Nightingale Florence

THE NURSING
PROCESS
 A systematic, rational method
of planning providing nursing
care.
Goal:
1. To identify a clients healthcare
status, and actual or potential
health problems
2. To establish plans to meet the
identified needs
3. To deliver specific nursing
interventions to address those
needs MENU
 ASSESSING
Collect data
Organize data
Validate data

O
Document data

V
DIAGNOSING
Analyze data
Identify health problems, risk, and strengths

E
Formulate diagnostic statements

R
PLANNING
Prioritize problems/diagnoses
Formulate goals/desired outcome

V
Select nursing interventions
Write nursing orders

I IMPLEMENTATION
Reassess the client
Determine the nurses need for assistance

E Implement the nursing interventions

Supervise delegated case
Document nursing activities

W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the clients care plan
 ASSESSMENT PHASE
The nurse carry out a
complete & holistic nursing
assessment of every
patient's needs

Utilizes an assessment
framework, based on a
nursing model or Waterlow
scoring wherein problems
are expressed as either
actual or potential
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 ASSESSMENT PHASE
Assessing is a 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
Nursing assessments focus on a
clients responses to a health
problem
should include the clients perceived
needs, health problems, related
experience, health practices, values,
and lifestyles MENU
Types of Assessment
Initial Assessment
Problem-focused Assessment
Emergency Assessment
Time-lapsed Reassessment
The assessment process involves four
closely related activities: collecting data,
organizing data, validating data, and
documenting data.
1). Collecting Data
Data collection is the process of
gathering information about a clients
health status. It must be both systematic
and continuous to prevent the omission of
significant data and reflect a clients
changing health status.
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 Types of Data

Subjective data, also referred to as

symptoms or covert data
- are apparent only to the person affected
and can be described or verified only by
that person. Itching, pain, and feelings of
worry are examples of subjective data. It all
includes the clients sensations, feelings,
values, beliefs, attitudes, and perception of
personal health status and life situation
Objective data, also referred to as
signs or overt data, are 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.
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Source of Data
Sources of data are primary or secondary. The client is
the primary source of data. Family members or other
support persons, other health professionals, records and
reports, laboratory and diagnostic analyses, and relevant
literature are secondary or indirect sources. In fact, all
sources other than the client are considered secondary
sources.

Data Collection Methods

Observing
To observe is to gather data by using the sense.
Observation is a conscious, deliberate skill that is
developed through effort and with an organized approach.
It has to aspects: (a) noticing the data and (b) selecting,
organizing, and interpreting the data.

Interviewing
An interview is a planned communication or a
conversation with purpose, for example, to get or give
information, identify problems of mutual concern, evaluate
change, teach, provide support, or provide counseling or
therapy. There are two approaches to interviewing:
directive, is highly structured and elicits specific
information.
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The nurse establishes the purpose of the interview and
controls the interview, at least at the outset, and
nondirective interview, 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.

Examining
The physical examination or physical assessment is a
systematic data-collection method that uses observation
(i.e., the senses of sight, hearing, smell, and touch) to
detect health problems. To conduct the examination the
nurses uses techniques of inspection, auscultation,
palpation, and percussion.

2). Organizing Data

The nurses use a written (or
computerized) format that organizes the
assessment data systematically. This is
often referred to as a nursing health
history, nursing assessment, or nursing
database form..
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The format may be modified according to
the clients physical status such as one
focused on musculoskeletal data for
orthopedic clients

3). Validating Data

The information gathered during the
assessment phase must be complete,
factual, and accurate because the nursing
diagnoses and interventions are based on
this information. Validation is the act of
double-checking or verifying data to
confirm that it is accurate and factual.

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Validating data helps the nurse complete
these tasks:
Ensure that assessment information is complete.
Ensure that objective and related subjective data
agree.
Obtain additional information that may have been
overlooked.
Differentiate between cues and inferences. Cues
are subjective and objective data that can be
directly observed by the nurse; that is, what the
client says or what the nurse can see, hear, feel,
smell, or measure. Inferences are the nurses
interpretation or conclusions made based on the
cues.
Avoid jumping to conclusions and focusing in the
wrong direction to identify problems.

