NURSING PROCESS – ADPIE (NUR 091)

D. Physical examination
E. Laboratory and diagnostic tests
ASSESSMENT
HISTORICAL DATA
ASSESSMENT
A. Biographic data
- The deliberate and systematic collection
B. Chief complaint
of information about a patient to
C. History of present illness
determine the patient's current and past
D. Past hx
health and functional status and his or her
E. Family hx
present and past coping patterns.
F. Lifestyle
- First step in the nursing process.
G. Social data
- Involves gathering of data and analysis of
H. Patterns of health care.
information about a patient's health status.
- Baseline used for evaluation.
PROFESSIONALISM IN HX TAKING
To display professionalism and a caring approach
ACTIVITIES IN ASSESSMENT/ PURPOSE OF
during an interview, look at the patient and not
ASSESSMENT
the computer screen. Use the computer if you
1. COLLECTING & ESTABLISHING DATA
must but position it in a way that does not distract
2. ORGANIZING DATA
from your focus on the patient.
3. VALIDATING DATA
4. DOCUMENTING DATA
TYPES OF DATA
SUBJECTIVE DATA
Documentation – the hallmark of nursing
- covert
accountability
OBJECTIVE DATA
- overt
4 DIFFERENT TYPES OF ASSESSMENT
CONSTANT DATA
INITIAL
- not changing
- within specified time after admission to
VARIABLE
hospital
- changing
- to establish a complete database for
problem identification reference and
SOURCES OF DATA
future comparison
Primary
PROBLEM FOCUSED
- best source of data
- on going process intergrated with nsg care
- mismong tao yung source or yung family
- to determine the status of a specific
ng patient
problem identified in an earlier assessment
Secondary
EMERGENCY
- mga nabasa mo na previous chart ng
- during any physiologic/psychological crisis
patient or previous record ng patient
of the client
galing sa books, chart, documents
- to identify life-threathening problems
TIMELAPSED REASSESSMENT
SIGN VS SYMPTOM
- several months after initial assessment
Sign
- to compare the client's current status to
- something that can be observed externally
baseline data previously obtained
Symptom
- is felt internally
WHAT DO WE ASSESS?
Client perceived needs/chief complaint
METHODS OF DATA COLLECTION
Health problem
Observing
Related experience
Interviewing
Health practices
Examining
Values and lifestyle
Culture
OBSERVING
SEQUENCE FOR OBSERVING EVENTS:
COLLECTING DATA 1. Clinical signs of client distress.
- Process of gathering information about a 2. Threats to client's safety, real or anticipated.
client's health status. It is both systematic 3. The presence and functioning of associated
and continous. equipment.
4. The middle environment, including the people
DATABASE in it.
- All the information about a client, it
includes;
A. Nursing health history
B. Physical assessment
C. Primary care provider's history
NURSING PROCESS – ADPIE (NUR 091)
INTERVIEWING BODY SYSTEM APPROACH
TWO APPROACHES TO INTERVIEWING
• DIRECTIVE - highly structured SCREENING EXAMINATION
• NONDIRECTIVE - known as rapport building - also called as review of system
interview - brief review of essential functioning of
various body parts or systems.
THE PATIENT-CENTERED INTERVIEW
Motivational Interviewing ORGANIZING DATA
Effective Communication - nurse uses a written/electronic format that
- trust building organizes the assessment systematically.
- presence
- rounding VALIDATING DATA
Interview Preparation - The act of "double checking" or verifying
Phases of an Interview data to confirm that it is accurate and
- Preinteraction factual.
- Orientation • CUES
- Working - subjective/objective data that can be
- Termination directly observed by the nurse.
• INFERENCES
TYPES OF INTERVIEW QUESTIONING - are the nurses' interpretation or conclusions
• CLOSE ENDED made based on the cues.
• OPEN ENDED
• NEUTRAL DOCUMENTING DATA
• LEADING - Accurate documentation is essential and
• BACK CHANNELING should include all data collected about
• PROBING the client's health status.

STAGES OF AN INTERVIEW
OPENING
- Most important part of the interview
- To establish rapport and orient the
interviewee
BODY
- Client communicates what he/she thinks,
feel, knows and perceives in response to
questions from the nurse.
CLOSING
- Nurse terminates the interview when the
needed information has been obtained.
PLANNING THE INTERVIEW SETTING
1. TIME
2. PLACE
3. SEATING ARRANGEMENT
4. DISTANCE
Most of the people feel comfortable in
maintaining a distance of 2-3 feet during
interview.
DIAGNOSING
DIAGNOSING
- 2nd phase of the nursing process.
- Nursing diagnoses are formulated in this
phase.
- Identifying what is the problem.
- Made when a nurse identifies a health-
related problem or the potential to
develop a problem based on patient
data.
- Human response
NORTH AMERICAN NURSING DIAGNOSIS
ASSOCIATION (NANDA)
PURPOSE OF NANDA
To define, refine and promote a taxonomy of
nursing diagnostic terminology of general use to
professional nurses.

