Nursing Process

INTRODUCTION:
Nursing process is a systematic problem solving approach used to identify, prevent and treat
actual or potential health problems and promote wellness. A systematic way to plan,
implement and evaluate care for individuals, families, groups and communities.
DEFINITION OF NURSING PROCESS:
Nursing process primarily refers to the independent responsibility of the nurse in providing
client care. It has been derived from the scientific method and adapted as an organized
systematic method for identifying clients concern and problems, choosing expected client
outcomes, determining interventions to resolve these problems and evaluating achievement
of expected outcomes following provision of nursing care.
COMPONENTS OF NURSING PROCESS:
The nursing process consists of five dynamic and interrelated phases-
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation
HEALTH ASSESSMENT:
INTRODUCTION:
 Health assessment is an essential nursing function which provides foundation for quality
nursing care and intervention
 It helps to identify the strengths of the clients in promoting health
 Health assessment helps to identify client’s needs, clinical problems
 To Evaluate responses of the person to health problems and intervention Health

Assessment
DEFINITION:
Assessment is the first step to determine heath status. It is gathering of information to have
all the “necessary puzzle pieces” to make a clear picture of the person’s health status
Definition : Assessment is the deliberate and systematic collection of data to determine
clients current and past health status, functional status and to determine client’s present and
coping pattern. ( Carpenito)
Assessment is a part of each activity the nurse does for and with the patient (Atkinson &
Muray – 1991 Nursing assessment focus upon the client’s response to a health problem
“ Nursing assessment should include client’s perceived needs, health problems related
experience, health practices values and life styles” ( Bandman and Bandman (1995)
PURPOSES OF ASSESSMENT:
1. To collect data pertinent to the patient’s health status – subjective /objective
2. To identify deviations from normal
3. To discover the patients strengths,limitations and coping resources
4. To pinpoint actual problems
5. To spot factors that place the pt at risk of health problems
6. To build rapport with patient and family
TYPES OF ASSESSMENT:
 INITIAL ASSESSMENT:
Initial Assessment It is done within specified time after admission to Hospital Purpose: To
establish a complete data base for problem identification, reference and future comparison
Eg: Admission assessment Focus or Ongoing.
 PROBLEM FOCUS ASSESSMENT:
A problem solving assessment collects data about a problem that has already been identified.
This type of assessment has a narrower scope and a shorter time frame than the initial
assessment. In focus assessments, nurse determines whether the problems still exist and
whether the status of the problem has changed.
 EMERGENCY ASSESSMENT:
It takes place in life threatening situations in which the preservation of life is the top priority.
Time is of the essence in rapid identification of and intervention for the client’s health
problem.
 TIME LAPSED ASSESSMENT:
Is is another types of assessment, takes place after the initial assessment to evaluate any
changes in the clients functional health. Nurses perform time lapsed reassessment when
substantial periods of time have elapsed between assessments.
METHODS OF ASSESSMENT:
The primary methods are –
 Observing:
Observing Is a conscious deliberate skill developed only through and with an organized
approach. Eg. Data observed with 4 senses – vision, hearing, smell and touch Interviewing Is
a planned communication or a conversation with a purpose Eg. History taking 2 approaches :
Directive , non directive
 Interviewing:
It is an essential skill for obtaining information for the nursing history, consists of asking
questions designed to elicit subjective data from the client or family members. The nursing
history focuses on client’s account of the actual or potential health problems and their impact
on his / her health status.
 Examining:
Systematic data collection to detect health problems using unit of measurements like-
 Physical Examination
 Systematic data collection method – Observational skills to detect health problems

