Module 3 Nursing Process

NCM103 FUNDAMENTALS OF 2/18/23
NURSING PRACTICE
NCM 103 MODULE 3:

NURSING PROCESS
MAE CHRISTIE LIMBARING-ELEGADO
LEVEL I, 2nd Semester 2023
Learning Outcomes:
⦿ After the concept discussion, the student will be
able to:
⌾ Describe nursing process as a framework of
care.
⌾ Discuss the relationship of the nursing process
to the problem solving approach.
⌾ Identify the 5 steps of the nursing process.
⌾ Discuss the purpose of nursing assessment.
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MODULE 3 | ASSESSMENT |
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NURSING PRACTICE
Learning Outcomes:
⦿ After the concept discussion, the student will be able to:
⌾ Identify the major activities associated with
the assessment process.
⌾ Differentiate objective from subjective data,
primary from secondary data.
⌾ State the sources of data for nursing
assessment.
Learning Outcomes:
⦿ After the concept discussion, the student will be able to:
⌾ Formulates Nursing Diagnosis using NANDA
classification.
⌾ Discuss the steps of planning.
⌾ Implement appropriate interventions based on
health needs.
⌾ Formulate an evaluation for a set of actions selected
for a client.
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NURSING PRACTICE
Something to think about:
⦿ “When an apple is cut, others see seeds in the apple. We,

as nurses, see apples in the seeds.”
-Martha Rogers
WHAT ARE YOUR

RESPONSIBILITIES?
⦿ Recognize health problems.
⦿ Anticipate complications.
⦿ Initiate actions to ensure
appropriate and timely
treatment.
BEGIN TO THINK CRITICALLY!

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NURSING PRACTICE
Critical Thinking and Nursing

⦿ It is disciplined,
purposeful, reflective
reasoning focused on
finding meaning and
improving the current
situation.
⦿ “out of the box” way of
thinking.
It means capable
of judging
carefully and
accurately
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NURSING PRACTICE
Nurses must be critical thinkers because of

the nature of the discipline and the nature of
their work
Reilly & Oermann states that one can think

critically about nursing without a basic
knowledge of its concepts, theories and
content
¢ Nurses use knowledge from other subjects and fields.

¢ Nurses deals with change in stressful environments.
¢ Nurses make important decisions
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NURSING PRACTICE
Formula for Good Critical Judgment
Good Critical Judgement =
Knowledge Clinical Reasoning Attitudes Standards

Experience Skills using
Nursing
Process
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Assessment
Evaluating Diagnosing
Critical Thinking
Implementing Planning
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NURSING PRACTICE
Nursing Process
⦿ What is its purpose ?
⌾ Serves as a
FRAMEWORK for the
practice of nursing
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Nursing Process
q Method of problem ⦿ An organized systematic
identification and problem method of giving nursing
solving (Gordons, 1982). care that focuses on human
response of a person or
group of person to an actual
or potential alteration in
health (Alfaro, 1986; ANA,
1991).
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NURSING PRACTICE
BENEFITS OF NURSING
PROCESS
• For the Client:
– Quality care
– Continuity of care
– Participation of
clients in their health
care.
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BENEFITS OF NURSING
PROCESS
• For the Nurse:
– Consistent and systematic nursing education.
– Job satisfaction.
– Professional growth.
– Avoidance of legal action.
– Meeting professional nursing standards.
– Meeting standards of accredited hospitals.
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Theoretical Comparisons
Problem Solving Scientific Methods Nursing Process
Encountering Problem Recognizing Problem Assessing
Collecting Data Collecting Data

Identifying Exact Nature of the Formulating Hypothesis Formulating Nursing
Problem Diagnosis
Determining Plan of Action Selecting Plan for Testing Planning

Hypothesis
Carrying out Plan Testing Hypothesis Implementing
Evaluating Plan in New Interpreting Results Evaluation

