Fundamental of Nursing

Unit-1 Nursing Process

Semester-II

FACULTY: SHAHNAWAZ SHAHOK ( CLINICAL NURSING INSTRUCTOR )

GLOBAL COLLEGE OF NURSING HYDERABAD
UNIT: I
NURSING PROCESS:
OBJECTIVES:
 Define nursing process.
 Describe purpose of nursing process
 Identify components of nursing process.
 Describe assessment phase of nursing process.
 Discuss purpose of assessment in nursing practice.
 Three major activities involved in assessment.
 Describe process of data collection.
 Define nursing diagnosis.
 Describe components of nursing diagnosis.
 Difference between nursing diagnosis and medical diagnosis.
 Formulate nursing diagnosis according to NANDA list.
 Define planning
 Purpose of planning.
 Define implementation and evaluation.
 Purpose of implementation and evaluation
 NURSING PROCESS:
Systematic problem-solving method by which nurses
individualize care for each client.
 Systematic method in which the nurse and client work
together to plan and carry out effective nursing care.
 An organized sequence of steps used to identify health
problems and to manage client care.
 Goal of Nursing Process:

To identify a client’s health status, his Actual/Present and

potential/possible health problems or needs.
 To establish a plan of care to meet identified needs.
 To provide nursing interventions to meet those needs
 Deliver specific nursing interventions to meet those needs
 To provide an individualized, effective and efficient
nursing care.
Benefits of the Nursing Process:

 Speed up diagnosis and treatment of actual and

potential health problems, reducing the
incidence of hospital stays;
 Improve communication; prevent errors, omissions,
and unnecessary repetitions
 Promotes independent thinking ;
 Helps nurses to gain satisfaction of getting results.
 Components of Nursing Process:

There are 5 components of Nursing Process which are:

1. A-Assessment (what data is collected?)
2. D-Diagnosis (what is the problem?)
3. P-Planning ((how to manage the problem)
4. I-Implementing (putting plan into action)
5. E-Evaluating (did the plan work?)
1-Assessment:
It is systematic and continuous collection, validation and
communication of
client data as compared to what is standard/norm.

Purpose:
 To establish baseline information on the client
 To determine the client’s normal function
 To determine the client’s risk for dysfunction
 To determine the client’s strengths
 To provide data for the diagnosis phase.
Types of Assessment:
1. Initial assessment: assessment performed within a specified time on
admission
 e.g. nursing admission assessment
2. Problem-focused assessment: use to determine status of a specific
problem identified in an earlier assessment
 e.g. problem on urination-assess on fluid intake & urine output
hourly
3. Emergency assessment: rapid assessment done during any
physiologic/physiologic
crisis of the client to identify life threatening problems.
 e.g. assessment of a client’s airway, breathing status & circulation
after a cardiac arrest.
4. Time-lapsed assessment: reassessment of client’s functional health
pattern done several months after initial assessment to compare the
client’s current status to baseline data previously obtained.
Assessment Skills:
1. Interview
2. Observation
3. physical Examination

Modes of Physical Examination:

 Inspection(sight)
 Palpation(touch)
 Percussion(tapping)
 Auscultation(hear by stethoscope)

Assessment Activities:
The activities that make up the assessment are the following:
 Validating Data: is the act of “double-checking” or verifying data to confirm that it is accurate
and factual.
 Documenting Communicate/Record Data:
 nurse records all data collected about the client’s health status
 Organizing The Data: Data must be organized.
 Data clustering is the process of putting the data together in order to identify areas of the client’s
problems and strengths
 2:Collection of Data.
 Collection of Data:
 Gathering of information about the client.
Types of Data
Subjective data:
 Also referred to as Symptom/Covert data
 Include feelings, perceptions, and concerns obtained through interviews with
the client.
 Example: pain, dizziness, ringing of ears. “I am the father of two boys.
“I paint houses for a living.
Objective data
 Also referred to as Sign/Overt
 Data that are obtained through observation, standard assessment techniques
performed
during the physical examination, and laboratory and diagnostic testing.
 Example: BP=150/100, yellow discoloration of skin.
 Client is 5 feet 10 inches and weighs 204 pounds.
Source of Data
Primary source: data directly gathered from the client using interview and
physical examination.
 Usually BEST source
2. 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.

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.
Physical Examination
 Systematic data collection to detect health problems
using unit of measurements, physical examination
techniques, laboratory results.
 Should be conducted systematically
 Head-to-toe assessment
 Examine all the body system
 Examine only particular area affected.
Nursing Health History:
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.

