NURSING PROCESS AND ITS

ADVANCEMENT SO FAR AND THE

NURSING CARE PLAN

BY

NJOKU LYDIA U. PG/MSC/19/00018

AND

NNADI LILIAN O. PG/MSC/19/89557

A PRESENTATION SUBMITED IN PARTIAL FULFILMENT OF THE COURSE:

CONCEPTS AND PRINCIPLES OF MEDICAL SURGICAL NURSING (NSC 711)

UNIVERSITY OF NIGERIA, ENUGU CAMPUS

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

DEPARTMENT OF NURSING SCIENCES

LECTURER: PROF. A.N. ANARADO

MARCH, 2020.

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INTRODUCTION
In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. The
Nursing Process can simply be defined as a systematic approach to care using the fundamental
principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks,
evidence-based practice (EBP) recommendations, and nursing intuition (Tammy J T, Jennifer M
T, 2019). It involves a holistic and scientific postulate to be integrated to provide the basis for
compassionate and quality-based care.

The Nursing process is a widely accepted method and has been suggested as a scientific method
to guide procedures and quality nursing care. As stated by Kim C, Kelly G, 2014, it is operating
through six interrelated steps which are Assessment, Diagnosis, Outcome Identification,
Planning, Implementation and Evaluation.

OBJECTIVES

The specific objectives of the study are to,

1. Define Nursing process.

2. Describe the steps of the nursing process.
3. Discuss the importance of the nursing process as it relates to client care.
4. State how it has performed so far.

The Advancement of Nursing Process

The term nursing according to the Oxford Advanced Learner’s Dictionary (8th Ed) can simply be
defined as a job or skill of caring for people who are sick or injured. It is a noble profession.

A process as stated by the same dictionary is a series of things that are done in order to achieve a
particular result. It can be said to be steps that follow a logical sequence.
Therefore the nursing process, which is the most important tool for putting nursing knowledge
into practice, can be defined as a systematic problem solving method for determining the health
care needs of a healthy or ill individual and for providing personalized care (Ayaro L. R, 2006).
It provides a logical framework on which the nursing care is based.

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The term Nursing Process was introduced by Lydia Hall in 1955. She identified three aspects of
nursing care; CARE, CURE AND CORE and the three steps of nursing process;
OBSERVATION, MINISTRATION OF CARE and VALIDATION. (Negi D, 2019).
In 1959, Dorothy Johnson described nursing as fostering the behavioral functioning of the client.
She furthered explained that there are three steps of nursing process which are; Assessment,
Decision and Nursing Action, while Ida Lois Orlando in 1961 gave a view of a three step nursing
process which are, Client’s behavior, Nurse’s reaction and Nurse’s actions.

Later on in 1963, Lois Knowles gave a five step nursing process using the ‘five D’s which stand
for. Discover, Delve, Decide, Do and Discriminate. The term, discover and delve steps are
related to the present assessment phase, decide is the planning stage, do is the implementation
stage and discriminate is related to the evaluation phase of client responses to nursing
interventions. (Negi. D, 2019).

Outcome identification is the most recent addition to the nursing process, as described in the
current American Nurses Association (ANA) Standards of Clinical Nursing Practice (2004). The
ANA describes seven measurement criteria for outcome identification, which include specifying
intermediate and long-term outcomes that focus on health promotion, health maintenance, or
health restoration.

NANDA International i.e. North American Nursing Diagnosis Association International

(formerly the North American Nursing Diagnosis Association) is a professional organization
of nurses interested in standardized nursing terminology. It was officially founded in 1982 and
develops researches, disseminates and refines the nomenclature, criteria, and taxonomy of
nursing diagnoses.

Basis for the nursing process

The nursing care planning process is based on the scientific method of problem-solving, which
involves:

- Stating the problem you observed

- Forming a hypothesis about the solution to the problem ('if... then' statements)
- Developing a method to test the hypothesis

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 - Collecting the test data
- Analyzing the data
- Drawing conclusions about the hypothesis.

A scientific fact is that most people use the scientific method instinctively, without being aware
they're doing it. Simply picking out which pair of shoes best complements your favourite outfit is
an exercise in the scientific method. So if you're familiar with the scientific process, the nursing
planning process probably seems familiar. The nursing process encompasses six steps which are
Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation
(Tammy J. T , Jennifer M. T, 2019).

Characteristics of Nursing Process

The nursing process has distinctive characteristics that enable the nurse to respond to the
changing health status of the client or patient. These characteristics include its cyclic and
dynamic nature, client centeredness; focus on problem solving and decision making,
interpersonal and collaborative style, universal applicability, and use of critical thinking. It can
end at any stage if the problem is solved. . The nursing process exists for every problem that the
individual/family/community has. The nursing process not only focuses on ways to improve
physical needs, but also on social and emotional needs as well. The characteristics of the nursing
process are as follows;

 The Nursing process is systematic and orderly. Each nursing activity is part of an
ordered sequence of activities. The nursing process directs each step of nursing care
in a sequentially ordered manner.
 It is dynamic. Data from each phase provide input into the next phase. In some
situations almost all the stages occur simultaneously.
 The nursing process is client centered and goal directed. The nurse organizes the
plan of care according to client problems.
 The nursing process is an adaptation of problem solving and system theory. The
medical model focuses on physiological system and disease process, whereas the

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 nursing process is directed towards a client’s response to real or potential disease and
illness.
 Decision making is involved in every phase of the nursing process.
 The nursing process is interpersonal and collaborative. It requires the nurse to
communicate directly and consistently with client and families to meet their needs.
 Nursing process is universally applicable in all nursing situations.
 The nursing process encourages corporation among nurses i.e. to work together to
help clients to use their strengths to meet all human needs. This also helps nurses to
explore their own strengths and limitations and to grow personally and professionally.
 It is outcome-oriented. The client benefits from continuity of care and each nurse’s
care moves the clients closer to the outcome achievement.
 The nursing process can also be used throughout the life span of a patient or client.
 The entire process is recorded or documented in order to inform all members of the
health care team.

