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.
ADPIE
Assessing

Diagnosing
Evaluating

Planning
Implementing
 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 professionals,
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
• Diagnosing
v formulate diagnostic
statement/interpreting data and identify
client strengths and problems
v 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
vActual Diagnosis
v Problem that is present at the time of the nursing
assessment and based on the presence of the
associated signs and symptoms.

vEx: Ineffective breathing pattern

 Types of Nursing Diagnoses

vRisk Nursing Diagnosis

v 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.
vEx: Risk for infection
 Types of Nursing Diagnoses
vWellness Diagnosis
v Describes human responses to levels of wellness
in an individual, family or community that have a
readiness for enhancement.
v Ex: Readiness for enhanced spiritual well-being or readiness
for enhanced family coping.
Formulating Diagnostic Statements
• Basic Two-Part Statements
q Problem (P): Statement of the client’s response
q 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
Risk for infection related to tissue desctruction
Formulating Diagnostic Statements
• Basic Three-Part Statements
PES format
q Problem (P): Statement of the client’s response
q Etiology (E) : Factors contributing to or probable
causes of the responses.
q Signs and Symptoms (S): defining characteristics
manifested by the client.
Ex: Actual Nursing Diagnoses
Ineffective airway clearance related to retained
mucous secretions as evidenced by unproductive
cough
Formulating Diagnostic Statements
• Basic One-Part Statements
q 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.
q Ex: Wellness diagnosis
qReadiness for enhanced --followed by the desired
higher level wellness (Readiness for enhanced
parenting/comfort/knowledge/nutrition).
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 – standardized 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/rela Defining
definition ted factors characteristics
Activity ØVerbal report of
Intolerance: Bed rest or fatigue or
Insufficient immobility weakness
physiological
ØAbnormal heart
or
Generalized rate or BP
psychological
weakness response
energy to
to activity
complete
required or Sedentary ØExertional
desired lifestyle discomfort or
outcome dyspnea
•Planning
– A deliberative systematic process that
involves decision making and problem
solving. Client’s assessment data and
diagnostic statements should be utilized in
formulating client goals.
Goal/ Desired Outcome/ Outcome Criteria/
Objective
Ø Refers to formulating & documenting, measurable,
realistic, client focused goals.
Ø Basis for evaluating nursing diagnosis.
Ø Written in a manner that they answer questions:
who, what actions, under what circumstances, how well,
and when.
Ø Involves determining beforehand the
strategies or course of action to be taken
before implementation of nursing care.
ØA broad statement about what the
client’s state will be after the nursing
intervention is carried out.
• Goal - A broad statement
Ex: Improved nutritional status
v Desired Outcome – specific
Ex: Gain 5 lb by April 25.
When goals are stated broadly, the care plan
should include goals and desired outcomes, it
can be combined into one statement linked by
the words “as evidenced by”
Ex: Improved nutritional status as evidenced by
weight gain of 5 lb by April 25.
Purpose of Goals/ Desired Goals
• Provide direction for planning nursing
interventions
• Serve as a criteria for evaluating client
progress
• Enable the client and the nurse to determine
if the problem has been resolved
• Help motivate the client and the nurse by
providing a sense of achievement.
Components of Goals/ Desired Goals
• Subject
The client or some attribute of the client
• Verb
denote directly observable behaviors (administer, show,
walk)
• Conditions or modifiers
Explain what, where, how, when (walks with the help of a
cane)
• Criterion of desired performance
criteria may specify time or speed, accuracy, distance, and
quality (Walks one block per day)
 Guidelines for Writing Goals/
Desired Goals
• Write goals and Outcomes in terms of client
response and not nurse activities.
Ex: Client will drink 100 ml of water per hour.
• Must be realistic for the client’s capabilities,
limitations and designated time span.
 Guidelines for Writing Goals/
Desired Goals
• Must be compatible with the therapies of
other health professionals
• Must be derived from only one nursing
diagnosis
• Use observable, measurable terms for
outcomes.
• Client should consider it as important and of
value
Guidelines for Writing Goals/ Desired Goals
S – Specific
M - Measurable
A – Attainable
R – Realistic
T – Time bounded
• Purposes:
1. To identify client’s goal and appropriate
nursing interventions.
2. To direct client care activities
3. To promote continuity of care
4. To focus charting requirements
5. To allow for delegation of specific activities.
• Intervention/
Implementation
Carry out the care plan,
Communicate the care plan to members of the
hlt. Care team.

