NURSING PROCESS

Nursing process is a systematic, rational method of planning and providing

nursing care. Its purpose is to identify a client’s health care status, and actual or
potential health problems, to establish plans to meet the identified needs, and to
deliver specific nursing interventions to address those needs. The nursing
process is cyclical; that is, its component follows 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 the cycle may continue with
reassessment, or the plan of care may be modified.

Characteristics of Nursing Process

The nursing process has distinctive 5 characteristics that enable the nurse
to respond to the changing health status of the client. These characteristics
include its cyclic centeredness; focus on problem solving and decision making,
interpersonal and collaborative style, universal applicability, and use of critical
thinking.

• Data from each phase provide input into the next phase. Findings from
evaluation feed back into the assessment. Hence, the nursing process
is a regularly repeated event or sequence of events (a cycle) that is
continuously changing (dynamic) rather than staying the same (static)
• The nursing process is client centered. The nurse organizes the plan of
care according to client problems rather than nursing goals. In the
assessment phase, the nurse collects data to determine the client’s
habits, routines, and needs, enabling the nurse to incorporate client
routines into the care plan as much as possible.
• The nursing process is an adaptation of problem solving and system
theory. It can be viewed as parallel to but separate from the process
used by physicians (the medical model). Both processes (a) begin with
data gathering and analysis, (b) bas action (intervention or treatment)
on a problem statement (nursing diagnosis or medical diagnosis), and
(c) include an evaluate component. However, the medical model
focuses on physiological systems and the disease process, whereas
the nursing process is directed toward a client’s responses to disease
illness.
• Decision making is involved in every phase of the nursing process.
Nurses can be highly creative in determining when and how to use
data to make decisions. They are not bound by standard responses
and may apply their repertoire of skills and knowledge to assists
clients. This facilitates the individualization of the nurse’s plan of care.
• The nursing process is interpersonal and collaborative. It requires the
nurse to communicate directly and consistently with clients and
families to meet their needs. It also requires that nurses collaborate, as
members of the health care team, in a joint effort to provide quality
client care.
 There are 5 phases of nursing process: assessing, diagnosing, planning,
implementing, and evaluating.

ASSESSING
Assessing is the systematic and continuous collection, organization,
validation, and documentation of data (information). In effect, assessing is a
continuous process carried out during all phases of the nursing process. For
example, in the evaluation phase, assessment is done to determine the
outcomes of the nursing strategies and to evaluate goal achievement. All phases
of the nursing process depend on the accurate and complete collection of data.
There are 4 different types of assessments: initial assessment, problem-focused
assessment, emergency assessment, and time-lapsed reassessment.
Assessments vary according to their purpose, timing, time available, and client
status.

The assessment process involves 4 closely related activities: collecting

data, organizing data, validating data, and documenting data.

Types of Assessment

TYPE TIME PURPOSE EXAMPLE

PERFORMANCE
Initial Assessment Performed within To establish a Nursing admission
specified time complete
after admission to database for
a health care problem
agency identification,
reference, and
future comparison

Problem-focused Ongoing process To determine the Hourly

Assessment integrated with status of a specific assessment of
nursing care problem identified client’s fluid intake
in an earlier and urinary output
assessment in an ICU

Assessment of
client’s ability to
perform self-care
while assisting the
client to bathe

Emergency During any To identify life- Rapid assessment

Assessment physiologic or threatening of a person’s
psychologic crisis problems airway, breathing
of the client status and
To identify new or circulation during
 overlooked a cardiac arrest
problems
Assessment of
suicidal
tendencies or
potential for
violence.

Time-lapsed Several months To compare the Reassessment of

Reassessment after initial client’s current a client’s
assessment status to baseline functional health
data previously patterns in a home
obtained care or outpatient
setting or, in a
hospital, at shift
change

• Collecting Data

Data collection is the process of gathering information about a client; it

includes the health theory, physical assessment, primary care provider’s history
and physical examination, results of laboratory and diagnostic tests, and material
contributed by the other personnel.
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, folk healing practices, and chronic diseases are
also example of historical data. Current data relate to present circumstances,
such as pain, nausea, sleep patterns, and religious practices. To collect data
accurately, both the client and nurse must actively participate. Data can be
subjective or objective and constant or variable types, and from a primary or
secondary source.

