Nursing process

A tool for evidence based practice

Lesson objectives

• At the end of the lesson, a student should be able to

• Define nursing process
• Identify major characteristics of nursing process
• Describe the phases of the nursing process
• Differentiate between subjective and objective data
• Differentiate between nursing diagnosis and medical
diagnosis
Lesson objectives

• Identify activities that occur in the planning process

• State the purpose of establishing client goals and
desired outcomes
• Identify essential guidelines for writing nursing care
plan
• Use the nursing process to nurse patients with ocular
problems
Overview
• Nursing process; it is a systematic, rational method of
planning and providing individualised nursing care.
• A systematic, client centred method for structuring the
delivery of nursing care
History
• Lydia hall originated the term nursing process in 1955,
Johnson in 1959, Orlando 1961 and Wiedenbach 1963
were among the first to use it to refer to a series of
phases describing the practice of nursing
• It gained additional legitimacy in 1973, when it was
included in American nurses association (ANA) standard
of nursing practice.
• . In Ghana it was incorporated into the curriculum in the
1980s
Purpose of nursing process
• To identify client health status, and actual or
potential health problem to establish plans and
deliver specific nursing interventions to meet the
identified problems
Characteristics
• Cyclical and dynamic-it is an ongoing and continuous
process throughout the stages of illness and treatment
and ends with the cease of illness
• Goal directed and client centred, the nursing process is
intended to treat the patient and is in the best interest
of the patient
• Interpersonal and collaborative-this explains the
amount of interaction that might be necessary between
nurses, patient and their families, and other
interdisciplinary team members
characteristics
• Universally applicable –it is a used as framework for nursing care
in all types of health care settings, with clients of all age groups.
The process remains same in all institutions
• Decision making and problem solving-nurses can be highly
creative in determining when and how to use data to make
decisions. Decision making is involved in every phase of the
nursing process.
• It is flexible-changes can be made at every stage making it
dynamic.
• Uses critical thinking.
Components/phases of the nursing
process
Assessing

Evaluating Diagnosing

Implementing Planning
Benefits of nursing process to the nurse

• It provides an orderly and systematic method of giving

care.
• Effective use of time and resources
• Consistent, systematic education and professional
growth.
• Enhances collaboration with health team members.
• Enhances professional accountability
Benefits of nursing process to the
nurse

• Avoids legal confrontations

• Facilitates documentation of care
• Provides a unity of language for the nursing profession
• Job satisfaction
• Defines nursing roles and function to outsiders
Benefits of nursing process to
patient
• Improve quality of care
• Scientific based and , holistic and individualised care
• High level of participation in the care
• High patient satisfaction
• Continuity of care
• Responsibility of own health
• Cost-effective healthcare.
Assessing
Assessing
• First and vital step
• Done systematically and continuously to reflect changes in
patient’s condition
• Purpose: to establish a database about the client’s response
to health concerns/illness and the ability to manage health care
needs.
• Done systematically and continuously to reflect changes in
patient’s condition
Types of Assessing
• Initial : performed soon after admission for problem
identification, reference and future comparison
• Problem- focused/ongoing: ongoing process integrated with
the nursing care to determine status of scientific problem and
identify new or overlooked problems.
• Emergency: performed during the physiological/psychological
crisis to identify the threatening problems.
• Time-lapsed: performed several months after initial assessment
to compare status with baseline data previously obtained.
ASSESSING STEPS
Diagnosing

Assessing
• Collect data
• Organise data
• Validate data Planning
• Document data

Implementing
Evaluating
Collecting data
• The process of gathering information about a client’s health status
done systematically and continuously to reflect clients changing
health status.
Types of data
• Subjective / covert data /symptoms
• Objective /overt data/signs
Sources of data
• Primary/ direct: the client
• Secondary/indirect family members, other support persons,
other health professionals, records and reports, laboratory
and diagnostic analyses and relevant literature.
Data collection methods
• Observing
• Conscious and deliberate effort at collecting data using the five
senses.
• Observation involves:
• Noticing the data
• Selecting, organizing and interpreting the data
Data collection methods
• Interviewing
• May be directive or structured/non directive or unstructured
• Primary with client ,and significant others as appropriate
• Each contact yields information ,verifies information or clarifies data
Data collection methods
• Examining
• Involves systematic physical assessment to detect health problems
• May be organised in a head –to-toe or systems approach
• Techniques incorporate the senses of sight, hearing, touch and smell-
inspection, palpation, percussion, auscultation, measurement
Characteristics of data
• Complete
• Accurate
• Factual
• Relevant
Organizing data
• Organizing data
• Uses written/computerised format that organises assessment data
systematically referred to as nursing assessment history /nursing
assessment /nursing data base form.
• Components may include available framework i.e. Nursing and non-
nursing models
Basic components of nursing health history