3 types of interventions:
1. Independent
2. dependent
3. collaborative/ interdependent
• Requirements of Implementation:
1. Knowledge
2. Teaching Skills
3. Communication Skills
4. Therapeutic use of self
• Evaluation
Ø Assessing the client’s response to nursing
interventions and then comparing the response
to predetermined standards or outcome
criteria.
ØEvaluate goal achievement
ØTerminate care for goals achieved
ØReassess and revise care plans if goals were not
achieved.
• Possible statements:

The goal was completely met… (The client

response is the same as the desired outcome
The goal was partially met…( partially attained)
The goal was completely unmet…
Two Parts of Evaluation Statement
• Conclusion:
is a statement that the goal was met/ not
met ….
• Supporting Data :
Oral intake 300 ml more than output; skin
turgor resilient, mucous membrane moist.
• Quality Client Care
• Continuity of Care
• Participation of clients in their health care
• Consistent systematic nursing education
• Job Satisfaction
• Professional Growth
• Avoidance of adverse legal consequences
• Meeting Professional Nursing Standards
• Meeting standards of accredited hospitals
• Problem Oriented
• Goal Oriented
• Systematic
orderly/planned
• Flexible/ Dynamic
Open to accepting new information during its application
• Interpersonal
nurse should communicate consistently with clients
• Permits creativity
• Cyclical
steps may overlap because it is interrelated
• Universal
applicable to all types of Clients
Humanistic
great consideration to the unique needs
and concerns of individual clients.

It is individualized and involves aspect of

human dignity.

Efficient
Relevant to the needs of the client

Promotes client’s satisfaction and

progress

Effective
Utilizes resources wisely in terms of
human, time, cost resources
 I. Family Assessment
1. Initial Data Base
a. Family Structure,
characteristics and dynamics

composition & demographic data

of the family or household.

Type of family, relationship within

the family members

Family interaction and

communication

Decision making patterns and

dynamics
b. Socio-economics and cultural
characteristics

Income, occupation, place

of work

Educational attainment of each

member

Ethnic background and religious

affiliation

Significant others & other roles

they play in the family’s life

Relationship of the family to the

larger community
c. Home environment
information on housing & sanitation
facilities.
availability of social, health,
communication & transportation
facilities in the community.

d. Health status of each member

past/current significant illness

beliefs or practices about health

nutritional and developmental health
status

decision-making on which or whom to

seek advice regarding health
e. Values and practices on
health promotion and
maintenance

preventive measures, adequate

rest, sleep, exercise and
relaxation activities

street management activities,

utilization of health care
facilities.

2. Family Health Tasks

II. Statement of Family
Health Conditions
statement of family’s
capabilities to maintain health
and prevent illness.
a. Ability to recognize the
signs of health and
development

b. Ability to manage health

and non- health crisis
 c. Ability to provide
health care to its members

d. Ability to provide a
home environment
conducive to good health
and personal development

e. Ability to utilize
community resources for
health care.
III. Formulating Goals and
Outcome Criteria

Goal – General statement of the

condition or the state to be brought
about by specific course or action.

Outcome Criteria
refer to more specific statements of
the desired results or outcomes of
care.
Eg.
Goal: After 2-3 months, the family will be
able to maintain ability to recognize signs of
health and development.
Outcome Criteria:

At the end of 2-3 months, the

family will:

Identify signs of health and

development.

Perform usual activities for

health and development.
IV. Family Health Care
Strategies
1. Assisting in prenatal care

a. History
b. Signs and symptoms of
pregnancy
c. prenatal check-ups
d. Immunization
e. Nutrition
f. Personal habits
g. others (sexual, travel,
activities, medications)
2. Care of the Newborn
a. Breast feeding (advantages,
steps)
b. Supplementary Feeding
c. cord care
d. bathing
e. immunization
3. Parenting
4. Environmental Care and
Sanitation
a. cleanliness in the home
b. backyard sanitation
5. Health Education
V. Evaluation
specifies how health care provider will determine the
achievement of the outcome of care.

Ex. Goal’s met as evidenced by…..