Dr.

Heba Elsayed
 Introduction
– The Whole Patient: The nursing process involves looking at the whole
patient at all times. It personalizes the patient. It also forces the health
care team to observe and interact with the patient, and not just the
task they are performing such as a dressing change, or a bed bath. The
process provides a roadmap that ensures good nursing care and
improves patient outcomes.
– First the nurse collects subjective data and objective data, then
organizes the data into a systematic pattern.
– • The patient must be the central character.
– • Nursing care needs to be directed at improving outcomes for the
patient; not about nursing goals.
– • The nursing process is an essential part of the nursing care plan.
• Definition of nursing process:

• Nursing process is a professional nurses’ approach to identify,

diagnose, and treat human responses to health and illness.
• Nursing process is an organizational framework for the
practice of nursing
• Purpose of nursing process:
• The major purpose is to provide framework within which the
individualized needs of the patient, family and community can be met.
• Benefits of Nursing Process
• Provides an orderly & systematic method for
planning & providing care
• Facilitates documentation of care
• Stresses the independent function of nurses
• Characteristics of nursing process:

• It is cyclic and dynamic.

• It is client centered.
• It is planned.
• It is goal directed.
• It is universally applicable
• Phases of nursing process:
• 1. Assessment
• 2. Diagnosis
• 3. Planning
• 4. Implementation
• 5. Evaluation
 1- Assessment:

• Definition of assessment:
•
• It is the first step of nursing process and
includes systemic collection, verification,
organization, interpretation and
documentation of data for use by health
care professionals.
• Purpose of assessment:
• 1. To establish a database concerning
patient's physical, psychological and
emotional health.

• 2. Identify health promoting behaviors as

well as actual and/or potential health
problems.

• 3. Determines the patient's functional

abilities and the absence or presence of
dysfunction.

• 5. To evaluate the physiologic outcomes

of health care and thus the progress of
patient's health problem.
 Types of
assessment

1. Comprehensive assessment
2. Focused assessment
3. Ongoing assessment
[Link] assessment
 • 1. Comprehensive assessment:

• It is usually completed upon admission to a

health care agency and includes a complete
health history and assessment of physical
and psychological aspects of the patient's
health, the perception of health, presence of
health risk factors and the patient's coping
patterns.
•
• 2. Focused assessment:

• It is an assessment that is limited in order to

focus on a particular need or health care
problem or potential health care risks.

• 3. Ongoing assessment:

• Is an assessment that includes systemic

monitoring and observation related to
specific problems, it is particularly
important when problems have been
4. Emergency assessment:
• It is an assessment that is done when a physiologic
or psychological crises occur to identify life
threatening problems.
 Elements of assessment process

A. Data collection
B. Data verification
C. Data Organization
D. Data interpretation
E. Data documentation
• A: Data collection:
• It often begins prior to initial contact between
the nurse and the patient through reviewing of
biographical data and medical records.
Systemic and ongoing data collection is the
key of accurate assessment of your patient.

• Priorities in data collection:

• A system must be established to determine

which data will be collected first. One of such
systems is Maslow's hierarchy of needs that
include: physiological, safety and security,
social, self-esteem and self-actualization
 Types of data

• 1. Subjective data:
– Data from patient's point of view and include feelings,
perceptions, and concerns. They cannot be readily
observed by another e.g. pain, nausea.
•
• 2. Objective data:
– Are observable and measurable data that are obtained
through observation, standard assessment techniques
performed during the physical examination, and laboratory
and diagnostic testing e.g. blood pressure, edema.
•
• 3. Historical data:
– Includes situations or events that have
occurred in the past, which are important in
identifying patient's health patterns and past
experiences that may have an impact upon
patient's health e.g. previous hospitalization.

• 4. Current data:
– Data related to events that are occurring
now e.g. vomiting, post operative pain.
Sources of data

1- The primary
source

2- Secondary
source
• A: Primary source:
• Usually the primary source of information is
the patient. He will offer a clear and concise
picture about his needs and problems and
what the expects in term of recovery and
nursing care.
•

• B: Secondary source:
• 1. Family members and/or friends.
• 2. Health team members
• 3. Patient's health record
 Methods of data collection

1. Observation
2. Interview
3. Health history
4. Physical examination
5. Laboratory and diagnostic data
• Observation:
• The nurse uses the skill of observation to carefully and attentively note the general appearance and
behavior of the patient.
• Interview:
• It is a therapeutic interaction that has a specific purpose. The purpose of assessment interview is to
collect information about patient's health history and current status in order to make determinations
about the patient's health needs.
• Health history:
• It is a review of the patient's functional health patterns prior to the current contact with a health care
agency, it includes:
• * Demographic information (name, age, sex, education... etc).
• * Reason for seeking health care
• * Previous hospitalization, illnesses, and surgeries.
• * Patient/family medical history
•
•4. Physical examination:
•The purpose of physical examination is to make direct observations of
any deviations from normal and to validate subjective data gathered
through the interview. Baseline measurements are obtained and physical
examination techniques are used to gather objective data.

