NURSING PROCESS: ASSESSMENT current problems and possible

& problems that the patient will face in

DIAGNOSIS the future).
The Nursing Process ▪ To establish plans to meet the
identified needs.
▪ To deliver specific nursing
interventions to meet those needs.
Phases:
▪ National Licesure Examination
for
Registered Nurses (NCLEX) – (5
Phases)
 Assessment
 Diagnosing
✓ A systematic, rational method  Planning Coutcome identification)
of planning and providing  Implementation
individualized nursing care.  Evaluation
✓ Was originated by Hall in 1955 ▪ American Nurses Association,
✓ Johnson, Orlando and Weidenbach 2010
(famous theorist) (6 Phases)
- Were among the first to use it to  Assessment
refer to a series of phases  Diagnosing
describing the practice of nursing.  Outcome Identification
✓ Legitimized in 1973  Planning
- When the phases were included in  Implementation
the American Nurses Association  Evaluation
(ANA) Standards of Nursing
Practice.
Who are the clients of the Nursing
Process?
✓ Individual
✓ Family
✓ Community
✓ Group
Purposes:
▪ To identify client’s health status
and actual or potential health care
problems or needs (what are the
 • Requires the nurse
to
↓ scientificbassidentifiedin obtain information that
care plan
clarifies the nature of
the problem and
suggest possible
solutions.
• Identify the goal or
address the
outcome
assessment  Directed towards client’s
response (rather than on
physiological systems &
disease process)

Nursing Diagnosis vs. Medical Diagnosis

Medical Diagnosis
▪ Refer to disease process- specific
pathophysiologic responses that
are fairly uniform
Characteristics of Nursing Process ▪ Remains the same as long as the
disease process is present
▪ Cyclic and dynamic nature
-

▪ Example: Diabetes mellitus

✓ Each phase provide input
into the next phase. Nursing Diagnosis
✓ Cyclic - nursing care plan ▪ Describe the human response
(physical, sociocultural,
▪ Client-centeredness
psychological, & spiritual response
✓ The plan of care is according
to an illness)
to the client problems, rather
"The patientwill
"
▪ Focus on the response of the
than the nursing goals.
maintain person
✓ Nursing process should
▪ Change as the client’s response
be CLIENT-CENTERED.
changes
▪ Focus on problem solving &
Example from NANDA:
decision making ▪ Risk for unstable blood glucose
 Problem-solving
▪ Risk for infection
• A mental activity in ▪ Deficient knowledge (patient has
which a problem is not enough information about the
identified that illness)
represents an
unsteady state.
 ▪ Imbalanced nutrition: less than
body requirement
▪ Interpersonal and collaborative
style
 Communicate directly to
clients
 Collaborate with other
members of HC team
▪ Universal applicability/applicable
 Use as a framework for
nursing care in all types of
healthcare settings
▪ Use of critical thinking and
clinical reasoning (come hand-in-
hand when using the nursing
process)
Critical Thinking
✓ The process of intentional higher-level
thinking to define a client’s problem,
examine the evidence-based practice
in caring for the client, and make
choices in the delivery of care
Clinical Reasoning
✓ The cognitive process that uses
thinking strategies to ⑩
gather and
⑧analyze client information, evaluate
the relevance of the information, and
decide on possible nursing actions to
improve the client’s psychological and
psycho social outcomes
✓ Requires the integration of critical
thinking in the identification of the most
appropriate interventions that will
improve the client’s condition
The Nursing Process
1. ASSESSMENT
The FIRST PHASE of the Nursing
Process
▪ The systematic and continuous
collection, organization, validation
and documentation of data.
