Steps in nursing process, Specific to the nursing profession A framework for critical thinking It’s purpose is to: “Diagnose and treat human responses to actual or potential health problems”

1. Mrs. Puvaneswari Ramesh
Associate Professor
NHCON , Bangalore
Steps in Nursing Process

2. Introduction
IMPLEMENTATION
PLANNING AND
OUTCOME IDENTIFICATION
NURSING DIAGNOSIS
ASSESSMENT
EVALUATION

3. Nursing Assessment
It is the deliberate and systematic
collection of information about a patient to determine
his or her current and past health and functional status
and his or her present and past coping patterns.
(Carpenito – Moyet‐ 2009)

4. Purposes of Assessment
To establish a database
To identify health‐promoting behaviors
To identify actual and/or potential health problems.

5. Types of nursing assessments
Ongoing
Comprehensive
Focused

6. Knowledge
Communication
Objectivity
Observation
ResourcesMeasurements
Procedures
&
Techniques
SKILLS INSKILLS IN
ASSESSMENTASSESSMENT

7. Steps in Nursing Assessment
STEPS 1.Collecting
data
2.Validating
data
3.Organizing
data
4.Interpreting
data
5.Documenting
data

8. Collecting Data

9. Sources of Assessment of Data

10. Subjective
data
• Itching
• Pain
• Feelings
• Perceptions
Types of dataTypes of data
Objective
data
• Discoloration of
skin
• Changes in
vital sign

11. Approaches for data collection
Gordon’s 11 Functional Health Patterns
Uses a series of questions which assist in formulating a
nursing diagnosis
Problem focused assessment
Focuses on the patient’s problem and develop the
plan of care around the problem

12. Gordon’s health patterns
Health perception‐
management
Nutritional‐metabolic
Elimination
Activity‐exercise
Sleep‐rest
Cognitive ‐perceptual
Self‐perception‐self‐
concept
Role‐relationship
Sexuality‐reproductive
Coping‐stress‐tolerance
Value‐belief

13. Framework for assessment
(Activities of living framework devised by Roper et al.) (2008)
Maintaining a safe
environment
Communicating Breathing
Eating and drinking Eliminating Personal cleansing
and dressing
Controlling body
temperature
Expressing sexuality Working and playing
Mobilising Sleeping Dying

14. Methods of Data Collection
Interview
Observation
History collection
Physical Examination
Results of Lab and Diagnostic tests.

15. Initiated for specific purpose and focused on a
Specific Content
Objectives of Interview
Establish Therapeutic Relationship
Cues for in‐depth investigation
Establish Nurses sense of caring
Introduce the facility in a non threatening manner
Obtain History and Identify Health Needs
1. Interview

16. 2.Observation
It is defined as a deliberate search carried out
with care and forethought ( Virginia Henderson)
PRINCIPLES
Depends on knowledge and past
experiences
Purposeful
Systematic
Baseline observation serve for future comparison

17. Biological information
Present illness
Past health history
Family history
Environmental history
Components
Reason for seeking health care
Psychosocial history
3.History Collection

18. 4. Physical Examination

19. 5. Lab and Diagnostic tests

20. Validation prevents omissions, misunderstandings, and
incorrect inferences and conclusions
Organising Data
Collected information must be organized to be useful.
Data Clustering is a useful tool to identify issues
Validating Data

21. Interpreting Data
Distinguish relevant and irrelevant data
Determine whether and where there are gaps in the data
Identify patterns of cause and effect
Documenting Data
Assessment data must be recorded and
reported.
Accurate and complete record communicates
information to health care team.