Situation Evaluating Hypothesis
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Assessment
Evaluation Diagnosis
Implementation Planning
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NURSING PRACTICE
It is open and flexible
Meet the unique needs of individual, family, group or community
It is cyclic and dynamic
Should be client centered
Should be planned and goal directed
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It is interpersonal and collaborative
It permits creativity for the nurse and patient to solve the stated health
problems
It emphasizes feedback, which leads either to reassessment of the problem or

to revision of the care plan
It is universally applicable
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NURSING PRACTICE
Assessment
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It is the systematic and

continuous collection of data
to determine a patients
current and past health
status and functional status
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NURSING PRACTICE
Assessment
Purpose:
– To establish a data base (all the information about the
client):
• nursing health history
• physical assessment
• the physician’s history & physical examination
• results of laboratory & diagnostic tests
• material from other health personnel
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Types of Assessment:
• Comprehensive / • Problem Focused • Ongoing
Database
– Limited in – Systematic
– information scope; targets monitoring
gathered on a particular or and
initial contact specific health observation
with the care concern related to
person. specific
problems
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NURSING PRACTICE
¢Performed with in specified time after admission to a

health care agency
¢ Also called an admission assessment
¢ Example: Nursing Admission Assessment
To evaluate health status

To identify functional health patterns
To provide an in depth comprehensive databases
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¢ Collects data about a problem that has already been identified

¢ Ongoing process integrated with nursing care
¢ Nurse determines whether problem still exist and whether the

status of the problem has changes
¢ Example: Hourly assessment of patient’s fluid intake and
urine output
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NURSING PRACTICE
¢Occurs during any life threatening condition

¢Any physiologic or psychologic crisis of the client
¢Example: Rapid assessment of patient’s vital signs

during cardiac arrest
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¢Several months after initial assessment

¢Evaluate the changes in the clients health &
functional status
¢ Example:
Periodic output patient clinic visits
Home health visits
Health & development screening
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NURSING PRACTICE
Checkpoint!
Baby Jane a 2 month infant goes into the doctor for her initial
immunization and well baby check-up. What type of
assessment should the nurse perform?
A. Comprehensive
B. Focused
C. Time-lapsed (on going)
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Assessment Process
Data Validation Organizin

Collection of Data g Data
Making
Categorizing
Recording initial or identifying
or reporting inferences patterns in the
data or
impressions
data
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NURSING PRACTICE
Assessment: Data Collection
Data Collection:
⦿ gathering of information about the client to build client’s
DATABASE
⦿ It must be both systematic and continuous.
⦿ Should include past history and current problem.
⦿ Can be subjective or objective.
⦿ From primary or secondary source.
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Assessment
Data Collection Consists of:
Data Base
Data Sources
Types of Data
Methods of Data Collection
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NURSING PRACTICE
Data Collection : Data Base

• The Data Base Should Include:
– Biographical
– CC/concerns
– History of present illness (HPI)
– Past Illnesses
– Family Health History
– Psychosocial
– Activity of Daily Living (ADL)
– Review of Systems (ROS)
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⦿ Formats That Can Be Utilized:

• Maslow’s Hierarchy of Needs
• Henderson’s Components of Nursing Care
• Gordon’s Functional Health Pattern
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NURSING PRACTICE
Formats That Can Be Utilized: Gordon’s Functional Health Pattern

⦿ HE alth Perception ¨ COG nitive – Perceptual
¨ SE lf-Perception / Self
Health Management
Concept
Pattern ¨ CO ping – Stress Tolerance
⦿ N utrition-Metabolic ¨ RO le Relationship
¨ SE xuality – Reproductive
⦿ E limination ¨ V alue Belief
⦿ A ctivity – Exercise
⦿ S leep – Rest
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Client’s
records
Support Health care
people professionals
Client
Sources Literature
of data
36
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NURSING PRACTICE
Data Collection : Sources of Data
• Client Primary Source
• Other individuals
• Previous records
• Consultations
• Diagnostics studies
• Relevant literature Secondary Sources
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Data Collection : Types of Data
Subjective Data
Objective Data
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NURSING PRACTICE
• Subjective Data
¨ also referred to as
Symptom/Covert data
¨ data from the client’s point of
view and include feelings,
perceptions, and concerns.
¨ information supplied by family
members, significant others,
other health professionals
39
Objective Data ⦿ also referred to as

