Nursing Process

 Is used to identify diagnose and treat

human response to health and illness.
 Variation of scientific reasoning that allows
nurses to organize and systematize
nursing practice.
 Applies to the care of the clients, systems,
individual, family, group or community.
 Allows the nurses to differentiate their
practice from that of physicians and other
health care professionals.
 Assessment
 Is the deliberate and systematic collection of data
to determine a client current and past health
status and functional status and determine the
client’s present and past coping patterns.
 To establish database about the clients perceived
needs, problems and responses to these
problems, related experience. It practices goals,
values, expectations held about the health care
system.
 Must be relevant to the patient’s health problems.
 Assessment is dynamic.
 2 steps
 1.Collection and verification of data
from a primary source (client) and
secondar (Family,health
professionals, medical records)
source.
 2.Analysis of all data as a basis for
developing nursing diagnosis and an
individualized plan of care for the
client.
 Critical thinking
 The nurse systematize relevant
knowledge, clinical experience
,critical thinking standards and
attitudes and standard of practice
simultaneously,
 Knowledge
 Enable the nurse to ask relevant
questions and collect record, history
and physical assessment data
related tot eh client’s presenting
health care needs.
 Prior clinical experience
 Curiosity, perseverance risk taking
and confidence to the nurse client
relationship.
 An overview is usually based on the
clients presenting priorities ,..Nurse
specialty of practice.
 One must be able to
differentiate important data
from the data mass.
 Cue

 Information that nurse acquires

through use of 5 senses.
 2 approaches in conducting a
more comprehensive
assessment
 1. Use a structured data base format base
upon an accepted theoretical framework
or practice standards, from general to
specific. Ex. Gordon's functional health
patterns, Agency for health care research
and quality’s
 Conducting a compeehnsive assesment is
the problem-oriented approach focuses on
the client’s presenting situation.
 Organization of data
gathering
 The nurse must know which data must be
collected,
 Interactions…during the nurse-client
interactions, the nurse continuously
process data.
 The client should present physiological
responses that relay information
 When making judgment the nurse
connects sense of experiences to nursing
knowledge to ensure accurate reasoning
 Data collection
 Must be descriptive, concise and
complete,
 We must encourage our client to tell their
story about their sickness with open-
mindedness,
 As client begins to reveal data, Nurse must
immediately anticipate the need for other
questions and considers what the existing
data means..
 The information is summarized in a short
format using medical terms.
 Confirm the data
 Types of data.
 Subjective data-client’s perception
about their health problems,
 Only clients can provide this

information
Ex.pain,fear
 Objective data
 Observations data are observations
or measurements made by the data
collector
 the measurement of objective data
is
 Ex. identification of the size of a
localized body rash.
 based on an accepted standard.
 Ex. celsius/farenheit.
 Sources of data
 Client-best source of information…
 Family and significant others
 Health care team members
 Medical records
 Other record such
as..educational,military,employment
records.
 Literature review
 Nurse’s experience
 Nursing health history
 Data collected about the client’s current
level of wellness, including a review of
body system, family and health history
 Biographical information
 Reason for seeking health care
 Client expectations
 Present illness or health concerns
 Health history
 Family history
 Environmental history
 Psychosocial history
 Spirirtual health
 Review of systems
 Methods of Data Collection
 Interview-organized conversation wit the
client.
 Being introduced to the client Explain each
roles
 Establish sense of caring fro the client
 Gain insight about the clients worries,
 Determine client’s goal and expectations
of the health care systems
 Obtain cues about which parts of the data
collection phase require further in depth
investigation.
 Phases of the interview
 1. Orientation phase
 Introduction to the client,
 Establishing of trust and confidence of the
client.
 “nurse-client relationship”
 Enhanced by the professionalism and
competence conveyed by the nurse’s
attitude, professional manner and
appearance a supportive therapeutic
relationship with the client.
 Working phase

 The nurse gather information about

the client's health status.
 The nurses uses interview
techniques, communication
strategies to gather a
comprehensive and complete data
base as possible
 Termination phase
 The interviewer should give clue that
the interview is coming to an end.
 The nurse summarizes the important
points and ask the client whether the
summary is accurate.