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 The purposes of the
Nursing Process
• Identify the client’s health care needs
• Determine priority of care goals and
expected outcomes
• Establish nursing care plan to meet
client-centered needs
• Provide nursing interventions designed
to meet these needs
• Evaluate the effectiveness of nursing
care
 Components of nursing process
1. Assessment

3. Diagnosis

5. Planning

7. Implementation

9. evaluation
 Nursing process
• Assessment: data collection:-
– Subjective data … pain
– Objective data …fever
• Diagnosis: determining the problem.
• Planning: developing a plan for care.
• Implementation: applying the plan.
• Evaluation: evaluating the outcomes.
 1. Assessment
Steps:-
• Health history
• Physical examination
• Laboratory data & diagnostic
procedures
• Validating data
• Documenting data
 Sources of data
• Client
• Family
• Health care team
• Medical records
• Military records
 Types of data
1- SUBJECTIVE DATA

Clients perception about his health problems

usually includes
A - Presence of pain
B- Feeling of anxiety
C- Physical discomfort
D. Mental stress
 Types of data
2- OBJECTIVE DATA
Observation or measurement made by the data
collector includes
A – observation (body rash )
B- measured (BP , T , R , head circumference )
 Methods of data collection

• Interview
• Nursing health history
• Physical examination
• Results of laboratory & diagnostic tests
 Physical examination
• Inspection, used to detect height,
weight, skin color, skin rash, scars,…
• Palpation, used to detect tenderness,
temperature, texture, pulse,…
• Percussion, used to detect the location
of organs.
• Auscultation, used to listen to sounds
produced by cardiovascular,
respiratory, gastrointestinal systems.
 2. Diagnosis
Steps:-
• Interpreting data
• Identify problems
• Formulating nursing diagnosis
• Documenting nursing diagnosis
Two types:-
- Actual
- Potential
 3. Planning
Steps:-
• Identify client’s goals
• Establish expected outcomes
• Selecting nursing actions
• Delegating action
• Writing nursing care plan
• Consulting
Types of goals:-

• short term goals

– Achieved in a short period, usually less
than one week.

• Long term goals

– Achieved over a long period, usually over
weeks or months.
 4. Implementation
Steps:-
• Reassessing client
• Reviewing and modifying existing care
plan
• Performing nursing action
 5. Evaluation
Steps:-
• Comparing client response to criteria
• Analyzing reasons for results
• Modifying care plan