Nursing Process Overview

The nursing process is a systematic, rational method for planning and providing care.
Its purpose is to identify clients' health status, actual or potential health problems.
It establishes plans to meet identified needs to deliver specific nursing interventions to address those needs.

The five phases are assessment, diagnosis, planning, implementation, and evaluation.
Each phase is closely interrelated and affects the others.

Assessment is the systematic and continuous collection, organization, validation and documentation of data.
It aims to prevent omitting significant data and reflect changing health status.
Types of assessment include initial, problem-focused, emergency, and time-lapsed assessments.

Initial Assessment: Performed after admission to identify problems, reference, and compare with future data (e.g., nursing admission assessment).
Problem-focused Assessment: Ongoing process integrated with nursing care, focusing on specific identified problems, such as hourly assessment in Intensive Care Units.
Emergency Assessment: Used during crises (physiological or psychological) to identify life-threatening problems. Examples include assessing airway, breathing, and circulation during cardiac arrest.
Time-lapsed Assessment: Carried out months after initial assessment to compare current status with previous baseline data, such as reassessing functional health patterns in outpatient settings.

Collecting Data: The process of gathering client health status information.
Data Base: All client information, including nursing health history, physical assessments, care provider history and physical examinations, laboratory and diagnostic test results.

Subjective Data (Symptoms): Information described/verified only by the affected person including sensations, feelings, values, beliefs, attitudes and perceptions of personal health status. Examples include itching, pain, and worry.
Objective Data (Signs): Information that can be observed, measured or tested against standards (e.g., discoloration of skin, blood pressure reading).

Primary Source: The client.
Secondary Sources: Family, support persons, other healthcare professionals, records, reports, laboratory and diagnostic analyses (indirect).

Observation: Gathering information using senses. (Vision, Smell, Hearing).
Interview: Planned communication/conversation.
Examination: Diagnostic procedures and lab investigations
Physical Examination Techniques:
- Inspection
- Palpation
- Percussion
- Auscultation

Definition: Clinical judgment about individual, family, or community responses to actual and potential health problems/life processes.
NANDA (North American Nursing Diagnosis Association): The organization that provides a working definition of nursing diagnosis.
Types:
- Actual Diagnosis: Client problem present during assessment (e.g. ineffective breathing pattern, anxiety).
- Risk (Potential) Diagnosis: No problem exists, but risk factors are present, indicating the likelihood of problem development (e.g., risk for infection)
- Health Promotion Diagnosis: Relates to the client's readiness to improve their health condition. (e.g. readiness for enhanced nutrition).

Problem (diagnostic label): Describes health problem (e.g., Deficient Knowledge, Medication).
Etiology (related factors/risk factors): Identifies probable causes of problems, guiding therapy.
Defining Characteristics (Signs & Symptoms): Cluster of signs and symptoms that indicate a health problem in actual diagnosis. No signs or symptoms are present in risk nursing diagnoses.
Statement Format: The diagnostic statement follows a “PES” format (Problem-Etiology-Signs).

This hierarchy prioritizes human needs, beginning with physiological requirements (air, water, food, shelter). Higher levels include safety, love/belonging, esteem, and self-actualization.

Interventions are any treatments performed by nurses to improve patients' health.

Implementation includes doing and documenting activities.
This involves performing nursing interventions and documenting implemented activities.

Evaluation is a planned, ongoing, purposeful activity.
It determines the client's progress toward achieving goals; it also evaluates the effectiveness of the care plan.

Identify evaluation criteria and standards.
Collect evaluation data.
Interpret and summarize the findings.
Document findings.
Care plan revision can include:
- Terminating the care plan.
- Modifying the care plan.
- Continuing the care plan.