NURSING PROCESS

WHAT IS NURSING
PROCESS?
•Nursing process is defined as a systematic,
rational method of planning that guides all nursing
actions in delivering holistic and patient-focused
care. 
•The nursing process is a form of scientific
reasoning and requires the nurse’s critical thinking
to provide the best care possible to the client.
 • To identify the client’s health status and actual or
potential health care problems or needs (through
assessment).
• To establish plans to meet the identified needs.
• To deliver specific nursing interventions to meet
those needs.
PURPOSE OF • To apply the best available caregiving evidence and
promote human functions and responses to health
NURSING and illness (ANA, 2010).
PROCESS • To protect nurses against legal problems related to
nursing care when the standards of the nursing
process are followed correctly.
• To help the nurse perform in a systematically
organized way their practice.
• To establish a database about the client’s health
status, health concerns, response to illness, and the
ability to manage health care needs.
CHARACTERISTICS OF THE
NURSING PROCESS
 1. PATIENT-CENTERED

• The unique approach of the nursing process

requires care respectful of and responsive to
the individual patient’s needs, preferences, and
values. The nurse functions as a patient
advocate by keeping the patient’s right to
practice informed decision-making and
maintaining patient-centered engagement in the
health care setting.
 2. INTERPERSONAL

• The nursing process provides the basis for the

therapeutic process in which the nurse and
patient respect each other as individuals, both
of them learning and growing due to the
interaction. It involves the interaction between
the nurse and the patient with a common goal.
 3. COLLABORATIVE

• The nursing process functions effectively in nursing and inter-professional

teams, promoting open communication, mutual respect, and shared
decision-making to achieve quality patient care.
 4. DYNAMIC AND CYCLICAL

• The nursing process is a dynamic, cyclical process in which each phase

interacts with and is influenced by the other phases.
 5. REQUIRES CRITICAL THINKING

• The use of the nursing process requires critical thinking which is a vital skill
required for nurses in identifying client problems and implementing
interventions to promote effective care outcomes
PHASES OF NURSING PROCESS
 ADPIE

ASSESSING

DIAGNOSING

PLANNING

IMPLEMMENTING

EVALUATING
 1. ASSESSING

• The first step in nursing process.

• is the systematic and continuous collection, organization,
validation, and documentation of data.
• assessing is a continuous process carried out during all phases
of the nursing process.
• A nursing assessment should include the client’s perceived
needs, health problems, related experience, health practices,
values, and lifestyles.
4 TYPES OF NURSING ASSESSMENT
 • Data collection is the process of gathering
information about a client’s health status.
COLLECTING
• It must be both systematic and continuous to prevent
DATA the omission of significant data and reflect a client’s
changing health status.
TYPES OF DATA
 SUBJECTIVE DATA (SYMPTOMS)

• covert data
• Are apparent only to the person affected and can be described or verified only
by that person.
• Itching, pain, and feelings of worry are examples of subjective data.
• Subjective data include the client’s sensations, feelings, values, beliefs, attitudes,
and perception of personal health status and life situation.
e.g. ”I am unwell today”
“I’m feeling bloated”
 OBJECTIVE DATA (SIGNS)

• overt data
• are detectable by an observer or can be measured or tested against an
accepted standard.
• They can be seen, heard, felt, or smelled, and they are obtained by
observation or physical examination.
• During the physical examination, the nurse obtains objective data to validate
subjective data and to complete the assessment phase of the nursing
process.
e.g Body temperature of 38.2
Distended abdomen
Foul smelling wound
•Constant data is information that does not change over
time such as race or blood type.
•Variable data can change quickly, frequently, or rarely and
include such data as blood pressure, level of pain, and age.
SOURCES OF DATA
• Sources of data can be primary,
secondary, and tertiary. The client is the
primary source of data, while family members,
support persons, records and reports, other
health professionals, laboratory and diagnostics
fall under secondary sources.
 PRIMARY DATA

• The best source of data is usually the client, unless the client is too ill, young,
or confused to communicate clearly.
• Most often, primary data refers to statements made by the client but also
include those objective data that can be directly obtained by the nurse from
the client such as gender.
 SECONDARY DATA

• A source is considered secondary data if it is provided from someone else

other than the client but within the client’s frame of reference.
• Information provided by the client’s family or significant others are considered
secondary sources of data if the client cannot speak for themselves, is lacking
facts and understanding, or is a child.
• Additionally, the client’s records and assessment data from other nurses or
other members of the healthcare team are considered secondary sources of
data.
 TERTIARY DATA

• Sources from outside the client’s frame of reference are considered tertiary

sources of data. Examples of tertiary data include information from
textbooks, medical and nursing journals, drug handbooks, surveys, and policy
and procedural manuals.
DATA COLLECTION
METHODS
 1. OBSERVING

• To observe is to gather data by using the senses.

