Nursing Process

❧ Assessment
❧ Nursing
Diagnosis
❧ Planning
❧ Implementing
❧ Evaluating

Nursing Process

Processes Involved:
Critical Problem
Thinking Solving

NURSING
PROCESS

Decision
Making

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 Nursing Process
❧ Specific to the nursing profession
❧ A framework for critical thinking
❧ It’s purpose is to:

“Diagnose and treat human responses to

actual or potential health problems”

Nursing Process
❧ Organized framework to guide practice
❧ Problem solving method
❧ Systematic
❧ Goal oriented
❧ Dynamic-always changing, flexible
❧ Utilizes critical thinking processes
❧ Universally applicable
❧ Client-centered
❧ Interpersonal and collaborative

Scientific Method of problem solving

❧ ID problem
❧ Collect data
❧ Form hypothesis
❧ Plan of action
❧ Hypothesis testing
❧ Interpret results
❧ Evaluate findings

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 Advantages of Nursing Process
❧ Provides individualized
care
❧ Client is an active
participant
❧ Promotes continuity of
care
❧ Provides more effective
communication among
nurses and healthcare
professionals
❧ Develops a clear and
efficient plan of care
❧ Provides personal
satisfaction as you see
client achieve goals
❧ Professional growth as
you evaluate
effectiveness of your
interventions

Nursing Process

-Collect Analyze Prioritize Problem Reassess Collect Data

-Organize Identify Problem Formulate Goals Implement Compare
-Validate Formulate Nsg Dx Select Interventions Supervise Relate to goals
-Document Write Interventions Assist Conclude
Document Continue/
Modify/
Terminate

Assessment
❧ First step of the Nursing Process
❧ Gather Information/Collect Data
●  Primary Source - Client / Family
●  Secondary Source - physical exam, nursing
history, team members, lab reports, diagnostic
tests…..
●  Subjective -from the client (symptom)
•  “I have a headache”
●  Objective - observable data (sign)
•  Blood Pressure 130/80

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Assessment-collecting data
❧ Nursing Interview (history)
❧ Health Assessment -Review of Systems
❧ Physical Exam
●  Inspection
●  Palpation
●  Percussion
●  Auscultation

Assessment-collecting data
❧ Make sure information is complete &
accurate
❧ Organize and cluster data
❧ Interpret and analyze data
Compare to “standard norms”
❧ Validate prn

Example of Assessment
❧ Obtain info from nursing assessment,
history and physical (H&P) etc…...

❧ Client diagnosed with hypertension

❧ B/P 160/90
❧ 2 Gm Na diet and antihypertensive
medications were prescribed
❧ Client statement “ I really don’t watch my
salt” “ It’s hard to do and I just don’t get it”

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 COMPONENTS OF NURSING
HEALTH HISTORY
1. Biographic data
2. Chief complaint / Reason for visit
3. History of present illness
4. Past history / Past illness
5. Family history of illness
6. Lifestyle
7. Social data

COMPONENTS OF NURSING
HEALTH HISTORY (cont..)
8. Psychologic Data
9. Patterns of Healthcare
10. Review of Systems

BIOGRAPHIC DATA

-  Client’s name
-  Age
-  Sex
-  Marital Status
-  Occupation
-  Religious affiliation
-  Others

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 CHIEF COMPLAINT

“What brought you to the hospital?”

> Chief complaint should be recorded in the
client’s own words.

HISTORY OF PRESENT ILLNESS

Ø Use CHRONOLOGIC story

-  When the symptoms started

-  Whether the onset of symptom was sudden
or gradual
-  How often the problem occurs
-  Exact location of distress
-  Character of complaint (e.g. intensity of
pain, quality of sputum)

HISTORY OF PRESENT ILLNESS

(cont..)

