Nursing Process

An organized sequence of problem-solving steps used to identify and to manage the

health problems of clients.
The Nursing Process is an organizational framework for the practice of nursing, is orderly
and systematic, central to all nursing care and encompasses all steps taken by the nurse in caring
for a patient.
The nursing process is a systematic method that directs the nurse and patient as together
they accomplish the following:
 Assess the patient to determine the need for nursing care.
 Determine nursing diagnoses for actual and potential health problems.
 Identify expected outcomes and plan care.
 Implement the care.
 Evaluate the results.
Benefits of using the Nursing Process
 Provides an orderly & systematic method for planning & providing care.
 Enhances nursing efficiency by standardizing nursing practice.
 Facilitates documentation of care.
 Provides a unity of language for the nursing profession.
 Is economical.
 Increases care quality through the use of deliberate actions.
 Increased client participation.
 Collaboration of care.
The Nursing Process
 Assessment
 Nursing Diagnosis
 Planning
 Implementation
 Evaluation

Characteristics of the Nursing Process

 To work within the legal scope of nursing.
 Based on knowledge-requiring critical thinking.

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 Planned-organized and systematic.
 Client-centered.
 Goal-directed.
 Prioritized.
Nursing Assessment
The first phase of the nursing process called assessment. It is the collection of data for
nursing purposes. Information is collected using the skills of Observation, Interviewing, Physical
examination, Intuition and from many sources, including clients, their family members or
significant others, health records, other health team members.
Reasons for doing assessment
 To establish baseline information on the client
 To determine the client’s normal function
 To determine the client’s risk for dysfunction
 To determine the client’s strengths
 To provide data for the diagnosis phase
Resources for data collection
 Primary source: Client.
 Secondary source: Client’s family, reports, test results, information in current and past
medical records, and discussions with other health care workers
Setting and environment
Assessment can take place in any setting where nurses care for clients and their family
members: in the client’s home, at a clinic, in a hospital room.
Assessment skills/ Assessment Activities
1- Observation
Comprises more than the nurse’s ability to see the client, nurses also use the senses of
smell, hearing, touch, and, rarely, the sense of taste. Observation includes looking, watching,
examining. Observation begins the moment the nurse meets the client. It is a conscious,
deliberate skill that is developed through efforts and with an organized approach.
2- Interviewing
Is a planned communication or a conversation with a purpose, for example to get or give
information, identify problems of mutual concern, evaluate change, teach, provide support.
3- Physical examination techniques
Is a systematic data collection method that uses the senses of sight, hearing, smell, and
touch to detect health problems. Four techniques are used: inspection, palpation, percussion, and
auscultation

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Inspection
Is visual examination of the client that is done in a methodical and deliberate manner.
The client is observed first from a general point of view and then with specific attention to detail.
Effective inspection requires adequate lighting and exposure of the body parts being observed.
Palpation
Uses the sense of touch to assess texture, temperature, moisture, organ location and size,
vibrations and pulsations, swelling, masses, and tenderness. Palpation requires a calm, gentle
approach and is used systematically, with light palpation preceding deep palpation and palpation
of tender areas performed last.
Percussion
Uses short, tapping strokes on the surface of the skin to create vibrations of underlying
organs. It is used for assessing the density of structures or determining the location and the size
of organs in the body.
Auscultation
Involves listening to sounds in the body that are created by movement of air or fluid.
Areas most often auscultated include the lungs, heart, abdomen, and blood vessels.
4- Intuition
Use of insight, instinct, and clinical experience to make clinical judgments about the
client. Intuition plays a role in the nurse’s ability to analyze cues rapidly, make clinical decisions
and implement nursing actions even though assessment data may be incomplete or ambiguous.
Collect data
The process of compiling information about the client begins with the first client contact.
Types of data:
Subjective data also known as symptoms or covert cues include the client's feeling and
statement about his or her health problems and are best recorded as direct quotations from the
client, such as'' Every time I move, I feel nauseated.''
Subjective data-information that only the client feels and can describe (Symptoms)
Objective data also known as signs or overt cues, are observable and measurable
(quantitative) data that are obtained through observation, standard assessment techniques
performed during the physical examination, and laboratory and diagnostic testing.
Objective data is a observable and measurable facts (Signs)
Nursing Diagnosis
A nursing diagnosis is a part of the nursing process and is a clinical judgment about
individual, family or community response to an actual or potential health problem/life processes
provide the basis for selection of nursing intervention to achieve outcome for which the nurse is
accountable. (NANDA 1970)

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 The primary organization for defining and dissemination of standardized nursing
diagnoses worldwide is NANDA-International formerly known as the North American Nursing
Diagnosis Association. North American Nursing Diagnosis Association.
Each NANDA describes the essence of the problem in as few words as possible.
 Acute Pain
 Altered nutrition
Medical Diagnosis
 Describes a disease or pathology
 Conditions Doctor treats
 Doctor cares for a patient with Congestive Heart Failure (CHF) treats pathology with
meds, oxygen, diet & fluid restriction.
Nursing Diagnosis
 Describes pt’s response to a health problem
 Situations RNs can treat
 Nursing diagnosis describe pt’s response to Congestive Heart Failure (CHF) such as:
Anxiety; Activity Intolerance, Powerlessness
Types of diagnoses
The NANDA-I system of nursing diagnosis provides for four categories.
Actual diagnosis - A clinical judgment about human experience/responses to health
conditions/life processes that exist in an individual, family or community. An example of an
actual nursing diagnosis is: Sleep deprivation.
Risk diagnosis - Describes human responses to health conditions/life processes that may develop
in a vulnerable individual/family/community. It is supported by risk factors that contribute to
increased vulnerability. An example of a risk diagnosis is: Risk for shock.
Wellness/Health promotion diagnosis - A clinical judgment about a person’s, family’s or
community’s motivation and desire to increase wellbeing and actualize human health potential as
expressed in the readiness to enhance specific health behaviors and can be used in any health
state. An example of a health promotion diagnosis is: Readiness for enhanced nutrition. Patient
functioning effectively but desires higher level of wellness
Syndrome diagnosis - "A clinical judgment describing a specific cluster of nursing diagnoses
that occur together and are best addressed together and through similar interventions." An
example of a syndrome diagnosis is: Relocation stress syndrome.
Structure of diagnoses
 An actual diagnosis has a three part statement.
 A risk diagnosis has a two part statement.
 A wellness diagnosis has a one part statement.
Actual Diagnostic Statement
 Three-Part Format
1. NANDA label

