Dr.

Heba Elsayed
Nursing process
 Introduction
– The Whole Patient: The nursing process involves looking at the whole
patient at all times. It personalizes the patient. It also forces the health care
team to observe and interact with the patient, and not just the task they are
performing such as a dressing change, or a bed bath. The process provides a
roadmap that ensures good nursing care and improves patient outcomes.
– First the nurse collects subjective data and objective data, then organizes the
data into a systematic pattern.
– • The patient must be the central character.
– • Nursing care needs to be directed at improving outcomes for the patient;
not about nursing goals.
– • The nursing process is an essential part of the nursing care plan.
• Definition of nursing process:

• Nursing process is a professional nurses’ approach to identify,

diagnose, and treat human responses to health and illness.
• Nursing process is an organizational framework for the
practice of nursing
• Purpose of nursing process:
• The major purpose is to provide framework within which the
individualized needs of the patient, family and community can be met.
• Benefits of Nursing Process
• Provides an orderly & systematic method for
planning & providing care
• Facilitates documentation of care
• Stresses the independent function of nurses
• Characteristics of nursing process:

• It is cyclic and dynamic.

• It is client centered.
• It is planned.
• It is goal directed.
• It is universally applicable
• Phases of nursing process:
• 1. Assessment
• 2. Diagnosis
• 3. Planning
• 4. Implementation
• 5. Evaluation
 1- Assessment:

• Definition of assessment:
•
• It is the first step of nursing process and
includes systemic collection, verification,
organization, interpretation and
documentation of data for use by health care
professionals.
• Purpose of assessment:
• 1. To establish a database concerning patient's
physical, psychological and emotional health.

• 2. Identify health promoting behaviors as well

as actual and/or potential health problems.

• 3. Determines the patient's functional abilities

and the absence or presence of dysfunction.

• 5. To evaluate the physiologic outcomes of

health care and thus the progress of patient's
health problem.
 Types of
assessment

1. Comprehensive assessment
2. Focused assessment
3. Ongoing assessment
4.Emergency assessment
 • 1. Comprehensive assessment:

• It is usually completed upon admission to a

health care agency and includes a complete
health history and assessment of physical and
psychological aspects of the patient's health, the
perception of health, presence of health risk
factors and the patient's coping patterns.
•
• 2. Focused assessment:

• It is an assessment that is limited in order to

focus on a particular need or health care
problem or potential health care risks.

• 3. Ongoing assessment:

• Is an assessment that includes systemic

monitoring and observation related to specific
problems, it is particularly important when
problems have been identified.
4. Emergency assessment:
• It is an assessment that is done when a physiologic
or psychological crises occur to identify life
threatening problems.
Elements of assessment process

A. Data collection
B. Data verification
C. Data Organization
D. Data interpretation
E. Data documentation
• A: Data collection:
• It often begins prior to initial contact between the
nurse and the patient through reviewing of
biographical data and medical records. Systemic and
ongoing data collection is the key of accurate
assessment of your patient.

• Priorities in data collection:

• A system must be established to determine which

data will be collected first. One of such systems is
Maslow's hierarchy of needs that include:
physiological, safety and security, social, self-esteem
and self-actualization needs.
 Types of data

• 1. Subjective data:
– Data from patient's point of view and include feelings,
perceptions, and concerns. They cannot be readily observed by
another e.g. pain, nausea.
•
• 2. Objective data:
– Are observable and measurable data that are obtained through
observation, standard assessment techniques performed during
the physical examination, and laboratory and diagnostic testing
e.g. blood pressure, edema.
•
• 3. Historical data:
– Includes situations or events that have occurred
in the past, which are important in identifying
patient's health patterns and past experiences that
may have an impact upon patient's health e.g.
previous hospitalization.

• 4. Current data:
– Data related to events that are occurring now e.g.
vomiting, post operative pain.
Sources of data

1- The primary
source

2- Secondary
source
• A: Primary source:
• Usually the primary source of information is the
patient. He will offer a clear and concise picture
about his needs and problems and what the
expects in term of recovery and nursing care.
•

• B: Secondary source:
• 1. Family members and/or friends.
• 2. Health team members
• 3. Patient's health record
Methods of data collection

Observation .1
Interview .2
Health history .3
Physical examination .4
Laboratory and diagnostic data .5
• Observation:
• The nurse uses the skill of observation to carefully and attentively note the general appearance and
behavior of the patient.
• Interview:
• It is a therapeutic interaction that has a specific purpose. The purpose of assessment interview is to
collect information about patient's health history and current status in order to make determinations
about the patient's health needs.
• Health history:
• It is a review of the patient's functional health patterns prior to the current contact with a health care
agency, it includes:
• * Demographic information (name, age, sex, education... etc).
• * Reason for seeking health care
• * Previous hospitalization, illnesses, and surgeries.
• * Patient/family medical history
•
•4. Physical examination:
•The purpose of physical examination is to make direct observations of any
deviations from normal and to validate subjective data gathered through the
interview. Baseline measurements are obtained and physical examination
techniques are used to gather objective data.

