THE NURSING

PROCESS
 THE NURSING PROCESS

Defined as an organized,
systematic method of planning
and providing individualized
care to clients
 HISTORY OF NP:
• term coined by LYDIA HALL.
• Before: dependent on nursing order.
• 1973: NANDA (NORTH AMERICAN
NURSING DIAGNOSIS ASSOCIATION) used
to classify nursing diagnosis.
• 1980: ANA (AMERICAN NURSES
ASSOCIATION) published standards of
care as guideline for prof. nurses.
 1984: JCAHO (JOINT COMMISSION ON
ACCREDITATION OF HEALTH CARE
ORGANIZATIONS launched
requirements for accredited hospitals
to use the nursing process as a means
of documenting all phases on client
care.
 CURRENT: NURSING PROCESS IS A
5-STEP PROCESS
STEPS OF THE NURSING PROCESS:

EVALUATION
INTERVENTION
PLANNING
DIAGNOSIS
ASSESSMENT
 ASSESSMENT

NURSING
EVALUATION DIAGNOSIS
PROCESS

IMPLEMENTATION PLANNING
UNIQUE CHARACTERISTICS OF
A NURSING PROCESS
 A problem-solving and decision-making method
 Cyclic, ongoing and dynamic.
 Is CLIENT-CENTERED
 interpersonal, technical and intellectual skills were
utilized
 Promotes collaboration
BENEFITS OF NURSING PROCESS:
 PROMOTES IMPROVED CARE AND CONTINUITY OF
CARE
 PROMOTES AND ENCOURAGES CLIENT
PARTICIPATION
 DELIVERY OF CARE & PROBLEM-SOLVING ARE
ORGANIZED, CONTINUOUS & SYSTEMATIC
 TIME & RESOURCES ARE UTILIZED MORE
EFFICIENTLY
 DELIVERY OF CARE MEETING EXPECTATIONS OF
BOTH THE HEALTH CARE CONSUMER &
STANDARDS OF THE NURSING PROFESSION
 HOLDS ALL NURSES ACCOUNTABLE &
RESPONSIBLE FOR ASSESSMENT, DIAGNOSIS,
PLANNING, IMPLEMENTATION AND EVALUATION
OF CARE.
 step 1: ASSESSMENT
Data collection, verification,
organization, interpretation and
documentation.
It involves the act of gathering
data about the health status of a
client.
It provides BASELINE DATA –
foundation of client database.
 Steps in ASSESSMENT:
1. DATA COLLECTION
METHODS OF DATA COLLECTION
1. INTERVIEWS
2. CONVERSATIONS
3. PERFORMING PHYSICAL ASSESSMENT
4. REVIEW OF DIAGNOSTIC STUDIES

SOURCES OF DATA:
1. Nursing records
2. Medical records and
3. Verbal or written consultations
2. VERIFICATION
3. ORGANIZATION
4. INTERPRETATION
5. DOCUMENTATION
 TYPES OF DATA COLLECTED:
• OBJECTIVE DATA – SIGNS;observable,
measurable
• SUBJECTIVE DATA – SYMPTOMS;
include the client’s communicated
description, perception, feelings, emotions
or concerns
Data collected may include: PHYSICAL,
PSYCHOLOGICAL, SOCIAL, CULTURAL,
SPIRITUAL, DEVELOPMENTAL AND
COGNITIVE AREAS.
 TYPES OF DATA
SUBJECTIVE OBJECTIVE
• What the person • Things that are
states eg. “ I am sad.” observable &
•These are feelings measurable by the
and perceptions examiner
• “I wish I were home.” •BP of 110/70
•“ I feel sick to my •Rash on right arm
stomach.” •Ambulates with a cane
•Ate 100 % breakfast
•425 ml cloudy urine
Objective data usually supports the
subjective data.
• Example:
S: Client states, “ I feel like my heart is racing.”
O: Pulse 150 beats per minute, regular strong
However, there may be times when objective
data will conflict or seem different from what the
client says.
• Example:
S: Client states, “ I have no pain.”
O: Color pale, respiratory rate increased from 20-
40 bpm.
 TIP: Just state the facts. Do NOT state
opinions and do NOT jump to conclusions.