Purpose of Nursing Process

 Define patient’s goal.
 Determine the nurse’s role.
 Provides consistency of care.
 Customizes care intervention
 Promotes holistic treatment.
 Provides quality patient care.

Benefits of Nursing Process for the Nurses

 Job satisfaction.
 Professional growth.
 Avoidance of legal action.
 Meeting professional nursing standard.
 Meeting standards of accredited hospital.

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THE 6 PHASES OF NURSING PROCESS.
The nursing process is a scientific method used by nurses to ensure the quality of patient care.
The approach can be broken down into six phases;

- Assessment phase
- Diagnosing phase
- Outcome Identification phase
- Planning phase
- Implementation phase
- Evaluation phase

Following these steps systematically in the order shown enables the nurse to organize and
prioritize patient care in the order that is needed. It also helps to ensure that no important
information is overlooked.

6 PHASES OF NURSING PROCESS

Assessment Phase

Evaluati Diagnosing
Phase
ng Phase

Implementation
Phase

Planning
Phase

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ASSESSMENT PHASE
It is a deliberate, systematic and logical collection of subjective and objective data that are
helpful to identify and define problems of the client, before the nurse proceeds to plan the care
(Vaz A. F, 2002). A comprehensive assessment is holistic and includes physical examination,
health history, psychological, sociocultural, emotional and spiritual factors that affect the client’s
health.

Assessing
- Initial assessment
- Focus assessment
-Time-lapsed re-
assement
- Emergency assessment

Evaluating Diagnosing

Outcome
Implementing
Identification

Planning

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Assessing is the systematic and continuous collection, organization, validation and
documentation of data (information). In effect, assessing is a continuous process carried out
during all phases of the nursing process. All phases of the nursing process depend on the
accurate and complete collection of data.

Assessment varies according to their purpose, timing, time available and client status. A nursing
assessment should include the client’s perceived needs, health problems, related experience,
health practice values and life styles. Therefore, nurses should think critically about what to
assess. The Joint Commission (2008) requires that each client have an initial nursing assessment
consisting of a history and physical examination performed and documented within 24hours of
admission as an inpatient.

Purpose of Assessment:

 Gather data about the client (individual, family or community).

 Use the data for diagnosing, identifying outcomes, planning and implementing care.

Reasons for Assessment:

 To gather baseline information about the client.

 To identify the client’s health status and the ability to manage the problems and need for
nursing care.
 To decide about the client’s risk for dysfunctions and presence of any dysfunctions.
 To identify client’s strengths based on how to plan individualized holistic care.
 To bring about positive changes in the client’s health status.
 To provide data for diagnosis.

Types of Assessment:

 Initial Assessment

 Problem-focused Assessment
 Time-lapsed Reassessment
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  Emergency Assessment

- Initial assessment – It is performed within specific time after admission into a healthcare
facility and the purpose is to establish a complete database for problem identification,
reference and future comparison e.g. nursing admission assessment.
- Problem-focused assessment – It is an ongoing process integrated with nursing care and
the purpose is to determine the status of a specific problem identified in earlier
assessment e.g. Hourly assessment of client fluid intake and output in the ICU.
- Emergency assessment – it is done during any pathological or psychological crisis of the
client and the purpose is to identify life threatening problems e.g. Rapid assessment of a
person’s airway, breathing status e.t.c
- Time-lapsed reassessment – it is done several months after initial assessment is over to
compare the client’s current status to baseline data previously obtained. e.g.
Reassessment of a client’s functional health pattern in a homecare or outpatient setting.

Assessment Skills:

Assessment involves recognizing and collecting cues. Cues are pieces of information about
a client’s health status and can be overt or covert (subjective or objective). The clinical
skills utilized for assessment include the following:

 Observation
 Interviewing
 Physical Examination
 Intuition.

Data collection

Data collection is the process of gathering information about a client’s health status. It must be
both systematic and continuous to prevent the omission of significant data and reflect a client’s
changing health status. Both subjective and objective data are collected. Nursing assessments

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provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing
assessment framework is used in practice to identify the patient's problems, risks and outcomes
for enhancing health. The use of an evidence-based nursing framework such as Gordon's
Functional Health Pattern Assessment should guide assessments that support nurses in
determination of NANDA-I nursing diagnoses. For accurate determination of nursing
diagnoses, a useful, evidence-based assessment framework is best practice.

Methods for data collection

- Observation method
- Interviewing method
- Examining method (physical examination)
- Family history/ report

Types of Data

There are two types of data;

1. Subjective data
2. Objective data.

1. Subjective data – are symptoms or covert cues. They are the client’s feelings and
statements about his or her health problems. It is apparently only peculiar to the person
affected and can be described or verified only by that person e.g. itching, pain and feeling
worried.
2. Objective data – it refers to the signs or overt data. They are detectable by an observer,
perceptible or can be measured or tested against an accepted standard. They can be seen,
heard, felt or smelt and they are obtained by observation or physical examination e.g.
dislocation of the skin or a blood pressure reading.

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 Sources of data
Sources of data are mainly from two important sources. These are,

- Primary sources
- Secondary sources

The primary source is the client himself while the secondary source includes family
members or significant others.

Another important source of data collection is the health sources which can also be classified
under the secondary source. It includes health record, laboratory tests and diagnostic
procedures, health team members and literature review.

The Nurse after gathering all the data or information collected documents them
systematically in the appropriate books. This can simply be referred to as organizing the
data. The recorded data collected, will form a permanent part of the medical record.

