NURSING PROCESS

OBJECTIVE
At the end of the course and given simulated conditions or situations, the students will
be able to:
Cognitive:
 Understand the concepts of Nursing Process
 Describe each component of Nursing Process
 Explain the relationship between critical thinking and steps of the nursing process
Affective:
 Communicate to clients following effective therapeutic communication skills
 Express appropriate assessment finding through proper documentation
 Show efficiency in coming up with a nursing care plan
Psychomotor:
 Utilize nursing process for the care of clients holistically
 Design an individualized nursing care plan that would promote optimum care to clients
 Demonstrate accuracy when documenting assessment findings and other pertinent
data
 NURSING
PROCESS

• It is a systematic, rational method of planning and

providing individualized nursing care.
• CRITICAL THINKING is
the process of
intentional higher level
thinking to define a
client’s problem,
examine the evidence-
based practice in caring
for the client, and make
choices in the delivery of
care.
• CLINICAL REASONING is
the cognitive process that
uses thinking strategies to
gather and analyze client
information, evaluate the
relevance of the
information, and decide on
possible nursing actions to
improve the client’s
physiological and
psychosocial outcomes.
 Identify a client’s health
Establish status
plans to meet the identified needs
Deliver specific nursing interventions
Phases of Nursing Process
ADPIE
ASSESSMENTPLANNING
DIAGNOSIS EVALUATION
IMPLEMENTATION
 D
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 ASSESSMENT
The process of collecting, validating & recording data
about a client’s health history & health status.

Methods of collecting data:

Observation
Interviewing
Examining
 Types of Data

Subjective Data Objective Data

Subjective Data

 Subjective data include the client’s sensations, feelings, values, beliefs,

attitudes, and perception of personal health status and life situation.
 Data from the client’s point of view.
 Provided by client.
 Methods: Interview
 Types of Data

Subjective Data Objective Data

Objective Data
 Data that can be measured or tested against an accepted
standard.
Method: Physical Examination/Assessment (IPPA/IAPePa)

Physical Assessment techniques

1. Inspection
2. Palpation
- Light palpation
- Deep palpation
3. Percussion
- Direct
- indirect
4. Auscultation
 Source of Data

Primary SECONDARY
 D
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 DIAGNOSIS
 Interpretation or analysis of Data.
 Identify health problems, risks & strengths
Formulate Nursing Diagnosis Statement (NANDA: North American Nursing
Diagnosis )
DIAGNOSIS
3 parts of Nursing Diagnosis:

1. Problem
- Describes the client's health problem or response
- May require specification
- Qualifiers added to give additional meaning

o Such as Deficient, Impaired, Decreased, Ineffective, and

Compromised

2. Etiology
- Identifies one or more probable causes of the health problem
- Gives direction to the required nursing therapy
- Enables the nurse to individualize the client's care

3. Signs and symptoms

- defining characteristic
- the phrase: as evidence by is joined to the first two parts.
DIAGNOSIS
Example
Ineffective Airway Clearance
Deficient Knowledge
Spiritual Distress
Ineffective Airway Clearance
r/t retained secretion
Deficient Knowledge
r/t misinterpretation of
information
Spiritual Distress
r/t separation from religious ties
Ineffective Airway Clearance
r/t retained secretion AEB
nasal flaring.
Deficient Knowledge
r/t misinterpretation of
information AEB inaccurate return
demonstration
Spiritual Distress
r/t separation from religious ties
AEB crying and withdrawal
 Type of Nursing Diagnoses

Actual Client’s problem that is present at the time of the nursing

assessment

Example:
1. Acute Pain related to fracture
2. Ineffective Airway Clearance related to retained mucus secretions
 Type of Nursing Diagnoses

Risk Indicates that a problem does not yet exist, but special risk
factors are present.

Example:
1. Risk for infection related to chemotherapy treatment
2. Risk for Impaired Skin Integrity related to immobility
 Type of Nursing Diagnoses

Wellness Indicates the client’s expression of a desire to attain a higher

level of wellness in some area of function.

