OVERVIEW OF

NURSING PROCESS
Learning Outcomes: After the discussion,
the students will be able to:
• Describe the phases of Nursing Process
• Identify major characteristics of the nursing process
• Identify the purpose of assessing, diagnosing,
planning, implementation, evaluation.
• Discuss types of Assessment, Planning,
Implementation and Evaluation.
NURSING PROCESS
 PURPOSES:
• To identify a client’s health status and
actual or potential health care problems or
needs
• To establish plans to meet the identified
needs
• To deliver specific interventions to meet
those needs
PHASES OF THE NURSING PROCESS
I. ASSESSMENT/ ASSESSING
• PURPOSE: TO ESTABLISH A DATA BASE

Systematic and continuous

collection, organization ,
validation and
documentation of data
 FOUR TYPES OF ASSESSMENT

1.Initial Comprehensive Assessment

2.Ongoing or Partial Assessment
3.Focused or Problem Oriented
Assessment
4.Emergency Assessment
 INITIAL COMPREHENSIVE
ASSESSMENT
• Performed within specified time
after admission to a health care
agency.
• To establish a complete database for
problem identification, reference and
future comparison.
• Involves collection of subjective data about
the client’s perception of her health of all
body parts or systems, past health history,
family history, and lifestyle and health
practices ( which includes information related
to the client’s overall function) as well as
objective data gathered during a step- by- step
physical examination.
Subjective data
➢ Data elicited and verified by
the client.
Objective data
➢ data directly or indirectly
observed through measurement.
• Collect subjective data, especially those
related to the client’s overall function.
• Depending on the setting, other members of
the health care team may participate in
various parts of the objective data collection.
- hospital( physician performs total physical
examination when the client is admitted,
Physical therapist perform musculoskeletal
examination (stroke) ).
➢Home setting( nurse usually responsible for
performing most of the physical examination).
➢Frequency of comprehensive assessment
depends on the client’s age, risk factors,
health status, health promotion practices, and
lifestyle.
 ONGOING- PARTIAL ASSESSMENT
• Consist of data collection that occurs after
the comprehensive database is
established.
• Consists of a mini-overview of the client’s
body systems and holistic health patterns
as a follow up on his health status.
• This type of assessment is usually
performed whenever the nurse or another
health care professional has an encounter
with the client.
 FOCUSED or PROBLEM -ORIENTED
ASSESSMENT

