nursing foundation: nursing process

1. NURSING
PROCESS
BY,
Ms. Ekta S Patel
Assistant Professor

2. “
▪ The term Nursing Process was first
used/ mentioned by Lydia Hall, a
nursing theorist, in 1955 wherein
she introduced 3 STEPs:
▪ observation,
▪ administration of care and
▪ validation.

3. “
▪ Since then, nursing process
continue to evolve: it used to be a
3-step process, then a 4-step
process (APIE), then a 5-step
(ADPIE), now a 6-step process
(ADOPIE) Assessment, Diagnosis,
Outcome, Identification, Planning,
Implementaton and Evaluation.

5. Definition

6. “
▪ Is a systematic, organized
method of planning, and
providing quality and
individualized nursing care.

7. “
▪ It is synonymous with the
PROBLEM SOLVING
APPROACH that directs the
nurse and the client to
determine the need for
nursing care, to plan and
implement the care and
evaluate the result.

8. “
▪ It is a G O S H approach (goal-
oriented, organized,
systematic and humanistic
care) for efficient and
effective provision of nursing
care.

9. ▪ Goal-oriented – nurse make her objective based
on client’s health needs.
▪ Remember: Goals and plan of care should be
base according to clients problems/needs NOT
according to your own problem as the nurse.

10. ▪ Organized/Systematic – the nursing process is
composed of 6 sequential and interrelated steps
and these 6 phases follow a logical sequence.

11. Humanistic care
▪ Plan to care is developed and implemented taking into
consideration the unique needs of the individual client.
▪ Plan of care therefore is individualized (no 2 person has
the same health needs even with same health
condition/illness)
▪ In providing care, it involves respect of human dignity

12. ▪ Efficient – plan of case is relevant/ related to the
needs of the client thereby promoting client
satisfaction and progress.
▪ Effective – in planning care, utilized resources
wisely (staff, time, money/cost)

13. Aside from GOSH, other
characteristic of Nursing Process:
▪ Cyclic and Dynamic in nature – data from each
phase provides the input into the next phase so
that is becomes a sequence of events (cycle) that
are constantly changing (dynamic) base on
client’s health status.

14. ▪ Involves skill in Decision-making – nurse makes
important decisions related to client care, she
choose the best action/steps to meet a desired
goal or to solve a problem. She must make
decisions whenever several choices or options
are available.

15. ▪ Uses Critical Thinking skills – the nurse may
encounter new ideas or less-than-routine or non-
ordinary situations where decisions must be
made using critical thinking.

16. Purpose of Nursing Process:
▪ To identify a client’s health status; his Actual/Present and
potential/possible health problems or needs.
▪ To establish a plan of care to meet identified needs.
▪ To provide nursing interventions to meet those needs.
▪ To provide an individualized, holistic, effective and efficient
nursing care.

17. Assessment

18. Assessment –
First Step in the
Nursing Process

19. Description
▪ It is systematic and continuous collection,
validation and communication of client data as
compared to what is standard/norm.
▪ It includes the client’s perceived needs, health
problems, related experiences, health practices,
values and lifestyles.

20. Assessment
▪ Observation of the patient + Interview of patient,
family & SO + examination of the patient +
Review of medical record

21. Purpose
▪ To establish a data base (all the information about the
client):
▪ nursing health history
▪ physical assessment
▪ the physician’s history & physical examination
▪ results of laboratory & diagnostic tests material from
other health personnel

22. FOUR Types of
Assessment

23. 1. Initial assessment
▪ assessment performed within a specified time on
admission
▫ Ex: nursing admission assessment

24. 2. Problem-focused assessment
▪ use to determine status of a specific problem
identified in an earlier assessment
▫ Ex: problem on urination-assess on fluid
intake & urine output hourly

25. 3. Emergency assessment
▪ rapid assessment done during any
physiologic/physiologic crisis of the client to
identify life threatening problems.
▫ Ex: assessment of a client’s airway,
breathing status & circulation after a
cardiac arrest.

26. 4. Time-lapsed assessment
▪ reassessment of client’s functional health pattern
done several months after initial assessment to
compare the client’s current status to baseline
data previously obtained.