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4). Documenting Data
To complete the assessment phase,
the nurse records client data. Accurate
documentation is essential and should
include all data collected about the clients
health status. Data are recorded in a
factual manner and not interpreted by the
nurse

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 ASSESSING
Collect data
Organize data
Validate data

O
Document data

V
DIAGNOSING
Analyze data
Identify health problems, risk, and strengths

E
Formulate diagnostic statements

R
PLANNING
Prioritize problems/diagnoses
Formulate goals/desired outcome

V
Select nursing interventions
Write nursing orders

I IMPLEMENTATION
Reassess the client
Determine the nurses need for assistance

E Implement the nursing interventions

Supervise delegated case
Document nursing activities

W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the clients care plan
 DIAGNOSING PHASE
The term diagnosing refers to the reasoning
process, whereas the term diagnosis is a
statement or conclusion regarding the nature of a
phenomenon. The standardized North American
Nursing Diagnosis Association (NANDA) names
for the diagnoses are called diagnostic labels;
and the clients problem statement, consisting of
the diagnostic label plus etiology (causal
relationship between a problem and its related or
risk factors), is called nursing diagnosis.

Types of Nursing Diagnoses

The five types of nursing diagnoses are actual, risk,
wellness, possible, and syndrome.
1). 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.
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 2). 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.
3). A wellness diagnosis describes human responses
to levels of wellness in an individual, family or
community that have a readiness for enhancement.
4). A possible nursing diagnosis is one in which
evidence about a health problem is incomplete or
unclear. A possible diagnosis requires more data either
to support or to refute it.
5). Syndrome diagnosis is a diagnosis that is
associated with a cluster of other diagnoses.

The Diagnostic Process

The diagnostic process uses the critical-
thinking skills of analysis and synthesis. Critical
thinking is a cognitive process during which a
person reviews data and considers explanations
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before forming an opinion. Analysis is the
separation into components, that is, the breaking
down of the whole into its parts. Synthesis is the
opposite, that is, the putting together of parts into
the whole. The diagnostic has three steps:
analyzing data, identifying health problems, risks,
and strengths, and formulating diagnostic
statements.

1). Analyzing Data

In the diagnostic process, analyzing
involves the following steps:
Compare data against standards (identify
significant cues).
Cluster cues (generate tentative
hypotheses).
Identify gaps and inconsistencies.

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2).Identifying Health Problems, Risks,
and Strengths.
After data are analyzed, the nurse and
client can together identify strengths and
problems. This is primarily a decision-
making process.
Determining problems and risk
After grouping and clustering the data, the
nurse and client together identify problems that
support tentative actual, risk, and possible
diagnoses. In addition, the nurse must determine
whether the clients problem is a nursing
diagnosis, medical diagnosis, or collaborative
problem.

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Determining strengths
At this stage, the nurse and client also establish
the clients strengths, resources, and abilities to
cope. Most people have a clearer perception of
their problems or weakness than of their
strengths and assets, which they often take for
granted. A clients strengths can be found in the
nursing assessment record (health, home life,
education, recreation, exercise, work, family and
friends, religious beliefs, and sense of humor).

3). Formulating Diagnostic Statements

Most nursing diagnoses are written as
two-part or three-part statements, but
there are variations of these.

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Basic two-part statements
The basic two-part statement includes the
following:
Problem (P): statement of the clients response.
Etiology (E): factors contributing to or probable
cause of the responses.

Basic three-part statements

The basic three-part nursing diagnosis
statement is called the PES format and includes
the following:
Problem (P): statement of the clients response.
Etiology (E): factors contributing to or probable
cause of the responses.
Signs and Symptoms (S): defining
characteristics manifested by the client.

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 ASSESSING
Collect data
Organize data
Validate data

