NURSING PROCESS

KEVIN M. TAMAYO, RN, LPT

Lecturer
A S S E S S M E N T
 N U R S I N G

D I A G N O S I S
P L A N N I N G
I N T E R V E N T I O N
E V A L U A T I O N
 Definition
Nursing process is a critical thinking
process that professional nurses use to
apply the best available evidence to
caregiving and promoting human functions
and responses to health and illness
(American Nurses Association, 2010).
• Nursing process is a systematic method of
providing care to clients.
• The nursing process is a systematic
method of planning and providing
individualized nursing care.
Purposes of nursing process
• To identify a client’s health status and
actual or potential health care problems or
needs.
• To establish plans to meet the identified
needs.
• To deliver specific nursing interventions to
meet those needs.
Components of nursing process
• It involves assessment (data collection),
nursing diagnosis, planning,
implementation, and evaluation.
 Assessment

Evaluation Nursing
diagnosis
Nursing
process

Implementation Planning
 Characteristics of Nursing Process
• Cyclic
• Dynamic nature,
• Client centeredness
• Focus on problem solving and decision
making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking and clinical reasoning.
ASSESSMENT
 Definition
Assessment is the systematic and continuous
collection, organization, validation, and
documentation of data (information).
 Types of assessment
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
1. Initial nursing assessment: Performed
within specified time after admission. To
establish a complete database for
problem identification.
Eg: Nursing admission assessment
2. Problem-focused assessment : To
determine the status of a specific problem
identified in an earlier assessment.
Eg: hourly checking of vital signs of
fever patient
3. Emergency assessment: During
emergency situation to identify any life
threatening situation.
Eg: Rapid assessment of an individual’s
airway, breathing status, and circulation
during a cardiac arrest.
4. Time-lapsed reassessment: Several
months after initial assessment. To
compare the client’s current health status
with the data previously obtained.
 Collection of data
Data collection is the process of
gathering information about a client’s health
status. It includes the health history, physical
examination, results of laboratory and
diagnostic tests, and material contributed by
other health personnel.
 Types of Data
Two types: subjective data and objective
data.
1. Subjective data, also referred to as
symptoms or covert data, are clear only
to the person affected and can be
described only by that person.
Itching, pain, and feelings of worry are
examples of subjective data.
2. Objective data, also referred to as signs
or overt data, are detectable by an
observer or can be measured or tested
against an accepted standard. They can
be seen, heard, felt, or smelled, and they
are obtained by observation or physical
examination.
For example, a discoloration of the skin or a
blood pressure reading is objective data.
 Sources of Data
Sources of data are primary or secondary.
1. Primary : It is the direct source of
information. The client is the primary source
of data.
2. Secondary: It is the indirect source of
information. All sources other than the client
are considered secondary sources. Family
members, health professionals, records and
reports, laboratory and diagnostic results are
secondary sources.
 Methods of data
collection
• The methods used to collect data are
observation, interview and examination.
❑Observation : It is gathering data by using
the senses. Vision, Smell and Hearing are
used.
❑Interview : An interview is a planned
communication or a conversation
with a purpose.
• There are two approaches to interviewing:
directive and nondirective.
• The directive interview is highly
structured and directly ask the questions.
And the nurse controls the interview.
• A nondirective interview, or rapport
building interview and the nurse allows the
client to control the interview.
STAGES OF AN INTERVIEW
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing
❑Examination : The physical examination
is a systematic data collection method to
detect health problems. To conduct the
examination, the nurse uses techniques of
inspection, palpation, percussion and
auscultation.
 Organization of data
The nurse uses a format that organizes
the assessment data systematically. This is
often referred to as nursing health history or
nursing assessment form.
 Validation of data
The information gathered during the
assessment is “double-checked” or verified
to confirm that it is accurate and complete.
 Documentation of data
To complete the assessment phase,
the nurse records client data. Accurate
documentation is essential and should
include all data collected about the client’s
health status.
DIAGNOSIS
• Diagnosis is the second phase of the
nursing process. In this phase, nurses use
critical thinking skills to interpret assessment
data to identify client problems.
• North American Nursing Diagnosis
Association (NANDA) define or refine
nursing diagnosis.
 Definition
• The official NANDA definition of a nursing
diagnosis is:
“a clinical judgment concerning a human
response to health conditions/life processes,
or a vulnerability for that response, by an
individual, family, group, or community.”
Status of the Nursing Diagnosis
The status of nursing diagnosis are actual,
health promotion and risk.
1. An actual diagnosis is a client problem
that is present at the time of the nursing
assessment.
2. A health promotion diagnosis relates to
clients’ preparedness to improve their
health condition.
• A risk nursing diagnosis is a clinical
judgement that a problem does not exist,
but the presence of risk factors indicates
that a problem may develop if adequate
care is not given.
 Components of a NANDA
Nursing Diagnosis
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
1. The problem statement describes the
client’s health problem.
2. The etiology component of a nursing
diagnosis identifies causes of the health
problem.
3. Defining characteristics are the cluster
of signs and symptoms that indicate the
presence of health problem.
Formulating Diagnostic Statements