Preffered distance during interview: TAXONOMY

- Arab (8-12 inches) - A classification system or set of categories
- US (18 inches) arranged based on a single principle or set
- Philippines (24 inches) of principles.
- Japan (36 inches) - science of naming organism

EXAMINING DIAGNOSIS
- Is a systematic data collection method - statement or conclusion regarding the
that uses observation and inspection, nature of a phenomenon
auscultation, palpation and percussion.

CEPHALOCAUDAL ASSESSMENT
- head to toe assessment
NURSING PROCESS – ADPIE (NUR 091)
NANDA NURSING DIAGNOSIS • Rape-Trauma
- Is a clinical judgement about individual, • Relocation Stress
family or community responses to actual, • Sudden Infant Death Syndrome
- and potential health problems/life
processes. COMPONENTS OF NANDA NURSING DIAGNOSIS
• Descriptor/Qualifier
Note: We cannot diagnose and treat a medical • The Problem
condition but we can provide diagnosis based on • The Etiology
response of a patient. • The Defining Characteristics

TYPES OF NURSING DIAGNOSIS QUALIFIERS/DESCRIPTOR

• ACTUAL DIAGNOSIS - Are words that have been added to some
• RISK DIAGNOSIS NANDA labels to give additional meaning
• WELLNESS DIAGNOSIS to the diagnostic meaning.
• POSSIBLE DIAGNOSIS • DEFICIENT
• SYNDROME DIAGNOSIS - Inadequate in amount, quality, or degree
not sufficient; incomplete.
1. ACTUAL DIAGNOSIS • IMPAIRED
- Problem-focused - Made worse, weakened, damaged.
- Client problem that is present at the time reduced, deteriorated.
of the nursing assessment. • DECREASED
- The statement starts with the problem of - Lesser in size, amount or degree.
your patient. • INEFFECTIVE
- Ex: Ineffective Breathing Pattern and - Not producing the desired effect.
Anxiety • COMPROMISED
- To make vulnerable to threat.
2. RISK DIAGNOSIS
- Clinical judgment that a problem does not PROBLEM
exist but PRESENCE OR RISK FACTOR (DIAGNOSTIC LABEL) AND DEFINITION
indicates that a problem is LIKELY TO - Describes the client's health problem or
DEVELOP unless nurses intervene. response for which nursing therapy is given.
- Risk for Infection. - Describes the client's health status clearly
- No problem, no etiology, no defining and concisely in a few words.
characteristics. - Directs the formation of client goals and
desired outcomes.
3. WELLNESS DIAGNOSIS
- Describes human responses to levels of ETIOLOGY
wellness in an individual, family, community (Related factors and Risk factors)
that have a readiness for enhancement. - Identifies one or more probable causes of
- Ready for discharge the health problem.
- Other term “health promotion diagnosis” - Gives direction to the required nursing
- Ex: Readiness for Enhanced Spiritual Well therapy.
Being or Readiness for Enhanced Family - Enables the nurse to individualize care.
Coping - "Related to"

