NURSING PROCESS

NURSING PROCESS
• Systematic, rational method of planning and providing individualized
nursing care .
• Lydia Hall originated the term “nursing process”

PURPOSES OF NURSING PROCESS

• Identify a client’s health status and actual or potential healthcare
problems or needs .
• To establish plans to meet the identified needs
• To deliver specific nursing interventions to meet those needs .
 NURSING PROCESS
CHARACTERISTICS OF NURSING PROCESS

• Regularly repeated event or sequence of events (a cycle) that is

continuously changing (dynamic) rather than staying the same
(static) .
• Client - centered
• Parallel to but separate from the medical model
• The medical model focuses on physiologic systems and disease process,
whereas the nursing process is directed toward a client’s response to real
or potential disease and illness .
• Decision making is involved in every phase of the nursing process .
 NURSING PROCESS
CHARACTERISTICS OF NURSING PROCESS

• Interpersonal and collaborative

• Universally applicable
• Nurses must use a variety of critical thinking skills to carry out the
nursing process .
• Nurses must utilize clinical reasoning throughout the delivery of
nursing care .
 NURSING PROCESS
OVERVIEW OF THE NURSING PROCESS
PHASE DESCRIPTION PURPOSE ACTIVITIES
ASSESSMENT Collect, organize, To establish a • Establish
validate, and database about the database
document client data . client’s response to • Update data as
health concerns or needed
illness and the ability • Organize data
to manage • Validate data
healthcare needs • Communicate and
document data
 NURSING PROCESS
OVERVIEW OF THE NURSING PROCESS
PHASE DESCRIPTION PURPOSE ACTIVITIES
DIAGNOSING Analyze and • To identify client strength • Interpret and
synthesize and health problems that analyze data
data can be prevented or • Determine client’s
resolved strengths, risks,
• To develop list of nursing and problems
and collaborative problems • Formulate nursing
diagnoses and
collaborative
problems
• Document nursing
diagnoses on care
plan
 NURSING PROCESS
OVERVIEW OF THE NURSING PROCESS
PHASE DESCRIPTION PURPOSE ACTIVITIES
PLANNING Determine : • To develop an • Set priorities and goals
• how to prevent, individualized or desired outcomes in
reduce, or care plan that collaboration with client .
resolve identified specifies client • Write goals or desired
priority client goals or outcomes .
problems desired • Select nursing
• how to implement outcomes and interventions
nursing related nursing • Write nursing
interventions in interventions interventions and nursing
an organized, care plan
individualized, • Communicate care plan
and goal - directed to relevant healthcare
manner providers
 NURSING PROCESS
OVERVIEW OF THE NURSING PROCESS
PHASE DESCRIPTION PURPOSE ACTIVITIES
IMPLEMENTATION Carrying out • To assist the • Reassess the client to
or delegating client to meet update the database .
and desired goals • Determine the nurse’s
documenting or outcomes need for assistance
the planned • Promote • Perform planned nursing
nursing wellness interventions .
intervention • Prevent • Communicate what
illness/disease nursing actions were
• Restore health implemented .
• Facilitate
coping with
altered function
 NURSING PROCESS
OVERVIEW OF THE NURSING PROCESS
PHASE DESCRIPTION PURPOSE ACTIVITIES
EVALUATION Measuring the • To determine • Collaborate with client and collect
degree to whether to data related to desired outcomes .
which goals continue, • Judge whether goals or outcomes
or outcomes modify, or have been achieved .
have been terminate • Relate nursing actions to client
achieved and the plan of goals or outcomes .
identifying care • Make decisions about problem
factors that status .
positively or • Review and modify the care plan
negatively as indicated or terminate nursing
influence goal care .
achievement . • Document achievement of
outcomes and modification of the
care plan .
ASSESSMENT
 ASSESSMENT

• Systematic and continuous collection, organization, validation, and

documentation of data .

• In effect, assessing is a continuous process carried out during all

phases of the nursing process .

