Process

is a series of planned actions or

operations directed toward a particular
result.
Nursing Process
Is a systematic rational method of
planning and providing nursing care.
 National Council of State
Boards of Nursing (1982)

Defined and described the 5

step NP
a. Assessing
b. Analyzing
c. Planning
d. Implementing
e. Evaluating
NANDA ( North American Nursing
Diagnosis Association) 1982
was organized and published a book in
1990 that serves as guide in
formulating nursing diagnosis.
Nursing Process
• A systematic rational method of planning and providing nursing care
• A cyclical process; its components follow a logical sequence, but
maybe one component maybe involved at one time.
GOALS OF THE
NURSING PROCESS

To identify client’s
actual or potential
health care
needs/problems

To establish plans to
meet the identified
needs

To deliver & evaluate

specific nursing
intervention to meet
those needs
•Assessing
Activities during assessment:

1. Collecting Data all the information

gathered is called DATABASE:

• Nursing Health History

• Physical Assessment
• Results of laboratory & diagnostic tests
• Materials contributed by to other health
personnel
2 Types of Data
a. Subjective Data
Those that can be describe only by the
person experiencing it. (symptoms or
covert data)

Examples: itching, pain, feelings of worry,

client’s sensation, feelings, values, beliefs,
attitude & perception of personal health
status & life situation.

b. Objective Data
Those that can be observed and
measured. (signs/overt data)

Examples: discoloration of the skin or a blood

pressure reading
Methods of
Data
Collection
a. Interview
b. Observation
c. Examination
Sources of Data
a. Primary
patient/client
b. Secondary
Family members, significant
others, Patient’s record/chart,
Health Care rofessionals, Literature, etc.
2. Verifying/ Validating Data
making sure that the information
gathered is correct.

3. Organizing Data
Clustering Facts into a group of
information.

4.Documenting/Recording
 Gordon’s Typology of 11 functional health
patterns

Gordon uses the word pattern to signify sequence of

recurring behavior

The nurse collects data about dysfunctional as well

as functional behavior.

Using Gordon’s framework to organize data, nurses

are able to discern (to detect/perceive by
eyes/intellect)
 1. Health Perception/Health management
– describes the client’s perceived pattern of health &
well being & how health is managed.

Aware/understand medical diagnosis

Gives thorough history of illnesses & surgeries
Relates progression of illness in detail
Expects to have antibiotic therapy & “go home in a day or
two”
States usual eating pattern “ 3 meals a day
 2. Nutritional/Metabolic Pattern
– Describes the clients pattern of food &
fluid consumption relative to metabolic need
& pattern indicators of local nutrient supply.

Eating pattern
Amount of fluid intake
Appetite
Weight & height
 3. Elimination pattern
Describes the patterns of excretory functions
(bladder, bowel & skin)

Urine elimination (approximate amount , color or any

discomfort)

Bowel elimination (color, consistency, frequency or any

discomfort)

4. Activity-exercise pattern
– Describes the pattern of exercise, activities,
leisure, & recreation.
 5. Sleep-rest pattern
– Describes patterns of sleep, rest & relaxation.

6. Cognitive-perceptual pattern
– Describes sensory-perceptual & cognitive
patterns

Orientation to time, place & person

Consciousness/responsiveness
Sensory deficits
Ability to think (reasoning, appropriateness of words,
manner of speech)
Self-perception/self-concept pattern
Describes the client’s self-concept and perceptions of self
(e.g., self-worth, comfort, body image, feelings state)

Role-relationship patterns
Describes the client’s pattern of role participation &
relationships.

Sexuality-reproductive pattern
Describes the client’s patterns of satisfaction &
dissatisfaction with sexuality pattern; describes
reproductive patterns
10. Coping/Stress-tolerance pattern
Describes the client’s general coping pattern &
effectiveness of the pattern in terms of tress
tolerance.

11. Value-belief pattern

Describes the patterns of values, beliefs (including
spiritual), and goals that guide the client’s choices or
decisions.
•Diagnosing
❖ formulate diagnostic statement/interpreting
data and identify client strengths and problems
❖ a pivotal step in the nursing process.
 Nursing Diagnoses
• A statement of nursing judgement and refers to a condition
that nurses, by virtue of their education, experience and
expertise are licensed to treat.
• Describe the human response, a client’s physical, sociocultural,
psychologic, and spiritual response to illness or health
problem.
• Change as the client response change.
Types of Nursing Diagnoses
❖Actual Diagnosis
❖ Problem that is present at the time of the nursing assessment and based on
the presence of the associated signs and symptoms.
❖Ex:Ineffective breathing pattern
Types of Nursing Diagnoses

❖Risk Nursing Diagnosis

❖ a clinical judgment that a problem does not exist,
but the presence of risk factors indicates that a
problem is likely to develop unless intervened.
❖Ex: Risk for infection
Types of Nursing Diagnoses
❖Wellness Diagnosis
❖ Describes human responses to levels of wellness in an individual, family or
community that have a readiness for enhancement.
❖ Ex: Readiness for enhanced spiritual well-being or readiness for enhanced family coping.
Types of Nursing Diagnoses
❖ A Possible Nursing Diagnosis
❖Evidence about the health problem is incomplete or unclear. This diagnosis
requires more data either to support or refute it.
❖Ex: Possible social isolation related to unknown etiology.
Types of Nursing Diagnoses
❖Syndrome diagnosis
❖ Diagnosis associated with cluster of other diagnoses