-  Activity in which the client was involved

when the problem occurred
-  Aggravating factors

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 HISTORY OF PRESENT ILLNESS
Three months prior to admission, pt developed sore
throat with purulent drainage accompanied with
high grade fever. Patient seek consultation and
throat culture was done. Pt was positive for
streptococcal tonsillitis and penicillin therapy was
started and completed at home. One month prior to
admission, pt consulted again for the same problem
and penicillin therapy was given 3 days PTA. Pt
developed moderate to high grade fever
accompanied by migratory joint pain and skin
lesion in the trunk. 1 day PTA, pt developed chest
pain and dyspnea on exertion. Pt rested and self-
medicated with analgesic but offered no releif
hence consultation.

HISTORY OF PRESENT ILLNESS

(cont..)

PE revealed heart murmur, subcutaneous nodules and

elevated ASO titer. Impression of Rheumatic Fever
was made, hence, admission was advised.

PAST HISTORY
•  Childhood Illness
•  Immunization
•  Allergies
•  Accidents and injuries
•  Hospitalization
•  Medication

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 PAST HISTORY
The patient had chickenpox when he
was 6 years old and mumps at the
age of 12. Other childhood illness
includes common colds and sore
throat. The patient received complete
childhood vaccination. Patient is
allergic to sea foods and penicillin.
Patient was not involved in any
accident or serious injuries. He was
hospitalized in 2002 at Fatima
Medical Center for Acute
Gastroenteritis. Patient is not taking
any medicine except for his daily
multivitamins OD.

FAMILY HISTORY OF ILLNESS

Mother Father
(+) HPN (-) HPN
(-) DM (-) DM
(-) PTB (+) PTB

LIFESTYLE
•  Personal habits – e.g. amount, frequency
and duration of substance use.
•  Diet – description of typical daily diet
•  Sleep / Rest patterns
•  Activities of Daily Living (ADL)
•  Recreation / Hobbies

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 LIFESTYLE
Patient is smoker and a social drinker. He started
smoking at the age of 17 consuming 5-10 sticks
of Marlboro Lights each day. His daily diet
includes “foods-on-the-go” and he seldom eats
fruits. His average sleeping hours per day is 4 to
6 hours with occasional 30-minute nap in the
afternoon. The patient can perform very well
most of his daily activities but
sometimes experiences
dyspnea on moderate to
heavy exertion.

LIFESTYLE (cont..)

He spends most of his free time watching TV or

playing chess with his neighbors.

SOCIAL DATA

-  Family relationship
-  Ethnic affiliation
-  Education history
-  Occupational History
-  Economic status
-  Home and neighborhood
conditions

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 SOCIAL DATA
Patient is 53 years old, male Filipino from Bicol and a
Roman Catholic. He is very close to his wife who is the
source of his strength in times of crisis. The patient is
a certified public accountant and working as a senior
consultant with monthly income of P120,000. His work
requires most of his time and effort and he is looking
forward to an early retirement. He maintains health
insurance for himself and his family.

PSYCHOLOGIC DATA

-  Major stressors
-  Usual coping patterns
-  Communication style

PSYCHOLOGIC DATA
The patient is coherent and very vocal with his
health concerns. He considers his work as his
major source of stress. He deals with it by
absenting from his work or taking a vacation.

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 PATTERNS OF HEALTH CARE

The patient undergoes regular annual check-up

through his HMO and he consults first his
family physician Concerning his health.

Nursing Diagnosis
❧ Second step of the Nursing Process

❧ Interpret & analyze clustered data

❧ Identify client’s problems and strengths

❧ Formulate Nursing Diagnosis (NANDA :

North American Nursing Diagnosis
Association)-Statement of how the client is
RESPONDING to an actual or potential
problem that requires nursing intervention

Nsg Dx vs MD Dx
❧ Within the scope of ❧ Within the scope of
nursing practice medical practice
❧ Identify responses ❧ Focuses on curing
to health and illness pathology
❧ Can change from ❧ Stays the same as
day to day long as the disease
is present

