The Nursing process

Shurouq Qadose
23/1/2008

The nursing process generally is defined as a

systematic problem- solving approach toward
giving individualized nursing care.
OR The nursing process is a systematic method
that directs the nurse and patient as together
they accomplish the following:
(1) Assess the patient to determine the need for
nursing care; (2) determine nursing diagnoses
for actual and potential health problems; (3)
identify expected outcomes and plan care; (4)
implement the care; and (5) evaluate the
results.

Phases
The six phases of the nursing process are assessment,
diagnosis, out come identification, planning,
implementation, and evaluation.

Nursing Assessment
The first phase of the nursing process, called
assessment, is the collection of data for nursing
purposes. Information is collected using the
skills of observation, interviewing, physical
examination, and intuition and from many
sources, including clients, their family
members or significant others, health records,
other health team members.

Reasons for doing assessment:- To establish baseline information on the client

- To determine the clients normal function
- To determine the clients risk for dysfunction
- To determine the clients strengths
- To provide data for the diagnosis phase

Preparing for assessment

Aim

Time frame

us assessment

Status determination of a specific

problem identified during previous
assessment.

Ongoing process, integrated with

nursing care, a few minutes to a f
hours between assessments.

ergency assessment

Identification of life threatening

situation

AT anytime

- Setting and environment

Assessment can take place in any setting
where nurses care for clients and their
family members: in the clients home, at a
clinic, in a hospital room.

Assessment skills
1- Observation
Comprises more than the nurses ability to see the
client, nurses also use the senses of smell, hearing,
touch, and, rarely, the sense of taste. Observation
includes looking, watching, examining. Observation
begins the moment the nurse meets the client. It is a
conscious, deliberate skill that is developed through
efforts and with an organized approach. Observation
has two aspects: (a) noticing the data and (b)
selecting, organizing, and interpreting the data.

Observation done in the following order:

Clinical signs of client distress.
Threats to the clients safety, real or
anticipated.
The presence and functioning of associated
equipment.
The immediate environment, including the
people in it.

2- Interviewing
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. There are two approaches to
interviewing, directive and nondirective.

The directive interview is 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. The
nondirective interview or rapport-building
interview, by contrast the nurse allows the
client to control the purpose, subject matter,
and pacing.

3- Physical examination techniques

Is a systematic data collection method that uses
the senses of sight, hearing, smell, and touch to
detect health problems. Four techniques are
used: inspection, palpation, percussion, and
auscultation

- Inspection
Is visual examination of the client that is done in
a methodical and deliberate manner. The client
is observed first from a general point of view
and then with specific attention to detail.
Effective inspection requires adequate lighting
and exposure of the body parts being observed.

- Palpation
Uses the sense of touch to assess texture,
temperature, moisture, organ location and size,
vibrations and pulsations, swelling, masses,
and tenderness. Palpation requires a calm,
gentle approach and is used systematically,
with light palpation preceding deep palpation
and palpation of tender areas performed last.

- Percussion
Uses short, tapping strokes on the surface of the
skin to create vibrations of underlying organs.
It is used for assessing the density of structures
or determining the location and the size of
organs in the body.

- Auscultation
Involves listening to sounds in the body that are
created by movement of air or fluid. Areas
most often auscultated include the lungs, heart,
abdomen, and blood vessels.

4- Intuition
Use of insight, instinct, and clinical experience
to make clinical judgments about the client.
Intuition plays a role in the nurses ability to
analyze cues rapidly, make clinical decisions,
and implement nursing actions even though
assessment data may be incomplete or
ambiguous.

Assessment Activities
The activities that make up the assessment are
the following:
1- Collect data
Data collection, the process of compiling
information about the client, begins with the
first client contact. Nurses use observation,
interviewing, and physical examination.

Types of data:
-Subjective data also known as symptoms or
covert cues include the client's feeling and
statement about his or her health problems and
are best recorded as direct quotations from the
client, such as
'' Every time I move, I feel nauseated.''

- Objective data also known as signs or overt

cues, are observable and measurable
(quantitative) data that are obtained through
observation, standard assessment techniques
performed during the physical examination,
and laboratory and diagnostic testing.

