CCON The nursing process

Nursing processNursing processMr. Ravi kumarMr. Ravi kumarB.S.C (N)1B.S.C (N)1stst year year

Chirayu college of nursingChirayu college of nursing

Nursing ProcessNursing Process The nursing process is a deliberate, problem-The nursing process is a deliberate, problem-

solving approach to meeting the health care solving approach to meeting the health care and nursing needs of patients. It involves and nursing needs of patients. It involves assessment (data collection), nursing assessment (data collection), nursing diagnosis, planning, implementation, and diagnosis, planning, implementation, and evaluation, with subsequent modifications evaluation, with subsequent modifications used as feedback mechanisms that promote used as feedback mechanisms that promote the resolution of the nursing diagnoses. The the resolution of the nursing diagnoses. The process as a whole is cyclical, the steps process as a whole is cyclical, the steps being interrelated, interdependent, and being interrelated, interdependent, and recurrent.recurrent.

Copyright 2008 by Pearson Education, Inc.

The Nursing ProcessThe Nursing Process


AssessingAssessing Collecting dataCollecting data Organizing dataOrganizing data Validating is the act of “double-Validating is the act of “double-

checking” or verifying data to confirm checking” or verifying data to confirm that it is accurate and factual. that it is accurate and factual.

Documenting dataDocumenting data GoalGoal

Establish a database about the client’s Establish a database about the client’s response to health concerns or illnessresponse to health concerns or illness


DiagnosingDiagnosing Analyzing and synthesizing dataAnalyzing and synthesizing data GoalsGoals

Identify client strengthsIdentify client strengths Identify health problems that can be Identify health problems that can be

prevented or resolved prevented or resolved Develop a list of nursing and Develop a list of nursing and

collaborative problemscollaborative problems


PlanningPlanning Determining how to prevent, reduce, or Determining how to prevent, reduce, or

resolve identified priority client problemsresolve identified priority client problems Determining how to support client Determining how to support client

strengthsstrengths Determining how to implement nursing Determining how to implement nursing

interventions in an organized, interventions in an organized, individualized, and goal-directed manner individualized, and goal-directed manner

GoalsGoals Develop an individualized care plan that Develop an individualized care plan that

specifies client goals/desired outcomesspecifies client goals/desired outcomes Related nursing interventionsRelated nursing interventions


ImplementingImplementing Carrying out (or delegating) and Carrying out (or delegating) and

documenting planned nursing documenting planned nursing interventionsinterventions

GoalsGoals Assist the client to meet desired Assist the client to meet desired

goals/outcomesgoals/outcomes Promote wellnessPromote wellness Prevent illness and diseasePrevent illness and disease Restore healthRestore health Facilitate coping with altered functioningFacilitate coping with altered functioning


EvaluatingEvaluating Measuring the degree to which Measuring the degree to which

goals/outcomes have been achievedgoals/outcomes have been achieved Identifying factors that positively or Identifying factors that positively or

negatively influence goal negatively influence goal achievementachievement

GoalGoal Determine whether to continue, modify, Determine whether to continue, modify,

or terminate the plan of careor terminate the plan of care


Characteristics of the Characteristics of the Nursing ProcessNursing Process

Cyclic and dynamic natureCyclic and dynamic nature Client centerednessClient centeredness Focus on problem-solving and Focus on problem-solving and

decision-makingdecision-making Interpersonal and collaborative styleInterpersonal and collaborative style Universal applicabilityUniversal applicability Use of critical thinkingUse of critical thinking


Characteristics of the Characteristics of the Nursing ProcessNursing Process

Types of AssessmentsTypes of Assessments InitialInitial

Performed within a specified time periodPerformed within a specified time period Establishes complete databaseEstablishes complete database

Problem-FocusedProblem-Focused Ongoing process integrated with careOngoing process integrated with care Determines status of a specific problemDetermines status of a specific problem

EmergencyEmergency Performed during physiologic or psychologic crisesPerformed during physiologic or psychologic crises Identifies life-threatening problemsIdentifies life-threatening problems Identifies new or overlooked problemsIdentifies new or overlooked problems

Time-lapsedTime-lapsed Occurs several months after initialOccurs several months after initial Compares current status to baselineCompares current status to baseline

Initial assessment is performed Initial assessment is performed within a specified time after within a specified time after admission to a health care agency admission to a health care agency for the purpose of establishing a for the purpose of establishing a complete database for problem complete database for problem identification, reference, and future identification, reference, and future comparison.comparison.

