Nursing Process

By: Grace C. Espino

History of the Nursing process
Lydia Hall – originated the term Nursing
process in 1955. She introduced
3 steps:
a. Observation
b. Administration of care
c. Validation
• In 1959, Dorothy Johnson identified three steps of
nursing process: assessment, decision and nursing
action
• In 1961 Ida Jean Orlando introduced the “Deliberative
Nursing Process Theory- which included five stages:
assessment, diagnosis, planning, implementation,
and evaluation. (ADPIE )
American Nurses Association
- introduced the following innovations
✓ Diagnosis* distinguished as a
separate step (1973).
✓ Diagnosis of actual and potential
health problems delineated as integral
part of nsg. Practice in (1980).
✓Outcome Identification* differentiated as a
distinct step of the nursing process.
Therefore, the six steps of the nursing
process are
A - ASSESSMENT
D - DIAGNOSIS
O - OUTCOME IDENTIFICATION
P - PLANNING
I - IMPLEMENTATION
E - EVALUATION
3 Steps (Observation, Administration of care Validation)

4 steps APIE (Assessment, Planning, Implementation,

Evaluation)

5 steps ADPIE (Assessment, Diagnosis, Planning,

Implementation, Evaluation)

6 steps ADOPIE (Assessment, Diagnosis, outcome

identification, Planning, Implementation, Evaluation
 Nursing Process
➢Is a systematic,
client centered
method for
structuring the
delivery of nursing
 ASSESSMENT

DIAGNOSIS
EVALUATION
INDIVIDUAL
FAMILIES
COMMUNITIES

OUTCOME
IMPLEMENTATION IDENTIFICATION

PLANNING

six phases of the Nursing

Process (ADOPIE)
The Nursing Process is:
G - Goal-oriented*
Efficient*
O - Organized*
S - Systematic* Effective*

H - Humanistic care*
 Six Phases of the Nursing
Process (ADOPIE)

♥ Collecting data
ASSESSMENT* ♥ Organizing data
♥ validate data,
♥ Document data

The assessment process involves four closely

related activities.
 Assessment

• Purpose:
To establish a data base for
problem identification,
reference, and future
comparison.
 Assessment Activities

1. Collection of Data*
Types of Data:
a. Subjective Data - (symptoms,
feelings, perceptions)*
– those that can be described only by the
person experiencing.
 Assessment Activities
b. Objective data (signs)– Those that can
be observed and measured.

E.g., pallor, diaphoresis, BP 120/80,

reddish urine..
 Assessment:
b. Objective Data or overt data
(signs)*
– Those that can be observed and
measured. They can be seen, heard,
felt, or smelled and they are obtained
by observation or physical examination.
 Assessment:
Methods of Collection of Data:
a. Interview - Planned communication
or conversation with a purpose.
b. Observation – to gather data with
the use of senses, use of units of
measure, physical examination
techniques*, interpretation of
laboratory results.*
 Comparing Subjective and
Objective Data
Subjective
Description Data elicited and verified by
the client
Sources Client, Family and SO, Client Observations and PA findings of
record, other HC
professionals
Methods used Client interview
to obtain Data
Skills needed Interview and therapeutic
to obtain Data communication skills
Caring ability and empathy
Examples “I have a headache.”
“It frightens me.”
“I am not hungry.”
Objective
Data directly or indirectly
observed through measurements
the RN or other HC professionals.
Observation and PE
Inspection
Palpation
Percussion
Auscultation
Respirations 16 per minute
BP 180/110, apical pulse 86 and
irregular
X-ray film reveals fractured pelvis.
 Assessment:

Sources of Data:
a. Primary *
b. Secondary*
 Assessment
2. Organizing Data
➢ clustering facts into groups of
information

3. Validating Data
Validation is the act of “double
checking” or verifying data to confirm
that it is accurate and factual.*
 Assessment:
4. Documenting Data:
To complete the assessment
phase, the RN records the data.
 Diagnosing

