Nursing Process

LEARNING OBJECTIVES
On completion of this chapter, the students will:
1. Identify component of nursing process.
2. Identify four sources for assessment data.
3. Differentiate between a data base assessment and a focus
assessment.
4. Distinguish between a nursing diagnosis and a
collaborative problem.
5. List three parts of a nursing diagnostic statement.
6. Describe the rationale for setting priorities.
7. Discuss appropriate circumstances for short-term and long-
term goals.
8. Discuss three outcomes that result from evaluation.
 Component of nursing process
:The steps of the nursing process
Assessment .1
Diagnosis .2
Planning .3
Implementation .4
Evaluation .5
Elements of Nursing process
 Assessment -1
:Definitions
Assessment; is the systematic and continuous
collection, organization, validation, and
.documentation of data (information)

Assessment; is the first step in the nursing process,

is the systematic collection of facts, or data.
Assessments vary according to their
- Purpose
- Timing, time available,
- Client status.
The registered nurse is responsible for the
collection of comprehensive data, including
physical, functional, psychosocial, emotional,
cognitive, sexual, cultural, age-related,
environmental, spiritual/transpersonal, and
economic assessments.
RNs may delegate some parts of an initial assessment
to an LPN, but the RN is still responsible for ensuring
that data collection is complete.
 Types of assessment

• There are two types of assessments:

A- Data base assessment.

B- Focus assessment.
 A- DATA BASE ASSESSMENT
A data base assessment (initial information about the
client’s physical, emotional, social, and spiritual health) is
lengthy and comprehensive. The nurse obtains data base
information during the admission interview and physical
examination.

Information obtained during a data base assessment serves

as a reference for comparing all future data and provides
the evidence used to identify the client’s initial problems.
Comparisons of ongoing assessments with baseline data
help determine whether the client’s health is improving,
deteriorating, or remaining unchanged.
 B- Focus assessment
A focus assessment is information that provides more details
about specific problems and expands the original data base.
Example if the client tells the nurse that he has constipation, the
nurse will obtain data about the client’s dietary habits, level of
activity, fluid intake, current medications, frequency of bowel
elimination, stool characteristics and may ask the client to save a
stool specimen for inspection.

Focus assessments generally are repeated frequently or on a

scheduled basis to determine client’s condition and
responses to therapeutic interventions.
Examples include monitoring the client’s level of pain before and
after administering medications.
Steps of assessment
 Collect data -1
Data collection is the process of gathering
information about a client’s health status.

Sources for Data:

The primary source for information is the client.
Secondary sources include the client’s family,
reports, test results, information in current and past
medical records, and discussions with other health
care workers.
 Cont. Collect data
Client data should include past history as well as
current problems.
For example:
- A history of an allergic reaction to penicillin is a vital
piece of historical data.
- Past surgical procedures, and chronic diseases are also
examples of historical data.
- Current data relate to present circumstances, such as
pain, nausea, sleep patterns, and religious practices.
 Data Collection Methods
The principal methods used to collect data are observing,
interviewing, and examining.

1- Observing; occurs whenever the nurse is in contact with

the client or support persons.

2- Interviewing; is used mainly while taking the nursing health

history.

3- Examining; is the major method used in the physical health

assessment.
 :Types of Data
1- Subjective data, also referred to as symptoms, can be
described or verified only by the patient.
Itching, pain, and feelings of worry are examples of subjective data.
Subjective data include the client’s sensations, feelings, values,
beliefs, attitudes, and perception of personal health status.

2- Objective data, also referred to as signs, can be detectable by

an observer or can be measured or tested against an accepted
standard.
They can be seen, heard, felt, or smelled and include such data
as blood pressure.
 Stop • Think + Respond BOX 2-1
Which of the following represent objective data?
1. A client rates his pain as 8 on a scale of 0 to10,
with 10 being the most pain he has ever
experienced.
2. A client has an incisional scar in the right lower
quadrant of the abdomen.
3. A client says she slept very well and feels rested.
4. A client’s blood pressure is 165/86 mm Hg.
5. A client’s heart rate is irregular.
 Organize data -2
Interpreting data is easier if information is organized.
Organization involves grouping related information.
For example, consider the following list of words: apple, wheels,
orchard, pedals, tree, and handlebars. At first glance, they appear
to be a jumble of terms. If asked to cluster the related terms,
however, most people would correctly group apple, tree, and
orchard together, and wheels, pedals, and handlebars together.
Nurses organize assessment data similarly. Using knowledge
and past experiences, they cluster related data.