The basic three-part nursing diagnosis

statement is called the PES format and
includes the following:
1. Problem (P): statement of the client’s
health problem (NANDA label)
2. Etiology (E): causes of the health problem
3. Signs and symptoms (S): defining
characteristics manifested by the client.
 Problem Etiology Signs and
Acute pain related symptoms
to abdominal Pain Surgery of Pain scale
abdomen and
surgery as discomfort of
patient
evidenced by patient
discomfort and
pain scale.
NANDA nursing diagnosis
 Differentiating Nursing Diagnosis
from Medical Diagnosis
Nursing diagnosis Medical diagnosis
A nursing diagnosis is a statement of A medical diagnosis is made
nursing judgment that made by by a physician.
nurse, by their education,
experience, and expertise, are
licensed to treat.
Nursing diagnoses describe the Medical diagnoses refer to
human response to an illness or a disease processes.
health problem.
Nursing diagnoses may change as A client’s medical diagnosis
the client’s responses change. remains the same for as long
as the disease is present.
Nursing diagnosis Medical diagnosis

Ineffective breathing pattern Asthma

Activity intolerance Cerebrovascular accident

Acute pain Appendicitis

Disturbed body image Amputation

PLANNING
• Planning involves decision making and
problem solving.
• It is the process of formulating client goals
and designing the nursing interventions
required to prevent, reduce, or eliminate
the client’s health problems.
 TYPES OF PLANNING
1. Initial Planning
2. Ongoing Planning
3. Discharge Planning
1. Initial Planning : Planning which is done
after the initial assessment.
2. Ongoing Planning : It is a continuous
planning.
3. Discharge Planning : Planning for needs
after discharge
 Planning process
Planning includes;
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and
activities
• Writing individualized nursing interventions
on care plans.
 Setting priorities
• The nurse begin planning by deciding
which nursing diagnosis requires attention
first, which second, and so on.
• Nurses frequently use Maslow’s hierarchy
of needs when setting priorities.
Establishing client goals/desired
outcomes
• After establishing priorities, the nurse set
goals for each nursing diagnosis. Goals
may be short term or long term.
 Nursing interventions
• A nursing intervention is any treatment,
that a nurse performs to improve patient’s
health.
 TYPES OF NURSING INTERVENTIONS

1. Independent interventions are those activities

that nurses are licensed to initiate on the basis
of their knowledge and skills.
2. Dependent interventions are activities carried
out under the orders or supervision of a
licensed physician.
3. Collaborative interventions are actions the
nurse carries out in collaboration with other
health team members
 Writing Individualized Nursing
Interventions
• After choosing the appropriate nursing
interventions, the nurse writes them on the
care plan.
• Nursing care plan is a written or
computerized information about the
client’s care.
IMPLEMENTATION
• Implementation consists of doing and
documenting the activities.
The process of implementation includes;
• Implementing the nursing interventions
• Documenting nursing activities
EVALUATION
• Evaluation is a planned, ongoing,
purposeful activity in which the nurse
determines
(a)the client’s progress toward achievement
of goals/outcomes and
(b)the effectiveness of the nursing care plan.
The evaluation includes;
• Comparing the data with desired
outcomes
• Continuing, modifying, or terminating the
nursing care plan.
EVALUATION TEST

MULTIPLE CHOICE TEST

Choose the letter of the best answer

1. The systematic problem-solving approach
towards providing individualized nursing
care is known as ___________________.