Sources of data
It can be primary or secondary. The client is the
primary source of data. Family members or
other support persons, other health
professionals, records and reports, laboratory
and diagnostic analyses, and relevant
literatures are secondary or indirect sources.

2- Validate data
Validation, commonly referred to as double
checking the information at hand, is the
process of confirming the accuracy of
assessment data collected. Validation assists in
verifying and clarifying cues and inference.

Examples of cues and inferences

Example 1
Group of cues client has
- Blurry vision or visual defect
- Headache
- Tingling and numbness in extremities
- Dizziness
Possible inferences
- Client has a brain tumor
- Client is having warning signals of a stroke
- Client may be diabetic
- Client is anxious

3- Organize data
After data collection is completed and
information is validated, the nurse organizes,
or clusters, the information together in order to
identify areas of strengths and weaknesses.
This process is known as data clustering.
How data are organized depends on the
assessment model used. One of these model is
Head to Toe model.

4- Documenting Data
To complete the assessment phase, the nurse
records client data. Accurate documentation is
essential and should include all data collected
about the clients health status. To increase
accuracy, the nurse records subjective data in
the clients own words to avoid the chance of
changing the original meaning.

Nursing Diagnosis
The second step in the nursing process involves
further analysis (breaking the whole down into
parts that can be examined) and synthesis
(putting data together in a new way) of the
data that have been collected.

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. Nursing diagnoses provide the basis
for selection of nursing interventions to
achieve outcomes for which the nurse is
accountable. (Carroll-Johnson, 1990, p. 50).

Purposes of nursing diagnosis

- Nursing diagnosis is unique in that it focuses
on a clients response to a health problem,
rather than on the problem itself, and it
provides the structure through which nursing
care can be delivered.
- Nursing diagnosis also provides a means for
effective communication.

- Holistic client, family, and community-focused

care are facilitated with the use of nursing
diagnosis.
- Nursing diagnosis has an important impact on
the health care delivery system

Components of a nursing
diagnosis:The Two-Part Statement
The components of a nursing diagnosis typically
consist of two parts. The first component is a
problem statement or diagnostic label. The
diagnostic label is the name of the nursing
diagnosis as listed in the NANDA. Some
examples include stress urinary incontinence,
Anxiety.

The second component of a two-part nursing

diagnosis is the etiology. The etiology is the
related cause or contributor to the problem.
The diagnostic label and etiology are linked by
the term related to (RT). Examples of nursing
diagnoses are Disturbed Body Image RT loss
of left lower extremity and Activity Intolerance
RT decreased oxygen-carrying capacity of
cells.

Descriptive words or terms may be added to

clarify specific nursing diagnoses. These
descriptive words are called qualifiers and
include Acute, Chronic, Decreased, Deficient,
Depleted, Disturbed, Dysfunctional, Enhanced,
Excessive, Impaired, Increased, Ineffective,
Intermittent, Potential for, and Risk. These
terms specify a degree of qualification for the
identified nursing diagnosis and are placed
(used) before the problem statement.

The Three-Part Statement

The nursing diagnosis can also be expressed as a
three part statement. As in the two-part
statement, the first two components are the
diagnostic label and the etiology. The third
component consists of defining
characteristics (collected data that are also
known as signs and symptoms, subjective and
objective data, or clinical manifestations).

In the three-part nursing diagnosis format, the

third part is joined to the first two components
with the connecting phrase as evidenced by
(AEB).

Differentiating Nursing Diagnosis versus

Medical Diagnosis
Nursing Diagnosis

Medical Diagnosis

- focus on unhealthy responses to

health and illness.

- identify diseases

- describe problems treated by

nurses within the scope of
independent nursing practice.

- describe problems for which the

physician directs the primary
treatment .

- may change from day to day as - remains the same for as long as
the patients responses change
the disease is present

Myocardial infarction (heart attack) is a medical

diagnosis.
Examples of nursing diagnoses for a person with
myocardial infarction include Fear, Altered
Health Maintenance, Knowledge Deficit, Pain,
and Altered Tissue Perfusion.

