data observed
through 4 senses that is through
vision, smell, hearing and touch.
MS. POOJA SEN

2. INTERVIEW – An interview is a planned communication
or a conversation with a purpose.
Example – Nursing History Collection
There are 2 Approach for interview ………………
Interview
Approach
Direct
Indirect
MS. POOJA SEN

3. EXAMINATION – The physical examinations a systematic
data collection method that uses observational skill to
detect health problems.
Example –Physical Assessment
ASSESSMENT
SEQUENCING
1. Head to Toe Examination
2. Body System Assessment
MS. POOJA SEN

ASSESSMENT SEQUENCING
1. Head to Toe Examination
General – Vital sign/Wight/ Nutritional Status
Mobility & Self Care – Posture/Gait/ ADL
LOC/Orientation/Mood/Memory/Sensory
Function/Vision Test/Examine Ear/Cranial Nerves
Head, Face & Neck /Chest/ Abdomen/Bowel
Elimination/Urinary
Elimination/Skin/Hair/Nails/Genitalia/Extremities
MS. POOJA SEN

ASSESSMENT SEQUENCING
2. Body System Assessment
1. Cardiovascular Assessment
2. Neurological Assessment
3. Musculoskeletal Assessment
4. Respiratory Assessment
5. Integumentary Assessment
6. Genitourinary Assessment
MS. POOJA SEN

ASSESSMENT TECHNIQUES
1. INSPECTION
2. PALPATION
3. PERCUSSION
4. AUSCULTATION
MS. POOJA SEN

1. INSPECTION – Close &
careful visualization of the
person as a whole and each
body system, inspected
color, shape ,symmetry ,
movement.
2. PERCUSSION– It is the
technique in which one
or both hands are used
to strike the body surface
to produce a sound
called percussion.
3. AUSCULTATION–
Listening the sound
produced by the
body.
MS. POOJA SEN

4. PALPITATIONS – It involves use of hands to
touch body parts for data collection. Nurses use
fingertips & palms to determine the size, shape.
TYPES –
1. Light Palpitation – about depressed 1 – 2
cm.
2. Deep Palpitation – Skin is depressed about 4
– 5 cm.
3. Bimanual Palpitation – it involves using
both hands to trap a structure between
them.
MS. POOJA SEN

TYPES OF DATA
Described by the
person who affected
it also called as a
symptoms or covert
data.
Ex. Itching, pain
Anxiety
Referred as signs
or overt data.
dectable by an
observer it can be
measured or
tested.
Ex. Discoloration
of skin, Blood
pressure ,
temperature
Subjective
Data
Objective
Data
MS. POOJA SEN

SOURCES OF DATA
1. Primary Source (Direct sources) – The primary source of
data is the patient the patient is considered to be the most
accurate reporter.
When the patient is unable to supply information because of
detoriation of mental status, age or seriousness, illness.
Secondary are used.
MS. POOJA SEN

SOURCES OF DATA
2. Secondary Source (Indirect sources) – It include family
members, significant others, medical records, diagnostic
procedures. Other health team professional are also helpful
secondary source(physician other nurses).
MS. POOJA SEN

SOURCES OF DATA
3. Medical Records – Medical History,
O T Notes, Progress Notes.
4. Records of Therapies done by health
professional – Social worker, dietician,
physical therapist .
5. Laboratory Worker - Blood test
Urine test
etc.
MS. POOJA SEN

The nurses use a written or computerized format that
organized the assessment data systematically , the format
may be modified according to the client physical status.
ORGANIZATION OF DATA
MS. POOJA SEN

Accurate documentation is essential and should include all
data collected about the client and health status, data are
recorded in a factual manner and not interpret by the
nurses.
DOCUMENTATING OF DATA
MS. POOJA SEN

The information gather during the assessment phase
must be complete factual and accurate because the
nursing diagnosis and interventions are based on
information.
Validation is the act of double checking or verification data
to confirm that it is accurate or factual.
VALIDATING OF DATA
MS. POOJA SEN

Diagnosis is the 2nd
phase of the nursing
process in this phase nurses use critical thinking
skills to interpret assessment data to identify
clients' problems.
Nursing diagnosis are developed based on data
obtained during the nursing assessment.
A nursing diagnosis increases patients' safety
and means more effective care MS. POOJA SEN
NURSING DIAGNOSIS

In 2002 NANDA change its name
to NANDA INTERNATIONAL
(NANDA – I) in 2018 NANDA – I
has approved 244 diagnosis for
clinical uses.
MS. POOJA SEN
1. MEDICAL
DIGNOSIS
Etiology
Focused
2. NURSING
DIAGNOSIS
Care Focused