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 DIAGNOSING

TYPES:
1. Actual
2. Risk
3. Wellness
4. Possible
5. Syndrome

Formulating a Nursing Diagnosis

❧ Composed of 3 parts:
❧ Problem statement- the client’s response
to a problem
❧ Etiology- what’s causing/contributing to the
client’s problem
❧ Defining Characteristics- what’s the
evidence of the problem

DIAGNOSING

PROBLEM: Activity intolerance

ETIOLOGY: imbalance between oxygen
supply / demand
S/Sx : a.m.b. abnormal HR and BP in
response to light activity

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 DIAGNOSING

TWO-PART DIAGNOSTIC STATEMENT

RELATED
PROBLEM ETIOLOGY
TO
Constipation Related to Prolonged laxative use
Ineffective
r/t Breast engorgement
Breastfeeding

Ingestion of
Diarrhea r/t
contaminated food / H20

DIAGNOSING

THREE-PART DIAGNOSTIC STATEMENT

PROBLEM r/t PROBLEM a.m.b. S/SX

Diarrhea r/t Ingestion of Watery
contaminated stools in 3
food occasions
Ineffective Tenacious Dyspnea and
airway r/t secretions ineffective
clearance coughing

Types of Nursing Diagnoses

❧ Actual
Imbalanced nutrition; less than body requirements
RT chronic diarrhea, nausea, and pain AEB height
5’5” weight 105 lbs.
❧ Risk
High Risk for falls RT altered gait and generalized
weakness
❧ Wellness
Family coping: potential for growth RT
unexpected birth of twins.

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 Collaborative Problems
❧ Require both nursing interventions and medical
interventions
EXAMPLE: Client admitted with medical dx of
pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy

GUIDELINES FOR WRITING A

NURSING DIAGNOSTIC STATEMENT

1. State in terms of problem, not a need:

Correct: Deficient fluid volume r/t fever
Wrong : Fluid replacement r/t fever

2. Non-self incriminating / legally advisable

Correct: Impaired skin integrity r/t immobility
Wrong : Impaired skin integrity r/t improper
positioning

GUIDELINES FOR WRITING A

NURSING DIAGNOSTIC STATEMENT

3. Use non-judgemental statements

Correct: Spiritual distress r/t inability to attend
church services secondary to immobility
Wrong: Spiritual distress r/t strict rules
necessiting church attendance

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 GUIDELINES FOR WRITING A
NURSING DIAGNOSTIC STATEMENT

4. Both elements of the statement do not say the

same thing
Correct: Risk for impaired skin integrity r/t
immobility
Wrong : Impaired skin integrity r/t ulceration of
sacral area

GUIDELINES FOR WRITING A

NURSING DIAGNOSTIC STATEMENT

5. Cause and effect are correctly stated

Correct: Severe headache r/t fear of addiction to
narcotics
Wrong : Pain related to severe headache

GUIDELINES FOR WRITING A

NURSING DIAGNOSTIC STATEMENT

6. Use nursing terminology rather than medical

terminology to describe the client’s response.
Correct: Risk for ineffective airway clearance r/t
to accumulation of secretions in lungs.
Wrong : Risk for ineffective airway clearance
related to pneumonia.

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 Planning
Third step of the Nursing Process
❧ This is when the nurse organizes a nursing care
plan based on the nursing diagnoses.
❧ Nurse and client formulate goals to help the
client with their problems
❧ Expected outcomes are identified
❧ Interventions (nursing orders) are selected to aid
the client reach these goals.

Planning – Begin by
prioritizing client problems
❧ Prioritize list of
client’s nursing
diagnoses using
Maslow
❧ Rank as high,
intermediate or low
❧ Client specific
❧ Priorities can change

Planning
Developing a goal and outcome statement
❧  Goal and outcome
statements are client
focused.
❧  Worded positively
❧  Measurable, specific
observable, time-limited,
and realistic
❧  Goal = broad statement
❧  Expected outcome =
objective criterion for
measurement of goal
❧  Utilize NOC as standard
EXAMPLE
❧  Goal:
Client will achieve
therapeutic management
of disease process….
❧  Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of
understanding importance
of dietary sodium
restrictions by day of
discharge.