Validating data

The information gathered during the assessment phase must be complete, factual and accurate
because the nursing diagnoses and intervention are based on this information. Validation is the
act of “double-checking” or verifying data to confirm that it is accurate and factual.

Validating helps the nurse to;

- Ensure that assessment information is complete.

- Ensure that objective and related subjective data agree.
- Obtain additional information that may have been overlooked.
- Avoid jumping to conclusions and focusing in the wrong direction to identify problems.

Documenting Data

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To complete the assessment phase, the nurse records the client’s data. Accurate documentation is
essential and should include all data collected about the client’s health status. Data is recorded in
factual manner and not interpreted by the nurse. For example, the nurse records the client’s
breakfast intake (objective data) as coffee 240mls, juice 120mls, 1 egg and 1 slice of bread.
Rather than as, “his appetite is good” (a judgment).

DIAGNOSING PHASE

Diagnosing is the second phase of the nursing process. In this phase, the nurse uses critical
thinking skills to interpret assessment data and identify the client’s strength and problems.
Nursing diagnoses represent the nurse's clinical judgment about actual or potential health
problems/life process occurring with the individual, family, group or community. The accuracy
of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the
defining characteristics, related factors and/or risk factors found within the patients assessment.
Multiple nursing diagnoses may be made for one client. For example, the diagnosis reflects not
only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor
nutrition, and conflict within the family or has the potential to cause complication e.g. respiratory
infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the
nurse’s care plan.

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 Assessing

Diagnosing
-Analyse data
-Identify health problem
Evaluating risk & strength
-Formulating diagnostic
statement

Outcome
Implementing
Identification

Planning

The diagnosing phase has three steps;

- Analyzing data
- Identifying health problems, risks and strengths
- Formulating diagnostic statement.

Analyzing data: involves the following steps;

- Compare data against standards (identify significant cues)

- Cluster the cues (generate tentative hypothesis)
- Identify gaps and inconsistencies

For experienced nurses, these activities occur continuously rather than sequentially.

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In comparing data with standards, the nurse uses a wide range of standards, such as growth and
development patterns, normal vital signs and laboratory values.

A cue is gotten from data from assessment. The nurse should look for relationships and patterns
from subjective and objective data that deviate from standards and norm. A cue is significant if it
does any of the following.

- Point to positive or negative change in a client’s health status or pattern e.g. the client
states, “I have recently experienced shortness of breath while climbing stairs” or “I have
not smoked for three months.
- Varies from norms of the client population – The client may consider a pattern e.g. eating
very small meals and having little appetite to be normal. This pattern however, may not
be healthy and may require further exploration.
- Indicates a developmental delay. To identify significant cues, the nurse must be aware of
the normal pattern and changes that occur as the person grows and develops e.g. by age
9months an infant is usually able to sit alone without support. The infant who has not
accomplished this task needs further assessment for possible developmental delays.
- Clustering cues involves putting the similar or related cues collected together in groups to
derive a meaning from the data collected, look for a pattern (several cues make up a
cluster).

A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan
care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy
based on basic fundamental needs innate for all individuals. Basic physiological needs/goals
must be met before higher needs/goals can be achieved such as self-esteem and self-
actualization. Physiological and safety needs provide the basis for the implementation of nursing
care and nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the
foundation for physical and emotional health.

Maslow's Hierarchy of Needs

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  Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway
(suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure)
(ABC's), sleep, sex, shelter, and exercise.

 Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation,
suicide precautions, fall precautions, car seat, helmets, seat belts), fostering a climate of
trust and safety (therapeutic relationship), patient education (modifiable risk factors for
stroke, heart disease).

 Love and Belonging: Foster supportive relationships, methods to avoid social isolation
(bullying), employ active listening techniques, therapeutic communication, and sexual
intimacy.

 Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of

control or empowerment, accepting one's physical appearance or body habitus.

 Self-Actualization: Empowering environment, spiritual growth, ability to recognize the

point of view of others, reaching one's maximum potential.

Components of Nursing Diagnosis

o Diagnostic label
o Qualifiers
o Definitions
o Defining characteristics
o Risk factors
o Related factors

o Diagnostic label is the name of the nursing diagnosis. It describes the essence of the
problem using as few words as possible. For example, stress incontinence.

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 o Qualifiers are words used to give additional meaning to a nursing diagnosis. Examples:
altered, impaired, deficient, excessive, dysfunctional, disturbed, ineffective, decreased,
increased, acute, chronic, and intermittent.

o Definition describes the characteristics of the human response under consideration.

o Defining characteristics are major and minor clinical cues that validate the presence of
an actual nursing diagnosis.

o Risk factors are identifiable intrinsic and extrinsic characteristics of the client. E.g. risk
for infection.

o Related factors describe the conditions, circumstances or etiologies that contribute to the
problem. E.g. fluid volume deficit related to vomiting.

After all these have been done, the nursing diagnosis is then documented and the care plan made.

OUTCOME IDENTIFICATION PHASE

This is the formulation of goals and measurable outcomes that provide the basis for evaluating
nursing diagnoses. Outcome identification is the most recent addition to the nursing process, as
described in the current American Nurses Association (ANA) Standards of Clinical Nursing
Practice (2004). The ANA describes seven measurement criteria for outcome identification,
which include specifying intermediate and long-term outcomes that focus on health promotion,
health maintenance, or health restoration.

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 Assessing

Evaluating Diagnosing

Outcome Identification
-Smart
-Measurement
Implementing -Attainable
-Realistic
-Time-framed

Planning

Outcome identification refers to formulating and documenting measurable realistic and client-
focused goals that will provide the basis for evaluating nursing diagnosis. The characteristics of
well-stated outcome criteria are;

 S = Smart
 M= Measurement
 A= Attainment
 R= Realistic
 T= Time-framed

The purpose of the outcome criteria is to ;

- Identify expected outcomes

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 - Provide individualized care. that is culturally appropriate
- Encourage client participation.
- Plan realistic and measurable care.
- Includes a timeline
- Encourage involvement of support people.

