Nursing Process System

S
P
N

NURSING PROCESS
is a systematic, rational method
of planning and providing individ
ualized nursing care.

ORIGINS
?

1st to use Nursing Process

Lydia E. Hall
Originated the te
rm nursing proce
ss in 1955

1st to use Nursing Process

Dorothy Johnson
Gained additional legitimacy
1959
in 1973, American Nurses
Jean
Association (ANA)Ida
Standards
Orlando
of Nursing
1961
Ernestine
Wiedenbach

PURPOSES of NPS
1. to identify a clients health status
and actual or potential health car
e problems or needs

PURPOSES of NPS
2. to establish plans to meet the ide
ntified needs

PURPOSES of NPS
3. to deliver specific nursing interven
tions to meet those needs.

Phases of the Nursing Process

ANA, 2010
NCLEX
1.assessment,
1.assessment,
2.diagnosis,
2.analysis,
3.outcomes identi 3.planning,
fication,
4.implementing,
4.planning,
5.Evaluation.
5.implementation,
6.evaluation

Characteristics of the Nursing Process

1. CYCLIC AND DYNAMIC NATUR

E

2. CLIENT CENTEREDNESS
.nurse organizes the plan of care
according to client problems rath
er than nursing goals.
RESPONSES,
BEHAVIOURS

3. FOCUS ON PROBLEM SOLVIN

G AND DECISION MAKING
.involved in every phase
.not bound by standard response
s and may apply their repertoire
of skills and knowledge

4. INTERPERSONAL AND COLLAB

ORATIVE
.Requires to communicate directl
y and consistently with clients an
d families to meet their needs
.requires to collaborate, as memb
ers of the health care team

5. UNIVERSAL APPLICABILITY
.used as a framework for nursing
care in all types of health care set
tings, with clients of all age grou
ps

6. USE OF CRITICAL THINKING A

ND CLINICAL REASONING
.utilize clinical reasoning through
out the delivery of nursing care

RATIONAL
ES

drawing a conclusion or
making a logical
judgment on the basis of
circumstantialevidence
and prior conclusions
rather than on the basis
of direct observation

6. USE OF CRITIC
AL THINKING
AND CLINICA
L REASONING

INDIVIDUAL PHA
SES

ASSESSMENT

ASSESSING
the systematic and continuous c
ollection, organization, validatio
n, and documentation of data in
formation
assessing is a continuous process
carried out during all phases

ASSESSMENT

vary according to their purpose, t

iming, time available, and client s
tatus
focus on a clients responses to a
health problem
data collected should be relevant
to a particular health problem

TYPES of ASSESSMENT

1.
2.
3.
4.

Initial assessment
Problem-focus assessment
Emergency assessment
Time-lapse assessment

TYPES

1. INITIAL ASSESSMENT
.Performed within specified time
after admission
.To establish a complete database
for problem identification, refere
nce, and future comparison

TYPES

2. PROBLEM-FOCUS ASSESSMEN
T
.Ongoing process integrated with
nursing care
.To determine the status of a spe
cific problem identified in an earl
ier assessment

TYPES

3. EMERGENCY ASSESSMENT
.During any physiological or psyc
hological crisis of the client
.To identify life-threatening probl
ems
.To identify new or overlooked pr
oblems

TYPES

4. TIME-LAPSED REASSESSMENT
.Several months after initial asses
sment
.To compare the clients current s
tatus to baseline data previously
obtained

COLLECTING DATA

DATA COLLECTION
the process of gathering informa
tion about a clients health status
must be both systematic and con
tinuous to prevent the omission
of significant data

DATABASE

contains all the information abo

ut a client
results of
nursing health history
laboratory and
diagnostic tests
physical assessment,
Other
materials
primary care providers
history
physical examination

TYPES OF DATA

1. SUBJECTIVE DATA
.also referred to as symptoms or
covert data
.can be described or verified only
by that person
Itch, pain, soreness

2. OBJECTIVE DATA
.referred to as signs or overt data
.Detectable by an observer or can
be measured or tested against a
n accepted standard
.can be seen, heard, felt, or smell
ed

SOURCES OF DATA

SOURCES OF DATA

1.
2.
3.
4.
5.