22. Example of Subjective and
Objective data
Subjective data Objective data
Mr. X tells that ,I am
worried about my
disease (Prostate
cancer) . What will
be my future?
Patient has
Poor eye contact
Facial expression
Clenches hands
Restlessness
ANXIETY

23. Nursing Diagnosis
A nursing diagnosis is defined as a clinical
judgment about an individual, family or community responses to
actual and potential health problems/life processes.
(NANDA, 2009)

24. Identifying client needs
Step 1: Problem‐Sensing
Step 2: Rule‐Out Process
Step 3: Synthesizing the Data
Step 4: Evaluating or Confirming the Hypothesis
Step 5: List the Client’s Needs
Step 6: Re‐evaluate the Problem List

25. Diagnostic Process
Data Clustering
Data interpretation
Formulation
of
Nursing
diagnosis

26. Components in Nursing Diagnosis
(PES Format)
Problem statement or diagnostic label
Etiology
Defining characteristics
Problem
statement
Etiology Defining
characteristics
Deficient fluid
volume
Diarrhea Dry skin ,dryness of
the mouth.

27. Problem
Etiology (P & E
)
Problem,
Etiology
Signs and
Symptoms (PES)
Title in hereTitle in here
THREE PART
STATEMENT
THREE PART
STATEMENT
Acute Pain, leg
related to tissue
distention
(edema)
Ineffective Coping,
related to
maturational crisis as
evidenced by inability
to meet role
expectations
and alcohol abuse.
Formulation of nursing Diagnosis
TWO PART
STATEMENT
Problem. (P)
Powerlessness
Spiritual Distress
Disuse Syndrome,
ONE PART
STATEMENT

28. Types of Nursing Diagnosis-
NANDA – I 2012
Wandering,
Impaired social interaction
Stress urinary incontinence
ACTUAL
Risk for loneliness,
High Risk for injury
RISK
Readiness for enhanced family
coping
Readiness for enhanced nutrition
HEALTH
PROMOTION
Post‐Trauma syndrome
SYNDROME

29. Advantages of nursing diagnosis
Communication
Identification of Appropriate Goals
Quality improvement
Standard for Nursing Practice
Acuity Information
Assist in Discharge planning
Common language

30. Limitations of Nursing Diagnosis
Lack of consensus
Nurses have less time with clients.
Care is organized around the medical diagnosis.
Afraid and unwilling to use
The nursing diagnosis list does not fit the
client situation.

31. Wrong diagnostic label
Failure to seek guidance
Failure to validate nursing
diagnosis
Inaccurate interpretation
of cues
Using insufficient , invalid
cue
Failure to consider culture
Lack of knowledge,
Inaccurate data
Disorganization
Missing data
Insufficient cluster of cues.
Premature or early closure
Incorrect clustering
CollectingCollecting
InterpretingInterpreting
ClusteringClusteringLabellingLabelling
Sources of diagnostic error

32. Potential Errors in Choosing a
Nursing Diagnosis
Formulation of nursing diagnosis
A client reports discomfort at the insertion site of an IV
catheter , area is slightly reddened
The nurse formulates a nursing diagnosis ie Discomfort ..
But fail to consider the Risk for infection.
Don’t use medical terms in nursing diagnosis
Self care deficit ,Hygiene related to Stroke
Self care deficit ,Hygiene related to weakness secondary to Stroke

33. Errors in Choosing a Nursing
Diagnosis
Don’t combine two problems at the same time
Pain and fear related to upcoming abdominal surgery
Pain related to tissue injury secondary to abdominal surgery as
evidenced by pain 6/10.
Don’t make statements that are legally inadvisable
Impaired skin integrity R/T infrequent turning aeb 3cm ankle ulcer
Impaired skin integrity R/T immobility related to fracture.

34. Overcoming Barriers to Nursing
Diagnosis
Familiarity of nursing diagnosis language
Support from Health care agency
Enhanced communication
Document a new nursing diagnosis
Experienced nurses need opportunities to review nursing
diagnoses.
Standardized Nursing education programs content

35. 3.Nursing Planning and Outcome
Identification
Planning is a category of nursing behaviour in
which client centered goals and expected outcomes are
established and nursing interventions are selected to achieve
the goals and outcomes of care

36. Ongoing
Planning
Ongoing
Planning
Initial
Planning
Initial
Planning
Discharge
Planning
Discharge
Planning
Phases of Planning

37. PLANNING PROCESS
1‐ Setting priorities.
2‐ Establishing client goals/desired out comes.
3‐ Selecting nursing strategies.
4‐ Writing nursing orders.