PLANNING PHASE

In agreement with the client, the nurse addresses each of the problems identified in the
diagnosing phase. When there are multiple nursing diagnoses to be addressed, the nurse
prioritizes which diagnoses will receive the most attention first according to their severity and
potential for causing more serious harm. The most common terminology for standardized
nursing diagnosis is that of the evidence-based terminology developed and refined by NANDA
International, the oldest and one of the most researched of all standardized nursing languages.
For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects
nursing interventions that will help achieve the goal/outcome, which are aimed at the related
factors (etiologies) not merely at symptoms (defining characteristics). A common method of
formulating the expected outcomes is to use the evidence-based Nursing Outcomes
Classification to allow for the use of standardized language which improves consistency of
terminology, definition and outcome measures. The interventions used in the Nursing
Interventions Classification again allow for the use of standardized language which improves
consistency of terminology, definition and ability to identify nursing activities, which can also be
linked to nursing workload and staffing indices. The result of this phase is a nursing care plan.

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 Assessing

Evaluating Diagnosing

Outcome
Identification
Implementing

Planning
-Specific
-Meaninful/Measurable-
Action-oriented/Attainable
-Result -oriented/Realistic
-Timely/Time-oriented

The planning stage is where goals and outcomes are formulated that directly impact patient care.
These patient-specific goals and the attainment of such assist in ensuring a positive outcome.
Nursing care plans are essential in this phase of goal setting. Care plans provide a course of
direction for personalized care tailored to an individual's unique needs. Overall condition and co
morbid conditions play a role in the construction of a care plan. Care plans enhance
communication, documentation, reimbursement, and continuity of care across the healthcare
continuum.

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Goals should be:

1. Specific

2. Measurable or Meaningful

3. Attainable or Action-Oriented

4. Realistic or Results-Oriented

5. Timely or Time-Oriented

In summary the nurse therefore needs to establish the priorities of the patient first before
developing the outcomes. An estimated timeline for the outcome to be achieved has to be set
before the intervention is carried out. The evidenced based trends /practice are put in place and
the care plan is then documented.

IMPLEMENTATION PHASE
This is the action phase of the nursing process. It is the actual initiation of the plan and
documenting of nursing actions in the nursing care plan. Implementing means to carry out, to
perform, to intervene or to do something. The nursing activities may be carried out by one nurse
or it may be delegated to a group of nurses. Interventions can be independent intervention. i.e.
the nurse is licensed to carry out independent or dependent interventions. i.e. those that are
carried out under the guidance/order of a physician.

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 Assessing

Evaluating Diagnosing

Implementing
-Reassess
-Prioritize Outcome Identification
-Performance
-Documenting

Planning

This phase requires nursing interventions such as applying a cardiac monitor or oxygen therapy,
direct or indirect care, medication administration and other standard treatment protocols. The
nurse implements the nursing care plan, performing the determined interventions that were
selected to help meet the goals/outcomes that were established. Delegated tasks and the
monitoring of them are included here as well.

The following activities are done before the implementing phase;

 pre-assessment of the client-done before just carrying out implementation to determine if it is

relevant
 determine need for assistance
 implementation of nursing orders
 delegating and supervising-determines who to carry out what action

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The purpose of the implementation phase is to provide technical and therapeutic nursing care
required to help the client achieve an optimum level of health.

The activities of Implementation are;

 Reassess the client

 Set priorities
 Perform nursing interventions
 Document nursing action.
Reassess the patient/client: This is necessary to have a basis for evaluation after nursing
care has been rendered.
Priority: As the client’s conditions changes, priorities also change. Nursing interventions
must be carried out based on the priority needs.
Perform Nursing Interventions: Nurses must carry out the nursing interventions listed
in the plan for each client.
Documentation: After implementing the plan, it must be documented in the client’s
record.

To carry out the implementation phase successfully, nurses must have the following skills.
- Intellectual skills.
- Interpersonal skills.
- Technical skills.
During the implementation phase the nurse is expected to do the following;

 Implement in a safe and timely manner

 Use evidence-based interventions
 Collaborate with colleagues
 Use community resources
 Coordinate care delivery
 Provide health teaching and health promotion
 Document implementation and any modification

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Evaluating phase

Evaluation can be defined as the judgment of the effectiveness of nursing care to meet client
goals; in this phase nurse compares the client’s behavioral responses with predetermined client
goals and outcome criteria (Craven, 1996).

This final step of the nursing process is vital to a positive patient outcome. Whenever a
healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the
desired outcome has been met. Reassessment may frequently be needed depending upon overall
patient condition. The plan of care may be adapted based on new assessment data.

Assessing

Evaluating
-Collecting data
-Comparing data
-Relating nursingactivities to
outcomes
Diagnosing
-Drawing conclusion
-Continuing,modifing or terminating
care

Outcome Identification

Planning

The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If
progress towards the goal is slow, or if regression has occurred, the nurse must change the plan
of care accordingly. Conversely, if the goal has been achieved then the care can cease. New
problems may be identified at this stage, and thus the process will start all over again. Evaluation
is crucial to determine whether, after application of the nursing process, the client's condition or

23
well-being improves. The nurse conducts evaluation measures to determine if expected
outcomes are met and not the nursing interventions. The nurses will have to use a variety of
skills to judge the effectiveness of nursing care. These skills include knowledge of standards of
care, normal client responses, and conceptual models of nursing, the ability to monitor the
effectiveness of nursing interventions and awareness of clinical research.

