Mrs. Puvaneswari RameshAssociate ProfessorNHCON , Bangalore

Steps in Nursing Process

Introduction

IMPLEMENTATION

PLANNING AND OUTCOME IDENTIFICATION

NURSING DIAGNOSIS

ASSESSMENT

EVALUATION

Nursing Assessment

It is the deliberate and  systematic 

collection of information about a patient to determine 

his or her current and past health and functional status 

and  his or her present and past coping patterns.

(Carpenito – Moyet‐ 2009)

Purposes of Assessment

To establish a database 

To identify health‐promoting behaviors 

To identify actual and/or potential health problems.

Types of nursing assessments

Ongoing

Comprehensive

Focused

Knowledge

Communication

Objectivity

Observation

ResourcesMeasurements

Procedures &

Techniques SKILLS IN SKILLS IN ASSESSMENT ASSESSMENT

Steps in Nursing Assessment

STEPS 1.Collecting data

2.Validating data

3.Organizing data

4.Interpreting data

5.Documenting data

Collecting Data

Sources of Assessment of Data

Subjective

data

• Itching

• Pain

• Feelings

• Perceptions

Types of dataTypes of data

Objective

data

• Discoloration of

skin

• Changes in

vital sign

Approaches for data collectionGordon’s 11 Functional Health Patterns

Uses a series of questions which assist in formulating a 

nursing diagnosis

Problem focused assessment

Focuses on the patient’s problem and develop the 

plan of care around the problem

Gordon’s health patterns

Health perception‐

management

Nutritional‐metabolic

Elimination

Activity‐exercise

Sleep‐rest

Cognitive ‐perceptual

Self‐perception‐self‐

concept

Role‐relationship

Sexuality‐reproductive

Coping‐stress‐tolerance

Value‐belief

Framework for assessment(Activities of living framework devised by Roper et al.) (2008)

Maintaining a safe environment 

Communicating Breathing

Eating and drinking Eliminating Personal cleansing and dressing

Controlling body temperature 

Expressing sexuality Working and playing 

Mobilising Sleeping Dying

Methods of Data Collection

Interview

Observation

History collection

Physical Examination

Results of Lab and Diagnostic tests.

Initiated for specific purpose and focused on a 

Specific Content

Objectives of Interview

Establish Therapeutic Relationship

Cues for in‐depth investigation 

Establish Nurses sense of caring 

Introduce the facility in a non threatening manner

Obtain  History  and  Identify Health Needs 

1. Interview

2.ObservationIt is defined as a deliberate search carried out 

with care and forethought             ( Virginia Henderson)

PRINCIPLES

Depends on knowledge and past  

experiences

Purposeful

Systematic 

Baseline observation serve for future comparison 

Biological information

Present illness

Past health history

Family history

Environmental history

Components

Reason for seeking health care

Psychosocial history

3.History Collection

4. Physical Examination

5. Lab and Diagnostic tests

Validation prevents  omissions, misunderstandings, and 

incorrect inferences and conclusions

Organising Data

Collected information must be organized to be useful.

Data Clustering is a useful tool to identify issues

Validating Data

Interpreting Data

Distinguish  relevant and irrelevant data

Determine  whether and where there are gaps in the data

Identify  patterns of cause and effect

Documenting DataAssessment data must be recorded and 

reported. 

Accurate and complete record   communicates  

information to health care team.

Example of Subjective and Objective data

Subjective data Objective data

Mr. X  tells that ,I am 

worried about my 

disease (Prostate 

cancer) . What will 

be my future? 

Patient has

Poor eye contact

Facial expression 

Clenches hands

Restlessness

ANXIETY

Nursing DiagnosisA nursing diagnosis is defined as  a clinical 

judgment about an individual, family or community responses to 

actual and potential health problems/life processes. 

(NANDA, 2009) 

Identifying client needs

Step 1: Problem‐Sensing

Step 2: Rule‐Out Process

Step 3: Synthesizing the Data

Step 4: Evaluating or Confirming the Hypothesis

Step 5: List the Client’s Needs

Step 6: Re‐evaluate the Problem List

Diagnostic Process

Data Clustering

Data interpretation

Formulation of 

Nursingdiagnosis

Components in Nursing Diagnosis (PES Format)

Problem statement or diagnostic label

Etiology

Defining characteristics

Problem statement

Etiology Defining characteristics

Deficient fluid volume

Diarrhea Dry skin ,dryness of the mouth.

Problem

Etiology (P & E

)

Problem, Etiology Signs and Symptoms (PES)

Title in hereTitle in here

THREE PART STATEMENTTHREE PART STATEMENT

Acute Pain, leg related to tissue distention (edema)

Ineffective Coping, related to maturational crisis as evidenced by inability to meet role expectationsand alcohol abuse.

