NURSING PROCESS APPROACH

INTRODUCTION

 It is a series of planned actions or operations directed towards a particular

result or goal.
 Nursing process is a systematic problem solving approach used to
identify ,prevent and treat actual or potential health problems and
promote wellness .a systematic way to plan ,implement and evaluate care
for individual ,families ,groups and communities .

DEFINITION

 The nursing process generally is defined as a systematic problem solving

approach for giving individualized comprehensive nursing care.
 It is a systematic , rational method of planning and providing
individualized nursing care
 Nursing process primarily refers to the independent responsibility of the
nurse in providing client care ,it has been derived from the scientific
method and adopted as an organized systematic method for identifying
clients concern and problems ,choosing expected client outcomes
,determining intervention to resolve these problems and evaluating
achievement of expected outcomes following provision of nursing care.

PURPOSE OF NURSING PROCESS

 To identify a clients health status and actual or potential health problems

or needs
 To deliver specific nursing intervention to meet the identified needs
 To establish plans to meet the identified needs
 To achieve scientifically based ,holistic ,individualized care for the
patient
 To achieve the opportunity to work collaboratively with client ,others
 To achieve continuity of care

BENEFITS OF NURSING PROCESS

 Continuity of care
 Prevention of duplication
 Individualized care
  Standards of care
 Increased client participation
 Collaboration of care

CHARACTERISTICS OF THE NURSING PROCESS

 It is cyclic and systematic – each nursing activity is part of an ordered

sequence of activities .the nursing process directs each step of nursing
care in a sequentially ordered manner
 It is dynamic – each step in nursing process flows on to the next step.
 Interpersonal – human beings is always the heart of nursing .in this
nurses are client centered not task centered
 The nursing process encourages nurses to work together to help clients to
use their strengths to meet all human needs
 It is outcome oriented – the client benefit from continuity of care each
nurse care moves the clients closer to outcome achievement
 Goal directed – the nursing process is a means for nurses and client to
work together to identify specific goals ( wellness promotion, disease
and illness prevention , health restoration , coping and altered
functioning ) that are most important to the client , and to match them
with the appropriate nursing action.
 Universally applicable – this process is universally applicable in all
nursing situations.

COMPONENTS OF NURSING PROCESS –

The nursing process consist of five dynamic and interrelated phases-

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

PHASES OF THE NURSING PROCESS -

 ASSESSMENT

EVALUATION DIAGNOSIS

IMPLEMET-
ATION PLANNING

1. ASSESSMENT – collecting subjective and objective data

2. DIAGNOSIS – analysis subjective and objective data to make a
nursing diagnosis.
3. PLANNING – determining outcome criteria and developing a plan .
4. IMPLEMENTATION – carrying out a plan.
5. EVALUATION – assessing whether outcome criteria have been met
and revising the plan as necessary.

HEALTH / NURSING ASSESSMENT –

Introduction – it is systematic and continuous collection, validation and

communication of client data as compared to what is the standard/ norm. It
includes the clients perceived needs , health problem , related experiences ,
health practise , values and lifestyles.

Definition –

 Nursing assessment focuses on gathering data about a client’s state of

wellness , functional ability ,physical status ,strengths and responses
to actual and potential health problems
  It is continuous process carried out during all phases of the nursing
process

Example – all phases of nursing process depend on the accurate and

complete collection of data.

PURPOSE OF ASSSESSMENT –

 To establish a data base (all information about the client )

 Nursing health history
 Physical assessment
 Results of laboratory and diagnostic test
 Material from other health personnel.

TYPES OF ASSESSMENT –

I. Initial comprehensive assessment

II. Problem focused assessment
III. Emergency assessment
IV. Time lapsed reassessment

TYPES TIME PURPOSE EXAMPLE

PERFORMED
Initial It is also called To establish a Nursing
assessment an admission complete admission
assessment , is database for assessment.
performed when problem
the client enters identification,
into the health reference and
care agency. future
comparison
Problem focused Ongoing process To determine the Hourly
assessment integrated with status of a assessment of
nursing care specific problem clients fluid
identified in an intake and
earlier urinary output in
assessment an icu.