Types of Data

Subjective data, referred to as symptoms or covert data, are apparent

only to the person affected and can be described or verified only by that person.
Itching, pain, and feeling of worry are examples of subjective data. Subjective
data include the client’s sensations, feelings, values, beliefs, attitudes, and
perception of personal health status and life situation.
Objective data , also referred to as signs or overt data, are detectable by
an observer or can be measured or tested against an accepted standard. They
can be seen, heard, felt, or smelted, and they are obtained by observation or
physical examination. For example, a discoloration of the skin or a blood
pressure reading is objective data.
 Constant data is information that does not change over time such as race
or blood type. Variable data can be change quickly, frequently, or rarely and
include such data as blood pressure, age, and level of pain.

Source of Data
Sources of data are primary and secondary. The client is the primary
source of data. Family member or other support persons, other health
professionals, records and reports, laboratory and diagnostic analyses, and
relevant literature are secondary or indirect sources.

Data Collection Methods

The principal methods used to collect data are observing, interviewing,
and examining.

Observing
To observe is to gather data by using the senses. Observation is a
conscious, deliberate skill that is developed through effort and with an organized
approach.

Interviewing
An interview is a planned communication or a conversation with a
purpose, for example, to get or give information, identify problems of mutual
concern, evaluate change, teach, provide support, or provide counseling or
therapy.
There are two approaches to interviewing: directives and non-directives.
The directive interview is highly structured and elicits specific information. The
nurse establishes the purpose of the interview and controls the interview, at least
at the outset. the client responds to questions but may have limited opportunity to
ask questions or discuss concerns.
During a non-directive interview, or rapport-building interview, by
contrast, the nurse allows the client to control the purpose, the subject matter,
and pacing. Rapport is an understanding between two or more people.

Examining
The physical examination or physical assessment is a systematic data
collection method that uses observation (i.e., the senses of sight, hearing, smell
and touch) to detect health problems. To conduct the examination the nurse uses
techniques of inspection, auscultation, palpation, and percussion.

• Organizing Data

The nurse uses a written (or computerized) format that organizes the
assessment data systematically. This is often referred to as a nursing history,
nursing assessment or nursing data-base form. The format may be modified
according to the client’s physical status such as one focused on musculoskeletal
data for orthopedic clients.
• Validating Data
 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. Validating data helps the nurse to
complete these tasks:

• Ensure that assessment information is complete

• Ensure that objective and related subjective data agree
• Obtain additional information that may have been over-looked.
• Differentiate between cues and inferences. Cues are subjective or
objective data that can be directly observe by the nurse; that is, what
the clients says or what the nurse can see, hear, smell, or measure.
Inference are the nurse’s interpretation or conclusions made based on
the cues (e.g., a nurse observes the cues that an incision is red, hot
and swollen; the nurse makes an inference that the incision is
infected).
• Avoid jumping to conclusions and focusing in the wrong direction to
identify problems.

• Documenting Data

To complete the assessment phase, the 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). A judgment or conclusion such as “appetite good”
or “normal appetite” may have different meanings for different people. To
increase accuracy, the nurse records subjective data in the client’s own words,
using quotation marks. Restating in other words what someone says increase the
chance of changing the original meaning.

DIAGNOSING
 Diagnosing is the second phase of the nursing process. In this phase,
nurses use critical thinking skills to interpret assessment data and identify client’s
strengths and problems. Diagnosing is a pivotal step in the nursing process.
Activities preceding this phase are directed toward formulating the nursing
diagnoses; the care-planning activities following this phase are based on the
nursing diagnoses.

Types of nursing diagnoses

The five types of nursing diagnoses are actual, risk, wellness, possible,
and syndrome.

