PATEL INSTITUTE OF NURSING & ALLIED HEALTH SCIENCES

Fundamental of Nursing
Nursing Process

DEFINITION:
The nursing process is a systematic, rational method of planning and providing nursing care.
 Hall originated the term nursing process in 1955,
 Johnson (1959)
 Orlando (1961)
 Wiedenbach (1963) were among the first to use it to refer to a series of phases
describing the practice of nursing. Since then, various nurses have described the process
of nursing and organized the phases in different ways.

OVERVIEW OF THE NURSING PROCESS

The use of the nursing process in clinical practice gained additional legitimacy in 1973 when
the phases were included in the American Nurses Association (ANA) Standards of Nursing
Practice.

PHASES OF THE NURSING PROCESS

The Standards of Practice within the most current Scope and Standards of Nursing
Practice include six phases of the nursing process:
1. Assessment,
2. Diagnosis,
3. Outcomes identification,
4. Planning,
5. Implementation,
6. Evaluation (ANA, 2010).

The national licensure examination for registered nurses (NCLEX) uses five phases:
1. Assessment,
2. Analysis,
3. Planning,
4. Implementing,
5. Evaluation.

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The nursing process is cyclical; that is, its components follow a logical sequence, but more
than one component may be involved at one time. At the end of the first cycle, care may be
terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of
care may be modified.

PURPOSE:
 To identify a client’s health care status, and actual or potential health problems,
 To establish plans to meet the identified needs,
 To deliver specific nursing interventions to address those needs.

CHARACTERISTICS OF THE NURSING PROCESS

 Cyclic and dynamic nature
 Client centeredness
 Focus on problem solving and decision making
 Interpersonal and collaborative style
 Universal applicability
 Use of critical thinking and clinical reasoning.

Phase and Description Purpose Activities

ASSESSING To establish a database about  Establish a database:
Collecting, organizing, the client’s response to health • Obtain a nursing health
validating, and concerns or illness and the history.
documenting client data ability to manage health care • Conduct a physical
needs assessment.
• Review client records.
• Review nursing literature.
• Consult support persons.
• Consult health
professionals.
 Update data as needed.
 Organize data.
 Validate data.
 Communicate/document
data.
DIAGNOSING  To identify client strengths  Interpret and analyze
Analyzing and and health problems that data:
synthesizing data can be prevented or • Compare data against
resolved by collaborative standards.
and independent nursing • Cluster or group data

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 interventions (generate tentative
 To develop a list of nursing hypotheses).
and collaborative problems • Identify gaps and
inconsistencies.
 Determine client’s
strengths, risks, and
problems.
 Formulate nursing
diagnoses and
collaborative problem
statements.
 Document nursing
diagnoses on the care
plan.
PLANNING To develop an individualized  Set priorities and
Determining how to care plan that specifies client goals/outcomes in
prevent, goals/desired outcomes, and collaboration with
reduce, related nursing interventions client.
or resolve the identified  Write goals/desired
priority client problems; outcomes.
how to  Select nursing
support strategies/interventions.
client strengths; and how  Consult other health
to implement nursing professionals.
interventions  Write nursing
in an organized, interventions and
individualized, and nursing care plan.
goal-  Communicate care plan
directed manner to relevant health care
providers.
IMPLEMENTING To assist the client to meet  Reassess the client to
Carrying out (or desired goals/outcomes; update the database.
delegating) and promote wellness; prevent  Determine the nurse’s
documenting the planned illness and disease; restore need for assistance.
nursing interventions health; and facilitate coping  Perform planned
with altered functioning nursing interventions.
 Communicate what
nursing actions were
implemented:
• Document care and client
responses to care.

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 • Give verbal reports as
necessary.
EVALUATING To determine whether to  Collaborate with client
Measuring the degree to continue, modify, or terminate and collect data related
which goals/outcomes the plan of care to desired outcomes.
have been achieved and  Judge whether
identifying factors that goals/outcomes have
positively or negatively been achieved.
influence goal  Relate nursing actions to
achievement client goals/outcomes.
 Make decisions about
problem status.
 Review and modify the
care plan as indicated or
terminate nursing care.
 Document achievement
of outcomes and
modification of the care
plan.

