UNIT-5

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Nursing Process
Objectives:
✓ Define the nursing process.
✓ Describe the 5 phases of nursing process.
Section :1 Assessment
✓ Explain the four major activities associated with the assessment
phase.

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✓ Identify the types and sources of data.
✓ Identify three methods of data collection.
Section: 2 Diagnosing
✓ Differentiate nursing diagnosis according to status.
✓ Identify the components of nursing diagnosis.
✓ Compare nursing diagnoses from medical diagnoses.
✓ Construct nursing diagnoses in different format.
Objectives
Section: 3 Planning
✓ Identify activities in the planning process.
✓ Compare the different types of planning.
✓ List the purposes of establishing goals/ outcomes.
✓ Identify the components of goals/ outcomes.
✓ Construct writing goals by using guidelines.

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✓ Describe the process of selecting and choosing nursing interventions.
Section: 4 Implementation
✓ Describe implementation phase.
Section: 5. Evaluation
✓ Describe evaluation process .
✓ Construct writing evaluation using guidelines.
What is Nursing Process?

• It is a systematic, rational method of planning

and providing individualized nursing care.
• Its purpose is to identify a client’s health care
status and actual or potential health problems /

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needs, to establish plans and deliver specific
nursing interventions according to the clients
need.
5 Phases or Steps Of Nursing Process

1. Assessment
2. Nursing Diagnosis

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3. Planning
4. Implementation
5. Evaluation
 ASSESSMENT

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Assessment
• Is the systematic and continuous collection ,
organization, validation and documentation of data. It
is a continuous process and carried out during all
phases of nursing process.

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• Purpose:
• To establish a database about the client’s response to
health concerns or illness and the ability to manage health
care needs.
Four Major Activities-Assessment
• Collecting Data
✓Nursing History
✓Physical examination
✓Laboratory and diagnostic tests

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• Organizing Data
✓Organizes the data systematically
• Validating Data
✓Double checking or verifying to confirm the data is
accurate, complete and factual.
• Documenting Data
✓Accurate documentation in a factual manner .
Collecting data : Types of data
Data should include the past and current problems. It can be
obtained as nursing history and health assessment. There
are 2 types of data: Data

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Objective (Signsor Overt) data:
Subjective (symptomsor covert) data: (What we observes)
(What the client says)
• can be seen, heard, felt, or
•Includes clients: sensations, smelled.
feelings, values, beliefs, attitudes, • Obtained by observation or
and perception of personal health physical examination
status and life situation.(i.e. Pain, • Measurable.
fear, worry, itching, etc.) (i.e., VS, skin discoloration, tremor,
etc)
 Sources of Data:
✓Client (Primary source)
✓Support people or Significant others
✓ Family members, Friends, caregivers

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✓Client Records
✓ Medical records, therapy records etc.
✓Health Care Professionals
✓ Nurses, Social workers, Primary care providers.
✓Literature
✓ Professional journals, Reference texts.
Three Methods of Data Collection
1. Observing

2. Interviewing

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3. Examining
 NURSING
DIAGNOSIS

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Nursing Diagnosis
✓Is the second phase of nursing process.
✓ A statement of present or potential health problem
that requires nursing intervention to be solved.
✓ Diagnostic labels (NANDA)+ etiology(cause)

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Three steps of diagnostic process
1. Analyze data
2. Identify health problems, risks, and strengths
3. Formulate diagnostic statements
Status of the Nursing Diagnosis
. The kinds of nursing diagnoses are:
1. Actual Diagnosis: Present at the time of assessment:
Eg: Ineffective Breathing Pattern, Anxiety
2. Risk Nursing Diagnosis: Likely to develop(risk factors)
Eg: Risk for Infection

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3. Health Promotion Diagnosis: Clients’ preparedness to
implement behaviors to improve their health condition.
Eg: Readiness for Enhanced Nutrition
Components of Nursing Diagnosis

It has 3 components:
1. The problem(Diagnostic Label) and definition-
Activity intolerance.

