Nursing Process

S6.M6.PPt-NCP
DEFINITION of NURSING PROCESS
The Nursing Process is a scientific method used
by nurses to ensure the quality of patient care.
All actions taken during the nursing process are documented in
Nursing Care Plan.
Nursing Care Plan (NCP) is a written guide of strategies to
implement and to help the client achieving optimal health.
The Objectives of Nursing Care Plan are:
1. To promote evidence-based care
2. To promote holistic care (includes physical, psychological,
social, and spiritual)
3. To support methods such as care pathways and care bundles
4. To record care.
5. To measure care.
PHASES OF NURSING PROCESS

1.Assessment

2.Diagnosis

3.Planning

4.Implementation

5.Evaluation
Assessment
Components of Assessment:
1. Data Collection
2. Chief Complaint
3. History of Present Illness
4. Past Health History (Past Medical
History, immunization, allergies,
drug history, last oral intake,
traveling)
5. Family History
Assessment
Types of Data:
1. Subjective Data/ Symptom
Information that is obtained verbally from the
client; it is what the client tells you about him
self or herself either spontaneously or as a
response to direct question (interview).
2. Objective Data/ Sign
Information that is obtained by performing a
physical assessment, taking vital signs, and
noting diagnostic test results.
Assessment
Sources of the Data:
1. Primary Source
Patient
2. Secondary Source
Family/Significant other,
Patient Medical Records(Present/Past)
History/Physical Progress Notes
Laboratory Diagnostic Test Result
Medication Lists & Literature
Assessment
Methods of Collecting Data:
1. Interview (ask open-ended questions)
2. Observation
3. Physical Examination
Assessment
Types of Assessment:
1. Comprehensive Initial Assessment
This type of Assessment includes a detailed health history
and physical examination of one body system or many
body systems; it is typically done on admission to the
hospital or onset of care in a primary care setting
2. Focused Assessment
This type of Assessment is more abbreviated assessment
used to evaluate the status of previously identified problem
and monitor for signs of new problems; it can be done
when a specific problem is identified; focus is on a problem
area
3. Emergency Assessment
This type of Assessment is used in an emergency or critical
care situation, may be done by rapid, specific questioning
of a patient while assessing and maintaining vital functions
Diagnosis

Types of Diagnosis:
1. Medical Diagnosis
Clinical judgment by the physician that identifies
or determines a specific disease, condition or
pathological state.
2. Nursing Diagnosis
A clinical judgment about individual, family, or
community responses to actual or potential
health problems/life process.
Nursing Diagnosis
Components of Nursing Diagnosis:
1. Problem
A term or phrase which is a name of diagnosed
condition as evidenced by defining characteristics and
etiology.
2. Defining Characteristics
Collected data, also known as signs and symptoms,
subjective and objective data or clinical manifestations.
3. Etiology
The related cause or contributor to the problem.
Nursing Diagnosis
Types of Nursing Diagnosis:
1. Actual Nursing Diagnosis
Indicates that a problem exists; composed of the diagnostic label, related
factors, and signs and symptoms.
2. Risk Nursing Diagnosis
Indicates that a problem does not yet exist but that specific risk factors are
present.
3. Possible Nursing Diagnosis
Indicates that the client’s data base doesn’t demonstrate the defining
characteristics or related factors of the diagnosis, but your intuition tells you
the diagnosis may be present.
4. Wellness Nursing Diagnosis
Indicates that a healthy client has a desire to achieve a higher level of
functioning in a specific area.
5. Syndrome Nursing Diagnosis
Indicates that the diagnosis is associated with a cluster of other diagnosis
(often seen in bedridden nursing home care residents). There are two syndrome
diagnoses on NANDA: disuse syndrome and rape and trauma syndrome.
Planning
There are two steps of planning:
a. Planning Expected Outcome
A detailed specific statement describing
the goals to be achieved after
implementing the treatment
b. Planning Intervention
The methods/actions used to achieve
the goals.
Planning Expected Outcome
Types of Planning Expected Outcome:
a. Initial Planning
It involves development of a preliminary
plan of care by the nurse who performs the
admission of assessment data.
b. Ongoing Planning
It updates the client's plan of care. New
information about the client is collected,
evaluated and revisions are made to the
plan of care.
c. Discharge Planning
It involves anticipation of planning for the
client's needs after discharge.
Planning Intervention
Types of Intervention:
a. Independent Nursing Intervention
Initiated by the nurse and does not
require direction or order from another
health care professional.
b. Interdependent Nursing Intervention
Implemented collaboratively by the nurse
in conjunction with other health care
professionals.
c. Dependent Nursing Intervention
Require an order from a physician or other
health care professional.
IMPLEMENTATION

Definition:
The fourth step. The performance of the nursing
interventions identified during the planning phase.
Involves delegation of some nursing interventions to
staff members.
EVALUATION

Definition:
Determines whether client’s goals have
been met, partially met, or not met.