• Observing has two aspects: (1) noticing the data and (2) selecting, organizing,
and interpreting the data.
• Nursing observations must be organized so that nothing significant is missed.
1. Clinical signs of client distress (e.g., pallor or flushing,
labored breathing, and behavior indicating pain or
emotional distress)
2. Threats to the client’s safety, real or anticipated (e.g., a
lowered side rail)
3. The presence and functioning of associated equipment
(e.g., intravenous equipment and oxygen)
4. The immediate environment, including the people in it.
 II. INTERVIEW

• An interview is a planned communication or a conversation with a purpose, to

get or give information, identify problems of mutual concern, evaluate change,
teach, provide support, or provide counseling or therapy.

SAMPLE FOOTER TEXT

 2 APPROACHES IN INTERVIEWING

1. The directive interview is highly II. A nondirective interview, or rapport

structured and elicits specific building interview, the nurse allows the
information. The nurse establishes the client to control the purpose, subject
purpose of the interview and controls matter, and pacing. Rapport is an
the interview, at least at the outset. The understanding between two or more
client responds to questions but may people.
have limited opportunity to ask
questions or discuss concerns. Nurses
frequently use directive interviews to
gather and to give information when
time is limited
TYPES OF INTERVIEW QUESTIONS
 1. CLOSED QUESTIONS

• Closed questions, used in the directive interview, are restrictive and generally
require only “yes” or “no” or short factual answers giving specific information.
• Closed questions often begin with “when,” “where,” “who,” “what,” “do (did,
does),” or “is (are, was).”
• Examples of closed questions are “What medication did you take?” “Are you
having pain now? Show me where it is.” “How old are you?” “When did you
fall?”
 II. OPEN ENDED QUESTIONS

• Open-ended questions, associated with the nondirective interview, invite

clients to discover and explore, elaborate, clarify, or illustrate their thoughts or
feelings.
• Open-ended questions may begin with “what” or “how.”
• Examples of open-ended questions are “How have you been feeling lately?”
“What brought you to the hospital?” “How did you feel in that situation?”
 FACTORS TO CONSIDER PRIOR TO
CONDUCTING AN INTERVIEW

• Time
• Place (A well-lighted, well-ventilated room that is relatively free of noise, movements, and
distractions)
• Seating Arrangement
• Distance (distance of 2 to 3 feet during an interview)
• Language
STAGES OF
INTERVIEW
 1. THE OPENING

• The opening can be the most important part of the interview because what is
said and done at that time sets the tone for the remainder of the interview.
• The purposes of the opening are to establish rapport and orient the
interviewee.
• In orientation, the nurse explains the purpose and nature of the interview.
 2. THE BODY

• In the body of the interview, the client communicates what he or she thinks,
feels, knows, and perceives in response to questions from the nurse.
 THE CLOSING

• The nurse terminates the interview when the needed information has been
obtained. In some cases, however, a client terminates it.
• The following techniques are commonly used to close an
interview:
1. Offer to answer questions: “Do you have any questions?” “I
would be glad to answer any questions you have.”.
2. Conclude by saying “Well, that’s all I need to know for now”
or “Well, those are all the questions I have for now.”
3. Thank the client.
4. Express concern for the person’s welfare and future: “I hope
all goes well for you.”
5. Plan for the next meeting, if there is to be one, or state what
will happen next. Include the day, time, place, topic, and
purpose.
6. Provide a summary to verify accuracy and agreement.
 III. EXAMINING

• The physical examination or physical assessment is a systematic data collection

method that uses observation to detect health problems.
• To conduct the examination the nurse uses techniques of inspection,
auscultation, palpation, and percussion
 ORGANIZING DATA

• The nurse uses a written (or electronic) format that

organizes the assessment data systematically. This is
often referred to as a nursing health history, nursing
assessment, or nursing database form.
 VALIDATING DATA

• Validation is the act of “double-checking” or verifying data to confirm that it is

accurate and factual.
• Not all data require validation. For example, data such as height, weight, birth
date, and most laboratory studies that can be measured with an accurate scale
can be accepted as factual.
• The nurse validates data when there are discrepancies between data obtained
in the nursing interview (subjective data) and the physical examination
(objective data), or when the client’s statements differ at different times in the
assessment.
 HOW TO VALIDATE?