Problem-focused assessment is an Problem-focused assessment is an ongoing process integrated with ongoing process integrated with nursing care to determine the nursing care to determine the status of a specific problem status of a specific problem identified in an earlier assessment.identified in an earlier assessment.

Emergency assessment occurs Emergency assessment occurs during any physiologic or during any physiologic or psychologic crisis of the client to psychologic crisis of the client to identify the life-threatening identify the life-threatening problems and to identify new or problems and to identify new or overlooked problems.overlooked problems.

Time-lapsed (expired)reassessment Time-lapsed (expired)reassessment occurs several months after the occurs several months after the initial assessment to compare the initial assessment to compare the client’s current status to baseline client’s current status to baseline data previously obtained.data previously obtained.

Assessment ActivitiesAssessment Activities

Collecting dataCollecting data Organizing dataOrganizing data Validating dataValidating data Documenting Documenting

datadata

Collecting dataCollecting data is the process of is the process of gathering information about a gathering information about a client’s health status. client’s health status.

Organizing dataOrganizing data is categorizing data is categorizing data systematically using a specified systematically using a specified format.format.

Validating dataValidating data is the act of “double- is the act of “double-checking” or verifying data to confirm checking” or verifying data to confirm that it is accurate and factual. that it is accurate and factual.

DocumentingDocumenting is accurately and is accurately and factually recording data.factually recording data.


Subjective DataSubjective Data Symptoms or covert dataSymptoms or covert data Apparent only to the person Apparent only to the person

affectedaffected Can be described only by person Can be described only by person

affectedaffected Includes sensations, feelings, Includes sensations, feelings,

values, beliefs, attitudes, and values, beliefs, attitudes, and perception of personal health status perception of personal health status and life situationsand life situations


Objective DataObjective Data Signs or overt dataSigns or overt data Detectable by an observerDetectable by an observer Can be measured or tested against Can be measured or tested against

an accepted standardan accepted standard Can be seen, heard, felt, or smelledCan be seen, heard, felt, or smelled Obtained through observation or Obtained through observation or

physical examinationphysical examination


Sources of DataSources of Data Primary SourcePrimary Source

The clientThe client Secondary SourcesSecondary Sources

All other sources of data All other sources of data Should be validated, if possibleShould be validated, if possible


Methods of Data Methods of Data CollectionCollection

ObservingObserving Gathering data using the sensesGathering data using the senses Used to obtain following types of data:Used to obtain following types of data:

Skin color (vision)Skin color (vision) Body or breath odors (smell)Body or breath odors (smell) Lung or heart sounds (hearing)Lung or heart sounds (hearing) Skin temperature (touch)Skin temperature (touch)



InterviewingInterviewing Planned communication or a Planned communication or a

conversation with a purpose conversation with a purpose Used to:Used to:

Identify problems of mutual concernIdentify problems of mutual concern Evaluate changeEvaluate change Teach Teach Provide supportProvide support Provide counseling or therapyProvide counseling or therapy



Examining (physical examination)Examining (physical examination) Systematic data-collection methodSystematic data-collection method Uses observation and inspection, Uses observation and inspection,

auscultation, palpation, and percussionauscultation, palpation, and percussion Blood pressureBlood pressure PulsesPulses Heart and lungs soundsHeart and lungs sounds Skin temperature and moistureSkin temperature and moisture Muscle strengthMuscle strength


Closed and Open-ended Closed and Open-ended QuestionsQuestions

Closed QuestionClosed Question RestrictiveRestrictive

Yes/noYes/no FactualFactual

Less effort and Less effort and information from information from clientclient

““What medications What medications did you take?”did you take?”

““Are you having pain Are you having pain now?”now?”

Open-ended QuestionOpen-ended Question Specify broad topic to Specify broad topic to

discussdiscuss Invite longer answersInvite longer answers Get more information Get more information

from clientfrom client Useful to change Useful to change

topics and elicit topics and elicit attitudesattitudes

““How have you been How have you been feeling lately?”feeling lately?”

