Objectives

At the completion of this unit learners will be able

to:
 Define nursing process.
 Describe the purposes of nursing process.
 Identify the components of the nursing process.
 Identify the four major activities associated with
assessing phase.
 Differentiate objective and subjective data and
primary and secondary data
 Identify the sources of data collection.
 Objectives
 Define nursing diagnosis.
 Differentiate between nursing diagnosis and
medical diagnosis type.
 Identify the types of nursing diagnosis.
 Identify the component of nursing diagnosis.
 Describe the formats for writing nursing
diagnoses.
 Define planning.
 Identify activities that occur in the planning
process.
 Nursing Process
The Nursing Process is a systematic, rational
method of planning and providing care to the
client.
Nursing Process is dynamic and requires
creativity in its application.
The purpose is to provide client care that is
individualized, holistic, effective and efficient
client care.
OR
The Nursing process is a systematic, rational
method of planning and providing individualized
nursing care.

OR
Nursing process is a patient centered, goal
oriented method of caring that provides a
frame work to the nursing care. It involves five
steps:
 Assessment
 Nursing diagnosis
 Planning
 Implementation
 Evaluation
 Assessment
This is the first step in the nursing process.
Assessing is the systematic and continuous
collection, organization, validation, and
documentation of data (information).
In effect, assessing is a continuous process carried
out during all the phases of the nursing process.
 Type of Assessment
There are four different types of
assessment:
 Initial Assessment
 Problem-focused Assessment
 Emergency Assessment
 Time-lapsed Assessment
Assessment vary according to their purpose,
timing, time available, and client status
 Methods of Assessment
 Interview
 Physical Examination
 Interview
 It is planned, communication or conversation
to give information, identify problem.
 Interview has two main types:
 Directive interview
 Non directive interview
 Directive interview

It is highly structured and elicits the specific

information. The interview is made purposeful
and controlled by asking specific questions that
are close ended questions i.e. Are you working in
this hospital? Answer will be yes or no form.
 Non directive interview
The nurses ask broad questions that are open in
nature. i.e. For interview setting and planning
important things are time, place, setting
arrangement.
Example:
Whatbrought you to the hospital?
Howdidyou feel in that situation?
 Physical Examination
In this the observational skills are used to detect
the health problems. The techniques that used
in examination are inspection, auscultation,
palpation and percussion. The physical
examination is done from head to toe.
 Assessment Process
 The assessment process involves four closely
related activities:

 Collecting Data
 Organization
 Validating Data
 Documenting Data
 Data Collection
This is the process of gathering information
about a client’s health status.
Database is all information about a client
includes health history, physical assessment,
physical examination and lab investigations.
 Types of Data
 Subjective data
 Objective data
 Subjective data

Subjective data are defined as symptoms or

covert data, and apparent only to person and
verified by that person.
Example : Pain, anxiety and feelings of worry
etc.
 Objective data

Objective data are signs or Overt data , are

detectable by the observers. Exp…….
Vital Signs: Blood pressure, heart rate, respiratory rate,
temperature, oxygen saturation.
 Source of Data
 Primary Source
 Client/Family
 Secondary Source
 Lab reports
 Records
 Team members
 Diagnostic tests
 Organizing Data
The nurse uses a written (or computerized)
format that organizes the assessment data
systematically.
OR
To obtain data systematically, the nurse uses and
organized assessment framework called health
history. Mostly used frame work is Gorden’s 11
functional health patterns.
 Validating Data
This is the act of double checking, verifying data
to conform that are accurate and factual.
Validating data helps the nurse to complete the
task.
 Nursing Diagnoses
Nursing diagnosis “Is a clinical judgment about
individual, Family, or community responses to
actual and potential health problems/life processes.
A nursing diagnosis provides the basis for selection
of nursing interventions to achieve outcome to
which the nurse is accountable.”
(NANDA International, 2005)
The first conference on nursing diagnosis was held
in 1973 to identify nursing knowledge and establish
a classification system.
 Difference between nursing diagnosis
and medical diagnosis
Nursing diagnosis Medical diagnosis

1. Nursing diagnosis is based on health 1. Medical diagnosis id based on the

problems. physiologic conditions.

2. Nursing diagnosis can be changed at 2. It remains same throughout course of

any time. disease.

3. Nursing diagnosis focus on human 3. Medical diagnosis focus on the disease

response to stimuli. process.
 Types of Nursing diagnosis
The five types of Nursing Diagnosis are:
 Actual diagnosis
 Potential, risk or high risk diagnosis
 Wellness diagnosis
 Possible diagnosis
 Syndrome diagnosis
 Actual diagnosis