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2. The etiology (Related and Risk factors: Immobility
3. The defining characteristics- verbal report of
weakness
 Formulating Nursing diagnosis
1.Basic 2 part statement
Problem Etiology
(Impaired skin integrity) (Immobility)

Nursing Diagnosis : Impaired skin integrity related to (r/t) Immobility.

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2.Basic 3 part statement

Problem Etiology Signs & symptoms

(Activity intolerance) (Bed rest) (Fatigue)

Activity intolerance related to bed rest as verbal report of fatigue.

Few Nursing Diagnoses
• Constipation related to prolonged laxative use.

• Ineffective breathing pattern related to Lung

tumor.

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• Potential fluid volume deficit related to
diarrhea.

• Anxiety related to hospitalization.

 Planning

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Planning:
Planning is a systematic phase of
the nursing process that involves
decision making and problem

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solving.
 Planning process engages
following activities:

1. Setting priorities
2. Establishing client goals

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3. Selecting nursing interventions
4. Writing individualized nursing interventions on
care plans.
Setting priorities

High priority(Life threatening-

Cardiac , Respiratory problems)
Priority

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Medium priority (Health threatening-
(Acute illness, decreased coping ability

Low priority (Normal

developmental needs)
Can you identify the priority?
1. Anxiety
2. Sleep disturbance
3. Breathing difficulty

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4. Bathing
5. Fluid volume deficit
6. Family coping difficulty
Establishing Client Goals

• Nursing goal: The desired outcome of nursing care; that

which the nurse hopes to achieve by implementing nursing
interventions.
• Purpose of Goals:

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✓Provide direction for planning nursing interventions.
✓Serve as criteria for evaluating client progress.
Components of goals/ expected outcomes statement

• Goal= subject + Verb + Conditions + criterion of desired

performance
• Subject-Client
• Verb - drinks
• Condition (modifier)- 2500 ml fluid

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• Criterion of desired performance - daily
Some examples:
The Client drinks 2500ml fluid daily.
The client maintains normal body temperature within 6 hrs.
The client sates the purpose of his medication before
discharge.
Short-term & Long-term goals
Short-term goals:
This is useful for client who require health care for a
short time and in acute care setting, which can be
achieved in hours, or days. Mostly used for in-
patients.

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Long-term goals:
This goals are often used for clients who live at home
and have chronic problems and for clients in nursing
homes, extended care facilities. May span from days,
weeks, or months. Mostly used for rehabilitation, and
outpatients.
Nursing Intervention
• Nursing interventions are identified and written
during the planning step of the nursing process;
• Types of nursing interventions
Independent interventions
*Physical care, ongoing assessment,
teaching, counseling, emotional support etc.

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Dependent interventions
*Medications, Iv therapy, Diagnostic tests,
treatment,diet, activity

Collaborative interventions
Collaboration with other
therapy
Physical therapy-Crutch walking
Criteria for best nursing interventions
• Safe and appropriate for age and health condition.
• Achievable with available resources.
• Congruent with other therapies.
• Within established standards- Laws, policies of the hospital

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• Few eg: of Nursing interventions:
• Explain the action of insulin.
• Encourage fluids, 1 glass of juice, every hour.
• Record intake & output for 24 hours.
• Offer analgesics every 3 to 4 hours, according to Dr. Order.
 Implementation

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Implementation
• Is the action phase.
• Doing and documenting activities
• Reassesses the client
• Psychomotor skill.

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 Evaluation

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Evaluation
Evaluation is the 5th phase of nursing process and it is
continuous.
Evaluation components:
• Collect data related to outcomes

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• Compare data with outcomes
• Continue, modify, or terminate the client’s care plan
How to write evaluation statement?
• The goal was met.
• The goal was partially met.
• The goal was not met

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The Public Authority for Applied Education & Training
College of Nursing
NURSING CARE PLAN
Student’s Name_________________________ Hospital ____________________ Date of Experience___________
Client’s Initial ________________ Age_________ Sex________Diagnosis________________________________

Assessment Nursing Diagnosis Nursing Goal Nursing Interventions Rationale Evaluation

Subjective data: Short term:

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Objective data: Long term:
Bibliography
• Berman,A.,Snyder,S. " Kozier and Erb’s
Fundamental of nursing " 10th edition, P.P 155-
218

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