Example:
1. Readiness for enhanced family coping.
2. Potential for Enhanced Nutrition.
 Type of Nursing Diagnoses
Statement about a health problem that the client might have
Possible now, but the nurse doesn’t yet have enough information to
make an actual diagnosis.

Example:
1. Possible Self-Esteem Disturbance related to recent
retirement and relocation.
 Type of Nursing Diagnoses

Syndrome Used when a cluster of nursing diagnosis are often seen

together.

Example:
1. Rape-trauma syndrome related to anxiety about potential
health problems as manifested by anger, genitourinary
discomfort and sleep pattern disturbance.
 D
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 PLANNING
 The process of developing, prioritizing plan of care and establishing SMART goals in
order to achieve a desired outcome.

 formulate goals/desired outcome

- Short term goal
- Long term goal

Select and write nursing interventions

 NURSING CARE PLAN
CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Pkaregenan ako >Ineffective breathing >Within my 8 hrs of care, pt >Check and monitor v/s. >To serve as baseline data. >After my 8 hrs of care, pt
guminawa”, as verbalized pattern r/t pulmonary will gradually manifest >Check and regulate IVF as >To prevent fluid overload. was able to gradually
by the pt. secretions. effective breathing pattern prescribed.   manifest effective breathing
>To promote comfort and
O: Received pt at 7:15 am as evidenced by decrease >Provide bedside and relaxation. pattern as evidenced by
lying on bed ,concsious, abnormal sounds upon morning care to pt. >To promote lung decrease abnormal sounds
coherent, oriented to time , auscultation. >Maintain HOB elevated. expansion. upon auscultation.
place and person with >Encourage rest periods >To avoid stress.  
oingoing IVF #4 D₅NM 1L between activities and sleep   Final V/S:
with 600 cc level left, to pt.   >Temperature 38° C
hooked at left arm >Encourage pt to perform >To promote optimum >Weight not taken
lung expansion and
regulated @ 30 gtts/min, coughing exercises. And to expectoration of >Pulse 114 bpm
infusing well. cough effectively. secretions. >Respiration 40cpm
>paleness noted >Teach and encourage >To promote lung
>restlessness noted breathing exercise. expansion and clearing.
>rhonchi heard upon >Perform chest >To expectorate secretions.
auscultation physiotherapy to the pt.  
>To achieve desired
>nasal flaring noted >Instruct pt to have strict therapeutic effect of meds
>use of accessory muscle compliance of medications. and facilitate faster
upon breathing   recovery.
>cheat pain 4/10 >Instruct pt and SO correct >To avoid spread of
Initial V/S: disposal of secretions. disposal.
>Temperature 39.6 ° C
>Weight not taken
>Pulse 114 bpm
>Respiration 52 cpm

 
 
 
 
 
 
 Types of Nursing Intervention

Independent Interdependent

Dependent
 D
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 IMPLEMENTATION

Implementing consists of doing and documenting the

activities that are specific nursing actions needed to carry
out the interventions. The nurse performs or delegates the
nursing activities for the interventions that were developed
in the planning step and then concludes the implementing
step.
 D
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 EVALUATION
Evaluating is the fifth phase of the nursing process. In this context,
evaluating is a planned, ongoing, purposeful activity in which
clients and health care professionals determine:
(a) the client’s progress toward achievement of goals/ outcomes
and
(b) the effectiveness of the nursing care plan.
ACTIVITY

4 PICS
C Y A N O S I S
 D I F F I C U L T Y
O F B R E A T H I N G
H Y P E R T E N S I O N
P A I N
A S S E S S M E N T
P A L E S K I N
This is Mrs. Soraya, 29 years Old who was admitted to
the hospital with an elevated temperature of 38c,
Respiratory rate of 30 cycles per minute, pulse rate of
92 bpm and a blood pressure of 110/80 mmhg. The
nurse also notes that Mrs. Sarah is having a
productive cough for several days with crackles noted
upon auscultation in the upper and lower lobes. Mrs.
Soraya states that, “Sobrang hirap huminga parang
may nakapatong na bato sa dibdib ko”. Laboratory
results and chest x-ray of Mrs. Sarah confirmed
COVID-19 infection.
Be A Nurse