▪ A continuous process carried out
during all phases of the nursing
process.
▪ Focus on a client’s response to a
health problem.
Should include the client’s
↓
▪
perceived need, health
problems, related experience,
health practices, values &
lifestyles.
▪ To be most useful, the data
collected should be relevant to a
particular health problem. institution that gives
▪ According to Joint Commission ~> approval recommendations
&
(2008) for quality health care
• Each client should have an
initial nursing assessment
consisting of a history &
-
physical examination
-
performed & documented
within o24 hours of
admission.
 • LPN (licensed practical
nurse) may gather data.
• RN (registered nurse)
responsible for care & must
assess the data determining
the needs of the client. o
Should also develop the
client’s plan of care.
TYPES OF ASSESSMENT
▪ Initial nursing assessment
 Performed within specified
time after admission to a
health care agency.
 Purpose: To establish a
ocomplete database for
problem identification,
reference & future
comparison.
 E.g. nursing admission
assessment
▪ Problem-focused assessment
 On going process integrated
with nursing care.
 Purpose: To determine the
status of a specific problem
identified in an earlier
assessment.
 E.g. Hourly assessment
2 amount
hourly
of urine pt
▪ Emergency assessment
 Performed during any
physiological or
psychological crisis of the
client.
 Purpose: To identify
lifethreatening problems and
identify new or overlooked
problems.
 E.g. Rapid assessment of a
patient having cardiac
arrest
- > accidents (e.g. mva)
▪ Time-lapsed reassessment
 Done several months after
initial assessment.
 Purpose: To compare the
client’s current status to
baseline data previously
obtained.
 E.g. reassessment of a
client’s functional health
patterns
(visiting nurses)
Data Collection
▪ Process of gathering information
about the client’s health status.
▪ Should be systematic and
continuous.
▪ DATABASE
 Contains all information
about the client.
 E.g. chart, files in the
computer  Includes:
• Nursing health history
• Physical assessment
• Primary care
provider’s history and
lets out physical
information
• Results of laboratory
& diagnostic tests
• Material contributed
other health personnel
Types of Data
 Subjective Data
• Symptoms or covert
 data that only the (go-signal to accept
affected person can authorization)
describe and verify. • Ethical issue to
• E.g. feeling of pain, observe: Not allowed
itching sensation, to get information from
anxiety, fear, & these support people
worry if the patient is
 Objective Data mentally able and will
• Signs or overt data not authorized us to
detectable by an get information from
observer. them.
• Can be seen, heard,  Client records
felt or smelled and • Information
obtained by documented by
observation or various health care
physical professionals.
examination. • Reviewing it allows
• E.g. facial grimacing, nurses to avoid
guarding previously answered
questions.
Sources of data • E.g. medical
 Client (Primary) records, record of
• Usually, the best therapies and
source of data, but laboratory records
• Unless, too ill, young  Health care professionals
or confused to  Literature
communicate. • E.g. professional
 Support people journals & reference
• Includes family texts (books)
members, friends &
caregivers who know Data collection methods
the client well (should  Observation
be specific that these • Gather data using the
people know the client senses.
well).
• Must be organized so
• Especially important nothing is missed.
for a client who is  Interview
young, unconscious or • Planned
confused. communication or a
• Authorized first, if conversation with a
client is mentally able. purpose.