CLIENT
SUPPORT PEOPLE
CLIENT RECORDS
HEALTHCARE PROFESSIONALS
LITERATURE

SOURCES

1. CLIENT
.best source of data
.client can provide subjective data
2. SUPPORT PEOPLE
.Family members, friends, and care
givers
.can supplement or verify informati

SOURCES

3. CLIENT RECORDS
.include information documented
by various health care professional
s
.also contain data regarding the cli
ents occupation, religion, and ma
rital status

SOURCES

4. HEALTH CARE PROFESSIONALS

.verbal reports from other health c
are professionals serve as other po
tential sources
.Nurses, social workers, primary ca
re providers, and physiotherapists

SOURCES

5. LITERATURE
.review of nursing and related liter
ature
.Professional journals and referenc
e texts

5. LITERATURE

SOURCES

.Standards or norms against which to

compare findings (e.g., height and weight table
s, normal developmental tasks for an age group)

.Cultural and social health practices

.Spiritual beliefs
.Assessment data needed for specific c
lient conditions

5. LITERATURE

SOURCES

.Nursing interventions and evaluation

criteria relevant to a clients
.health problems
.Information about medical diagnoses,
treatment, and prognoses
.Current methodologies and research f
indings.

Data Collecti
on Methods

Data Collection Methods

1. Observing
2. Interviewing
3. Examining

1. Observing
.Using of senses
.a conscious, deliberate skill t
hat is developed through eff
ort and with an organized a
pproach.
.While in contact with the cli

2. Interviewing
.a planned communicati
on or a conversation wit
h a purpose
.while taking the nursing
health history

2 APPROACHES: (interview)
a. Directive Interview
.is highly structured and elicits specifi
c information
.establishes the purpose of the interv
iew and controls the interview
.limited opportunity to ask questions
or discuss concerns

2 APPROACHES:
b. Nondirective Interview
.Rapport building interview
.allows the client to control the pur
pose, subject matter, and pacing

Types of Interview Questions:

1. Close Ended
.used in the directive interview, are
restrictive and generally require on
ly yes or no or short factual ans
wers

Types
2. Open Ended
.invite clients to discover and explo
re, elaborate, clarify, or illustrate th
eir thoughts or feelings
SUPPLEMENTAL
READING:
TABLE 11-6, PAGE
165

Types of Int. Questions:

3. Neutral
.a question the client can answer w
ithout direction or pressure from t
he nurse
.open ended, and is used in nondir
ective interviews

Types of Int. Questions:

4. Leading
.usually closed, used in a directive i
nterview, and thus directs the clien
ts answer

Stages of an Interview:
1. The Opening
2. The Body
3. The Closing

Data Collection Methods

3. Examining
.a systematic data collection meth
od that uses observation (i.e., the
senses) to detect health problems
.Major method used in the physica
l health assessment

Data Collection Methods

3. Examining
.uses techniques of inspection, aus
cultation, palpation, and percussio
n
.carried out systematically
a head-to-toe approach or a bo

ORGANIZING DAT

 uses a written (or electronic) for

mat that organizes the assessme
nt data systematically
often referred to as:
a nursing health history,
nursing assessment,
nursing database form

VALIDATING DATA

 information must be complete, f

actual, and accurate
nursing diagnoses and interve
ntions are based on this
double-checking or verifying da
ta to confirm that it is accurate a
nd factual.

AGNOSIN

 use critical thinking skills to inter

pret assessment data and identif
y client strengths and problems

Definition

a statement or conclusion regardin

g the nature of a phenomenon.
a clinical judgment concerning a h
uman response to health condition
s/ life processes, or a vulnerability f
or that response, by an individual, f
amily, group, or community - NAN

ORIGINS

Identification and development of

nursing diagnoses
formally began in 1973
Saint Louis University,Kristine G
ebbie and Mary Ann Lavin

ORIGINS

International recognition
First Canadian Conference in T
oronto in 1977
International Nursing Conferen
ce in May 1987 in Calgary, Albe
rta, Canada

ORIGINS

1982, the conference group acce

pted the name North American
Nursing Diagnosis Association (N
ANDA)

NANDA
define, refine, and promote a tax
onomy (classifications) of nursin
g diagnostic terminology of gene
ral use to professional nurses

modified

Knowledge of key concepts, or nur

sing diagnostic foci, is necessary be
fore beginning an assessment. Exa
mples of critical concepts important
to nursing practice include breathin
g, elimination, thermoregulation, p
hysical comfort, self-care, and skin i

TAXONOMY
a classification system or set of c
ategories arranged based on a si
ngle principle or set of principles

DIAGNOSTIC LABELS
Problem
The standardized NANDA names
for the diagnoses

ETIOLOGY
clients problem statement
causal relationship between a pr
oblem and its related or risk fact
ors

Diagnostic lab
el

+ETIOLOGY
=
Nursing
Diagnosis

Kinds of Nursing Diagnosis

1.
2.
3.
4.