Data organized into small groups is easier to analyze and

takes on more significance than when the nurse considers
each fact separately or examines the entire group at once.
Question
 BOX 2-3 ! Organization of Data
Assessment Findings
• Fatigue; distended abdomen; dry/hard stool
passed with difficulty; fever; weak cough; thick
sputum
Organized data:
• Fatigue, fever
• Weak cough, thick sputum
• Distended abdomen; dry, hard stool passed with
difficulty
 Validating data -3
The information gathered during the assessment
phase must be complete, factual, and accurate
because the nursing diagnoses and interventions
are based on this information. Validation is the
act of “double-checking” or verifying data to
confirm that it is accurate and factual.
 Documenting data -4
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.
Data are recorded in a factual manner and not
interpreted by the nurse.
For example, the nurse records the client’s breakfast intake
(objective data) as “coffee 240 mL, juice 120 mL, 1 egg, and 1
slice of toast,” rather than as “appetite good” (a judgment).
To increase accuracy, the nurse records subjective data
in the client’s own words, using quotation marks.
 Diagnosis -2

• Diagnosis, the second step in the nursing process,

is the identification of health-related problems.

• Diagnosis results from analyzing the collected

data and determining whether they suggest
normal or abnormal findings.
 A nursing diagnosis
– A nursing diagnosis is a health issue that can
be prevented, reduced, resolved, or
enhanced through independent nursing
measures.

– It is an exclusive nursing responsibility.

Steps of diagnosis
 Analyzing Data -1
In the diagnostic process, analyzing involves the
following steps:

1. Compare data against standards (identify

significant cues).

2. Cluster the cues (generate tentative

hypotheses).

3. Identify gaps and inconsistencies.

 Identifying Health Problems, -2
Risks, and Strengths

After data are analyzed, the nurse and client can

together identify strengths and problems.
This is primarily a decision-making process
 Formulate nursing diagnosis -3

The name of the nursing diagnosis is linked to

the etiology with the phrase “related to,” and
the signs and symptoms are identified with the
phrase “as manifested (or evidenced) by”.
(Box 2-4). P: 21 chapter #1
 Categories of nursing diagnosis

1- Actual nursing diagnosis:

An actual nursing diagnostic statement contains three

parts:

1. Name of the health-related issue or problem as

identified in the NANDA list.

2. Etiology (its cause).

3. Signs and symptoms.

:Risk diagnoses -2

Risk diagnoses are prefaced with the term “risk for,” as

in Risk for Impaired Skin Integrity related to inactivity.

The word “possible” is used in a diagnostic statement

to indicate uncertainty—for example, Possible Sexual
Dysfunction related to anxiety.

Risk and possible nursing diagnoses do not include the

third part of the statement.
 Collaborative Problems
• Collaborative problems are physiologic
complications that require both nurse- and
physician-prescribed interventions.
• They represent an interdependent domain of
nursing practice
 Planning -3
Planning, is the third step in the nursing process.

Planning, is the process of prioritizing nursing

diagnoses and collaborative problems, identifying
measurable goals or outcomes, selecting
appropriate interventions, and documenting the
plan of care.
Steps of planning
 setting priorities -1

Setting priorities, is important to determine which

problems require the most immediate attention.
Prioritization involves ranking from those that are
most serious or immediate to those of lesser
importance.
The ranking can change as problems are resolved or
new problems develop.
 Establishing Goals /formulate outcome -2
A goal (expected or desired outcome) helps the nursing team know
whether the nursing care has been appropriate for managing the
.client’s problems

:There are two types of goal

a) Short-term goal: outcomes achievable in a few days to 1 week,
most often in acute care settings because most hospital stays are
no longer than 1 week.

b) Long-term goal: desirable outcomes that take weeks or months

to accomplish) for clients with chronic health problems that
require extended care in a nursing home or who receive
community health or home health services.
An example of a long-term goal for the client with a cerebrovascular
accident (stroke) is the return of full or partial function to a paralyzed limb.
 characteristics of Short-term goals
(SMART)
1. Developed from the problem portion of the
diagnostic statement.
2. Client-centered, reflecting what the client will
accomplish, not the nurse
3. Measurable, identifying specific criteria that provide
evidence of goal achievement
4. Realistic, to avoid setting unattainable goals, which
can be self-defeating and frustrating
5. Accompanied by a target date for accomplishment,
the predicted time when the goal will be met.
BOX 2-6 !Components of Short-Term
Goals
Nursing Diagnostic Statement
• Constipation related to decreased fluid intake, lack of dietary
fiber, and lack of exercise as manifested by no normal bowel
movement for the past 3 days, abdominal cramping, and straining
to pass stool

Short-Term Goal
• The client will_________________ client–centered
• have a bowel movement _________ identifies measurable criteria
that reflect the problem portion of the diagnostic statement
• in 2 days (specify date) __________ identifies a target date for
achievement within a realistic time frame

(The client will have a bowel movement in 2 days)

 Selecting Nursing Interventions -3
Both of the patient and the nurse are responsible for
selecting nursing interventions which will be used for
accomplishing goals.