O
Document data

V
DIAGNOSING
Analyze data
Identify health problems, risk, and strengths

E
Formulate diagnostic statements

R
PLANNING
Prioritize problems/diagnoses
Formulate goals/desired outcome

V
Select nursing interventions
Write nursing orders

I IMPLEMENTATION
Reassess the client
Determine the nurses need for assistance

E Implement the nursing interventions

Supervise delegated case
Document nursing activities

W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the clients care plan
 PLANNING PHASE
The third phase of the nursing process, in
which the nurse and client develop client
goals/desired outcomes and nursing interventions
to prevent, reduce, or alleviate the clients health
problems.
Planning is a deliberative, systematic phase of
the nursing process that involves decision making
and problem solving. In planning, the nurse refers
to the clients assessment data and diagnostic
statements for direction in formulating clients
goals and designing the nursing interventions
required to prevent, reduce, or eliminate the
clients health problems. A nursing intervention is
any treatment, based upon clinical judgment and
knowledge that a nurse performs to enhance
patient/client outcomes
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Types of Planning
Planning begins with the first client contact and
continues until the nurse-client relationship ends,
usually when the client is discharges from the
health care agency.
Initial Planning
The nurse perform the admission assessment
usually develops the initial comprehensive plan of
care. This nurse has the benefit of the clients
body language as well as some intuitive kinds of
information that are not available solely from the
written database. Planning should be initiated as
soon as possible after the initial assessment,
especially because of the trend toward shorter
hospital stays.
Ongoing Planning
Is done by all nurses who work with the client.
As nurses obtain new information evaluate the
clients 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.
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 Discharge Planning
The process of anticipating and planning for
needs after discharge, is a crucial part of
comprehensive health care and should be
addressed in each clients care plan.

The Planning Process

In the process of developing client care, the nurse
engages in the following activities:
1). Priority Setting
Is the process of establishing a
preferential sequence for addressing
nursing diagnoses and interventions. The
nurse and client begin planning by
deciding which nursing diagnosis
requires attention first, which second,
and so on. Instead of rank-ordering
diagnoses, nurses can group them as
having high, medium, or low priority.
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Life-threatening problems such as loss of respiratory or
cardiac function are designated as high priority. The
nurse must consider a variety of factors when
assigning priorities, including the following:
Clients health values and beliefs
Clients priorities
Resources available to the nurse and
client
Urgency of the health problem
Medical treatment plan

2). Establishing Client Goals/Desired

Outcomes
After establishing priorities, the nurse
and client set goals for each nursing
diagnosis. On a care plan the
goals/desired outcome describe, in terms
of observable client responses, what the
nurse hopes to achieve by implementing
the nursing interventions.
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The term goal and desired outcome are
used interchangeably in this text, except
when discussing and using standardized
language.

3). Selecting Nursing Interventions

and Activities
Nursing interventions and activities are
the actions that a nurse performs to
achieve client goals. The specific
interventions chosen should focus on
eliminating or reducing the etiology of the
nursing diagnosis, which is the second
clause of the diagnostic statement.
Types of Nursing Interventions
Independent interventions are those activities that
nurses are licensed to initiate on the basis of their
knowledge and skills.
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They include physical care, ongoing assessment,
emotional support and comfort, teaching,
counseling, environmental management, and
making referrals to other health care
professionals.
Dependent interventions are activities carried out
under the physicians orders or supervision, or
according to specified routines.
Collaborative interventions are actions the nurse
carries out in collaboration with other health team
members, such as physical therapist, social
workers, dietitians, and physicians.

Criteria for Choosing Nursing

Interventions
The following criteria can help the nurse to
choose the best nursing interventions. The plan
must be:
- Safe and appropriate for the individuals age,
health, and condition.
- Achievable with the resources available.
- Congruent with the clients values, beliefs, and
culture. MENU
- Congruent with other therapies.
- Based on nursing knowledge and experience or
- knowledge from relevant sciences.
- Within established standards of care as
determined by state laws, professional
associations, and the policies of the institution.

4). Writing Nursing Order

After choosing the appropriate nursing
interventions, the nurse writes them on
the care plan as nursing orders. Nursing
orders are instructions for the specific
individualized activities the nurse
performs to help the client meet
established health care goals. The term
order connotes a sense of accountability
for the nurse who gives the order and for
the nurse who carries it out.
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 ASSESSING
Collect data
Organize data
Validate data

O
Document data

V
DIAGNOSING
Analyze data
Identify health problems, risk, and strengths

E
Formulate diagnostic statements

R
PLANNING
Prioritize problems/diagnoses
Formulate goals/desired outcome

V
Select nursing interventions
Write nursing orders

I IMPLEMENTATION
Reassess the client
Determine the nurses need for assistance

E Implement the nursing interventions

Supervise delegated case
Document nursing activities

W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the clients care plan
IMPLEMENTATION PHASE
The methods by which the goal will be
achieved are also recorded at this stage.
The methods of implementation must be
recorded in an explicit and tangible
format in a way that the patient can
understand should he wish to read it.
Clarity is essential as it will aid
communication between those tasked
with carrying out patient care.
Implementing consists of doing and
documenting the activities that are
specific nursing actions needed to carry
out the interventions that were developed
in the planning step and then concludes
the implementing step by recording
nursing activities and the resulting client
responses.
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Implementing Skills
To implement the care plan successfully, nurses
need cognitive, interpersonal, and technical skills.
These skills are distinct from one another; in
practice, however, nurses use them in various
combinations and with different emphasis,
depending on the activity. Having these skills
contributes to the greater improvement of the
nurse's delivery of health care to the patient,
including the patient's level of health, or health
status.