Types of Nursing DiagnosisTypes of Nursing Diagnosis ActualActual RiskRisk WellnessWellness PossiblePossible SyndromeSyndrome

Actual DiagnosisActual Diagnosis

Problem present at the time of the Problem present at the time of the assessmentassessment

Presence of associated signs and Presence of associated signs and symptomssymptoms

(ineffective breathing pattern)(ineffective breathing pattern)

Risk DiagnosisRisk Diagnosis

Problem does not existProblem does not exist Presence of risk factorsPresence of risk factors

Wellness DiagnosisWellness Diagnosis

Readiness for enhancementReadiness for enhancement describes human responses to describes human responses to

levels of wellness in an individual, levels of wellness in an individual, family, or community that have a family, or community that have a readiness enhancement.”readiness enhancement.”

(readiness for enhanced spiritual (readiness for enhanced spiritual well-being or readiness for well-being or readiness for enhanced family coping)enhanced family coping)

Possible DiagnosisPossible Diagnosis

Evidence about a health problem Evidence about a health problem incomplete or unclearincomplete or unclear

Requires more data to either support or Requires more data to either support or to refute itto refute it

(possible social isolation)(possible social isolation)

Syndrome DiagnosisSyndrome Diagnosis

Associated with a cluster of other Associated with a cluster of other diagnosesdiagnoses

(risk for disuse syndrome)(risk for disuse syndrome)

Components of a Nursing Components of a Nursing DiagnosisDiagnosis

ProblemProblem EtiologyEtiology Defining characteristicsDefining characteristics

Problem Statement Problem Statement (Diagnostic Label)(Diagnostic Label)

Describes the client’s health problem or Describes the client’s health problem or responseresponse

Etiology (Related Factors Etiology (Related Factors and Risk Factors)and Risk Factors)

Identifies one or more probable causes Identifies one or more probable causes of the health problem of the health problem

Defining CharacteristicsDefining Characteristics

Cluster of signs and symptoms Cluster of signs and symptoms indicating the presence of a indicating the presence of a particular diagnostic label (actual particular diagnostic label (actual diagnoses)diagnoses)

Factors that cause the client to be Factors that cause the client to be more vulnerable to the problem (risk more vulnerable to the problem (risk diagnoses)diagnoses)

Steps in Diagnostic Steps in Diagnostic ProcessProcess

Analyzing dataAnalyzing data Compare data against standardsCompare data against standards Cluster cuesCluster cues Identify gaps and inconsistenciesIdentify gaps and inconsistencies

Identifying health problems, risks, Identifying health problems, risks, and strengthsand strengths

Formulating diagnostic statementsFormulating diagnostic statements

Formats for Writing Nursing Formats for Writing Nursing DiagnosesDiagnoses

Basic two-part statementBasic two-part statement Problem (P)Problem (P) Etiology (E) Etiology (E)

Basic three-part statementBasic three-part statement Problem (P)Problem (P) Etiology (E)Etiology (E) Signs and symptoms (S)Signs and symptoms (S)

One-part statementOne-part statement Wellness (readiness for enhanced)Wellness (readiness for enhanced)

Syndrome Syndrome

VariationsVariations

Unknown etiologyUnknown etiology Complex factorsComplex factors PossiblePossible SecondarySecondary Other additions for precisionsOther additions for precisions

There are five variations There are five variations of the basic formats:of the basic formats:

Writing Writing unknown etiologyunknown etiology when the when the defining characteristics are present defining characteristics are present but the nurse does not know the but the nurse does not know the cause or contributing factorscause or contributing factors

Using the phrase Using the phrase complex factorscomplex factors when there are too many etiologic when there are too many etiologic factors or when they are too factors or when they are too complex to state in a brief phrasecomplex to state in a brief phrase

Using the wordUsing the word possible possible to describe to describe either the problem or the etiology either the problem or the etiology when the nurse believes more data when the nurse believes more data are needed about the client’s are needed about the client’s problem or the etiologyproblem or the etiology

Using Using secondarysecondary to divide the etiology to divide the etiology into two parts, thereby making the into two parts, thereby making the statement more descriptive and useful statement more descriptive and useful (the part following (the part following secondary tosecondary to is is often a pathophysiologic or disease often a pathophysiologic or disease process or a medical diagnosis)process or a medical diagnosis)

Adding a second part to the general Adding a second part to the general response or NANDA label to make it response or NANDA label to make it more precisemore precise

The following are guidelines The following are guidelines for writing nursing diagnosis for writing nursing diagnosis statements:statements:

Write statements in terms of a Write statements in terms of a problem instead of a need.problem instead of a need.

Word the statement so that it is Word the statement so that it is legally advisable.legally advisable.

