Nursing process
By Sr. Frida Zawedde
Objectives
By the end of the lesson, learners should be able to;
• Define the nursing process
• Outline the characteristics of the nursing process
• Explain the advantages of using the nursing process
• Describe the components of the nursing process
• Apply the nursing process in provision of nursing care
Introduction
The nursing process is;
• Specific to the nursing profession
• A framework for critical thinking
• Its purpose is to; Diagnose and treat human responses
to actual or potential health problems
DEFINITION
• It is a systematic, organized, dynamic, method
focusing on identifying and treating unique
responses of individuals or groups to actual or
potential alterations in health
Characteristics
• Organized framework to guide practice
• Problem solving method - client focused
• Systematic- sequential steps
• Goal oriented- outcome criteria
• Dynamic-always changing, flexible
• Utilizes critical thinking processes
Advantages of the nursing process
• Provides individualized care
• Client is an active participant
• Promotes continuity of care
• Provides more effective communication among nurses and
healthcare professionals
• Develops a clear and efficient plan of care
• Provides personal satisfaction as you see client achieve goals
• Professional growth as you evaluate effectiveness of your
interventions
Steps/phases/components in the nursing
process
Assessment
• It is the first step of the nursing process
• Involves gathering information (Data) about the patient’s
health and illness
• Assessment is defines as a systematic and continuous
collection, organization, validation, analysis and
documentation of data
Data collection
• Data collection is a process of gathering information
about the patient’s health status in order to develop a
data base which can be analyzed in various ways
depending on the intended use
Types of data
• Subjective data
• Objective data
Subjective data/covert data/symptom
• This is information obtained from the patient through
interview and can only be verified by the patient
• It includes symptoms felt by the patient only
Objective data (overt/observable data)- sign
• This is information obtained independently by the nurse or any
member of the health care team
• It can be obtained by senses through observation, physical
examination and investigations or diagnostic tests
Sources of data
• Primary Source - Client / Family
• Secondary Source - physical exam, nursing history, team members,
lab reports, diagnostic tests, family members or significant others
Methods of data collection
Observation- involves use of the sense of sight such as observing
patient’s gait, appearance, nutritional status
Interviewing- involves taking history from the patient/client or
significant other
Physical examination- involves inspection, palpation, percussion and
auscultation
Cont..
• Make sure information is complete & accurate
• Validate prn
• Interpret and analyze data
• Compare to “standard norms”
• Organize and cluster data
Nursing history
• The nursing history is different from the medical history
• It provides data from which the nurse can identify the
existing and potential problem of the patient and is used
as a base for;
Planning
Implementation
Evaluation of nursing care
Taking history
• Biographical /personal information
• Presenting/main complaint
• Social history
• Family history
• Medical history
Taking history cont..
• Surgical history
• Past medications received
• Gynecological history
• Andrological history
• Sexual gender based violence
Assignment
Describe the 4 techniques used in physical examination
Functional health pattern approach
Example
• Client diagnosed with hypertension
• B/P 160/90
• 2 Gm Na diet and antihypertensive medications were
prescribed
• Client statement “ I really don’t watch my salt” “ It’s
hard to do and I just don’t get it”
Nursing diagnosis
• It refers to a clinical judgement made by a professional nurse that
describes potential and actual problems of the patient or Statement of
how the client is RESPONDING to an actual or potential problem
that requires nursing intervention
• It is the second step of the Nursing Process
• Interpret & analyze clustered data
• Identify client’s problems and strengths
• Formulate Nursing Diagnosis (NANDA : North American Nursing
Diagnosis Association)
Differences between nursing dx and medical
dx
• Nursing • Medical
• Within the scope of • Within the scope of
nursing practice medical practice
• Identify responses to • Focuses on curing
health and illness pathology
• Can change from day to • Stays the same as long as
day the disease is present
Formulating the nursing diagnosis
Composed of 3 parts:
• Problem statement- the client’s response to a problem
• Etiology- what’s causing/contributing to the client’s problem
• Defining Characteristics- what’s the evidence of the problem
Nursing diagnosis
• Problem( Diagnostic Label)-based on your assessment of client…
(gathered information), pick a problem from the NANDA list.