38. 1.Priorities of planning
Priority setting is the ordering of nursing diagnosis
and patient problems using determinations of urgency and or
importance to establish a preferential order for nursing actions
Hendry and walker 2004

39. Intermediate Low
High
Classification of priorites

40. 2.Goals of care and expected
outcome
Goal - It reflects a patients highest possible level of
wellness and independence in funtion
Expected outcome
An expected outcome is a meaurable change
in a patients status that is expected to occur in response to
nursing care .
GoalGoalShort term Long term

41. MACROS criteria- For Goal
M easurable and observable
A chievable and time limited
C lient centred
R ealistic
O utcome written
S hort

42. Example for Goal and expected
outcome
Goal
Mr. X will ambulate independently in 3 days
Expected outcome
Mr.X will turn in bed independently in 24 hours
Mr.X will get up to chair 3 times daily for next 2 days
Mr.X will walk with assistance to hallway in 48 hours

43. 3.Selection of intervention
Characteristics of nursing diagnosis
Goals and expected outcome
Feasibility of the intervention
Acceptability of the patient
Own competency
Evidence base for the interventions
Bulechek et al 2008

44. Selecting Nursing
Interventions/ Strategies
Actions
initiated by
nurse that do
not require
direction or an
order
Actions
initiated by
nurse that do
not require
direction or an
order
Actions
implemented
in
collaborative
manner
Actions
implemented
in
collaborative
manner
Actions
that
require an
order
Actions
that
require an
order

45. Planning Nursing care
Realistic
Explicit
Evidence
based
Prioritised
Involved
Goal
centred

46. Systems for Planning nursing
care
Nursing kardex
Critical pathways
Nursing care plan

47. The Nursing Care Plan
A written guide that organizes data about a
client’s care into a formal statement of the strategies that will
be implemented to help the client achieve optimal health.
Purposes
Helps to identify the nursing actions to be delivered
Identify and coordinate resources to deliver nursing care
Enhance continuity of care

48. Care Plan in various settings
Institutional care plan
Interdisciplinary care
Computerized care plan
Student care plan
Care plan in community settings

49. GUIDELINES FOR WRITING
NURSING CARE PLAN
Incorporates preventive , health maintenance and restorative
aspects.
Use standardized Medical or English symbols . Eg. Clean
wound with H2O2 , b.i.d.
Be specific.
Use category headings and Date and sign the plan

50. GUIDELINES FOR WRITING
NURSING CARE PLAN
Refer to procedure books or other sources of information
Tailor the plan to the unique characteristics of the client .
Plan the interventions for ongoing assessment of the
client (eg. Inspect incision q8h)
Include collaborative and co‐ordination activities .

51. 4. Writing Nursing orders
After choosing appropriate nursing
interventions the nurse write those on care plan on nursing
orders.
Components of Nursing order
Monitor Vital signs Every q4h
Auscultate Abdomen q6h
Date Action Content Time Sign

52. Eg- for Planning and Rationale
for Acute pain in urethra – A client with UTI
Planning Rationale
Assess pain noting location,
intensity (scale of 0‐10) and
duration.
Encourage increased fluid
intake
Observe the changes in mental
status behaviour and Level of
consiousness
Provide information aid in choice
of determining choice or
effectiveness of interventions
Increased hydration flushes
bacteria and toxins
Accumulation of uremic waste and
electrolyte imbalances may be
toxic to CNS

53. Implementation
This fourth step of the nursing process involves the
execution of the nursing care plan derived during the
Planning phase.
Direct care Indirect care
INTERVENTION