SUBJECTIVE OPINION/CONCLUSION
• “I don’t want to have • Client is angry or hostile
the test.
OBJECTIVE
• Dressed and shaved • able to attend ADLs
this morning
•Hands tremble •Client is afraid or anxious
 USE YOUR SENSES OF
OBSERVATION
• LOOK – note pt.’s general appearance
- note body language / posture
• LISTEN
• FEEL
• SMELL
• BE SENSITIVE - be aware of your method of
interaction
• BE AWARE OF CULTURAL DIFFERENCES.
 NURSING TIPS:
• Always promote communication while
assessing
• Ask questions and then allow time for
response
• Do not rely on memory. Write it down.
• Choose a method for organizing your
assessment, eg. Head to toe, body
systems.
• Use your physical examination techniques.
 2. DIAGNOSIS
Diagnosis – the pivotal second phase of the nursing
process, in which the nurse interprets assessment
data, identifies client’s strengths and health
problems, and formulates diagnostic statements.
The NANDA defines nursing diagnosis as “a clinical
judgment about individual, family and community
responses to actual or potential health problems/life
processes.
Activities
 NANDA nursing diagnosis
 Diagnostic process
 Ongoing development of nursing diagnoses
 DIAGNOSIS/activities
NANDA nursing diagnoses – client’s problem statement and
its related risk factors
Types
1. Actual diagnosis – problem present at time of assessment
2. Risk nursing diagnosis – clinical judgment that a problem
does not exist but the presence of risk factors indicates that
a problem is likely to develop
3. Wellness diagnosis – human responses to levels of
wellness in an individual, family or community
4. Possible nursing diagnosis – is one in which evidence
about a health problem is incomplete or unclear
5. Syndrome diagnosis – associated with a cluster of other
diagnoses
DIAGNOSIS/activities
Diagnostic process – uses the critical-thinking skills
of analysis and synthesis
3 steps

1. Analyzing data – comparing against standards,

clustering cues, identifying gaps and
inconsistencies
2. Identifying health problems, risks, and strengths –
determining problems and risks, determining
strengths
 Formulating diagnostic statements
-Basic 2-part statement – problem + etiology
-Basic 3-part statement – problem + etiology + s/s
-One part statement – NANDA label only
 Examples of NSG DIAGNOSIS
 Anxiety related to insufficient knowledge regarding surgical
experience
 Risk for injury related to sensory and integrative dysfunction
as manifested by altered mobility and faulty judgment
Correct/incorrect nursing diagnoses
Correct: High risk for ineffective airway clearance related to
thick, copious mucus secretions
Incorrect: High risk for ineffective airway clearance related to
pneumonia
MEDICAL versus NURSING DIAGNOSIS
MEDICAL DIAGNOSIS NURSING DIAGNOSIS
• made by the physician 1. Applies to the label
•Refers to a disease, 2. Nurses assign meaning
condition or pathological to collected assessment
state data.
•Remains constant until 3. Actual & potential
client recovers from problems of the client
disease/illness are identified.
4. May change as the
client’s responses
change
 MEDICAL versus NURSING
DIAGNOSIS
MEDICAL DIAGNOSIS NURSING DIAGNOSIS
Examples Examples

• Pneumonia • Impaired gas exchange

•COPD Exacerbation • Ineffective breathing

pattern

•Prostatitis • Altered urinary

elimination
CHARACTERISTICS OF NSG DIAGNOSES:

• ACTUAL NURSING DIAGNOSIS –describe the

client’s response to a physical, sociocultural
psychological &/or spiritual illness/disease or
condition.
- actual signs and symptoms are present
Examples:
Hyperthermia, client’s temp is 38 degrees C
Impaired gas exchange, client’s O2 saturation in
arterial blood is 92 %
Self-care deficit, client is unable to perform ADLs
 POTENTIAL/RISK DIAGNOSIS
• - a clinical judgment made when the client
is more vulnerable to develop the problem
than others in the same or similar
situations.”
• Examples:
• Cancer patient, Risk for infection r/t
inadequate secondary defenses,
immunosuppression
• Client who is vomiting, unconscious, Risk
for aspiration r/t reduced level of
consciousness, vomiting
 COMPONENTS OF
ACTUAL NSG DIAGNOSIS RISK NSG DIAGNOSIS

PROBLEM + ETIOLOGY + PROBLEM +

DEFINING ETIOLOGY
CHARACTERISTICS
• PROBLEM –is the identified label of the
client’s health condition/response to the
medical illness or therapy. Also known as
nursing diagnosis.
• ETIOLOGY – or cause; written as Related
To; includes all condition most likely to be
involved in the development of a problem.
• DEFINING CHARACTERISTICS -
written AS EVIDENCED BY; are clinical
signs and symptoms.
 Step 3: PLANNING
Planning – the third phase of the nursing process, in which the
nurse and client develop client goals/desired outcomes and nursing
interventions to prevent, reduce, or alleviate the client’s health
problem
Types of Planning
Initial planning – the nurse who performs the admission
assessment usually develops the initial
comprehensive plan of care
Ongoing planning – is done by all nurses who work with the
client. It also occurs at the beginning of
a shift
Discharge planning – process of anticipating and planning for
needs after discharge.
 PLANNING
Developing nursing care plan

