NURSING PROCESS nur 114, 2025.pdf ihs francistown

NURSING PROCESS
L.N.TAPSON
MNS(CHN)
BCUR

OBJECTIVES
 Terms
 Nursing, process, nursing process
 Components of the nursing process
• Assessment
• Diagnosis
• Planning
• Interventions
• Nursing care plan
• Implementation
• evaluation

The nursing process is a deliberate, problem-
solving approach to meeting the health care
and nursing needs of patients. It involves
assessment (data collection), nursing diagnosis,
planning, implementation, and evaluation. The
process as a whole is cyclical, the steps being
interrelated, interdependent, and recurrent.

CHARACTERISTICS OF NURSING
PROCESS
 Cyclic and dynamic nature
 Client centeredness
 Focus on problem-solving and decision-making
 Interpersonal and collaborative style
 Universal applicability
 Use of critical thinking

 Collecting data is the process of gathering information
about a client’s health status.
 Organizing data is categorizing data systematically
using a specified format.
 Validating data is the act of “double-checking” or
verifying data to confirm that it is accurate and factual.
 Documenting is accurately and factually recording
data.

TYPES OF ASSESSMENT
 Initial
 Performed within a specified time period
 Establishes complete database
 Problem-Focused
 Ongoing process integrated with care
 Determines status of a specific problem
 Emergency
 Performed during physiologic or psychologic crises
 Identifies life-threatening problems
 Identifies new or overlooked problems
 Time-lapsed
 Occurs several months after initial
 Compares current status to baseline

Assessment
 Initial assessment is performed within a specified time
after admission to a health care facility for the purpose
of establishing a complete database for problem
identification, reference, and future comparison.
 Problem-focused assessment is an ongoing process
integrated with nursing care to determine the status of a
specific problem identified in an earlier assessment.

Assessment
 Emergency assessment occurs during any physiologic or
psychologic crisis of the client to identify the life-
threatening problems and to identify new or overlooked
problems.
 Time-lapsed (expired)reassessment occurs several
months after the initial assessment to compare the
client’s current status to baseline data previously
obtained.

SUBJECTIVE DATA
Subjective data (what the patient tells you, also
called SYMPTOMS)
Apparent only to the person affected
Can be described only by person affected
Includes sensations, feelings, values, beliefs,
attitudes, and perception of personal health
status and life situations

What, when, where
Provoking factors
Quality (sharp, dull)
Relieving factors
Severity (scale of 1 to 10 for pain)
 Time/duration

OBJECTIVE DATA
 Signs or unconcealed data
 Detectable by an observer
 Can be measured or tested against an accepted
standard
 Can be seen, heard, felt, or smelled
 Obtained through observation or physical examination

What you see, hear, feel, smell
Inspection
Auscultation
Percussion
Palpation

 Kagiso female aged 28, has come to the clinic after
passing out twice in the past 2 days. She tells the nurse
that she becomes light headed after almost all types of
activities. She has experienced some nausea and she
vomited this morning after breakfast. She also tells the
nurse that she is very nervous about this occurrences
because her mother had similar symptoms when she
suffered from a brain disorder. The nurses notices that
kagiso s gait is unsteady, and her skin is pale. The client
also has large bruises on her right arm and forehead

SOURCES OF DATA
Primary Source
The client
Secondary Sources
All other sources of data e.g……
Should be validated, if possible

METHODS OF DATA COLLECTION
Observation
Interview
Physical examination

OBSERVATION
Gathering data using the senses
Used to obtain following types of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)

INTERVEIW
 Planned communication or a conversation with a purpose
 Used to:
Identify problems of mutual concern
Evaluate change
Teach
Provide support
Provide counseling or therapy

APROACHES TO INTERVEIW
directed interview
Highly structured and elicits specific information. The
nurse establishes the purpose of the interview and
controls the interview. The client responds to questions
but may have limited opportunities to ask questions or
discuss concerns.

Assessment cont’
non directed interview or rapport-building
interview,
by contrast the nurse allows the client to control
the purpose, subject matter, and pacing.

PHASES OF INTERVEIW
1. Preparatory
❑Review medical record first
❑Obtain/organize needed materials
❑Prepare the room
❑Provide privacy

PHASES OF INTERVIEW
2. Introductory
❑ establish rapport
❑ explain purpose
❑ duration
❑ confidentiality

PHASES OF INTERVEIW
3. Maintenance/ Working: Conducting interview
❑Nurse gathers info for subjective data
❑Excellent communication skills are needed

.
Closed and Open-ended
Questions
Closed Question
 Restrictive
 Yes/no
 Factual
 Less effort and
information from client
 “What medications did
you take?”
 “Are you having pain
now?”
Open-ended Question
Specify broad topic
to discuss
Invite longer answers
Get more information
from client
Useful to change
topics and elicit
attitudes
“How have you been
feeling lately?”