DIAGNOSING – analyzing the

subjective and objective data
to make a professional
judgement (nsg. Diagnosis).
 Diagnosing
• Analyze data
• Identify health
problems, risks,
DIAGNOSING and strengths
• Formulate
diagnostic
statements
 Diagnosing

• Nursing diagnosis – is defined by

NANDA (North American Nursing
Diagnosis Association) as a “Clinical
judgement about individuals, family or
community responses to actual and
potential health problems and life
processes. Uses PRS/PES format.
 Diagnosing
Types:
1. Actual Nursing Diagnosis – is a client
problem that is present at the time of
the nursing assessment.
Example: Ineffective airway clearance r/t
tracheobronchial infection as manifested by
productive cough, adventitious breath
sounds, and thick green sputum production.
 Diagnosing
Types:
2. Risk Nursing Diagnosis – indicates
the client does not currently have the
problem but is at high risk for developing it.
Example:
Risk for impaired skin integrity r/t immobility
 Diagnosing
Types:
2. Wellness Nursing Diagnosis – indicates
that the client has the opportunity for
enhancement of a health state.
Example:
Readiness for enhanced effective
breastfeeding r/t confident mother and
normal breast structure AMB infant
contentment after feeding.
 Comparison of correct &
incorrect nursing Diagnosis
• High risk for ineffective airway
clearance related to copious
mucus secretions Correct
• High risk for ineffective airway
clearance related to pneumonia.
Incorrect
•H
 Comparison of correct &
incorrect nursing Diagnosis

• High risk for injury related to

disorientation. correct
• High risk for injury related to
absence of side rails. incorrect
•H
 Components of a NANDA
Nursing diagnosis
1. (P) Problem - the statement of the
client’s response (NANDA label)
2. (E) Etiology – factors contributing to or
probable causes of the responses.
3. (S) Signs / symptoms or the Defining
characteristics manifested by the client.
 Qualifiers:
- Are words that have been added to some
NANDA labels to give additional meaning
to the diagnostic statement:
• Deficient ( inadequate in amount,
quality, or degree; not sufficient;
incomplete)
• Impaired (made worse, weakened,
damaged, reduced, deteriorated)
 Qualifiers:
• Decreased (lesser in size, amount or
degree)
• Ineffective ( not producing the desired
effect)
• Compromised (to make vulnerable to
threat)
 Formulating Diagnostic
statements
• Basic two-part statement
Problem r/t(Implies a relationship) Etiology
Impaired skin integrity r/t immobility
• Basic three-part statement – PES Format
cannot be used for risk diagnosis.
Acute pain r/t tissue trauma as manifested by
grimacing and guarding behavior
 Formulating Diagnostic
statements
• One part statement
used for wellness/syndrome diagnoses
Readiness for enhanced Parenting
Rape-trauma syndrome
 • Prioritize problem/
OUTCOME
IDENTIFICATION
diagnoses
• Formulate goals/
desired outcomes
 Outcome identification

➢ refers to formulating and

documenting measurable, realistic,
client-focused goals/desired outcome.
➢It provides basis for evaluating
nursing diagnosis
 Outcome identification
Purposes:
✓ To provide individualized care
✓ To promote client participation
✓ To plan care that is realistic and
measurable
✓ To allow involvement of support
people
 Outcome identification
Activities during outcome identification:
✓Establish priorities
✓A 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
client.
 Outcome identification
Activities during outcome identification:
✓ Establishing priorities involve the
following:
a. Life threatening situations should be
given highest priority
e.g. Difficulty in breathing
Hemorrhage
suicidal tendencies
 Outcome identification
b. Use the principle of ABC’s ( airway,
Breathing, circulation); Airway
should always be given the
highest priority.
c. Use Maslow’s hierarchy of needs;
physiologic needs are given priority
over psychosocial needs.
 Outcome identification

d. Consider something that is very

important to the client
e.g. pain, anxiety
e. Clients with unstable condition
should be given priority over those
with stable conditions.
 Outcome identification

