NURSING

PROCESS
PREPARED AND PRESENTED BY
MRS.S.ANUKRISHNAN,
VICE PRINCIPAL CUM HOD OBG NURSING,
P.D.BHARATESH COLLEGE OF NURSING,
HALAGA, BELGAUM.

NURSING PROCESS - INTRODUCTION
The term NURSING PROCESS originated in
1955 by Haul.
Johnson (1959), Orlando (1961), and
Wiedenbach (1963) were the first users of the
term nursing process.
The Nursing Process enables the nurse to
organize and deliver nursing care.

NURSING PROCESS -
INTRODUCTION
For the successful application of Nursing
Process,
the nurse integrates elements of critical thinking to
make judgments
and take actions based on reason.
The nursing process is used to
identify, diagnose and treat human responses to
health and illness.
Critical
thinking
ASSESSMENT
DIAGNOSING
PLANNING IMPLEMENTING
EVALUATING
It is a dynamic continuous process as the
clients need change.
The use of Nursing Process promotes
individualized nursing care
And assists the nurse in responding to client
needs in a timely and reasonable manner to
improve or maintain the clients level of
health.

NURSING PROCESS -
INTRODUCTION
1. Definition
It is a systematic, rational method of
planning and providing nursing care. Its
goal is to identify a clients health care
status and actual or potential health
problems, to establish plans to meet the
identified needs, and to deliver specific
nursing interventions to address those
needs.


The Nursing Process is:
A systematic, rational method of planning
and
providing individualized nursing care.
Definition
The nursing process is cyclical, that is,
its components follow a logical
sequence, but more than one
component may be involved at one time.
At the end of the first cycle, care may be
terminated if goals are achieved, or
cycle may continue with reassessment
or plan of care may be modified.

It is synonymous with the PROBLEM
SOLVING APPROACH that directs the nurse
and the client to determine the need for
nursing care, to plan and implement the care
and evaluate the result.
It is a G O S H approach (goal-oriented,
organized, systematic and humanistic care)
for efficient and effective provision of nursing
care.

2. PURPOSE OF THE
NURSING PROCESS
1. Identify a clients health status and actual or
Potential health problems or needs.
2. To establish plans to meet the identified
needs.
3. Deliver specific nursing interventions to meet
those needs.
PURPOSE OF THE NURSING PROCESS
4. To Achieve Scientifically-
Based, Holistic, Individualized
Care For The Client.
5. To Achieve The Opportunity To
Work Collaboratively With
Clients, Others.
6. To Achieve Continuity Of Care.
3. Benefits of Nursing Process
1. Provides an orderly & systematic method for planning
& providing care
2. Enhances nursing efficiency by standardizing nursing
practice
3. Facilitates documentation of care
4. Provides a unity of language for the nursing
profession
5. Is economical
6. Stresses the independent function of nurses
7. Increases care quality through the use of deliberate
actions
3. Benefits of Nursing Process
1. Continuity of care
2. Prevention of duplication
3. Individualized care
4. Standards of care
5. Increased client participation
6. Collaboration of care


4. Characteristics of the Nursing
Process
1] Cyclic & dynamic in nature
2] Client centered
3] Focus on problem solving & Decision making
4] Interpersonal & Collaborative style
5] Universal applicability
6] Use of critical thinking.
7] Data from each phase provide input into the next
phase.
8]Decision making involved in every phase of nursing
process.
CHARACTERISTICS:
a. Systematic:
The nursing process has an ordered sequence of
activities and each activity depends on the accuracy
of the activity that precedes it and influences the
activity following it.


b.Dynamic:
The nursing process has great interaction and
overlapping among the activities and each activity
is fluid and flows into the next activity

c. Interpersonal: The nursing process ensures that
nurses are client-centered rather than task-centered
and encourages them to work to enhance clients
strengths and meet human needs.

d. Goal-directed: The nursing process is a means
for nurses and clients 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 actions

e. Universally applicable:
The nursing process allows nurses to practice
nursing with well or ill people, young or old, in any
type of practice setting
5. Phases/Steps nursing
process
a. Assessing
b. Diagnosing
c. Planning
d. Implementing
e. Evaluating

5. EVALUATION
a. Collect data related to outcomes
b. Compare data with outcomes
c. Relate nursing actions to client goals/outcomes
d. Draw conclusions about problem status
e. Continue, modify, or terminate the clients care plan










4. IMPLEMENTATION
a. Reassess the client
b. Determine the nurses need for
assistance
c. Implement the nursing interventions
d. Supervise delegated case
e. Document nursing activities