•5. Laboratory and diagnostic data:

•Results of laboratory and diagnostic tests can be useful objective data as
these values often serve as defining characteristics for various altered
health states; these can also be helpful in ruling out certain suspected
problems. For example, diabetic patients who are poorly controlled on diet
and/or medication will usually have an elevated blood glucose level. In
addition, the effectiveness of nursing and medical interventions and
progress toward health restoration are often monitored through laboratory
and diagnostic test data.
Characteristics of data collection

A. Systemic.

B. Ongoing
• 1. Systemic:
• The nurse should assess the patient systematically from
head to toe, major body systems and functional health
patterns. Head to toe: head, neck, chest, abdomen, back,
extremities and genitalia. Major body systems: The nurse
examines: Cardiovascular, respiratory, urinary,
reproductive, gastro-intestinal, neurologic, skin and
musculoskeletal system.

• 2. Ongoing:
• Reassessment to evaluate patient's progress.

• B: Data verification:
• Is the process through which data are validated as being
complete and accurate. This process is particularly
important if data sources are considered unreliable e.g. if
a patient is confused or unable to communicate or if two
sources provide conflicting data, it is necessary for the
nurse to seek further information or clarification.
• C: Data organization:
• After data collection is completed and information is
validated, the nurses organize or cluster the
information together in order to identify areas of
strengths and weaknesses.

• D: Data interpretation:
• Data clustering facilitates determination of further
data is needed in order to identify nursing
diagnosis.

• E: Data documentation:
• Accurate and complete recording of assessment
data, which is essential for communicating
information to other health care team members. It is
the basis for determining quality of care and should
include appropriate data to support identified
problems.
 What to assess.
• 1. Social condition of the patient:
• Including personal data (age, sex, marital status, education, occupation,
religion, income, and personal habits), this information can be identified
through interview. .
•
• 2-Physical condition:
• Including height, weight, vital signs, and condition of skin, scalp, teeth,
eyes, body alignment, position, general sensation and motor function
Determination of patient physical condition through physical examination
by using previously mentioned methods.
•
• 3. Mental and psychological condition:
• Including fears, worries, anxieties, and the nurse can determine
psychological condition of the patient through interviewing the patient and
his family
•
• 4. Therapeutic aspect:
• Including medication, treatment, investigation, allergic condition........etc.
Therapeutic aspect can be identified through checking patient's record or
consultation with members of health team. .
 Signs and Symptoms
• Signs:
• They are objective indication of disease or
abnormality. They are detected by the examiner
through using special methods of
examination or through the use of special
instruments e.g. fever can be detected by the
clinical thermometer.
• Symptoms:
• Refer to any indication of disease or condition,
which may be felt by the patient or observed
by the examiner. pain
• Classification of symptoms:
• Subjective symptoms:
• These conditions that perceived by the patient such as pain and
the observer may not see the deviation e.g. pain, nausea.

• Objective symptoms:
• These conditions are identified by the observer whether the nurse
or physician e.g. pallor, cyanosis, swelling.
 Types of symptoms
• Cardinal symptoms: These major symptom that physician use to make
a diagnosis
• Constitutional symptoms: Those that are produced by the effect of the
disease on the whole body.
• Prodromal symptoms: These are occurring in the initial stages of the
disease e.g. running nose as an initial stage of measles.
• Local symptoms: These are noticed in special area or part of the body
as swelling in hands.
• Syndrome: It is a combination of symptoms that make up a
characteristic picture of a particular disease.
 2- Nursing diagnosis
"A nursing diagnosis is a standardized statement about the health
of a patient (who can be an individual, a family, or a community)
for the purpose of providing nursing care. Nursing diagnoses are
developed during the course of performing the nursing
assessments

[Link] Elsayed OR
• Nurses only make nursing diagnoses:

• Once the nurse have identified the patient's problems

related to his health status, then formulate a nursing
diagnosis for each of them. The nurse will also prioritize
the problems in formulating the plan and goals. The
nursing diagnoses are categorized by a system commonly
referred to as NANDA.
• Difference Between Nursing and Medical Diagnosis
• Nursing Diagnosis- statement used to describe the client's
actual or potential response to a health problem
i.e.-Impaired skin integrity - Risk for Infection, etc.
• Medical Diagnosis- physician "clinical judgment of the
disease- i.e. diabetes mellitus.
• Types of Nursing Diagnosis
• Actual problem
• Risk for problem

• Actual diagnosis: a statement about a health problem that the patient has
and the benefit from nursing care.
• An example of an actual nursing diagnosis is: Ineffective airway clearance
stagnation of secretion related to decreased energy secondary to
prolonged bed rest as manifested by an ineffective cough.

•
• Risk diagnosis: a statement about health problems that a patient
doesn't have yet, but is at a higher than normal risk of developing
in the near future.
• An example of a risk diagnosis is: Risk for injury related to altered
mobility and disorientation.
 • Components of a nursing diagnosis
•
• I.
Diagnostic Label
• - Name of nursing diagnosis listed in taxonomy, describes essence of
problem
• - Example: Stress Incontinence; Anxiety; Self-Care Deficit

• II. Qualifiers
• - add additional meaning to a nursing diagnosis, changes in condition,
etc.
• - Example: Altered; Impaired; Ineffective; etc.

• III. Etiology :( related factor and risk factor): identifies one or more
probable causes of the health problem.

• IV. Defining Characteristics

• - Are cluster of signs and symptoms that indicate the presence of a
particular diagnostic label.
• Activity Intolerance • Nutrition, Imbalanced: Less than Body
• Airway Clearance, Ineffective Requirements
• Anxiety • Nutrition, Imbalanced: More than Body
• Body Image, Disturbed Requirements
• Body Temperature: Imbalanced, Risk for • pain, Acute
• Ineffective breathing pattern • Pain, Chronic
• Constipation • Self-Care Deficit: Bathing/Hygiene
• Constipation, Risk for • Self-Care Deficit: Dressing/Grooming
• Hyperthermia • Self-Care Deficit: Feeding
• Hypothermia • Self-Care Deficit: Toileting
• Infection, Risk for • Skin Integrity, Impaired
• Injury, Risk for • Skin Integrity, Risk for Impaired
• Insomnia • Social Isolation
• Knowledge, Deficient (Specify) • Urinary Elimination, Impaired
• Mobility: Physical, Impaired • Urinary Retention
• Nausea
• Types of Nursing Diagnosis
• A- Actual diagnosis:
• a statement about a health problem that the patient has and the benefit
from nursing care. An example of an actual nursing diagnosis is:
Ineffective airway clearance stagnation of secretion related to decreased
energy secondary to prolonged bed rest as manifested by an ineffective
cough.

• B- Risk diagnosis:
• a statement about health problems that a patient doesn't have yet, but
is at a higher than normal risk of developing in the near future. An
example of a risk diagnosis is: Risk for injury related to altered mobility
and disorientation
 3- Planning
• Definition:
• It is the process of prioritizing nursing diagnoses and, identifying
measurable goals or outcomes, selecting appropriate
interventions, and documenting the plan of care.
• Planning steps:
• Establishes Priorities
• Writes Client Goals/Outcomes
• Selects Nursing Interventions
• Communicates The Plan
 Planning Process:

1-Setting priorities:
Is the process of establishing a preferential
order for nursing diagnosis and interventions.

- The nurse and client begin planning by

deciding which nursing diagnosis requires
attention first, which second, and so on.
 Types of priority
43
• High: nursing diagnosis that if untreated, could result in
harm to the client or others have the highest priority. sever
bleeding

• Intermediate: nursing diagnosis involves the non-emergency,

non-life threatening needs of the clients

• Low: nursing diagnosis are client’s needs that may not be

directly to a specific illness or prognosis
[Link] Elsayed
 2- Establishing client goal/desired outcomes

The nurse client set goals for each nursing

diagnosis.