1. Ensures that assessment information is double-checked, verified, and complete.

2. Ensure that objective and related subjective data are valid and accurate.
3. Ensure that the nurse does not come to a conclusion without adequate data to
support the conclusion.
4. Ensure that any ambiguous or vague statements are clarified.
5. Acquire additional details that may have been overlooked.
6. Distinguish between cues and inferences.
Cues are subjective or objective data that can be directly observed by the nurse; that is,
what the client says or what the nurse can see, hear, feel, smell, or measure. On the other
hand, inferences are the nurse’s interpretation or conclusions made based on the cues.
For example, the nurse observes the cues that the incision is red, hot, and swollen and
makes an inference that the incision is infected.
 DATA DOCUMENTATION

• To complete the assessment phase, the nurse records client data. Accurate
documentation is essential and should include all data collected about the
client’s health status.
• Data are recorded in a factual manner and not interpreted by the nurse
 II. DIAGNOSING

• Diagnosing is the second phase of the nursing process. In this phase, nurses use
critical thinking skills to interpret assessment data and identify client strengths
and problems.
 MEDICAL DIAGNOSIS VS. NURSING
DIAGNOSIS

• A nursing diagnosis is a statement of • A medical diagnosis is made by a

nursing judgment and refers to a physician and refers to a condition that
condition that nurses, by virtue of their only a physician can treat.
education, experience, and expertise, are
• Medical diagnoses refer to disease
licensed to treat.
processes— specific pathophysiologic
• Nursing diagnoses describe the human responses that are fairly uniform from
response, a client’s physical, sociocultural, one client to another.
psychological, and spiritual responses to
an illness or a health problem
 NURSING DIAGNOSIS VS COLLABORATIVE
DIAGNOSIS
• A collaborative problem is a type of potential problem that nurses manage
using both independent and physician-prescribed interventions. Independent
nursing interventions for a collaborative problem focus mainly on monitoring
the client’s condition and preventing development of the potential
complication
• Nursing diagnoses, involve human responses, which vary greatly from one
person to the next. Therefore, the same set of nursing diagnoses cannot be
expected to occur with all persons who have a particular disease or condition.
• For example, all postpartum clients have similar collaborative problems, such as
“Potential complication of childbearing: postpartum hemorrhage,” but not all
new mothers have the same nursing diagnoses. Some might experience
Impaired Parenting (delayed bonding), but most will not; some might have
Deficient Knowledge, whereas others will not.
 PURPOSES OF NURSING DIAGNOSIS

• Helps identify nursing priorities and help direct nursing interventions based on
identified priorities.
• Nursing diagnoses help identify how a client or group responds to actual or
potential health and life processes and knowing their available resources of
strengths that can be drawn upon to prevent or resolve problems.
• Provides a common language and forms a basis for communication and
understanding between nursing professionals and the healthcare team.
• Provides a basis of evaluation to determine if nursing care was beneficial to the
client and cost-effective.
• For nursing students, nursing diagnoses are an effective teaching tool to help
sharpen their problem-solving and critical thinking skills.
 TYPES OF NURSING DIAGNOSIS

1. Problem-Focused Nursing Diagnosis- also known as actual diagnosis, is a

client problem that is present at the time of the nursing assessment. These
diagnoses are based on the presence of associated signs and symptoms.
Ex. Pain related to post operative site as expressed by frowning and
supporting the wound.
2. Risk Nursing Diagnosis- These are clinical judgments that a problem does
not exist, but the presence of risk factors indicates that a problem is likely to
develop unless nurses intervene. There are no etiological factors (related
factors) for risk diagnoses.
Ex. Risk for infection as evidenced by immunosuppresion
3. Health Promotion Diagnosis- also known
as wellness diagnosis is a clinical judgment about
motivation and desire to increase well-being. Health
promotion diagnosis is concerned with the individual,
family, or community transition from a specific level of
wellness to a higher level of wellness.
Ex. Readiness for enhanced parenting
COMPONENTS
OF A NANDA-I
NURSING
DIAGNOSIS
• A nursing diagnosis has three components: (1) the problem
and its definition, (2) the etiology, and (3) the defining
characteristics. Each component serves a specific purpose.
 1. PROBLEM (DIAGNOSTIC LABEL) AND
DEFINITION