PURPOSES
ꙮ It states clear & concise health problems.
ꙮ It derived from existing evidence about the client.
ꙮ It is potentially amenable to nursing therapy.
ꙮ It is the basis for planning & carrying out nursing care.
ꙮ Provides acuity information.
ꙮ Can create a standard for nursing process.
ꙮ Facilitates, communication and documentation. MS. POOJA SEN

DEFINITIONS
1. According to Nanda, 2009 - Nursing diagnosis as a
clinical judgment about individual or community response
to actual or potential health problems/life reprocess.
2. According to Gordon(1976)- Nursing diagnosis as an
actual or potential health problems which nurses by virtue
of their education and experiences are capable and licensed
to treat.

DEFINITIONS
3. Nursing diagnosis is a
statement of the high
risk or an actual
problems in the client
health status the nurse is
licensed competent to
treat.

TYPES OF NURSING
DIAGNOSIS
1. Actual Nursing Diagnosis
2. Risk Nursing Diagnosis
MS. POOJA SEN
3. Health Promotion Nursing
Diagnosis
4. Possible Nursing Diagnosis
5. Syndrome Diagnosis

Actual nursing diagnosis is a client problem that is
present at the time of nursing assessment, confirm
diagnosis supported by nurses' findings, It is based on
the presence of associated symptoms.
Example –
• Ineffective airway clearance related to bacterial infection.
• Anxiety is related to change in heath status & situational crisis.
1. Actual Nursing Diagnosis
MS. POOJA SEN

It is a clinical judgment that a problem does not exist but
the presence of risk factors indicates that a problem is
likely to develop unless nurse's interventions.
Example –
• Risk for infection related to compromised immune system.
• Risk for aspiration is related to decreased gag reflexes.
• Risk for injury related to altered mobility.
2. Risk Nursing Diagnosis
MS. POOJA SEN

It is a clinical judgment about a person family or
community motivation & desire to increase well being,
actualize human health potential as expressed, in the
readiness to enhance specific health behavior & can be
used in any health states.
Example –
• Readiness for enhance self esteem.
• Readiness for enhanced family coping.
• Readiness for enhanced spiritual well being.
3. Health Promotion Nursing Diagnosis
MS. POOJA SEN

• A possible nursing diagnosis is one which evidence
about a health problem is incomplete or unclear.
• A possible diagnosis require more data either to
support or to refuse it.
• Tentative or additional data needed to confirm or rule
out problems.
Example –
• Potential risk for constipation as result of enforced bed rest.
• Potential risk of pressure sore development fro
4. Possible Nursing Diagnosis
MS. POOJA SEN

• A clinical judgement describing a specific cluster of
nursing diagnosis that occur together and are best
addressed together & through similar intervention.
Example – Trauma syndrome related to anxiety about potential
health problems
• Impaired physical mobility
• Impaired gas exchange
• Risk for infection
• Risk for injury
5. A Syndrome Diagnosis
MS. POOJA SEN

WRITING DIAGNOSTIC STATEMENT
ONE PART
TWO PART
THREE PART
MS. POOJA SEN

Nursing diagnosis are usually written as one part
statement because related factors are always the same.
1. ONE PART FORMAT
MS. POOJA SEN
Example – Readiness for enhance breast feeding.
Readiness for enhance coping.

Risk for possible nursing diagnosis have 2-part statement
the first part is diagnostic label, and the 2nd
is validation for
risk nursing diagnosis.
Problem …………related to…………. Etiology
2. TWO PART FORMAT
MS. POOJA SEN
Example – Risk for infection related to impaired skin integrity.
Ineffective sleep pattern related to chronic pain.
Risk for falls related to medication side effects.

Three part nursing diagnosis statement is also called as PES
format which include
Problem ….related to…..Etiology…...As evidence by…… sign &
symptoms
3. THREE PART FORMAT
Example –
• Constipation related to decreased mobility & inadequate fiber
intake as evidenced by infrequent bowel.
• Risk for infection related to surgical incision as evidenced by
elevated white blood cell.
• Altered nutrition related to nausea & vomiting as evidenced by
weight loss.
MS. POOJA SEN

COMPONENT OF NURSING DIAGNOSIS
 LABLE – Provide name for the diagnosis.
 QUALIFIERS – Qualifiers are some words that have been
added to some NANDA label to given additional meaning to
diagnosis.
Deficit, Impaired, Altered, Decreased, Ineffective , Disturbed
 DEFINITION – Definition describe the characteristics of the
human response based on data collection.
Poor circulation, Poor sleep pattern MS. POOJA SEN