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

nursing assessment. Examples are ineffective breathing pattern and
anxiety. An actual nursing diagnosis is based on the presence of
associated signs and symptoms.
2. A risk nursing diagnosis is a clinical judgment that a problem does not
exist, but the presence of risk factors indicates that a problem is likely to
develop unless nurses intervene. For example, all people admitted to
hospital have some possibility of acquiring an infection; however, a client
with diabetes or a compromised immune system is at higher risk than
others. Therefore, the nurse would appropriately use the label risk for
infection to describe the clients health status.
3. A wellness diagnosis “describes human responses to levels of wellness in
an individual, family or community that have a readiness for
enhancement”. Examples of wellness diagnoses would be readiness for
enhanced spiritual well-being or readiness for enhance family coping.
4. A possible nursing diagnosis is one in which evidence about a health
problem is incomplete or unclear. A possible diagnosis requires more data
either to support or to refute it. Fro example, an elderly widow who lives
alone is admitted to the hospital. The nurse notices that she has no
visitors and is pleased with attention and conversation from the nursing
staff. Until more data are collected, the nurse may write a nursing
diagnosis of possible social isolation related to unknown etiology.
5. A syndrome diagnosis is a diagnosis in which is associated with a cluster
of other diagnoses. Currently six syndrome diagnoses are on the NANDA
international list. Risk for disuse syndrome, for example, may be
experienced by long-term bedridden clients. Clusters of diagnoses
associated with this syndrome include impaired physical mobility, risk for
impaired tissue integrity, risk for activity intolerance, risk for constipation,
risk for infection, risk for injury, risk for powerless, impaired gas
exchanged, and so on.

Analyzing Data
In the diagnostic process, analyzing involves the following steps:
1. Compare date against standards (identify significant cues).
2. Cluster cues (generate tentative hypothesis).
3. Identify gaps and inconsistencies.

For experienced nurses, these activities occur continuously rather than

sequentially.

Comparing data with Standards

Nurses draw a knowledge and experience to compare client data to
standards and norms and identify significant and relevant cues. A standard or
norm is generally accepted measure, rule, model, or pattern. The nurse uses a
wide range of standards, such as growth and developmental patterns, normal
vital signs, and laboratory values.

Clustering Cues
Data Clustering or grouping cues is a process of determining the
relatedness of facts and determining whether any patterns are present, whether
the data represent isolated incidents, and whether the data are significant. This is
the beginning of synthesis.

Identifying Gaps and Inconsistencies

Skillful assessment minimizes gaps and inconsistencies in data. However,
data analysis should include a final check to ensure that the data are complete
and concrete.
Inconsistencies are conflicting data. Possible sources of conflicting data
include measurement error, expectations, and inconsistent or unreliable reports.
For example, the nurse may learn from the nursing history that the client reports
not having seen a doctor in 15 years, yet during the physical health examination,
he states, “My doctor takes my blood pressure every year.” All inconsistencies
must be clarified before a valid pattern can be established.

Identifying Health Problems, Risks, and Strengths

After data are analyzed, the nurse and client can together identify
strengths and problems. This is primarily a decision-making process.

Determining Problem and Risks

After grouping and clustering the data, the nurse and client together
identify problems that support tentative actual, risk, and possible diagnosis. In
addition, the nurse must determine whether the client’s problem is a nursing
diagnosis, medical diagnosis or collaborative problem.

Determining Strengths
At this stage, the nurse and client’s strengths, resources, and abilities to
cope. Most people have a clearer perception of their problems or weaknesses
than of their strengths and assets, which they often take for granted. By taking
inventory strengths, the client can develop a better-rounded self concept and self
image. Strengths can be an aid to immobilizing health and regenerative
processes.
 Formulating Diagnostic Statements

Most nursing diagnoses are written as two-part or three-part statements,

but there are variations of these.

Basic Two-Part Statements

The basic two-part statement includes the following:
1. Problem (P): statement of the client’s response
2. Etiology (E): factors contributing to or probable causes of the responses.

The two-parts are joined by the words related to rather than due to. The
phrase due to implies that one part causes or is responsible for the other part. By
contrast, the phrase related to merely implies a relationship.

Basic Three-Part Statements

The basic three-part nursing diagnosis statement is called the PES format
and includes the following:
1. Problem (P): statement of the client’s response
2. Etiology (E): factors contributing to or probable causes of the response
3. Signs and Symptoms (S): defining the characteristics manifested by the client.