Emergency During any To identify life Rapid

assessment physiological threatening assessment of a
crisis of the client problems person’s airway ,
breathing status
 and cardiac
arrest
,assessment of
suicidal
tendencies or
potential for
violence.
Time lapsed Several months To compare the Reassessment of
reassessment after initial client’s current a client’s
reassessment. status to baseline functional health
data previously patterns in a
obtained home care or
outpatient setting
or in a hospital at
shift change.

Steps of assessment –

1. Collection of data
 Subjective data collection b. Objective data collection
2. Validation of data
3. Organization of data
4. Recording/documentation of data

Assessment = observation of the patient + interview of patient, family

and society +examination of the patient + review of

medical record

 Collection of data –
 It is the process of gathering information about the client ‘s health status
 It includes physical, psychological, emotion, socio-cultural, spiritual
factors that may affect client’s health status
 It includes past health history of client (allergies, past surgeries, chronic
diseases, use of folk healing methods)
 It includes current/present problems of client (pain, nausea, sleep pattern,
religious practices, meds or treatment the client is taking now)

 Types of Data:
 Subjective data

 also referred to as Symptom/Covert data

 information from the client’s point of view or are described by the person
experiencing it.
 information supplied by family members, significant others, other health
professionals are considered subjective data.
 Example: pain, dizziness, ringing of ears/Tinnitus

Objective data
 also referred to as Sign/Overt data
 those that can be detected, observed or measured/tested using accepted
standard or norm.
 Mainly collection by general observation and by using the four physical
examination techniques – inspection, percussion, palpation and
auscultation.
 Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Methods of Data Collection:

Interview –
 a planned, purposeful conversation/communication with the client to get
information, identify problems, evaluate change, to teach, or to provide
support or counseling.
 it is used while taking the nursing history of a client
 interview an essential skill for obtaining information for the nursing
history .

Observation –
 use to gather data by using the 5 senses and instruments.
 Observation occurs whenever the nurses is contact with the client or
support persons
 Observation is a ,conscious ,deliberate skill that is developed through
effort and withan organized approach
.
Examination –

 systematic data collection to detect health problems using unit of

measurements, physical examination techniques (IPPA), interpretation of
laboratory results.
 should be conducted systematically:

ASSESSMENT SEQUENCING -
 Cephalocaudal approach – head-to-toe assessment -
Physical assessment using head to toe approach

I. General – General health status ,vital signs and weight, nutritional

status.
II. Mobility and self care – observe posture ,assess gait and balance ,
evaluate mobility ,activities of daily living.
III. Head face and neck – evaluate cognition ,level of consciousness
,orientation , mood ,language, and memory, sensory function ,cranial
nerves ,inspect lymph nodes ,inspect neck veins.
IV. Skin ,hair and nails - inspect scalp ,hair and nail . evaluate skin
turgor. Observe skin lesion ,assess wound.
V. Chest – inspect and palpate breast ,inspect and auscultation lungs,
auscultate heart.
VI. Abdomen – inspect, auscultation and palpate four quadrants ,palpate
and percuses liver ,stomach and bladder ,bowel elimination .urinary
elimination
VII. Genitalia – inspect genitalia of male and female client’s accordingly.
VIII. Extremities – palpate arterial pulses ,observe capillary refill
,evaluate edema assess joint mobility measure strength ,assess
sensory function

 Body System approach – examine all the body system

Review of system

 General presentation of symptoms – fever, chills , malaise ,pain ,

sleep pattern .
 Diet – appetite likes and dislikes ,restrictions written diary of food
intake.
 Skin ,hair, and nails – rash or eruption ,itching ,color or texture
changes , excessive sweating ,abnormal nail and hair growth.
 Musculoskeletal – joint stiffness ,pain ,restricted motion ,swelling
,recent, change in vision
.
head and neck -
 Eyes – visual activity , blurring ,diplopia ,photophobia ,pain ,recent
change in vision
 Ears – hearing loss ,loss ,pain ,discharge ,tinnitus ,vertigo
 Nose – sense of smell ,frequency of colds ,obstruction , epistaxis ,
sinus pain , or postnasal discharge
  Throat and mouth – hoarseness or change in voice ,frequent sore
throat ,bleeding or swelling , of gums ,recent tooth abscesses or
extraction ,soreness of tongue or mucosa.