27. Activities

28. ▪ Collection of data
▪ Validation of data
▪ Organization of data
▪ Analyzing of data
▪ Recording/documentation of data

29. Collection of data

30. ▪ gathering of information about the client
▪ includes physical, psychological, emotion, socio-cultural,
spiritual factors that may affect client’s health status
▪ includes past health history of client (allergies, past
surgeries, chronic diseases, use of folk healing methods)
▪ includes current/present problems of client (pain, nausea,
sleep pattern, religious practices, meds or treatment the
client is taking now)

31. Types of Data

32. Subjective data
▫ also referred to as Symptom/Covert data
▫ Information from the client’s point of view or are
described by the person experiencing it.
▫ Information supplied by family members, significant
others; other health professionals are considered
subjective data.
▫ Example: pain, dizziness, ringing of ears/Tinnitus

33. Objective data
also referred to as Sign/Overt data
▫ Those that can be detected observed or
measured/tested using accepted standard
or norm.
▫ Example: pallor, diaphoresis,
BP=150/100, yellow discoloration of skin

34. Methods of Data
Collection

35. 1. Interview
▫ A planned, purposeful
conversation/communication with the
client to get information, identify problems,
evaluate change, to teach, or to provide
support or counseling.
▫ it is used while taking the nursing history
of a client

36. 2. Observation
▫ Use to gather data by using the 5 senses
and instruments.

37. 3. Examination
▪ Systematic data collection to detect health problems
using unit of measurements, physical examination
techniques (IPPA), interpretation of laboratory results.
▫ should be conducted systematically:
▫ Cephalocaudal approach – head-to-toe assessment
▫ Body System approach – examine all the body system
▫ Review of System approach – examine only particular
area affected

38. Source of data

39. 1. Primary source –
▪ data directly gathered from the client using
interview and physical examination.

40. 2. Secondary source –
▪ data gathered from client’s family members,
significant others, client’s medical records/chart,
other members of health team, and related care
literature/journals.
▫ In the Assessment Phase, obtain a Nursing
Health History – a structured interview
designed to collect specific data and to
obtain a detailed health record of a client.

41. Components of a
Nursing Health
History:

42. 1. Biographic data – name, address, age, sex, martial
status, occupation, religion.
2. Reason for visit/Chief complaint – primary reason why
client seek consultation or hospitalization.
3. History of present Illness – includes: usual health
status, chronological story, family history, disability
assessment.
4. Past Health History – includes all previous
immunizations, experiences with illness.

43. 5. Family History – reveals risk factors for certain disease
diseases (Diabetes, hypertension, cancer, mental
illness).
6. Review of systems – review of all health problems by
body systems
7. Lifestyle – include personal habits, diets, sleep or rest
patterns, activities of daily living, recreation or hobbies.
8. Social data – include family relationships, ethnic and
educational background, economic status, home and
neighborhood conditions.

44. 9. Psychological data – information about the
client’s emotional state.
10. Pattern of health care – includes all health care
resources: hospitals, clinics, health centers,
family doctors.

45. Validation of
Data

46. ▪ The act of “double-checking” or verifying data to
confirm that it is accurate and complete.

47. Purposes of data validation
▪ ensure that data collection is complete
▪ ensure that objective and subjective data agree
▪ obtain additional data that may have been
overlooked
▪ avoid jumping to conclusion
▪ differentiate cues and inferences

48. Cues
▪ Subjective or objective data observed by the
nurse; it is what the client says, or what the nurse
can see, hear, feel, smell or measure.

49. Inferences
▪ The nurse interpretation or conclusion based on
the cues.
▪ Example:
▫ Red swollen wound = infected wound
▫ Dry skin = dehydrated

50. Organization of
Data

51. ▪ Uses a written or computerized format that
organizes assessment data systematically.
▪ Maslow’s basic needs
▪ Body System Model
▪ Gordon’s Functional Health Patterns:

52. Analyze data

53. ▪ Compare data against standard and identify
significant cues. Standard/norm are generally
accepted measurements, model, pattern:
Ex: Normal vital signs, standard Weight and
Height, normal laboratory/diagnostic values,
normal growth and development pattern

54. Communicate/Record
/Document Data

55. ▪ Nurse records all data collected about the client’s
health status
▪ Data are recorded in a factual manner not as
interpreted by the nurse
▪ Record subjective data in client’s word; restating
in other words what client says might change its
original meaning

56. Diagnosis –
Second Step in
the Nursing
Process

57. Meaning

58. ▪ Is the 2nd step of the nursing process.
▪ the process of reasoning or the clinical act of
identifying problems

59. DEFINITION

60. ▪ Diagnosing refers to the reasoning process.
▪ Diagnosis A statement or conclusion regarding
the nature of phenomenon.