• All phases of the nursing process depend on the accurate and

complete collection of data .
 ASSESSMENT
TYPES OF ASSESSMENT

TYPE TIME PERFORMED PURPOSE

Initial Assessment Performed within a To establish a complete
specified time after database for problem
admission to a identification, reference,
healthcare agency and future comparison .
Problem - focused Ongoing process To determine the status
Assessment integrated with of a specific problem
nursing care identified in an earlier
assessment
 ASSESSMENT
TYPES OF ASSESSMENT

TYPE TIME PERFORMED PURPOSE

Emergency During anyTo identify life -
Assessment physiologic orthreatening problems
psychologic crisis ofTo identify new or
the client overlooked problems
Time - lapsed Several months after To compare the client’s
Reassessment initial assessment current status to
baseline data previously
obtained
 DATA COLLECTION
• Process of gathering information about a client’s health status .

• Data collection must be both systematic and continuous to prevent

the omission of significant data and reflect a client’s changing health
status .

• A database contains all the information about a client ; it includes the

nursing health history, physical assessment, primary care provider’s
history and physical examination, results of laboratory and
diagnostic tests, and material contributed by other health personnel .
 DATA COLLECTION
COMPONENTS OF NURSING HEALTH HISTORY
• Biographic Data
• Chief Complaint or Reason for Visit
• History of Present Illness
• Past Medical History
Illness Accidents and Injuries
Immunization Hospitalization for serious illness
Allergies Medications
• Family History of Illness
 DATA COLLECTION
COMPONENTS OF NURSING HEALTH HISTORY
• Lifestyle
Personal Habits Activities of Daily Living
Diet Recreation and Hobbies
Sleep Patterns
• Social Data
Family Relationships and Friendships
Ethnic Affiliation
Educational History
Occupational History
Economic Status
Home and Neighborhood Conditions
 DATA COLLECTION
COMPONENTS OF NURSING HEALTH HISTORY
• Psychologic Data
Major stressors
Usual Coping Pattern
Communication Style
• Patterns of Healthcare
All healthcare resources client is currently using and has used in the past .
 DATA COLLECTION
TYPES OF DATA
• Subjective Data (Symptoms, Covert Data)
• Apparent only to the individual affected and can be described/verified only
by that individual
• Objective Data (Signs, Overt Data)
• Detectable by an observer or can be measured or tested against an
accepted standard

• Constant Data
• Information that does not change over time
• Variable Data
• Change quickly, frequently, or rarely .
 DATA COLLECTION
SOURCES OF DATA
• Primary Source : Client
• The best source of data is usually the client, unless the client is too ill,
young, or confused to communicate clearly .
• When establishing a rapport with the client it is important to share that, by
gathering a thorough assessment, the nurse will be able to meet the needs
of the client to ensure better health outcomes .

• Secondary Source : All sources other than the client

• Support People : Family members, friends, and caregivers
• Client Records
• Healthcare Professionals
• Literature
 DATA COLLECTION
DATA COLLECTION METHODS
• Observation : gather data by using senses
• Involves two aspects : (a) noticing the data (b) selecting, organizing, and
interpreting the data
• Nursing observation must be organized so that nothing significant is
missed . Most nurses develop a particular sequence for observing events,
usually focusing on the client first .
• Clinical signs of distress
• Threats to client’s safety
• Presence and functioning of associated equipment
• Immediate environment, including people in it

• Examination : physical assessment, screening examination/review of

systems
 DATA COLLECTION
DATA COLLECTION METHODS
• Interview : planned communication or conversation with a purpose
• Focused Interview : nurse asks specific questions to collect information
related to client’s problem

Approaches of Interview
• Directive
• Highly structured and elicits specific information
• Nurse establishes the purpose of interview and controls the interview .
• Nondirective (Rapport - Building Interview)
• The nurse allows the client to control the purpose, subject matter, and
pacing .
 DATA COLLECTION
Types of Interview Questions
• Closed questions
• Used in the directive interview, are restrictive, and generally require only
yes/no or short factual answers that provide specific information .
• Often used when information is needed quickly or if the individual is highly
stressed or have difficulty communicating .

• Open- ended questions

• Associated with the nondirective interview, invite clients to discover and
explore, elaborate, clarify, or illustrate their thoughts or feelings .
• Invites answer longer than one or two words .
• Useful at the beginning of an interview or to change topics and to elicit
attitudes .
 DATA COLLECTION
Types of Interview Questions
• Neutral questions
• Client can answer without direction or pressure from the nurse, is open -
ended, and is used in non- directive interviews .