COMPONENT OF NURSING DIAGNOSIS
 CHRACTERSTICS – Sign and symptoms.
 RISK FACTORS – Environmental factor physiological,
psychological genetic or chemical elements.
 RELATED FACTOR – Factors that may precede contribute to
or to be associated with the human response
Fluid volume deficit related to vometing
MS. POOJA SEN

PLANNING &
INTERVENTION
Planning is based on assessment findings and diagnostic
statement predetermined plan nursing interventions.
It is defined as predetermined a course of action in order to
arrive at a desired result.
MS. POOJA SEN

PLANNING &
INTERVENTION
According to Douglas 1986
A continuous process of assessing establishing goals
and objective, implementing & evaluating them and
subjective these to change as new facts are known.
Planning is a deliberative( Carefully thought or
discuss), systematic phase of the nursing process
that involves decision making and problem
solving.
MS. POOJA SEN

COMPONENT
MS. POOJA SEN
1. Direct client care
activities
2. Focus on proper
documentation
3. Establishing
continuity of care

TYPES & STEPS
1. Initial
Planning
2. Ongoing
Planning
3. Discharge
Planning
MS. POOJA SEN

1. Initial Planning – Done by the nurse who perform admission
assessment in order to prioritizing problems, identifying goals and
correlate nursing care to resolve problems.
2. Ongoing Planning – It involves continuous updating of
the client plan of care, every nurse who care for the client, every
nurse who care for the client is involved in ongoing planning.
3. Discharge Planning – It involves anticipation and
planning for the client needs after discharge.
MS. POOJA SEN

ELEMENTS
1. Prioritizing
the problems
2. Formulate
goals and
desired
outcomes
3. Selecting
nursing
interventions
4. Writing
individualized
intervention or
care plan
MS. POOJA SEN

ELEMENTS OF PLANNING
 Prioritizing the problems – Priority setting is the process of establishing a preferential
sequence for addressing nursing diagnosis and interventions.
 High priority ( e.g. – Ineffective breathing)
 Medium priority ( e.g. – Impaired skin integrity)
 Low priority ( e.g. – knowledge deficient)
Setting Priorities – Factor affecting priorities .
• Client health
• Client priority
• Resources available to the nurse & client
• Urgency of health patient
• Medical treatment plan
MS. POOJA SEN

ELEMENTS OF
PLANNING
Establishing client goals/desired outcome – Nurses hope to achieve by
implanting the nursing intervention.
PURPOSE OF DESIRED GOAL –
• Provide direction for planning.
• Serve as a criteria for evaluation.
MS. POOJA SEN

TYPES OF GOAL
SHORT TERM GOAL
Can be meet quickly hours &
day .
LONG TERM GOAL
Covers a long-time span
MS. POOJA SEN

ELEMENTS OF
PLANNING
Selecting nursing interventions – Nursing intervention is any treatment
based on clinical judgement and knowledge that a nurse perform to enhance
patient outcome.
 Independent intervention
 Dependent intervention
 Collaborative intervention
MS. POOJA SEN

 Independent intervention – Are those activities that nurses are licensed to
initiate on the basis of their knowledge & skill.
• Physical care
• Teaching
• Counselling
• Emotional support
• Ongoing assessment
• Making referral of other health care professional.
MS. POOJA SEN

 Dependent intervention – Are activities carried out under the physician
order or supervision or supervision or according to specific routine .
• Medication
• Treatment
• I V Therapy
• Diagnostic test
• Diet and activity
MS. POOJA SEN

 Collaborative intervention – Are action the nurse carries out in
collaboration with other health team members such as physical therapist,
social worker Dietician and physician.
MS. POOJA SEN

IMLEMENTATION
This is 4th
step of the nursing process involves
the execution of the nursing care plan derived
during the planning phase.
IMPLANTATION PROCESS –
Revised the data –-----Revised the Nursing
diagnosis-----Revise the specific
intervention-------Choose the evaluation
MS. POOJA SEN

EVALUATION
 Evaluation is defined as the judgement of the
effectiveness of nursing care to meet client goals
in this phase nurse compare the client behavioral
responses with predetermined client goals and
outcome criteria.
Craven 1996
 Evaluation is defined as the process of determine
both the client progress towards the attainment of
expected outcome and effectiveness of nursing
care.
MS. POOJA SEN

EVALUATION
 Determine the client behavioral response.
 Compare the client response with outcome criteria.
 Assess the collaboration of client and health team.
 Appraise the extent to which client goal.
 Identify the error in plan care.
 Monitor quality of nursing care.
MS. POOJA SEN

NURSING PROCESS AND ITS STEPS .pptx

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NURSING PROCESS AND ITS STEPS .pptx