How will I

help my
patient?
My patient
looks terribly
sick, why?
What are
nursing
interventions
suited for my
patient? What if my
patient did
not recover?
How will I
know my
nursing care
are effective?
Let’s talk about
THE NURSING
PROCESS
Review of Nursing Process
 NURSING PROCESS
 It is an organized, systematic manner of
providing goal- oriented and humanistic care
that is both efficient and effective.
 It is composed of five sequential and
interrelated steps: Assessment, Nursing
Diagnosis, Planning, Implementation and
Evaluation.
 NURSING PROCESS
 It is EFFECTIVE because it is relevant to the
needs of the patient. It promotes patient
satisfaction and progress.
 It is EFFICIENT because it utilizes resources
widely in terms of human, time and cost
resources.
PHASES OF THE NURSING PROCESS
Assessment

Evaluation Diagnosis

Outcome
Implementation Identification
& Planning
 ASSESSMENT

Evaluation Diagnosis

Outcome
Implementation Identification
& Planning
 ASSESSTMENT
 It is collecting, validating,
organizing and recording data
about the patient ’ s health
status.
 Purpose: To establish a data
base.
 Types of Assessment
 Initial Comprehensive Assessment
- Involves client’s perception of his health status, past health
history, family history, lifestyle/practices and data from
physical examinations
 Partial or On-going Assessment
- To gather data from ICA that is need to be re-assessed to
determine major changes
 Types of Assessment
 Focused or Problem-Oriented Assessment
- A thorough assessment of client’s particular problem and does not
cover areas not related to the problem.
 Emergency Assessment
- A very rapid assessment performed in life-threatening
situations.
ACTIVTIES DURING ASSESSTMENT

 Data collection
 Validating
 Interpretation
 Documentation
 DATA COLLECTION
 This involves gathering of information about
the following patients’ conditions in:
1.Physical
2.Psychological
3.Socio-cultural
4.Spiritual
 These may affect the patient’s health status.
 TYPES OF DATA
 Subjective Data
- can be elicited by the client.
- are sensations, feelings, perceptions,
preferences, beliefs, ideas, values and
personal information.
EXAMPLES OF SUBJECTIVE DATA

Give one example each!

 TYPES OF DATA
 Objective Data
- Are directly observed and measured by the
nurse
- Through general observation or the IPPA
method
EXAMPLES OF OBJECTIVE DATA

Give one example each!

 METHODS OF COLLECTION OF DATA
Interview
 It is planned purposeful conversation.
 To allow the nurse to obtain specific
information necessary for diagnosis and
planning.
 To promote the nurse/client relationship by
providing an opportunity for dialogue.
 To allow the client to receive information and
to participate in problem identification and
goal setting.
 To help the nurse in identifying areas for
specific investigation during the other parts of
the assessment.
 Examples:
Collection of data for health history
Admission of a patient to a health care
facility
 METHODS OF COLLECTION OF DATA

Observations
 Use of senses: vision, hearing, touch, smell
 Use of Physical Examination: IPPA Method
 Use of units of measure: mmHg for BP, pounds
or kilograms for weight, feet or centimeter for
height, Celsius for temperature
 METHODS OF COLLECTION OF DATA

