1. NURSING PROCESS

2. Introduction
 The Nursing Process enables the nurse to
organize and deliver nursing care.
 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.
 It is a dynamic continuous process as the clients
need change.

3.  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 client’s
level of health.
 The term Nursing process originated in
1955 by Hall and Johnson (1959),
 Orlando (1961) & Wiedenbach (1963)
were the first user with a series of phases

4. Definition
 It is a systematic, rational method of
planning and providing nursing care. Its
goal is to identify a client’s 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.

5. 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.

6. Purposes
1] Identify a client’s health status & 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.

7. Phases/Steps nursing process
1] Assessing
2] Diagnosing
3] Planning
4] Implementing
5] Evaluating

8. 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

9. Assessing
 It is the systematic and continuous collection,
organization, validation, and documentation of
data (information).
 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.

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

11. Type Time performed Purpose Example
Initial Performed To establish a Nursing
assessment within complete admission
specified time database for assessment
after problem
admission to a identification,
health care reference, and
agency. future
comparison

12. Type Time performed Purpose Example
Problem- Ongoing To determine Hourly
assessment of
focused process the status of a client’s fluid
assessment integrated with specific intake and
urinary output
nursing care problem in an ICU
identified in
Assessment of
an earlier client’s ability
assessment to perform self
care while
assisting a
client to bathe.

13. Type Time performed Purpose Example
Emergency During any To identify life- Rapid
assessment of
assessment physiologic or threatening a person’s
psychologic problems airway,
breathing
crisis of the status, and
client circulation
during a
cardiac arrest
Assessment of
suicidal
tendencies or
potential for
violence.

14. Type Time performed Purpose Example
Time-lapsed Several To compare the Reassessment
of a client’s
reassessment months after client’s current functional
initial status to health patterns
in a home care
assessment baseline data or outpatient
previously setting or, in a
hospital, at
obtained. shift change.

15.  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.

16. ASSESSMENT
EVALUATING DIAGNOSING
Critical
thinking
IMPLEMENTING PLANNING

17. Description of the assessment
phase Description
Phase Purpose Activities
Assessment Collecting, Establish a database
To establish  Obtain a nursing health
history
Organizing, database about the  Conduct a physical
assessment
Validating & client’s response  Review client records
 Review Nursing
Documentin to health concerns literature
 Consult support
g client data. or illness and the persons
ability to manage  Consult health
professionals update
health care needs. data as needed organize
data validate data
communicate /
document data.

18. Collecting Data
 Is the process of gathering information
about a client’s health status.
 It must be both systematic & continuous
 To prevent the omission of significant
data &
 reflect a client’s changing health status.

19.  A data base is all the information about
a client; it includes
◦ Nursing health history,
◦ Physical assessment,
◦ The history & physical examination,
◦ Results of laboratory & diagnostic tests,
◦ And material contributed by other health
personnel.
To collect data clearly both the client &
nurse must actively participate.

20. • Client data includes past history as well
as current problems.
 Eg of Past history  Eg of Current
◦ History of allergic Problems
to penicillin ◦ pain, nausea, sleep
◦ Past surgical patterns & religious
procedures practices.
◦ Folk healing
practices
◦ Chronic disease

21. Types of data
Subjective Data Objective data
 also referred to as  also referred to as signs or
symptoms or covert data overt data,
 can be verified described by  are detectable by an observer
only the person who or
affected.  can be measured or tested
 Eg. Itching, pain, feelings of against an accepted standard.
worry.  They can be seen, heard felt
 It includes the client’s or smelled and
sensations, feelings values,  they are obtained by
beliefs, attitudes and observation or physical
perception of personal examination
health status and life
 for Eg. Discoloration of skin,

22.  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

23. Eg. Of subjective & objective
data.
Sl. Subjective Data Objective Data
No.
1 I have fever Body tem – 1000F
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.

24. 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.

25. 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.

26. 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 client’s
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.

27. Client Records
 It includes information documented by various health
care professionals.
 Client records also contain data regarding the client’s
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,

28. Laboratory records and
Health care professionals.

29. Data Collection Methods
 The primary methods of data collection
are
◦ Observing – Occurs whenever the nursing is
in contact with the client or support persons.
◦ Interviewing – is used while taking the
nursing health History
◦ Examining – Major method used in the
physical health assessment.

30.  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.

31. Observing
 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.

32. ◦ 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)

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

34.  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 client’s 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.

35. 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

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

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

38. Closed question Open ended Neutral Leading
question questions question
Used in direct Associated with Is a question the Used in directive
interview, nondirective client can answer interview &
Are restrictive interview with out direction or
Thus directs client
pressure from the
Invite clients to nurse. answer.
Generally requires
yes of No or short discover & explore,
factual answers elaborate, clarify or Eg.
illustrate their Used in non
Often begin with thoughts or feelings. directive that
You’re stressed
question.
when, where, who, It specifies only the about surgery
what, do, did or broad topic to be Eg. tomorrow, aren’t
does, or is, are, was. discussed & invites How do you feel you?
longer that one or about that?
Eg. two words. You’ll take medicine
Are you having pain won’t you?
now? An open ended Why do you think
What medication did question begins with you had the
what or how? operation?
you take?
Eg. What brought
you to hospital?

39. 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.

40.  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:-

41. Stages of an interview
 Opening or introduction 2 steps
1] establish rapport
2] orientation
 Body or development – closing

42. 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.

43.  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

44.  The physical examination is carried
our systematically.
 It may be organized according to
the examiner’s preference,
 Head to toe approach
 System wise approach

45. 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

46.  Validating data helps nurse in following
tasks.
1] Ensure that assessment information is
complete.
2] Ensure that objective data & related
subjective data agree.
3] Obtain additional information that may
have been overlooked.
4] Differentiate between cues &

47.  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
(Eg. cues nurse observes incision is red, hot
& swollen. nurse makes the inference that
the incision is infected

48. 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 client’s own words (more
accuracy)