61. Nursing diagnosis definition by
NANDA (1990):-
▪ A nursing diagnosis is a clinical judgment about
individual, family or community response to
actual and potential health problems/ life
process. Nursing diagnosis provides the basis for
selection of nursing intervention to achieve the
outcome for which the nurse is accountable.

62. PURPOSE

63. ▪ Identify how an individual, group or Community responds
to actual or potential health and life processes.
▪ Identify factors that contribute to or cause health
problems (etiologies).
▪ Identify resources or strengths the individual, group or
community can draw on to prevent or resolve problems.

64. Three Activities
in Diagnosing:

65. ▪ Data Analysis
▪ Problem Identification
▪ Formulation of Nursing Diagnosis

66. Characteristics
of Nursing
Diagnosis

67. ▪ It states a clear and concise health problem.
▪ It is derived from existing evidences about the
client.
▪ It is potentially amenable to nursing therapy.
▪ It is the basis for planning and carrying out
nursing care.

68. PURPOSE OF
NANDA

69. NANDA- NORTH AMERICAN
NURSING DIAGNOSIS
ASSOCIATION
▪ To define, refine and promote a taxonomy of Nursing
diagnostic terminology of general use to Professional
Nurses.
▪ Members of Nanda Staff Nurses, Clinical Specialists,
faculty, Directors of Nursing, Deans, Theorists &
Researchers.

70. In 2000 NANDA approved new
Taxonomy II,
▪ which has 13 Domains, 106 classes and
155Diagnosis.
▪ Taxonomy II Domains

71. ▪ Domain 1 : Health Promotion.
▪ 2 : Nutrition
▪ 3 : Elimination
▪ 4 : Activity / Rest
▪ 5 : Perception / Cognition
▪ 6 : Self – perception
▪ 7 : Role relationships

72. ▪ 8 : Sexuality
▪ 9 : Coping / Stress tolerance
▪ 10 : Life principles
▪ 11 : Safety / Protection
▪ 12 : Comfort
▪ 13 : Growth / Development

73. NURSING DIAGNOSIS
VERSES MEDICAL
DIAGNOSIS

74. TYPES OF
NURSING
DIAGNOSIS

75. ▪ Actual Nursing Diagnosis
▪ Risk Nursing
▪ Possible Nursing Diagnosis
▪ Syndrome Nursing Diagnosis
▪ Wellness Nursing

76. Actual Nursing Diagnosis:
▪ It is judgment about the client response to a
health problem that is present at a time of
nursing assessment.
▪ Eg: Ineffective breathing pattern &anxiety

77. Risk Nursing Diagnosis
▪ It is a clinical judgment that a client is more
vulnerable to develop the problem than others in
the same or similar situation.
▪ Eg: Risk for impaired skin integrity related to
surgery.

78. Possible Nursing Diagnosis
▪ It describe a suspected problem for which
current and available data are insufficient to
validate the problem.
▪ Eg: Possible social isolation related to unknown
etiology.

79. Syndrome Nursing Diagnosis
▪ It is a cluster of nursing diagnosis that frequently
go together and present a clinical picture.
▪ Eg: Rape Trauma Syndrome

80. Wellness Nursing Diagnosis
▪ It is clinical judgment about an individual, group
or community in transition from a specific level of
wellness to a higher level of wellness. Eg: Family
coping: potential for growth related to
unexpected birth of twins.