• Biographical information
• Reasons for seeking health care /chief complaint/Presenting
complaint.
• Present illness/health history
• Family history e.g. allergies, chronic medical conditions
• Psychosocial and cultural history
• Review of systems(ROS)
Validating data
• Double checking /verifying data/comparing data with another source
to confirm that they are accurate and factual
• Ensure assessment data is complete
• Ensure objective data and subjective data agree
• Provide additional information that may be overlooked
• Help differentiate cues and inferences
• Literature review confirms that data are consistent with medical
diagnosis
Documenting data
• Accurate recording of all data about the client ‘s health status is
essential
• Data are recorded in a factual manner and not interpreted by the
nurse
• Subjective data are recorded in client’s own words
Diagnosis
Diagnosing
• A pivotal step that demands critical thinking skills to
interpret assessment data and identify client strength and
problems
• Nursing diagnosis is a statement that describes the client’s
actual /potential response to a health problem that the
nurse is licensed and competent to treat.
Types of nursing diagnosis
• Actual nursing diagnosis: problem is present, and based on the
presence of associated S&S. e.g. body image disturbance related to
protruding eyeball and orbital swelling.Risk for corneal injury.
• High risk nursing diagnosis: presence of risk factors indicates that a
problem is likely to develop .e.g. high risk for infection.
• Possible nursing diagnosis:Statements describing a suspected
problem for which additional data is needed to confirm .eg possible
fluid volume deficit related to profuse vomiting for three days.
• Wellness diagnosis: indicates a healthy response. Client desires a
higher level of wellness. E.g. readiness for enhanced nutrition
Types of nursing diagnosis
• Syndrome diagnosis: associated with a cluster of other diagnoses.
E.g. rape trauma syndrome
• NANDA nursing diagnosis/diagnosis statement
• Problem/diagnostic label: describes the client’s health problem in a
few words. Directs formation of goals and expected outcomes and
may suggest some nursing interventions. Need to be specific,
stating area of problem e.g. Knowledge deficit (medications). May
require use of qualifiers to give additional meaning. E.g. altered,
deficient, impaired, ineffective, acute, and chronic. Etc.
Diagnosing steps
Assessing
Diagnosing
 Analysing data
Evaluating  Identify health problems
risks and strengths
 Formulate diagnostic
statements
 Evaluate the quality of
diagnostic statements.
Implementing

Planning
Analyzing data
• Comparing data with standards/norms based on knowledge and
experience.
• Clustering clues: involves determining the relatedness of facts and
whether any patterns are present.
• Nurse interprets the possible meaning of cue clusters and labels them
with tentative diagnostic statements.
Identifying health problems, risks & strengths
• Determining problems and risks: the nurse and patient identify actual
risk and possible problems and determine the type of problem and
the need for help in dealing with each problem.
• Determining aetiologies: the nurse examines the casual relationships
between problems and their related risk factors.
• Determining strengths: they establish client’s strengths, resources and
abilities to cope.
Formulating diagnostic statements
• Basic two part statements: problem (P): statement of client’s
response + aetiology: factors contributing to probable causes of
the response. Examples are ineffective breastfeeding related to
burst engorgement and constipation related to prolonged
laxative use
• The two parts are joined together by related to/associated
with, merely implying a relationship
• Basic three-part statements: PES format Problem+ Aetiology+
Signs & Symptoms, where S&S are the defining characteristics
manifested by the client (for actual problems only). The parts
are joined by related to and as manifested by. E.g. fluid volume
deficit related to persistent diarrhoea and reduced fluid intake
as manifested by dry skin mucous membranes, reduced urine
output and poor skin turgor.