•
Get information about
the history of the
client, diagnosis,
previous
hospitalization and let
your client know about
the purpose of getting
information.
 Examining
• Systematic
collection of data
collection method that
uses observation to
detect health
problems.
• Cephalocaudal
method head to toe
• Uses the technique of
inspection
according to pt...
▪ &nothing
Should include all data collected
about the client’s health status.
written
done
is not
▪ Should be factual rather than
interpreted by the nurse.
2. DIAGNOSING
The SECOND PHASE of the Nursing
Process
▪ Analyzing of data.
▪ Identifying problems, risks, and
strengths.
▪ Formulation of the diagnostic
statement.
Nursing Diagnosis
▪ A clinical judgement concerning
human response to health
conditions/life processes or a

[
vulnerability for that response, by
1PpA auscultation,
an individual, family, group or
palpation &
community (NANDA).
percussion.
▪ Provides the basis for selection of
Organizing Data nursing interventions to achieve
outcomes for which the nurse has
▪ All assessment data should be
accountability (NANDA-I Think
organized.
Tank, 2009).
▪ E.g. Gordon’s Functional Health
▪ Nursing diagnosis
Patterns
 Includes the (1) diagnostic
Validation Data label plus (2) etiology. o
Diagnostic labels
▪ Act of “double-checking” or  Standardized NANDA
verifying data to confirm that it is names for the diagnoses.
accurate and factual.
o Etiology -> the cause
▪ Nurse’s assumptions are validated "related to..."
or further questioning may be
Example 1:
prompt.
Imbalanced nutrition: less than body
Documenting Data ▪ requirement related to insufficient
intake to meet metabolic demands
▪ Recording of client’s data. as manifested by the body mass
index of 15.
  Yellow- indicates the
diagnostic label
 Blue- indicated etiology
Example 2:
▪ Impaired gas exchange related to
the collection of mucus in the
airways as manifested by
tachypnea and an oxygen
saturation of 90%
Different kinds of Nursing Diagnosis
according to status:
Status of Nursing Diagnosis
▪ Refers to the actuality or
potentiality of the
problems/syndrome or
categorization of the diagnosis as
a problem is likely to develop
health promotion diagnosis. (ni
exist or pwede ba mu exist)
❑ Kinds of nursing diagnosis
based according to status:
▪ Actual diagnosis
▪ Health promotion diagnosis
▪ Risk nursing diagnosis
▪ Syndrome diagnosis
Actual Nursing Diagnosis
▪ A client problem that is present at
the time of the nursing
assessment.
▪ Based on the presence of
associated signs and symptoms.
▪ E.g.
 Ineffective breathing
pattern
 Anxiety
 Impaired memory
Health Promotion Nursing Diagnosis
▪ Related to client’s preparedness
to implement behaviors to
improve their health condition.
▪ Begin with the phrase “Readiness
for enhance…”
Examples:
 Readiness for enhanced
nutrition.
 Readiness for enhanced
knowledge (symptoms that or interested
he is ready to learn more ~>
-
to
improve
about his condition).
Risk Nursing Diagnosis
▪ A clinical judgement that a problem
does not exist, but the presence
of the risk factors indicated that a
unless nurses intervene. Wala pa
▪ E.g. Risk for Infection
->
 Risk for injury Syndrome
!
Diagnosis
▪ Assigned by a nurse’s clinical
judgement to describe a cluster
of nursing diagnoses that have
similar interventions.
▪ Naay word na syndrome sa
diagnostic label.
▪ E.g. relocation stress syndrome
 Physiological and/or
psychosocial disturbance
following transfer
from one environment to
another.
 In order for us to find the
right nursing diagnosis, we
must each first understand
the definition of the diagnosis
that we are about to use.
Components of NANDA Nursing Diagnosis
3 Components of Nursing Diagnosis by
NANDA
▪ The problem and its definition
▪ The etiology
▪ Defining characteristics
A. Problem (Diagnostic Label)
▪ Describe the client’s health
problem or response for which
nursing therapy is given.
▪ Describe the client’s health status
clearly & concisely.
▪ Purposes: To direct the formation
of client goals and desired
outcomes.
▪ May also suggest nursing
interventions that could be done to
solve the problem.
▪ Has QUALIFIERS
 Words that have been added
to give additional meaning to
the diagnostic statement.
 E.g.
• Deficient -
inadequate; 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.
B. Etiology (Talks about Related
factors/
Risk factors)
▪ Identifies 1 or more probable
causes of the health problem.
▪ What is the cause of that
problem?
▪ Gives direction to the required
nursing therapy.
▪ Enables the nurse to individualize
the client’s care.
C. Defining Characteristics
▪ Cluster of signs and symptoms
that indicate the presence of a
particular diagnostic label
▪ Actual nursing diagnosis
 Type of nursing diagnosis
having the 3 NANDA
components.
 Supported with the presence
of the client’s signs and
symptoms seen during the
assessment.
▪ Risk nursing diagnosis
 Probable problem
 No subjective/objective data.
 Factors that cause the client
to be more vulnerable to the
problem (“cues”).
Components of a NANDA Nursing
Diagnosis
Example: Actual Nursing Diagnosis
▪ Imbalanced nutrition: less than
body requirements related to
insufficient intake to meet
doesn'thave all3

components, itas
metabolic demands as manifested ▪ Identify whether data are significant
exist yet by a body index mass of 15. or not and if patterns are present.
- ▪ May cluster inductively or begin
Example: Risk Nursing Diagnosis with a framework. (Gordon’s
Risk for ▪related to Functional
infection impaired Health Pattern)
primary c. Identifying gaps and inconsistencies
defense mechanism. in data
Cue/s: presence of 2-inch
✓ Should include a final check to ensure
laceration at the right forearm
that data are complete and correct
(supported with variables or
CUES) II. Identifying Health Problems Risks
▪ No manifestation or defining and
characteristics. Strengths

3 Steps of the Diagnostic Process ▪ Determine problems and risks

 After data are analyzed, the
▪ Analyzing data ① nurse & client can together
▪ Identifying health problems ② identify problems.
▪ Formulating diagnostic statements③ ▪ Determining strengths -> ex. nonsmoker