•5. Laboratory and diagnostic data:

•Results of laboratory and diagnostic tests can be useful objective data as these
values often serve as defining characteristics for various altered health states;
these can also be helpful in ruling out certain suspected problems. For
example, diabetic patients who are poorly controlled on diet and/or medication
will usually have an elevated blood glucose level. In addition, the effectiveness
of nursing and medical interventions and progress toward health restoration
are often monitored through laboratory and diagnostic test data.
Characteristics of data
collection

A. Systemic.

B. Ongoing
• 1. Systemic:
• The nurse should assess the patient systematically from head to toe,
major body systems and functional health patterns. Head to toe: head,
neck, chest, abdomen, back, extremities and genitalia. Major body
systems: The nurse examines: Cardiovascular, respiratory, urinary,
reproductive, gastro-intestinal, neurologic, skin and musculoskeletal
system.

• 2. Ongoing:
• Reassessment to evaluate patient's progress.

• B: Data verification:
• Is the process through which data are validated as being complete
and accurate. This process is particularly important if data sources
are considered unreliable e.g. if a patient is confused or unable to
communicate or if two sources provide conflicting data, it is
necessary for the nurse to seek further information or clarification.
• C: Data organization:
• After data collection is completed and information is validated,
the nurses organize or cluster the information together in
order to identify areas of strengths and weaknesses.

• D: Data interpretation:
• Data clustering facilitates determination of further data is
needed in order to identify nursing diagnosis.

• E: Data documentation:
• Accurate and complete recording of assessment data, which is
essential for communicating information to other health care
team members. It is the basis for determining quality of care
and should include appropriate data to support identified
problems.
 What to assess.
• 1. Social condition of the patient:
• Including personal data (age, sex, marital status, education, occupation, religion,
income, and personal habits), this information can be identified through interview. .
•
• 2-Physical condition:
• Including height, weight, vital signs, and condition of skin, scalp, teeth, eyes, body
alignment, position, general sensation and motor function Determination of patient
physical condition through physical examination by using previously mentioned
methods.
•
• 3. Mental and psychological condition:
• Including fears, worries, anxieties, and the nurse can determine psychological
condition of the patient through interviewing the patient and his family
•
• 4. Therapeutic aspect:
• Including medication, treatment, investigation, allergic condition........etc. Therapeutic
aspect can be identified through checking patient's record or consultation with
members of health team. .
 Signs and Symptoms
• Signs:
• They are objective indication of disease or abnormality.
They are detected by the examiner through using special
methods of examination or through the use of special
instruments e.g. fever can be detected by the clinical
thermometer.

• Symptoms:
• Refer to any indication of disease or condition, which
may be felt by the patient or observed by the examiner.
pain
• Classification of symptoms:
• Subjective symptoms:
• These conditions that perceived by the patient such as pain and
the observer may not see the deviation e.g. pain, nausea.

• Objective symptoms:
• These conditions are identified by the observer whether the nurse
or physician e.g. pallor, cyanosis, swelling.
 Types of symptoms
• Cardinal symptoms: These major symptom that physician use to make
a diagnosis
• Constitutional symptoms: Those that are produced by the effect of the
disease on the whole body.
• Prodromal symptoms: These are occurring in the initial stages of the
disease e.g. running nose as an initial stage of measles.
• Local symptoms: These are noticed in special area or part of the body
as swelling in hands.
• Syndrome: It is a combination of symptoms that make up a
characteristic picture of a particular disease.
 2- Nursing diagnosis
"A nursing diagnosis is a standardized statement about the health
of a patient (who can be an individual, a family, or a
community) for the purpose of providing nursing care. Nursing
diagnoses are developed during the course of performing the
nursing assessments

Dr.Heba Elsayed OR
• Nurses only make nursing diagnoses:

• Once the nurse have identified the patient's problems related to

his health status, then formulate a nursing diagnosis for each
of them. The nurse will also prioritize the problems in
formulating the plan and goals. The nursing diagnoses are
categorized by a system commonly referred to as NANDA.
• Difference Between Nursing and Medical Diagnosis
• Nursing Diagnosis- statement used to describe the client's
actual or potential response to a health problem
i.e.-Impaired skin integrity - Risk for Infection, etc.
• Medical Diagnosis- physician "clinical judgment of the
disease- i.e. diabetes mellitus.
• Types of Nursing Diagnosis
• Actual problem
• Risk for problem

• Actual diagnosis: a statement about a health problem that the patient has
and the benefit from nursing care.
• An example of an actual nursing diagnosis is: Ineffective airway
clearance stagnation of secretion related to decreased energy secondary
to prolonged bed rest as manifested by an ineffective cough.

•
• Risk diagnosis: a statement about health problems that a patient
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.
 • Components of a nursing diagnosis
•
• I.
Diagnostic Label
• - Name of nursing diagnosis listed in taxonomy, describes essence of problem
• - Example: Stress Incontinence; Anxiety; Self-Care Deficit

• II. Qualifiers
• - add additional meaning to a nursing diagnosis, changes in condition, etc.
• - Example: Altered; Impaired; Ineffective; etc.

• III. Etiology :( related factor and risk factor): identifies one or more probable
causes of the health problem.

• IV. Defining Characteristics

• - Are cluster of signs and symptoms that indicate the presence of a particular
diagnostic label.
• Nutrition, Imbalanced: Less than Body • Activity Intolerance
Requirements • Airway Clearance, Ineffective
• Nutrition, Imbalanced: More than Body • Anxiety
Requirements • Body Image, Disturbed
• pain, Acute • Body Temperature: Imbalanced, Risk for
• Pain, Chronic • Ineffective breathing pattern
• Self-Care Deficit: Bathing/Hygiene • Constipation
• Self-Care Deficit: Dressing/Grooming • Constipation, Risk for
• Self-Care Deficit: Feeding • Hyperthermia
• Self-Care Deficit: Toileting • Hypothermia
• Skin Integrity, Impaired • Infection, Risk for
• Skin Integrity, Risk for Impaired • Injury, Risk for
• Social Isolation • Insomnia
• Urinary Elimination, Impaired • Knowledge, Deficient (Specify)
• Urinary Retention • Mobility: Physical, Impaired
• Nausea
• Types of Nursing Diagnosis
• A- Actual diagnosis:
• a statement about a health problem that the patient has and the benefit
from nursing care. An example of an actual nursing diagnosis is:
Ineffective airway clearance stagnation of secretion related to decreased
energy secondary to prolonged bed rest as manifested by an ineffective
cough.

• B- Risk diagnosis:
• a statement about health problems that a patient 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
Planning -3
 3- Planning
• Definition:
• It is the process of prioritizing nursing diagnoses and,
identifying measurable goals or outcomes, selecting appropriate
interventions, and documenting the plan of care.
• Planning steps:
• Establishes Priorities
• Writes Client Goals/Outcomes
• Selects Nursing Interventions
• Communicates The Plan
 :Planning Process

1-Setting priorities:
Is the process of establishing a preferential order
for nursing diagnosis and interventions.
- The nurse and client begin planning by deciding
which nursing diagnosis requires attention first,
which second, and so on.
 Types of priority
43
• High: nursing diagnosis that if untreated, could result in
harm to the client or others have the highest priority. sever
bleeding

• Intermediate: nursing diagnosis involves the non-

emergency, non-life threatening needs of the clients

• Low: nursing diagnosis are client’s needs that may not be

directly to a specific illness or prognosis
Dr.Heba Elsayed
Establishing client goal/desired outcomes -2

The nurse client set goals for each nursing diagnosis.

Types of Goals:
a- Short Term Goals:
For a client who require health care for a short time.

b- Long Term Goals:

Are often used for clients who live at home and have
a chronic health problem.

Dr.Heba Elsayed
• Guidelines for writing goals

• Patient centered
• Singular goal or outcome
• Observable
• Measurable
• Time-limited
• Realistic
Dr.Heba Elsayed
 :Formula for Writing Goals/Outcomes
Goal statement (long or short term) = patient behavior + criteria + time + conditions (if needed)

1. Subject -patient

2. Verb -action/behavior which pt performs

3. Criteria -acceptable performance

4. Within specified time period

5. Condition (if needed) circumstances under which behavior performed

Example:

• The patient (1) will walk (2) the length of the hall (3)

with a walker (5) by the end of the shift (4).