4. POSSIBLE DIAGNOSIS DEFINING CHARACTERISTICS

- POTENTIAL - The cluster of signs and symptoms that
- Evidence about a health problem is indicate the presence of a particular
incomplete or unclear. diagnostic label.
- Requires more data to either support or to - "As evidenced by"/ "As manifested by"
refuse it. - Take note: If Risk Nursing Diagnosis it has no
- Ex: Possible Social Isolation related to subjective and objective signs
unknown etiology.
Example:
5. SYNDROME DIAGNOSIS Activity tolerance: Insufficient physiological energy
- Associated with cluster of other diagnosis. to endure desired daily activities related to
- Only SIX (6) SYNDROME DIAGNOSIS are generalized weakness as manifested by:
available in NANDA. A. Verbal report of fatigue
B. Abnormal heart rate or blood pressure
SIX (6) SYNDROME DIAGNOSIS response to activity
• Disuse Syndrome C. Exertional discomfort or dyspnea.
• Environmental Interpretation
• Post-Trauma
NURSING PROCESS – ADPIE (NUR 091)
NURSING VS MEDICAL DIAGNOSIS
NURSING DIAGNOSIS
- Statement of nursing judgment and refers
to a condition that nurses, by virtue of their
education, experience and expertise are
licensed to treat.
MEDICAL DIAGNOSIS
- Made by a physician and refer to a
condition that only a physician can treat.
3 Steps in Diagnostic Process
Uses critical thinking skills of analysis and
synthesis.
1. ANALYZING DATA
− compare, cluster, identify gaps
2. IDENTIFYING HEALTH PROBLEMS, RISK AND
STRENGTHS
3. FORMULATING DIAGNOSTIC STATEMENTS
PES FORMAT
FORMULATING DIAGNOSTIC STATEMENTS
1. ONE PART STATEMENT
- Applicable for health promotion and
syndrome nursing diagnosis.
- It consist of a NANDA LABEL ONLY.
- An etiology is not needed.
Ex.
Health promotion diagnosis
- Readiness for enhanced parenting
Syndrome nursing diagnosis
- Risk for disuse syndrome
Impaired physical mobility
Risk for impaired tissue integrity
2. TWO PART STATEMENT
- Problem (P) + Etiology (E)
- P and E are joined together by the words
RELATED TO
Ex: Noncompliance (diabetic diet) RELATED TO
denial of having disease.
3. THREE PART STATEMENT
- PES format
- Problem (P) + Etiology (E) + Signs and
Symptoms (S/S)
- Is especially recommended for beginning
diagnosticians because the signs and
symptoms validate why the diagnosis was
chosen
Ex.
Noncompliance (diabetic diet) RELATED TO
unresolved anger about diagnosis as manifested
by:
Subjective
• "I forget to take my pills"
• "I can't live without sugar in my food"
Objective
• Weight of 98kgs (gain of 5.5kg)
• BP of 190/100
PLANNING
PLANNING
- A deliberate, systematic phase of nursing
process that involves decision making and
problem solving.
- Prioritization of nursing diagnoses, care and
selection of nursing intervention.
- “how to manage the problem?”
ACTIVITIES IN THE PLANNING PROCESS
• Prioritizing Problems/Diagnoses
• Selecting Nursing Interventions
• Formulating Client Goals/Desired
Outcomes
• Writing Individualized Nursing Interventions
TYPES OF PLANNING
Initial
- done by the nurse who conducts the
admission assessment.
Ongoing
- done by all the nurses who work with the
client.
- also occurs at the beginning of a shift.
Discharge
- process of anticipating and planning for
needs after discharge.
- start discharge planning for all clients when
they are admitted to any health care
setting.
DEVELOPING NURSING CARE PLANS
NURSING CARE PLAN
• Formal Nursing Care Plan
- written/computerized guide that
organize information about the
clients care
• Informal Nursing Care Plan
- strategy for option that exist in the
nurse mind
NURSING PROCESS – ADPIE (NUR 091)
FORMAL NURSING CARE PLAN Which should be prioritized?
• Standardized Care Plan 1. INEFFECTIVE AIRWAY CLEARANCE
- Group of client with common 2. IMPAIRED GAS EXCHANGE
needs and similar problems 3. ANXIETY
• Individualized Care Plan 4. INEFFECTIVE COPING
- plan for specific client
- unique needs FACTORS TO CONSIDER WHEN SETTING
PRIORITIES
STANDARDIZED APPROACHES TO CARE • Client's Health Values and Beliefs
PLANNING • Client's Priorities
Standards Of Care • Resources Available to the Nurse and
- nursing action for client with similar Client
medical condition rather than individual • Urgency of the Health Problem
Standardized Care Plans • Medical Treatment Plan
- preprinted guides for the nursing care of a
client who has a need that arises ESTABLISHING CLIENT GOALS/DESIRED
frequently in the agency OUTCOMES
Protocols GOALS
- preprinted to indicate the action • broad
commonly required for a particular group • general statement about the client's status
of clients OBJECTIVES
Policies and Procedures • more specific
- develop to govern the handing of • observable criteria
- frequently occurring situation • used to evaluate whether the goals have
been met.
INDIVIDUALIZATION OF STANDARDIZED CARE PLANS
• Must include unique needs of each client PURPOSE OF GOALS/DESIRED OUTCOMES
• Usually consists of both preprinted and • Provides direction for planning nursing
nurse-created sections. interventions
• Individual plan for unusual problems or • Serves as criteria for evaluating client
problems needing special attention. progress
• Enables determination of problem
FORMATS FOR NURSING CARE PLANS resolution
• Student Care Plans • Helps motivate the nurse by providing a
• Concept Maps sense of achievement
• Computerized Care Plans
• Multidisciplinary Care Plans PLANNING: GOALS
Long Term
GUIDELINES FOR WRITING NURSING CARE PLANS - chronic
• Include interventions for ongoing - weeks/
assessment. - months/year
• Include collaborative and coordination Short Term
activities. - acute
• Include discharge plans and home care - houfs/days/weeks
needs.
COMPONENTS OF GOALS/DESIRED OUTCOME
THE PLANNING PROCESS: STATEMENTS
CONSISTS OF THE FOLLOWING ACTIVITIES: SUBJECT
• Setting Priorities • client, any part of the client
• Establishing Client Goals/Desired VERB
Outcomes • specifies an action the client is to perform
• Selecting Nursing Interventions CONDITION OR MODIFIER
• Writing Individualized Nursing Interventions • added to verb to explain circumstances
On Care Plans under which behavior is to be performed
CRITERION OF DESIRED PERFORMANCE
PRIORITY SETTING • inidicates standard by which the
- is the process of establishing a performance is evaluated
PREFERENTIAL SEQUENCE for addressing
nursing diagnoses and interventions.
HIGH PRIORITY
MEDIUM PRIORITY
LOW PRIORITY