I. Analyzing Data  Both nurse and client province resident

establish the client’s
a. Comparing data with Standards strengths, resources and
▪ “standard” or “norm” - generally abilities to cope.
accepted measure, rule, model or III. Formulating Diagnostic Statements
pattern. (bp - 120/80) ▪ Basic Two-part Statements
▪ Cues are considered significant (PE is risk nursing diagnosis
if: format)
 Points to negative or - Problem statement of the
positive change in a client’s (P) client’s
health status or pattern. response (NANDA label).
 Varies from norms of the Etiology factors
client population. (E)- contributing to
 Indicates a developmental or probable causes of the
delay. eX. 4mos infant unable responses.
roll over. (3-4mos; standard)
to
▪ E.g. Risk for infection related to
b. Clustering Cues
impaired primary defense
▪ “data clustering or “grouping of mechanism Cue/s: presence of 2-
cues” inch laceration at the right forearm
▪ Process of determining relatedness
of facts and determining whether ***joined together by the words
any patterns are present.
 ⑧ related “”
to
unsa naka cause sa
noncompliance)
▪ Basic Three-part Statements (PES)  Use of “complex factors”
 Problem when there are too many
 Etiology
 Signs and
IPES etiologic factors (E.g.
Chronic low selfesteem
symptoms - related to complex factors)
defining  Using the word “possible” -
characteristics to describe either the
manifested by the problem or the etiology (can
client. add before the problem or
before the etiology) (E.g.
✓ Actual diagnosis Possible low self-esteem
✓ Group together - all subjective data related to the loss of job or
first and all objective data first (dili Altered thought processes
pwede mag sagol). P possibly related to
✓ E.g. complicated grieving related unfamiliar surroundings)
E
to insufficient social support as  Using “secondary” - divides
manifested by decreased in the etiology into 2 parts (E.g.
S Impaired skin integrity
functioning in life roles.
related to decrease
▪ One-Part Statement peripheral circulation

o
 Health promotion nursing
diagnoses
E.g. readiness for
enhanced comfort
①
 Syndrome nursing
diagnoses
Risk for disused
· syndrome
****an etiology may not be needed
▪ Variations of Basic Formats
 Writing “unknown etiology”
defining characteristics are
present, but the nurse does
not know the cause (E.g.
Noncompliance related to
an unknown etiology - wala
kahibaw ang nurse kung
secondary to
diabetes)
 Adding a second part to
the NANDA label to make it
more precise.
Avoiding Errors in Diagnostic Reasoning
✓ Verify
▪ Hypothesize possible explanations
of the data but realize they are only
tentative once verified.
▪ Talk to client and family.
▪ Ask what their health problems are
and the causes.
▪ Confirm accuracy and relevance.
✓ Build a good knowledge base and
acquire clinical experience
 ▪ Apply knowledge from many 3. PLANNING
different areas to recognize The THIRD PHASE of the Nursing
significant cues patterns and Process
generate hypotheses about the
data. ⚫ Deliberative, systematic phase of
the nursing process.
✓ Have a working knowledge of what Involves decision-
is normal making
▪ Need to know the population norms problem-
for vital signs, laboratory values, solving.
⚫and
developmental milestones, etc.
▪ Need to know what is normal for a
⚫ Begins with the first client contact
particular person.
and continues until the nurse-client
✓ Consult resources relationship ends
▪ Professional Literature (Nursing ⚫ End of product: plan of care
Diagnoses Handbook) ⚫ Prioritizing problems/diagnosis
⚫ Formulate goals/desired
▪ Nursing colleagues
outcomes.
▪ Other professionals
⚫ Select nursing interventions based
✓ Base diagnoses in patterns-that is,
on behavior over time-rather than on the problem identified.
on an isolated incident. ⚫ Write nursing interventions.

- dili ta pwede mu identify ug problem

if nakit.an ra nato kadyot, it must be
continuously present.
- Nursing diagnosis should always
be changing.
✓ Improve critical thinking skills
▪ Critical thinking
 Review data and consider
explanations before forming
an opinion.
Nursing Interventions
✓ Any treatment, based upon clinical
▪ Avoid overgeneralizing,
judgement and knowledge, that a nurse
stereotyping and making
performs to enhance client’s outcome.
unwarranted assumptions. o
Cannot use critical thinking skills if Multidisciplinary
there are no basic concepts of the ⚫ Nurses are not the only ones
diseases or normal anatomy of the involved in the planning processes
body. but alsohealth care providers