THE

NURSING PROCESS

THE NURSING PROCESS

The NURSING Process

is the way one thinks like a nurse.
This process is the foundation,
the essential, enduring skill that
has characterized nursing from
the beginning of the profession.

 The

nursing process is a
systematic, rational method of
planning and providing
individualized nursing care for
individuals, families, groups
and communities.

Nursing Process
- provides the framework in which
nurses use their knowledge and skills
to express human caring and to help
clients meet their health needs.
- a systematic, rational method of
planning and providing care using the
process of ADPIE.

Through the years the nursing

process has changed and evolved,
growing in clarity and
understanding

Its goal are:

to identify a clients actual or
potential health care needs,
to establish plans to meet the
identified needs, and
to deliver and evaluate specific
nursing interventions to meet those
needs. (Kozier.2004)

Characteristics of the Nursing

Process:
1. Systematic
2. Skills and Knowledge-based
3. Cyclical
4. Dynamic
5. Client-centered
6. Interpersonal and Collaborative
7. Universal
8. Goal-oriented
9. Priority-based

The NURSING Process is

divided into five steps

Steps:
1. ASSESSMENT
2. DIANOSIS
3. PLANNING
4. IMPLEMENTATION
5. EVALUATION

1. ASSESSMENT

What brought you to the hospital?

Let me have a look at that.
Describe how you are feeling.

STANDARD I. The nurse collects

client health data.

PHASE I:
ASSESSMENT

- is Collecting, Organizing,
Validating, and Recording data
about a clients health status.
Purpose:
- To establish a data base.

4 Types of Assessment:

1. Initial Assessment
- completed upon admission.
- Ex. Nursing History, Assessment
Worksheet
2. Problem-Focused/Ongoing
Assessment
- on-going assessment performed
during nursing care.
- Ex. Hourly Assessment of Intake and
Output

3. Emergency Assessment
- rapid assessment of the patients
ABC during any physiologic and
psychologic crisis.
- Ex. Cardiac Arrest, Suicidal Ideation
4. Time-Lapse Reassessment
- assessment performed in two periods
of time.
- Ex. Operation Timbang, Assessment
for Hypertension

Different Methods of Assessment:

1. Observation
- gathering data using the 5 senses.
2. Interview
- a planned and purposive conversation
between the nurse and the client.
A. Directive interview:
- highly structured
- elicits specific information.
B. Nondirective interview:
- less structured
- allows the client to verbalize his thoughts
and feelings.

3 Types of Interview Questions:

1. Closed-ended
2. Open-ended
3. Leading questions

3. Physical Examination
- systematic data collection method
using the techniques of IPPA.
- objective data are collected.
2 Types of Data:
1. Subjective
- data that are apparent only to the
person affected.
2. Objective
- data that can be seen, heard, felt,
smelled, or even tasted.

2. DIAGNOSIS

What

is the problem?
What is the Cause?
How do I know it?

STANDARD II. The nurse

analyzes the assessment

PHASE II:
NURSING DIAGNOSIS

- is a clinical judgment about

individual,
family,
or
community
responses to actual and potential health
problems/life processes.

C clustering
A analysis
N nursing diagnosis formulation

TYPES OF NURSING DIAGNOSIS:

1. ACTUAL DIAGNOSIS
- judgment about a clients response to a
health problem at the time of assessment
and signified by the presence of
associated signs of symptoms.
Examples:
Fluid volume deficit
Ineffective airway clearance

2. RISK NURSING DIAGNOSIS

- a clinical judgment that a client is
more vulnerable to develop the
problem than others in the same
situation.
Examples:
Risk for injury
Risk for infection

3. POSSIBLE NURSING DIAGNOSIS

- evidence about a certain health
problem is unclear or the causative
factors are unknown; needs collection of
more data either to support or refute it;
not a real type or nursing diagnosis.
Examples:
Possible social isolation
Possible ineffective coping

4. WELLNESS DIAGNOSIS
- is a clinical judgment about an
individual, family, or community in
transition from a specific level of
wellness to a higher level of wellness.
Example:
Readiness for enhanced spiritual
well-being

COMPONENTS OF A NURSING
DIAGNOSIS:
1. Problem
- clients response to his/her illness.
- ex. Elimination, Breathing pattern,
airway clearance
* Qualifiers words added to give
meaning to the diagnostic statement.
- ex. Decreased, Ineffective,
Impaired

2. Etiology
- related factor/probable cause.
3. Signs and symptoms
- defining characteristics.
- evidences or manifestations.

Guidelines for Writing Nursing

Diagnosis

1. Word the statement so that it is

legally advisable.
Example:
Impaired skin integrity related to
improper positioning

2. Make sure that both elements of the

statement do not say the same thing.
Example:
Impaired skin integrity related to skin
ulceration.

3. Make sure to use universally

accepted abbreviations.
Example:
Ineffective airway clearance related to
accumulation of secretions

4. Use nursing terminology rather than

medical term to describe the clients
response.
Example:
Ineffective airway clearance related to
pneumonia.

5. Use non-judgmental statements.

Example:
Ineffective sexuality pattern related to
sexual role confusion.

6. Word the diagnosis specifically and

precisely to provide direction for
planning nursing intervention.
Example:
Impaired oral mucous membrane
related to noxious agent.

NURSING DIAGNOSIS
VERSUS
MEDICAL DIAGNOSIS
Nursing Diagnosis
Focus on identifying human
responses to health and illness
Describe problems treated by
nurses within the scope of
independent nursing practice
Changes from day to day as the
client responses change

Medical Diagnosis
Identifies diseases
Describe problems for which the
physician directs the primary
treatment

Remains the same for as long as

the disease is present

3. PLANNING

What can I do about it?

