Facilitates documentation of care

Provider a unity af language for the nursing professional

Is economical
Stresses the independent function af nurses
In creases care quality through the use of deliberate actions

Characteristics of nursing process

1.
2.
3.
4.
5.
6.
7.

Withi the legal scope of nursing

Based on knowledge-requiring critical thinking
Planned-organized and systematic
Client-centered
Goal-directed
Prioritized
Dynamic

Benefit of using the nursing process

1.
2.
3.
4.
5.

Continuity of care
Prevention of duplication
Individualized care
Standar client participation
Collaboration of care

Holistic
1.
2.
3.
4.
5.

Physical
Emotionl
Psychosocial
Develomental
Spiritual being

5 components of thr nursing process:

1.
2.
3.
4.
5.

Assessment
Diagnosis
Planning
Implementing
Evaluating

The nursing process

1.
2.
3.
4.

Assessing (gather data)

Analyzing (i.D problem. Formulate nursing diagnosa)
Planning ( write care plan meet goals)
Implementing (carry out plan )

5. Evaluating (collect objective data to determine the extent to which goals

were achived revise plan as needed
Component of the nursing process
Assessment
1. The first phase of the nursing process, called assesment, is the collection
of data for nursing purposes
2. Information is the collected using the skills of the skills of observation,
interviewing, physical examination, and intuition
3. From many sources, incluiding clients, their family members or significant
others, health records, other health team members

Assessing :
1. Identify assessment priorities determined by the purpose of the
assessment and the patients conditition
2. Organize or cluster the data to ensure systematic collection
3. Establish the database ( nursing history, nursing examination, review of
the patient record and nursing literatur , consultation with the patiens
support persons and healthcare professionals )
4. Continuously uptudate the database
5. Validate data
6. Communicate data
Diagnosing
Outcame identification and planning
Implementing
Evaluating

Componen of the nursing process

Assessment :
1. Data collection
a. Assesment involves taking vital signs ( TPR BP & pain assesment )
b. Performing a head to toe assessment
c. Listening to the patients comments and questions about his health
status
d. Observing his reactions and interactions with others. It invalves asking
pertinent questions about his signs (observable ) and symtoms (nonobservable), and listening carefully to the answers
During assessment, the care provider:
a. Establishes a Data base

b. Continuously updates the data base

c. Validates data
d. Communicates data

Preparing for assessment

Type, aim, time frame
1. Initial assessment ( initial identification of normal function, funtional
status , and collection of date concerining actual or potential dysfunction.
Baseline for reference and furture comparison). (within the sfecified time
frame after admission to a hospital, nursing home, ambulatory healthcare
center.
2. Focus assessment ( status determination of a spesific problem identified
during previos assessment) . ( ongoing process, integrated with nursing
care, a few minutes to a few bours between assessments).
3. Time lapsed reassessment ( comparison of clients current status to
baseline obtained previonsly, detection of changes in all fungtional health
patterns after an extended period of time has passed ). ( several months
(3,6,9, months or more) between assessment)
4. Emergency assessment ( identification of life threatening situation) . ( AT
anytime )

Setting and enviroment

Assessment can take place in naysetting where nurses care for clients and their
family members : in the clients home , at a clinic, an a hospital room,
Assessment skills
1. Observation
a. Comprises more than the nurses ability to see the client, nurses also use
that senses of smell, hearing, touch, and, rarely, the sense of taste.
b. Observation includes looking, wathching, examiniting
c. Observation begiens the moment the nurses meets the client. It is conscious,
deliberate skill that is developed through efforts and with an organized
approach.
d. Observation has two aspects:
Noticing the data and
Selecting, organizing, and interpreting the data.

Observation done in the following order ;

1.
2.
3.
4.

Clinical signs of clients distress

Threats to the clients safety, real or anticipated
The presence and functioning of associated equipment
The immediate enviroment, including the people in it