• Does not take the place of the

comprehensive health assessment.
• It is performed when comprehensive
database exists for a client who comes
to he health care agency with a
specific health concern.
• Consists of a thorough assessment of
a particular client problem and does
not cover areas not related to the
problem.
• It would not be appropriate to repeat
all system examinations such as the
heart and neck vessel or abnormal
assessment.
 EMERGENCY ASSESSMENT
• During any physiological or psychological
crisis of the client.
• To identify life threatening problems. In such
situations(choking, cardiac arrest,
drowning).
• An immediate diagnosis is needed to
provide prompt treatment.
• To identify new or overlooked problems.
• Ex. Evaluation of the client’s airway,
breathing, and circulation when
cardiac arrest is suspected.
• The major and only concern during
this type od assessment is to
determine the status of the client’s
life- sustaining physical functions.
 STEPS OF HEALTH ASSESSMENT
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation data
PREPARING FOR THE ASSESSMENT
1. Review client’s record. if available.
2. Knowing the client’s basic biographical
data( age, sex, religion, and occupation)
- Provides background about chronic disease
and gives clues to how a present illness may
impact the client’s activities of daily living
(ADL).
3. Review client’s status with other health care
team members who have taken care of or
interacted with him .
4. Keep on open mind. Validate information with
the client and be prepared to collect additional
data.
5. Use this time to educate yourself about the
client’s diagnoses or tests performed.
6. Reflect on your feelings regarding your initial
encounter with the client.
7. Remember to obtain and organize materials
that you will need for the assessment.
 II. DIAGNOSIS
Purposes:
• To identify the client’s healthcare needs and
to prepare diagnostic statement.
• To identify health care needs and prepare a
Nursing Diagnosis.
• To diagnose in nursing
• It means to analyse assessment information
and derive meaning from this analysis
• NURSING DIAGNOSIS
• Is a statement of a client’s potential or actual
health problem resulting from analysis of
data.
• Is a statement of client’s potential or actual
alterations/changes in his health status
• A statement that describes a client’s actual or
potential health problems that a nurse can
identify and for which she can order nursing
interventions to maintain the health status, to
reduce, eliminate or prevent
alterations/changes.
• Is the problem statement that the nurse
makes regarding a client’s condition which she
uses to communicate professionally.
 COMPONENTS OF NURSING
DIAGNOSIS
1) PROBLEM
2) ETIOLOGY
3) DEFINING CHARACTERISTICS
• 1) PROBLEM –statement of the client’s
response
• 2) ETIOLOGY – factors contributing to or
probable causes of the response
• 3) SIGNS and SYMPTOMS – defining
characteristics manifested by the patient
 EXAMPLES
• INEFFECTIVE AIRWAY CLEARANCE RELATED TO THE
PRESENCE OF THICK, TENACIOUS SECRETIONS AEB
RALES ON THE RIGHT UPPER LUNG LOBE,
PRODUCTIVE COUGH, TACHYPNEA AND LABORED
BREATHING
• SELF-ESTEEM DISTURBANCE RELATED TO REJECTION
BY THE HUSBAND AS MANIFESTED BY
HYPERSENSITIVITY TO CRITICSM AND REJECTION OF
POSITIVE FEEDBACK
 III. PLANNING
• PURPOSES:
• TO IDENTIFY THE CLIENT’S GOAL 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
TYPES OF PLANNING
1) INITIAL PLANNING
2) ONGOING PLANNING
3) DISCHARGE PLANNING
INITIAL PLANNING
- Admission assessment, initial comprehensive
plan of care.
ONGOING PLANNING
- All nurses who work with the client
DISCHARGE PLANNING
- Anticipating and planning for needs after
discharge
 Establishing priorities incl:
• Life- threatening situations
• Use of the CAB principles
• Maslow’s hierarchy of needs
• Consider something that is very important to
the client ex. Pain, anxiety
• Clients unstable condition
• Resources
• Actual problems take precedence over potential
concerns.
• Attend to the client before the equipment
 FACTORS WHEN ASSIGNING
PRIORITIES
1. Clients health values and beliefs.
2. Clients priorities.
3. Resources available to the nurse and client
4. Urgency of the health problem
5. Medical treatment plan.
 Classifications:
• High- priority- potentially life-threatening and
required immediate action
• Medium-priority- problems that can result to
unhealthy consequences but not life-
threatening
• Low-priority- problems that can be resolve
easily with minimal interventions
 FORMULATE NURSING GOALS/ CLIENT-
OUTCOME
CRITERIA:
1.SPECIFIC
2.MEASURABLE
3.ATTAINABLE
4.REALISTIC
5.TIME-BOUND
 TYPES OF NURSING GOALS
• SHORT TERM- GOAL
- most common in acute care facilities
- outcome that can be attained in an hour
to days (may vary)
• LONG-TERM GOAL
-most common in nursing homes,
rehabilitative centers and extended
facilities
- Outcome that can be meet in weeks-
months (may vary)
 COMPONENTS OF GOALS/ DESIRED
OUTCOME STATEMENTS
1. Subject
2. Verb
3. Conditions or modifiers
4. Criterion of desired performance.
 EXAMPLE OF A NURSING GOAL
• AFTER 2 HOURS OF NURSING INTERVENTION,
THE PATIENT WILL ATTAIN A NORMAL
TEMPERATURE AMB/AEB
• TEMP- 36.5-37.4C
• ABSENCE OF FACIAL FLUSHES
• SKIN IS NO LONGER WARM TO TOUCH
• NO EXCESSIVE SWEATING (DIAPHORESIS)
 IV. IMPLEMENTING
• PURPOSE:
• TO GIVE AN APPROPRIATE, WHOLISTIC AND
PROMPT QUALITY HEALTHCARE SERVICE TO
THE CLIENT
TYPES OF NURSING
INTERVENTIONS
1) INDEPENDENT
2) DEPENDENT
3) COLLABORATIVE
 V. EVALUATING

• PURPOSE:
• TO DETERMINE THE CLIENT’S
RESPONSE WITH REGARDS TO
THE INTERVENTIONS RENDERED
• TYPES
1. ONGOING EVALUATION
2. INTERMITTENT EVALUATION
3. TERMINAL EVALUATION
FOUR POSSIBLE JUDGMENT OF THE
OUTCOME
• COMPLETELY MET/ GOAL MET
• PARTIALLY MET
• COMPLETELY UNMET/ GOAL NOT
MET
• NEW PROBLEMS OR NURSING
DIAGNOSES HAVE DEVELOPED