54. Implementation skills
1.Cognitive Skills
2.Interpersonal Skills
3. Psychomotor skills

55. Standard Nursing Interventions
Clinical practice guidelines and protocols
Standing orders
NIC interventions
Standards of Practice

56. Task
allocation
Title
Managing Nursing Care in the
Clinical Environment
Client
allocation
Team
nursing
Primary
nursing
Person‐centred
planning
Care programme
approach
Caseload
management

57. Implementation process
1. Reassessing the client
2. Reviewing and revising the existing nursing care plan
3. Organizing resources and care delivery
4. Anticipating and preventing complications
5. Implementing nursing interventions.

58. 1.Reassesses the client
Before implementing the nurse must
reassess . It helps to identify the proposed nursing actions
are still appropriate for or the patients level of wellness

59. 2. Reviewing and revising the
existing nursing care plan
If the client status has changed then modify the care plan.
Modification of existing care plan
Revise the
Data
Revise the
nursing
Diagnosis
Revise the
specific
intervention
Choose the
evaluation
method

60. 3.Organising Resources And
Care Delivery

61. 4. Anticipating and preventing
complications
It can be resulted from both the illness and
treatment.
A nurse with a
Thorough Knowledge on pathophysiology
Thorough assessment
Scientific rationale for interventions

62. 5. Implementing Interventions
Indirect care
Direct care
•ADL
•IADL
•Physical care
Techniques
•Life saving measures
•Counselling
•Teaching
•Communicating
Interventions
•Delegating, Supervising
and evaluating the work
of staff

63. Eg- for Implementaion –
Acute pain in urethra – A client with UTI
Planning Implementation
Assess pain noting location,
intensity (scale of 0‐10) and
duration.
Encourage increased fluid
intake
Observe the changes in
mental status behaviour and
Level of consiousness
Client complained burning pain in urethra
during micturition which scores 5 /10
lasting for 15 min with each urination.
Oral and IV therapy started. (NS‐ 10
Drops/min). Intake – 3000 ml and Out put
– 2200ml for the last 24 Hours
Electrolytes and Uremic levels were normal
Urea‐ 18mg/dl ,Creatinine‐0 .8 mg/dl.
Client has appropriate mental status
behaviour.

64. Evaluation
Evaluation is defined as the judgment of the
effectiveness of nursing care to meet client goals; in this
phase nurse compare the client behavioral responses with
predetermined client goals and outcome criteria.
{CRAVEN 1996}

65. Purposes
1. Determine client’s behavioral response .
2.Compare the client’s response with outcome criteria.
3. Appraise the extent to which client’s goals .
4.Assess the collaboration of client and health team
5.Identify the errors in the plan of care.
6. Monitor the quality of nursing care.

66. COMPONENTS OF EVALUATION
Draw
conclusion
Draw
conclusion
Collect
the data
Collect
the data
Compare
the data
Compare
the data
Continue
modify,
Terminate
care plan
Continue
modify,
Terminate
care plan
Relating
nursing
activities
Relating
nursing
activities

67. Competencies For Evaluation
Criterion based Evaluation
Document the results
Care plan revision
Collaborating and evaluate effectiveness of intervention
ANA-2010

68. Methods of Evaluation of nursing
care
Evaluating
nursing
care
Reflection
Reflect on own
experiences
both socially with
other friends..
Nursing handover
Hand over information
about the nursing care
of clients to nurses
Reviewing the
plan
Evaluates the care
given against the
set goals.
Patient
satisfaction
Appreciation that is
sometimes offered
by clients

69. Evaluation skill required for
nurses
Know the hospital policies, procedure and protocols of
interventions and recording
Up to date knowledge and information of many subject.
Intellectual and technical skill
Knowledge and skill of collecting subjective data and
objective data.

70. Example for Evaluation
At the end of 8 hours , patient pain has
reduced as evidenced by pain score 2/10 and improved
activity