Sign/Overt data
⦿ those that can be detected,

observed or
measured/tested using
accepted standard or norm.
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NURSING PRACTICE
Checkpoint!
Which of the following are objective data and which are
subjective data.
A. Nausea
B. Vomiting
C. Unsteady gait
D. Anxiety
E. Bruises on the right arms and face
F. Temperature 101 F
41
Interview
Auscultation
Percussion Observation
Palpation
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NURSING PRACTICE
Data Collection : Methods
For Subjective Data: For Objective Data:

⦿ Observation
⦿ Interview
⌾ Physical Examination (IPPA)
⌾ PQRST
• V/S
⌾ Psychosocial • Cephalo-caudal
⌾ Developmental assessment
⌾ Diagnostic/ Laboratory
Findings
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Observing
• Observation is conscious, deliberate skill that is developed
through effort and with an organized approach.
Eg:- Using the senses to observe client data
• Methods observation :
– Vision
– Smell
– Hearing
– Touch
• Aspects of data :
– Noticing data
– Selecting, organizing and interpreting the data
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NURSING PRACTICE
Interviewing
• An interview is a planned communication or a
conversation with a purpose
Eg: Nursing health history
• Approaches of an interview:
– Direct interview
– Indirect interview
• Types of interview questions:
– Closed questions (Are you having pain now?)
– Open ended question (what brought you to hospital?)
– Neutral questions (how do you feel about that?)
– Leading questions (you are stressed about surgery tomorrow
aren't you?)
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Closed and Open-ended Questions

⦿ Closed Question
⌾ Restrictive
• Yes/no
• Factual
⌾ Less effort and information from client
⌾ “What medications did you take?”
⌾ “Are you having pain now?”
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NURSING PRACTICE
Closed and Open-ended Questions
⦿ Open-ended Question
⌾ Specify broad topic to discuss
⌾ Invite longer answers
⌾ Get more information from client
⌾ Useful to change topics and elicit attitudes
47
Interviewing
• Planning the interview and setting:
– Time
– Place
– Seating arrangement
– Distance
– Language
• Stages of an interview
– The opening and introduction
– The body or development
– The closing
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NURSING PRACTICE
Examination
• Techniques
– Inspection
– Palpation
– Percussion
– Auscultation
• Physical examination can be,
– Cephalocaudal approach
– Screening examination
– Review of systems
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Assessment Process
Data Validation of Organizing

Collection Data Data
Making Categorizing or
Recording initial identifying
data or data
impressions
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NURSING PRACTICE
Validation of Data
⦿ the act of “double-checking” or verifying

data to confirm that it is accurate and
complete.
⦿ Purposes of data validation:
⌾ ensure that data collection is complete
⌾ ensure that objective and subjective data agree
⌾ obtain additional data that may have been overlooked
⌾ differentiate cues from conclusion/opinion
51
1. Deciding whether the data

require validation
2. Determining ways to validate the
data
3. Identifying areas where data are
missing
4. Failure to validate data may
result in premature closure of
assessment or collection of
inaccurate data
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NURSING PRACTICE
Assessment Process

data or data
impressions
53
Organization of Data
⦿ The use a written or computerized format that organizes the
assessment data systematically.
⦿ Sorting out the relevant data (“GI-GO”)
⦿ Formats (example):
¤ Maslow’s Hierarchy of Needs
¤ Gordon’s Functional Health Pattern
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NURSING PRACTICE
Organization of Data
¨ Example:
Data Base
¤“Eats 3 meals a day with 2 snacks.”
¤“Sleeps at 9 pm and wakes up at 5 am.”
¤“I feel the love of my husband.”
¤“As the boss, I am confident that I can handle my office.”
55
Organization of Data: Maslow’s
Love and
Physiologic Needs Self-Esteem
Belonging
“Eats 3 meals a “I feel the love of “As the boss, I am
day with 2 snacks.” my husband.” confident that I can
handle my office.”
“Sleeps at 9 pm
and wake up at 5
am.”
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NURSING PRACTICE
Organization of Data: Gordons
Nutrition and Role Self-

Perception / Sleep and
Metabolic Relationship
Pattern Pattern Self-Concept Rest Pattern
Patten
“Eats 3 meals “I feel the “As the boss, “Sleeps at 9
a day with 2 love of my I am confident pm and wake
snacks.” husband.” that I can up at 5 am.”
handle my
office.”
57
Assessment Process

data or data
impressions
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NURSING PRACTICE
Documentation of data
§ Assessment data must be recorded and reported.

