NCM 100 SKILLS

THE NURSING PROCESS

o The cornerstone of nursing profession.

o It is used to be 3 – step process, then 4 – step process (APIE), then a 5 – step process
(ADPIE), now a 6 – process (ADOPIE) – Assessment, Diagnosis, Outcome, Identification,
Planning, Implementation, and Evaluation.
o Lydia Hall originated the term “Nursing Process” in 1955. She introduced three – steps
of nursing process: _______________, _______________, ________________.
o Dorothy Johnson introduced three (3) steps of nursing process as
follows:____________, _____________, _________________ (1959).
o Ida Jean Orlando identified three steps of nursing process:________________,
____________, (1961).
o Yura and Walsh suggested the four components of nursing process namely, assessing,
planning, implementing, and evaluating (1967).
o Knowles described nursing process as discover, delve, decide, do, discriminate (1967).
o American Nurses Association introduced the following innovation in the nursing
process:
 Diagnosis distinguished as separate step of nursing process.
 Diagnosis of actual and potential health problems delineated as integral part of nursing
practice (1980).
 Outcome identification differentiated as a distinct step of the nursing process are as
follows: Assessment, Diagnosis, Outcome Identification, Planning, Implementation,
Evaluation (1991).

NURSING PROCESS is:

1. Organized & Systematic
2. Humanistic
3. Goal – oriented
4. Humanistic Care

SIX PHASES OF THE NURSING PROCESS

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
 A. ASSESSMENT – is collecting, validating, organizing and recording data about the client’s
health status (may be an individual, family or community).

Purpose: To establish a data base.

Activities during Assessment:
1. __________________________
Gathering information about the client, considering the physical, psychological,
emotional, socio- cultural, and spiritual factors that may affect his/ her health status.

 Types of Data:
a. Subjective Data (Symptoms)
- Those that can be described only by the person experiencing it, e.g. vertigo is dizziness,
tinnitus is ringing in the ears.

b. Objective data (Signs)

- Those that can be observed and measured, e.g. pallor, diaphoresis, BP= 120/ 80,
reddish urine.

METHODS OF COLLECTION OF DATA:

a. Interview – planned purposeful conversation.
b. Observation – e.g. use of senses, use of units of measure, physical examination
techniques, interpretation of laboratory results.

2. Verifying/ Validating Data – making sure your information is accurate.

3. Organizing data – clustering facts into groups of information.

B. _____________________– is a process which results to a diagnostic statement or nursing

diagnosis.
o It is the clinical art of identifying problems.
o To diagnose in nursing, it means to analyze assessment information and derive meaning
from this analysis.
Purpose: To identify the client’s health care needs and to prepare diagnostic statements.

Nursing Diagnosis –________________________________________________________. It

uses the critical – thinking skills of analysis and synthesis. Uses PRS/ PES format.
P – problem
R – related to factors
S – signs and symptoms
P – problem
E – etiology
S – signs and symptoms
ACTIVITIES DURING DIAGNOSING:
o Organize cluster or group data. E.g. pallor, dyspnea, weakness, fatigue, RBC=4
M/cu.mm, Hgb =10g/dl., pertain to problems with oxygenation.
o Compare data against standards.
___________________- are accepted norms, measures, or patterns for purposes of
comparison. (e.g. the standard color of the sclera is white; the standard color of the urine is
amber).
o Analyze data after comparing with standards.
o Identify gaps and inconsistencies in data.
o Determine the client’s health problems, health risks, and strengths.
o Formulate Nursing Diagnoses statements.

Examples of Nursing Diagnoses:

1. Anxiety related to insufficient knowledge regarding surgical experience.
2. Risk for injury related to sensory and integrative dysfunction as manifested by altered
mobility and faulty judgment.
3. Ineffective airway clearance related to tracheobronchial infection as manifested by
weak cough, adventitious breath sounds, and copious green sputum production

Comparison of Correct and Incorrect Nursing Diagnoses:

 Correct: High risk for ineffective airway clearance related to thick, copious mucus
secretions
 Incorrect: High risk for ineffective airway clearance related to pneumonia.
 Correct: High risk for injury related to disorientation.
 Incorrect: High risk for injury related to absence of side rails.
 Correct: High risk for self – concept disturbance related to the effects of mastectomy
(surgical removal of breast)
 Incorrect: Mastectomy related to cancer.