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2. Related factors (follows NANDA & linked by the words “related to”)
3. Defining characteristics (follows related factors & linked by the words “as manifested by”)

Actual Diagnostic Statement Example

1. Impaired Physical Mobility
2. related to decreased motor dysfunction and muscle weakness
3. as manifested by limited ROM “Range Of Motion”
Risk Diagnostic Statement
 Two-Part Format
1. NANDA label
2. Risk factors (follows NANDA label and is linked by the words related to)
Risk Diagnostic Statement Example
1. Risk for Impaired Physical Mobility
2. related to (r/t) AIDS
 “Risk for Impaired Physical Mobility r/t AIDS”
Wellness Diagnostic Statement
Is a one part statement consisting only of the NANDA Used when pt doesn’t have a health
problem but can attain higher level of health:
 Readiness for Enhanced Parenting
 Readiness for Enhanced Family Processes.
Nursing planning/ outcome
 Identify the nursing interventions most likely to assist the patient to meet the goals
 Establish priorities
 Select nursing interventions
 Write goal or outcome and develop an evaluative strategy
 Communicate the plan of nursing care
There are two types of goals in nursing outcome or planning:
Short-term goal: A stepping stone on the way to reaching long term goal and will be completed
soon in hours or days. Short term goal should be Attainable & realistic during your time with
patient.
Long term goal: Objective expected to be achieved over weeks or months.
Long Term Goal Characteristics
 Is a broad statement that reflects?
 Progress towards resolution of a problem.
 Prevention of a problem.
 Should be attainable and realistic for the patient.
 Is expected to be achieved during length of stay in facility

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 Implementation
 Nursing actions planned in the previous step are carried out
 The purpose of implementation is to assist the patient in achieving a desired health goal:
promote the health, attain health, restore health, and prevent disease or illness.
 Document care
Evaluation
 Measure how well the patient has achieved desired goal/outcomes
 Identify the factors contributing the patients success or failure
 Modify the plan of care if needed

Critical thinking
In the term critical thinking, the word critical, (Grk. kritikos = “critic”) identifies the
intellectual capacity and the means “of judgment” and of being “able to discern”.
Critical thinking is defined as: "the process of actively and skillfully conceptualizing,
applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion.
Critical thinking is the intellectually disciplined process of actively and skillfully
conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from,
or generated by, observation, experience, reflection, reasoning, or communication, as a guide to
belief and action.
The list of core critical thinking skills includes observation, interpretation, analysis,
inference, evaluation, explanation, and metacognition.
According to Reynolds (2011), an individual or group engaged in a strong way of critical
thinking gives due consideration to establish for instance
 Evidence through reality
 Context skills to isolate the problem from context.
 Relevant criteria for making the judgment well
 Applicable methods or techniques for forming the judgment
 Applicable theoretical constructs for understanding the problem and the question at hand
Documentation
Documentation is anything written or electronically generated that describes the status of
a client or the care or services given to that client (Perry, A.G., Potter, P.A., 2010). Nursing
documentation refers to written or electronically generated client information obtained through
the nursing process (ARNNL, 2010). Documentation is an integral part of nursing practice and
professional patient care rather than something that takes away from patient care. Documentation
is not optional.
Nursing documentation is a vital component of safe, ethical and effective nursing
practice, regardless of the context of practice or whether the documentation is paper-based or

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electronic. This document is intended to provide registered nurses (RNs) with guidelines for
professional accountability in documentation and to describe the expectations for nursing
documentation in all practice settings, regardless of the method or storage of that documentation.
The intention of the document is to assist the registered nurse to meet their standards of practice
related to documentation.
To determine what is essential to document, for each episode of care or service the health
record should contain:
 A clear, concise statement of client status (including: physical, psychological, spiritual)
 Relevant assessment data (include client/family comments as appropriate)
 All ongoing monitoring and communications
 The care/service provided (all interventions, including advocacy, counseling, consultation
and teaching)
 An evaluation of outcomes, including the client’s response and plans for follow up
 Discharge planning.
Professional Principles of Documentation
Nursing documentation must provide an accurate and honest account of what and when events
occurred, as well as identify who provided the care. Good documentation has six important
characteristics. It should be:
• Factual
• Accurate
• Complete
• Current (timely)
• Organized
• Compliant with standards (Potter & Perry, 2010 p212).
These core principles of nursing documentation apply to every type of documentation in
every practice setting.
Documentation which reflects the nursing process demonstrates that an RN has fulfilled
her/his duty of care. It also demonstrates the unique contribution of nursing to the care of clients.
Nurses should record data collected through all aspects of the nursing process. As a general rule,
any information that is clinically significant should be documented.