Formulation of nursing Diagnosis

TWO PART STATEMENT

Problem. (P)PowerlessnessSpiritual DistressDisuse Syndrome,

ONE PART STATEMENT

Types of Nursing Diagnosis-NANDA – I 2012

Wandering,Impaired social interaction  Stress urinary incontinence 

ACTUAL

Risk for loneliness,High Risk for injury

RISK

Readiness for enhanced  family coping

Readiness for enhanced nutrition

HEALTH PROMOTION

Post‐Trauma syndrome SYNDROME

Advantages of nursing diagnosis

Communication 

Identification of Appropriate Goals

Quality improvement

Standard for Nursing Practice

Acuity Information

Assist in Discharge planning

Common language

Limitations of Nursing Diagnosis

Lack of consensus 

Nurses  have less time with clients.

Care is organized around the medical diagnosis. 

Afraid and unwilling to use

The nursing diagnosis list does not  fit the 

client situation.

Wrong diagnostic labelFailure to seek guidanceFailure to validate nursing diagnosis

Inaccurate  interpretation of cuesUsing insufficient , invalid cueFailure to consider culture

Lack of knowledge, Inaccurate data DisorganizationMissing data

Insufficient cluster of cues.Premature or early closureIncorrect clustering

CollectingCollecting

InterpretingInterpreting

ClusteringClusteringLabellingLabelling

Sources of diagnostic error

Potential Errors in Choosing a Nursing Diagnosis

Formulation of nursing diagnosis

A client reports discomfort at the insertion site of an  IV 

catheter , area is slightly reddened

The nurse formulates a nursing diagnosis ie  Discomfort ..

But fail to  consider the  Risk for infection. 

Don’t use medical terms in nursing diagnosis

Self care deficit ,Hygiene related to Stroke 

Self care deficit ,Hygiene related to weakness secondary to Stroke

Errors in Choosing a Nursing Diagnosis

Don’t combine two problems at  the same time

Pain and fear related to upcoming abdominal surgery

Pain related to tissue injury secondary to abdominal surgery as 

evidenced by pain 6/10.

Don’t make statements that are legally inadvisable

Impaired skin integrity R/T infrequent turning aeb 3cm ankle ulcer

Impaired skin integrity R/T immobility related to fracture.

Overcoming Barriers to Nursing Diagnosis

Familiarity of nursing diagnosis language

Support from  Health care agency  

Enhanced communication 

Document a new nursing diagnosis

Experienced nurses need opportunities to review nursing 

diagnoses. 

Standardized Nursing education programs content

3.Nursing Planning and Outcome Identification

Planning is a category of nursing behaviour in 

which client centered goals and expected outcomes are 

established and nursing interventions are selected to achieve 

the goals and outcomes of care

Ongoing PlanningOngoing Planning

Initial Planning

Initial Planning Discharge

PlanningDischarge Planning

Phases of Planning

PLANNING PROCESS

1‐ Setting priorities.

2‐ Establishing client goals/desired out comes.

3‐ Selecting nursing strategies.

4‐Writing nursing orders.

1.Priorities of planning

Priority setting is the ordering of nursing  diagnosis 

and patient problems using determinations of urgency and or 

importance to establish a preferential order for nursing actions

Hendry and walker 2004

Intermediate Low

High

Classification of priorites

2.Goals of care and expected outcome

Goal - It reflects a patients highest possible level of 

wellness and independence in funtion

Expected outcome

An expected outcome is a  meaurable change 

in a patients status that is expected to occur in response to 

nursing care .

GoalGoalShort term Long term

MACROS criteria- For Goal

M easurable and observable 

A chievable and time limited

C lient centred

R ealistic

O utcome written

S hort 

Example for Goal and expected outcome

Goal

Mr. X will ambulate independently in 3 days 

Expected outcome

Mr.X will  turn in bed independently in 24 hours

Mr.X  will get up to chair 3 times daily for next 2 days

Mr.X  will walk with assistance to hallway in 48 hours

3.Selection of interventionCharacteristics of nursing diagnosis

Goals and expected outcome

Feasibility of the intervention 

Acceptability of the patient

Own competency 

Evidence base for the interventions

Bulechek et al 2008

Selecting Nursing Interventions/ Strategies

Actions initiated by

nurse that do not require

direction or an order

Actions initiated by

nurse that do not require

direction or an order

Actions implemented

in collaborative

manner

Actions implemented

in collaborative

manner

Actions that

require an order

Actions that

require an order

Planning Nursing care

Realistic

Explicit

Evidence based

Prioritised

Involved

Goal centred

Systems for Planning nursing care

Nursing kardex 

Critical pathways

Nursing care plan

The Nursing Care PlanA written guide that organizes data about a 

client’s care into a formal statement of the strategies that will 

be implemented to help the client achieve optimal health.

PurposesHelps to identify the nursing actions to be delivered

Identify and coordinate resources to deliver nursing care 

Enhance continuity of care 

Care Plan in various settings

Institutional care plan

Interdisciplinary care

Computerized care plan

Student care plan

Care plan in community settings

GUIDELINES FOR WRITING NURSING CARE PLAN

Incorporates preventive , health maintenance  and restorative 

aspects. 

Use standardized Medical or English symbols . Eg. Clean 

wound with H2O2 , b.i.d. 

Be specific. 