C. OUTCOME IDENTIFICATION
- ___________________________________________________________.
- It provides the basis for evaluating nursing diagnosis.
Purposes:
o To provide individualized care.
o To promote client participation.
o To plan care that is realistic and measurable.
o To allow involvement of support people.

Activities during Outcome Identification:

o Establish priorities.
 o PRIORITY – is something that takes precedence in position, deemed the most
important among several items.

_____________________– is a decision – making process that ranks the order of

nursing diagnoses in terms of importance to the client.

o ESTABLISHING PRIORITIES INVOLVE THE FOLLOWING:

a. Life – threatening situations should be given highest priority, e.g. difficulty in breathing,
hemorrhage, suicidal tendencies.
b. Use the principle of ABC’s (Airway, Breathing, Circulation); Airway should always be
given the highest priority.
c. Use Maslow’s hierarchy of needs; Physiologic needs are given priority over psychosocial
needs.
d. Consider something that is very important to the client, e.g. pain, anxiety.
e. Clients with unstable condition should be given priority over those with stable
conditions. E.g. attend to the client with fever before attending to the client who is
scheduled for physical therapy in the afternoon.
f. Consider the amount of time, materials, equipment required to care for clients, e.g.
attend to the client who requires dressing change for postop wound before attending to the
client who requires health teachings and is ready to be discharged late in the afternoon.
g. An actual problem takes precedence over potential concerns.
h. Attend to the client before equipment, e.g. assess the client before checking contraptions
like IV fluids, urinary catheter, drainage tubes.

o Nursing diagnoses are classified as high – priority, medium – priority and low -
priority:
a. High – priority nursing diagnoses – are those that are potentially life – threatening and
require immediate action. Examples include Impaired Gas Exchange, Ineffective
Breathing Pattern, Self – Directed Risk for Violence.

b. Medium – priority nursing diagnoses – are those that could result in unhealthy
consequences, such as physical or emotional impairment, but are not life – threatening.
Examples include Fatigue, Activity Intolerance, Ineffective Coping, and Dysfunctional
Grieving.

c. Low – priority nursing diagnoses – involve problems that usually can be resolved easily
with minimal interventions and are unlikely to cause significant dysfunction. Examples
include sensation of hunger in a client who is on NPO (nothing by mouth), I preparation for
a diagnostic procedure; minimal pain on the third postoperative day, related to
ambulation.
ESTABLISH CLIENT’S GOALS AND OUTCOME CRITERIA:

o _________________________– is an educated guess, made as a broad statement,

about what the client’s state will be after the nursing intervention is carried out.
o Behavioral goals are written to indicate a desired state. They contain an action verb and
a qualifier that indicate the level of performance that needs to be achieved.

Examples of behavioral verbs used in client goals are as follows:

Calculate distinguish participate classify
Draw practice communicate explain
Recall compare express recite
Define Identify record demonstrate
List state describe name
Use construct maintain verbalize
Contrast perform

ESTABLISH CLIENT’S GOALS AND OUTCOME CRITERIA:

o The qualifier is a description of the parameter for achieving the goal.
o “Ambulates safely with one – person assistance;” “Demonstrates signs of sufficient rest
before surgery;” Identifies actual and high – risk environmental hazards;” States the
importance of adopting appropriate health maintenance behaviors.
o Goals may be short – term or long – term.
____________________ – can be met in a relatively short period (within days or less than a
week).
____________________ – requires more time (several weeks or months).

o Outcome criteria – are specific, measurable, , realistic statements or goal attainment.

