NURSING PROCESS

Rohini Pandey1st Year M.Sc NursingKGMU Institute of Nursing

introduction

HISTORYIda Jean Orlando 1958• 4 stage Nursingprocess

DEFINITION• Nursing Process is a critical thinking

process that professional nurses use to apply

the best available evidence to care giving

and promoting human functions and

responses to health and illness.

The nursing process is cyclical & 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.

Purpose of Nursing Process

• To identify Clients health status and potential

health care problems.

• To establish plans to meet identified needs.

• To deliver specific nursing interventions to

meet those need.

• To achieve continuity of care.

Components of Nursing Process

ASSESSMENT

NURSING DIAGNOSIS

PLANNINGIMPLEMENTATION

EVALUATIONNursing Process

Characteristics of Nursing Process• Cyclic.• Dynamic Nature.• Client Centred.• Focus on problem solving & decision making.• Universal applicability.• Use of critical thinking & clinical reasoning.• Data from each phase provide input into the

next phase.

NURSING PROCESS OVERVIEW1. ASSESSINGa. Collect datab. Organize datac. Validate datad. Analyze datae. Document data

2. DIAGNOSINGa. Analyze datab. Identify health problems, risk, and

strengthsc. Formulate diagnostic statements

2. DIAGNOSINGa. Analyze datab. Identify health problems, risk, and

strengthsc. Formulate diagnostic statements

3. PLANNINGa. Prioritize problems/diagnosesb. Formulate goals/desired outcomec. Select nursing interventionsd. Write nursing orders

4. IMPLEMENTATIONa. Reassess the clientb. Determine the nurse’s need for

assistancec. Implement the nursing interventionsd. Supervise delegated casee. Document nursing activities5. EVALUATION

a. Collect data related to outcomesb. Compare data with outcomesc. Relate nursing actions to client goals/outcomesd. Draw conclusions about problem statuse. Continue, modify, or terminate the client’s care plan

1. ASSESSMENTASSESSING

•Collect Data•Organize Data•Validate Data•Document Data

Nursing Diagnosis

INTERVENTION

IMPLEMENTATION

EVALUATION

1. Assessment• Assessment is the systematic & continuous

collection, organization, validation and documentation of data (information).

• TYPESi. Initial Nursing Assessmentii. Problem focused Assessmentiii. Emergency Assessmentiv. Time-lapsed Assessment

1.1 Collection of DataProcess of gathering

information about clients health status.

TYPES OF DATAa. Subjective Datab. Objective DataSOURCES OF DATAc. Primary sourced. Secondary source

METHOD OF DATA COLLECTION

a. Observationb. Interviewc. Examination

1.2 Organize Data

• The nurse uses a format that organizes the

assessment data systematically. This is often

referred to as nursing health history or

nursing assessment form.

1.3 Validate Data

• The information gathered during the

assessment is “double-checked” or verified

to confirm that it is accurate and complete.

1.4 Documentation Of Data To complete the assessment phase, the nurse

records client data. Accurate documentation

is essential and should include all data

collected about the client’s health status.

Nursing Diagnosis•Analyze Data•Identify Health problems, risks & strengths

INTERVENTION

ASSESSMENT

EVALUATION

IMPLEMENTATION

2. NURSING DIAGNOSIS• In this phase, nurses use critical thinking

skills to interpret assessment data to identify client problems.

• North American Nursing Diagnosis Association (NANDA) define or refine nursing diagnosis.

• The status of nursing diagnosis are Actual, Health Promotion and Risk.

1. An actual diagnosis is a client problem that is present at the time of the nursing assessment.

• Example:Impaired thermoregulation related to infectionas evidenced by increased body temperature.

A health promotion diagnosis relates to clients’ preparedness to improve their health condition.

Example:Deficit knowledge related to disease outcome

as evidenced by frequent asking of question by the patient.

• A risk nursing diagnosis is a clinical judgement that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given.

Example:Risk for infection related to prolong

hospitalization.

Components of NANDA Nursing Diagnosis

PROBLEM

ETIOLOGY

DEFINING CHARACTERISTICS

• Acute pain related to abdominal surgery as

Problem Etiology

evidenced by patient discomfort and pain

scale

Sign & Symptoms

ASSESSMENT

NURSING DIAGNOSIS

3. PLANNINGa. Prioritize

problems/diagnosesb. Formulate goals/desired

outcomec. Select nursing

interventionsd. Write nursing orders

IMPLEMENTATION

EVALUATION

3. PLANNING/INTERVENTION• Planning involves decision making and

problem solving. • It is the process of formulating client

goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems.

TYPES OF PLANNING• Initial planning• Ongoing planning• Discharge planning

3.1 Prioritize Problems • Planned by deciding which nursing

diagnosis requires attention first, which second and so on.

• Nurses frequently use Maslow’s Hierarchy of Needs when setting Priority.

3.2 Establishing Goal After establishing priorities, the

nurse set goals for each nursing Diagnosis. Goals may be short term or long term.

3.2 Nursing Intervention A Nursing intervention is any treatment

that a nurse performs to improve patient’s health.

Types Of Nursing Intervention: • Independent Intervention• Dependent Intervention• Collaboration Intervention

3.4 Writing Intervention• After choosing the appropriate

nursing interventions, the nurse writes them on the care plan.• Nursing care plan is written or

computerized information about the client’s care.

ASSESSMENT NURSING DIAGNOSIS

4. IMPLEMENTATIONa. Reassess the clientb. Determine the nurse’s need

for assistancec. Implement the nursing

interventionsd. Supervise delegated casee. Document nursing activities

PLANNING/INTERVENTION

EVALUATION

4. IMPLEMENTATION

• Implementation consists of doing and

documenting the activities.

• The process of implementation includes

– Implementing the nursing interventions

– Documenting nursing activities

ASSESSMENT

NURSING DIAGNOSIS

5. EVALUATIONa. Collect data related to outcomesb. Compare data with outcomesc. Relate nursing actions to client

goals/outcomesd. Draw conclusions about

problem statuse. Continue, modify, or terminate

the client’s care plan

PLANNING/INTERVENTION

IMPLEMENTATION

5. EVALUATION• Evaluation is a planned, ongoing, purposeful

activity in which the nurse determinesa. the client’s progress toward achievement of

goals/outcomes andb. effectiveness of the nursing care plan. • The evaluation includes• Comparing the data with desired outcomes • Continuing, modifying, or terminating the

nursing care plan.

ASSESSMENT

NURSING DIAGNOSI

S

GOAL INTERVENTION

RATIONALE

IMPLEMENTATION

EVALUATION

Subjective DataPatient complaining of pain.

Objective DataModerate level of pain is observed & abdominal surgery done.

Acute pain related to abdominal surgery as evidenced by verbalization of pain and pain scale.

Patients pain level will be reduced and will gain comfort.

• Assess level of pain.•Provide comfortable position to the client.•Provide diversion therapy to the client.•Allow visit of family member.•Administer analgesic as advised by physician.

• To identify the level of pain.•To provide comfort to the patient.•To divert the mind.•Evidences shows decrease use of analgesics.•It will reduce pain.

• Pain level assessed & found as Moderate.•Semi fowler position provided.•Music therapy provided.•Family visit allowed.•Diclofenac 1 ampule IM /TDS given.

Pain is reduced.

ANY QUESTION?

SUMMARY

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