THERAPHEUTIC COMMUNICATION
SKILLS
SELF STUDY

PHASES OF INTERVIEW
4. Concluding:
❑Summarize & answer questions
❑Inform patient when nearing end of interview
❑Ensure patient knows what will happen with information
❑Offer patient chance to add anything

Assessment cont’
Components of data collection
Health History
❑ Biographical information
❑ Reasons for seeking healthcare
❑ Present illness or health concern
❑ Past medical history
❑ Family history
❑ social history
❑ Review of systems or functional health patterns

PHYSICAL EXAMINATION
 Systematic data-collection method
 Uses observation and inspection, auscultation, palpation, and
percussion
Blood pressure
Pulses
Heart and lungs sounds
Skin temperature and moisture
Muscle strength

Assessment cont’
 Validating is the act of “double-checking” or verifying data to confirm that it is accurate
and factual.
Organization/ data clustering
It is categorizing data systematically using a
specified format.
Body Systems Model (medical model) Focuses on anatomical systems
Head to Toe Model Systematic approach starting with head &
progressing downward

Assessment cont’
Documenting Data
The nurse records client data.
Accurate documentation is essential and should include all
data collected about the client’s health status.
To increase accuracy, the nurse records subjective data in the
“client’s own words” to avoid the chance of changing the
original meaning.

OBJECTIVES
 At the end of the session, learners should be able to :
Explain the purpose of diagnosis
Describe the components of a nursing diagnosis
Describe the steps for formulating a diagnosis
Explain the types of diagnosis
Differentiate between nursing and medical diagnosis

NURSING DIAGNOSIS
Diagnosis is the second phase of the nursing
process. In this phase, nurses use critical
thinking skills to interpret assessment data to
identify client problems. North American Nursing
Diagnosis Association (NANDÀ) define or refine
nursing diagnosis.

STEPS OF NURSING DIAGNOSIS
❑Review data and find actual and potential
problems
❑Use diagnostic reasoning to identify patient
needs
❑Reach conclusions for patient needs
❑Determine Nursing Diagnosis according to
NANDA approved diagnoses

DEFINITION
According to the North American Nursing
Diagnosis Association (NANDA) a nursing
diagnosis is a clinical judgment about individual,
family, or community responses to actual or
potential health problems/life processes

PURPOSE OF NURSING DIAGNOSIS
To identify a client's health care status, and actual or
potential health problems
 To establish plans to meet the identified needs,
To deliver specific nursing interventions to address
those needs

PURPOSE OF NURSING DIAGNOSIS
 FOR NURSING
1. Facilitates communication, documentation
2. Continuity of care among health care providers
 FOR CLIENT
1. Individualization of care
2. Appropriate selection of interventions
3. Establishment of goal

FORMULATING A NURSING DIAGNOSIS
 1. ANALYSING DATA
A. Compare data against standards (identify significant cues)
 accepted measure, model rule, or pattern for vital signs , Laboratory results
B. Cluster cues (generate tentative hypotheses)
 determining the relatedness of facts and determining whether data are
significant
C. Identify gaps & inconsistencies
 validating data

FORMULATING A NURSING DIAGNOSIS
 2. IDENTIFYING HEALTH PROBLEMS, RISKS & STRENGTHS
A.problems that support tentative actual, risk, and possible diagnoses
 eg I feel weak
B.determining strengths
 Eg. Absence of allergies & Non smoker.
 NB:
 done by both nurse & patient
 Done after gaping and clustering the data

 3.FORMULATING DIAGNOSTIC STATEMENTS
 Most Nursing Diagnoses are written as two part
or three part statements, but there are variations
of these.
1. Basic three part statement - actual
2. Basic two part statement - risk
3. One part statement - wellness

Components of a NANDA Nursing
Diagnosis A nursing diagnosis has three
components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics

 Formulating Diagnostic Statements 2
The basic three-part nursing diagnosis statement is
called the PES format and includes the following:
 1. Problem (P): statement of the client's health problem
(NANDA label)
 2. Etiology (E): causes of the health problem
 3. Signs and symptoms (S): defining characteristics
manifested by the client

1. The problem statement describes the client's
health problem.
2. The etiology component of a nursing
diagnosis identifies causes of the health
problem.
3. Defining characteristics are the cluster of signs
and symptoms that indicate the presence of
health problem