Interpretation of Laboratory or Diagnostic

Results
 All should be present in the patient’s
chart.
 Results should be clear and without
erasures.
 Examples: Urinalysis, CBC, Chest x-ray
 SOURCES OF DATA
Primary Source
 Patient
Secondary Sources
 Family members, significant others
 Patient’s chart
 Health team members
 Related literature such as books, journal,
researches.
 VALIDATING DATA
 It is a method in confirming if the data
collected are reliable and accurate.
 Data that needs validating:
- Gap between subjective and objective data
- Inconsistency of client ’ s responses to
questions
- Inconsistency in observation and physical
examinations in measurements
 METHODS OF VALIDATION
 Recheck your own data through re-
assessment.
 Clarifying data by asking the client additional
questions.
 Verify data with another HC professional.
 Compare your subjective and objective data to
verify discrepancies.
 EXAMPLE
1. The patient’s urine is dark yellow in color.
 This may indicate dehydration or the patient
may had taken certain medication or food.
 Assess patient for vomiting, loose bowel
movements, dry skin.
 Check for other parameters such as changes
in weight, urine output, skin turgor and vital
signs.
 EXAMPLE
2. The patient refuses to take her lunch served
at 11:30 am.
 This may indicate anorexia or feeling of
fullness.
 Ask the patient her last meal.
 Observe for any signs of anorexia such as
irrational fear of gaining weight, low body
weight, distorted appearance.
 DOCUMENTATION
 Provides chronologic source of client’s data,
outline of client’s course of care.
 Makes the client’s data accessible to
members of the HC team.
 Serve as a basis for establishing diagnoses.
 Comply to the nurse’s legal obligations.
 GUIDELINES FOR DOCUMENTATION

 Document legibly or print neatly in non-

erasable ink.
 Use correct grammar and spelling. Use
only approved abbreviations.
 Avoid wordiness that creates
redundancy.
 Use phrases instead of sentences.
 GUIDELINES FOR DOCUMENTATION

 Record data findings, not they were

obtained. Writes entries objectively.
 Record the client’s understanding of
problems
 Specifically record the data findings.
 EXAMPLE DOCUMENTATION

Subjective Cue:
“I do not feel well because I have fever.”
Objective Cues:
>Skin warm to touch
>With flushed and dry skin
>Latest WBC of 13.5 K/ul
> Temperature: 40°C per axilla
 Assessment

Evaluation DIAGNOSIS

Outcome
Implementation Identification&
Planning
 NURSING DIAGNOSIS
 It is the clinical act of identifying problems.
 To diagnose in Nursing, means to analyze
assessment information and derived meaning
from this analysis.
 Purpose: To identify the patient’s health care
needs and to prepare diagnostic statements.
 It is s statement of patient’s potential or
actual alteration in health status.
 NURSING DIAGNOSIS
 PRS format.  PSE format.

P - problem P – problem

R – related to factors S – signs and symptoms

S – signs and symptoms E – etiology

 ACTIVITIES IN
NURSING DIAGNOSIS
1. Organizing data
 Means clustering of facts into group of
information.
 Identifying specific subjective and objective
cues that are interrelated.
 One need to be familiar with the disease
condition of his/her patient.
 EXAMPLES
A. Data about patient’s
nutritional status
 Subjective data:
“I have no appetite to eat.”
“Food and drinks tastes
bitter.”
“I feel weak and easily get
tired.”
“I feel dizzy most of the
time.”
 EXAMPLES
A. Data about patient’s
nutritional status
 Objective data:
Weight loss (10 lbs in 2 weeks)
Pallor
Poor skin turgor
Dry and sore mucous
membrane in the mouth,
cracked lips.
RBC: 3 million/cu.mm (below
normal range)
 EXAMPLES
B. Data about patient’s fluid
balance status
 Subjective data:
“I have 15 watery stools
since last night until
morning.”
“I feel very thirsty.”
“I feel warm.”
“ I feel weak and nauseous.”
 EXAMPLES
B. Data about patient’s fluid balance status
 Objective data:
Temperature: 37.9°C
Urine: dark and concentrated, 20-25 ml/hr (low)
Skin: Flushed, warm and dry
Soft, sunken eyeballs
Pulse rate: 110 bpm
Hematocrit: 54% (elevated)
 ACTIVITIES IN
NURSING DIAGNOSIS
2. Compare gathered data from standards
*Standards are accepted norms, measures or
patterns for purpose of comparison.
Examples:
Normal skin – pinkish
Normal RBC level – 4.5-5.5 million/cu.mm
Normal PR – 60-100 bpm
Normal urine output – 30-60 ml/hr
 ACTIVITIES IN
NURSING DIAGNOSIS
3. Analyze data after comparing with standards
Examples:
 Passage of frequent watery stool may lead to
dehydration and loss of electrolytes (K, Na).
 RBC: 4 m/cu.mm, pallor may indicate
inadequate oxygenation.
 Poor appetite, weight loss weakness indicate
inadequate nutritional intake.
 ACTIVITIES IN
NURSING DIAGNOSIS
4. Identifying gaps and inconsistencies in data
Example:
 Patient claims she is gaining too much weight
but actually she is underweight.
 Patient claims he is warm and feverish but the
actual body temperature is within normal
range.
 ACTIVITIES IN
NURSING DIAGNOSIS
5. Proposed possible nursing diagnosis based on
NANDA.
 Wellness diagnoses – patient has the
opportunity for enhancement of health care.
 Risk diagnoses – patient does not have current
problem but is at high risk.
 Actual nursing diagnoses – patient has problem.
 ACTIVITIES IN
NURSING DIAGNOSIS
6. Formulate Nursing Diagnosis statements.
Examples:
 Altered Nutrition less than body
requirements related to poor appetite to eat.
 Fluid volume deficit related to frequent
passage of watery stool
 Inadequate oxygenation related to poor
oxygen-carrying capacity of the blood.
 Assessment