81. COMPONENT OF
NURSING
DIAGNOSIS

82. PES
▪ Problem Statement
▪ Defining Etiology
▪ Sign and symptoms Or Characterstics

83. Problem Statement (Diagnostic
Label):
▪ It describe the client health problem or response
for which nursing therapy is given clearly and
concisely in a few words. Eg: Knowledge
deficit(medications) Some Qualifier are also
added to give additional meaning to the
statement such as Impaired, Decreased,
Ineffective, Acute, Chronic.

84. Etiology (Related Factors & Risk
Factors):
▪ This component identifies one or more probable
causes of health problem. It help the nurse to
give individualized patient care. Eg: Anxiety
related to hospitalization.

85. Defining Characteristics:
These are the clusters of signs and symptoms that
indicate the presence of a particular
diagnosticlebel. Eg: Fluid volume deficit related
to decreased oral intake manifested by dry skin
and mucus membranes.

86. Nursing
diagnosis
formulation
process

89. ADVANTAGES

90. ▪ COMMUNICATION
▪ CHARTING
▪ QUALITY IMPROVEMENT

91. LIMITATION

92. ▪ LIMIT NURSING PRACTICE
▪ IMPRESICE LANGUAGE
▪ LIMITED TO NURSING PROFESSIONAL

93. Outcome
Identification

94. Definition

95. ▪ Refers to formulating and documenting
measurable, realistic and client-focused goals
that will provide the basis for evaluating nursing
diagnosis.

96. Purposes

97. ▪ To provide individualized care
▪ To promote client participation
▪ To plan care that is realistic and measurable
▪ To allow involvement of support people

98. Activities during
Outcome
Identification

99. ▪ Establish client’s goals and outcome criteria

100. Client Goal

101. ▪ Is an educated guess made as a broad statement
about what the client’s state or condition will be
AFTER the nursing intervention is carried out.
▪ Are written to indicate a desired state. They
contain action word/verb and a qualifier that
indicate the level of performance that needs to
be achieved.

102. Example of verbs used in client goals:
▫Calculate
▫Classify
▫Communicate
▫Compare
▫Define
▫Demonstrate
▫Describe
▫Construct
▫Contrast
▫Distinguish
▫Draw
▫Explain
▫Express
▫Identify
▫List
▫Name
▫Maintain
▫Perform
▫Particular
▫Practice
▫Recall
▫Recite
▫Record
▫State
▫Use
▫Verbalize
▫Ambulates

103. Goals may be
short term or
long term

104. ▪ Short Term Goal (STG) – can be met in a short
period (within days or less than a week)
▪ Long Term Goal (LTG) – requires more time
(several weeks or months)

105. Outcome Criteria

106. ▪ Outcome Criteria – are specific, measurable,
realistic statements goal attainment. They are
written in a manner that they answer the
questions: who, what actions, under what
circumstance, how well and when.

107. The
characteristic of
well-stared
outcome criteria
are:

108. ▪ S = smart
▪ M = measurement
▪ A = attainable
▪ R = realistic
▪ T = time-framed

109. Example of Goals
and Outcome
Criteria

110. ▪ Goal – The client will report a decreased anxiety level
regarding Surgery.
▪ Possible Outcome Criteria:
▪ The client discusses fears & concern regarding surgical
procedure after client teaching.
▪ After client teaching, the client verbalizes decreased
anxiety.
▪ The client identifies a support system and strategies to
use to reduce stress and anxiety related to the surgical
experience.
Example 1:

111. ▪ Goal – The client will demonstrate safety habits when performing
activities of daily living.
▪ Possible Outcome Criteria:
▪ Immediately after instruction by the nurse, the client uses call light
system for assistance when needs to use the bathroom.
▪ The client demonstrates safety practices when dressing and doing
personal hygiene.
▪ The client uses over-the-bed lights, non-skid slippers when transferring
to chair or getting out of bed.
▪ The client identifies modification for home safety (removal of throw
pillows, installation of hand rails in hallway, better lighting of hallway
and stairway), 12 hours after nurse’s instruction about home safety.
Example 2:

112. ▪ Goal – The client will mobilize lung secretions.
▪ Possible Outcome Criteria:
▪ After teaching session, the client demonstrates proper
coughing techniques.
▪ The client drinks at least 6 glasses of water per day while
in the hospital.
▪ The caregiver or significant other demonstrates proper
technique of chest physiotherapy including percussion,
vibration and postural drainage before discharge.
Example 3:

113. Planning

114. Definition

115. ▪ Involves determining before and the strategies or
course of actions to be taken before
implementation of nursing care. To be effective,
the client and his family should be involve in
planning.