Endocrine and reproductive -

Thyroid enlargement or tenderness ,heal or cold intolerance ,
unexplained weight change ,polyuria ,polydipsia, changes in
distribution of facial hair.

Males – puberty onset ,difficulty with erections ,testicular pain ,liido ,

infertility.

Females - menses (onset ,regularity ,duration and amount)

dysmenorrhea, last menstrual period ,pregnancies ,frequency of
intercourse ,age at menopause ,type of delivery , complications ,use of
contraceptives , breast

Chest and lungs – pain related to respiration, dyspnoea, cyanosis ,

wheezing , cough , sputum ( character and quantity ),exposure to
tuberculosis

Heart and blood vessel – chest pain or distress ,precipitation causes

,timing and duration ,relieving factors ,dyspnoea edema ,
hypertension ,exercise tolerance.

Gastrointestinal – appetite ,digestion ,food intolerance dysphagia ,

heartburn ,nausea or vomiting , bowel regularity ,changes in stool
color ,constipation or diarrhoea

Genitourinary - dysuria , flank, or suprapublic pain ,urgency

hematuria, polyuria ,edema ,sexually transmitted diease

neurological – syncope ,seizures ,weakness, or paralysis ,tremors loss

of memory

 Review of System approach – examine only particular area affected.

ASSESSMENT TECHNIQUES –
Inspection – inspection is the visual examination of the client.

Guidelines for effective inspection –

 Be systematic
  Fully expose the area to be inspected , cover other body parts to
respect the client’s modesty.
 Use good light, preferably natural light.
 Maintain comfortable room temperature.
 Observe color , shape ,size ,symmetry, position ,and movement.
 Compare bilateral structures for similarities and differences

Palpation – palpation uses the sense of touch to assess various parts of the
body and helps to confirm finding that are noted on inspection .
The hands ,especially the fingers tips are used to assess skin temperature ,
check pulse ,texture ,moisture ,lumps, tenderness or pain .ask the client for
permission first and explain to your client what you intend to examine.please
remember to use warm hands.

Types of palpation -
 Light palpation -to check muscle tone and assess for tenderness
 Deep palpation – to identify abdominal organs and abdominal mass.

Percussion –percussion is the striking of the body surface with short , sharp
strokes in order to produce palpable vibration and characteristic sounds .it is
used to determine the location size, shape, and density of underfying structure to
detect the presence of air or fluid in a body space and to elicit tenderness.

Type of percussion –
 Direct percussion –percussion in which one hand is used and the striking
finger of the examiner touches the surface being percussed
 Indirect percussion – percussion in which two hands are used and the
plexor ,strikes the finger of the examiner s other hand which is in contact
with the body surface being percussed.
 Blunt percussion – percussion which the ulnar surface of the hand or firt
is used in place of the fingers to strike the body surface , either directly or
indirectly.

Percussion sound –
 Resonance: a hollow sound
 Hyper resonance :a booming sound
 Tympani :a musical sound or drum drum sound like that produced by the
stomach.
 Dullness:- thud sound produced by dense structures such as the liver ,and
enlarged spleen, or a full bladder.
 Flatness:- an extremely dull sound like that produced by very dense
structures such as muscle or bone.
 AUSCULTATION:-
Auscultation is listening to sounds produced inside the body . these
include breath sound , heart sound , vascular sounds, and bowel sound it
is used to detect the presence of normal and abnormal sounds and to
assess them in terms of loudness ,pitch ,quality ,frequency and duration.

Source of data:

 Primary source – data directly gathered from the client using interview
and physical examination.
 Secondary source – data gathered from client’s family members,
significant others, client’s medical records/chart, other members of health
team, and related care literature/journals.
In the Assessment Phase, obtain a Nursing Health History – a structured
interview designed to collect specific data and to obtain a detailed health record
of a client.