Use category headings and  Date and  sign the plan

GUIDELINES FOR WRITING NURSING CARE PLAN

Refer to procedure books or other sources of information

Tailor the plan to the unique characteristics of the client .

Plan the  interventions for ongoing assessment of the 

client  (eg. Inspect incision q8h)

Include collaborative and co‐ordination activities .

4. Writing Nursing ordersAfter choosing appropriate nursing 

interventions the nurse write those on care plan on nursing 

orders.

Components of Nursing order

Monitor Vital signs Every q4h 

Auscultate Abdomen q6h 

Date Action Content Time Sign

Eg- for Planning and Rationale for Acute pain in urethra – A client with UTI

Planning RationaleAssess pain noting location, 

intensity (scale of 0‐10) and 

duration.

Encourage increased fluid 

intake

Observe the changes in mental 

status behaviour and Level of 

consiousness

Provide information aid in choice 

of determining choice or 

effectiveness of interventions

Increased hydration flushes 

bacteria and toxins

Accumulation of uremic waste and  

electrolyte imbalances may be 

toxic to CNS

Implementation

This fourth step of the nursing process involves the 

execution of the nursing care plan derived during the 

Planning phase.

Direct care Indirect care

INTERVENTION

Implementation skills

1.Cognitive Skills 

2.Interpersonal Skills

3.  Psychomotor skills 

Standard Nursing Interventions

Clinical practice guidelines and protocols

Standing orders

NIC interventions

Standards of Practice

Task allocation

Title

Managing Nursing Care in the Clinical Environment

Client allocation

Team nursing

Primary nursing

Person‐centred planningCare programme approachCaseload management

Implementation process1. Reassessing the client

2. Reviewing and revising the existing nursing care plan

3. Organizing resources and care delivery

4. Anticipating and preventing complications

5. Implementing nursing interventions.

1.Reassesses the client

Before implementing the nurse must

reassess . It helps to identify the proposed nursing  actions 

are still appropriate for or the patients level of wellness

2. Reviewing and revising the existing nursing care plan

If the client status has changed then modify the care plan.

Modification of existing care plan

Revise the Data

Revise the nursing Diagnosis

Revise the specific 

intervention

Choose the evaluation method

3.Organising Resources And Care Delivery

4. Anticipating and preventing complications

It can be resulted from both the illness and 

treatment.

A nurse with a 

Thorough Knowledge on pathophysiology

Thorough   assessment

Scientific rationale for interventions

5. Implementing Interventions

Indirect care

Direct care

•ADL

•IADL

•Physical care 

Techniques

•Life saving measures

•Counselling 

•Teaching

•Communicating 

Interventions

•Delegating, Supervising 

and evaluating the work 

of staff

Eg- for Implementaion –Acute pain in urethra – A client with UTI

Planning Implementation

Assess pain noting location, 

intensity (scale of 0‐10) and 

duration.

Encourage increased fluid 

intake

Observe the changes in 

mental status behaviour and 

Level of consiousness

Client complained  burning pain in urethra 

during micturition which  scores 5 /10 

lasting for 15 min with each urination.

Oral and IV therapy started. (NS‐ 10 

Drops/min).  Intake – 3000 ml and Out put 

– 2200ml   for the last 24 Hours

Electrolytes and Uremic levels were normal  

Urea‐ 18mg/dl ,Creatinine‐0 .8 mg/dl. 

Client  has appropriate mental status   

behaviour. 

Evaluation

Evaluation is defined as the judgment of the 

effectiveness of nursing care to meet client goals; in this 

phase nurse compare the client behavioral responses with 

predetermined client goals and outcome criteria. 

{CRAVEN 1996} 

Purposes1. Determine  client’s behavioral response .

2.Compare the client’s response with outcome criteria.

3. Appraise the extent to which client’s goals .

4.Assess the collaboration of client and health team

5.Identify the errors in the plan of care.

6. Monitor the quality of nursing care. 

COMPONENTS OF EVALUATION

DrawconclusionDraw

conclusionCollectthe dataCollectthe data

Compare the dataCompare the data

Continuemodify,  Terminate care plan 

Continuemodify,  Terminate care plan 

Relating nursing activities 

Relating nursing activities 

Competencies For Evaluation

Criterion based Evaluation

Document the results

Care plan revision

Collaborating  and evaluate effectiveness  of  intervention

ANA-2010

Methods of Evaluation of nursing care

Evaluating nursing

careReflection

Reflect on own  experiencesboth socially with other friends..

Nursing handover

Hand over information about the nursing care of clients to nurses

Reviewing the plan

Evaluates the care given against the set goals.

Patient satisfaction

Appreciation that is sometimes offered 

by clients

Evaluation skill required for nurses

Know the hospital policies, procedure and protocols of 

interventions and recording

Up to date knowledge and information of many subject. 

Intellectual and technical skill

Knowledge and skill of collecting subjective data and 

objective data. 

Example for Evaluation

At the end of 8 hours , patient pain has 

reduced as evidenced by pain score 2/10 and improved 

activity