Use nonjudgmental statements.Use nonjudgmental statements. Be sure both elements of the Be sure both elements of the

statement do not say the say thing.statement do not say the say thing.

Be sure cause and effect are stated Be sure cause and effect are stated correctly.correctly.

Word diagnosis specifically and precisely.Word diagnosis specifically and precisely. Use nursing terminology rather than Use nursing terminology rather than

medical terminology to describe the medical terminology to describe the client’s response.client’s response.

Using nursing terminology rather than Using nursing terminology rather than medical terminology to describe the medical terminology to describe the probable cause of the client’s response.probable cause of the client’s response.

. To improve diagnostic reasoning and avoid . To improve diagnostic reasoning and avoid diagnostic reasoning errors, the nurse diagnostic reasoning errors, the nurse should do the following: verify diagnoses by should do the following: verify diagnoses by talking with the client and family, build a talking with the client and family, build a good knowledge base and acquire clinical good knowledge base and acquire clinical experience, have a working knowledge of experience, have a working knowledge of what is normal, consult resources, base what is normal, consult resources, base diagnoses on patterns (that is, behavior diagnoses on patterns (that is, behavior over time) rather than an isolated incident, over time) rather than an isolated incident, and improve critical-thinking skills.and improve critical-thinking skills.

Advantages of a Taxonomy of Advantages of a Taxonomy of Nursing DiagnosesNursing Diagnoses

Development of a standardized Development of a standardized nursing languagenursing language

Nursing minimum data setNursing minimum data set

Identify activities that occur in Identify activities that occur in the planning process.the planning process.

Activities in the Planning ProcessActivities in the Planning Process Prioritizing problems/diagnosesPrioritizing problems/diagnoses Formulating client goals/desired Formulating client goals/desired

outcomesoutcomes Selecting nursing interventionsSelecting nursing interventions Writing individualized nursing Writing individualized nursing

interventionsinterventions

Identify essential guidelines Identify essential guidelines for writing nursing care for writing nursing care

plans.plans.Guidelines for Writing Guidelines for Writing

Nursing Care PlansNursing Care Plans Date and sign the planDate and sign the plan Use category headingsUse category headings Use standardized/approved terminology Use standardized/approved terminology

and symbolsand symbols Be specificBe specific

Refer to other sourcesRefer to other sources Individualize the plan to the clientIndividualize the plan to the client Incorporate prevention and health Incorporate prevention and health

maintenancemaintenance Include discharge and home care Include discharge and home care

plansplans

Identify factors that the Identify factors that the nurse must consider when nurse must consider when

setting priorities.setting priorities. Setting PrioritiesSetting Priorities Establishing a preferential sequence Establishing a preferential sequence

for addressing nursing diagnoses for addressing nursing diagnoses and interventionsand interventions High priority (life-threatening)High priority (life-threatening) Medium priority (health-threatening)Medium priority (health-threatening) Low priority (developmental needs)Low priority (developmental needs)

Factors to Consider Factors to Consider When Setting PrioritiesWhen Setting Priorities

Client’s health values and beliefsClient’s health values and beliefs Client’s prioritiesClient’s priorities Resources available to the nurse Resources available to the nurse

and clientand client Urgency of the health problemUrgency of the health problem Medical treatment planMedical treatment plan

Describe the relationship of Describe the relationship of goals/desired outcomes to goals/desired outcomes to

the nursing diagnoses.the nursing diagnoses. Goals/Desired Outcomes and Nursing Goals/Desired Outcomes and Nursing

DiagnosisDiagnosis Goals derived from diagnostic labelGoals derived from diagnostic label Diagnostic label contains the unhealthy Diagnostic label contains the unhealthy

response (problem)response (problem) Goal/desired outcome demonstrates Goal/desired outcome demonstrates

resolution of the unhealthy response resolution of the unhealthy response (problem)(problem)

Identify guidelines for writing Identify guidelines for writing goals/desired outcomes.goals/desired outcomes.

Components of Goal/Desired Components of Goal/Desired Outcome StatementsOutcome Statements

SubjectSubject VerbVerb Condition or modifierCondition or modifier Criterion of desired performanceCriterion of desired performance

Guidelines for Writing Guidelines for Writing Goal/Outcome Goal/Outcome

StatementsStatements Write in terms of the client Write in terms of the client

responsesresponses Must be realisticMust be realistic Ensure compatibility with the Ensure compatibility with the

therapies of other professionalstherapies of other professionals Derive from only one nursing Derive from only one nursing

diagnosisdiagnosis Use observable, measurable termsUse observable, measurable terms

Describe the process of Describe the process of selecting and choosing selecting and choosing nursing interventions.nursing interventions.

