The Nursing Process

Tigist E. (BSc, Msc)

February,2019G.C

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 Learning objectives
At the end of this session the student will be able to:
• Describe the nursing process
• Identify characteristics of nursing process
• Describe components of the nursing process
• Discuss the phases of nursing process
• Explain types of nursing diagnosis
• Mention the benefits of nursing process
• Perform proper documentation by using the nursing
process

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 Introduction to Nursing Process
• Definition: It is a systematic problem solving approach of
giving individualized nursing care.
• It ensures consistent, continuous, quality nursing care and
provides a basis for professional accountability.

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 Characteristics of Nursing Process
• It is a frame work for providing nursing care to patient ,
family and community
• It is orderly and systematic
• It is cyclical and interrelated
• It provides individual care
• It is patient centered
• It is practical for use over the life span
• It can be used for all setting (wide application).

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 Benefits of the Nursing Process
• Improved quality of care
• Promotes client participation in care
• Delivery of care is organized, continuous and systematic
• Efficient use of time and resources
• Expectations of client and standards of care are met
• Holds nurses accountable and responsibilities
• 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
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 Components of the Nursing Process
1. Assessment,
2. Diagnosis,
3. Planning,
4. Implementation, and
5. Evaluation.

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 1. Nursing Assessment
• It is the first phase of nursing process.
• It is the systematic collection of subjective and objective
data with the goal of making a clinical nursing judgment
about a patient or family.
• During assessment the nurse appraise patient’s total
situation by considering the physical, psychological,
emotional, socio cultural, and spiritual factors that may
affect his or her health status.

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 Types of Nursing Assessment
Initial assessment
• Performed at the time the patient enters the health care
facility.
• Very broad and leads us to a center of our diagnosis
• The aim of initial assessment is collection of data
concerning actual or potential dysfunction.
Focused Assessment
• It is concentrated on certain diagnosis
• It leads us to the general condition of the specific
diagnosis.
• Its aim is to determine status of a specific problems
identified during previous assessment.
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 Types of Nursing Assessment
Time lapsed assessment
• It is the final assessment done after a period of time
• This assessment is focused type.
• Its aim is comparing the patient’s current status to
baseline data obtained previously after an extended
period of time.
Emergency assessment
• Assessment done on the life treating situation
• This assessment should be fast, correct and leading to
aggressive management.
• Its aim is identification of life threatening situation

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Assessment skills
Observation : ability to observe and identify problems
Interviewing (history taking): the ability to communicate
with others.
Physical examination
• Analysis of bodily function using techniques of
inspection, palpation, percussion and auscultation
Assessment Activities (Components
 Collect data: Compiling information about the patient
 Validate data: double checking, the process of
confirming the accuracy of assessment data collected
e.g. “ I feel hot” check body temperature. how is it?
 Organize data: use functional health pattern
 Recording data

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Types of data
Subjective data
• Also know as symptoms or covert data.
• It include the patients feeling and statements about his or
her health problems.
• It should always be taken by the patient words.
E.g. “I get sharp pain in my chest.”
Objective data
• Also known as sign or overt data or cues.
• They are observable and measurable.
• It is an information witnessed by the examiner
E.g. -BP- 120/80mmHg
-RR-20 b/m
-PR-72 bpm
-Tempreture- 37Co 11
Source of Data
Primary sources
• The patient
 Secondary sources
• Family members or significant others
• Health record
• Laboratory test

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 2. Nursing Diagnosis
• It is the second phase of nursing process
• To diagnose means to analyze assume information and
drive meaning.
• It is “A clinical judgment about individual, family or
community response to the actual or potential health
problems” (North American Nursing diagnosis
association, NANDA).

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• Nursing activities in this part include:
Identify the patient’s nursing problems.
Identify the defining characteristics of the nursing
problems.
Identify the etiology of the nursing problems.
State nursing diagnoses concisely and precisely
using the:
Nursing problem
Defining characteristics and
Etiology of the problem
Identify potential problems or complications that
require collaborative interventions.
Identify health team members with whom
collaboration is essential.

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 Types of Nursing Diagnosis
1. Actual nursing diagnosis: Describe human response
to a health problem that is currently being manifested .

2. High risk nursing diagnosis: Is a clinical judgment

that a person, family or community is more vulnerable
to develop the problem (potential problem).

3. A Possible Nursing Diagnosis- a health problem is

unclear and causative factor is unknown.

4. Wellness Diagnosis-indicating a well response of the

patient
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 Components of Actual Nursing Diagnosis
• This type of nursing diagnosis has three parts: PES
Diagnostic label (problem) P
Contributing factor (Etiology) E
Sign and symptoms/Defining characteristics (S)
1. The actual problem component (diagnostic label):
describes the patients response to health problem.
e.g. Hypothermia : It is “The state in which an
individual’s body temperature is reduced below the normal
range “ (NANDA – 1990).
2. Related factors: Described the etiology or likely cause
of the problem.
3. Defining characteristics: they are the major and
minor clinical sign and symptoms that validate the
presence of actual nursing diagnosis. 16
 Difference between Nursing & Medical
Diagnosis
Nursing diagnosis: Describes the patient’s response to
the disease process.
e.g. -Ineffective Airway clearance related to
tracheobronchial secretion as evidenced by cough,
difficulty of breathing, etc.(Actual nursing diagnosis)

-Risk for impaired airway clearance related to

excessive airway secretion.(Potential nursing diagnosis)

 Medical Diagnosis: Describes the pathological process

of disease. e.g. Pneumonia
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 3. Planning
• If refers to the design of nursing strategies to resolve
patients problem.
Purpose
• Direct (Guide) patient care activities
• keep continuity of care
• Allow for the handing over of specific activities
Activities
• Establish priorities – based on nursing diagnosis
• writing patient goal and out come criteria
• Selecting appropriate nursing intervention
• communicate the nursing care plan.