Components of A Nursing Health History:

 Biographic data: name, address, age, sex, marital status, occupation, religion.
 Reason for visit/Chief complaint: primary reason why client seek consultation or
hospitalization.
 History of present Illness: includes: usual health status, chronological story, disability
assessment.
 Past Health History: includes all previous immunizations, experiences with illness.
 Family History: reveals risk factors for certain disease diseases (Diabetes, hypertension,
cancer, mental illness).
 Review of systems :review of all health problems by body systems
 Lifestyle: include personal habits, diets, sleep or rest patterns, activities of daily
living, recreation or hobbies.
 Social data: include family relationships, and educational background, economic
status, home and neighborhood conditions.
 Psychological data: information about the client’s emotional state.
 Pattern of health care: includes all health care resources: hospitals, clinics, health centers,
family doctors.
3-Nursing Diagnosis:
Diagnosis is the science and art of identifying problems or
conditions.
 Second step of the Nursing Process
 According to North American Nursing Diagnosis Association
(NANDA) :
 "A clinical judgment about individual, family or community
responses to actual and
potential health problems/ life processes."
 A method of identifying patient problems that can be treated
with nursing care

Purpose:
 Identify client strengths
 Identify health problems that can be prevented or resolved
Components of A Nursing Diagnosis (PES Or PE)

1. P= Problem statement/diagnostic label:

statement that describes the health problem of the patient clearly
& concisely.
2. E=Etiology/related factors/causes:
The reason (etiology) that identifies the physiological,
psychological, social, & environmental factors related to the
problem.
3. S=Defining characteristics/signs and symptoms:
The subjective & objective data that signal the existence of the
problem.
DIFFRENECE BETWEEN NURSING AND MEDICAL DIAGNOSIS:
MEDICAL DIAGNOSIS NURSING DIAGNOSIS

Focuses on the responses to actual or potential health

Focuses on curing pathology
problems or life processes

Changes as the client’s response and/or the health

Remains constant until a cure is effected.
problem changes.

Stays the same as long as the disease is present Can change from day to day

Within the scope of medical practice

Within the scope of nursing practice
Types of Nursing Diagnosis

1. Actual Diagnosis
2. Risk Diagnosis
3. Wellness Diagnosis
4. Possible Diagnosis
5. Syndrome Diagnosis
1. Actual Diagnosis:
Problem presents at the time of the assessment
Presence of associated signs and symptoms
e.g. (ineffective breathing pattern)
Patient problem + Etiology – replace the (+) symbol with the words
“RELATED
TO” abbreviated as r/t.
Problem + Etiology + S/S
2. Risk Diagnosis:
Problem does not exist
Presence of risk factors
e.g. (High risk for complication)
Problem + Risk Factors
3. Wellness Diagnosis:
 Readiness for enhancement (improvement)
 Describes human responses to levels of wellness in an
individual, family, or
community that have a readiness enhancement.”

4. Possible Diagnosis:

 Evidence about a health problem incomplete or unclear
 Requires more data to either support or to refute it
 (possible social isolation)
 Problem + Etiology

5. Syndrome Diagnosis:

 Associated with a cluster of other diagnoses
 (risk for disuse syndrome)
 Formats for Nursing Diagnoses:

 Problem Statement (Diagnostic Label):

 Describes the client’s health problem or response
Two-part statement
 Problem (P)
 Etiology (E)
Three-part statement:

Third part linked to the first two by the

term as evidenced by (AEB) or AMB.
Problem (P)
Etiology (E)
Signs and symptoms (S)
 3-Planning:
 Third step of the Nursing Process
 This is when the nurse organizes a nursing care plan based on
the nursing diagnoses.
 Determine how to prevent or reduce client problem
 Determine how to support client strength

 Purpose:

 Develop an individualized care plan that specifies client

goals/desired outcomes
 Related nursing intervention
 Determine goals of care /case of actions.
 Promote continuity of care .
Activities Of Planning Phase (Or Step);

 Establish priorities.
 Identify expected patient outcome.
 Select evidence- based nursing intervention.
 Communicate the plan of care.

Goals Must Be:

SMART:
 Specific: What needs to be accomplished?
 Measurable: How will we know when the goal has been met?
 Attainable: Possible to meet goal with available resources.
 Relevant or Realistic: Patient must have the capacity to meet the goal.
 Time Bound: When will the goal be achieved?
Stages of Planning;

 Initial planning: is developed by the nurse, who

performs the admission nursing history and the physical
assessment.
 Ongoing planning: continuous updating of the client’s
plan of care. Every nurse who cares for the client is involved
in ongoing planning.
 Discharge planning: is best carried out by the nurse,
who has worked most closely with patient and family.
 Planning for the client’s needs after discharge.
4-Implementation:

 The fourth step in the Nursing Process in which planned

nursing actions are carried out and documented.
 This is the “Doing” step.
 Carrying out nursing interventions (orders) selected during
the planning step
 Any treatment, based upon clinical judgment and
knowledge that a nurse performs to enhance(improve) client
outcomes
Types:
• Direct care: is an intervention performed through interaction with the
client.
• Indirect care: is an intervention performed away from but on behalf
of the client such as management of the care environment.
• Independent ( Nurse initiated )- any action the nurse can initiate
without direct supervision
• Dependent ( Physician initiated )-nursing actions requiring MD
orders
• Collaborative- nursing actions performed jointly with other health
care team members Carrying out (or delegating) and documenting
planned nursing interventions.
Purpose:

Assist the client to meet desired goals/outcomes

Promote wellness
Prevent illness and disease
Restore health
Facilitate coping with altered functioning.
Clinical Skill in Implementation:

 (Cognitive Skills) Knowledge – include intellectual skills

like problem-solving, decision-making and teaching.
 Technical skills – to carry out treatment and procedures.
 Communication skills – use of verbal and non-verbal
communication to carry out planned nursing interventions.
 Therapeutic use of self – is being willing and being able to
care.
 5-Evaluation:

 Judgment of effectiveness of nursing care to meet client goals

based on client behavioral response.
 Measuring the degree to which goals/outcomes have been
achieved
 Identifying factors that positively or negatively influence goal
achievement.
 It is continual process
Purpose:
 Determine whether to continue, modify, or terminate the plan of
care.
 Determines whether client goals have been met, partially met, or
not met.
Difference between Assessment and Evaluation
 During the assessment phase the nurse collects data for
the purpose of making diagnoses.
 During the evaluation step the nurse collects data for the
purpose of comparing the data to preselected goals and
judging the effectiveness of the nursing care.
 Critical Thinking:

 Reasonable reflective thinking that is focused on deciding what to Believe or do.

 Critical thinking can be defined as "the process of thinking of possible
explanations for outcomes and findings, and determining how compatible the
possible explanations are with the outcomes and findings."
 A person who demonstrates significant critical thinking is thinking like a
scientist.
 Critical thinking is a skill that can be taught and improves with practice.
 Components:
Critical thinking is composed of three primary components:
1. Mental operations.
2. knowledge
3. Attitudes.
Critical Thinking Skills:
 Interpretation: Categorize, decode(make sense of) sentences, clarify meanings
 Analysis: Examine ideas, identify and analyze arguments
 Influence :Query(question) evidence (proof), draw conclusions
 Explanation: State results, justify procedures, present arguments(opinion, point
of view)
 Evaluation: Assess claims, assess arguments
 Self-regulation: Self-examination, self-correction (if necessary)
 Characteristics of Critical Thinking:
 RATIONAL & REFLECTION :
It is rational (based on reason) & reflective.
 HEALTHY , CONSTRUCTIVE SKEPTICISM;
It involves healthy constructive (positive helpful beneficial) skepticism (disbelief or
doubt).
 AUTONOMY:
It is autonomous.
 CREATIVE THINKING:
It includes creative thinking.
 FAIR THINKING ;
It is fair thinking.
 FOCUS ON WHAT TO BELIEVE AND DO:
It focuses on what to believe & do
SKILLS USED IN CRITICAL THINKING

 Critical analysis
 Reasoning inductively
 Reasoning deductively
 Making valid inferences
 Differentiating fact from opinion
 Evaluating the credibility of info sources
 Clarifying concepts
 Recognizing assumptions
Identify the three major factors that affect
thinking
EDUCATION & COMPREHENSION
ENVIRONMENT PROVIDED
ANXIETYs
Attitude
Level of preparation
Learning style
Intellectual development
Formula For Critical Thinking:

Start Thinking
 Why Ask Why
 Ask the Right Questions
 Are you an expert?
 Importance Of Critical Thinking In Nursing:
 Critical thinking skill is considered as one of the important skills in nursing field.
Nurses are frequently facing the complex situation.
 Critical thinking Provide Expert Patient Care.
 Critical thinking in nursing is an essential component of professional accountability and
quality nursing care
 Critical thinking skills can help nurses apply the process of examination.
 Nurses through critical thinking skills can question, evaluate, and reconstruct the nursing
care process it can help nurse problem solve, reflect, and make a conclusive decision
about the current situation they face.
 Critical thinking creates "new possibilities for the development of the nursing
knowledge.
 Nurses work in rapidly changing situations. Treatments, medications, and technology
change constantly, and a client's condition may change from minute to minute. Routine
actions may therefore not be adequate to deal with the situation at hand. Critical thinking
enables the nurse to recognize important cues(signal for actions), respond quickly, and
adapt interventions to meet specific client needs.
 They need to have critical thinking skill to analyze situation, to provide some alternative,
to consider some other ideas, to develop the make the important decision