A. Nursing care plan

B. Nursing process
C. Nurses practice act
D. Nursing method
2. Name the association established to
develop, refine, and promote the
taxonomy of nursing diagnostic
terminology used by nurses.

A. North American Nursing Diagnosis

Association International
B. American nurses association
C. Ethical Nursing Association
D. Humane Nursing Association
3. This step of the nursing process includes the
systematic collection of all subjective and
objective data about the client in which the nurse
focuses holistically on the client- physical,
psychological, emotional, sociocultural, and
spiritual. Name this step.

A. Assessment
B. Planning
C. Implementation
D. Diagnosis
4. What is the name of the assessment that
focuses on past medical history, family history,
the reason for admission, medications currently
ttaken previous hospitalization, surgeries,
psychosocial assessment, nutrition, and complete
physical assessment?

A. Initial assessment
B. Focus assessment
C. Emergency assessment
D. Comprehensive assessment
5. Name the assessment process that
collects data about a problem that has
already been identified and determines if the
problem still exists or any changes.

A. Focus assessment
B. Initial assessment
C. Emergency assessment
D. Non-invasive assessment
6. Complete the sentence- A
________________________ is performed to
identify a life-threatening problem (choking, stab
wound, heart attack).

A. Initial assessment
B. Focus assessment
C. Emergency assessment
D. Critical assessment
7. Information verbalized or stated by
the client is called ____________.

A. Objective data
B. Subjective data
C. Integral data
D. Holistic data
8. Observable and measurable
information is known as
__________________.

A. Objective data
B. Subjective data
C. Visible data
D. Obscured data
9. What are the 4 types of nursing
diagnosis?

A. Actual
B. Risk
C. Health promotion
D. Wellness
E. Safety
10. What are the 3 parts of the nursing
diagnosis (PES)?

A. Patient
B. Problem
C. Signs and symptoms
D. Physical assessment
E. Etiology
11. This is the step of the nursing
process where you do the PES.

A. Planning
B. Implementation
C. Assessment
D. Diagnosis
12. In this step of the nursing process, you
prioritize the diagnosis in order of importance and
figure out what nursing interventions need to take
place to accomplish these as well as goals to
achieve your care plan.

A. Planning
B. Implementation
C. Assessment
D. Evaluation
13. This step begins after the care plan
has been made and is recognized as
the step where the nurse performs the
interventions to achieve goals.

A. Planning
B. Implementation
C. Assessment
D. Evaluation
14. Name the stage where you
determine if the patient has achieved
the expected outcomes.

A. Planning
B. Implementation
C. Assessment
D. Evaluation
15. What purpose does the nursing
process serve?

A. Assisting family members in making important

healthcare decisions
B. Providing nurses with a framework to aid
them in delivering comprehensive care
C. Help other healthcare professionals know
what is going on with the client
D. Organize information so the doctor knows
what is wrong with the client
16. Which could be considered
objective data from the following?

A. A temperature of 100.1 degrees

Fahrenheit
B. A patient’s report of moderate pain
C. Complaints of nausea
D. Feelings of sleepiness
17. Which nursing diagnosis should receive
the highest priority in the case of a female
patient who is diagnosed with deep vein
thrombosis?
A. Impaired gas exchange relating to an
increased blood flow
B. Fluid volume excess relating to peripheral
vascular disease
C. Risk of injury from edema
D. Altered peripheral tissue perfusion related to
venous congestion
18. From the following, which independent
nursing intervention can a nurse include in
the plan of care for a patient with a fractured
tibia?
A. Administer aspirin 325 mg every 4 hours as
needed
B. Apply a cold pack to the tibia
C. Perform a range of motion to right leg every 4
hours
D. Elevate the leg 5 inches above the heart
19. To participate in goal setting clients
must be:

A. Ambulatory and mobile

B. Able to read and write
C. Alert and have some degree of independence
D. Be able to talk
20. A client-centered goal is a specific
and measurable behavior or response
that reflects a client’s:

A. Highest possible level of wellness and

independence in function
B. Response when compared to another client
with a like problem
C. Physician’s goal for the specific client
D. Desire for specific healthcare interventions