Outcome criteria are written in a manner that they answer the questions: who, what
actions, under what circumstances, how well, and when.
o Therefore the characteristics of well stated outcome criteria are as follows:
S- _____________; M – ______________; A – ______________; R –____________ ;
T – _______________

Examples of goals and outcome criteria are as follows:

1. Goal
The client will report a decreased anxiety level regarding surgery.

Possible outcome criteria

 During client teaching, the client discusses fears and concerns regarding surgical
procedure.
 After client teaching, the client verbalizes decreased anxiety.
 The client identifies a support system and strategies to use to reduce stress and anxiety
related to the surgical experience.

2. Goal
The client will demonstrate safety habits when performing ADL’s (activities of daily
living) and injury prevention.
Possible outcome criteria
 The client uses call light system for assistance at each need to use bathroom
immediately after instruction by the nurse.
 The client demonstrates safety practices in dressing and hygiene.
 The client uses over – the – bed – lights, non – skid slippers when transferring to chair
or out of bed.
 The client identifies modification for home safety (removal of throw rugs, installation of
hand rails in hallway, better lighting of hallway and stairway) 12 hours after nurse’s
instruction about home safety.

3. Goal
The client will mobilize pulmonary secretions

Possible outcome criteria

 After teaching session, the client demonstrates proper coughing techniques.
 The client drinks at least six glasses of water per day while in hospital.
 The caregiver or significant other demonstrates proper techniques of chest
physiotherapy including percussion, vibration, and postural drainage , before discharge.

D. PLANNING – involves determining beforehand the strategies or course of actions to be

taken before implementation of nursing care. To be effective, involve the client and his
family in planning.

Purposes:
 To identify the client’s goals and appropriate nursing interventions.
 To direct client care activities.
 To promote continuity of care.
 To focus charting requirements.
 To allow for delegation of specific activities.

o Plan nursing intervention.

 To direct activities to be carried out in the implementation phase.
 Nursing interventions are “ any treatment, based upon clinical judgment and
knowledge, that a nurse performs to enhance client outcomes”. They are used to
monitor health status ; prevent, resolve, or control a problem; assist with activities of
daily living (ADL’s); or promote optimum health and independence.
 Nursing interventions are also called NURSING ORDERS.
 Nursing interventions are independent, dependent, and interdependent activities that
nurses carry out to provide client care.

o Write a nursing plan of care.

 _____________________– is a written summary of the care that a client is to receive. It
is the “blueprint” of the nursing process.
 The plan of care is nursing centered. This is essential to identify the scope and depth of
the nursing practice . By focusing on the treatment of human responses to actual or
potential health problems, the nurse remains in the nursing practice domain.
o PLAN NURSING INTERVENTION.
 The plan of care is a step – step process. This is evidenced by the following.
 Sufficient data are collected to substantiate nursing diagnoses.
 At least one goal must be stated for each nursing diagnosis.
 Outcome criteria must be identified for each goal.
 Nursing interventions must be specifically designed to meet the identified goal.
Each intervention should be supported by a scientific rationale. The scientific rationale
is the justification or reason for carrying out the intervention.

SAMPLE NURSING PLAN OF CARE

 NURSING DIAGNOSIS
(Use the NANDA – accepted list of nursing diagnoses. List in priority order. Use the
diagnostic label “related to”(supporting defining characteristics).
Risk for injury related to sensory and integrative dysfunction manifested by altered
mobility and faulty judgment.

 Client Goal
(One or more client goals established from nursing diagnosis . A broadly stated
objective that indicates an overall picture of the state of the client if the problem is
resolved.)

Client will demonstrate safety habits when performing ADL’s and injury prevention.
 Client Outcome Criteria
(Specific, measurable, realistic statements, that can be evaluated to judge goal
attainment. Stated as behavioral objectives, they include a verb, a short phase
describing the specific measure to be accomplished, and a time reference.)
 Client uses call light system for assistance for each need to use the bathroom
immediately after instruction by the nurse.
 Client demonstrates safety practices in dressing and hygiene.
 Client uses over – the – bed lights, nonskid slippers each time when transferring to
chair or out of bed.
  Client identifies modification for home safety (removal of throw rugs, installation of
hand rails in hall way, better lighting of hallway and stairway) 12 hours after nurse’s
instruction about home safety.