• Leading questions
• Usually closed, used in a directive interview, and thus directs the client’s
answer .
• Can create problem if the client, in an effort to please the nurse, gives
inaccurate responses . This can result in inaccurate data
 DATA COLLECTION
Planning the Interview and Setting
• Time
• Client is physically comfortable and free of pain .
• Interruptions by friends, family, and other health professionals are minimal .

• Place
• Well- lit, well - ventilated room that is relatively free of noise, movements,
and distractions .
• Where others cannot overhear or see
 DATA COLLECTION
Planning the Interview and Setting
• Seating Arrangement
• When a client is in bed, the nurse can sit at a 45 - degree angle to the bed.
• During an initial admission interview, a client may feel less confronted if
there is an overbed table between the client and the nurse .
• A seating arrangement in which the parties sit on two chairs placed at right
angles to a desk or table or a few feet apart, with no table between, creates
a less formal atmosphere, and the nurse and client tend to feel on equal
terms .
• In groups, a horseshoe or circular chair arrangement can avoid a superior
or head - of- the- table position .
• Distance
• Most people feel comfortable maintaining a distance of 2 to 3 feet during an
interview .
 DATA COLLECTION
STAGES OF AN INTERVIEW
• Opening
• Can be the most important part of the interview because what is said and
done at that time sets the tone for the remainder of the interview .
• The purposes of the opening are to establish rapport and orient the
interviewee .
• Body
• Client communicates what he or she thinks, feels, knows, and perceives in
response to questions from the nurse .
• Closing
• The nurse terminates the interview when the needed information has been
obtained
• In some cases, however, a client terminates it, for example, when deciding
not to give any more information or when unable to offer more information
for some other reason
DIAGNOSING
 STATUS OF THE NURSING DIAGNOSES
• Actual Nursing Diagnosis (Problem - Based Diagnosis)
• Present at the time of nursing assessment
• Risk Nursing Diagnosis
• Problem does not exist but the presence of risk factors indicates that a
problem is likely to develop unless nurses intervene .
• Health Promotion Diagnosis
• Relates to clients’ preparedness to implement behaviors to improve their
health condition .
• These diagnosis labels begin with the phrase willingness to learn or
willingness to change
• Syndrome Diagnosis
• Clinical nursing judgement when a client has several similar nursing
diagnosis
 COMPONENTS OF A NURSING DIAGNOSIS
• Problem (Diagnostic Label) and Definition
• Etiology (Related Factors and Risk Factors)
• Defining characteristics (Signs and Symptoms)
Example :
• Impaired Skin Integrity related to prolonged immobility as evidenced
by a stage 2 pressure ulcer on the sacral area
• Risk for Falls related to impaired balance
• Readiness for Enhanced Nutrition as evidenced by verbal expression
of desire to improve dietary habits, willingness to attend nutrition
classes, and setting personal goals for healthy eating .
• Post - Trauma Syndrome related to physical assault and prolonged
exposure to violence, as evidenced by nightmares, hypervigilance,
avoidance of reminders, and verbalization of fear .
PLANNING
 PLANNING
• Intentional, systematic phase of the nursing process that involves
decision - making and problem - solving .
• The nurse refers to the client’s assessment data and diagnostic
statements for direction in formulating client goals and designing
the nursing interventions required to prevent, reduce, or eliminate
the client’s health problems .
• Although planning is basically the nurse’s responsibility, input from
the client and support persons is essential if a plan is to be effective .
Nurses do not plan for the client but encourage the client to
participate actively to the extent possible .
• In a home setting, the client’s support people and caregivers are the
ones who implement the plan of care ; thus, its effectiveness
depends largely on them .
 PLANNING
TYPES OF PLANNING
• Initial Planning
• The nurse who performs the admission assessment usually develops the
initial comprehensive plan of care .
• Planning should be initiated as soon as possible after the initial
assessment .
• Ongoing Planning
• As nurses obtain new information and evaluate the client’s responses to
care, they can individualize the initial care plan further .
• Ongoing planning also occurs at the beginning of a shift as the nurse plans
the care to be given that day.
• Discharge Planning
• Effective discharge planning begins at first client contact and involves
comprehensive and ongoing assessment to obtain information about the
client’s ongoing needs .
 PLANNING
DEVELOPING NURSING CARE PLANS
• Informal Nursing Care Plan
• Strategy for action that exists in the nurse’s mind
• Formal Nursing Care Plan
• Written or computerized guide that organizes information about client’s
care
• Provides for continuity of care
• Standardized Care Plan
• Formal plan that specifies the nursing care for groups of clients with
common needs
• Individualized Care Plan
• Tailored to meet the unique needs of a specific client – needs that are not
addressed by standardized plan .
 PLANNING
THE PLANNING PROCESS