ASSESSING
 Assessing is the systematic and continuous collection, organization, validation, and
documentation of data (information).
 Assessing is a continuous process carried out during all phases of the nursing process.
For example, in the evaluation phase, the client is reassessed to determine the outcomes
of the nursing strategies and to evaluate goal achievement.
 All phases of the nursing process depend on the accurate and complete collection of
data.
Types of Assessment:
Type Time Performed Purpose Example
Initial Performed within To establish a Nursing admission
assessment specified time after complete database assessment
admission to a for problem
health care agency identification,
reference, and
future comparison
Problem-focused Ongoing process To determine the  Hourly
assessment integrated with status of a specific assessment of
nursing care problem identified client’s fluid
in an earlier intake and
assessment urinary output in
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 an ICU
 Assessment of
client’s ability to
perform self-care
while assisting a
client to bathe
Emergency During any  To identify life-  Rapid assessment
assessment physiological or threatening of an individual’s
psychological problems airway, breathing
crisis of the  To identify new status, and
client or overlooked circulation
problems during a cardiac
arrest
 Assessment of
suicidal
tendencies or
potential for
violence
Time-lapsed Several months To compare the Reassessment of a
reassessment after initial client’s current client’s functional
assessment status to baseline health patterns in a
data previously home care or
obtained outpatient setting or,
in a hospital, at shift
change.

Techniques of Assessment:
• Observation: the technique of looking at the client or watching for general
characteristics, such as overall appearance, skin color, grooming, body posture, gait,
mood, interactions with others, and other factors that do not require closer scrutiny or the
use of measurement aids (e.g., a stethoscope).
 Inspection: careful, close, and detailed visual examination of a body part
 Auscultation: listening for sounds from within the body, usually with the aid of a
stethoscope or an ultrasound (Doppler)
 Palpation: feeling body tissues or parts with the hands or fingers
 Percussion: tapping or striking the fingers or a special “percussion hammer” against
the body; the resulting sounds indicate the location and density of body tissues or
organs. Percussion requires a high level of expertise, developed with experience.

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Assessment: 4 Major Activities:
 Collecting Data
 Organize Data
 Validate data
 Document data

 Collecting Date:
 Data collection is the process of gathering information about a client’s health status.
 It must be both systematic and continuous to prevent the omission of significant data
and reflect a client’s changing health status
 Data can be of subjective or objective and constant or variable types, and from
Primary & Secondary source.

Types of Data:
Subjective data
 Referred to as symptoms or covert data,
 Apparent only to the person affected and can be described or verified only by that
person.
Examples of subjective data:
Itching, pain, and feelings of worry.

Objective data,
 Referred to as signs or overt data
 Detectable by an observer or can be measured or tested against an accepted standard.
 They can be seen, heard, felt, or smelled, and they are obtained by observation or
physical examination.
Examples of subjective data:
A discoloration of the skin or a blood pressure reading.

During the physical examination, the nurse obtains objective data to validate subjective
data and to complete the assessment phase of the nursing process.

Sources of Data:
 Primary source
 Patient
 Secondary source
 Family members  Other healthcare professionals
 Significant other  Health records

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Data Collection Method:

a) Observing:
 Gathering data using senses
 Used to obtain following types of data:
 Skin color (vision)  Lung or heart sound (hearing)
 Body or breath odor (smell)  Skin temperature (touch)

b) Interviewing:
Planned communication or a conversation with a purpose focused interview the nurse asks
the client specific questions to collect information related to the client’s problem.
c) Focused interview the nurse asks the client specific questions to collect information
related to the client’s problem.

There are two approaches to Interviewing:

 Directive: is highly structured and elicited specific information.
Nurses frequently use directive interviews to gather and to give information when time
is limited (e.g., in an emergency situation).
 Nondirective: or rapport-building interview, by contrast, the nurse allows the client to
control the purpose, subject matter, and pacing .
Rapport: is an understanding between two or more people.

Types of Interview Questions

o Open-ended Question
o Closed-ended Question
 Open-ended Question
o Associated with the nondirective interview, invite client to discover and explore,
elaborate, clarify, or illustrate their thought and feelings.
Example:
o What brought you to the hospital?
 Closed-ended Question
o Used in the directive interview, are restrictive generally require only “Yes” or “No”
or short factual answers giving specific information.
Example:
• Are you having pain now?
• When did you fall?

 Organizing Data
• The nurse uses a written (or computerized) format that organizes the assessment
data systematically.
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 Validating Data
• Is the act of “double-checking” or verifying data to confirm that is accurate and
factual. Validating data helps the nurse complete these task:
• Ensure that assessment information is complete.
• Ensure that objective and related subjective data agree.
• Obtain additional information that may have been over looked.
• Difference between cues and inferences.
 Document Data
• To complete the assessment phase, the nurse records client data.