3. PLANNING
a. Prioritize problems/diagnoses
b. Formulate goals/desired outcome
c. Select nursing interventions
d. Write nursing orders



2. DIAGNOSING
a. Analyze data
b. Identify health problems, risk, and
strengths
c. Formulate diagnostic statements






1. ASSESSING
a. Collect data
b. Organize data
c. Validate data
d. Analyze data
e. Document data












O
V
E
R
V
I
E
W
5. a. Assessing - Definition
It is the systematic and continuous collection,
organization, validation, and documentation of data
(information) as compared to what is standard /
norm .
It is continuous process carried out during all
phases of the nursing process.
For Eg. In evaluation phase assessment is done
to determine the outcomes of the nursing strategies
and to evaluate goal achievement.
All phases of nursing process depend on the
accurate and complete collection of data.

5. b. Purpose of
Assessment
1. To establish a data base (all the information
about the client):
2. Nursing health history
3. Physical assessment
4. The physicians history & physical
examination
5. Results of laboratory & diagnostic tests
6. Material from other health personnel

5. c. Types of assessment
There are 4 different types of
assessment:-
1] Initial assessment
2] Problem focused assessment
3] Emergency assessment
4] Time lapsed reassessment

Type Time performed Purpose Example
1.Initial
assessment
Performed
within
specified time
after
admission to
a health care
agency.
To establish a
complete
database for
problem
identification,
reference, and
future
comparison
Nursing
admission
assessment
Type Time performed Purpose Example
2.Problem-
focused
assessment
Ongoing
process
integrated with
nursing care
To determine
the status of a
specific
problem
identified in an
earlier
assessment
Hourly
assessment of
clients fluid
intake and
urinary output
in an ICU

Assessment of
clients ability
to perform self
care while
assisting a
client to bathe.
Type Time performed Purpose Example
3.Emergenc
y assessment
During any
physiologic or
psychologic
crisis of the
client
To identify life-
threatening
problems
Rapid
assessment of a
persons
airway,
breathing
status, and
circulation
during a
cardiac arrest
Assessment of
suicidal
tendencies or
potential for
violence.
Type Time
performed
Purpose Example
4.Time-
lapsed
reassessment
Several
months after
initial
assessment
To compare the
clients current
status to
baseline data
previously
obtained.
Reassessment
of a clients
functional
health patterns
in a home care
or outpatient
setting or, in a
hospital, at
shift change.
Assessment varies according to
purpose,
timing,
time available &
client status.
Nursing assessments focus on a client response to
a health problem.
A Nursing assessment include the clients perceived
needs, health problems, related experience , health
practices, values and life styles.
Data should be relevant to a particular health
problem.

Activities in Assessing phase

Activities:
a. Collection of data
b. Validation of data
c. Organization of data
d. Analyzing of data
e. Recording/documentation of data
Assessment = Observation of the patient +
Interview of patient, family & Significant Others +
examination of the patient + Review of medical
record

5. d. Description of the assessment
phase
Phase Description Purpose Activities
i. Assessment Collecting,
Organizing,
Validating ,
Analyzing &
Documenting
client data.
To establish
database about
the clients
response to
health concerns
or illness and the
ability to
manage health
care needs.
Establish a database
Obtain a nursing
health history
Conduct a physical
assessment
Review client
records
Review Nursing
literature
Consult support
persons
Consult health
professionals
update data as
needed organize
data validate data
communicate /
document data.
5. d) a. Collecting Data i.
Meaning
Is the process of gathering information
about a clients health status.
It must be both systematic & continuous
To prevent the omission of significant
data &
reflect a clients changing health status.
To collect data clearly both the client & nurse
must actively participate.

Client data includes past history as well
as current problems.

Eg of Past history
History of allergic to
penicillin
Past surgical
procedures
Folk healing
practices
Chronic disease

Eg of Current Problems
pain, nausea, sleep
patterns & religious
practices.
5. d) a. ii.Types of data
Subjective Data
Also referred to as
symptoms or covert data
Can be verified described by
only the person who
affected.
Eg. Itching, pain, feelings of
worry.
It includes the clients
sensations, feelings values,
beliefs, attitudes and
perception of personal
health status and life
situation.

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 eg. Discoloration of skin,
BP reading.
During Physical Examination, the nurse obtains
objective data to validate subjective data.
Information supplied by family members, significant
others or health professionals are considered
subjective if it is not based on fact.
A complete data base of both subjective & objective
data provides a base line for comparing the clients
responses to nursing & medical intervention.
Eg. Of subjective & objective
data.