Types of Goals:
a- Short Term Goals:
For a client who require health care for a short
time.

b- Long Term Goals:

Are often used for clients who live at home and
have a chronic health problem.
[Link] Elsayed
• Guidelines for writing goals

• Patient centered
• Singular goal or outcome
• Observable
• Measurable
• Time-limited
• Realistic
[Link] Elsayed
 Formula for Writing Goals/Outcomes:
Goal statement (long or short term) = patient behavior + criteria + time + conditions (if

needed)

1. Subject -patient

2. Verb -action/behavior which pt performs

3. Criteria -acceptable performance

4. Within specified time period

5. Condition (if needed) circumstances under which behavior

performed

Example:

• The patient (1) will walk (2) the length of the hall
[Link] Elsayed
 Example of nursing diagnosis &
patient goal
47

Nursing diagnosis Outcome criteria

( patient goal)
1. Ineffective breathing pattern((Problem) Patient will return to normal
related to bronchial spasm ( etiology) as breathing pattern within 30 min
manifested by shortness of breath (
defining characteristics s+s)

2. Altered body temperature hyperthermia Patient will return to normal body

(Problem) related to infection ( etiology) as temperature (37 C) within 30 min
manifested by increase body temperature
(38.3C) ( defining characteristics)

[Link] Elsayed
 Example of nursing diagnosis &
patient goal
48

Nursing diagnosis Outcome criteria

( patient goal)

Altered body temperature hypothermia Patient will return to normal body

(Problem) related to decreased activity ( temperature (37 C) within 30 min
etiology) as manifested by decrease body
temperature (36.3C) ( defining characteristics)

[Link] Elsayed
 Example of nursing diagnosis &
patient goal
49

Nursing diagnosis Outcome

criteria
( patient goal)

Altered body temperature hypothermia Patient will return to normal

(Problem) related to decreased activity ( body temperature (37 C) within
etiology) as manifested by decrease body 30 min
temperature (36.3C) ( defining
characteristics)

[Link] Elsayed
[Link] Elsayed
 4- Implementation
• Definition:
• Is the phase in which the nurse puts the nursing care
plan into action.
• Steps of implementation:
• 1. Reassessing patient
• 2. Reviewing and modifying existing care plan
• 3. Performing nursing actions
[Link] Elsayed
• Types of Nursing Intervention:
1- Independent intervention: are those activities that nurses are
licensed to initiate on the basis of their knowledge and skills (as
measuring V/S).

2- Dependent intervention: are activities carried out under the

physician orders (as administering medication).

3- Collaborative intervention: are actions the nurse carries out in

collaboration with other health team member.
[Link] Elsayed
[Link] Elsayed
• 5- Evaluation (Re-assessment):
• Definition: Evaluation is measuring the extent to which
client goals have been met and examining the need for
adjustments and changes as well.
• Evaluation steps:
• 1. Comparing patient response to criteria
• 2. Analyzing reasons for results and conclusions
• 3. Modifying care plan

[Link] Elsayed
 Examples of nursing diagnosis & patient goal
Nursing diagnosis Planning ( patient goal)

1. Ineffective (qualifier) breathing pattern (diagnostic Patient will state that he breaths easily within 30
label) related to bronchial spasm (etiology) as min of interventions.
manifested by shortness of breath ( defining
characteristics or s+s)
2. Altered (qualifier) body temperature Patient will return to normal body temperature
hyperthermia (diagnostic label) related to infection (37 °C) within 30 min
(etiology) as manifested by increase body
temperature (38.3°C) (defining
characteristics)
3. Altered (qualifier) body temperature hypothermia Patient will return to normal body temperature
(diagnostic label) related to decreased activity ( (37 °C) within 30 min
etiology) as manifested by decrease body
temperature (36.3°C) (defining characteristics)

4. pain (diagnostic label) related to surgical incision Patient will state that pain is relieved or decreased
(etiology) as manifested by patient statement- I have within 30 minutes.
moderate incision pain (defining characteristics)

5. Risk for impaired (qualifier) skin integrity Patient will have intact skin.
(diagnostic label) related to prolonged bed rest
(etiology).
[Link] Elsayed
 Example of nursing care plan
Student Name ---------------------------
Patient Name-------------------------------------- Diagnosis------------------------------------------- Bed N:----------
Room N:-------------
58
Therapeutic Diet:----------------------------------------- Date of admission------------------------------- Date of operation

Nursing Nursing Planning Implementation Evaluation

assessmen diagnosis ( patient goal) = nursing =
t interventions reassessme
nt
Fever Altered Patient will As mentioned in Resolved
body
(38.3 C) return to the lecture Or
temperature
related normal body temperatur
to….as temperature eStill high
manifested within 30 (38.3 C)
by increase
minutes of
body
temperature interventions
(38.3 C)

[Link] Elsayed
[Link] Elsayed