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 PLANNING

TYPES:
Initial – admission
Ongoing – confinement
Discharge – before discharge

Planning- Types of goals

❧ Short term goals
❧ Long term goals

Goals are patient-centered and

SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)

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Planning-select interventions
❧ Interventions are selected and written.
❧ The nurse uses clinical judgment and
professional knowledge to select
appropriate interventions that will aid the
client in reaching their goal.
❧ Interventions should be examined for
feasibility and acceptability to the client
❧ Interventions should be written clearly and
specifically.

Interventions – 3 types
❧ Independent ( Nurse initiated )- any
action the nurse can initiate without direct
supervision
❧ Dependent ( Physician initiated )-nursing
actions requiring MD orders
❧ Collaborative- nursing actions performed
jointly with other health care team members

PLANNING

Setting Priorities:
Use: Maslow’s Hierarchy of Human Needs
ABC of Life

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 PLANNING

Other Factors in Prioritizing:

- client’s health status and belief
- client’s priorities
- available resources
- urgency of the health problem
- medical treatment plan

PLANNING

Prioritize the following nursing diagnoses:

- anxiety related to difficulty in breathing
- deficient fluid volume r/t high grade fever
- sleep pattern disturbance r/t persistent
cough
- Ineffective airway clearance r/t tenacious
secretions

PLANNING

CRITERION OF
CONDITIONS/
SUBJECT VERB DESIRED
MODIFIERS PERFORMANCE

Correct insulin Using aseptic

Client Administers
dose technique
Leg ROM
Client Performs exercise as Evey 8 hours
taught
client drinks 2500 ml fluid daily

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 EXPECTED OUTCOMES

DIAGNOSIS GOAL STATEMENT

Ineffective airway clearance r/t Within 48-72 hours, pt’s lungs
tenacious secretions will be clear on auscultation
Fluid volume deficit related to Within 24-48 hours, client will
diarrhea show fluid balance as
evidenced by urine output of
greater than 30ml/hr and good
skin turgor

NURSING ORDERS
Components:
Date and Shift : 4-26-23 7-3 pm
Verb : Palpate
Content Area : Uterine Fundus for Firmness
Time Element : q 30 mins x 2h, then q1h, q4h
Signature : F. Vasquez, RN, MAN

DATE AND SHIFT NURSING ORDER SIGNATURE

Palpate uterine fundus for

4-26-23
firmness q30mins x2h, q1h, F. Vasquez, RN, MAN
7-3 shift
q4, q24h

Implemention
❧ The fourth step in the Nursing Process
❧ This is the “Doing” step
❧ Carrying out nursing interventions (orders)
selected during the planning step
❧ This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating
physicians orders and monitoring cost
effectiveness of interventions
❧ Utilize NIC as standard

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 IMPLEMENTING

-  Putting the plan into action:

TYPES
Independent
Interdependent / Collaborative
Dependent

Implementing- “Doing”
❧ Teach potential
❧ Monitor VS q4h
complications of
❧ Maintain prescribed diet hypertension to instill
(2 Gm Na) importance of
❧ Teach client amount of maintaining Na
sodium restriction, foods restrictions
high in sodium, use of ❧ Assess for cultural
nutrition labels, food factors affecting
preparation and sodium dietary regime
substitutes

Implementing – “Doing”
❧ Teach the client- ❧ Teach client importance
hypertension can’t be of life style changes:
cured but it can be (weight reduction,
controlled. smoking cessation,
❧ Remind the client to increasing activity)
continue medication ❧ Stress the importance of
even though no S/S ongoing follow-up care
are present. even though the patient
feels well.