Sl.
No.
Subjective Data Objective Data
1 I have fever Body tem 100
0
F
Tachycardia 100 bt/mt
Dull & tired
Dried lips
2 I feel sick to my stomach Vomited 100ml of green tinged fluid
Abdomen firm
Slightly distended
Active bowel sounds in all 4 quadrants
3 I am short of breath RR 28br/mt
Tachypnoea
Lung sound diminished in lower lobe.
5. d) a. iii.Sources of Data
Sources of data are primary or secondary.
The client is the primary source of data.
Secondary or indirect sources are family members or
other support persons, other health professionals,
records & reports laboratory and diagnostic analyses,
and relevant literature.
All sources other than the client are considered
secondary sources.

Client
The best source of data
unless the client is to ill, young or
confused to communicate clearly.
The client can provide subjective data
that no one else can offer.

Support people
Family members, friends and care givers who know
the client well often can supplement or verify
information provided by the client.
They might convey information about the clients
response to illness
the stresses client was experiencing before the
illness,
family attitudes on illness and health,
and the clients home environment.
Support people data are very important in case of a
client who is very young unconscious or confused.
Eg. Mentally ill

Client Records
It includes information documented by various health
care professionals.
Client records also contain data regarding the clients
occupation, religion, and marital status.
By reviewing the records the nurse can avoid asking
questions for which answers have already been
supplied.
Medical records (Medical history, physical
examination, operative report, progress notes &
consultations by Physicians.)
Records of therapies Social workers, nutritionists,
dietitians or physical therapists


Laboratory records and
Health care professionals.


5. d) a. iv. Data Collection
Methods
The primary methods of data collection
are
I. Observing Occurs whenever the nurse is
in contact with the client or support persons.
II. Interviewing is used while taking the
nursing health History
III. Examining Major method used in the
physical health assessment.
In reality, the nurse uses all three
methods simultaneously when
assessing clients.
for Eg. During the client interview the
nurse observes, listens, asks
questions, and mentally retains
information to explore in the physical
examination.

5. d) a. iv. I. Observing - Meaning
is to gather data by using the senses.
Observation is a conscious, deliberate
skill that is developed through effort &
with an organized approach.
Eg. Using the senses to observe client
data.

i. b. Methods of Observation
Vision :- overall appearance (body size ,
general weight, signs of distress or posture
& grooming) discomfort, facial & body
gestures, skin colour & lesions
Smell: - Body or Breath odors.
Hearing: - lung, heart sounds, bowel
sounds, ability to communicate, language
spoken.
Touch :- Skin temperature, moisture,
muscle strength (Hand grip)

i. c.Aspects of Observation

1] Noticing the data
2] Selecting, organizing & interpreting the
data
Eg : - A nurse who observes that a clients
face is flushed, must relate that observation
to body temperature, activity, environmental
temperature, and blood pressure.
Errors can occur in selecting, organizing &
interpreting data.

Nursing observations must be organized so that nothing
significant is missed.
Most nurses develop a particular sequence for observing
events, usually focusing on the client first.
For Eg. A nurse walks into a clients room and observes, in
the following order.
1]Clinical signs of client distress (Eg. pallor or flushing, labored
breathing, and behavior indicating pain or emotional distress)
2] Threats to clients safety, real or anticipated (Eg. a lowered side rail)
3]The presence and functioning of associated equipment (Eg.
Equipment & oxygen)
4] The immediate environment, including the people in it.
5. d) a. iv. II. Interviewing
An interview is a planned communication
or a conversation with a purpose
for Eg. to get or give information, identify
problems of mutual concern, evaluate
change, teach
Eg. for an Interview is nursing Health
history.
There are 2 approaches in interview

Direct Indirect or nondirective
Direct Indirect or nondirective
Highly structured & elicits
specific informations
Rapport- building interview
(understanding between two
or more people)
Nurse establishes purpose of
interview and controls the
interview
Nurse allows the client to
control the purpose, subject
matter and pacing
Clients who responds may
have limited opportunity to
ask question or Discuss
concerns

Types of interview
questions
There are 4 types of interview questions
Closed question
Open ended question
Neutral questions
Leading question

Closed question Open ended
question
Neutral questions Leading question
1. Used in direct
interview,

2. Are restrictive

3. Generally requires
yes of No or short
factual answers

4. Often begin with
when, where, who,
what, do, did or
does, or is, are,
was.
Eg.
a. Are you having pain
now?
b. What medication did
you take?
1. Associated with
nondirective
interview
2. Invite clients to
discover &
explore, elaborate,
clarify or illustrate
their thoughts or
feelings.