1. Setting Priorities
• Life - threatening problems are designated as high priority
• Health - threatening problems are assigned medium priority
• Low priority problem is one that arises from normal developmental needs
or requires only minimal nursing support
 PLANNING
THE PLANNING PROCESS
2. Establishing Client Goals or Desired Outcomes
• Goals may be short - term or long - term
• Short term goals are useful for clients who require healthcare for a
short time or are frustrated by long - term goals that seem difficult to
attain and who need the satisfaction of achieving a short - term goal .
COMPONENTS OF GOALS
• Subject
• Verb
• Condition or Modifiers
• Criterion of Desired Performance : time or speed, accuracy, distance,
and quality
 PLANNING
THE PLANNING PROCESS
2. Establishing Client Goals or Desired Outcomes

COMPONENTS OF GOALS
• The client will be able to administer the correct insulin dose using
aseptic technique
• The patient will be able to identify foods high in salt before discharge
time .
 PLANNING
THE PLANNING PROCESS
2. Establishing Client Goals or Desired Outcomes
Guidelines for writing goals or desired outcomes
• Write goals and outcomes in terms of client responses not nursing
activities
• Be sure that desired outcomes are realistic for the client’s capabilities,
limitations, and designated time span, if it is indicated .
• Ensure that the goals or desired outcomes are compatible with the
therapies of other professionals .
• Make sure that each goal is derived from only one nursing diagnosis
• Use observable, measurable terms for outcomes . Avoid words that are
vague and require interpretation or judgment by the observer .
• Make sure the client considers the goals or desired outcomes important
and values them .
 PLANNING
THE PLANNING PROCESS
3. Select nursing interventions and activities
• Independent Interventions
• Dependent Interventions
• Collaborative Interventions
Criteria for Choosing Nursing Interventions
• Safe and appropriate for individual’s age, health, and condition
• Achievable with the resources available
• Congruent with client’s values, beliefs, and culture
• Congruent with other therapies
• Based on nursing knowledge and experience or knowledge from relevant
sources
• Within established standards of care as determined by state laws,
professional organizations, and the policies of the institution
 PLANNING
THE PLANNING PROCESS
4. Writing individualized nursing interventions on care plans
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE: Within 12 hours • Assess and document • Frequent After 12 hours of
• Mild of nursing the condition of the assessments help nursing
discomfort intervention, the sacral wound and detect early signs intervention, the
felt on the patient will be erythematous areas of deterioration or patient:
sacral area Impaired Skin able to: every shift . improvement .
Integrity related
OBJECTIVE: to prolonged • Verbalize • Reposition the patient • Relieves pressure • Reported less
• Pressure immobility as relief from at least every 2 hours . from vulnerable discomfort on at
ulcer with evidenced by discomfort areas and the pressure
surrounding Stage II pressure promotes sites
redness and ulcer on sacral circulation .
minimal area and • Maintain skin • Sacral ulcer
serous erythema of both integrity as • Clean the wound with • Cleansing and showed reduced
drainage on heels evidenced by normal saline and dressing support a redness with no
the sacral improvement apply prescribed moist healing increase in
area in the dressings . environment and drainage and no
appearance prevent infection . new pressure
• Redness on of existing areas noted
both heels ulcer
IMPLEMENTATION
 IMPLEMENTATION
IMPLEMENTING SKILLS
• Cognitive (Intellectual) skills
• Problem - solving, decision - making, critical thinking, clinical reasoning, and
creativity .
• Interpersonal Skills
• All of the activities, verbal and nonverbal, people use when interacting
directly with one another
• Include conveying knowledge, attitudes, feelings, interest, and appreciation
of the client’s cultural values and lifestyle .
• Before nurses can be highly skilled in interpersonal relations, they must
have self - awareness and sensitivity to others .
• Technical Skills
• Purposeful “hands - on” skills (procedures, task, psychomotor skills)
 IMPLEMENTATION
PROCESS OF IMPLEMENTING
1. Reassessing the client
• Just before implementing an intervention, the nurse must reassess
the client to make sure the intervention is still needed . Even though an
order is written on the care plan, the client’s condition may have
changed .
• New data may indicate a need to change the priorities of care or the
nursing activities .
 IMPLEMENTATION
PROCESS OF IMPLEMENTING
2. Determining the nurse’s need for assistance
When implementing some nursing interventions, the nurse may require
assistance for one or more of the following reasons :
• The nurse is unable to implement the nursing activity safely or
efficiently alone .
• Assistance would reduce stress on the client
• The nurse lacks the knowledge or skills to implement a particular
nursing activity
 IMPLEMENTATION
PROCESS OF IMPLEMENTING
3. 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 expected
outcome is .
• When implementing interventions, nurses should follow these guidelines :
• Base nursing interventions on scientific knowledge, nursing research, and
professional standards of care (evidence - based practice) when these exist .
• Clearly understand the interventions to be implemented and question any
that are not understood .
• Adapt activities to the individual client .
• Implement safe care
• Provide teaching, support, and comfort
• Be holistic
• Respect the dignity of the client and enhance the client’s self - esteem .
• Encourage clients to actively participate in implementing the nursing
interventions .
 IMPLEMENTATION
PROCESS OF IMPLEMENTING
4. Supervising the assigned care
• If care has been assigned or delegated to other healthcare personnel, the
nurse responsible for the client’s overall care must ensure that the
activities have been implemented according to the care plan .
• The nurse is accountable for any delegation of care and for evaluation of the
care that has been implemented .
5. Documenting nursing activities
• After carrying out the nursing activities, the nurse completes the
implementing phase by recording the interventions and client responses in
the nursing progress notes .
• Nursing care must not be recorded in advance because the nurse may
determine on reassessment of the client that the intervention should not or
cannot be implemented .
EVALUATION
 EVALUATION
• Planned, ongoing, purposeful activity in which client and healthcare
professionals determine :
• Client’s progress toward achievement of goals or outcomes
• The effectiveness of nursing care plan
• Evaluation is continuous . Evaluation done while or immediately after
implementing a nursing order enables the nurse to make on- the-
spot modifications in an intervention .
• Evaluation performed at specified intervals shows the extent of
progress toward achievement of goals or outcomes and enables the
nurse to correct any deficiencies and modify the care plan as
needed .
• Evaluation at discharge includes the status of goal achievement and
the client’s self - care abilities with regard to follow - up care .
 EVALUATION
PROCESS OF EVALUATING CLIENT RESPONSES