Nursing interventions are directed at eliminating the

etiologies.

Nursing interventions must be safe, within the legal

scope of nursing practice, and compatible with medical
orders.
 Documenting the Plan of Care -4
Plans of care can be written by hand, standardized
forms, computer generated, or based on an
agency’s written standards or clinical pathways.

Documenting the Plan of Care; describe the

routine care needed to meet basic needs (e.g.,
bathing, nutrition), or documents that specify the
nurse’s responsibilities in carrying out the medical
plan of care (e.g., keeping the client from eating
or drinking before surgery).
 Implementation -4
Implementation, the fourth step in the nursing
process, means carrying out the plan of care.

The nurse implements medical orders as well as

nursing orders, which should complement each
other.
Implementing the plan involves the client and one
or more members of the health care team.
Steps of Implementation
 Reassessing the client-1
Just before implementing an intervention, the
nurse must reassess the client to make sure the
intervention is still needed.
Even though an order is written on the care plan,
the client’s condition may have changed.
For New data may indicate a need to change the
priorities of care or the nursing activities.
 DETERMINING THE NURSE’S -2
NEED FOR ASSISTANCE
When implementing some nursing interventions,
the nurse may require assistance for one or more of
the following reasons:

1- The nurse is unable to implement the nursing

activity safely or efficiently alone.
2- Assistance would reduce stress on the client (e.g.,
turning).
3- The nurse has lacks of knowledge or skills to
implement a new particular nursing activity.
 IMPLEMENTING THE NURSING INTERVENTIONS -3

It is important to explain to the client what interventions will be done, what

sensations to expect, what the client is expected to do, and what the
expected outcome is.

When implementing interventions, nurses should follow these guidelines:

1- Base nursing interventions on scientific knowledge, nursing research, and
professional standards of care.
2- Clearly understand the interventions to be implemented
3- Adapt activities to the individual client.
4- Implement safe care. For example, when changing a sterile dressing, the
nurse practices sterile technique to prevent infection.
5- Provide teaching, support, and comfort.
6- Be holistic. The nurse must always view the client as a whole and
consider the client’s responses in that context.
SUPERVISING DELEGATED CARE -4

If care has been delegated to other health care

personnel, the nurse responsible for the client’s
overall care must ensure that the activities have
been implemented according to the care plan.
 DOCUMENTING NURSING ACTIVITIES -5
After carrying out the nursing activities, the nurse completes the
implementing phase by recording the interventions and client responses in
the nursing progress notes.

These are a part of the agency’s permanent record for the client.

Nursing care must not be recorded in advance because the nurse may
determine on reassessment of the client that the intervention should not or
cannot be implemented.

The nurse may record routine or recurring activities (e.g., mouth care) in the
client record at the end of a shift.
In the meantime, the nurse maintains a personal record of these
interventions on a worksheet.
The medical record is legal evidence that the plan of care
has been more than just a paper trail.

The information in the chart shows a correlation between

the plan and the care that has been provided.

The record also describes the quantity and quality of the

client’s response.

Appropriate documentation maintains open lines of

communication among members of the health care team,
ensures the client’s continuing progress, complies with
accreditation standards, and helps ensure reimbursement
from government or private insurance companies.
 Evaluation -5
Evaluation, the fifth and final step in the nursing
process, is the way by which nurses determine
whether a client has reached a goal.

By analyzing the client’s response, evaluation helps

to determine the effectiveness of nursing care.
Patient, health team members, or families may
invite the to participate for discontinuing, adding, or
changing.
Steps of evaluation
 COLLECTING DATA -1
Using the clearly stated, precise, and measurable
desired outcomes as a guide, the nurse collects
data so that conclusions can be drawn about
whether goals have been met.

Some data may require interpretation.

- Examples of objective data requiring interpretation
are the degree of tissue turgor of a dehydrated client -
Examples of subjective data needing interpretation
include complaints of nausea or pain by the client.
 COMPARING DATA WITH DESIRED OUTCOMES -2
Both the nurse and client play an active role in comparing the
client’s actual responses with the desired outcomes.
Did the client drink 3,000 mL of fluid in 24 hours? Did the client walk
unassisted the specified distance per day?

