Nursing

Process
Ns. Heni Dwi Windarwati,
M.Kep.Sp.Kep.J

Objective
After reading this chapter, the
student will be able to
Define nursing process
Identify six steps of the nursing
process and describe nursing action
associated with each
Describe the benefits of using nursing
process

Back Ground
The nursing process is based on a nursing theory
developed by Ida Jean Orlando. She developed this
theory in the late 1950's as she observed nurses in
action. She saw "good" nursing and "bad" nursing.
From her observations she learned that the patient
must be the central character.
Nursing care needs to be directed at improving outcomes
for the patient, and not about nursing goals.
The nursing process is an essential part of the nursing care
plan.

The Nursing Process is:

A systematic, rational method of planning
and providing individualized nursing care.
An organizational framework for
the practice of nursing
Orderly, systematic
Central to all nursing care
Encompasses all steps taken by
the nurse in caring for a patient

Definition of the Nursing

An organized Process
sequence of problemsolving steps used to identify and to
manage the health problems of
clients
It is accepted for clinical practice
established by the American Nurses
Association

Benefits of 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
Stresses the independent function of nurses
Increases care quality through the use of
deliberate actions

Characteristics of the Nursing

Process
Within the legal scope of nursing
Based on knowledge-requiring
critical thinking
Planned-organized and systematic
Client-centered
Goal-directed
Prioritized
Dynamic

Benefits of using the

nursing process

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

Holistic

PhysicalEmotionalPsychosocialDevelopmentalSpiritual Being

Medical
Diagnosis

Nursing
Diagnosis

Rheumatoid
Arthritis

Self-care deficit:
bathing, related
to joint stiffness

5 Components of the Nursing Process:

1. Assessment
2. Diagnosis
3. Planning
4. Implementing
5. Evaluating

1st Component of the Nursing Process-

ASSESSMENT
The first phase of the nursing process, called
assessment, is the collection of data for nursing
purposes.
Information is collected using the skills of
observation, interviewing, physical examination, and
intuition
from many sources, including clients, their family
members or significant others, health records, other
health team members.

1st Component of the Nursing ProcessASSESSMENT:

Data Collection

Assessment involves taking vital signs

(TPR BP & Pain assessment.
Performing a head to toe assessment
Listening to the patient's comments and
questions about his health status
Observing his reactions and interactions
with others. It involves asking pertinent
questions about his signs (observable)
and symptoms (Non-observable), 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,
functional status, and
collection of data
concerning actual or
potential dysfunction.
Baseline for reference
and future comparison.

Within the specified time

frame after admission to
a hospital, nursing home,
ambulatory healthcare
center.

2- Focus assessment

Status determination of a
specific problem
identified during previous
assessment.

Ongoing process,
integrated with nursing
care, a few minutes to a
few hours between
assessments.

3- Time lapsed
reassessment

Comparison of clients
Several months (3,6,9
current status to baseline months or more)
obtained previously,
between assessment
detection of changes in
all functional health
patterns after an
extended period of time
has passed
AT anytime
Identification of life
threatening situation

4- Emergency
assessment

Setting and environment

Assessment can take place in any setting
where nurses care for clients and their
family members: in the clients home, at
a clinic, in a hospital room.

Assessment skills
1- Observation
Comprises more than the nurses 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.
Observation has two aspects:
noticing the data and
selecting, organizing, and interpreting the data.

Observation done in the following order:

Clinical signs of client distress.
Threats to the clients safety, real or
anticipated.
The presence and functioning of
associated equipment.
The immediate environment, including
the people in it.

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.
There are two approaches to interviewing
directive
nondirective.

The directive interview

Is highly structured and elicits specific information.
The nurse establishes the purpose of the interview and
controls the interview.
The client responds to questions but may have limited
opportunities to ask questions or discuss concerns.

The nondirective interview or rapport-building

interview, by contrast the nurse allows the client to
control the purpose, subject matter, and pacing.

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
Auscultation

1. 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.

2. 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.

3. 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.

4. 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.

Assessment Activities
The activities that make up the assessment are
:the following
Collect data- 1
Data collection, the process of compiling
information about the client, begins with the first
client contact.
Nurses use observation, interviewing, and physical
examination.

Validate data- 2
Validation, commonly referred to as double
checking the information at hand, is the process of
confirming the accuracy of assessment data
collected.
Validation assists in verifying and clarifying cues
and inference.

