Nursing Process
Mrs. Sumaira Noreen
Senior Nursing Instructor
Objectives :
At the end of this lecture students will be able to:
1) Define the Nursing process.
2) What is the main origin of Nursing Process?
3) Explain steps of Nursing Process in detail.
4) How to use the Nursing Process ?
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Definition of Nursing Process
“The nursing process is a deliberate problem solving
approach for meeting people’s health care and nursing
needs”.
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Steps of Nursing Process
the steps of nursing process have been stated in
various ways by different writers, the common
components cited are :
1) Assessment
2) Diagnosis
3) Planning
4) Implementation
5) And Evaluation
(Carpenito, 2013)
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The ANA’s Standards of Clinical Nursing
Practice(2010b) includes an additional component
entitled outcome identification and establishes the
sequence of steps in the following order:
1) Assessment
2) Diagnosis
3) Outcome identification
4) Planning
5) Implementation
6) Evaluation .
For the purpose of this text , the nursing process is based
on the traditional five steps .
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Assessment
The systematic collection of data that will be used in
the next step of the nursing process to determine the
patient’s health status and any actual or potential
health problems.
Analysis of data is included as part of the assessment.
Analysis may also be identified as a separate step of
the nursing process .
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Diagnosis
Identification of the following two types of patient
problems:
Nursing diagnoses: Actual or potential health problems
that can be managed by independent nursing
intervention.
Collaborative problems: According to
Carpenitino(2013), “Certain physiologic complications
that nurse monitor to detect onset or change in status.
Nurse manage collaborative problems using physician
prescribed and nurse prescribed interventions to
minimize the complications of the events”(p.23).
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Planning
Developments of goals and outcomes as well as a plan
of care designed to assist the patient in resolving the
diagnosed problems and achieving the identified goals
and desired outcome.
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Implementation
Actualization or carrying out the plan of care through
nursing intervention.
Evaluation
Determination of the patient’s response to the nursing
interventions and the extent to which the outcomes
have been achieved.
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Use of Nursing Process
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Assessment
The nursing assessment, the first step in the five steps
of the nursing process.
“It includes the systematic and continuous collection
of data; sorting, analyzing, and organizing that data
and the documentation and communication of the
collected data”.
Assessment data are gathered through the health
history and the physical assessment.
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Definition
According to Carpenito :
“Assessment is the deliberate
and systematic collection of data to determine a
client's current and past health status functional
status and to determine the client's present and
coping patterns”.
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Purpose of Assessment
To establish a data base (all the information about the
client):
nursing health history
physical assessment
the physician’s history & physical examination
results of laboratory & diagnostic tests material from
other health personnel
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Conti ...
To gather information regarding clients health.
To determine patient’s normal function
To organize the collected information
To frame Nursing diagnose
To identify the health problem
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Health history
The health history is conducted to determine a persons
state of wellness or illness and is best accomplished as
part of a paned interview.
The interview is a personal dialogue between a patent
and a nurse that is conducted to obtain information.
Nurse must use the techniques of therapeutic
communication for taking health history.
Therapeutic communication techniques
1. Listening 2. Silence
3. Restating 4. Reflection
5. Clarification 6. focusing
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7. Broad opening 8. Humor
9. Informing 10. sharing perceptions
11. Theme identification 12. Suggesting
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Physical Assessment
A physical assessment maybe carried out before,
during, or after the health history depending on a
patent’s physical and emotional statues and the
immediate priorities of the situation.
The purpose of the physical assessment is to identify
those aspects of a patent’s physical, psychological,
and emotional state that indicate a need for nursing
care.
It requires the use of sight, hearing, touch and smell, as
well as appropriate interview skills and techniques.
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Types of Assessment
1) Initial nursing assessment
2) Problem focused assessment
3) Emergency assessment
4) Time-lapsed assessment
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Initial Assessment
It is performed within specified time after admission to
a health care agency.
Purpose
Also called a triage, the initial assessment's purpose is
to determine the origin and nature of the problem and
to use that information to prepare for the next
assessment stages.
Due to the fact that the rest of the medical process
relies on the accuracy of this initial assessment, it is
the most thorough phase of the entire process.
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It usually consists of getting the patient's medical
history and performing a physical exam on them or,
in the case of patients with mental issues, performing
a psychological assessment.
Depending on the patient's condition, the initial
assessment may also include recording the patient's
vital signs and looking for subtle symptoms that may
be signs of an underlying condition.
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Problem –Focused Assessment
A detailed nursing assessment of specific body
systems relating to the presenting problem or other
current concerns required. This may involve one or
more body system.
Ongoing process integrated with nursing care.
