2. NURSING PROCESS
“ A Systematic method of providing
Nursing care”
• It provides a framework for planning
and implementing Nursing care.
• This involves a problem-solving
approach that enables the nurse to
identify patient problems and potential
at-risk needs (problems) and to plan,
deliver, and evaluate nursing care in an
orderly, scientific manner.

3. Components of nursing process:
The nursing process consists of five dynamic
and interrelated phases:
1. assessment
2. diagnosis
3. planning
4. implementation
5. evaluation.

4. How the nursing process applies to the
scientific method
Scientific method Nursing process
State an observed problem Assessment
Form a hypothesis about the Nursing diagnosis
problem
Develop a method to test the Outcome Identification and
hypothesis Planning
Collect the data Implementation
Analyze the data
Draw conclusions about the Evaluation
hypothesis
4

5. Assessment
Assessment involves the systemic collection of
Patient data.(collect data, validate data,
organize data, document data)
Data Collection
( subjective &objective data)
• Nursing history( Biographic data, current
physical &emotional complaints, past medical
history, past and current ability to perform
ADL’S, socio-economic factors)
• Physical Assessment.
• Review of lab &Diagnostic test results.
• Review other available Health Information.

6. Validation of data
The information gathered during the assessment
phase must be complete, factual, and accurate
Because the nursing diagnosis interventions are
based on this information.
Validation is the act of "double-checking“ or
verifying data to confirm that it is accurate
and factual.
Organization of data
The nurse uses a written or computerized format
that organizes the assessment data
systematically. The format may be modified
according to the client's physical status.

7. Documenting data:
To complete the assessment phase, the nurse
records client's data.
Accurate documentation is essential and should
include all data collected about the client's
health status. Data are recorded in a factual
manner and not interpreted by the nurse.
E.g.: the nurse record the client's
breakfast intake as" coffee 240 ml. Juice 120 ml, 1
egg". Rather than as "appetite good".

8. PURPOSE OF ASSESSMENT:
• To validate a diagnosis
• To provide basis for effective nursing
care.
• It helps in effective decision making
• Basis for accurate diagnosis
• It promote holistic nursing care
• To provide effective and innovative
nursing care
• To collecting data for nursing research
• To evaluation of nursing care

9. TYPES OF ASSESSMENT
Type Aim Time frame
1- Initial assessment Initial identification of normal Within the specified time
function, functional status, and frame after admission to a
collection of data concerning hospital, nursing home,
actual or potential dysfunction. ambulatory healthcare center.
Baseline for reference and
future comparison.
2- Focus assessment Status determination of a Ongoing process, integrated
specific problem identified with nursing care, a few
during previous assessment. minutes to a few hours
between assessments.
Comparison of client’s current Several months (3,6,9 months
3- Time – lapsed status to baseline obtained or more) between assessment
reassessment previously, detection of
changes in all functional health
patterns after an extended
period of time has passed
Identification of life – AT anytime
4- Emergency threatening situation
assessment

10. NURSING DIAGNOSIS
Nursing diagnosis is a clinical judgment about
individual, family, or community responses to
actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection of
nursing interventions to achieve outcomes for
which the nurse is accountable (NANDA, 1997).
Steps:
Each Nursing Diagnosis has three components:
*Label an actual or potential health problems that
Nursing care can affect.
*Related factors- Factors that may precede,
contribute to or be associated with the human
response.
*Evidence – Signs symptoms that point to the Nursing
Diagnosis.

11. TYPES OF NURSING DIAGNOSIS
• Actual Diagnosis: An actual diagnosis is a
statement about a health problem that the
client has, and could benefit from nursing care.
An example of an actual nursing diagnosis is:
---Ineffective airway clearance related to
decreased energy and manifested by an
ineffective cough.
• A risk diagnosis is a statement about a health
problem that the client doesn't have yet, but is
at a higher than normal risk of developing in the
near future. An example of a risk diagnosis is:
---Risk for injury related to altered mobility and
disorientation.

12. While walking Mrs. Lin to the bathroom, she
complains of dizziness:
• Ask her if the dizziness is related to an activity
• Take her blood pressure in lying and standing
positions
• Determine what interventions will reduce her
dizziness
• Later, in the day, check with her if additional
episodes have occurred
• Teach her to change her position slowly
• Formulate the nursing diagnosis “High Risk for
Injury related to vertigo secondary to postural
hypotension”

13. • A complete nursing diagnosis is written in
the format problem related to cause of
problem as evidenced by symptoms of
problem
• An example of such a nursing diagnosis
would be Impaired gas exchange related to
excessive secretions as evidenced by O2
saturation of 86%.

