NURSING PROCESS
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.
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
describing the process of nursing.
DefinitionIt 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.
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.
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.
Phases/Steps nursing process
1] Assessing
2] Diagnosing
3] Planning
4] Implementing
5] Evaluating
Characteristics of the Nursing Process1] 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
process.
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.
Types of assessment
There are 4 different types of
assessment:-
1] Initial assessment
2] Problem focused assessment
3] Emergency assessment
4] Time lapsed reassessment
Type Time performed Purpose Example
Initial
assessment
Performed
within
specified time
after
admission to a
health care
agency.
To establish a
complete
database for
problem
identification,
reference, and
future
comparison
Nursing
admission
assessment
Type Time performed Purpose Example
Problem-
focused
assessment
Ongoing
process
integrated with
nursing care
To determine
the status of a
specific
problem
identified in
an earlier
assessment
Hourly assessment of client’s fluid intake and urinary output in an ICU
Assessment of client’s ability to perform self care while assisting a client to bathe.
Type Time performed Purpose Example
Emergency
assessment
During any
physiologic or
psychologic
crisis of the
client
To identify life-
threatening
problems
Rapid assessment of a person’s airway, breathing status, and circulation during a cardiac arrest Assessment of suicidal tendencies or potential for violence.
Type Time performed Purpose Example
Time-lapsed
reassessment
Several
months after
initial
assessment
To compare the
client’s current
status to
baseline data
previously
obtained.
Reassessment of a client’s functional health patterns in a home care or outpatient setting or, in a hospital, at shift change.
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.
Critical thinking
ASSESSMENT
DIAGNOSING
PLANNING
IMPLEMENTING
EVALUATING
Description of the assessment phasePhase Description Purpose Activities
AssessmentCollecting,
Organizing,
Validating &
Documentin
g client data.
To establish
database about the
client’s response
to health concerns
or illness and the
ability to manage
health care needs.
Establish a database Obtain a nursing health
history Conduct a physical
assessment Review client records Review Nursing
literature Consult support
persons Consult health
professionals update data as needed organize data validate data communicate / document data.
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.
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.
• Client data includes past history as well as current problems.
Eg of Past history◦History of
allergic to penicillin
◦Past surgical procedures
◦Folk healing practices
◦Chronic disease
Eg of Current Problems◦pain, nausea,
sleep patterns & religious practices.
Types of data Subjective Data
also referred to as symptoms
or covert data
can be verified described by
only the person who
affected.
Eg. Itching, pain, feelings of
worry.
It includes the client’s
sensations, feelings values,
beliefs, attitudes and
perception of personal health
status and life situation.
Objective data
also referred to as signs or overt
data,
are detectable by an observer or
can be measured or tested
against an accepted standard.
They can be seen, heard felt or
smelled and
they are obtained by observation
or physical examination
for Eg. Discoloration of skin, BP
reading.
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
comparing the client’s responses to
nursing & medical intervention.
Eg. Of subjective & objective data.Sl. No.
Subjective Data Objective Data
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.
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.
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.
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. Eg.
Mentally ill
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,
dietitians or physical therapists
Laboratory records and Health care professionals.
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.
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.
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.
◦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)
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.
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.
InterviewingAn 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
Direct Indirect or nondirective
Direct Indirect or nondirective
Highly structured & elicits specific informations
Rapport- building interview (understanding between two or more people)
Nurse establishes purpose of interview and controls the interview
Nurse allows the client to control the purpose, subject matter and pacing
Clients who responds may have limited opportunity to ask question or Discuss concerns
Types of interview questions
There are 4 types of interview
questions
Closed question
Open ended question
Neutral questions
Leading question
Closed question Open ended question
Neutral questions
Leading question
Used in direct interview, Are restrictive
Generally requires yes of No or short factual answers
Often begin with when, where, who, what, do, did or does, or is, are, was.
Eg. Are you having pain now?What medication did you take?
Associated with nondirective interview
Invite clients to discover & explore, elaborate, clarify or illustrate their thoughts or feelings.
It specifies only the broad topic to be discussed & invites longer that one or two words.
An open ended question begins with what or how?Eg. What brought you to hospital?How did you feel in that?
Is a question the client can answer with out direction or pressure from the nurse.
Used in non directive that question.
Eg. How do you feel about that?
Why do you think you had the operation?
Used in directive interview &
Thus directs client answer.
Eg.
You’re stressed about surgery tomorrow, aren’t you?
You’ll take medicine won’t you?
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.
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:-
Stages of an interview
Opening or introduction 2 steps
1] establish rapport
2] orientation
Body or development – closing
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.
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
with a light hammer upon any part of the
body.
The physical examination is
carried our systematically.
It may be organized
according to the examiner’s
preference,
Head to toe approach
System wise approach
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
factual.
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 &
inferences.
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
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)