NURSING

PROCESS
NURSING PROCESS
 This is a systematic process in which Assess
the nurse plans and provide care for
patients.
 This involves a problem – solving Evaluate
Diagnose
approach to meet the health care and
nursing needs of the patient. Hence, it
allows you to identify actual and
potential health problems of the
patient. Plan and
Implement Identify
 Once you identify these problems, Outcome
you are then able to plan, deliver, and
evaluate nursing care in an orderly
and scientific manner.
1. ASSESSMENT
 The first step and most important step in
Assess
the nursing process as it sets the tone for
the rest of the process.

Evaluate
 This is the systematic collection, Diagnose
validation, and clustering of data to
determine the health status of the patient.

 You do not perform this only once, but Plan and

Implement Identify
throughout the nursing process. Outcome
2. NURSING DIAGNOSIS
 This process involves the Assess

identification and
prioritization of actual or Evaluate
Diagnose
potential problems or
responses.
Plan and
Implement Identify
Outcome
Nursing diagnosis can be:
a. Actual Nursing Diagnosis
 Identifies occurring health problem of the patient. Assess
b. Potential Nursing Diagnosis
 Identifies a high-risk problem that is most likely will occur
unless preventive measures have been done. Evaluate
c. Possible Nursing Diagnosis Diagnose
 This needs further data to support it.
d. Collaborative Problem
 A potential medical complication that needs medical and
Plan and
nursing interventions. Identify
e. Wellness diagnosis
Implement
Outcome
 This focuses in promoting or enhancing the level of
wellness of the patient.
3. PLANNING
Assess
 In this stage, we set our goals and
outcomes to assist our patient in
solving the nursing diagnosis. Evaluate
Diagnose

 We stablish goals and desirable

measurable outcomes.
Plan and
 Specific, Measurable, Attainable, Implement Identify
Outcome
Realistic, Timely/Time-bound
o Short-term
o Long-term
 4. IMPLEMENTATION
 AKA Intervention Assess
 This is the “doing” phase of the nursing
process since you carry out your plan to
achieve your goals and outcomes. Evaluate
Diagnose
 As you implement your plan, you continue
to assess your patient and modify the plan
if necessary. Plan and
Implement Identify
 Make sure to document your care. Outcome
5. EVALUATION
 This determines the effectiveness of your Assess
plan. Hence, you assess the responses of the
patient to your nursing interventions based
Evaluate
on the criteria you set for the outcome. Diagnose

 If your goals were not met, you have to

Plan and
rethink your plan and work through the Identify
Implement
process again and develop a more effective Outcome
plan of care for your patient.
Ms. Kurdapia was earning Php 40,000.00 monthly but lost her job six
months ago due to the pandemic. She entered the psychiatric unit two
days ago with the diagnosis of major depression. Upon admission, she
states that “I just can’t live like this anymore… I missed the life that I
used to have. I messed up. I cannot even sleep like I used to. I just want
to die”. Ms. Kurdapia lost 15 kg in the past 6 months, she weighs 40 kg
and is 5 feet 6 inches tall. She is often tearful, sighs often, ignore
NURSING
question at times, keeps repeating that she is a loser and has poor eye
contact during the interview. She becomes restless and irritable when
CARE
asked about her previous job and is not oriented to time, place and date.
Ms.
PLAN
Kurdapia stays in her room all day and refuse to join any
activities, including her personal hygiene. She is no longer interested in
baking and cooking like she used to. She has unkempt hair and clothes;
she was unable to fix her bed and her books were scattered on the floor.
When asked, she admits of having thoughts of killing herself. She states
that she attempted to do so by taking the whole bottle of multivitamins,
but she was caught by her sister who stopped the incident. Hence, they
take her to the emergency department.
Assessment Nursing Diagnosis Expected Outcome Interventions Rationale Evaluation

Subjective: “I just Ineffective Coping STO: Assess factors To gain After your
can’t live like this related to major At the end of the contributing to understanding of interventions, were
anymore… I missed depression in shift: ineffective coping the patient’s current you able to meet
the life that I used response to the patient will be such as poor self- situation and to help your
to have. I messed stressors associated able to engage in concept, lack of her with effective goals/objectives?
up. I can’t even with loss of job reality – based social support or coping strategies.  
sleep like I used to. during the interactions. lack of problem Met, Unmet,
I just want to die” pandemic. The patient will be solving. Partially Met
oriented to person, Serves as a baseline
Objective: place, and time. Assess the level of and to plan for
- Disorientation understanding of relevant
- Ruminating the patient and her interventions.
thoughts such as readiness to learn
repetitive necessary lifestyle
verbalisation of changes
being a loser.
- Anhedonia characterised by her LTO: Assess available Some patients may lack
lack of interest in daily activities After five days of support systems sufficient support system
- Sleep disturbances: early working with the   outside the hospital facility
awakening, insomnia patient:  
- Generalised restlessness or she will be able to  
agitation express or verbalise Provide a safe Physical safety of the patient
- Poor eye contact emotions with the environment for the  
- Suicidal ideas or behaviour nurse and the patient
- Poor self-care significant other   This will allow the patient to
- Poor communication by without being Encourage patient express negative feelings
patterns like ignoring restless or irritable. to express or regarding her current
questions and giving bizarre She will be able to verbalise feelings situation
identify and
answers at times
initiates effective
- Decrease used of social coping strategies in
support characterised by lack adapting to
of interest in socialising. situational crisis or
stress.
ROLES OF NURSES

1. PRACTITIONER
 We are directly involved in meeting the health
care and nursing needs of our patients, families,
and significant others.

 This includes staff nurses at all rungs, advanced-

practice nurses and community-based nurses.
Coordinator

Registerednursing.com
 Coordinate and plans care
 Liaison in the health care
team
Communicator

 Establish rapport with our Tigerconnect.com

patient
 Use therapeutic
communication – verbal or
nonverbal cues
Teacher
 We educate our patient for them to Wolterskluwer.com
move toward independence and
develop self – care abilities.
 We provide knowledge to enable
our patients to make informed
decisions.
 Through our health teachings, we
promote health, prevent illness,
restore health and facilitate coping.
Counsellor

Careertrend.com
 We assist patients in
solving their problems or
in making informed
decisions.
Advocate

Dailynurse.com
 We are the representative
of the patient. Hence, we
protect and support our
patient.
 We promote self
determination
 Assertiveness
2. LEADER CLIPARTPANDA.COM

 This involves deciding, relating,

influencing or facilitating that
affects the actions of others and is
directed toward the determination
and achievement of our goals.

 This can be formal leadership or

informal roles that are regularly
assumed by nurses.
3. RESEARCHER
 This involves the implementation of
studies in determining the actual effects
of nursing care to expand scientific-
based nursing practice.

 It can be done bay all nurses, not just

academicians, nurse scientist and
graduate nursing students.
4. TEAM
PLAYER
We are part of the team, and do not
work alone.
5. CRITICAL THINKER

Emergingleader.com
 “Think Outside the Box”
 Open to new ideas
6. INNOVATOR

Nurseinnovator.com
 We initiate change
 We take actions to make
things happen.
 We see problems and look
for solutions