Use Maslow's hierarchy of needs.

NURSING PROCESS – ADPIE (NUR 091)
GUIDELINES FOR WRITING GOALS/DESIRED
OUTCOME
1. Write in terms of the CLIENT responses NOT
nurse's activities.
- Begin with the client/patient will
- Avoid statements that starts with enable,
facilitate, allow, let, permit or similar words
followed by the word "client”
2. Must be REALISTIC for client's capablities,
limitations and designated time span.
3. Ensure COMPATIBILITY with the therapies of
other professionals.
4. Derived from only one nursing diagnosis.
5. Use OBSERVABLE and MEASURABLE terms.
S – pecific
M – easurable
A – ttainable
R – ealistic
T – ime bound
IMPLEMENTATION AND EVALUATION
Implementation
- putting the plan into action
Evaluation
- “did the plan work?”
NURSING INTERVENTION
- These are activities or actions that a nurse
performs to achieve client goals.
Interventions chosen should focus on
eliminating or reducing the etiology of the
nursing diagnosis. As for risk nursing
diagnoses, interventions should focus on
reducing the client's risk factors. In this step,
nursing interventions are identified and
written during the planning step of the
nursing process; however, they are
actually performed during the
implementation step.
Nursing interventions should be:
• Safe and appropriate for the client’s age,
health, and condition.
• Achievable with the resources and time
available.
• Inline with the client’s values, culture, and
beliefs.
• Inline with other therapies.
• Based on nursing knowledge and
experience or knowledge from relevant
sciences.
When writing nursing interventions, follow these
tips:
1. Write the date and sign the plan. The date
the plan is written is essential for
evaluation, review, and future planning.
The nurse’s signature demonstrates
accountability.
2. Nursing interventions should be specific
and clearly stated, beginning with an
action verb indicating what the nurse is
expected to do. Action verb starts the
intervention and must be precise. Qualifiers
of how, when, where, time, frequency,
and amount provide the content of the
planned activity.
For example: “Educate parents on how to
take temperature and notify of any
changes,” or “Assess urine for color,
amount, odor, and turbidity.”
3. Use only abbreviations accepted by the
institution.
Providing Rationale
Rationales, also known as scientific
explanations, explain why the nursing
intervention was chosen for the NCP.

• Actions nurse performs to achieve

goals/desired outcomes.
• Focus on eliminating or reducing etiology
of nursing diagnosis.
• Treat sign and symptoms and defining
characteristics.

TYPES OF NURSING INTERVENTION

INDEPENDENT
- are activities that nurses are licensed to
initiate based on their sound judgement
and skills.
DEPENDENT
- are activities carried out under the
physician’s orders or supervision.
COLLABORATIVE/ INTERDEPENDENT
- are actions that the nurse carries out in
collaboration with other health team
members, such as physicians, social
workers, dietitians, and therapists.
NURSING PROCESS – ADPIE (NUR 091)

Evaluation
- is a planned, ongoing, purposeful activity
in which the client’s progress towards
achieving goals or desired outcomes is
assessed, and the effectiveness of the
nursing care plan (NCP).
- Evaluation is an essential aspect of the
nursing process because the conclusions
drawn from this step determine whether
the nursing intervention should be
terminated, continued, or changed.