 Informal ncp – is a strategy for action that is in the mind

of the nurse
 Formal ncp – written/computerized guide that organizes
information about the patient’s care
 Standardized ncp – formal plan that specifies nursing
care for groups of clients with common needs
 Individualized ncp – tailored to meet unique needs of a
specific client
 PLANNING
Formats of NCPs
 Student care plans – rationale, concept map
 Computerized care plans – being used to create and store
NCPs
Guidelines for writing NCPs
 Date and sign the plan
 Use category headings
 Use standardized medical/english symbols and key words
 Be specific
 Refer to procedure books than putting all the steps in the NCP
 Ensure that NCP incorporates preventive and health
maintenance
 PLANNING
Planning process
 Setting priorities (high, medium, low)
 Establishing client goals/desired outcomes
 Selecting nursing interventions and activities
(independent, dependent, collaborative interventions)
 Writing nursing orders (date, action verb, content
area, time element, signature, etc)
 Delegating implementation (delegation, assignment)
 Step 4: IMPLEMENTATION/
INTERVENTION
 involves the execution of the nursing care
plan.
 Steps in Implementation:
1. Activating the plan of care
2. Carrying out planned interventions.
3. Continued assessment as interventions are
carried out
4. Recording and documenting care provided,
interventions carried out and client responses
 CLASSIFICATION OF NURSING
INTERVENTIONS
• INDEPENDENT
• DEPENDENT
• COLLABORATIVE
 NURSING INTERVENTIONS
1. INDEPENDENT- does not need a doctor’s
order. A must for nurses to perform in
delivering care to clients.
• Eg:
- positioning pts. properly according to
condition.
- giving tepid sponge bath when pt. is febrile
- providing health teachings to pt.
• DEPENDENT – relies on doctor’s orders.
It must be written in the patient’s chart
before nurses carry them out.
Eg:
- Giving medications
- Dressing
- Procedures such as enema, inserting foley
catheter
- Inserting IV lines/taking specimen for
laboratory
• COLLABORATIVE - requires referring
unusualities/observations/assessment to
other health team members to ensure
continuity and collaboration of care.
• Examples:
- Referring to medical technologists for
laboratory readings/analysis
- Informing doctors/health team members of
current condition of the pt.
- Collaborates with dietician for preparing the
prescribed diet of the pt.
 NURSING TIPS:
NURSING INTERVENTIONS INVOLVE:
• Assisting with activities of daily living (ADL)
• Delivering skilled therapeutic interventions
• Discharge planning
• Monitoring response to medical and
nursing care
• Supervising and coordinating nursing
personnel
• Teaching the client.
 step 5: EVALUATION
 involves analysis of all aspects of
phenomena and comparison to a set
of standards, criteria, interventions or
expectations to determine the
effectiveness of the standard,
behavior or intervention.
Check your goals/ objectives if met,
unmet or partially met. Then do care
plan modification of needed.
 DOCUMENTATION
• Is the process of preparing a record reflecting
the assessment data and both the client’s health
status and response to care.
• To be effective: requires use of common
vocabulary, legibility and neatness, use of only
authorized abbreviations & symbols, factual and
time-bounded, accurate including any errors that
occurred, following facility protocol
• May be SOAPIE charting, Narrative or FOCUS
charting
DOCUMENTING/REPORTING
Documenting – process of making entry on client record
(recording, charting)
 Ethical/legal considerations (confidentiality)
 Purposes of client records (communication, planning client
care, auditing health agencies, research, education,
reimbursement, legal documentation, health care analysis)
 Documentation systems (database, problem list, plan of
care, progress notes)
 Documenting nursing activities
 Long-term care documentation
 Home care documentation
 General guidelines for recording
 DOCUMENTING/REPORTING
General guidelines for recording

 Date and time Sequence

 Timing Appropriateness
 Legibility completeness
 Permanence
 Accepted terminology
 Correct spelling
 Signature
 Accuracy
 DOCUMENTING/REPORTING
Reporting – is oral, written, or computer-
based communication intended to
convey information to others
 Change –of-shift reports
 Telephone reports
 Telephone orders
 Care plan conference
 Nursing rounds
 NURSING TIP:

• ALWAYS MAINTAIN
CLIENT’S
CONFIDENTIALITY.
 ACTIVITY: ½ crosswise
Refer to NANDA for your answers:
Formulate a nursing diagnosis based on the
following situations: (3 points each)
1. Patient experiencing acute asthma attack
2. Multiple injuries due to vehicular accident
3. Postpartum mother recovering after giving
birth via normal vaginal delivery
4. Paralyzed patient after suffering from
stroke
5. Patient hospitalized over a long period,
have difficulty sleeping
 INDIVIDUAL SEAT WORK
Refer to NANDA for your answers:
Formulate a nursing diagnosis based on the
following situations:
1. An infant with loose bowel movement and is
frequently vomiting.
2. A patient who is about to go home and has
improved level of health
3. A teenager who has suffered burns
4. A boy who has a temperature of 40 degrees
Celsius
5. A woman suffering from scanty urination and
flank pain, with a diagnosis of UTI
THANK YOU FOR BEING
GOOD STUDENTS…GOOD
LUCK ON YOUR JOURNEY
…KEEP ON PRAYING.

GOD BLESS!  -