Nursing Diagnosis versus Collaborative

Problems
If such problems require physician prescribed and
nurse prescribed action, however, they are
collaborative health problems. Collaborative
problems refer to actual or potential physiologic
complications that can result from disease,
trauma, treatment, or diagnostic studies for which
nurses intervene in collaboration with personnel
of other disciplines.

Example 1
56-year-old mother of seven; 167 lb; Whenever
I sneeze lately, I dribble urine. This is
embarrassing.
Diagnostic statement
Stress Urinary Incontinence related to
degenerative changes in pelvic muscles and
structural supports associated with advanced
age, obesity, gravid uterus

Select nursing responses

Teach Kegel exercises to increase muscle tone;
explore patients willingness and motivation to
pursue weight reduction and exercise program;
evaluate need for bladder-training program.

Example 2
42-year-old woman; 1 hour after delivery; spinal
anesthesia; 1500 mL fluid infused in past 4
hours without patient voiding; unable to void.
Diagnostic statement
Potential complication: Urinary Retention
related to fluid overload and effects of
anesthesia.

Example 2
42-year-old woman; 1 hour after delivery; spinal
anesthesia; 1500 mL fluid infused in past 4
hours without patient voiding; unable to void.
Diagnostic statement
Potential complication: Urinary Retention
related to fluid overload and effects of
anesthesia.

Select nursing responses

Monitor for signs of increasing urine retention;
offer bedpan, and encourage voiding with
running water, warm water dripped over
perineum, and so forth; if no result, administer
physician-prescribed medication; if no result,
perform physician-prescribed catheterization.

Example 3
Whenever I have to urinate it burns terribly. I
also feel like I have to go all the timereal
bad. Small, frequent voidings, cloudy urine;
T100.8F
Diagnostic statement
Cystitis
Select nursing responses
Report signs and symptoms to physician; obtain
urine culture; report results to physician;
administer appropriate physician-prescribed
antibiotic.

Types of Nursing Diagnoses

1- Actual Nursing Diagnoses
Describe a human response to a health problem
that is being manifested. They are written as
three- part statements: diagnostic label, related
factors, defining characteristics.

Example Acute pain related to surgical trauma

and inflammation, as evidenced by grimacing
and verbal reports of pain.

Q- Which One is accurate nursing diagnosis?

1- Impaired physical mobility related to pain
2- Ineffective movement related to arthritis

2- Risk nursing diagnosis

As defined by NANDA, describes human
responses to health conditions that may
develop in a vulnerable individual, family, or
community. It is supported by risk factors that
contribute to increased vulnerability.

Risk nursing diagnoses are two part statements

because they do not include defining
characteristics (diagnostic label, risk factors).

Example - Risk for infection related to surgery

and immunosuppression.
Risk for aspiration related to reduced level of
consciousness
Risk for Impaired Skin Integrity related to
inability to turn self from side to side in bed.

3- Wellness nursing diagnosis

Is a diagnostic statement that describe the human
response to levels of wellness in an individual,
family, or community that have a potential for
enhancement to a higher state (NANDA,
2005).

Wellness nursing diagnosis are one part

statement includes diagnostic label.
Example
Readiness for enhanced spiritual well being
- Readiness for Enhanced Self-Esteem.

Q- Which One is accurate nursing diagnosis?

1- Readiness for Enhanced Family Coping
2- Family coping potential due to desire for
better health

4- Possible Nursing Diagnoses

Is made when not enough evidence supports the
presence of the problem but the nurse thinks
that is highly probable and wants to collect
more information.

Possible Nursing Diagnoses are two part

statement includes diagnostic label, related
factors (unknown).
Example- Possible self esteem disturbance
related to unknown etiology
Q- Which One is accurate nursing diagnosis?
Adjustment impaired, possibly due to recent car
accident that resulted in quadriplegia
Possible impaired adjustment related to unknown
etiology

Validate Diagnosis
For each diagnosis, the nurse should discuss with
the client the significance of the problem,
determine the clients perception of the reason
for the problem, and ask whether the client
desires help to resolve or to diminish the
problem.