Types of Nursing Diagnosis
 Actual
 Risk
 Wellness

 Status of the 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.
 2. A health promotion diagnosis relates to clients'
preparedness to improve their health condition
 3. Risk diagnosis

Actual diagnosis
Problem present at the time of the
assessment
Presence of associated signs and
symptoms
Example, ineffective breathing pattern

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.
Risk of aspiration related to impaired
swallowing

Wellness diagnosis
 Readiness for enhancement
 describes human responses to levels of
wellness in an individual, family, or community
that have a readiness enhancement.”
 Example, readiness for enhanced family
coping

Acute pain related to abdominal
surgery as evidenced by patient
verbalising 7/10 on the pain scale
Ineffective breathing patterns
related to bronchial obstruction as
evidenced by tachypnea of 32b/m

Differentiating Nursing Diagnosis from
Medical Diagnosis Nursing diagnosis
NURSING
 nursing nurse, by their education
experience, and expertise, are
licensed to treat
 Nursing diagnoses describe the
human response to an illness or a
health problem
 Nursing diagnoses may change as
the client's responses change
MEDICAL
 Medical diagnosis is a statement
of A medical diagnosis is made
judgment that made by a
physician
 Medical diagnoses refer to
disease processes
 A client's medical diagnosis
remains the same for as long as
the disease is present

Nursing diagnosis
 Ineffective breathing pattern
 Activity intolerance
 Acute pain
Medical diagnosis
 Asthma
 Cardio vascular accident CVA
 Appendicitis

PLANNING
Setting Priorities
Establishing a preferential sequence for
addressing nursing diagnoses and interventions
High priority (life-threatening)
Medium priority (health-threatening)
Low priority (developmental needs)

Identify activities that occur in the
planning process.
Prioritizing problems/diagnoses
Formulating client goals/desired
outcomes
Selecting nursing interventions
Writing individualized nursing interventions

Identify essential guidelines for writing
nursing care plans.
Guidelines for Writing Nursing
Care Plans
Date and sign the plan
Use category headings
Use standardized/approved terminology and
symbols
Be specific

Identify factors that the nurse must
consider when setting priorities.
 Setting Priorities
 Establishing a preferential sequence for addressing nursing diagnoses and
interventions
 High priority (life-threatening)
 Medium priority (health-threatening)
 Low priority (developmental needs)

Factors to Consider When Setting
Priorities
 Client’s health values and beliefs
 Client’s priorities
 Resources available to the nurse and client
 Urgency of the health problem
 Medical treatment plan

Goals/Desired Outcomes and Nursing Diagnosis
Goals derived from diagnostic label
Diagnostic label contains the unhealthy
response (problem)
Goal/desired outcome demonstrates resolution
of the unhealthy response (problem)

Identify guidelines for writing goals/desired
outcomes.
Components of Goal/Desired Outcome
Statements
Subject
Verb
Condition or modifier
Criterion of desired performance

Guidelines for Writing Goal/Outcome
Statements
 Write in terms of the client responses
 Must be realistic
 Ensure compatibility with the therapies of
other professionals
 Derive from only one nursing diagnosis
 Use observable, measurable terms

Nursing Interventions and Activities
Actions nurse performs to achieve goals/desired
outcomes
Focus on eliminating or reducing etiology of
nursing diagnosis
Treat signs/symptoms and defining
characteristics

Describe the relationship of
goals/desired outcomes to the
nursing diagnoses.
 Goals/Desired Outcomes and Nursing Diagnosis
 Goals derived from diagnostic label
 Diagnostic label contains the unhealthy response (problem)
 Goal/desired outcome demonstrates resolution of the unhealthy response
(problem)

Guidelines for Writing Goal/Outcome
Statements
 Write in terms of the client responses
 Must be realistic
 Ensure compatibility with the therapies of other
professionals
 Derive from only one nursing diagnosis
 Use observable, measurable terms

NURSING INTERVENTIONS
The specific actions and treatments a
nurse performs to help a patient
achieve desired health outcomes,
improve comfort, and promote
recovery from illness or injury.

Describe the process of selecting and
choosing nursing interventions.
Nursing Interventions and Activities
Actions nurse performs to achieve
goals/desired outcomes
Focus on eliminating or reducing etiology of
nursing diagnosis
Treat signs/symptoms and defining
characteristics

Nursing Interventions
 Direct
 Indirect

Direct care is an intervention performed
through interaction with the client.
 Indirect care is an intervention performed
away from but on behalf of the client such
as interdisciplinary collaboration or
management of the care environment.