Organize data- 3
After data collection is completed and information
is validated, the nurse organizes, or clusters, the
information together in order to identify areas of
strengths and weaknesses.
This process is known as data clustering. How
data are organized depends on the assessment
model used. One of these model is Head to Toe
model.

4- Documenting Data
To complete the assessment phase, the nurse
records client data.
Accurate documentation is essential and should
include all data collected about the clients health
status.
To increase accuracy, the nurse records subjective
data in the clients own words to avoid the chance
of changing the original meaning.

Types of data:
Subjective data. 1
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''

2. 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.

Sources of data
It can be primary or secondary.
The client is the primary source of data.
Family members or other support persons,
other health professionals, records and reports,
laboratory and diagnostic analyses, and
relevant literatures are secondary or indirect
sources.

2nd Component of the Nursing Process-

NURSING DIAGNOSIS

The second step in the nursing process

involves further analysis (breaking the whole
down into parts that can be examined) and
synthesis (putting data together in a new way)
of the data that have been collected.

 According to the North American Nursing

Diagnosis Association (NANDA)
a nursing diagnosis is a clinical judgment about
individual, family, or community responses to
actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection
of nursing interventions to achieve outcomes for
which the nurse is accountable. (Carroll-Johnson,
1990, p. 50).

Purposes of nursing diagnosis

- Nursing diagnosis is unique in that it focuses
on a clients response to a health problem,
rather than on the problem itself, and it
provides the structure through which nursing
care can be delivered.
- Nursing diagnosis also provides a means for
effective communication.

- Holistic client, family, and community-focused

care are facilitated with the use of nursing
diagnosis.
- Nursing diagnosis has an important impact on
the health care delivery system

Differentiating Nursing Diagnosis versus Medical Diagnosis

Nursing Diagnosis
- focus on unhealthy
responses to health and
illness.
- describe problems
treated by nurses within
the scope of independent
nursing practice.
- may change from day to
day as the patients
responses change

Medical Diagnosis
- identify diseases

- describe problems for

which the physician
directs the primary
treatment .
- remains the same for as
long as the disease is
present

 Myocardial infarction (heart attack) is a

medical diagnosis.
Examples of nursing diagnoses for a person
with myocardial infarction include Fear,
Altered Health Maintenance, Knowledge
Deficit, Pain, and Altered Tissue Perfusion.

Nursing Diagnosis versus

Collaborative Problems

If such problems require physician prescribed and

nurse prescribed action, however, they are
collaborative health problems.
Collaborative problems refer to actual or potential
physiologic complications that can result from
disease, trauma, treatment, or diagnostic studies for
which nurses intervene in collaboration with
personnel of other disciplines.

Types of Nursing Diagnoses

1- Actual Nursing Diagnoses
Describe a human response to a health problem that is
being manifested. They are written as three- part
statements: diagnostic label, related factors, defining
characteristics.
Example Acute pain related to surgical trauma and
inflammation, as evidenced by grimacing and verbal
reports of pain.

Q- Which One is accurate nursing diagnosis?

1- Impaired physical mobility related to pain
2- Ineffective movement related to arthritis

2- Risk nursing diagnosis

As defined by NANDA, describes human

responses to health conditions that may
develop in a vulnerable individual, family,
or community. It is supported by risk
factors that contribute to increased
vulnerability.

3- Wellness nursing diagnosis

Is a diagnostic statement that describe the
human response to levels of wellness in an
individual, family, or community that have a
potential for enhancement to a higher state
(NANDA, 2005).

4- Possible Nursing Diagnoses

Is made when not enough evidence supports
the presence of the problem but the nurse
thinks that is highly probable and wants to
collect more information.

Validate Diagnosis
For each diagnosis, the nurse should discuss
with the client the significance of the problem,
determine the clients perception of the reason
for the problem, and ask whether the client
desires help to resolve or to diminish the
problem.

3rd component of the Nursing Process- Planning:

The third step of the nursing process includes the

formulation of guidelines that establish the
proposed course of nursing action in the resolution
of nursing diagnoses and the development of the
clients plan of care.
The planning of nursing care occurs in three
phases: initial, ongoing, and discharge. Each type
of planning contributes to the coordination of the
clients comprehensive plan of care.

Initial planning
involves development of beginning of care by the
nurse who performs the admission assessment and
gathers the comprehensive admission assessment
data.
Initial planning is important in addressing each
prioritized problem, identifying appropriate client
goals, and correlating nursing care to hasten
resolution of the clients problems.