Actual nursing diagnoses can be documented by using the three-part

statement because the signs and symptoms have been identified. This format
cannot be used for risk diagnoses because the client does not have signs and
symptoms of the diagnosis.

The PES format is especially recommended for beginning diagnosticians

because the signs and symptoms validate why the diagnosis was chosen and
make the problem statement more descriptive.

One-Part Statement
Some diagnostic statements, such as wellness, diagnoses and syndrome
nursing diagnoses, consist of a NANDA label only. As the diagnostic labels are
refined, they tend to become more specific, so that nursing interventions can be
derived from the label itself. Therefore, an etiology may not be needed. For
example, adding an etiology to the label Rape-Trauma Syndrome does not make
the label any more descriptive or useful.

Evaluating the Quality of the Diagnostic Statement

In addition, to using the correct format, nurse must consider the content of
their diagnostic statements. The statements should, for example, be accurate,
concise, descriptive, and specific. The nurse must always validate the diagnostic
statements with the client and compare the client’s signs and symptoms to the
NANDA defining characteristics. For risk problems, the nurse compares the
client’s risk factors to NANDA risk factors.
 PLANNING
Planning is a deliberative, systematic phase of the nursing process that
involves decision making and problem solving. In planning, the nurse refers to
the client’s assessment data and diagnostic statements for direction in
formulating client goals and designing the nursing interventions required to
prevent, reduce, or eliminate the client’s health problems. A Nursing intervention
is “any treatment, based upon clinical judgment and knowledge that a nurse
performs to enhance patient/client outcomes”. The end product of the planning
phase is a client care plan.
Although planning is basically the nurse’s responsibility, input from the
client and support persons is essential if a plan is to be effective. Nurses do not
plan for the client, but encourage the client to participate actively to the extent
possible. In a home setting, the client’s support people and caregivers are the
one’s who implement the plan of care; thus, its effectiveness depends largely on
them.

Types of planning

Planning begins with first client contact and continues until the nurse-client
relationship ends, usually when the client is discharge from the health care
agency. All planning is multidisciplinary (involves all health care providers
interacting with the client) and includes the client and family to the fullest extent
possible in every step.

• Initial planning

The nurse who performs the admission assessment usually develops the
initial comprehensive plan of care. This nurse has the benefit of the client’s body
language as well as some intuitive kinds of information that are not available
solely from the written database. Planning should be initiated as soon as possible
after the initial assessment, especially because of the trend toward shorter
hospital stays.

• Ongoing planning

Ongoing planning is done by all nurses who work with the client. As
nurses obtain new information and evaluate the client’s responses to care, they
can individualize the initial care plan further. Ongoing planning also occurs at the
beginning of a shift as the nurse plans the care to be given that day. Using
ongoing assessment data, the nurse carries out daily planning for the following
purposes:

1. to determine whether the client’s health status has changed

2. to set priorities for the client’s care during the shift
3. to decide which problems to focus on during the shift
4. to coordinate the nurse’s activities so that more than one problem can
be addressed at each client contact.
• Discharge planning

Discharge planning, the process of anticipating and planning for needs

after discharge, is a crucial part of comprehensive health care and should be
addressed in each client’s care plan. Because the average stay of clients in
acute care hospitals has become shorter, people are sometimes discharge still
needing care. Although many clients are discharge to other agencies (e.g. long-
term care facilities), such care is increasingly being delivered in the home.
Effective discharge planning begins at first client contact and involves
comprehensive and ongoing assessment to obtain information about the client’s
ongoing needs.

Developing a nursing care plan

The end product of the planning phase of the nursing process is a formal
or informal plan of care. An informal nursing care plan is a strategy for action that
exists in the nurse’s mind. For example, the nurse may think, “Mrs. Pham is very
tired. I will need to reinforce her teaching after she is rested.” A formal nursing
care plan is a written or computerized guide that organizes information about the
client’s care. The most obvious benefit of formal written care plan is that it
provides for continuity of care.
A standardized care plan is a formal plan that specifies the nursing care
for groups of clients with common needs. An individualized care plan is tailored
to meet the unique needs of specific client-needs that are not addressed by the
standardized plan.

