BACHELOR OF SCIENCE IN NURSING

NCMA 113 (Fundamentals of Nursing)

COURSE MODULE COURSE UNIT WEEK
2 8&9 9 & 10
NURSING PROCESS: PUTTING IT ALL-TOGETHER

• Read course and unit objectives

• Read study guide prior to class attendance
• Read required learning resources; refer to unit terminologies for jargons
• Proactively participate in classroom discussions
• Participate in weekly discussion board (Canvas)
• Answer and submit course unit tasks.

Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts,
process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition

At the end of the course unit (CM), learners will be able to:
Cognitive
• Apply the steps of the nursing process to the provided scenario.
• Discuss each step of the nursing process, actions taken by nurses during each step, and the
rationale of each action as it is applied.
Affective
• Identify how critical thinking is an important element of the nursing process.
 Psychomotor
• Create a nursing care plan.

Nursing Care Plan – A document that provides direction on the type of nursing care the
individual/family/community may need. This facilitates standardized, evidence-based and holistic
care.

The nursing process is a cyclic, ongoing method of providing client-centered care. It is a tool
used by nurses to promote organization and utilization of the steps to achieve desired outcomes,
that is, goal attainment and problem resolution.
As the client enters the health care system, nurses are involved in decision making. Care is
planned for the client based on data continuously collected and analyzed. Initial data collected
become the database used for comparison of future data.
Nurses use skills vital to all steps of the nursing process: critical thinking, problem solving
and decision-making. Critical thinking is a purposeful thought process, in which deliberate
questions are asked in search of meaning of data. Nurses solve problems by the analyzing
collected data in order to understand and make decisions regarding client needs. Decisions are
made based on the nurse’s understanding of scientifically based theories and knowledge of
standards. These skills and others are employed as nurses interact with clients. Each intersection
is an opportunity for the nurse to assess and evaluate client responses to care and medical
treatment, as well as the effectiveness of care.
In this module, a review of the nursing is presented. The nursing process steps are applied
to a sample scenario, as if providing care to a client. A nursing care plan is a document that
provides direction on the type of nursing care the individual/family/community may need. This
facilitates standardized, evidence-based and holistic care.

SAMPLE SCENARIO
John is a 38-year old architect. He is still single and enjoying his bachelor’s life.
He is a nonsmoker but drinks alcohol – “occasionally two to three drinks.” Later he
says he has drunk this amount almost daily for the past 10 years. Since his
appendectomy around 13 years ago, he has not had any medical examination.
“the past few months have been stressful at work and my eating habits have been
irregular. Sometimes I have occasional nausea and vomiting.” This has advanced
from being a mild epigastric upset to constant midepigastric pain radiating to the
back. This pain at first was relieved by pain medications, but “now it is not relieved
by anything, although I realized sitting forward helps me to relax a little bit while
 waiting in the doctor’s clinic for my turn.” The clinic desk clerk described that John
entered the doctor’s clinic walking bent forward with his hands holding his
epigastric area. During examination, he reported severe pain (9/10) with
abdominal guarding and with purplish discoloration of the umbilical area. His
respirations are shallow with rate of 26 breaths per minute. Heart rate was 110
beats/minute with a BP 120/80 mmHg. He was diagnosed with acute pancreatitis.

STEP 1. ASSESSMENT
Assessment includes collection, validation, organization, and interpretation of data. As the data are
collected, verified, and validatedfor accuracy, the nurse assigns meaning and groups data into
clusters. Data clustering is used to determine the relatedness of facts, to find patterns, and to
determine if further data are needed.

Subjective and Objective Data

Subjective Data Objective Data
Non smoker Abdominal guarding (hand holding the
Drinks alcohol for the past 10 years epigastric area)
History of Appendectomy Purplish discoloration of the umbilical area
Complained of stress at work RR – 26 breaths per minute
Irregular eating habits Shallow respirations
Occasional nausea and vomiting HR – 110 beats per minute
(+) midepigastric pain
Pain relief while sitting forward
Pain scale of 9 out of 10

Clustering Data
Pain
(+) midepigastric pain
Pain relief while sitting forward
Pain scale of 9 out of 10
Abdominal guarding (hand holding
the epigastric area)
Purplish discoloration of the umbilical
area
Hydration Physical Regulation
Occasional Drinks alcohol for the past 10 years
nausea and History of Appendectomy
vomiting Complained of stress at work
Irregular eating habits
RR – 26 breaths per minute
Shallow respirations
HR – 110 beats per minute

STEP 2. DIAGNOSIS
Diagnosis involves critical thought and judgment to analyze, organize, and interpret assessment
data. Problems, risk problems, and strengths are identified and labeled with NANDA nursing
diagnoses.
 • Acute pain related to inflammation of the pancreas as evidenced by guarding behavior, pain
scale of 9/10, increased heart rate and respiratory rate
• Risk for deficient fluid volume risk factors include excessing gastric losses (vomiting)
STEP 3. PLANNING
Planning the care for the client involves several steps:
• Identifying priority problems
• Setting realistic goals and expected outcomes
• Determining nursing interventions and scientific rationale
• Communicating and documenting the care plan
The planning step should involve discussing the plan with the client for input and collaboration.
This encourages client participation and promotes the client’s sense of control. Careful, effective
planning advocates and ensures delivery of quality care.