• The problem statement, or diagnostic label, describes the client’s health

problem or response for which nursing therapy is given.
• The purpose of the diagnostic label is to direct the formation of client goals
and desired outcomes. It may also suggest some nursing interventions.
• Qualifiers are words that have been added to some
NANDA labels to give additional meaning to the diagnostic
statement; for example:
■ Deficient (inadequate in amount, quality, or degree; not
sufficient; incomplete)
■ Impaired (made worse, weakened, damaged, reduced,
deteriorated)
■ Decreased (lesser in size, amount, or degree)
■ Ineffective (not producing the desired effect)
■ Compromised (to make vulnerable to threat).
 II. ETIOLOGY (RELATED FACTORS AND RISK
FACTORS)

• The etiology component of a nursing diagnosis identifies one or more

probable causes of the health problem, gives direction to the required nursing
therapy, and enables the nurse to individualize the client’s care
 III. DEFINING CHARACTERISTICS

• are the cluster of signs and symptoms that indicate the presence of a particular
diagnostic label. For actual nursing diagnoses, the defining characteristics are
the client’s signs and symptoms. For risk nursing diagnoses, no subjective and
objective signs are present.
 THE DIAGNOSTIC PROCESS

The diagnostic process uses the critical

thinking skills of analysis and synthesis.
In critical thinking, a person reviews
data and considers explanations before
forming an opinion. Analysis is the
separation into components, that is, the
breaking down of the whole into its
parts (deductive reasoning). Synthesis is
the opposite, that is, the putting
together of parts into the whole
(inductive reasoning).
The diagnostic process has three steps:

■ Analyzing data

■ Identifying health problems, risks, and strengths

■ Formulating diagnostic statements.

 1. ANALYZING DATA

• Analysis of data involves comparing patient data against standards, clustering

the cues, and identifying gaps and inconsistencies.
 2. IDENTIFYING HEALTH PROBLEMS, RISKS,
AND STRENGTHS

• In this decision-making step after data analysis, the nurse together with the
client identify problems that support tentative actual, risk, and possible
diagnoses. It involves determining whether a problem is a nursing diagnosis,
medical diagnosis, or a collaborative problem. Also, at this stage is wherein the
nurse and the client identify the client’s strengths, resources, and abilities to
cope.
 FORMULATING DIAGNOSTIC STATEMENTS

Basic Two-Part Statements

1. Problem (P): statement of the client’s response (NANDA label)
2. Etiology (E): factors contributing to or probable causes of the responses.
The two parts are joined by the words related to, rather than, due to. The phrase
due to implies that one-part causes or is responsible for the other part. By
contrast, the phrase related to merely implies a relationship.
Ex.
Constipation related to prolonged laxative use
Imbalanced Nutrition: Less than body requirements related to decreased
appetite
Basic Three-Part Statements
• The basic three-part nursing diagnosis statement is called the PES format and
includes the following:
1. Problem (P): statement of the client’s response (NANDA label)
2. Etiology (E): factors contributing to or probable causes of the
response
3. Signs and symptoms (S): defining characteristics manifested by the client.
• Actual nursing diagnoses can be documented by using the three-part statement
because the signs and symptoms have been identified. This format cannot be
used for risk diagnoses because the client does not have signs and symptoms
of the diagnosis.
Ex. Impaired Physical Mobility related to decreased muscle control as
evidenced by inability to control lower extremities.
Acute Pain related to tissue ischemia as evidenced by statement of “I
feel severe pain on my chest!”
One-Part Statements Some diagnostic statements, such as wellness diagnoses and
syndrome nursing diagnoses, consist of a NANDA label only.
• As the diagnostic labels are refined, they tend to become more specific, so that
nursing interventions can be derived from the label itself. Therefore, an etiology
may not be needed.
• NANDA has specified that any new wellness diagnoses will be developed as
one-part statements beginning with the words Readiness for Enhanced
followed by the desired higher level of wellness
• A syndrome diagnosis is a diagnosis that is associated with a cluster of other
diagnoses.
• Risk for Disuse Syndrome, for example, may be experienced by long-term
bedridden clients. Clusters of diagnoses associated with this syndrome include
Impaired Physical Mobility, Risk for Impaired Tissue Integrity, Risk for Activity
Intolerance, Risk for Constipation, Risk for Infection, Risk for Injury, Risk for
Powerlessness, Impaired Gas Exchange, and so on.