Ongoing planning
entails continuous updating of the clients plan
of care. Every nurse who cares for the client is
involved in ongoing planning.
Discharge planning
involves critical anticipation and planning for
the clients needs after discharge.

3rd component of the Nursing ProcessPlanning:

The establishment of client
goals/outcomes

Working with the client, to prevent, reduce, or

resolve problems
To determine related nursing interventions
(actions) that are most likely to assist client in
achieving goals
This is about improving the quality of life for
your patient.
This is about what your patient needs to do to
improve his health status or better cope with his
illness.

During Planning, the provider:

A. Establishes Priorities
B. Writes Client Goals/Outcomes And
Develops An Evaluative Strategy
C. Selects Nursing Interventions
D. Communicates The Plan

The four critical elements of planning

include:
Establishing priorities
Setting goals and developing expected
outcomes (outcome identification)
Planning nursing interventions (with
collaboration and consultation as needed)
Documenting

1- Establishing Priorities
The establishment of priorities is the first element of
planning. In establishing priorities, the nurse
examines the clients nursing diagnoses and ranks
them in order of physiological or psychological
importance.
Various guidelines are used in the establishment of
priorities for determining which nursing diagnosis
will be addressed initially.

 The clients basic needs, safety, and desires, as well as

anticipation of future diagnoses must be considered. One of
the most common methods of selecting priorities is the
consideration of Maslows hierarchy of needs, which requires
that a life-threatening diagnosis be given more urgency than a
non life threatening diagnosis.
The client must participate in the identification of priorities so
that the nature of the problem, as well as the clients values,
are reflected in the selected course of action.

2- Establishing Goals and Expected Outcomes

The purposes of setting goals and expected
outcomes are to provide guidelines for
individualized nursing interventions and to
establish evaluation criteria to measure the
effectiveness of the nursing care plan.
A goal is an aim, an intent, or an end.

A goal is a broad or globally written statement

describing the intended or desired change in
the clients behavior, response, or outcome.
An expected outcome is a detailed, specific
statement that describes the methods through
which the goal will be achieved.

Goals should be established to meet the

immediate, as well as long-term prevention and
rehabilitation, needs of the client.
A short-term goal is a statement written in
objective format demonstrating an expectation
to be achieved in resolution of the nursing
diagnosis in a short period of time, usually in a
few hours or days.

A long-term goal is a statement written in

objective format demonstrating an
expectation to be achieved in resolution of
the nursing diagnosis over a longer period
of time, usually over weeks or months.

Guidelines for Writing Outcomes

Written outcomes can be evaluated by seeing if

they conform to the following criteria:
Each set of outcomes is derived from only one nursing
diagnosis.
At least one of the outcomes shows a direct resolution
of the problem statement in the nursing diagnosis.
Both long-term and short-term outcomes are
identified as necessary.

 Cognitive, psychomotor, and affective outcomes

appropriately signal the type of change needed by the
patient.
The patient and family value the outcomes.
Each outcome is brief and specific (clearly describes
one observable, measurable patient
behavior/manifestation), is phrased positively, and
specifies a time line.
The outcomes are supportive of the total treatment
plan

Example
NURSING DIAGNOSIS: Disturbed Sleep Pattern
Goal: Client will sleep uninterrupted for 6 hours.
EXPECTED OUTCOMES
Client will request back massage for relaxation.
Client will set limits to family and significant other
visits.

3- Planning Nursing Interventions

Once the goals have been mutually agreed on by
the nurse and client, the nurse should use a
decision-making process to select appropriate
nursing interventions.
Nursing interventions are treatment, based upon
clinical judgment and knowledge that a nurse
performs to enhance patient / client outcomes.

Writing a client plan of care

Two important concepts guide a client plan of care:
1- The plan of care is client centered.
2- The plan of care is a step by step process.
Sufficient data are collected to substantiate nursing
diagnoses.
At least one goal must be stated for each nursing
diagnosis
Outcome criteria must be identified for each goal

 Nursing interventions must be specifically

designed to meet the identified goal.
Each intervention should be supported by a
scientific rationale.
Evaluation must address whether each goal was
completely met, partially met, or completely
unmet.