• Etiology- determine what the problem is caused by or related to (R/T).
• Defining characteristics- then state as evidenced by (AEB) the specific
facts the problem is based on...
Types of the nursing diagnosis
• Actual diagnosis
• Risk/potential diagnosis
• Wellness diagnosis
Example
• Ineffective therapeutic regimen management R/T difficulty
maintaining lifestyle changes and lack of knowledge AEB
B/P= 160/90, dietary sodium restrictions not being observed,
and client statements of “ I don’t watch my salt” “It’s hard to
do and I just don’t get it”.
Collaborative problems
• Require both nursing interventions and medical
interventions EXAMPLE: Client admitted with medical
dx of pneumonia
• Collaborative problem = respiratory insufficiency
• Nursing interventions: Raise HOB MD interventions:
Antibiotics IV, O2 therapy
Planning
• Third step of the Nursing Process
• This is when the nurse organizes a nursing care plan based
on the nursing diagnoses.
• Nurse and client formulate goals to help the client with their
problems
• Expected outcomes are identified
• Interventions (nursing orders) are selected to aid the client
reach these goals.
Planning – Begin by prioritizing
client problems
• Prioritize list of client’s
nursing diagnoses using
Maslow
• Rank as high,
intermediate or low
• Client specific
• Priorities can change
Developing a goal and outcome
statement
• Goal and outcome statements are client focused.
• Worded positively
• Measurable, specific observable, time-limited, and
realistic
• Goal = broad statement
• Expected outcome = objective criterion for
measurement of a goal
Cont..
EXAMPLE
• Goal: Client will achieve therapeutic management of
disease process….
• Outcome Statement: AEB B/P readings of 110-120 /
70-80 and client statement of understanding
importance of dietary sodium restrictions by day of
discharge.
Types of goals
• Short term goals
• Long term goals
• Cognitive goals
• Psychomotor goals
• Affective goals
Cont.…
• Goals are patient-centered and SMART;
• Specific
• Measurable
• Attainable
• Relevant
• Time Bound
Select interventions
• Interventions are selected and written.
• The nurse uses clinical judgment and professional
knowledge to select appropriate interventions that will
aid the client in reaching their goal.
• Interventions should be examined for feasibility and
acceptability to the client
• Interventions should be written clearly and
specifically
Interventions
• Independent ( Nurse initiated )- any action the nurse
can initiate without direct supervision
• Dependent ( Physician initiated )-nursing actions
requiring MD orders
• Collaborative- nursing actions performed jointly with
other health care team members
Implementation
• The fourth step in the Nursing Process
• This is the “Doing” step
• Carrying out nursing interventions (orders) selected
during the planning step
• This includes monitoring, teaching, further assessing,
reviewing NCP, incorporating physicians orders and
monitoring cost effectiveness of interventions
Implementation cont.
• Monitor VS q4h • Teach potential
• Maintain prescribed diet complications of
(2 Gm Na) hypertension to instill
importance of
• Teach client amount of
maintaining Na
sodium restriction, foods
restrictions
high in sodium, use of
nutrition labels, food • Assess for cultural factors
preparation and sodium affecting dietary regime
substitutes
Implementation cont.
• Teach the client that • Teach client importance
hypertension can’t be of life style changes:
cured but it can be (weight reduction,
controlled. smoking cessation,
• Remind the client to increasing activity)
continue medication even • Stress the importance of
though no S/S are present ongoing follow-up care
even though the patient
feels well.
Evaluation- To determine
effectiveness of NCP
• Final step of the Nursing Process but also done
concurrently throughout client care
• A comparison of client behavior and/or response to the
established outcome criteria
• Continuous review of the nursing care plan
• Examines if nursing interventions are working
• Determines changes needed to help client reach stated
goals
Evaluation
• Outcome criteria met? Problem resolved!
• Outcome criteria not fully met? Continue plan of care-
ongoing.
• Outcome criteria unobtainable- review each previous
step of NCP and determine if modification of the NCP
is needed.
• Were the nursing interventions appropriate/effective?
Factors that impede goal attainment
• Incomplete database
• Unrealistic client outcomes
• Nonspecific nursing interventions
• Inadequate time for clients to achieve outcomes