Purpose of Evaluation

- Gather subjective and objective data to make judgments about the nursing care delivered
- Identify the client’s behavioral response to nursing interventions.
- Compare the client’s response with predetermined outcome criteria.
- Appraise the extent to which client’s goals were attained and problems resolved.
- Assess the collaboration of client and health care team members and family members.
- Identify the errors in the plan of care.
- Monitor the quality of nursing care and its beneficial effects on the client’s health status.

Types of Evaluation
 Structure evaluation
 Process evaluation
 Outcome evaluation
Evaluation can concentrate on the improvement of quality of care given to the clients. Quality
improvement means measuring the extent to which standards have been achieved.

Advantages of Nursing Process

It promotes accountability for nursing activities, which in turn promotes quality assurance and
quality health care provision. It promotes critical thinking, decision-making and problem-solving
for the benefits of health care provision. It's outcome-focused and encourages the evaluation of
results.

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  It is patient-centered, helping to ensure that your patient's health problems and his
response to them are the primary focus of care.
 It enables you to individualized care for each patient.
 It promotes the patient's participation in their care, encourages independence and
concordance and gives the patient a greater sense of control - important factors in a
positive health outcome.
 It improves communication by providing you and other nurses with a summary of the
patient's recognized problems or needs so you all work towards the same goals.
 It promotes accountability for nursing activities, which in turn promotes quality assurance
and quality health care provision.
 It promotes critical thinking, decision-making and problem-solving for the benefits of
health care provision.
 It's outcome-focused and encourages the evaluation of results.
 It minimizes errors and omissions in care planning.
 It can be used as a legal document
 It serves as a universal means of documentation all around Nigeria and the world in
general.
 It can be used as a research document.
 High quality patient care depends on the comprehensive care plan developed by the
nurses.

Disadvantages of Nursing Process.

There is little or no disadvantage of the nursing process. A few are,

- Some nurses have not fully understood the concept of the nursing process.
- Some nurses lack the knowledge of the execution of the nursing process.
- Problems related to documenting the nursing process and care plan.
- Problem of continuity of evaluation and re-assessment when necessary.

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How Far Has It Performed In Teaching Hospitals?

According to current American and Canadian practice standards, nursing practice demands the
efficient use of Nursing Process. The professional participation in the activities that contributed
to the present development of knowledge about the methodology is also of utmost importance.
Alfaro. L . (2006). This has therefore led to the demand to establish the Nursing process in
practical care in every health institution, within hospitals as well as in the community as a whole.
Vaz A F, 2002).

In practice, however in teaching hospitals in Nigeria, not all steps are fully systematically
implemented. Studies have revealed difficulties of some nurses in establishing and using the
nursing process within some institutions her in Nigeria. Some private hospitals don’t even have
time to do the care plan. In the work of Reppetto M A, (2005), the evolution of expected results,
in particular, was not adequately recorded in some countries. In some teaching hospitals in
Nigeria, it can be said that it has not met up to the standard due to;

o Lack of motivation of the nurses.

o Lack of manpower.
o Scarce resources e.g. nursing care plan sheets.
o Increased workload leading to lack of time to document in the care plan.

CONCLUTION
The utilization of the nursing process to guide care is critically significant in this dynamic,
complex twenty-first century world of patient care. Healthcare is changing, and the traditional
roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses
are in a position to promote change and impact a more positive patient care delivery in the future.
Critical thinking skills will play a vital role as we develop plans of care for these patient
populations with multiple co morbidities and embrace this challenging healthcare arena.

In the future, nurses must be able to solve problems in a multitude of situations and conditions
they find themselves. Examples are, the challenging nurse-patient ratios, multifaceted

26
approaches to prioritization of care, fewer resources (improvising), nursing informatics
(navigation of the electronic health record) as well as functioning well within the health team and
dynamic leadership style.

A CASE SCENARIO

Mrs. Nwoke an 80yrs old petty trader was rushed to the hospital was rushed to the hospital with
history of stroke by her son who complained that she is unable to speak and eat for 24hours. He
noticed that mouth was now slanted to the left and she was losing consciousness so she was
brought to the hospital.
On examination, she is unconscious with GCS of 5/15 (E1, V1, M3). Vital signs on admission
were T36.5*C, P80b/m, R40c/m, Bp190/110mmHg, SpO2 80%.

Nursing Diagnosis
1. Ineffective breathing pattern related to respiratory muscle fatigue evidenced by
respiratory rate of 40% (tachypnea).
2. Decreased cardiac output related to altered after load evidenced by Bp of
190/110mmHg.
3. Bathing self-care deficit related to unconsciousness (weakness) evidenced by
patient unable to bath herself.
4. Imbalanced nutrition less than body requirement related to insufficient dietary
intake evidenced by food intake less than the recommended daily allowance
(NGTfeeding).
5. Risk for pressure ulcer related to extended period of immobility on the bed.

The cues for the first nursing diagnosis are, being unable to speak, for 24hrs, unconsciousness
with GCS of 5/15, respiratory rate of 40c/m and SPO2 of 80%.
The cues for the second nursing diagnosis are, history of stroke, unable to speak or eat for 24hrs,
mouth slanting to the left, losing consciousness, GCS of 5/15, Bp of 190/110mmHg.
The cues for the third nursing diagnosis are, history of stroke, unable to speak or eat for 24hrs,
mouth slanting to the left, losing consciousness, GCS of 5/15.
The cues for the fourth nursing diagnosis are, unable to eat or speak for 24hrs, mouth slanting to
the left, losing consciousness, GCS of 5/15.
The cues for the fifth nursing diagnosis are, history of stroke, mouth slanting to one side, losing
consciousness, GCS of 5/15.