What is most important?
What do I want to happen, by when?

STANDARD III. The nurse identifies

expected outcomes individualized to
the client.
STANDARD IV. The nurse develops a
plan of care that prescribes
intervention to attain expected
outcomes.

PHASE III:
PLANNING

- a deliberative, systematic phase of the

nursing process that involves decision
making and problem solving.
- the nurse refers to the assessment
data and the diagnostic statement.
- the end product is the creation of NCP.
- begins upon the admission and ends
when nurse-patient relationships ends.

PLANNING involves the following

activities:
Establishing priorities.
Writing goals/outcomes and
developing an evaluate strategy.
Selecting nursing
strategies/interventions.
Developing nursing care plans
Communicate the plan of nursing care.

Types of Planning:

1. INITIAL PLANNING
- the nurse who performs the
initial
admission
assessment
develops the initial comprehensive
plan of care; needs refinements when
missing data becomes available.

2. ONGOING PLANNING
- using ingoing assessment data, the
nurse carries out daily planning for the
following purposes:
a. to determine whether the clients health
status has changed
b. to set the priorities for the clients care
during the shift
c. to decide which problems to focus on
during the shift
d. to coordinate the nurses activities so
that more than one problem can be
addressed at each client contact

3. DISCHARGE PLANNING
- the process of anticipating and
planning for needs after discharge; is
becoming
a
crucial
part
of
comprehensive healthcare.

Effective discharge planning begins at the

time of admission where each client is
assessed for:
a. potential health needs
b. availability and ability of the clients
support network to assist with these
needs
c. how the home environment supports the
client, and
d. client, family, and community resources

Types of Discharge Planning:

A. Simple/Basic
- patient has been discharged from
the agency and proceeded directly into
his/her home.
B. Complex
- patient is discharged from the
agency and returned to another health
care institution.

Setting Priorities
- the process of establishing the
preferential sequence or rank of
interventions in accordance to the
clients most immediate needs.

Nursing Goal/Expected Outcome

- declaration of purpose/ intention
which directs interventions.
Types of Goals:
1. Short Term
- can be achieved in a short period of
time.
2. Long Term
- requires longer period of time to be
accomplished.

PURPOSE of GOALS/EXPECTED
OUTCOMES:

1. Provide direction for planning nursing

interventions.
2. Provide a time span for planned
activities.
3. Serve as a criteria for evaluation of client
progress
4. Enable client and nurse to determine
when the problem has been resolved.
5. Help motivate client and nurse by
providing a sense of achievement.

Guidelines in Writing Goals and Outcomes:

1. The goals must pertain to the client.

2. It should be realistic.
3. It should be compatible with the
therapies of other health professionals.
4. It must be specific.
5. It must be written in behavioral terms.
6. It should be measurable.
7. It should be time-bounded.

Intervention Selection
1. Independent
- nurse-initiated.
Example:
Health Teaching,
Taking Vital Signs,
Making NCP

2. Dependent
- physician-initiated.
- performed under the doctors
order and supervision.
Example:
Medications,
Blood Transfusion,
Catheterization

3. Collaborative/Interdependent
- overlapping functions among
health care team.
Example:
Diet,
Laboratory Exams

4. IMPLEMENTATION
Move

into action.
Carry out the plan.
STANDARD V. The nurse
implements the interventions
identified in the plan of care.

PHASE IV:
IMPLEMENTATION

- is putting the nursing care plan in

action.
Activities:
1. Reassessing
2. Set priorities
3. Perform nursing intervention
4. Record actions

Composed of 3 Ds:
1. Doing
2. Delegating
3. Documenting

Doing
* Cognitive Skills intellectual skills
* Technical Skills psychomotor
skills
* Interpersonal Skills
communication skills
Activities:
1. Reassessing the client.
2. Prepare the client physically and
psychologically.
3. Prepare the equipment and supplies.
4. Implement the interventions.
5. Communicate the nursing actions.

Delegation
- the transfer of responsibility or task to a
subordinate with commensurate authority
while retaining accountability for the
outcome.
5 Rights to Delegation
1. Right Task
2. Right Circumstance
3. Right Person
4. Right Direction/Communication
5. Right Supervision

Activities that cannot be delegated:

1. Initial and ongoing assessment.
2. Planning, nursing diagnosis
formulation and evaluation.
3. Education and supervision of the
nursing personnel.
4. Special activities like Sterile
procedures.
5. Speech and signing of names.

Activities that can be delegated:

1. Routine activities.
- Vital signs taking
- Bed bath
2. Clean procedure.
- Enema
- Ear irrigation

5. EVALUATION
Did it work?
Why or why not?
Is the problem solved, or do I need
to try again?

STANDARD VI. The nurse

evaluates the clients progress
towards attainment of outcomes.

PHASE V:
EVALUATION

- is assessing the clients response

to nursing interventions and then
comparing the response to
predetermined standards or outcome
criteria.

Purpose:
To appraise the extent to which
goals and outcome criteria of nursing
care have been achieved.

3 Types of Evaluation:
1. Ongoing
2. Intermittent
3. Terminal

3 Possible Judgments during

Evaluation:
1. Goal met
2. Goal partially met
3. Goal not met

4 Types of Outcome Evaluated:

1. Cognitive
2. Psychomotor
3. Affective
4. Physiologic

Quality Assurance

1. Structure Evaluation
- physical settings, condition through
which care is given.
2. Process Evaluation
- pertains to the manner on how the
care was given.
3. Outcome Evaluation
- pertains to any changes in the
clients health status as a result of the
nursing intervention.

Nursing Care Plan blueprint of

the nursing process