NURSING INTERVENTIONS SCIENTIFIC RATIONALE

(Write nursing interventions/ nursing
orders that are related to the goal.
Interventions include who, what,
when, and how the order is to be
carried out.)
1. Position bed in lowest position.
2. Place client call light system within
reach of hand and give instruction.
3. Explain all safety modifications of
the client’s room: removal of clutter,
providing a clear path to bathroom,
use of a night light, installing breaks on
bed and chairs, placement of call light.
4. Perform frequent visual checks of
the patient.
5. Evaluate the client’s ability to use
toilet; obtain raised toilet seat or grab
bars if indicated.
6. Evaluate the client’s ability to use
toilet; obtain raised toilet seat or grab
bars if indicated.
obtain raised toilet seat or grab bars if
indicated.
7. Assist the client to perform hygiene
at sink with large mirror; encourage
client to scan the whole visual field.
8. Discuss floor plan of home with
client and support person. Make
suggestions for modifications that will
lead to a safer environment.
(Give reason for carrying out the
intervention. Demonstrates synthesis of
physiologic, psychological and
pathophysiological concepts).
1. Low bed position minimizes distance to
floor if client falls.
2. A call light allows client to call for help.
3. Client and family will feel safer if they
are aware of safety promotion strategies.
4. Client may attempt to get out of bed or
chair without calling for assistance.
5. A safety belt allows for control/
monitoring of client movement without
trauma to any body part.
6. Clients with hip muscle weakness may
be unable to rise from low toilet seat.
Grab bars may assist the weak person to
move slowly and safely.
7. Mirror provides client with visual
reinforcement of activity.
8. Client and support person need
to be involved in planning from
client’s safety in the home.

E. IMPLEMENTATION – is putting the nursing care plan into action.

Purpose: To carry out planned nursing interventions to help the client attain goals and achieve
optimal level of health.
Activities:
 Reassessing. To ensure prompt attention to emerging problems.
 Set Priorities. To determine the order in which the nursing interventions are carried
out.
 Perform Nursing Interventions. These may be independent, dependent, or
collaborative measures.

Record Actions. To complete nursing interventions, relevant documentation should be done.

REQUIREMENTS OF IMPLEMENTATION
1. Knowledge. Include intellectual skills like problem – solving decision – making and
teaching.
2. Technical skills – To carry out treatments and procedures.
3. Communication Skills – Use of verbal and non – verbal communication to carry out
planned nursing interventions.
4. Therapeutic Use of Self. It is being willing and being able to care.

F. EVALUATION
- Is assessing the client’s 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.

Activities:
 Collect data about the client’s response.
 Compare the client’s response to goals and outcome criteria.
 The four possible judgments that may be made are as follows:
 The goal was completely met.
 The goal was partially met.
 The goal was completely unmet.
 New problems or nursing diagnoses have developed.

CHARACTERISTIC OF NURSING PROCESS

 Problem- oriented. It is comparable with scientific problem solving approach.
 Goal oriented.
 Orderly planned, step by step (systematic).
  Open to accepting new information during its application. It is applicable to meet the
unique needs of client, family, group or community (dynamic).
 Interpersonal. It requires that the nurse communicate directly and consistently with
the client.
 Permits creativity among nurses and clients in devising ways to solve the health
problems.
 Cyclical. Steps may overlap because they are interrelated.
 Universal. It is applicable to individuals, families and communities.

BENEFITS OF THE NURSING PROCESS FOR THE CLIENTS

1. Quality client care. It meets standards of care.
2. Continuity of care.
3. Participation by the clients in their health care. This reflects respect for human dignity.

BENEFITS OF THE NURSING PROCESS FOR THE NURSE

1. Consistent and systemic nursing education.
2. Job satisfaction.
3. Professional growth.
4. Avoidance of legal action.
5. Meeting professional nursing standards.
6. Meeting standards of accredited hospitals.