27
NURSING CARE PLAN OF A PATIENT WITH CARDIOVASCULAR ACCIDENT

Nursing Diagnosis Nursing Nursing Order Scientific Evaluation

Objectives Principle
1.Ineffective Patient will be 1, Put patient in 1, Semi-fowlers Patient breathes
breathing pattern able to breathe semi-fowlers position ensures with ease after
related to with ease at position. proper placement ½ hr of nursing
respiratory fatigue 20c/m within of intra-abdominal intervention.
evidenced by resp. 2hrs of nursing organ thus
40c/m (tachypnea). intervention. relieving pressure
on the diaphragm,
thereby reducing
respiratory
embarrassment.
2, Put the 2, Well ventilated
patient in a room ensures
well ventilated proper air supply
area. for breathing.
3, O2
3, Administer administration
oxygen as increases the
necessary. amount of oxygen
in the patient’s
blood.
4, Observation
4, Observe vital ensures a check on
signs the vital signs.
frequently.
2, Decreased Patient’s Bp will 1, Admit 1, It reduces noise Patient’s Bp
cardiac output come down to patient in a & maintains came down to
related to altered normal (120/80 quiet corner. calmness. within normal
afterload – 130/90mmHg) 2, Encourage 2, this helps to range after 1wk
evidenced by Bp of within 2wks of limitation of encourage rest. of nursing
190/110mmHg nursing visitors and intervention.
intervention. stress
producing
interaction. 3, Anti-
3, Give hypertensive
prescribed reduces Bp by
antihypertensiv relaxing blood
e e.g. vessels so blood
Amlodipine, can flow more
Losartan etc. easily.

28
 4, Antibiotics
4, give resolves infection
prescribed by bacteriostatic or
antibiotics. bacteriocidal
effect.
5, Pulse and Bp
checking will
5, Check vital show when blood
signs especially volume is
Bp & pulse returning to
4hrly and normal.
document
3, Bathing self- Patient activities 1, Bath patient 1, It makes the Patient
care deficit related of daily living daily. patient activities of
to unconsciousness will be comfortable. daily living was
(weakness) maintained until 2, It prevents maintained until
evidenced by she will be able 2, Do oral care she could help
twice daily. mouth odour.
patient unable to to handle it by herself.
bath herself. herself. 3, Do passive 3, It encourages
exercise of the blood circulation.
joint in the
arms, hands,
legs and foot.
4, Imbalanced Patient will not 1, Pass 1, To enable the Patient did not
nutrition less than show any sign of nasogastric patient to feed show any sign
body requirement malnutrition tube for well. of malnutrition
related to within 2 weeks feeding. 2, It prevents fluid after one week
insufficient dietary of nursing 2, Give low retention thereby of nursing
intake evidenced intervention. sodium feed. preventing oedema intervention.
by food intake less
than recommended 3, To improve the
daily allowance 3, Give well health condition of
(NGT feeding). balanced diet. the patient.
4, To assess the
progress of
4, Weigh the therapy.
patient daily.
5, To control fluid
5, maintain balance in the
fluid intake and body.
output chart.
5,Risk for pressure Patient will not 1, Observe 1, Identifies the Patient did not
sore ulcer related develop any pressure point development of develop any
to extended period pressure within pressure sore. pressure after
of immobility on 2-3 weeks of 2, It prevents thee two weeks of
2, Treat

29
the bed. nursing action. pressure areas development of nursing action
every 4hrs. bed sores.
3, Turn patient 3,, It reduces
every 2hrs & pressure on the
change her pressure points
position 4, Maintaining dry
4, Ensure beddings will
dryness & reduce the risk of
protect elbows, friction and
knees and pressure sore.
health with soft
pads.
5, Carry out
pressure limb 5, Exercise
exercise. reduces the risk of
muscle stiffness

30
REFERENCES

Alfaro Lefevre R. Nursing Process Overview. In Kogut H, editor, Applying Nursing Process 6 th
ed. Philadelphia: Lippincot Williams & Wilkins, 2006 p.4-41.

Davis B D, Billing, R, Ryland R K. Evaluation of Nursing Process Documentation, Advanced

Nursing 1994; 19(5):960-8.

Hale C A, Thomas L H, Bond S, Todd C. The Nursing Record as a Research tool to identify
Nursing interventions. J Clin Nurs 1994;6:207-14.

Huckabay LM, editor. Clinical reasoned judgment and nursing process. Nursing Forum. 2009;
44:72-78.
Kim C, Kelly G (2014). Foundations and Adult Health Nursing 7 th Ed. Elsevier Health Services
Division.

Munro N. Evidence- based assessment: No more pride or prejudice. AACN clin issues
2004:15(4): 501-5.

Negi D. (2019).Nursing process. Retrieved on 27/02/2020 from www.canestat.com.

Oxford Advanced Learner’s Dictionary 8th Edition.

Shourideh FA, Ashktorab T. factors Influencing Implementation of Nursing Process by Nurses:

A Qualitative Study, Knowledge Health. 2011; 4:23-6.
Toney-Butler TJ, Thayer JM.(2019) Nursing Process. Retrieved on 27/02/2020 from
https://www.ncbi.nlm.nih.gov/books>google.com.

Vahid Zamanzadeh, Leila Valizadeh, Mojghan Lotfi (2015) Challenges associated with the
implementation of the nursing process: A systemic review. Retrieved on 02/03/2020 from
https://www.ncbi.nlm.nih.gov.

31
Vaz A F, Macedo D D, Montagnoli ETL, MHBM, Grion R C Implementation of Nursing
Process. Rev Latino-am 2002:10(3):288-97.