116. Purpose

117. ▪ To determine the goals of care and the course of
actions to be undertaken during the
implementation phase.
▪ To promote continuity of care.
▪ To focus charting requirements.
▪ To allow for delegation of specific activities.

118. 1. Establish/Set
priorities

119. ▪ Priority – is something that takes precedence in
position, and considered the most important
among several items. It is a decision making
process that ranks the order of nursing diagnosis
in terms of importance to the client.

120. Guideline for setting priorities:
▪ Life-threatening situations should be given
highest priority.
▪ Use the principle of ABC’s (airway, breathing,
circulation)
▪ Use Maslow’s hierarchy of needs.
▪ Consider something that is very important to the
client.

121. ▪ Actual problems take precedence over potential
concerns.
▪ Clients with unstable condition should be given
priority over those with stable conditions. Ex:
attend to client with fever before attending to
client who is scheduled for physical therapy in the
afternoon.

122. ▪ Consider the amount of time, materials,
equipment required to care for clients. Ex: attend
to client who requires dressing change for post
op wound before attending to client who
requires health teachings & is ready to be
discharged late in the afternoon.
▪ Attend to client before equipment. Ex: assess the
client before checking IV fluids, urinary catheter,
and drainage tube.

123. 2. Plan nursing
interventions/nursing
orders to direct activities
to be carried out in the
implementation phase.

124. Nursing interventions
▪ Any treatment, based upon clinical judgment and
knowledge, that a nurse performs to enhance client
outcomes.
▪ They are used to monitor health status; prevent, resolve or
control a problem; assist with activities of daily living; or
promote optimum health and independence.
▪ They maybe independent, dependent and
independent/collaborative activities that nurses carry out to
provide client care.

125. ▪ Independent Nursing Intervention – those
activities that the nurse is licensed to initiate as a
result of the nurse’s own knowledge and skills.

126. ▪ Dependent Nursing Intervention – those
activities carried out on the order of a physician,
under a physician’s supervision, or according to
specific routines.

127. ▪ Interdependent/Collaborative – those activities
the nurse carries out in collaboration or in
relation with other members of the health care
team.

128. 3. Write a
Nursing Care
Plan

129. ▪ A written summary of the care that a client is to
receive.
▪ It is the “blueprint” of the nursing process.
▪ It is nursing centered in that the nurse remains in
the scope of nursing practice domain in treating
human responses to actual or potential health
problems.

130. ▪ It is s step-by-step process as evidence by:
▫ Sufficient data are collected to substantiate nursing
diagnosis.
▫ 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, which is the justification or
reason for carrying out the intervention.
▫ Evaluation must address whether each goal was
completely met, partially met or completely unmet.

131. Implementation

132. Definition

133. ▪ It is putting the nursing care plan into action.

134. Purpose

135. ▪ To carry out planned nursing interventions to
help the client attain goals and achieve optimal
level of health.

136. Activities

137. ▪ Reassessing – to ensure prompt attention to emerging
problems.
▪ Set priorities – to determine the order in which
nursing interventions are carried out.
▪ Perform nursing interventions – these may be
independent. Dependent or collaborative measures.
▪ Record actions – to complete nursing interventions,
relevant documentation should be done. Remember:
Something that is NOT written is considered as NOT
done at all.

138. Requirements of
Implementation

139. ▪ Knowledge – include intellectual skills like
problem-solving, decision-making and teaching.
▪ Technical skills – to carry out treatment and
procedures.
▪ Communication skills – use of verbal and non-
verbal communication to carry out planned
nursing interventions.
▪ Therapeutic use of self – is being willing and
being able to care.

140. Evaluation

141. Introduction

142. ▪ Evaluation, the final step of the nursing process, is crucial
to determine whether, after application of the nursing
process, the client’s condition or well-being improves.
▪ The nurse applies all that is known about a client and the
client’s condition, as well as experience with previous
clients, to evaluate whether nursing care was effective.
▪ The nurse conducts evaluation measures to determine if
expected outcomes are met, not the nursing
interventions.