NURSING DIAGNOSE

The official NANDA definition of a nursing diagnosis is:

“. . . A clinical judgment concerning a human response to health conditions/life processes,
or a vulnerability for that response, by an individual family, group, or community”
(Herdman & Kamitsuru, 2014,p. 464).

In 2009 the NANDA-I Think Tank statement was developed.

It states, “A nursing diagnosis provides the basis for selection of nursing interventions to
achieve outcomes for which the nurse has accountability” (Herdman & Kamitsuru, 2014, p.
464).

Medical Diagnosis v/s Nursing Diagnosis

Nursing Diagnosis Medical Diagnosis

Within the scope of nursing practice Within the scope of medical practice

Identify responses to health and illness Focuses on curing pathology

Can change from day to day as client

Stays the same as long as the disease
respond to treatment and nursing
is present
intervention

Example: Impaired gas exchange Example: Pneumonia

Types of diagnose:

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a) An actual diagnosis is a client problem that is present at the time of the nursing
assessment.
Examples are Ineffective Breathing Pattern and Anxiety.
An actual nursing diagnosis is based on the presence of associated signs and symptoms.

b) A health promotion diagnosis relates to clients’ preparedness to implement behaviors

to improve their health condition.
Example: These diagnosis labels begin with the phrase Readiness for Enhanced, as in
Readiness for Enhanced Nutrition.

c) A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to develop unless nurses
intervene.
For example, all people admitted to a hospital have some possibility of acquiring an
infection; however, a client with diabetes or a compromised immune system is at higher
risk than others. Therefore, the nurse would appropriately use the label Risk for
Infection to describe the client’s health status.

d) A syndrome diagnosis is assigned by a nurse’s clinical judgment to describe a cluster of

nursing diagnoses that have similar interventions (Herdman & Kamitsuru, 2014, p. 23).

e) Wellness Nursing Diagnosis: Describes the human responses to levels of wellness in

an individual, family or community
Wellness nursing diagnosis
Composed of 1 part
 Problem statement- the client’s potential to enhance level of wellness.
Example: potential for enhanced parenting

Components of a NANDA Nursing Diagnoses:

A nursing Diagnosis has three components:
1. The problem and its definition
2. The etiology, and
3. The defining characteristics
Each component serves a specific purpose.

 Problem (Diagnostic Label) and Definition: the problem statement, or diagnostic

label, describes the client’s health problem or response for which nursing therapy is
given.
To be clinically useful, diagnostic labels need to specific; when the word Specify
follows a NANDA label, the nurse states the area in which the problem occurs, for

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example, Deficient Knowledge (Medications) or Deficient Knowledge (Dietary
Adjustments).

 Etiology ( Related Factors and Risk Factors):

The etiology component of nursing diagnosis identifies one or more probable causes of
the health problem, gives direction to the required nursing therapy, and enables the nurse to
individualize the client’s care.

 Defining Characteristics: are the cluster of sign and symptoms that indicate the
presence of a particular diagnostic label.

The NANDA lists of defining characteristic are still being developed and refined

DIAGNOSIS AND RELATED FACTORS DEFINING

DEFINITION CHARACTERISTICS

Activity Intolerance: • Bed rest or immobility • Verbal report of fatigue

Insufficient physical and • Generalized weakness or weakness
psychological energy to • Imbalance between • Abnormal heart rate or
endure or complete oxygen supply/demand blood pressure response
required or desired daily • Sedentary lifestyle to activity
activities. • ECG changes reflecting
arrhythmias or
ischemia
• Exertional discomfort
or dyspnea

The Diagnostic Process

The Diagnostic process has three steps:
1. Analyzing data
• Compare data against standards (identifies significant cues).
• Cluster Cues (generative tentative hypothesis).
• Identify gaps and inconsistencies
2. Identifying health problems, risks, and strengths
• Determining problems and Risk
• Determining strengths
3. Formulating diagnostic statements
• Basic Two-Part Statements
• Basic Three-Part Statements
• One-Part Statements
Formulating diagnostic statements

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Most nursing diagnoses are written as two-part or three-part statements, but there are
variations of these.
 Basic Two-Part Statements: the Basic Two-Part Statements includes the following:
Problem (P): statement of the client ‘s response (NANDA label).
Etiology (E): factors contributing to or probable cause of the responses.
The two-part are joined by the word related to rather than due to.
Example:
Problem Related to Etiology
Constipation related to prolong laxative use

 Basic Three-Part Statements: the Basic Three-Part nursing diagnosis Statements is

called the PES format and includes the following:
Problem (P): statement of the client‘s response (NANDA label).
Etiology (E): factors contributing to or probable cause of the responses.
Sign & Symptoms (S): defining characteristic manifested by the client.