32
33
References[edit]

1. Funnell, R., Koutoukidis, G.& Lawrence, K. (2009)Tabbner's Nursing Care (5th Edition),
p. 72, Elsevier Pub, Australia.
2. Ackley, B. J., & Ladwig, G. B. (2017). Nursing diagnosis handbook: An evidence-based
guide to planning care (10 ed.). St. Louis: Mosby/Elsevier
3. Marriner-Tomey & Allgood (2006) Nursing Theorists and their work. p. 432
4. Reed, P. (2009) Inspired knowing in nursing. p. 63 in Loscin & Purnell (Eds) (2009)
Contemporary Nursing Process.Springer Pub
5. Kim, H (2010) The Nature of Theoretical Thinking in Nursing. p. 6.
6. Bradshaw, J & Lowenstein (2010) Innovative Teaching Strategies in Nursing and
Related Health Professions.
7. Funnell, R., Koutoukidis, G.& Lawrence, K. (2009) Tabbner's Nursing Care (5th
Edition), p. 222, Elsevier Pub, Australia.
8. "RogerianNursingScience - Chapter 7 Practice
Methods". rogeriannursingscience.wikispaces.com. Retrieved 18 April 2018.

34
 9. ^ Tastan, S., Linch, G. C., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., ... &
Wilkie, D. J. (2014). "Evidence for the existing American Nurses Association-recognized
standardized nursing terminologies: A systematic review". International Journal of
Nursing Studies. 51: 1160–1170.
10. ^ Kozier, Barbara, et al. (2004) Assessing, Fundamentals of Nursing: concepts, process
and practice, 2nd ed., p. 261
11. ^ Barbara Kuhn Timby (2008-01-01), Fundamental Nursing Skills and Concepts,
p. 114, ISBN 978-0-7817-7909-8
12. Oxford Advanced Learner’s Dictionary 8th Edition
13. Vahid Zamanzadeh, Leila Valizadeh, Mojghan Lotfi Challenges associated with the
implementation of the nursing process: A systemic review.

Huckabay LM, editor. Clinical reasoned judgement and nursing process. Nursing Forum. 2009; 44:72-78.

Shourideh FA, Ashktorab T. factors Influencing Implementation of Nursing Process by Nurses: A

Qualitative Study, Knowledge Health. 2011;4:23-6.

References
Toney-Butler TJ, Thayer JM. Nursing Process. [Updated 2019 Jul
30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499937/

Salmond SW, Echevarria M, Allread V. Care Bundles: Increasing

Consistency of Care. Orthop Nurs. 2017 Jan/Feb;36(1):45-
48. [PubMed]

10.

Rigolosi R, Salmond S. The journey to independent nurse practitioner

practice. J Am Assoc Nurse Pract. 2014 Dec;26(12):649-57. [PubMed]

Maslow's Hierarchy of Needs for Nursing. Contributed by Tammy J. Toney-

Butler, AS, RN, CEN, TCRN, CPEN

35
Nursing Process
Tammy J. Toney-Butler; Jennifer M. Thayer.
Author Information

Last Update: July 30, 2019.

Theoretical Basis of Nursing Process:

System theory

Problem-solving process

Decision making process

Information processing theory

Diagnostic reasoning process

36
Issues of Concern
According to a 2011 study conducted in Mekelle Zone hospitals, nurses lack
the knowledge to implement the nursing process into practice and factors
such as nurse-patient ratios inhibit from doing so. Ninety percent of study
participants lacked sufficient experience to apply the nursing process into
standard practice. The study also concluded that a shortage of available
resources, coupled with increased workloads due to high patient-nurse ratios,
contributed to the lack of the nursing process implementation in the delivery
of patient care.[6][7][8]
Go to:

Clinical Significance
The utilization of the nursing process to guide care is clinically significant
going forward in this dynamic, complex world of patient care. Aging
populations carry with them a multitude of health problems and inherent risks
of missed opportunities to spot a life-altering condition.
As explored by Salmond and Echevarria, healthcare is changing, and the
traditional roles of nurses are transforming to meet the demands of this new
healthcare environment. Nurses are in a position to promote change and
impact patient delivery care models in the future.[9][10]
Go to:

Other Issues
Critical thinking skills will play a vital role as we develop plans of care for
these patient populations with multiple comorbidities and embrace this
challenging healthcare arena. Thus, the trend towards concept-based
curriculum changes will assist us in the navigation of these uncharted waters.
Concept-Based Curriculum
Baron further explores this need for a concept-based curriculum as opposed
to the traditional educational model and the challenges faced with its
37
implementation. A direct impact on quality patient care and positive
outcomes. Nursing practice and educational environments form a bond with
clinical knowledge and expertise, and that bond facilitates the transition into
the current workforce as an indispensable team player and leader in this new
wave of healthcare.
Learning should be the focus and the integration into current practice.
Learning is a dynamic process, propelled by a force that must coexist within
the same learning milieu between educator and student, preceptor and novice,
mentor, and trainee.
IN the future, nurses must be able to problem solve in a multitude of
situations and conditions to meet these new adversities: challenging nurse-
patient ratios, multifaceted approaches to prioritization of care, fewer
resources, navigation of the electronic health record as well as functionality
within the team dynamic and leadership style.

Advantages of nursing process.

It can be used as a legal document

It seves as a universal meams of documentation all around niugeria
and the world in genrral.
As research document.
High quality patient care depends onb the comprehensive care plan
developed by the nurses.
With more education and update courses the effectiveness and
accuracy of the nusing process will improve. Be upgraded. Nurses are
becoming more competent.

38
Nursing process provides a professional problem solving approach,
creativity and critical thinking skills, and a humanistic approach, is
accepted tobe a method for explaining science based nursing
interventions.
Taskin Yilmaz F, Sabanciogullari S, Aldemir K. the opinions of nursing
students regarding the nursing process and their levels of proficiency
in Turkey. J Caring Sci 2015; 4(4): 267-75.
Paans W, Nieweg RMB, Van der Schans CP, Sermeus W. What
factors influence the prevailence and accuracy bof nursing diagnosis
documentatipn in clinical practice? A systematic literature review.
Journal on clinical nursing. 2011;20(17-18):2386-2403.
Ardic M. the importance of quality of nursing services. Journal of
Health the Capital. 2011;20:36-8.
Sparks Ralph S, Taylor CM. Nursing diagnosis reference manual 6th
ed. Philadelpheia: Lipppincott Williams and Wilkin’s; 2005.