Guidelines for writing nursing care plan

The nurse should use the following guidelines when writing nursing care
plans:

1. Date and sign the plan.

2. Use category headings.
3. Use standardized/approved medical or English symbols and key words
rather than complete sentences to communicate your ideas unless the
agency policy dictates otherwise.
4. Be specific.
5. Refer to procedure books or other sources of information rather than
including all the steps on a written plan.
6. Tailor the plan to the unique characteristics of the client by ensuring that
the client’s choices, such as preferences about the times of care and the
methods used.
7. Ensure that the nursing plan incorporates preventive and health
maintenance aspects as well as restorative ones.
8. Ensure that the plan contains interventions for ongoing assessment of the
client.
9. Include collaborative and coordination activities in the plan.
 10. Include plans for the client’s discharge and home care needs.

IMPLEMENTING
In the nursing process, implementing is the action phase in which the
nurse performs the nursing interventions. Using NIC terminology, implementing
consists of doing and documenting the activities that are the specific nursing
actions needed to carry out interventions. The nurse performs or delegates the
nursing activities for the intervention that were developed in the planning step
and then concludes the implementing step by recording nursing activities and the
resulting client responses.

Implementing Skills

To implement the care plan successfully, nurses need cognitive,

interpersonal and technical skills. These skills are distinct from one another; in
practice, however, nurses use them in various combinations and with different
emphasis, depending on the activity. For instance, when inserting a urinary
catheter the nurse needs cognitive knowledge of the principles and steps of the
procedure, interpersonal skills to inform and reassure the client. And technical
skill in draping the client and manipulating the equipment.
The cognitive skills (intellectual skills) include problem solving, decision
making, critical thinking, and creativity. They are crucial to safe, intelligent
nursing care.
Interpersonal skills are all of the activities, verbal and non-verbal people
use when interacting directly with one another. The effectiveness of a nursing
action often depends largely on the nurse’s ability to communicate with others.
The nurse uses therapeutic communication to understand the client and in turn
be understood. A nurse also needs to work effectively with others as a member
of the health care team
Technical skills are purposely “hands-on” skills such as manipulating
equipment, giving injections, bandaging, moving, lifting and repositioning the
clients. These skills are also called tasks, procedures or psychomotor skills. The
term psychomotor refers to physical actions that are controlled by the mind, not
reflexive.

Process of implementing

The process of implementing normally includes the following:

• Reassessing the client

• Determining the nurse’s need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
 EVALUATING
To evaluate is to judge or to appraise. Evaluating is the fifth and last
phase of the nursing process. In this context, evaluating is a planned, ongoing,
purposely activity in which clients and health care professionals determine (a) the
client’s progress toward achievement of goals/outcomes and (b) the
effectiveness of the nursing care plan. Evaluation is an important aspect of the
nursing process because conclusions drawn from the evaluation determine
whether the nursing interventions should be terminated, continued or changed.
Evaluation is continuous. Evaluation done while or immediately after
implementing a nursing order enables the nurse to make on-the-spot
modifications in an intervention. Evaluation performed at specified intervals (e.g.
once a week for the home care client) shows the extent of progress toward goal
achievement and enables the nurse to correct any deficiencies and modify the
care plan as needed. Evaluation continuous until the client achieves the health
goals or is discharged from nursing care. Evaluation at discharge includes the
status of goal achievement and the client’s self-care abilities with regard to
follow-up care. Most agencies have a special discharge record for this
evaluation.
Through evaluating, nurses demonstrates responsibility and accountability
for their actions, indicate interest in the results of the nursing activities, and
demonstrates a desire not to perpetuate ineffective actions but to adopt more
effective ones.

Process of evaluating client response

Before evaluation, the nurse identifies the desired outcomes (indicators)

that will be used to measure client goal achievement. (This is done in the
planning step). Desired outcomes serve twp purposes: They establish the kind of
evaluative data that need to be collected and provide a standard against which
the data are judged. For example, given the following expected outcomes, any
nurse caring for the client would know what data to collect.

• Daily fluid intake will not be less than 2500ml.

• Urinary output will balance with fluid intake.
• Residual urine will be less than 100ml.

The evaluation process has 5 components

• Collecting data related to the desired outcome (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.