15. NURSING PLANNING
The third step of the nursing process; includes
the formulation of guidelines that establish
the proposed course of nursing action in the
resolution of nursing diagnoses and the
development of the client’s plan of care.
The planning of nursing care occurs in three
phases:
(initial, ongoing, and discharge.)
Each type of planning contributes to the
coordination of the client’s comprehensive
plan of care.

16. The four critical elements of planning
1.Establishing priorities.
In establishing priorities,
the nurse examines the
client’s nursing
diagnoses and ranks
them in order of
physiological or
psychological
importance.
One of the most common
methods of selecting
priorities is the
consideration of Maslow’s
hierarchy of needs, which
requires that a life-
threatening diagnosis be
given more urgency than a
non life threatening
diagnosis.

18. 2.Setting goals and developing expected
outcomes
A goal is a specific and measurable objective
designed to reflect the patient highest level
of wellness and independence in function.
There are 2 categories in goals.
• Short term – Can be met fairly and quickly
(hours or days)
• Long term – cover a long time span
e.g.
The patient will be free of infection throughout
hospitalization.

19. 3. Developing Expected outcomes
Expected outcome define when a patient
goal has been met and assist in evaluating
the extent to which the Nursing diagnosis
has been resolved.
e.g.
Goal : The patient lung will remain clear post
operatively .
Expected outcomes:
- The sputum will remain white
- The patient will remain afebrile
- The lungs will be clear to auscultation

21. 4.Planning nursing interventions (with
collaboration and consultation as needed)
Nursing interventions are treatment, based
upon clinical judgment and knowledge that a
nurse performs to enhance patient / client
outcomes.
Dependent – a nursing action based on the
instruction of another professional.
Independent – requires no supervision.
Interdependent – actions carried out by the
nurse in collaboration with another health
care professional.
• Nursing interventions must be specifically
designed to meet the identified goal.
• Each intervention should be supported by a
scientific rationale.

23. IMPLEMENTATION
While implementing nursing orders, the
nurse continues to reassess the client at
every contact, gathering data about the
client’s responses to nursing activities and
about any new problems that may develop.
To implement the care plan successfully,
nurses need cognitive, interpersonal, and
technical skills. These skills are distinct
from one another.
The cognitive skills (intellectual skills) include
problem solving, decision making, critical
thinking, and creativity.

24. 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 order to be implemented and
question any that are not understood.
• Adapt activities to the individual client, a client’s beliefs,
values; age, health status, and environment are factors
that can affect the success of a nursing action.
• Implement safe care
• Provide teaching, support and comfort to enhance the
effectiveness of nursing care plans.
• Be holistic; view the client as a whole.
• Respect the dignity of the client and enhance the client’s
self- esteem
• Encourage client to participate actively in implementing
the nursing interventions.

25. Documenting Nursing Activities,
• the nurse complete the implementing phase
by recording the interventions and client
responses in the nursing process notes.
• The nurse may record routine or recurring
activities such as mouth care in the client
record at the end of shift, while some
actions recorded in special worksheets
according to agency policy.
• Immediate recording helps safeguard the
client to prevent double actions.

26. EVALUATION
• The last phase of the nursing process, follows
implementation of the plan of care, it’s the
judgment of the effectiveness of nursing care to
meet client goals based on the client’s behavioral
responses.
When determining whether a goal has been achieved,
the nurse can draw one of the three possible
conclusions:
– The goal was met, that is the client response is
the same as the desired outcomes.
– The goal was partially met, that is either a short
term goal was achieved but the long term was
not, or the desired outcome was only partially
attained.
– The goal was not met.

27. “When goals have been partially met or when
goals have not been met, two conclusions
may be drawn:
• The care plan may need to be revised,
since the problem is only partially
resolved
OR
• The care plan does not need revision,
because the client merely needs more
time to achieve the previously
established goals.
• So the nurse must reassess why the
goals are not being partially achieved.

