The Nursing Process
Elizabeth Bruderle
Villanova University

The Nursing Process

In 1980, The American Nurses’ Association (ANA) defined nursing as:

        The diagnosis and treatment of HUMAN RESPONSES to actual or potential health problems



     A problem-solving method
 Systematic, goal-directed, flexible, rational approach
 Ensures consistent, continuous, quality nursing care
Provides a basis for professional accountability
 Input of nurse and patient/family critical

  The Steps of the Nursing Process are cyclic, overlapping and interrelated:


Step One of the Nursing Process:

 Assessment:  the most critical step

Answers the questions: “What is happening?” (actual problem), or 
“What could happen?” (potential problem)

    Involves collecting, organizing, and analyzing information/data about the patient

Results in  Nursing Diagnoses

    Two parts: Data collection & Data analysis

1. Data Collection: A Holistic Approach

  Types of data

     Subjective: “symptoms” that the patient describes; e.g. “I can’t do anything for myself”
 Objective: signs that can be observed, measured, and verified; e.g. swollen joints

  Sources of data

      Primary: the patient; is always the best source
  Secondary: everything/everybody else

 Methods of Data Collection


    Requires practice and skill
Systematic, head-to-toe (cephalocaudal)

Results in objective, factual information
Document exactly what you observe

         e.g. “Yawned frequently, had dark circles under eyes”

                  NOT “Patient seems tired”     

Observation results in a General Survey   

The General Survey: a brief description of patient’s appearance and behavior.

          64 year old, well groomed African-American male in acute distress. Awake, alert, and oriented. Approximately 6’, 170lbs. Hair sparse and gray, eyes brown. Sitting on side of bed, holding siderail for support. Verbal responses coherent but halting.       



Methods of data collection


Structured form of communicationPurpose: to provide care specific to this individual’s needs and problems
Focus: patient’s perceptions
Nurse must: explain purpose of interview, provide comfort and privacy, ensure confidentialityResult: A comprehensive Health History

Components of  the Health History

    Demographic data
CC: chief complaint
HPI: history of present illness
PMH: past medical history
FMH: family medical history (genogram)
ROS: review of systems
Psychosocial history

 Methods of Data Collection



Nurse must: explain what you are doing, provide privacy, and ask permission before you touch the patient   

2. Data Analysis

     Data review

          Are data accurate and complete?

     Data interpretation

          What are the patient’s actual and/or potential problems?
Develop a problem list based on the data
Prioritize the patient’s problems


Step Two of the Nursing Process  

Nursing Diagnosis:  a statement  that describes a specific human response to an actual or potential  health problem that requires nursing intervention  

       Written in P E format

          P = Problem: use North American Nursing Diagnosis Association (NANDA) category  
[due to or related to]

          E = Etiology: cause of the problem


The Patient

 A Holistic-Physical-Emotional-Psychosocial-Developmental-Spiritual Being

                         Data Base

Medical Diagnosis        Nursing Diagnosis

Rheumatoid Arthritis Self-care deficit:bathing, related to joint stiffness                        


Step Three of the Nursing Process

    Plan: to provide consistent, contiuous care that will meet the patient’s unique needs.

     Includes Patient Goals & Nursing Orders

        Patient Goals: describe the desired result of  nursing care                       

          What will the patient (or part of the patient) do to resolve or lessen the problem identified in the         nursing diagnosis?

           By when will this be accomplished?           


Patient Goals are directly related to the patient’s problem as stated in the nursing diagnosis:

          One goal should describe resolution of the problem
Additional goals should describe steps that contribute to problem resolution
Patient Goals  can be long term or short term

Patient Goals are:

    Focused on the patient   
Clear and Concise
Observable, Measurable, Realistic: how much? how far? how long? how well?
Written with a specific time frame: by when should the goal be accomplished?
Determined by the nurse and the patient
Mr. H. will perform entire bath unassisted by 4-4-01


Nursing Orders

          Describe what the nurse will do to help the patient achieve the goals.

      Nursing Orders must:

        Focus on nursing actions
    Describe when and how the nurse will perform nursing actions
   Include the date & be signed by the nurse 3/30/01 
       The nurse will assist Mr. H. with bathing qAM until he is able to bathe independently. E. Bruderle, RN 


Step Four of the Nursing Process

    Implement: Carry out the care plan

          Reassess the patient
Validate that the care plan is accurate
Carry out nurses’ orders
Document on  patient’s chart

Step Five of the Nursing Process  

     Evaluate: Compare the patient’s current status with the stated Patient Goals

          Were the goals achieved? Why not?
Review the nursing process


Problem: “I can’t do anything for myself”

Nursing Diagnosis: Self care deficit: bathing, related to joint stiffness
Patient Goal
(resolution): Mr. H. will perform entire bath unassisted by 4-4-00.
Patient Goal
(contributory): Mr. H. will bathe his upper body unassisted by 4-1-00.
Nursing order
: 3/30/01 The nurse will assist Mr. H. with bathing q AM until he is able to bathe independently. E.Bruderle RN Evaluation: Was Mr.. H. able to bathe unassisted by 4-4-00?