39
References

Shih CY, Huang CY, Huang ML, Chen CM, Lin CC, Tang FI. The
association of sociodemographic factors and needs of haemodialysis
patients according to Maslow's hierarchy of needs. J Clin Nurs. 2019
Jan;28(1-2):270-278. [PubMed]

5.

Maslow K, Mezey M. Recognition of dementia in hospitalized older

adults. Am J Nurs. 2008 Jan;108(1):40-9; quiz, 50. [PubMed]

Salmond SW, Echevarria M, Allread V. Care Bundles: Increasing

Consistency of Care. Orthop Nurs. 2017 Jan/Feb;36(1):45-
48. [PubMed]

10.

40
Mrs. Nwoke an 80yrs old petty trader was rushed to the hospital was rushed to the
hospital with history of stroke by her son who complained that she is unable to speak
and eat for 24hours. He noticed that mouth was now slanted to the left and she was
losing consciousness so she was brought to the hospital.
On examination, she is unconscious with GCS of 5/15 (E1, V1, M3). Vital signs on
admission were T36.5*C, P80b/m, R40c/m, Bp190/110mmHg, SpO2 80%.

Nursing Diagnosis
6. Ineffective breathing pattern related to respiratory muscle fatigue
evidenced by respiratory rate of 40% (tachypnea).
7. Decreased cardiac output related to altered after load evidenced by Bp of
190/110mmHg.
8. Bathing self-care deficit related to unconsciousness (weakness)
evidenced by patient unable to bath herself.
9. Imbalanced nutrition less than body requirement related to insufficient
dietary intake evidenced by food intake less than the recommended daily
allowance (NGTfeeding).

41
 10. Risk for pressure ulcer related to extended period of immobility on the
bed.

NURSING CARE PLAN OF A PATIENT WITH CARDIOVASCULAR ACCIDENT

Nursing Nursing Nursing Scientific Evaluation

Diagnosis Objectives Order Principle
1.Ineffective Patient will be 1, Put patient 1, Semi-fowlers Patient
breathing pattern able to breathe in semi- position ensures breathes with
related to with ease at fowlers proper ease after ½
respiratory 20c/m within position. placement of hr of nursing
fatigue 2hrs of nursing intra-abdominal intervention.
evidenced by intervention. organ thus
resp. 40c/m relieving
(tachypnea). pressure on the
diaphragm,
thereby reducing
respiratory

42
 embarrassment.
2, Well ventilated
room ensures
proper air supply
2, Put the for breathing.
patient in a
well ventilated 3, O2
area. administration
increases the
amount of
3, Administer oxygen in the
oxygen as patient’s blood.
necessary. 4, Observation
ensures a check
on the vital
signs.

4, Observe
vital signs
frequently.
2, Decreased Patient’s Bp 1, Admit 1, It reduces Patient’s Bp
cardiac output will come down patient in a noise & came down to
related to altered to normal quiet corner. maintains within normal
afterload (120/80 – 2, Encourage calmness. range after
evidenced by Bp 130/90mmHg) limitation of 2, Anti- 1wk of nursing
of 190/110mmHg within 2wks of visitors and hypertensive intervention.
nursing stress reduces Bp by
intervention. producing relaxing blood
interaction. vessels so blood
3, Give can flow more
prescribed easily.
antihypertensi 4, Antibiotics
ve e.g. resolves
Amlodipine, infection by
Losartan etc. bacteriostatic or
4, give bacteriocidal
prescribed effect.
antibiotics. 5, Pulse and Bp
5, Check vital checking will
signs show when
especially Bp blood volume is
& pulse 4hrly returning to
and document normal.

43
3, Bathing self- Patient 1, Bath 1, It makes the Patient
care deficit activities of patient daily. patient activities of
related to daily living will 2, Do oral comfortable. daily living
unconsciousness be maintained care twice 2, It prevents was
(weakness) until she will be daily. mouth odour. maintained
evidenced by able to handle until she could
patient unable to it by herself. 3, Do passive 3, It encourages help herself.
bath herself. exercise of blood circulation.
the joint in the
arms, hands,
legs and foot.
4, Imbalanced Patient will not 1, Pass 1, To enable the Patient did not
nutrition less show any sign nasogastric patient to feed show any sign
than body of malnutrition tube for well. of malnutrition
requirement within 2 weeks feeding. 2, It prevents after one week
related to of nursing 2, Give low fluid retention of nursing
insufficient intervention. sodium feed. thereby intervention.
dietary intake preventing
evidenced by oedema
food intake less
than 3, To improve
3, Give well the health
recommended
balanced diet. condition of the
daily allowance
(NGT feeding). patient.
4, To assess the
progress of
4, Weigh the
therapy.
patient daily.
5, To control fluid
5, maintain
balance in the
fluid intake
body.
and output
chart.
5,Risk for Patient will not 1, Observe 1, Identifies the Patient did not
pressure sore develop any pressure point development of develop any
ulcer related to pressure within 2, Treat pressure sore. pressure after
extended period 2-3 weeks of pressure 2, It prevents two weeks of
of immobility on nursing action. areas every thee nursing action
the bed. 4hrs. development of
3, Turn bed sores.
patient every 3,, It reduces
2hrs & pressure on the
change her pressure points
position 4, Maintaining
4, Ensure dry beddings will
dryness & reduce the risk of

44
protect friction and
elbows, knees pressure sore.
and health 5, Exercise
with soft reduces the risk
pads. of muscle
Pressure limb stiffness
exercise.

45