The PES format is especially recommended for beginning diagnosticians because the sign
& symptoms validate why the diagnosis was chosen and make the problem statement more
descriptive.
This format cannot be used for risk diagnoses because client does not have sign &
symptoms of the diagnosis.

Example:
Problem Related to Etiology
Situational Low Self-Esteem related to feeling of rejection by husband
As Manifested by Sign & Symptoms
as manifested by hypersensitivity to criticism;
states” I do not know if I can manage myself “ and reject positive feedback.

 One-Part Statements: some diagnostic statements, such as wellness diagnoses and

syndrome nursing diagnoses consist of a NANDA label only.
Example:
o Readiness for Enhanced Parenting
o Health Seeking Behavior(low fat diet )

PLANNING
• Planning is a deliberative, systematic phase of the nursing process that involve decision
making and problem solving.

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• In planning, the nurse refers to the client's assessment data and diagnostic statements for
direction in formulating client goals and designing the nursing interventions required to
prevent, reduce, or eliminate the client ‘s health problem s.

Types of Planning
• Initial Planning: the nurse who performs the admission assessment usually
develops the initial comprehensive plan of care.
• Ongoing Planning: is done by all nurses who work with the client. As nurse obtain
new information and evaluate the client’s responses to care, they can individualize
the initial care plan further.
Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be
given that day.
• Discharge Planning: the process of anticipating and planning for need after
discharge, is a crucial part of comprehensive health care and should be addressed in
each client’s care plan.

GOALS:
Goals indicate the desired change in the client’s health status. Goals are client centered and
give direction to the care plan. It focuses on problem, prevention, resolution or
rehabilitation
Types of goals
 Short term goals
 Long term goals
 Expected outcome
 Short term Goal: Is an objective that is expected to be achieved within a short time
frame, usually less then a week.
 Long term Goal: Is an objective that is expected to be achieved over a longer time
frame, usually over weeks or months. Long term goals may be more appropriate for
problem resolution after discharge, especially from acute care settings.

 Expected Outcome: Is a specific measurable change in client's status that is

expected to occur in response to nursing care.
(Carpenito, 1997)
Goals should be SMART
Specific
Measurable
Achievable
Realistic
Time bound
Expected outcomes are more specific than goals and describe methods through which goals
are achieved.

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 IMPLEMENTATION
Is the action phase in which the nurse performs the nursing interventions.

Nursing Interventions:
Nursing interventions and activities are the actions that a nurse performs to achieve
client goals.
Type of Nursing Intervention
• Independent Intervention: are those activities that nurses are licensed to initiate on
the basis of their knowledge and skills.
• Dependent Intervention: are activities carried out under the physician ‘s orders or
supervision, or according to specified routines.
• Collaborative Intervention: are the actions the nurse carries out in collaboration
with other health care team members, such as physical therapists, social workers,
dietitian and physician.

Process of Implementing
The process of implementing normally includes the following;
• Reassessing the client
• Determining the nurse’s need for assistance
• Implementing nursing interventions
• Supervising the delegated care
• Documenting nursing activities

EVALUATION

• Is a planned, ongoing, purposeful activity in which clients and health care professionals
determine; (a) the client progress toward achievement of goal/outcomes and (b) the
effectiveness of the nursing care nursing care plan.
• Evaluation is an important aspect of the nursing process because conclusions drawn
from the evaluation determine whether the nursing interventions should be terminated,
continued, or changed.
Process of Evaluating Client Response
The evaluation process has five components:
• Collecting data related to the desired outcome (NOC indicators).
• Comparing the data with outcomes.
• Relating nursing activities to outcomes.
• Drawing conclusions about problem status.
• Continuing, modifying, or terminating the nursing care plan.

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Reference:
• Berman, [Link], Barbara. (Eds.) (2008) Kozier & Erb's fundamentals of
nursing :concepts, process, and practice Upper Saddle River, N.J. : Pearson Prentice
Hall,
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