Components of a Nursing Health History:-

 Biographic data – name, address, age, sex, martial status, occupation,

religion.
 Reason for visit/Chief complaint – primary reason why client seek
consultation or hospitalization.
 History of present Illness – includes: usual health status, chronological
story, family history, disability assessment.
 Past Health History – includes all previous immunizations, experiences
with illness.
 Family History – reveals risk factors for certain disease diseases
(Diabetes, hypertension, cancer, mental illness).
 Review of systems – review of all health problems by body systems
 Lifestyle – include personal habits, diets, sleep or rest patterns, activities
of daily living, recreation or hobbies.
 Social data – include family relationships, ethnic and educational
background, economic status, home and neighborhood conditions.
 Psychological data – information about the client’s emotional state.
 Pattern of health care – includes all health care resources: hospitals,
clinics, health centers, family doctors.
 II. Validation of Data – the act of “double-checking” or verifying data to
confirm that it is accurate and complete.

Purposes of data validation:

 ensure that data collection is complete
 ensure that objective and subjective data agree
 obtain additional data that may have been overlooked
 avoid jumping to conclusion
 differentiate cues and inferences

methods of validation:-
 recheck your own data through a repeat assessment for example take the
clients temperature again with a different thermometer.
 Clarify data with the client by asking additional questions.
Eg.:- If a client is holding his abdominal the nurse may assume he is
having abdominal pain , when actually the client is very upset about his
diagnosis and is feeling anxiety
 Verify the data with another health care professional
.eg:-. ask a more experienced nurse to listen to the abdominal heart sound
you think you have just heard.
 Compare your objective finding with your subjective finding tonuncover
discrepancies
.eg:-if the client states that she never gets any time in the sun yet has dark
,wrinkled ,suntanned skin ,you need to validation the client’s perception
of never getting any time in the sun.

III. Organization of Data –

It uses a written or computerized format that organizes assessment

data systematically.

Maslow’s basic needs :-

Abraham maslow who put forward the hierarchy of human needs
is the best way used for the organization of data in the nursing
process .his model got the world’s attention because of its high
value in health care.
 slef
actualization

self esteem

love and beloningness

safety and security

physiological needs

MASLOW ‘S BASIC NEED MODEL

a. Body System Model:- the body systems model ( also called the medical
model or review of systems) focuses on the client’s major anatomic
system. The framework allows nurse to collect data about past and
present condition of each organ or body system and to examine
thoroughly all body system for actual and potential problem.

b. Gordon’s Functional Health Patterns:-the client’s strengths, talents

and functional health patterns are an integral part of the assessment of
functional health focuses on client’s normal function and his or her
altered function or risk for altered function.
 Health perception-health management pattern.
 Nutritional-metabolic pattern
 Elimination pattern
 Activity-exercise pattern
 Sleep-rest pattern
 Cognitive-perceptual pattern
 Self-perception-concept pattern
 Role-relationship pattern
 Sexuality-reproductive pattern
 Coping-stress tolerance pattern
 Value-belief pattern
 V. Analyze data –
compare data against standard and identify significant cues.
Standard/norm are generally accepted measurements, model, pattern
Ex:- Normal vital signs, standard Weight and Height, normal
laboratory/diagnostic values, normal growth and development
pattern

V. Communicate/Record/Document Data
 nurse records all data collected about the client’s health status
 data are recorded in a factual manner not as interpreted by the nurse
 record subjective data in client’s word; restating in other words what
client says might change its original meaning.

Purpose of documentation:-

1. provides a chronological source of client assessment data and a

progressive record of assessment findings that outline the client’s course
of care
2. ensures that information about the client and family is easily accessible to
member of the health care team provides a vehicle for communication
and prevents fragmentation ,repetition and delays in carrying out the plan
of care.
3. Establish s basis for screening or validation proposed diagnosis.
4. Acts as a source of information to help diadnose new problem.
5. Provides a basis for determining the educational eligibility for care and
reimbursement ,careful recording of data can support financial
reimbursement or gain additional reimbursement for transitional or
skilled care needed by the client.
6. Constitutes a permanent legal record of the care that was or was not given
to the cliet

BIBLIOGRAPHY:-
 SHEBEER . P. BASHEER AND S. YASEEN KHAN ‘S
TEXTBOOK OF ADVANCE NURSING PRACTICE PAGE NO.
504,505,506,507,508,509,510,511,512
 SR. NANCY’S TEXTBOOK OF PRINCIPLES AND PRACTICE
OF NURSING VOL. 1 PAGE NO. 52,53,54,55,56,57,58
 WWW.GOOGLE .COM
 WWW.SLIDESHARE.NET