 Independent interventions
 Dependent interventions
 Collaborative interventions

TYPES OF INTERVENTIONS
 independent interventions, those activities that nurses are licensed to
initiate on the basis of their knowledge and skills;
 dependent interventions, activities carried out under the primary care
provider’s orders or supervision, or according to specified routines;
 collaborative interventions, actions the nurse carries out in collaboration
with other health team members. The nurse must choose interventions that
are most likely to achieve the goal/desired outcome.

independent
 Patient Education: Informing patients and their families about a condition,
treatment plan, or medication side effects.
 Emotional Support: Providing counseling and active listening to help
patients cope with their illness.
 Mobility Therapy: Teaching patients exercises to improve their physical
mobility.
 Comfort Measures: Repositioning patients to prevent pressure ulcers or
helping them establish healthy sleep patterns.
 Self-Care Promotion: Empowering patients to perform self-care activities to
maximize their independence.

dependent
 Medication Administration: Giving prescribed drugs to treat a condition or
manage symptoms.
 Wound Care: Dressing a wound as instructed by the physician.
 Intravenous (IV) Therapy: Starting an IV and administering IV fluids as
ordered by the physician.
 Implementing Invasive Procedures: Inserting a Foley catheter or other
invasive medical devices when ordered.

Collaborative
 physical Therapy: Coordinating pain medication administration with a
physical therapist for a patient's therapy session.
 Dietary Management: Working with a dietitian to develop a meal plan that
meets the patient's specific nutritional needs.
 Care Conferences: Participating in meetings with other providers, social
workers, and therapists to discuss a patient's care plan.
 Infection Control: Following hospital-wide procedures with other staff to
maintain a safe medical facility and prevent infections.

Criteria for Choosing Appropriate
Intervention
 Safe and appropriate for the client’s age, health, and
condition
 Achievable with the resources available
 Congruent with the client’s values, beliefs, and culture
 Congruent with other therapies
 Based on nursing knowledge and experience or
knowledge from relevant sciences
 Within established standards of care

evaluation
Measuring the degree to which goals/outcomes
have been achieved
Identifying factors that positively or
negatively influence goal achievement
Goal
Determine whether to continue, modify,
or terminate the plan of care

evaluation
A planned, ongoing, purposeful activity in which
clients and health care professionals determine
the client’s progress toward achievement of
goals/ outcomes and the effectiveness of the
nursing care plan. Successful evaluation
depends on the effectiveness of the steps that
precede it.

 Assessment data must be accurate and complete so the
nurse can formulate appropriate nursing diagnoses and
goals/desired outcomes.
 The goals/desired outcomes must be stated concretely
in behavioral terms to be useful for evaluating client
responses.
 the plan is put into action, OTHERWISE there would be
nothing to evaluate.
 The evaluating and assessing phases overlap.

During the evaluation step the nurse collects
data for the purpose of comparing the data to
preselected goals and judging the effectiveness
of the nursing care.
The act of assessing (data collection) is the
same. The differences lie in when the data are
collected and how the data are used.

 Collecting data related to the desired outcomes
( nursing outcomes classifications NOC indicators)
 Comparing the data with outcomes
 Relating nursing activities to outcomes
 Drawing conclusions about problem status
 Continuing, modifying, or terminating the nursing care
plan

DOCUMENTATION
 Eligible
 Dated
 Signed and counter signed

SOAPIE
 SUBJECTIVE AND OBJECTIVE
 ASSESMENT (NURSINING DIAGNOSIS)
 PLANNING
 INTERVENTIONS
 EVALUATION

 S-patient reports having diarrhoea since 2 days ago, she reports watery
stool at least 3 three times day . She also reports that she becomes light
headed after almost all types of activities. She has vomited twice this
morning after breakfast ,and feels very thirsty
 O-vitals signs bp 110/75mmHg, pulse 99b/m, temp 37.7degreescelcious.
Respirations18b/m. patient is wake and well oriented to self, time and
place. Patient has sunken eyes and dry and cracking lips. Patient has
decreased skin turgor of 4 seconds. Nil other abnormalities noted.
 A-deficient fluid volume related to active fluid loss(diarrhoea and vomiting)
as evidenced by ………………………………
 Inadequate fluid volume

 P-monitor vital signs every 4 hours
-give the patient prescribed amount of oral fluid
-Administer iv fluids as prescribed
-monitor intake and output
I-vitals signs monitored
Iv fluids (0.9% N/S ) put up
Intake and output monitoring on going
E-

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