Actual diagnosis
Health promotion diagnosis
Risk nursing diagnosis
Syndrome diagnosis

1. Actual diagnosis
client problem that is present at t
he time of the nursing assessme
nt
based on the presence of associa
ted signs and symptoms
Ex.: Ineffective breathing pattern

2. Health promotion diagnosis

clients preparedness to impleme
nt behaviors to improve their hea
lth condition
labels begin with the phrase Rea
diness for Enhanced
Ex. Readiness for Enhanced Nutri

3. Risk nursing diagnosis

clinical judgment that a problem
does not exist, but the presence
of risk factors indicates that a pr
oblem is likely to develop unless
nurses intervene
Ex. Risk for Infection R/T

4. Syndrome diagnosis
to describe a cluster of nursing di
agnoses that have similar Interve
ntions or occurred together
There must be two or more nursi
ng diagnoses be used as defining
characteristics

COMPONENTS OF NANDA NDx

1. the problem and its definition

2. the etiology, and
3. the defining characteristics

PROBLEM (DIAGNOSTIC LABEL) &

DEFINITION

It describes the clients health sta

tus clearly and concisely in a few
words.

ETIOLOGY (RELATED FACTORS AND RISK FACTORS)

identifies one or more probable c
auses of the health problem
Differentiating among possible c
auses in the nursing diagnosis is
essential because each may requi
re different nursing interventions

DEFINING CHARACTERISTICS

cluster of signs and symptoms that i

ndicate the presence of a particular
diagnostic label
For actual nursing diagnoses, the defining c
haracteristics are the clients signs and sympt
oms.
For risk nursing diagnoses, no subjective and
objective signs are present

Differentiating Nursing Diagnoses

from Medical Diagnoses

FORMULATING Dx STATEMENTS

BASIC TWO-PART STATEMENTS (P

E)
1. Problem (P): statement of the clients respo
nse (NANDA label)
2. Etiology (E): factors contributing to or prob
able causes of the responses.

Basic Two-Part Diagnostic Statement

FORMULATING Dx STATEMENTS

BASIC THREE-PART STATEMENTS (P

ES)
1. Problem (P): statement of the clients
response (NANDA label)
2. Etiology (E): factors contributing to o
r probable causes of the Response
3. Signs and symptoms (S): defining cha

Basic Three-Part Diagnostic Statement

FORMULATING NDx

PLANNING

 involves decision making and probl

em solving
Refers to the assessment data and
diagnostic statements for direction i
n formulating client goals and desig
ning the nursing interventions requi
red to prevent, reduce, or eliminate
the clients health problems

 Begins with the first client contact

& continue until client discharge
Nursing Intervention
any treatment, based upon clinical
judgment and knowledge, that a n
urse performs to enhance patient/cl
ient outcomes

TYPES OF PLANNING

1. Initial Planning
2. Ongoing Planning
3. Discharge Planning

1. Initial Planning
.admission assessment usuall
y develops the initial compre
hensive plan of care.

2. Ongoing Planning
.Nurses obtain new informati
on and evaluate the clients r
esponses to care, they can in
dividualize the initial care pla
n further

Ongoing Planning- Purpose

1. To determine whether the clients he
alth status has changed
2. To set priorities for the clients care d
uring the shift

3. To decide which problems to focus o

n during the shift
4. To coordinate the nurses activities s
o that more than one problem can b
e addressed at each client contact.

3. Discharge Planning
the process of anticipating and
planning for needs after
discharge, is a crucial part of a
comprehensive health care plan
and should be addressed in each
clients care plan

DEVELOPING
NURSING CARE PLA
NS

NURSING CARE PLAN

The end products of the plannin
g phase of the NP.
Either formal or informal

Formal
a written or computerized guide
that organizes information about
the clients care.
provides for continuity of care

Informal
a strategy for action that exists in
the nurses mind

STANDARDIZED CARE PLAN

a formal plan that specifies the n
ursing care for groups of clients
with common needs
e.g., all clients with myocardial in
farction

INDIVIDUALIZED CARE PLAN

Tailored to meet the unique nee
ds of a specific clientneeds that
are not addressed by the standar
dized plan

FORMAT for NCP

Differs from agency to agency
Often organized into four:
1.
2.
3.
4.

