NURSING PROCESS

The NURSING PROCESS is: CHARACTERISTICS:

A systematic, rational method of planning A. Systematic – the nursing process has
and providing individualized nursing care. an ordered sequence of activities
and each activity depends on the
accuracy of the activity that
Background:
precedes it and influences the
Ida J. Orlando – the nursing process is based activity following it.
on a nursing theory developed by Ida Jean B. Dynamic – has great interaction
Orlando. She developed this theory in the (from assessment to evaluation) and
late 1950’s as she observed nurses in overlapping among the activities and
action. She saw “good” nursing and “bad” each activity is
nursing. fluid and flows into the next activity
C. Interpersonal – ensures that nurses
● From her observations, she learned that
are client-centered rather than task-
the patient must be the central character
centered and encourages them to
- Nursing care needs to be directed at improving
work to enhance client’s strengths
outcomes for the patient, and not about
and meet human needs
nursing goals.
D. Goal-directed – means for nurses
- The nursing process is an essential part of the
and clients wo work together to
nursing care plan.
identify specific goals (wellness
promotion, disease and illness
Characteristics of Nursing Process
prevention, health restoration,
- Within the legal scope of nursing
coping and altered functioning) that
- Based on knowledge-requiring critical thinking
are most important to the client,
→
and to match them with the
(clinical reasoning: common in nursing
appropriate nursing actions.
practice with enough knowledge;
E. Universally applicable – allows
clinical thinking in a clinical
nurses to practice nursing with well
situation)
or ill people, young or old, in any
- Planned-organized and systematic
type of practice setting
-identify through actual (physiologic
needs) and potential health problem
- Client-centered PURPOSE OF NURSING PROCESS
- Goal-directed
- To Achieve Scientifically – Based, Holistic,
- Prioritized
Individualized Care For the Client
- Dynamic
- To Achieve the Opportunity to Work
Collaboratively with Clients, Others
- To Achieve Continuity of Care
THE NURSING PROCESS - Observing his reactions and interactions
with others. It involves asking
▪ Assessing – Gather data
pertinent questions about his signs
▪ Analyzing – Identification of problem
(observable) and symptoms (non-
and formulation of nursing diagnosis
observable), and listening carefully
▪ Planning – Write care plan to meet goals
to the answers.
▪ Implementing – Carry out plan
▪ Evaluating – Collect objective data to
determine the extent to which goals
Data Collection
were achieved. Revise plan as needed.
- Observation
- Interview
Components of the Nursing Process - Types of questions
- Setting
1. Assessment
- Rapport
2. Diagnosis
- Examination
3. Outcome Identification (Goal)
4. Planning
DURING Assessment, the care provider:
5. Implementing
a. Establishes a Data Base
6. Evaluating
b. Continuously Updates the
Data Base
Holistic c. Validates Data
d. Communicates Data
▪ Physical
▪ Emotional
Review of systems – subjective
▪ Psychosocial
Physical assessment - objective
▪ Developmental
▪ Spiritual being
Ex:
2nd component: DIAGNOSIS
Medical Diagnosis: Rheumatoid Arthritis
Nursing Diagnosis: Self-care deficit: bathing, ▪ Sort, cluster, analyze information
related to joint stiffness ▪ Identify potential problems and
strengths
▪ Write statement of problem or
1st Component of Nursing Process: strength
ASSESSMENT Ex:
-Risk of infection related to compromised
▪ Data Collection
nutrition
- Assessment involves taking vital signs (TPR
-Potential for effective breastfeeding
BP & Pain Assessment)
related to knowledge level and
- Performing a head to toe assessment
support system
- Listening to the patient’s comments and
questions about his health status
 -Ineffective tissue perfusion sa renal (kidney maintained as evidence by 6 x 10 / 2
failure) inches (necrotize)
-Altered urinary elimination or bowel No development of new bed sore in sacral or
pattern other bony prominences
▪ Prioritize the problems Long-term goal: at the end of 3 months, the
▪ Not a medical diagnosis bed sore will manifest healing by
tertiary intention as evidenced by
c. Selects Nursing Interventions
TYPES OF DIAGNOSIS
d. Communicates the Plan
- Actual diagnosis – problem is present
- Risk nursing diagnosis – risk for injury, 4th component: IMPLEMENTATION
aspiration/falls
▪ carry plan of care
- Possible diagnosis
- Wellness diagnosis - strength DURING Implementation, the care provider:
- Carries out the plan of nursing care of
setting your plans in motion and delegating
3rd component: PLANNING
responsibilities for each step
▪ The establishment of client
- Continues data collection and modifies the
goals/outcomes (SMART)
plan of care as needed
- Working with the client, to prevent, reduce, or
resolve problems - Documents care
- To determine related nursing interventions
(actions) that are most likely to assist
client in achieving goals 5th component: EVALUTATING
- This is about improving the quality of life for the
▪ the measure of the extent to which
patient
client goals have been met
- This is about what your patient needs to do to
▪ evaluation involves not only
improve his health status or better cope
analyzing the success of the goals
with his illness.
and interventions, but examining
the need for adjustments and
DURING planning, the provider:
changes as well
a. Establishes priorities
▪ the evaluation incorporates all input
b. Writes Client Goals/Outcomes and
from the entire health care team,
Develops an Evaluative Strategy ->
including the patient
Criteria or parameter
Ex.: Impaired tissue integrity related to
prolonged immobility (etiology) DURING Evaluating, the care provider:
Short-term goal: at the end of 8 hrs of shift,
the patient’s tissue integrity will be
- Measures the clients achievement of
desired goals/outcomes
- Identifies factors that contribute to the
client’s success or failure
- Modifies the Plan of Care, if indicated