Cognitive or Intellectual Skills, such as analyzing

the problem, problem solving, critical thinking and
making judgments regarding the patient's needs.
Included in these skills are the ability to identify,
differentiate actual and potential health problems
through observation and decision making by
synthesizing nursing knowledge previously
acquired.
Interpersonal Skills, which includes therapeutic
communication, active listening, conveying
knowledge and information, developing trust or
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rapport-building with the patient, and ethically
obtaining needed and relevant information from
the patient which is then to be utilized in health
problem formulation and analysis.
Technical Skills, which includes knowledge and
skills needed to properly and safely manipulate
and handle appropriate equipment needed by the
patient in performing medical or diagnostic
procedures, such as vital signs, and medication
administrations.

Process of Implementing
The process of implementing normally
includes:
1). Reassessing the Client
Just before implementing an
intervention, the nurse must reassess the
client to make sure the intervention is still
needed. Even though an order is written
on the care plan, the clients condition
may have changed.
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2). Determining the Nurses Need for
Assistance
When implementing some nursing
interventions, the nurse may require
assistance for one of the following
reasons:
-The nurse is unable to implement the
nursing activity safely alone (e.g.,
ambulating an unsteady obese client).
-Assistance would reduce stress on the
client (e.g., turning a person who
experiences acute pain when moved).
-The nurse lacks the knowledge skills to
implement a particular nursing activity
(e.g., a nurse who is not familiar with a
particular model of traction equipment
needs assistance the first time it is
applied). MENU
3). Implementing the Nursing
Interventions
It is important to explain to the client what
interventions will be done, what
sensations to expect, what the client is
expected to do, and what the expected
outcome is. For many nursing activities it
is important to ensure the clients privacy,
for example by closing doors, pulling
curtains, or draping the client. When
implementing interventions, nurses
should follow these guidelines:
-Base nursing interventions on scientific
knowledge, nursing research, and professional
standards of care whenever possible.
-Clearly understand the orders to be implemented
and question any that are not understood.
-Adapt activities to the individual client.
-Implement safe care.
-Provide teaching, support, and comfort.
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-Be holistic.
-Respect dignity of the client and enhance the
clients self-esteem.
-Encourage clients to participate actively in
implementing the nursing interventions.

4). Supervising Delegated Care

If care has been delegated to other
health care personnel, the nurse
responsible for the clients overall care
must ensure that the activities have been
implemented according to the care plan.
Other caregivers may be required to
communicate their activities to the nurse
by documenting them on the client
record, reporting verbally, or filling out a
written form. The nurse validates and
responds to any adverse findings or
client responses. MENU
5). Documenting Nursing Activities
After carrying out the nursing activities,
the nurse completes the implementing
phase by recording the interventions and
client responses in the nursing progress
notes. These are a part of the agencys
permanent record for the client. Nursing
care must not be recorded in advance
because the nurse may determine on
reassessment of the client that the
intervention should not or cannot be
implemented.

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 ASSESSING
Collect data
Organize data
Validate data

O
Document data

V
DIAGNOSING
Analyze data
Identify health problems, risk, and strengths

E
Formulate diagnostic statements

R
PLANNING
Prioritize problems/diagnoses
Formulate goals/desired outcome

V
Select nursing interventions
Write nursing orders

I IMPLEMENTATION
Reassess the client
Determine the nurses need for assistance

E Implement the nursing interventions

Supervise delegated case
Document nursing activities

W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the clients care plan
 EVALUATION PHASE
To evaluate is to judge or to appraise.
Evaluating is a planned, ongoing, purposely
activity in which clients and health care
professionals determine (a) the clients progress
toward achievement of goals/outcomes and (b)
the effectiveness of the nursing care plan. The
purpose of this stage is to evaluate progress
toward the goals identified in the previous stages.
If progress towards the goal is slow, or if
regression has occurred, the nurse must change
the plan of care accordingly. Conversely, if the
goal has been achieved then the care can cease.
New problems may be identified at this stage,
and thus the process will start all over again. It is
due to this stage that measurable goals must be
set - failure to set measurable goals will result in
poor evaluations. The entire process is recorded
or documented in an agreed format in the
patient's care plan in order to allow all members
of the nursing team to perform the agreed care
and make additions or changes where
appropriate.
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Process of Evaluating Client
Responses
Before evaluation, the nurse identifies
the desired outcomes (indicators) that
will be used to measure client goal
achievement. Desired outcomes serve
two purposes: they establish the kind of
evaluative data that needed to be
collected and provide a standard against
which the data are judged. The
evaluation process has five components:

1). Collecting Data

Using the clearly stated, precise, and
measurable desired outcomes as a
guide, the nurse collects data so that
conclusions can be drawn about whether
the goals have been met. It is usually
necessary to collect both objective and
subjective data. MENU
2). Comparing Data with Outcomes
If the first two parts of the evaluation
process have been carried out
effectively, it is relatively simple to
determine whether a desired outcome
has been met. Both the nurse and the
client play an active role in comparing
clients actual responses with the desired
outcomes. After determining whether a
goal has been met, the nurse writes an
evaluative statement (either on the care
plan or in the nurses notes). An
evaluation statement consists of two
parts: a conclusion (is a statement that
the goal/desired outcomes was met,
partially met, or not met), and supporting
data (are the list of client responses that
support the conclusion). MENU
3). Relating Nursing Activities to
Outcomes
The fourth aspect of the evaluating
process is determining whether the
nursing activities had any relation to the
outcomes. It should never be assumed
that a nursing activity was the cause of or
the only factor in meeting, partially
meeting, or not meeting a goal.
4). Drawing Conclusions about
Problem Status
The nurse uses the judgments about
goal achievement to determine whether
the care plan was effective in resolving,
reducing, or preventing client problems.
When goals have been met, the nurse
can draw one of the following
conclusions about the status of the
clients problem: MENU
-The actual problem stated in the nursing
diagnosis has been resolved; or potential problem
is being prevented and the risk factors no longer
exist. In these instances, the nurse documents
that the goals have been met and discontinues
the care for the problem.
-The potential problem stated in the nursing
diagnosis is being prevented, but the risk factors
are still present. In this case, the nurse keeps the
problem on the care plan.
-The actual problem still exists even though some
goals are being met. The nursing interventions
must be continued.

5). Continuing, Modifying, and

Terminating the Nursing Care Plan
After drawing conclusions about the
status of the clients problems, the nurse
modifies the care plan as indicated.
Depending on the agency, modifications
may be made by drawing a line through
proportions of the care plan,
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or marking portions using a highlighting
pen, or writing Discontinued (dcd) and
the date. Whether or not goals were met,
a number of decisions need to be made
about continuing, modifying, or
terminating nursing care for each
problem. Before making individual
modifications, the nurse must first
determine why the plan as a whole was
not completely effective. This requires a
review of the entire care plan and a
critique of the nursing process steps
involved in its development for a
checklist to use when reviewing a care
plan.
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Evaluating the Quality of Nursing Care
In addition to evaluating goal achievement for
individual clients, nurses are also involved in
evaluating and modifying the overall quality of
care given to groups of clients. This is an
essential part of professional accountability.

Quality Assurance
A quality-assurance (QA) program is an ongoing,
systematic process designed to evaluate and
promote excellence in the health care provided to
clients. Quality assurance frequently refers to
evaluation of the level of care provided in a health
care agency, but it may be limited to the
evaluation of the performance of one nurse or
more broadly involve the evaluation of the quality
of the care in an agency, or even in a country. It
consists of three components of care: the
structure evaluation (focuses on the setting in
which care is given. It answers this question:
what effect does the setting have on the quality of
care?), the process evaluation (focuses on how
the care was given.
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It answers question such as these: Is the care
relevant to the clients needs? Is the care
appropriate, complete and timely?), and outcome
evaluation (focuses on demonstrable changes in
the clients health status as a result of nursing
care. Outcome criteria are written in terms of
client responses or health status.

Quality Improvement
Quality improvement (QI) is also known as
continuous quality improvement (CQI), total
quality management (TQM), performance
improvement (PI), or persistent quality
improvement (PQI)

Nursing Audit
An audit means the examination or review of
records. A retrospective audit is the evaluation of
a clients record after discharge from an agency.
Retrospective means relating to past events.
These evaluations use interviewing, direct
observation of nursing care, and review of clinical
records to determine whether specific evaluative
criteria have been met.
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