Nursing diagnosis
Goals/desired outcomes
Nursing Interventions
Evaluation

SETTING PRIORITIES

change as the clients responses,

problems, and therapies change.
nurse and client begin planning
by deciding which nursing diagn
osis requires attention first, whic
h second, and so on

 Nurse must consider a variety of

factors:
1. Clients health values and belie
fs
2. Clients priorities
3. Resources available to the nurs
e and client
4. Urgency of the health problem

GOALS/OUT
COMES

PURPOSE OF GOALS/DESIRED OUTC

OMES
1. Provide direction for planning nursin
g interventions
2. Serve as criteria for evaluating client
progress
3. Enable the client and nurse to deter
mine when the problem has been re
solved.
4. Help motivate the client and nurse b

LONG TERM
SHORT TERM

COMPONENTS OF GOAL STATEMENT

S
1.
2.
3.
4.

Subject
Verb
Conditions or modifiers
Criterion of desired performance

INTERVEN
TIONS

Nursing Interventions and Activities

actions that a nurse performs to ac

hieve client goals
specific interventions chosen shoul
d focus on eliminating or reducing
the etiology of the nursing diagno
sis

TYPES OF NURSING INTERVENTIONS

1. Independent interventions
.activities that nurses are licensed to ini
tiate on the basis of their knowledge a
nd skills
2. Dependent interventions
.activities carried out under the orders
or supervision of a licensed physician o
r other health care provider authorized

TYPES OF NURSING INTERVENTIONS

3. Collaborative interventions / Interde
pendent
.actions the nurse carries out in collabo
ration with other health team member
s
.reflect the overlapping responsibilities
of, and collegial relationships among,
health personnel.

IMPLEMEN
TATION

IMPLEMENTING

the action phase in which the nurs

e performs the nursing interventio
ns
Consists of doing and documentin
g the activities that are the specific
nursing actions needed to carry ou

NEEDED IMPLEMENTING SKILLS

1. Cognitive for safe, intelligent n

ursing care
2. Interpersonal - effectiveness of a
nursing action often depends lar
gely on the nurses ability to com
municate with others

NEEDED IMPLEMENTING SKILLS

3. Technical
.hands-on skills such as manipulat
ing equipment, giving injections, b
andaging, moving, lifting, and rep
ositioning clients

PROCESS of IMPLEMENTING

Reassessing the client

Determining the nurses need for a
ssistance
Implementing the nursing interven
tions
Supervising the delegated care

EVALU
ATION

EVALUATING

a planned, ongoing, purposeful ac

tivity in which clients and health ca
re professionals determine (a) the
clients progress toward achieveme
nt of goals/outcomes and (b) the e
ffectiveness of the nursing care pla
n.

FORMATIVE EVALUATION
Aka internal evaluation
Method of judging the worth of
a program while the program act
ivities are forming (in progress)

SUMMATIVE EVALUATION
AKA external
A method of judging the worth
of a program at the end of the p
rogram activities (summation)
Focus on the outcome

ACTUAL

NCP SAMPLE

ASSESSMEN
T

DX

SB

GOALS

S/O>

incision on
the L arm
(ORIFtreated
D/3 radius
L with
bone
grafting)
posterior

cast &
bandage
on L arm

swelling
on the L
arm

pale pink
nail beds
@ L hand
BP =

140/90mm
Hg

Acute
Pain r/t

Acute pain is
described as
an unpleasant
sensory or
emotional
experience
associated
with actual or
potential
tissue damage
or injury as
lasting from
seconds to 6
months. In
cases of
fracture, pain
is continuous
& increasing in
severity until
bone
fragments are
immobilized.

After 2 days of
nursing
intervention, the
patient:
verbalizes

minimized
or
controlled
feeling of
pain
verbalizes

methods
that
provide
relief
demonstrate

s use of
relaxation
skills &
diversional
activities as
indicated
for his
situation

surgery
incision
on L arm

Add

INT

RATIONALE

Independent

Assessed LOC &

turned q 2
hours, to
unoperative
side only.

Adjusted
constricting
bandage &
advised to
elevate L arm.

Dependent NI:

Administer pain
reliever as
ordered

One must be
conscious &
awake in
order to feel
pain. Turning
of position
prevent bed
sores.
This is to
prevent
diminished
circulatory &
nerve
function &
control
swelling of the
site.
NSAID
activity
includes
modulation
of T-cell
function,
inhibition of
inflammatory

EVAL
Pain is
reduced
to a
tolerable
extent
as
verbalize
d.

DOCUMENTATION

END