Assessment sequencing
 Head – to- Toe assessment
 Body system assessment (Signs and symptoms – complaints – lead to clues )
Using Techniques of –
 INSPECTION :
close and careful visualization of the person and of each body system Eg Rashes…. Color
changes … edema.
 PALPATION:
 Palpation uses the sense of touch to assess various parts of the body and helps to
confirm findings that are noted on inspection.
 The hand especially the fingers tips are used to assess-
 Temp
 Texture
 Moisture
 organ size & location
 Rigidity & spasticity
 Crepitation /vibration
 Position& size
 Tenderness/pain
 Presence of lumps & masses
 PERCUSSION :
Assess underlying structures of location, size, density of underlying tissues

AUSCULTATION : Listening to sounds produced by the body
 Stethoscope
 Doppler
 Feto- scope
 ASCULTATION:
It is listened to sounds produced inside the body. These sounds includes breath sound, heart
sounds, vascular sounds, and bowel sounds. It is used to detect the presence of normal and
abnormal sounds and to assess them in terms of loudness, pitch, quality, frequency, and
duration.
VALIDATING DATA:
 Double checking or verifying the data whether it is factual or accurate
 The assessment information must be accurate, factual and complete
 Nursing diagnosis and interventions based on this
ORGANIZING DATA :
Cluster the data into groups of information ( identify the pattern of illness) (Data base)
DOCUMENTING DATA :
 Accurate documentation is essential which include all data collected about client’s health
status. Record in a FACTUAL manner NOT interpretation
 Eg. Recording the breakfast intake as – Ate 2 pieces of Bread toast , 1 egg and a cup of
coffee Instead of “Good appetite”
REPORTING :
 When you will Report?
 Depending on each Patient
 Disease conditions – potential problems
 Family interests
 Psychological upset – may lead to suicidal attempt
CONCLUSION:
A section of the nursing assessment may be delegated to certified nurses aides. Vitals and
EKG's may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017) It
differs from a medical diagnosis. In some instances, the nursing assessment is very broad in
scope and in other cases it may focus on one body system or mental health. Nursing
assessment is used to identify current and future patient care needs. It incorporates the
recognition of normal versus abnormal body physiology. Prompt recognition of pertinent
changes along with the skill of critical thinking allows the nurse to identify
and prioritize appropriate interventions.
BIBLIOGRAPHY:
 P. Basheer shebeer, Khan s. yaseen, a concise textbook of advanced nursing practice,

EMMESS publication, 1st edition, page no 504-509.
 Brar Kaur Navdeep, Rawat HC, textbook of advance nursing practice, jaypee
publication, page no 715-729.
 https://en.wikipedia.org/wiki/Nursing_assessment
 https://www.slideshare.net/shantapeter/nursing-health-assessment-48824855

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INTRODUCTION:

DEFINITION OF NURSING PROCESS:

COMPONENTS OF NURSING PROCESS:

The nursing process consists of five dynamic and interrelated phases-

 It helps to identify the strengths of the clients in promoting health

 Health assessment helps to identify client’s needs, clinical problems

 To Evaluate responses of the person to health problems and intervention Health

1. To collect data pertinent to the patient’s health status – subjective /objective

2. To identify deviations from normal

3. To discover the patients strengths,limitations and coping resources

4. To pinpoint actual problems

5. To spot factors that place the pt at risk of health problems

6. To build rapport with patient and family

 PROBLEM FOCUS ASSESSMENT:

 TIME LAPSED ASSESSMENT:

The primary methods are –

 Systematic data collection method – Observational skills to detect health problems

 Head – to- Toe assessment

 Body system assessment (Signs and symptoms – complaints – lead to clues )

 The hand especially the fingers tips are used to assess-

 organ size & location

 Rigidity & spasticity

 Presence of lumps & masses

Assess underlying structures of location, size, density of underlying tissues

 Double checking or verifying the data whether it is factual or accurate

 The assessment information must be accurate, factual and complete

 Nursing diagnosis and interventions based on this

 When you will Report?

 Depending on each Patient

 Disease conditions – potential problems

 Psychological upset – may lead to suicidal attempt

 P. Basheer shebeer, Khan s. yaseen, a concise textbook of advanced nursing practice,

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