28. APPENDECTOMY
Client assessment database:
Activity & rest: May report Malaise
Circulation: may exhibit Tachycardia
Elimination: May report Constipation of recent onset of diarrhea
Abdominal distension, tenderness/
rebound tenderness, rigidity, decreased
May exhibit or absent bowel sound .
Food/fluid : may report Anorexia , nausea , Vomiting
Pain/ Discomfort : May report Abdominal pain around the epigastrium
and umbilicus, which may have an
insidious onset and become
increasingly severe (RLQ) at mc Burney’s
point.
Respiration: May exhibit Tachypnea, Shallow respirations

29. Diagnostic studies:
• CBC: WBC s are often elevated,
neutrophil count elevated
• Abdominal CT, USG, Abdominal
radiographs.
Nursing Priorities:
• Prevent complication
• Promote comfort
• Provide information about surgical
procedure/prognosis, treatment needs, and
potential complications.

30. Discharge Goals:
• Complication prevented / minimized
• Pain alleviated/controlled
• Surgical procedure/ prognosis , treatment
understood.

31. Nursing Diagnosis: Risk For infection
Outcome criteria: wound healing
Actions/ Interventions Rationale
Independent
Practice / instruct in good hand Reduces the risk of spread of bacteria
washing and aseptic wound care.
Encourage and provide perineal care
Inspect Incision and dressings. Note Provides for early detection of
characteristics of drainage from developing infectious process.
wound/drains, presence of erythema
Monitor vital signs . Note if fever, Suggestive of presence of infection/
chills diaphoresis, changes in developing sepsis, abscess, peritonitis
mentation , report if increase
abdominal pain.
Collaborative
Administer antibiotic as appropriate Antibiotics given before
appendectomy primarily for
prophylaxis of wound infection and
continued post operatively

32. Nursing Diagnosis: Risk For deficient fluid volume
Outcome criteria: hydration(Maintain adequate fluid balance as evidenced by
moist mucous membrane, good skin turgor, stable vital signs, adequate
urine output.
Action/Intervention Rationale
Independent
Monitor Vital signs Variations help identify intra vascular
volume.
Inspect mucous membrane ; assess skin Indicators adequacy of peripheral
turgor and capillary refill. circulation and cellular hydration.
Monitor I&O; note urine color Decreasing output concentrated urine
concentration, specific gravity. with increasing specific gravity suggests
dehydration.
Auscultate bowel sounds. Note passing Indicators return of peristalsis , readiness
flatus , bowel movement to begin oral intake
Provide clear liquids in small amounts Reduces the risk of gastric irritation/
,when oral resumed vomiting and fluid loss
Give frequent mouth care with special Dehydration results in drying & painful
care to protect lips cracking of lips and mouth

33. Collaborative
Maintain gastric / intestinal suction as To decompress the bowel, promote
indicated intestinal rest, and prevent vomiting
Administer IV fluids and electrolytes The peritoneum reacts to irritation/
infection by producing large amount of
intestinal fluid , possibly reducing
circulating blood volume, resulting in
dehydration and relative electrolyte
imbalances.
Nursing Diagnosis: Acute pain related to inflammation / presence of surgical
incision.
Outcome criteria: report pain relieved / minimized
Actions/ interventions Rationale
Pain management
Independent
Assess pain, noting location, Use full in monitoring effectiveness of
characteristics, severity (0-10 scale) medication, progression of healing.
Changes in characteristics of pain may
indicate developing abscess/peritonitis
require medical evaluation and
interventions

34. Provide accurate , honest information Being informed about progress of
to client situation provides emotional support,
helping to decrease anxiety
Keep at rest in semi fowler's position Relieving abdominal tension, which is
accentuated by supine position.
Encourage early ambulation Promotes normalization of organ
function
Provide diversional activities. Refocuses attention , promotes
relaxation.
Collaborative
Keep NPO/Maintain NG suction initially Decreases the discomfort of early
intestinal peristalsis and gastric
irritation/vomiting
Administer analgesics as indicated Relief of pain facilitates cooperation
with other therapeutic interventions
e.g. ambulation , pulmonary toilet.

35. Nursing Diagnosis: Deficient Knowledge ( regarding condition, prognosis,
treatment, self care, and discharge needs.)
Outcome criteria: Verbalization of understandings
Independent
Teaching disease process
Identify symptoms requiring medical Prompt interventions reduces risk of
evaluation e.g. increasing pain, edema/ serious complications e.g. delayed
erythema around wound , presence of wound healing, peritonitis
drainage, fever
Review post operative activity Provides information client to plan for
restrictions, e.g. heavy lifting, exercise, return usual routines.
sports, driving
Encourage progressive activities as Prevent fatigue, promotes healing and
tolerated with periodic rest periods well being
Discuss the care of incision , including Understanding promotes cooperation
dressing changes, bathing restrictions, with therapeutic regimen, enhancing
and return to physician. healing and recovery process.