Dr.Heba Elsayed
 Example of nursing diagnosis & patient goal
47

Nursing diagnosis Outcome criteria

)patient goal (
Ineffective breathing pattern((Problem) .1 Patient will return to normal
related to bronchial spasm ( etiology) as breathing pattern within 30 min
manifested by shortness of breath ( defining
characteristics s+s)

Altered body temperature hyperthermia .2 Patient will return to normal body

(Problem) related to infection ( etiology) as temperature (37 C) within 30 min
manifested by increase body temperature
(38.3C) ( defining characteristics) Dr.Heba Elsayed
 Example of nursing diagnosis & patient goal
48

Nursing diagnosis Outcome criteria

)patient goal (

Altered body temperature hypothermia Patient will return to normal body

(Problem) related to decreased activity temperature (37 C) within 30 min
( etiology) as manifested by decrease body
temperature (36.3C) ( defining characteristics)

Dr.Heba Elsayed
 Example of nursing diagnosis & patient goal
49

Nursing diagnosis Outcome criteria

)patient goal (

Altered body temperature hypothermia Patient will return to normal body

(Problem) related to decreased activity temperature (37 C) within 30 min
( etiology) as manifested by decrease body
temperature (36.3C) ( defining
characteristics)

Dr.Heba Elsayed
Implementation
Dr.Heba Elsayed
 4- Implementation
• Definition:
• Is the phase in which the nurse puts the nursing care
plan into action.
• Steps of implementation:
• 1. Reassessing patient
• 2. Reviewing and modifying existing care plan
• 3. Performing nursing actions
Dr.Heba Elsayed
• Types of Nursing Intervention:
1- Independent intervention: are those activities that nurses are
licensed to initiate on the basis of their knowledge and skills (as
measuring V/S).

2- Dependent intervention: are activities carried out under the

physician orders (as administering medication).

3- Collaborative intervention: are actions the nurse carries out

in collaboration with other health team member.
Dr.Heba Elsayed
Dr.Heba Elsayed
• 5- Evaluation (Re-assessment):
• Definition: Evaluation is measuring the extent to which
client goals have been met and examining the need for
adjustments and changes as well.
• Evaluation steps:
• 1. Comparing patient response to criteria
• 2. Analyzing reasons for results and conclusions
• 3. Modifying care plan

Dr.Heba Elsayed
 Examples of nursing diagnosis & patient goal
Planning ( patient goal) Nursing diagnosis

Patient will state that he breaths easily within 30 1. Ineffective (qualifier) breathing pattern (diagnostic
min of interventions. label) related to bronchial spasm (etiology) as
manifested by shortness of breath ( defining
characteristics or s+s)
Patient will return to normal body temperature (37 2. Altered (qualifier) body temperature
°C) within 30 min hyperthermia (diagnostic label) related to infection
(etiology) as manifested by increase body
temperature (38.3°C) (defining
characteristics)
Patient will return to normal body temperature (37 3. Altered (qualifier) body temperature hypothermia
°C) within 30 min (diagnostic label) related to decreased activity
( etiology) as manifested by decrease body
temperature (36.3°C) (defining characteristics)

Patient will state that pain is relieved or decreased 4. pain (diagnostic label) related to surgical incision
within 30 minutes. (etiology) as manifested by patient statement- I have
moderate incision pain (defining characteristics)

Patient will have intact skin. 5. Risk for impaired (qualifier) skin integrity
(diagnostic label) related to prolonged bed rest
(etiology).

Dr.Heba Elsayed
 Example of nursing care Student
planName
---------------------------
Patient Name-------------------------------------- Diagnosis------------------------------------------- Bed N :----------
Room N:-------------
58
Therapeutic Diet:----------------------------------------- Date of admission------------------------------- Date of
operation

Nursing Nursing Planning Implementation Evaluation

assessment diagnosis )patient goal ( nursing = reassessment =
interventions
Fever Altered body Patient will As mentioned in the Resolved
temperature
)C 38.3( return to lecture Or
related to….as
manifested by normal body temperatureS
increase body temperature till high
temperature within 30 (38.3 C)
)C 38.3(
minutes of
interventions

Dr.Heba Elsayed
Dr.Heba Elsayed