Nursing Planning
The third step of the nursing process includes
the formulation of guidelines that establish the
proposed course of nursing action in the
resolution of nursing diagnoses and the
development of the clients plan of care.
The planning of nursing care occurs in three
phases: initial, ongoing, and discharge. Each
type of planning contributes to the
coordination of the clients comprehensive
plan of care.

- Initial planning involves development of

beginning of care by the nurse who performs
the admission assessment and gathers the
comprehensive admission assessment data.
Initial planning is important in addressing each
prioritized problem, identifying appropriate
client goals, and correlating nursing care to
hasten resolution of the clients problems.

- Ongoing planning entails continuous updating

of the clients plan of care. Every nurse who
cares for the client is involved in ongoing
planning.
- Discharge planning involves critical
anticipation and planning for the clients needs
after discharge.

The four critical elements of planning include:

Establishing priorities
Setting goals and developing expected
outcomes (outcome identification)
Planning nursing interventions (with
collaboration and consultation as needed)
Documenting

1- Establishing Priorities
The establishment of priorities is the first
element of planning. In establishing priorities,
the nurse examines the clients nursing
diagnoses and ranks them in order of
physiological or psychological importance.
Various guidelines are used in the establishment
of priorities for determining which nursing
diagnosis will be addressed initially.

The clients basic needs, safety, and desires, as

well as anticipation of future diagnoses must
be considered. One of the most common
methods of selecting priorities is the
consideration of Maslows hierarchy of needs,
which requires that a life-threatening diagnosis
be given more urgency than a non life
threatening diagnosis.
The client must participate in the identification
of priorities so that the nature of the problem,
as well as the clients values, are reflected in
the selected course of action.

2- Establishing Goals and Expected Outcomes

The purposes of setting goals and expected
outcomes are to provide guidelines for
individualized nursing interventions and to
establish evaluation criteria to measure the
effectiveness of the nursing care plan. A goal
is an aim, an intent, or an end.

A goal is a broad or globally written statement

describing the intended or desired change in
the clients behavior, response, or outcome. An
expected outcome is a detailed, specific
statement that describes the methods through
which the goal will be achieved.

Goals should be established to meet the

immediate, as well as long-term prevention
and rehabilitation, needs of the client.
A short-term goal is a statement written in
objective format demonstrating an expectation
to be achieved in resolution of the nursing
diagnosis in a short period of time, usually in a
few hours or days.

A long-term goal is a statement written in

objective format demonstrating an expectation
to be achieved in resolution of the nursing
diagnosis over a longer period of time, usually
over weeks or months.

Guidelines for Writing Outcomes

Written outcomes can be evaluated by seeing if
they conform to the following criteria:
Each set of outcomes is derived from only one
nursing diagnosis.
At least one of the outcomes shows a direct
resolution of the problem statement in the
nursing diagnosis.
Both long-term and short-term outcomes are
identified as necessary.

 Cognitive, psychomotor, and affective

outcomes appropriately signal the type of
change needed by the patient.
The patient and family value the outcomes.
Each outcome is brief and specific (clearly
describes one observable, measurable patient
behavior/manifestation), is phrased positively,
and specifies a time line.
The outcomes are supportive of the total
treatment plan

Example
NURSING DIAGNOSIS: Disturbed Sleep
Pattern
Goal: Client will sleep uninterrupted for 6 hours.
EXPECTED OUTCOMES
Client will request back massage for relaxation.
Client will set limits to family and significant
other visits.

NURSING DIAGNOSIS: Ineffective Tissue

Perfusion: Peripheral
Goal: Client will have palpable peripheral pulses
in 1 week.
EXPECTED OUTCOMES
Client will identify three factors to improve
peripheral circulation.
Clients feet will be warm to touch.

3- Planning Nursing Interventions

Once the goals have been mutually agreed on by
the nurse and client, the nurse should use a
decision-making process to select appropriate
nursing interventions.
Nursing interventions are treatment, based
upon clinical judgment and knowledge that a
nurse performs to enhance patient / client
outcomes.