• Collecting data related to desired outcomes

• Comparing the data with desired outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem status
• Continuing, modifying, or terminating the nursing care plan
 EVALUATION
EVALUATING THE QUALITY OF NURSING CARE
• Quality Assurance (QA)
• Ongoing, systematic process designed to evaluate and promote excellence
in the healthcare provided to clients
• Requires evaluation of three components of care
• Structure evaluation : focuses on the setting in which care is given .
• Process evaluation : focuses on how the care was given
• Outcome evaluation : focuses on demonstrable changes in the client’s
health status as a result of nursing care .
 EVALUATION
EVALUATING THE QUALITY OF NURSING CARE
• Quality Improvement (QI)
• AKA : Total Quality Management (TQM), Continuous Quality Improvement
(CQI), Performance Improvement (PI), Persistent Quality Improvement (PQI)
• Focus on identifying and correcting a system’s problem .
• A sentinel event is an unexpected occurrence involving death, permanent
harm, or severe temporary harm and intervention required to sustain life .
• Root cause analysis is a process for identifying the factors that bring about
deviations in practices that lead to the event . It focuses primarily on
systems and processes, not individual performance .
• Unlike QA, it uses a systematic approach with the intention of improving the
quality of care rather than ensuring the quality of care .
 EVALUATION
EVALUATING THE QUALITY OF NURSING CARE
• Nursing Audits : examination or review of records
• Retrospective audit : evaluation of a client’s record after discharge from an
agency
• Concurrent audit : evaluation of a client’s healthcare while the client is still
receiving care from the agency .