this is prepared in easy language.....

1. NURSING PROCESS
Mo.Faishal
Nursing Tutor
Rama College Of Nursing

2. Nursing Process
Process-
“It is a series of planned actions or
operations directed towards a
particular result or goal”
Nursing Process-
“It is a systematic, rational method of
planning and providing individualized
nursing care”

3. Purpose of Nursing
Process
 To identify a client’s health status,
actual or potential health care
problems or needs.
 To establish plans to meet the
identified needs, and to deliver
specific nursing interventions to meet
those needs.
 It helps nurses in arriving at decisions
and in predicting and evaluating
consequences.

4. Characteristics Of Nursing
Process
 Goal oriented
 Dynamic
 Client centered
 Planned
 Interpersonal and collaborative
 Open and flexible
 Cyclical
 Outcome focused
 Universally applicable

5. Phases of Nursing Process or
Steps
Assessment
Diagnosis
Goal
planning
implementation
Evaluation

6. Assessment
 Assessment is the deliberate and
systematic collection of data determine a
clients current and past health status
and to determine the clients present and
post coping patterns. (Carpenito)

7. Types of Assessment
1. Initial assessment – performed within
specified time after admission to a
health care agency E.g. Nursing
Admission Assessment
2. Problem focused assessment –
ongoing process integrated with
nursing care to determine specific
problem identified in an earlier
assessment and to identify new or
overlooked problems.

8. 3. Emergency Assessment – Done
during psychiatric or physiological
crisis of the client to identify life
threatening problems. E.g. Rapid
assessment of airway , breathing and
circulation during cardiac arrest .
4. Time Lapsed Reassessment – done
several months after initial assessment
to compare the clients status to
baseline data previously obtained

9. Purpose of Assessment
 To validate a diagnosis
 To provide basis for effective nursing
care
 Basis for accurate diagnosis
 It helps in effective decision making
 To promote holistic nursing care
 To evaluate of nursing care
 To collecting data for nursing research

10. Clinical skills used in
assessment
Observation – it is not just seeing the
client uses such as looking , watching
, examining , scanning etc.
Interview – interview means
purposeful interaction between two
person
Physical Examination –
Intuition – intuition is defined as the
use of insight or clinical experience to
make clinical judgment about client

11. Assessment Activities
Data
collection
Organizing
data
Validating data
Documenting data

12. Assessment Activities
1.COLLECTION OF DATA
“data collection is the process of gathering
information about a clients health status”
 Subjective data – Also referred to as
symptoms or cobert . it is verified only by
the person. E.g. itching , pain ,feeling of
worry.
 Objective data – Also referred to as signs
or overt data . these are detectible by the
observer

13. Source of data collection
 Primary source(Direct source) – client
are the best source.
 Secondary source (Indirect source) –
family member , clients records
II. Organizing data :- nurses uses a
written or computerized format for
arranging the data systematically.
III. Validating data :- validating – the act
of double checking
IV. Documentation of data :- record in
permanent records

14. Nursing Diagnosis
 Nursing diagnosis is “A clinical
judgmental about individuals or
community responses to actual or
potential health problems/life process.
(Nanda 2009)

15. Purpose
 Gives nurses a common language
 Promotes identification of appropriate
goals
 Provide acuity information
 Can create a standard for nursing
process
 Provides a quality improvement base
 Facilitates communication
documentation

16. Types of nursing diagnosis
 Actual Nursing Diagnosis
 Risk nursing diagnosis
 Health – promotion nursing diagnosis
 Possible nursing diagnosis

17. Actual Nursing Diagnosis
 Also known as three statement
diagnosis
 It is a client problem that is present at
the time of nursing assessment
 It is based on the presence of
associated signs and symptoms.
 E.g. Actual problem + related to +
evidenced

18. Risk Nursing Diagnosis
 It is a clinical judgment that a problem
doesn't exist , but the presence of risk
factors indicates that a problem is
likely to develop unless nurses
intervenes.
 It is also known two statement nursing
diagnosis
 E.g. possible risk + related to

19. Health promotion nursing
diagnosis
 Clinical judgment about a person’s,
family’s or community’s motivation and
desire to increase well being .
 E.g readiness + Health promotion
 Readiness for enhanced family coping

20. Possible Nursing Diagnosis
 Possible nursing diagnosis is one in
which evidenced about a health
problem is incomplete or unclear.
 E.g. possible risk + related to +
Evidenced by

21. Components Of Nursing Process
1. Label
2. Qualifiers
3. Defining Characteristics
4. Risk factors
5. Related Factors

22.  Label-
 Provides a name for a diagnosis
 Describes the clients health problem or
responses for which nursing therapy is
given
 It may includes modifiers
 E.g. Stress incontinence

23. Qualifiers –
Qualifiers are words that have been
adds to some NANDA labels to give
additional meaning to the diagnostic
statement.
Eg . Deficit , impaired , altered,
decreased , ineffective etc.

24. Definition-
 Definition describes the characteristics
of the human response under
consideration based on data collected.
 E.g. poor sleep pattern , poor
circulation

25. Defining characteristics
 These are the cluster of signs and
symptoms that indicate the presence
of a particular diagnostic label
Risk Factors
 Environmental factors and
physiological , psychological , genetic
or chemical elements that increase the
vulnerability of an individual , family or
community to an unhealthful events.

26. Related Factors
 Factors that may precede , contribute
to or be associated with the human
response .

27. Planning
 It is defined as predetermining a
course of action in order to arrive at a
desired result.
 A continuous process of assessing
goals and objectives, implementing
and evaluating them and subjecting
these to changes as new facts are
known.

28. Purpose
 Direct client care activities.
 Focus on the proper documentation
 Establish continuity care
Step of planning
 Initial planning – done by the nurse
who perform admission assessment in
order to prioritize problems , identify
goals and correlate nursing care to
resolve the problems.

29.  Ongoing planning –involves
continuous updating of the client’s
plan of care . every nurse who cares
for the client is involved in ongoing
planning.
 Discharge planning–involves
anticipation and planning for the
client’s need after discharge.

30. Element of planning
 Prioritizing the problems /nursing
diagnosis
 formulate goals /desired outcomes
 Short term
 Long term
 Select nursing interventions
 Write nursing intervention

31. Implementation
 This fourth step of the nursing process
involves the execution of the nursing
care plan derived during the planning
phase.

32. Process of implementation
Revise the
data
Revise the
nursing
diagnosis
Revise the
specific
intervention
Choose the
evaluation
method

33. 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 .

34. Purpose
 Determine client’s behavioral
response.
 Compare the client’s response with
outcome criteria.
 Assess the collaboration of client and
health team.
 Apprise the extent to which client’s
goal
 Identify the errors in the plan of care
 Monitor the quality of nursing care

35. Components of evaluation
 Collection of data
 Compare of data
 Relating nursing activities
 Draw conclusion
 Continue modify , terminate care plan