Evaluation Diagnosis

Outcome
Implementation Identification&
Planning
 OUTCOME IDENTIFICATION
Refers to formulating
and documenting
 Provide individualized
focused goals and
care
provides basis for
evaluating the  Promote patient
diagnosis participation
 Plan care
 Allow involvement of
support people
 ACTIVITIES IN
OUTCOME IDENTIFICATION
1. Establishing priorities
 Priority is something that takes precedence in
position, deemed the most important among
several items.
 Priority Setting is a decision-making process that
ranks the order of nursing diagnoses in terms of
importance to the patient.
So, how do the nurses PRIORITIZE
the problems that they identified
from their patients?
 PRIORITY SETTING INVOLVES THE
FOLLOWING
 Life threatening  Mental and
situations emotional status of
 Patient with unstable patients
condition
 Use of C-A-B  Time and resources
principle required
 Maslow’s Hierarchy  Actual over potential
of Needs problems
 Assess first before
implementation
HIGH, MODERATE,LOW PRIORITY
High
 Potentially life-threatening and
require immediate action.
 Examples: Impaired Gas Exchange,
Ineffective Breathing Pattern, Self-
directed Risk for Violence
HIGH, MODERATE,LOW PRIORITY
Moderate
 Can result to unhealthy
consequences such as physical or
emotional impairment but not life-
threatening.
 Examples: Fatigue, Activity
Intolerance, and Ineffective coping
 HIGH, MODERATE,LOW PRIORITY
Low
 Problems can be resolved easily with
minimal interventions.
 Unlikely to cause significant dysfunction.
 Examples: hunger due to NPO,
preparation for diagnostic procedure,
minimal pain due to ambulation
 ACTIVITIES IN
OUTCOME IDENTIFICATION
2. Establish patient’s goals and outcome criteria
 Patient goal is an “educated guess”, made as
broad statement about what the patient’s
state will be after the nursing intervention is
carried out.
 ACTIVITIES IN
OUTCOME IDENTIFICATION
2. Establish patient’s goals and outcome criteria
 Behavioral Goals are written to indicate a desired
state.
 It contains action verbs and a qualifier that
indicate the level of performance that needs to be
achieved.
 ACTIVITIES IN
OUTCOME IDENTIFICATION