In our scenario, John demonstrated outstanding signs and symptoms in the area of pain, hydration
and activity. After collaborating with the client, he confirmed that pain is his priority problem at the
moment. Establishing goals and outcomes follow priority problem identification.

Nursing Diagnosis: Acute pain related to inflammation of the pancreas as evidenced by guarding
behavior, pain scale of 9/10, increased heart rate and respiratory rate

Goal/client outcome: John will report decreased sensation of pain and absence of abdominal
guarding within 2 hours.

STEP 4. IMPLEMENTATION

Planned nursing interventions are executed during implementation. Each interaction with the client,
during this phase, is an opportunity to assess and reassess, and collect ongoing data and
comparing it to baseline. Priority interventions are carried out first. However, nurse may perform
interventions for more than one problem at the same time.

STEP 5. EVALUATION

Evaluation measures the effectiveness of nursing care and the quality of care provided. Like
assessment, evaluation is an ongoing and cyclical activity. After each intervention was carried out,
client responses are evaluated and client is reassessed. Evaluation will help the nurse decide
whether to modify, sustain or to end the plan of care.

Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts,
process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition
Seaback, Wanda (2007) Nursing process: concepts & application Singapore, Delmar Learning, 2nd
edition
Weber, Janet R. Kelley, Jane H. (2013) Health Assessment in Nursing Lippincott Williams and
Wilkins, 5th edition

Baumann, A., & Blythe, J. (2008). Globalization of higher education in nursing. The Online
Journal of Issues in Nursing, 13(2).
Baxter, P. E., & Boblin, S. L. (2007). he Moral Development of Baccalaureate Nursing
Students: Understanding Unethical Behavior in Classroom and Clinical Settings. Journal
of Nursing Education.
Brooks, A. (2019, August 19). What Is a Nursing Intervention? A Beginner’s Guide. Retrieved
from Rassmusen College: https://www.rasmussen.edu/degrees/nursing/blog/nursing-
intervention-beginners-guide/
Categorizing Care: A Guide to Nursing Interventions. (2017, July). Retrieved from Husson
University: https://online.husson.edu/nursing-interventions-nic-system/
NANDA. (2020). NANDA Nursing Diagnosis List. Retrieved from NANDA Nursing Diagnosis
List: http://www.nandanursingdiagnosislist.org/
Nurse Journal.org. (n.d.). The Value of Critical Thinking in Nursing + Examples. Retrieved from
Nurse Journal: https://nursejournal.org/community/the-value-of-critical-thinking-in-
nursing/
Registered Nursing.org. (2020, March 2). Therapeutic Communication: NCLEX-RN. Retrieved
from Registered : https://www.registerednursing.org/nclex/therapeutic-communication/
Roseman University ABSN. (n.d.). What is a three-part nursing diagnosis? Retrieved from
Roseman University of Health Sciences:
https://acceleratednursing.roseman.edu/blog/three-part-nursing-diagnosis/
Science Direct. (2019). Nursing Process. Retrieved from science Direct:
https://www.sciencedirect.com/topics/nursing-and-health-professions/nursing-process
Toney-Butler, T. J., & Thayer, J. M. (2019). Nursing Process. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK499937/

WEEK 9
Choose one and read the case scenario and apply the five steps of the nursing process.
Identify three appropriate nursing diagnoses. For each nursing diagnosis provide one
goal/expected outcome, three nursing interventions with scientific rationale, and one
evaluative statement. Follow the standard format of a nursing care plan. Outputs will be
critiqued on the next week.

Steve Rogers, an 80-year old man, was taken to the hospital by his daughter who
stated that her father was weak, vomited four times, and has pain in his belly. She is
also informed that his appetite is poor and he is very anxious. On assessment of the
client, he is lethargic, states his pain is a 9 on a scale of 1-10. He vomited three times,
100 milliliters each of greenish fluid, and passed approximately 150 milliliters of urine in
the urinal. His temperature is 38.2 C, pulse 80bpm, respiration 22cpm and blood
pressure 140/80 mmHg.

Tony Stark is a 36-y/o police officer assigned to a high crime police precinct. One week
ago he received a surface bullet wound to his arm. Today he arrives at the outpatient
clinic to have the wound redressed. While speaking with the nurse, Mr. Stark mentions
that he has been promoted to the rank of detective and has assumed new
responsibilities. He states that since his promotion, he has experienced increasing
difficulty falling asleep and sometimes staying asleep. He expresses concern over the
danger of his occupation and his desire to do well in his new position. He complains of
waking up feeling tired and irritable. During interview the nurse notes that he is pale,
drawn with dark circles under his eyes. Temp: 37.0 C Pulse: 80 bpm, Resp: 18cpm,
BP: 140/90mmHg

WEEK 10. PEER CRITIQUING. Submitted nursing care plans will be distributed among the
class. Each student must submit a critique paper on the nursing care plan done by his/her
classmate.