Writing a client plan of care

Two important concepts guide a client plan of
care:
1- The plan of care is client centered.
2- The plan of care is a step by step process.
Sufficient data are collected to substantiate
nursing diagnoses.
At least one goal must be stated for each
nursing diagnosis
Outcome criteria must be identified for each
goal

 Nursing interventions must be specifically

designed to meet the identified goal.
Each intervention should be supported by a
scientific rationale.
Evaluation must address whether each goal
was completely met, partially met, or
completely unmet.

Implementing
Consists of doing and documenting the activities
that are the specific nursing actions needed to
carry out the interventions or nursing orders.
The first three nursing process phasesassessing, diagnosing, and planning-provide
the basis for the nursing actions performed
during the implementing step. In turn, the
implementing phase, provide the actual
nursing activities and client responses that are
examined in the final phase, the evaluating
phase.

While implementing nursing orders, the nurse

continues to reassess the client at every
contact, gathering data about the clients
responses to nursing activities and about any
new problems that may develop. To implement
the care plan successfully, nurses need
cognitive, interpersonal, and technical skills.
These skills are distinct from one another. The
cognitive skills (intellectual skills) include
problem solving, decision making, critical
thinking, and creativity.

Interpersonal skills are all of the activities, verbal

and nonverbal, people use when interacting
directly with one another, this depends on the
ability of the nurse to communicate effectively
with others. It is necessary for all nursing
activities, caring, comforting, advocating,
referring, counseling, and supporting others.
Technical skills are hands-on skills such as
manipulating equipments, giving injections and
bandaging, moving lifting, and repositioning
clients. These are called procedures, tasks, or
psychomotor skills.

Process of Implementing
Reassessing the client
Determining the nurses need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities

Reassess the Client, to make sure the

intervention is still needed. Even though an
order is written on the care plan, the clients
condition may have changed. The nurse also
provides supportive communication to help
alleviate the clients stress.

Determining the Nurses Need for Assistance,

for one of the following reasons:
The nurse is unable to implement the nursing
activities safely alone
Assistance would reduce stress on the client
The nurse lacks the knowledge or skills to
implement a particular nursing activities

Implementing the nursing Interventions, 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 outcome is. Ensure client privacy,
coordinate client care, and involve scheduling
client contacts with other departments.

When implementing interventions, nurses should

follow these guidelines:
Base nursing interventions on scientific
knowledge, nursing research, and professional
standards of care whenever possible.
Clearly understand the order to be
implemented and question any that are not
understood.
Adapt activities to the individual client, a
clients beliefs, values; age, health status, and
environment are factors that can affect the
success of a nursing action.

 Implement safe care

Provide teaching, support and comfort to
enhance the effectiveness of nursing care plans.
Be holistic; view the client as a whole.
Respect the dignity of the client and enhance the
clients self- esteem
Encourage client to participate actively in
implementing the nursing interventions.

Supervising Delegating Care, if care has been

delegated to other health care personnel, the
nurse responsible for all the clients care must
ensure that the activities have been
implemented according to the care plan.

Documenting Nursing Activities, the nurse complete

the implementing phase by recording the
interventions and client responses in the nursing
process notes. The nurse may record routine or
recurring activities such as mouth care in the client
record at the end of shift, while some actions
recorded in special worksheets according to agency
policy. Immediate recording helps safeguard the
client to prevent double actions.

Evaluation
The last phase of the nursing process, follows
implementation of the plan of care, its the
judgment of the effectiveness of nursing care
to meet client goals based on the clients
behavioral responses.

Process of Evaluating Client Responses

Collecting data related to the desired outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the
nursing care plan.

When determining whether a goal has been

achieved, the nurse can draw one of the three
possible conclusions:
The goal was met, that is the client response
is the same as the desired outcomes.
The goal was partially met, that is either a
short term goal was achieved but the long
term was not, or the desired outcome was
only partially attained.
The goal was not met.

Relationship of Evaluation to Nursing Process

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
OR
The care plan does not need revision,
because the client merely needs more time
to achieve the previously established goals.
So the nurse must reassess why the goals
are not being partially achieved.