-- When determining whether a goal has been achieved, the nurse

can draw one of three possible conclusions:
1. The goal was met; that is, the client response is the same as the
desired outcome.
2. The goal was partially met; that is, either a short-term outcome
was achieved but the long-term goal was not, or the desired goal
was incompletely attained.
3. The goal was not met.
After determining whether or not a goal has been
met, the nurse writes an evaluation statement
(either on the care plan or in the nurse’s notes).
An evaluation statement consists of two parts:
1. A conclusion.
2. Supporting data.

Goal met: Oral intake 300 mL more than output;

skin turgor resilient; mucous membranes moist.
 RELATING NURSING ACTIVITIES TO OUTCOMES -3
The third phase of the evaluating process is
determining whether the nursing activities had any
relation to the outcomes.
It should never be assumed that a nursing activity was
the cause of or the only factor in meeting, partially
meeting, or not meeting a goal.
For example, a client was obese and needed to lose 14 kg.
When the nurse and client drew up a care plan, one goal
was “Lose 1.4 kg in 4 weeks.” A nursing strategy in the care
plan was “Explain how to plan and prepare a 1,200-calorie
diet.” Four weeks later, the client weighed herself and had
lost 1.8 kg. The goal had been met—in fact, exceeded.
DRAWING CONCLUSIONS ABOUT PROBLEM STATUS -4
The nurse uses the judgments 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 of the
following conclusions about the status of the client’s problem:
1- Discontinues the care for the 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.
2- The nurse keeps the problem on the care plan>>>>The potential problem
stated in the nursing diagnosis is being prevented, but the risk factors are still
present.
3- The nursing interventions must be continued even though this one goal was
met>>>The actual problem still exists even though some goals are being met.
For example, a desired outcome on a client’s care plan is “Will drink 3,000 mL of fluid
daily.” Even though the data may show this outcome has been achieved, other data (dry
oral mucous membranes) may indicate that the nursing diagnosis Deficient Fluid Volume
is applicable. Therefore,
When goals have been partially met or when goals have not been
met, two conclusions may be drawn:
• The care plan may need to be revised, since the problem is
only partially resolved. The revisions may need to occur during
the assessing, diagnosing, or planning phases, as well as
implementing.

OR

• The care plan does not need revision, because the client merely
needs more time to achieve the previously established goal(s). To
make this decision, the nurse must assess why the goals are being
only partially achieved, including whether the evaluation was
conducted too soon
 CONTINUING, MODIFYING, OR TERMINATING -5
THE NURSING CARE PLAN
After drawing conclusions about the status of the client’s
problems, the nurse modifies the care plan as indicated.
Depending on the agency, modifications may be made by
drawing a line through portions of the care plan, marking
portions using a highlighting pen, or indicating revisions as
appropriate for electronic charting systems.

The nurse may also write “Discontinued” (“dc’d”), “goal met,”

or “problem resolved” and the date.
Whether or not goals were met, a number of decisions need
to be made about continuing, modifying, or terminating
nursing care.
 QUESTIONS#1
• Three nursing diagnoses are on a client’s plan
of care:
(Ineffective Breathing Pattern, Social Isolation,
and Anxiety)
• Which has the highest priority, and why?
 QUESTIONS#2
When managing the care of a client, which of the
following nursing actions is most appropriate to
perform first?
1. Develop a plan of care.
2. Determine the client’s needs.
3. Assess the client physically.
4. Collaborate on goals for care.
 QUESTIONS#3
• According to most nurse practice acts, if a
charge nurse assigns a licensed practical nurse
to admit a new client, the licensed practical
nurse’s primary role is to
1. Create an initial nursing care plan.
2. Gather basic information from the client.
3. Develop a list of the client’s nursing diagnoses.
4. Report assessment data to the client’s
physician.
 QUESTIONS#4
• At a team conference, staff members discuss a client’s
nursing diagnoses. A nursing assistant questions which
nursing diagnosis is of highest priority. From the list that
follows, the licensed practical nurse is most accurate in
identifying
1. Ineffective Airway Clearance
2. Ineffective Coping
3. Deficient Diversional Activity
4. Interrupted Family Processes
 :References
1- Timby, B K. Fundamental Nursing Skills and
Concepts, 12th Edition (International Edition), 2020.
ISBN/ISSN 9781975141769 Publisher: Wolters
Kluwer.
2- Berman, A. Snyder, C and Frandsen, G. Kozier &
Erb's Fundamentals of Nursing, 10th Edition, 2016.
ISBN13: 9781292106106 Publisher: Pearson