Nursing Interventions and ActivitiesNursing Interventions and Activities Actions nurse performs to achieve Actions nurse performs to achieve

goals/desired outcomesgoals/desired outcomes Focus on eliminating or reducing Focus on eliminating or reducing

etiology of nursing diagnosisetiology of nursing diagnosis Treat signs/symptoms and defining Treat signs/symptoms and defining

characteristicscharacteristics

Types of Nursing InterventionsTypes of Nursing Interventions DirectDirect IndirectIndirect Independent interventionsIndependent interventions Dependent interventionsDependent interventions Collaborative interventionsCollaborative interventions

Direct care is an intervention Direct care is an intervention performed through interaction with performed through interaction with the client.the client.

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

independent interventionsindependent interventions, those , those activities that nurses are licensed to activities that nurses are licensed to initiate on the basis of their knowledge initiate on the basis of their knowledge and skills; and skills;

dependent interventionsdependent interventions, activities , activities carried out under the primary care carried out under the primary care provider’s orders or supervision, or provider’s orders or supervision, or according to specified routines; according to specified routines;

collaborative interventionscollaborative interventions, actions , actions the nurse carries out in collaboration the nurse carries out in collaboration with other health team members. The with other health team members. The nurse must choose interventions that are nurse must choose interventions that are most likely to achieve the goal/desired most likely to achieve the goal/desired outcome. outcome.

Criteria for Choosing Criteria for Choosing Appropriate InterventionAppropriate Intervention

Safe and appropriate for the client’s age, Safe and appropriate for the client’s age, health, and conditionhealth, and condition

Achievable with the resources availableAchievable with the resources available Congruent with the client’s values, beliefs, Congruent with the client’s values, beliefs,

and cultureand culture Congruent with other therapiesCongruent with other therapies Based on nursing knowledge and experience Based on nursing knowledge and experience

or knowledge from relevant sciencesor knowledge from relevant sciences Within established standards of careWithin established standards of care

Discuss the five activities of the Discuss the five activities of the implementing phase.implementing phase.

Five Activities of the Implementing Five Activities of the Implementing PhasePhase Reassessing the clientReassessing the client Determining the nurse’s need for Determining the nurse’s need for

assistanceassistance Implementing nursing interventionsImplementing nursing interventions Supervising delegated careSupervising delegated care

Explain how evaluating relates Explain how evaluating relates to other phases of the nursing to other phases of the nursing

process.process. Nursing Process—EvaluatingNursing Process—Evaluating Depends on the effectiveness of Depends on the effectiveness of

phases that precedephases that precede Assessing and nursing diagnosis Assessing and nursing diagnosis

must be accuratemust be accurate Goals/desired outcomes must be Goals/desired outcomes must be

stated behaviorally to be useful for stated behaviorally to be useful for evaluatingevaluating

Without implementing phase, there Without implementing phase, there would be nothing to evaluatewould be nothing to evaluate

Evaluating and assessing phases overlapEvaluating and assessing phases overlap 1.1. Evaluating is a planned, ongoing, Evaluating is a planned, ongoing,

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

Assessment data must be accurate and Assessment data must be accurate and complete so the nurse can formulate complete so the nurse can formulate appropriate nursing diagnoses and appropriate nursing diagnoses and goals/desired outcomes. The goals/desired goals/desired outcomes. The goals/desired outcomes must be stated concretely in outcomes must be stated concretely in behavioral terms to be useful for evaluating behavioral terms to be useful for evaluating client responses. Without the implementing client responses. Without the implementing phase in which the plan is put into action, phase in which the plan is put into action, there would be nothing to evaluate. The there would be nothing to evaluate. The evaluating and assessing phases overlap.evaluating and assessing phases overlap.

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

Components of the Components of the Evaluation ProcessEvaluation Process

Collecting data related to the desired Collecting data related to the desired outcomes outcomes

( nursing outcomes classifications NOC ( nursing outcomes classifications NOC indicators)indicators)

Comparing the data with outcomesComparing the data with outcomes Relating nursing activities to outcomesRelating nursing activities to outcomes Drawing conclusions about problem statusDrawing conclusions about problem status Continuing, modifying, or terminating the Continuing, modifying, or terminating the

nursing care plannursing care plan