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 Planning…
Goal is the broad statement about the state of the patient
after the nursing interventions are carried out.
• It addresses directly the problem stated in nursing
diagnosis
• Are two types: Short term (few hours or days) and
Long term (over weeks or months)
• Uses the words like “the patient will maintain…”
Expected outcomes are specific, measurable and
realistic statements of goal attainment.
• They answer the questions who? what action? Under
which circumstance? How? when?

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Example of plan
 Nursing diagnosis: Fluid volume deficit R/T inadequate
oral intake as manifested by concentrated urine out put of
urine, dry mouth and hypotension.

Goal : Attainment of normal fluid balance (Rehydration ).

Expected outcome:
Patient maintains adequate fluid intake on 30/06/2011.
Patient maintains adequate urine output with in 24 hrs.

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 Criteria for good outcome criteria
1. Clearly stated in terms of patient behavior or
observable assessment factors
2. Realistic, achievable, safe, and acceptable from the
patient’s viewpoint
3. Written in specific, concrete terms depicting/showing
patient action
4. Directly observable by use of at least one of the five
senses
5. Expected outcomes are patient centered rather than
nurse centered.

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 4. Implementation
• It is the action phase of the nursing process in which
nursing care is provided.
• It is the actual initiation of the plan evaluation of the
response to the plan and recording of nursing action.
• Activities include:
Reassess,
set priorities,
perform nursing interventions and
record nursing action.

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• Re-Assess: Every time assess the patients’ functional
health (for all pts).
• Set priority based on:
The patients condition
New information from reassessment
Time and resources available for nursing intervention
Feed back from the patient and family
The nurse’s experience in assessing situations and
setting priorities

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 5. Evaluation
• It is the fifth component of nursing process.
• It is the judgment of effectiveness of nursing care to meet
patient's goal.
• It is the phase in which the nurse compares the patient’s
behavioral response with predetermined patient goals and
out come criteria.
• Evaluation simply means assessing what progress has
been made toward meeting the expected outcomes.
• It is the most ignored phase of the nursing process

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• Activities in Evaluation
• Review patient goals and outcome criteria
• Collect data (subjective and objective data) to judge
patient's response to nursing intervention.
• Measure goal attainment
• Record the measure
• Modify nursing care plan.
Documenting the Nursing Process
• The ability to communicate clearly in writing is a
critical nursing skill.
• Accurate, concise, timely and relevant documentation
provides all the members of the care giving team with
a picture of the patient.
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 Prioritized nursing diagnosis &
implementations
• Diagnosis: Ineffective airway clearance related to copious
tracheobronchial secretions as evidenced by ineffective
coughing and tick sputum
• Goal: to maintain patent airway
• Outcome criteria: Patient will demonstrate effective
coughing and increased gas exchange tomorrow after
instruction.
• Implementations
• I instruct the patient to sit up in side of the bed and I
exercise him after assessing his condition. he just take
two deep breath through nose and breath out via mouth
and cough.
• Instructed to use home drinks for soothing the throat.
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• Diagnosis : Imbalanced Nutrition: Less Than Body
Requirements related to nausea and poor appetite
• Goal: Food and fluid intake adequate to meet nutritional needs
• Outcome criteria: patient will maintain weight appropriate for
height and able to list measure to improve ideal body weight by
the time of discharge
• Implementations
• I gave him mouth care in the morning to stimulate appetite
• Instruct him to take small but frequent session of food.
• He also takes appetizer like fruit juice before taking his meal
• I inform him to increase his mobility in the ward of the
hospital for good appetite
• I regularly(morning) take his weight to monitor Wt loss
related to loss of appetite

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• Diagnosis : Activity intolerance related to lack of energy,
altered nutritional status, and acute phase of the illness as
evidenced by patient verbal report(inability to have bath).
• Goal: restoring ability for activity
• Outcome criteria: Demonstrate gradual increase in
activity tolerance and reports ability to perform daily
activities with scheduled rest schedule
• Implementations
limit environmental stimuli for promoting rest
I inform and demonstrate how he can maintain his
muscle tone while he is on bed and in the ward and he
able to participate on ADL.
I inform him the weakness is because of acute phase of
the illness
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Progress report
The full format for documenting progress is based on
the acronym SOAPIER, which stands for
 Subjective data,
 Objective data,
 Analysis/assessment,
 Plan,
 Intervention,
 Evaluation, and
 Revision.
As the plan of care is implemented for each numbered,
prioritized problem, it is documented using the
SOAPIER format.
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THANK YOU

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