143. ▪ The expected outcomes are the standards against
which the nurse judges if goals have been met and
thus if care is successful.
▪ Providing health care in a timely, competent, and
cost-effective manner is complex and challenging.
▪ The evaluation process will determine the
effectiveness of care, make necessary modifications,
and to continuously ensure favorable client
outcomes.

144. Definition

145. ▪ Is assesing the client’s response to nursing
interventions and then comparing that response
to predetermined standards or outcome criteria.
▪ “Evaluation is defined as the judgment of the
effectiveness of nursing care to meet client goals;
in this phase nurse compare the client behavioral
responses with predetermined client goals and
outcome criteria.” –CRAVEN 1996

146. Sample Case
Study (Example)

147. ▪ Nursing Diagnosis : Impaired skin integrity
related to physical mobility
▪ Expected Outcomes : The patient will be able to
get recovery of pressure sore.

148. ▪ Planning:
▪ Pressure sore dressing
▫ Rationale: Cleansing the area will prevent further
infection
▪ Back care
▫ Rationale: It will promote blood circulation
▪ Change the position frequently
▫ Rationale: It will relieve pressure on the sore site
▪ Encourage the patient to ambulate
▫ Rationale: It will relieve pressure on the sore site
▪ Take protein rich diet
▫ Rationale: Protein helps in repair of tissues

149. ▪ Evaluation: Wound healing was observed (tissues
were red, healthy)

150. Purposes

151. ▪ Determine client’s behavioral response to
nursing interventions.
▪ Compare the client’s response with
predetermined outcome criteria.
▪ Appraise the extent to which client’s goals were
attained.
▪ Assess the collaboration of client and health care
team members.
▪ Identify the errors in the plan of care.
▪ Monitor the quality of nursing care.

153. Components of
Evaluation

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

155. Collecting the
data

156. ▪ The nurse collects the data so that conclusion can
be drawn about whether goals have been met. It
is usually necessary to collect both subjective &
objective data. Data must be recorded concisely
and accurately to facilitate the next part of the
evaluating process.

157. Comparing the
data with
outcomes

158. ▪ If the first part of the evaluation process has
been carried out effectively , it is relatively simple
to determine whether a desired outcome has
been met. Both the nurse and client play an
active role in comparing the client’s actual
responses with the desired outcomes.

159. Relating nursing
activities to
outcomes

160. ▪ The third aspect of the evaluating process is
determined whether the nursing activities had
any relation to the outcome.

161. Drawing
conclusion about
problem status

162. ▪ The nurse uses the judgment about goal achievement to determine whether
the care plan was effective in resolving, reducing or preventing client
problems.
▪ When goals have been met the nurse can draw one the following
conclusions about the status of the client’s problem.
▫ The actual problem stated in the nursing diagnosis has been
resolved , or the potential problem is being prevented and the risk
factors no longer exist. In these instances , the nurse documents
that the goals have been met and discontinues the care for the
problem.
▫ The potential problem is being prevented, but the risk factors still
present. In this case , the nurse keeps the problem on the care
plan.
▫ The actual problem still exists even though some goals are being
met. In this case the nursing interventions must be continued.

163. Continuing ,
modifying , or
terminating the
nursing care plan

164. ▪ After drawing conclusion about the status of the
client’s problems , the nurse modifies the care
plan as indicated.
▪ Whether or not goals were met, a number of
decision need to be made about continuing,
modifying or terminating nursing care for each
problem.
▪ Before making individual modification, the nurse
must first determine why the plan as a whole was
not completely effective. This require a review of
the entire plan.

165. Factors Affecting
Goal Attainment

166. ▪ Family Members
▪ Health Team Members
▪ Nurse

167. Evaluation Skill
Required for
Nurses

168. ▪ Nurse must know the hospital policies, procedure
and protocols of interventions and recording.
▪ Nurse must have up to date knowledge and
information of many subject.
▪ Nurse must have intellectual and technical skill to
monitor the effectiveness of nursing
interventions.
▪ Nurse must have knowledge and skill of
collecting subjective data and objective data.