3. It specifies only
the broad topic to
be discussed &
invites longer that
one or two words.

4. An open ended
question begins
with what or how?
Eg.
a. What brought you to
hospital?
b. How did you feel in
that?
1. Is a question the
client can answer
without direction or
pressure from the
nurse.

2. Used in non
directive that
question.

Eg.
a. How do you feel
about that?

b. Why do you think
you had the
operation?
1. Used in directive
interview &
2. Thus directs client
answer.

Eg.

a. Youre stressed
about surgery
tomorrow, arent
you?

b. Youll take medicine
wont you?
Planning the interview and
setting
Before beginning an interview, the nurse
reviews available information.
Eg. Operative report, information about
the current illness.
Each interview is influenced by time,
place, seating arrangement or distance,
and language.

Time: -
Nurse need to plan for an interview with hospitalized clients
physically comfortable,
free of pain,
when interruptions by friends, family, and other health
professionals are minimal.
The client should be made to feel comfortable & unhurried.
Place: - Well lighted, well ventilated, moderate sized room,
free of nurse, movements, interruptions encourages the
communication.
Seating arrangements: -
Distance:-
Stages of an interview
Opening or introduction 2 steps
1] establish rapport
2] orientation
Body or development closing

5. d) a. iv. III. Examining
Physical examination or physical
assessment is a systematic data
collection method that uses observation
to detect health problems.
To conduct examination the nurse uses
techniques of 1) Inspection 2)
auscultation, 3) palpation, 4)
percussion.


Inspection
Palpation
Auscultation

Percussion
Inspection: - Process of checking that
things are in the correct condition.
Auscultation: - Examining the internal
organs by listening to the sounds that they
give out
Palpation: - Examination of organ by
touches or pressure of the hand over the
part.
Percussion: - Tapping with the fingers or
with a light hammer upon any part of the
body.

The physical examination is carried our
systematically.
It may be organized according to the
examiners preference,
Head to toe approach (Cephalo caudal approach)
System wise approach examine all the body
system
Review of system approach examine only
particular area affected
b. Organization of data
Uses a written or computerized format that
organizes assessment data systematically.
Maslows basic needs
Body system model
Gordons functional health patterns

BODY SYSTEM MODEL

1)THE INTEGUMENTARY SYSTEM
2)THE SKELETAL SYSTEM
3)THE MUSCULAR SYSTEM
4)THE NERVOUS SYSTEM
5)THE ENDOCRINE SYSTEM
6)THE CIRCULATORY SYSTEM
7)THE LYMPHATIC SYSTEM
8)THE RESPIRATORY SYSTEM
9)THE DIGESTIVE SYSTEM
10)THE URINARY SYSTEM
11)THE REPRODUCTIVE SYSTEM



Gordons Functional Health Patterns:
i. Health perception-health management pattern.
ii. Nutritional-metabolic pattern
iii. Elimination pattern
iv. Activity-exercise pattern
v. Sleep-rest pattern
vi. Cognitive-perceptual pattern
vii. Self-perception-concept pattern
viii. Role-relationship pattern
ix. Sexuality-reproductive pattern
x. Coping-stress tolerance pattern
xi. Value-belief pattern

c.Validating Data
The information gathered during
assessment phase must be complete,
factual, and accurate because the
nursing diagnoses and interventions
are based on this information.
Validation is double checking or
verifying the data is accurate and
factual.

Purposes of data validation
1. Ensure that data collection is complete
2. Ensure that objective and subjective data
agree
3. Obtain additional data that may have
been overlooked
4. Avoid jumping to conclusion
5. Differentiate cues and inferences
Cues - subjective and objective data that can be
directly observed by the nurse.
(What client can say, what the nurse can see, hear,
feel, smell or measure)
Inferences - Nurses interpretation or conclusions
made based on the cues
Example:
1. Red, swollen wound = infected wound
2. Dry skin = dehydrated

d. Analyze data
Compare data against standard and identify
significant cues.
Standard/norm are generally accepted
measurements, model, pattern:
Ex:
1. Normal vital signs,
2. Standard weight and height,
3. Normal laboratory/diagnostic values,
4. Normal growth and development pattern

e. Documenting data
To complete the assessment phase, the nurse records
client data.
record in a factual manner
It includes all data collected about client status.
Eg. Data in factual manner Wrong manner
Slice of toast I Appetite is good
Egg - I normal appetite
Juice - 250ml.
Coffee- 240ml.
- Record subjective data in clients own words (more
accuracy)