An actual diagnosis is a client problem that is

present at the time of the nursing assessment.
Examples are Ineffective breathing pattern and
Anxiety.
 Risk Nursing Diagnosis
An risk nursing diagnosis is clinical judgment that a
problem does not exist, but the presence of risk
factors indicates that a problem is likely to
develop unless nurses intervene.
For Example, all people admitted to the hospital
have some possibility of acquiring an infection ;
however, a client with diabetes or a compromised
immune system is at high risk than others.
Therefore, the nurse appropriately use the label
Risk for infection to describe the client’s health
status.
 Wellness Diagnosis:
”Describes human responses to levels of
wellness in an individual, family or community
that have a readiness for enhancement “
(NANDA International, 2005)
 Possible Nursing Diagnosis
A possible Nursing Diagnosis is one in which
evidence about a health problem is incomplete or
unclear. A possible diagnosis requires more data
either to support or to refute it.
For example , an elderly widow who lives alone is
admitted to the hospital. The nurse notices that she
has no visitors and is pleased with attention and
conversation from the nursing staff. Until more data
are collected, the nurse may write a nursing
diagnosis of possible Social Isolation related to
unknown etiology.
 Syndrome Diagnosis
A Syndrome Diagnosis : is diagnosis that is
associated with a cluster of other diagnoses.
(Carpenito-Moyet, 2006)
For example , may be experienced by long-term
bedridden clients. Cluster of diagnoses associated
with this syndrome include
Impaired physical mobility, Risk for Impaired
Tissues Integrity , Risk for Activity Intolerance, Risk
for Constipation, Risk for Infection, Risk for Injury,
Risk for Powerlessness, Impaired Gas Exchange
Components of Nursing Diagnosis
A nursing Diagnosis has three components:
1. The problem and its definition
2. The etiology (related factors)
3. The defining characteristics
 Problem Statement (diagnostic label)
This describe the client’s health problem for which
nursing therapy is given and describes health status
clearly and consciously in few words. Qualifiers
(words added to the label to give additional specific
meaning are altered (change) impaired (worse,
weak, damage, reduce, ineffective, acute and
chronic. Each label is approved by NANDA.
For example: altered thought process, altered
nutrition less than body requirement, impaired
physical mobility, ineffective air ways clearance etc..
 Etiology ( Related Factors)
This identifies one or more cause or risk factor
of health problem. For example: Fluid volume
deficit related to dehydration secondary to
cholera as evidence by loss of skin turgor.
 Defining Characteristics
This is cluster of sign and symptoms that
indicate the presence of a particular diagnostics
label for actual nursing diagnosis.
For example: anxiety related disease process as
evidence by restlessness. Restlessness is the
defining of diagnostics label.
Formulating diagnostic statements
 One part statement:
This consist of one statement such as in wellness
or syndrome diagnosis.
For example: Post stress trauma syndrome, rape
trauma syndrome, etc…
 Two part statement:
This is used for risk, high risk and potential and
possible nursing diagnosis. It includes the P
(Problem), E (Etiology). It is format is called P.E
format. For example: Risk for infection related to
diabetic foot.
 Third part statement:
This is used for actual nursing diagnosis. This format
is called PES. P (problem), E (Etiology), S (Sign and
symptoms/ Defining characteristics). For example:
altered breathing pattern related bronchospasm
secondary to bronchial asthma as evidence by use
of accessory muscles.
 Planning
This is 3rd phase of nursing process involves
decision making and problem solving. In this
phase nurse formulates the client goals (short
term and long term) and decision strategies to
prevent, reduce or eliminate the problem.
 Planning Process
 Priority setting
 Goal setting
 Selecting strategies
 Priority setting

In this process preferential orders for nursing

strategies are made. Life threading problem
such as loss of the respiratory or cardiac
functions are called high priority.
 Goal setting
The goal may be short or long term. In acute
cases, immediate needs most goals are short
term goal.
 Types of Goals
 Short term Goal: Is an objective that is expected to be
achieved within a short time frame, usually less then a
week.
 Long term Goal: Is an objective that is expected to be
achieved over a longer time frame, usually over weeks or
months. Long term goals may be more appropriate for
problem resolution after discharge, especially from acute
care settings.

 Expected Outcome: Is a specific measurable change in

client's status that is expected to occur in response to
nursing care.
 Selecting strategies
In this nursing strategies are selected to achieve
the goal.
 Implementation
In this phase nurse puts the nursing care plan
into action.
Skills of implementation
 Cognitive skills
 Interpersonal skills
 Technical skills.
 Cognitive skills

These include problem solving, decision making,

critical thinking and reasoning, intellectual,
judgment etc.…
 Interpersonal skills

• These include verbal and non verbal

communication to solve the patient health
problem.
 Technical skills
These include administration of drugs,
bandaging, moving, lifting or doing any nursing
procedures e.g. Lumber puncture,
catheterization, enema, etc.….
 Evaluation
 Evaluation is the fifth and last phase of the
nursing process. To evaluate mean to judge
that aim, target or goal is achieved or not.
 It is process to judge the actions.
 Evaluation has two main types:
 Formative evaluation
 Summative evaluation
 Formative evaluation

Formative evaluation done during nursing

actions. Taking temperature during sponging is
formative evaluation. Mid term examination is
also formative evaluation.
ASSESSEMENT NURSING DIAGNOSIS PLANNING IMPLIMENTATOIN EVALUATION
Short-Term Goals:
Subjective Data: Hyperthermia The patient’s body Administer 1. *Evaluate
Patient reports feeling temperature will decrease Antipyretic
related to the to within normal limits
Temperature
excessively warm or
(98.6°F or 37°C) within 24-
Medications as Changes.
uncomfortable. infectious 48 hours. Prescribed.
- Patient complains of
chills or sweating. process as The patient will report a
reduction in symptoms
Encourage Fluid
2. Assess Patient
- Patient expresses evidenced by associated with
fatigue or malaise. hyperthermia, such as Intake. Comfort.
elevated body feeling less warm and
*Objective Data:* temperature. experiencing fewer chills,
Promote Rest and 3. Review Fluid
within 24 hours.
Elevated body Comfort.
Long-Term Goals: Intake and
temperature. The patient will
Increased heart rate demonstrate effective
Hydration Status.
and respiratory rate. management of body
Monitor and
Flushed or warm skin temperature as evidenced Manage Underlying
by stable temperature
4. Monitor and
upon assessment. Infection.
Laboratory findings within normal ranges and Document
absence of symptoms
indicating infection related to hyperthermia Educate the Patient Progress.
(e.g., elevated white throughout the treatment and Family.
blood cell count). period.
The patient will achieve
Vitals. resolution of the
underlying infection, as
Bp: 118/78
indicated by normalizing
RR: 18bt/min laboratory values and
HR: 98 improvement in overall
TEM:N 103.2F health status.
SPO2: 94%