Examples of behavioral verbs used in

Patient Goals:
Calculate, distinguish, participate,
explain, identify, state, describe,
maintain, use, demonstrate,
perform
 ACTIVITIES IN
OUTCOME IDENTIFICATION
Qualifier is a description of the parameter for
achieving the goal.
Examples:
Ambulates safely with one person assistance.
Demonstrate signs of sufficient rest before
surgery.
States the importance of proper hand washing
 PLANNING
It involves Purpose:
determining  Identify goals and NI
beforehand the  Provide direct patient
care activities
strategies or course
 Promote continuity of
of actions to be care
taken before  Allow for delegation
implementation of of specific activities
nursing care.
 ACTIVITIES IN
PLANNING

1. Identify the goals.

 Short Term Goal (STG) can be within days or
weeks.
 Long Term Goals (LTG) requires more time
(several weeks or months)
 ACTIVITIES IN
PLANNING

2. Planning nursing interventions.

 To direct activities to be carried out in the
implementation phase.
 It can be independent, dependent and
interdependent in nature.
 ACTIVITIES IN
PLANNING

*Nursing Interventions are any treatment,

based upon clinical judgment and
knowledge that a nurse performs to
enhance patient outcomes.
 ACTIVITIES IN
PLANNING
3. Write a nursing plan of care.
 It is the “blueprint” of the Nursing process.
 It should be nursing-centered and patient-
centered.
 Each should be supported by scientific
rationale.
 EXAMPLES
Goal: After 4 hours of nursing intervention, the patient will report
decrease anxiety level regarding surgery.
Possible Outcome Criteria:
 During health teachings, the patient discusses fears and
concerns regarding surgical procedure.
 The patient identifies support system and strategies to use to
reduce stress and anxiety related to the surgical procedure.
 After health teaching, the patient will verbalize decreased
anxiety.
 EXAMPLES
Goal: After 8 hours of nursing intervention, the patient will
mobilize pulmonary secretions.
Possible Outcome Criteria:
 After the health teachings, the patient demonstrates
proper coughing techniques.
 The patient will drink 8 glasses of water/day while in the
hospital.
 The caregiver or SO demonstrates proper techniques in
physiotherapy.
 Assessment

Evaluation Diagnosis

OUTCOME
IMPLEMENTATION IDENTIFICATION
& PLANNING
 IMPLEMENTATION

Purpose: To carry out planned nursing

interventions to help patient attain
goals and achieve optimal level of
health.
 IMPLEMENTATION
 Reassessing
 Setting priorities
 Performing nursing interventions
 Recording actions
 IMPLEMENTATION
Requirements for Implementations:
 Knowledge are intellectual skills
 Technical skills to carry out treatments or
procedures.
 Communication Skills thru therapeutic
use of self
 Assessment

EVALUATION Diagnosis

Outcome
Implementation Identification&
Planning
 EVALUATION
Purpose:
 It is the assessment of the patient’s response
to nursing interventions.
 And also, it is the comparison of the
response to predetermined standards or
outcome criteria
 ACTIVITIES IN EVALUATION

1. Collect data about the patient’s response.

2. Compare the gathered data to goals and
outcome criteria.
3. Analyze reasons for the outcomes.
 ACTIVITIES IN EVALUATION

4. Modify plan as needed.

5. It may maybe completely met, partially met,
completely unmet.
6. New problems or nursing diagnoses have
developed
 CHARACTERISTICS OF
NURSING PROCESS
 Problem oriented
 Goal oriented
 Orderly, planned and step by step
 Open to accepting new information
 Permits creativity among nurses and patients
 Can overlap
 Universal
 BENEFITS OF NURSING PROCESS
FOR THE PATIENTS

 Provides quality nursing care based on

standards.
 Provides Continuity of care
 Reflects respect for human dignity as it
permits patient to participate.
 BENEFITS OF NURSING PROCESS
FOR THE NURSES
 Provides systematic and consistent nursing
education
 Promotes job satisfaction
 Provides professional growth
 Avoids malpractice and negligence
 Meets professional nursing standards
 Meets standards in accredited hospitals
Prepare for a 30-item quiz
next meeting!