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 IMPLEMENTING

Key Components in Intervention

M – MONITOR
T – TEACH
A – ADMINISTER
P - PERFORM

Evaluation- To determine
effectiveness of NCP
❧ Final step of the Nursing Process but
also done concurrently throughout client care
❧ A comparison of client behavior and/or response
to the established outcome criteria
❧ Continuous review of the nursing care plan
❧ Examines if nursing interventions are working
❧ Determines changes needed to help client reach
stated goals.

EVALUATING

-  An appraisal whether expected outcomes are

met
-  An appraisal of the effectiveness of nursing
care plan
Possible Results:
GOAL is - MET
- PARTIALLY MET
- NOT MET

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Evaluation
❧ Outcome criteria met? Problem resolved!
❧ Outcome criteria not fully met? Continue
plan of care- ongoing.
❧ Outcome criteria unobtainable- review each
previous step of NCP and determine if
modification of the NCP is needed.
❧ Were the nsg interventions appropriate/
effective?

Evaluation
Factors that impede goal attainment:

❧ Incomplete database
❧ Unrealistic client outcomes
❧ Nonspecific nsg interventions
❧ Inadequate time for clients to achieve
outcomes.

EVALUATING

DIAGNOSIS GOAL/EO INTERVENTION EVALUATION

Ineffective Within 48-72 - Place the pt in Lungs are
semi-fowler’s
airway hours, pt’s position clear on
clearance r/t lungs will be - Increase OFI to auscultation
tenacious clear on 10 glass/day if
not
secretions auscultation contraindicated,
Instruct breathing
and coughing
techniques
- Administer
prescribed
expectorants as
scheduled

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 Checkpoint
Identify which stage of the nursing process
is being described below:

❧ The nurse writes nursing interventions

❧ A goal is agreed upon
❧ The nurse performs a physical assessment
❧ A revision is made to the NCP
❧ The nurse administers antibiotic medication
❧ A statement is written that outlines the clients
response to a potential health problem

S and O Data Quiz

❧ RR 22/min, even unlabored
❧ “I can only walk 3 blocks before my legs start to
hurt”
❧ Pain rated 3 on a scale of 0-10
❧ Skin pink, warm and dry
❧ Urine output 300mL/8 hr
❧ “My wife doesn’t come to visit very often”
❧ Dressing clean, dry and intact.

NCLEX Time
❧ The nurse records the following subjective
data in the client’s medical record:
❧ A.Breath sounds clear to auscultation
❧ B.Amber urine in sufficient quantities
❧ C.Pain intensity 8 out of 10
❧ D.Skin warm and dry

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NCLEX Time
❧ When interviewing a client, the nurse uses the
following open-ended style sentence:
❧ A.Do you have any concerns right now?
❧ B.Is your family worried about you being in the
hospital?
❧ C.How many times do you get up to go to the
bathroom at night?
❧ D.What do you mean when you say, “I don’t feel
quite right?”

NCLEX Time
In order for an actual nursing diagnosis to be
valid it must have one or more supporting:
❧ A.Laboratory results
❧ B.Diagnostic data
❧ C.Defining characteristics
❧ D.Medical diagnoses

NCLEX Time
Nursing diagnoses are aimed at identifying
client problems that are treatable by
_______.
❧ A.The physician
❧ B.The nurse
❧ C.Invasive techniques
❧ D.Complementary strategies

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Client’s Name: Algeen Morales
Age: 23 y/o
1 day PTA, client attended a wedding ceremony. He ate
baked mussels and carbonara. 8 hrs PTC, client
experienced abdominal pain and 2 bouts of watery
stools. Client self-medicated with Diatabs but offered
no relief. 2 hrs PTC client experienced 3 bouts of watery
stools and abdominal pain. Client stated “ Grabe and
pagtatae ko at hinanghina na ako.” Examination
revealed a sunken eyeballs, poor skin turgor, body
weakness, BP of 90/80, HR of 110 bpm and T of 38.5C
hence client was admitted. Buscopan 10 mg 1 tab prn
for abdominal pain and Hydrite 1 tab dissolve in 1 glass
of water per LBM were ordered by AP.

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