To determine status of a specific problem identified in
an earlier assessment and to identify new or
overlooked problem.
For example hourly assessment of a fluid overload
patient.
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Emergency Assessment
The emergency assessment is performed during
emergency procedures, when it is crucial to evaluate
the patient's airway, breathing and circulation, as well
as the exact cause of the problem.
Using the acronym ABCCS, nurses perform
emergency assessments when they meet a patient and
repeat them anytime they determine that their patient’s
condition could be becoming unstable.
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Here’s what the acronym stands for:
A = airway – ensure the airway is not obstructed or
compromised
B = breathing – ensure patient is breathing, and if it is absent
or labored to intervene immediately
C = circulation – check to ensure the patient has a pulse, and
if patient is on cardiac monitoring (which they should be if
circulation is a concern!) then check the patients heart rhythm
C = consciousness – check their level of consciousness and
observe for any abrupt changes
S = safety – ensure that the patient is safe from risk of harm
Once the patient stabilizes, the nurse may discontinue
emergency assessments and transition to an initial or focused
assessment, depending on the situation.
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Time lapsed Assessment
The time-lapsed assessment is scheduled to compare
a patient's current status to baseline data obtained
earlier. Periodic time-lapsed assessments are done to
reassess health status and to make necessary revisions
in the plan of care.
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Activities
1) Collection of data
2) Validation of data
3) Organization of data
4) Analyzing of data
5) Recording/documentation of data
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Collection of data
Gathering of information about the client
Includes physical, psychological, emotion, socio-
cultural, spiritual factors that may affect client’s health
status
Includes past health history of client (allergies, past
surgeries, chronic diseases, use of folk healing
methods)
Includes current/present problems of client (pain,
nausea, sleep pattern, religious practices, meds or
treatment the client is taking now)
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Types of data
1)Subjective data
also referred to as Symptom/Covert data
Information from the client’s point of view.
Information supplied by family members, significant others;
other health professionals are considered subjective data.
Example: pain, dizziness, ringing of ears/Tinnitus
2)Objective data
also referred to as Sign/Overt data
Those that can be detected observed by the nurse.
Example: pallor, diaphoresis, BP=150/100, yellow
discoloration of skin
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Methods of data collection
Interview
A planned, purposeful conversation/communication with
the client to get information, identify problems, evaluate
change, to teach, or to provide support or counseling.
it is used while taking the nursing history of a client
Observation
Use to gather data by using the 5 senses and instruments.
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Conti...
Examination
Systematic data collection to detect health problems
using unit of measurements, physical examination
techniques (IPPA), interpretation of laboratory results.
should be conducted systematically:
Cephalocaudal approach – head-to-toe assessment
Body System approach – examine all the body system
Review of System approach – examine only particular area
affected
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Sources of data
Primary source – data directly gathered from the
client using interview and physical examination.
Secondary source – data gathered from client’s family
members, significant others, client’s medical
records/chart, other members of health team, and
related care literature/journals.
In the Assessment Phase, obtain a Nursing Health
History – a structured interview designed to collect
specific data and to obtain a detailed health record of a
client.
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Components of Nursing Health History
1) Identified data
2) Reliability
3) Chief complaint
4) Present illness
5) Past history
6) Family history
7) Personal and social history
8) Review of system
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Validation of data
The act of “double-checking” or verifying data to
confirm that it is accurate and complete.
Purposes of data validation
ensure that data collection is complete
ensure that objective and subjective data agree
obtain additional data that may have been overlooked
avoid jumping to conclusion
differentiate cues and inferences
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Organization of data
Uses a written or computerized format that organizes
assessment data systematically.
1. Maslow’s basic needs
2. Body System Model
3. Gordon’s Functional Health Patterns:
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Gordon’s 11 Functional Health Patterns
1) Health perception-health management pattern.
2) Nutritional-metabolic pattern
3) Elimination pattern
4) Activity-exercise pattern
5) Sleep-rest pattern
6) Cognitive-perceptual pattern
7) Self-perception-concept pattern
8) Role-relationship pattern
9) Sexuality-reproductive pattern
10) Coping-stress tolerance pattern
11) Value-belief pattern
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Analyze the data
Compare data against standard and identify significant
cues. Standard/norm are generally accepted
measurements, model, pattern:
Ex: Normal vital signs, standard Weight and Height,
normal laboratory/diagnostic values, normal growth
and development pattern
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Document the data
Nurse records all data collected about the client’s
health status
Data are recorded in a factual manner not as
interpreted by the nurse
Record subjective data in client’s word; restating in
other words what client says might change its original
meaning.
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