e.g. Attend to the client with fever

before attending to the client
who is scheduled for physical
therapy in the afternoon.
 Outcome identification
f. Consider the amount of time,
materials, equipment required to
care for clients.
e.g. attend to the client who
requires wound dressing change
before attending to the client who
requires discharge instructions.
 Outcome identification
g. Actual problems take precedence
over potential problems.
h. Attend to the client before
equipment.
e.g. assess the client before
checking contraptions like IV fluids,
urinary catheter, drainage tubes.
 Outcome identification
Goals/ desired outcome
- What the nurse hopes to achieve
by implementing the nursing
interventions.
- Other terms used: Expected
outcome, predicted outcome,
outcome criterion and objective
 Outcome identification
Goal – is an educated guess, made as
a broad statement about what the
client’s state will be after the nursing
intervention is carried out. It is derived
from the client’s nsg. Dx.
Desired outcome – are specific,
measurable, realistic statement of goal
attainment.
 Outcome identification
Characteristics of well stated
outcome criteria are:
S - Specific
M - Measurable
A – Attainable
R - Realistic
T – Time-framed
 Outcome identification
Goal (broad) – The client will report a
decreased anxiety level regarding
surgery.
Desired outcome (specific) – During
client teaching, the client discusses
fears and concerns regarding surgical
procedure.
 Outcome identification
Short term goal – are useful for clients
who require health care for a short
time.
Long term Goal – used for clients who
live At home and have chronic health
problems, extended care facilities and
rehabilitation centers.
 Planning

• Involves determining
beforehand the course of
action to be taken before
implementation of nursing care
 • Select nursing
interventions
PLANNING
• Write nursing
care plan
 Planning
Plan nursing intervention:
Nursing interventions
✓ are “Any treatment, based upon clinical
judgment and knowledge, that a nurse
performs to enhance client outcomes.”
✓ are also called Nursing orders.
✓ are independent, dependent and
interdependent activities that nurses
carry out to provide client care
 Planning
Write a nursing care plan:
Nursing Care plan
✓ is a written summary of the care that a
client is to receive. It is the “blueprint” of
the nursing process.
✓ Nursing centered
✓ The plan of care is a step-to-step
process.
Implementation

• Is putting the nursing care

plan into action.
 IMPLEMENTING
• Reassessing
• Set priorities
• Perform nursing interventions
• Record actions
 Implementation:

• Nursing interventions are the actions

that a nurse performs to achieve
client goals.
• The specific interventions chosen
should focus on eliminating or
reducing the etiology of the nursing
Diagnosis.
Types of nursing interventions
1. Independent interventions
➢ are those activities that nurses are
licensed to initiate on the basis of their
knowledge and skills.
➢ includes physical care, ongoing
assessment, emotional support and comfort
teaching, counseling, environmental
management, referrals to other HC
professionals.
Nsg. Dx. Impaired Oral mucous membranes

Independent intervention:
providing special mouth care
Types of nursing interventions
Dependent interventions
➢Are activities carried out under the
physician’s order or supervision
➢ include orders for medications, IV
therapy, diagnostic tests, treatments,
diet and activity.
Nsg. Dx: Ineffective airway clearance r/t
accumulation of secretions in the
tracheobronchial tree.

Dependent intervention:
Nebulization with salbutamol administered
every 4 hours
Types of nursing interventions
Collaborative interventions
➢ are actions the nurse carries out in
collaboration with other Health team
members, such physical therapists,
social workers, dietitians, and
physicians.
 Types of nursing interventions
Collaborative interventions
➢Ex: The DR orders Physical therapy to
teach the client crutch-walking.
➢ The nurse would be responsible for
informing the physical therapy Department
 Evaluation

Is assessing the client’s response

to nursing interventions and then
comparing the response to
predetermined standards of
outcome criteria.
 EVALUATING

• Collect data about the client’s response

• Compare the client’s response to goals and
outcome criteria
• Analyze the reasons for the outcome
• Modify care plan as needed
 Evaluation statement
➢Consists of two parts: a conclusion and
supporting data.
➢The conclusion is a statement that the
goal/desired outcome was met, partially
met, or not met.