Nursing process

UNIT-I
Nursing Process
Nursing process is a patient centered, goal oriented method of caring that provides
a frame work to the nursing care. It involves five major steps of assessement, nursing
diagnosis, planning, and implementation and evaluating.
Characteristics of nursing process
1. Cyclic and Dynamic
Nursing process has unique properties that enable it to respond to changing health
2. Systematic
It is well organized and applied stepwise.
3. Clint Centered
Nurse organize the plan of care according to client problem
4. Universal applicable
It is applicable/ useful not only for disease but also in wellness
5. Problem solving
In this process nurse solve the patients health problem.
6. Scientific
It is scientific in nature.

Component of Nursing Process

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process
1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementing
5. Evaluation

Step # 1 Assessment
This is first phase of nursing process; it involves data collection, data organizing,
and data validation.

Types of assessment

Initial assessment
Performed with in specific time after admission to health care center.

Focus assessment
Ongoing process to determine the status of specific problem.

Emergency assessment
Done during physiological and psychological crises.

Time Lapsed assessment

Assessment after several months of initial assessment

Methods of Assessment

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process

Interview

Physical Examination

Interview
It is planned, communication, or conversation, to give information, identify problem.
Interview has two main types

Directive interview

Non directive interview

Directive Interview
It is highly structured and elicits the specific information. The interview is made
purposeful and controlled by asking specific questions that are close ended questions i.e.
Are you you working in this hospital? Answer will be in yes or no form.
Non Directive
The nurses ask broad questions that are open in nature. i.e.

For interview setting and

planning important things are time, place, setting arrangement. Distance between nurse
and client is about three to four feet.
Physical examination
In this the observational skills are used to detect the health problems. The techniques that
used in examination are inspection, auscultation, palpation, and percussion. The physical
examination is done the from head to toe. In this cephalic caudal approach is used.

Assessment Process

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process

Data collection

Organizing data

Validating data

Data collection
This is process of gathering information about clients health status. It must be systematic
and continuous to prevent the omission of significant data and client changing status.
Database is all information about client includes health history, physical assessment, and
lab: investigations.
Types of Data

Subjective data

Objective data

Subjective data
Subjective data are defined as symptoms, and apparent only to person and verified
by that person for example pain, worry, anxiety, etc
Objective Data
Objective data are signs and detected by the observers. Pulse 90 beat/ minute, BP
120/80 mm Hg. Jaundice, edema, etc
Organizing data
To obtain data systematically, the nurse uses and organized assessment
framework called nursing health history the data is largely subjective. Mostly used
framework is Gordons 11 functional health patterns.

Validating Data

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process
This is the act of double checking, verifying data to conform that are accurate and
factual.

Step # 2 Nursing Diagnoses

Nursing diagnosis is a clinical judgment about individual, family, or community
responses to actual or potential health problems/life processes. Nursing diagnoses
provide the basis for selection of nursing interventions to achieve outcomes for
which the nurse is accountable."
The first conference on nursing diagnosis was held in 1973 to identify nursing knowledge
and establish a classification system to be used for computerization.

Difference between nursing diagnosis and medical diagnosis

Nursing diagnosis

Medical diagnosis

1. Nursing diagnosis is based on health 1. Medical

problems.

diagnosis

is

based

on

the

physiologic conditions.

2. Nursig diagnosis can be changed at any 2.It remains same throughout course of
time.
3.

disease

Nursing diagnoses focus on human 3. Medical diagnosis focus on the disease

response to stimuli,

process

Types of Nursing Diagnosis

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process

Actual diagnosis

Potential, risk or high risk diagnosis

Wellness diagnosis

Syndrome diagnosis

Actual diagnosis
Client response to health problem that is present at the of health assessment associated
sign or symptoms are basis for the actual diagnosis.Infection related to autolysis
secondary to appendicitis as evidence by hot skin

Potential diagnosis Risk diagnosis

A clinical judgment that has a client is more vulnerable to develop the problem than
others in a same situation. These are also known as risk nursing diagnosis. i.e. Risk for
infection related to diabetic food secondary to diabetic mellitus.

Wellness nursing diagnosis

These diagnosis are used to enhance the health, i.e potential for enhanced

Syndrome diagnosis
is used when a cluster of nursing diagnoses are often seen together. i.e. Rape trauma
syndrome, Post stress trauma syndrome, Disuse syndrome

Component of nursing diagnosis

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process

Problem statement (Diagnostic label)

Etiology (related factors)

Defining characteristics

Problem statement (diagnostic label)

This describes the clients health problem for which nursing therapy is given and
describes health status clearly and consciously in few words. Qualifiers (words added to
the label to give additional specific meaning are altered (change), impaired (worse,
weak, damage, reduce, decreased in degree or size, ineffective, acute, chronic. Each
label is approved by NANDA. For example altered thought process, altered nutrition
less than body requirement, impaired physical mobility mobility, Ineffective air ways
clearance etc .
Etiology (related factor)
This identifies one or more cause or risk factor of health problem. For example fluid
volume deficit related to dehydration secondary to cholera as evidence by loss of skin
turger.
Defining characteristics
This is cluster of sign and symptoms that indicate the presence of a particular diagnostics
label for actual nursing diagnosis. For example Anxiety related disease process as
evidence by restlessness. Restlessness is the defining of diagnostics label.

Formatting diagnosis statement

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process
One part statement
This consist of one statement such as in wellness or syndrome diagnosis, for example
post stress trauma syndrome, rape trauma syndrome, etc ..

Two part statement

This is used for risk, high risk, and potential. and possible nursing diagnosis. It includes
the P (Problem), E (Etiology), its format is called P.E format. For example Risk for
infection related to diabetic foot.
Three part statement
This is used for actual nursing diagnosis. This format is called PES. P (problem), E
(Etiology), S (sign and Symptoms/ Defining characteristics). For example altered
breathing pattern related bronchospasm secondary to bronchial asthma as evidence by
use of accessory muscles.

Step# 03 Planning
This is 3rd phase of nursing process involves decision making and problem solving. In
this phase nurse formulates the client goals (short term and long term) and decision
strategies to prevent, reduce, or eliminate the problem.
Planning Process

Priority setting

Goal setting

Selecting strategies

Priority setting

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process
In this process preferential orders for nursing strategies are made. Life threading
problem such as loss of the respiratory or cardiac cardiac functions are called high
priority.
Goal setting
The goal may be short term or long term. In acute cases, immediate needs most goals
are short term goal.
Selecting strategies
In this nursing strategies are selected to achieve the goal.

Step # 4 Implementation
In this phase nurse puts the nursing care plan into action.
Skills of Implementation

Cognitive skills

Interpersonal skills

Technical skills

Cognitive skills
These include problem solving, decision making, critical thinking, and reasoning,
intellectual, judgment etc..
Interpersonal skills
These include verbal and non verbal communication to solve the patient health
problem.
Technical skills

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

Nursing process
These include administration of drugs, bandaging, moving, lifting or doing any
nursing procedures e.g. Lumber puncture, catheterization, enema, etc .

Step # 5 Evaluation
To evaluate mean to judge that aim, target or goal is achieved or not.
It is process to judge the actions.
Evaluation has two main types

Formative evaluation
Formative evaluation done during nursing actions. Taking temperature during
sponging is formative evaluation. Mid term examination is also formative evaluation.
Summative evaluation
Summative evaluation done after the completion of any procedure or project.
Final examination is an example of summative evaluation

Badil dass, lecturer, Institute of Nursing, DUHS Karachi

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