4th Component of the Nursing Process-

Implementing:
The provider carries out the plan of care

Implementing
Consists of doing and documenting the activities that are
the specific nursing actions needed to carry out the
interventions or nursing orders.
The first three nursing process phases-assessing,
diagnosing, and planning-provide the basis for the
nursing actions performed during the implementing step.
In turn, the implementing phase, provide the actual
nursing activities and client responses that are examined
in the final phase, the evaluating phase.

 While implementing nursing orders, the nurse

continues to reassess the client at every contact,
gathering data about the clients responses to nursing
activities and about any new problems that may
develop.
To implement the care plan successfully, nurses need
cognitive, interpersonal, and technical skills. These
skills are distinct from one another.

The cognitive skills (intellectual skills) include problem

solving, decision making, critical thinking, and creativity.
Interpersonal skills are all of the activities, verbal and
nonverbal, people use when interacting directly with one
another, this depends on the ability of the nurse to
communicate effectively with others. It is necessary for all
nursing activities, caring, comforting, advocating, referring,
counseling, and supporting others.
Technical skills are hands-on skills such as manipulating
equipments, giving injections and bandaging, moving lifting,
and repositioning clients. These are called procedures, tasks, or
psychomotor skills.

Process of Implementing

Reassessing the client

Determining the nurses need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities

Reassess the Client, to make sure the

intervention is still needed.
Even though an order is written on the care
plan, the clients condition may have changed.
The nurse also provides supportive
communication to help alleviate the clients
stress.

Determining the Nurses Need for Assistance, for one of the

following reasons:

The nurse is unable to implement the nursing

activities safely alone
Assistance would reduce stress on the client
The nurse lacks the knowledge or skills to
implement a particular nursing activities

Implementing the nursing Interventions, it is

important to explain to the client what interventions
will be done, what sensations to expect, what the
client is expected to do, and what the outcome is.
Ensure client privacy, coordinate client care, and
involve scheduling client contacts with other
departments.

When implementing interventions, nurses should follow these

guidelines:

Base nursing interventions on scientific knowledge,

nursing research, and professional standards of care
whenever possible.
Clearly understand the order to be implemented and
question any that are not understood.
Adapt activities to the individual client, a clients
beliefs, values; age, health status, and environment
are factors that can affect the success of a nursing
action.

 Implement safe care

Provide teaching, support and comfort to enhance the
effectiveness of nursing care plans.
Be holistic; view the client as a whole.
Respect the dignity of the client and enhance the
clients self- esteem
Encourage client to participate actively in
implementing the nursing interventions.

Supervising Delegating Care, if care has

been delegated to other health care personnel,
the nurse responsible for all the clients care
must ensure that the activities have been
implemented according to the care plan.

Documenting Nursing Activities, the nurse complete

the implementing phase by recording the
interventions and client responses in the nursing
process notes.
The nurse may record routine or recurring activities such as
mouth care in the client record at the end of shift, while
some actions recorded in special worksheets according to
agency policy.
Immediate recording helps safeguard the client to prevent
double actions.

During Implementing, the care provider:

Carries Out The Plan Of Nursing Care or

Setting your plans in motion and delegating
responsibilities for each step.

Continues Data Collection And Modifies The

Plan Of Care As Needed

Documents Care

5th Component of the Nursing Process-

Evaluating:
The last phase of the nursing process,
follows implementation of the plan of care,
its the judgment of the effectiveness of
nursing care to meet client goals based on
the clients behavioral responses.

5th Component of the Nursing Process-

Evaluating:
The measuring of the extent to which
client goals have been met
Evaluation involves not only
analyzing the success of the goals and
interventions, but examining the need
for adjustments and changes as well.
The evaluation incorporates all input
from the entire health care team,
including the patient.

Process of Evaluating Client Responses

Collecting data related to the desired
outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the
nursing care plan.

When determining whether a goal has been achieved,

the nurse can draw one of the three possible
conclusions:
The goal was met, that is the client response is the same as
the desired outcomes.
The goal was partially met, that is either a short term goal
was achieved but the long term was not, or the desired
outcome was only partially attained.
The goal was not met.

Relationship of Evaluation to Nursing Process

During Evaluating, the care provider:

Measures The Clients Achievement Of

Desired Goals/Outcomes

Identifies Factors That Contribute To

The Clients Success Or Failure

Modifies The Plan Of Care, If Indicated

Purpose of the nursing process:

To Achieve ScientificallyBased, Holistic, Individualized

Care For The Client
To Achieve The Opportunity To
Work Collaboratively With
Clients, Others
To Achieve Continuity Of Care

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