• Example: risk for disuse syndrome (long term bedridden clients), impaired physical
mobility, risk for activity intolerance, risk for impaired tissue integrity, risk for injury.
Formulating Diagnostic Statements
• Basic Two-Part Statements
❑ Problem (P): Statement of the client’s response
❑ Etiology (E) : Factors contributing to or probable causes of the responses.
2 parts are joined by the words related to (implies relationship) rather than due
to (one part causes or responsible for the other).
Ex: Risk Nursing diagnoses
Formulating Diagnostic Statements
• Basic Three-Part Statements
PES format
❑ Problem (P): Statement of the client’s response
❑ Etiology (E) : Factors contributing to or probable causes of
the responses.
❑ Signs and Symptoms (S): defining characteristics
manifested by the client.
Ex: Actual Nursing Diagnoses
Formulating Diagnostic Statements
• Basic One-Part Statements
❑ As the diagnostic labels are refined, they tend to become more specific that,
so that the nursing interventions can be derived from the label itself.
Therefore an etiology may not be needed.
❑ Ex: Wellness diadnosis
❑Readiness for enhanced followed by the desired higher level wellness (Readiness for
enhanced parenting).
Variations of Basic Formats
❑Writing Unknown Etiology
Noncompliance (medication regimen) related to unknown
etiology.
❑ Using the phrase Complex Factors
Chronic Low Self Esteem related to complex factors.
❑ using the word Possible
Possible low self-esteem related to loss of job
Altered thought processes possibly related to unfamiliar
surroundings.
Variations of Basic Formats
❑Using secondary to (dividing etiology into 2 parts)
Risk for impaired skin integrity related to decreased
peripheral circulation secondary to diabetes.
❑ Adding a second part/descriptor to a general
response to make it more precise
Impaired skin integrity (left lateral ankle)related to
decreased peripheral circulation.
NANDA
Purpose of NANDA is to define, refine, and promote a taxonomy
of nursing diagnostic terminology of general use to professional
nurses.

Taxonomy is a classification system or set of categories

arranged based on a single principles.

DEFINITIONS:
Diagnosing - refers to reasoning process.
Diagnosis – statement or conclusion regarding the nature of a
phenomenon.
Diagnostic Labels – standardize NANDA names for diagnoses.
 Activities During Diagnosing
1. Organize or cluster data
2. Compare data against standards
3. Analyze Data
4. Identify gaps and inconsistencies in data
5. Determine the client’s health problems
6. Formulate nursing diagnosis statements
7. Validate the diagnosis
 Components of Nursing Diagnosis
Diagnosis & Etiology/relate Defining
definition d factors characteristics
Bed rest or ➢Verbal report of
Activity immobility fatigue or
Intolerance: weakness
Insufficient
Generalized ➢Abnormal heart
physiological or
weakness rate or BP response
psychological
to activity
energy to
complete Sedentary life ➢Exertional
required or style discomfort or
desired outcome dyspnea
 Guidelines for writing a Nursing Diagnostic Statement

Correct Incorrect & ambiguous

Guideline
Statement statement

1. statement Deficient fluid

of a problem, volume (problem) Fluid replacement
not a need related to fever (need) related to fever

Impaired skin
2. word the integrity related Impaired skin integrity
statement so to immobility related to improper
that it is legally (legally positioning (implies
advisable acceptable) legal liability)
Guidelines for writing a Nursing Diagnostic Statement
Correct Incorrect &
Guideline
Statement ambiguous statement
Spiritual distress
related to
inability to
attend church Spiritual distress
services related to strict rules
3. use non- secondary to necessitating church
judgmental immobility (non- attendance
statement judgmental) (judgmental
 Guidelines for writing a Nursing Diagnostic Statement

Guideline Correct Statement Incorrect & ambiguous statement

4. make sure that both

elements of the Risk impaired skin Impaired skin integrity related to
statement do not say integrity related to ulceration of sacral area (response &
the same thing immobility probable cause are the same)

5. be sure that the

cause & effect are
correctly stated that is
etiology causes the Pain: severe headache
problem or puts the related to fear of addiction
client risk for the to narcotics
problem Pain Related to head Ache
 Guidelines for writing a Nursing Diagnostic Statement
Incorrect & ambiguous
Guideline Correct Statement
statement
Impaired oral mucous
6. word the diagnosis
specifically &
membrane related to
precisely to provide decrease salivation
direction for secondary to radiation Impaired oral mucous
planning nursing of neck (specific) membrane related to noxious
intervention agent (vague)

Risk of ineffective airway

7. use nursing clearance related to
terminology to accumulation of
describe the secretions in lings (nursing Risk for pneumonia (medical
client's response. terminology) terminology)
 Guidelines for writing a Nursing Diagnostic Statement

Incorrect & ambiguous

Guideline Correct Statement
statement

8. Use nursing
terminology rather
than medical Risk for Ineffective
terminology to airway clearance
describe the related to Risk for ineffective airway
probable cause of accumulation of clearance related to
the client’s secretions in the lungs emphysema (medical
response (nursing terminology) terminology)