Nursing Process

NURSING PROCESS
(by Ns. Antarini Idriansari)

DEFINITION OF NURSING PROCESS
The nursing process is defined as a systematic problem

solving approach for giving a comprehensive
nursing care.
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Nurse do assessment, make some plans, and
give nursing care!
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The nursing process is a systematic method that helps
the client and the nurse to carry out the following:
1. Assessment
2. Nursing diagnosis
3. Nursing care plan identification
4. Implementation
5. Evaluation
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1 Nursing assessment
It is a systematic and logical collection of
subjective and objective data that are
helpful to identify and define
problems of client.
Purpose of assessment is gather data or gather
baseline information about client.
Assessment provides data for diagnose client‘s problem health.
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Assessment of client in which the
need for nursing care is determined.
A comprehensive assessment is
holistic, includes physical examination,
health history, psyochological,
sosiocultural, emotional, and spiritual
factors that affect the clients’s health.
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The clinical skill utilized for
assessment includes the
following:
1. Interview
2. Physical examination
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The Clinical Skill Utilized for Assessment
Interview Physical examination

It means collection client‘s health It means an examination of
data by giving some questions bodily functions and condition of
about: an individual.
a. Personal identity
b. Health history Physical examination is carried
c. Sensation or symptom out through a head to toe.
d. Feeling and desire
e. Beliefs
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Interviewing
Some questions
a. How are you feeling today?

b. Have you ever been hospitalised?
c. What is your chief complaint?
d. Do you feel feverish?
e. Do you have any difficulty in breathing?
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Physical
examination
Evaluating objective
anatomic findings through
the use of observation,
palpation, percussion, and
auscultation.
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2 Nursing diagnosis
This is the clinical trial act of identifying
client’s health problems.
Nursing Diagnosis
A nursing diagnosis is
formulated based on the
physical assessment of patient
and can be changed or altered
as nursing care continues to be
provided.
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Nursing Diagnosis
The nursing diagnosis is
comprised of three parts or
commponets as follows:
.....
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Three components of nursing diagnosis
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02
Problem
Statement Etiology 03
Defining
Characteristics
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01
Problem Statement
The problem statement

pertains to the patient’s
current health problem and
needed nursing interventions.
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02
Etiology
The etiology or related factors

identifies probable causes of
the health problem or the
conditions involved in the
development of the problem.
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03
Defining Characteristic
Defining characteristics are the

groups of signs and symptoms
that indicate the presence of a
particular diagnostic label.
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Guideline For Writing Nursing Diagnosis
P: Phrase patient’s problem (need)

- link with phrase “related to”
E: Etiology suspected cause for problem
- link with phrase “as evidenced by”
S: List signs/symptoms (cues identified assessment that
substantiate the nurse diagnosis)
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Example of Nursing Diagnosis
Problem statement Etiology Defining Chacarteristics
Deficient fluid volume Diarrhea Dry skin, dryness of the mouth
Nursing Diagnosis
“Deficient fluid volume related to diarrhea as evidenced by
dry skin and dryness of the mouth”
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Example of Nursing Diagnosis
Problem statement Etiology Defining Chacarteristics
Ineffective airway Bronchial airway Coarse rhonchi to bilateral

clearance inflammation apices heard on auscultation
Nursing Diagnosis
“Ineffective airway clearance related to bronchial airway inflammation
as evidenced by coarse rhonchi to bilateral apices heard on auscultation”
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3 nursing care plan
actions a nurse takes to implement their patient care
plan, including any treatments, procedures, or
teaching moments intended to improve
the patient's comfort and health.
Nursing interventions are the actual treatments and actions that are
performed to help the patient to reach the goals that are set for them.
The nurse uses knowledge, experience, and critical-thinking skills to decide

which interventions will help the patient the most.
Interventions can be focused on basic physiological needs, complex

physiological needs, behavioral functioning, promoting safety, caring for the
family, using the health system and/or the overall health of the community.
As nurses, we are caring for the total patient, so there are can be
interventions concerning every area of the patient's life.
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Nursing Diagnosis Outcomes (NOC) Intervention (NIC)
............. ........... ...............
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4 implementation
Implementation is the step that involves action
or doing and actual carrying out of nursing
interventions outlined in the plan of care.
5 evaluation
In the final step of a care plan, NURSE will evaluate
whether the desired outcome has been met.
Thanks!
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Nursing Process

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NURSING PROCESS

(by Ns. Antarini Idriansari)

The nursing process is defined as a systematic problem

Assessment provides data for diagnose client‘s problem health.

Interview Physical examination

a. How are you feeling today?

The problem statement

The etiology or related factors

Defining characteristics are the

P: Phrase patient’s problem (need)

Problem statement Etiology Defining Chacarteristics

Deficient fluid volume Diarrhea Dry skin, dryness of the mouth

Problem statement Etiology Defining Chacarteristics

Ineffective airway Bronchial airway Coarse rhonchi to bilateral

as evidenced by coarse rhonchi to bilateral apices heard on auscultation”

The nurse uses knowledge, experience, and critical-thinking skills to decide

Interventions can be focused on basic physiological needs, complex

............. ........... ...............

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