§Accurate and complete record communicates
information to health care team.
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PURPOSES OF DOCUMENTATION
Provides chronological source of client assessment data
Ensure that information about the client and family is easily

accessible to members of the health care team
Establishes a basis for screening for proposed diagnosis
Offers a basis fordetermining the educational needs of the client,

family and significant others
Act as a source of information to help diagnose new problems
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NURSING PRACTICE
¢ Document legibly or print neatly in un erasable ink

¢ Use correct grammar and spelling
¢ Avoid wordiness that creates redundancy
¢ Use phrases instead of sentences to record data
¢ Record data findings objectively with sequence
¢ Avoid short form of words
¢ Record complete information and details for all

client symptoms or experiences
¢ Support objective data with specific observations
obtained during physical examination
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In Summary:
q Nursing Process q Assessment
§ Purpose § Definition
§ Definition § Purpose
§ Theoretical § Types
comparisons § Process
§ Steps (ADPIE)
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NURSING PRACTICE
“Time for
Worksheet 1!”
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MELEGADO 2023 32

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NCM103 FUNDAMENTALS OF 2/18/23

NCM 103 MODULE 3:

Something to think about:

⦿ “When an apple is cut, others see seeds in the apple. We,

WHAT ARE YOUR

BEGIN TO THINK CRITICALLY!

Critical Thinking and Nursing

Nurses must be critical thinkers because of

Reilly & Oermann states that one can think

¢ Nurses use knowledge from other subjects and fields.

Formula for Good Critical Judgment

Good Critical Judgement =

Knowledge Clinical Reasoning Attitudes Standards

Collecting Data Collecting Data

Determining Plan of Action Selecting Plan for Testing Planning

Carrying out Plan Testing Hypothesis Implementing

Evaluating Plan in New Interpreting Results Evaluation

It is open and flexible

Meet the unique needs of individual, family, group or community

It is cyclic and dynamic

Should be client centered

Should be planned and goal directed

It is interpersonal and collaborative

It emphasizes feedback, which leads either to reassessment of the problem or

It is the systematic and

¢Performed with in specified time after admission to a

To evaluate health status

¢ Collects data about a problem that has already been identified

¢ Nurse determines whether problem still exist and whether the

¢Occurs during any life threatening condition

¢Example: Rapid assessment of patient’s vital signs

¢Several months after initial assessment

Data Validation Organizin

Assessment: Data Collection

Data Collection : Data Base

Data Collection : Data Base

⦿ Formats That Can Be Utilized:

Data Collection : Data Base

Formats That Can Be Utilized: Gordon’s Functional Health Pattern

Data Collection : Sources of Data

• Client Primary Source

Data Collection : Types of Data

Data Collection : Types of Data

Data Collection : Types of Data

Objective Data ⦿ also referred to as

⦿ those that can be detected,

Data Collection : Methods

For Subjective Data: For Objective Data:

Closed and Open-ended Questions

Closed and Open-ended Questions

Data Validation of Organizing

⦿ the act of “double-checking” or verifying

1. Deciding whether the data

Data Validation of Organizing

⦿ Sorting out the relevant data (“GI-GO”)

¤“Sleeps at 9 pm and wakes up at 5 am.”

¤“I feel the love of my husband.”

¤“As the boss, I am confident that I can handle my office.”

Organization of Data: Maslow’s

Organization of Data: Gordons

Nutrition and Role Self-

Data Validation of Organizing

§ Assessment data must be recorded and reported.