NURSING PROCESS

Definition:
It is a systematic, client-centered method for structuring the delivery of nursing care.

Phases:
1. Assessment
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating

Characteristics:

1. It is cyclical and dynamic in nature.

2. It is client-centered.
3. It adapts problem solving.
4. Decision-making is involved in every phase.
5. It is interpersonal and collaborative.
6. It is universally applicable.
7. It uses variety of critical thinking skills.
-----------------------------------

ASSESSMENT

Definition: It is a systematic and continuous collection, organization, validation and

documentation of data.

Characteristics:
1. It focuses on a clients responses to a health problem.
2. It should include the clients perceived needs, health problems, related experience,
health practices, values and lifestyle.
3. To be most useful, the data collected should be relevant to a particular health
problem.

Activities:
1. Collecting Data 3. Validating Data
2. Organizing data 4. Documenting Data

COLLECTING DATA/ DATA COLLECTION

 - process of gathering information about a clients health status

Database/ baseline data- all the information about a client

-which includes:

1. nursing health history

2. physical assessment
3. physicians history
4. physical examination
5. results of laboratory and diagnostic tests

TYPES OF DATA:
1. Subjective Data
- information given verbally by the patient
- information perceived only by the affected person
- symptoms complained by the patient

example:
Correct: I feel so nervous
Get out of my room
Sakit akong samad
Incorrect: Patient is anxious
Patient is hostile
Patient has pain

2. Objective data
- are detectable by an observe
- consists of information that is perceptible to the senses
- can be tested against an accepted standard
- factual data observed by the Nurse
example:
Correct: hair combed, make-up applied Concise
drag right leg when walking
tremors of both hands and
250 cc dark amber urine Descriptive

Incorrect: neatly- groomed Judgmental

Improve body image
Patient very afraid and
Voided large amount Conclusive

Sources of Data:
1. Primary- client
 2. Secondary- significant others, other health personnel records and reports
- relevant literature

Data Collection Methods

A. Observation
- occurs whenever the nurse is in contact with the client or support persons
- gather data by using the 5 senses

B. Interviewing
- structured form of communication that the nurse uses to collect data or a conversation
with a purpose

2 Approaches
1. Directive
2. Non- directive

Directive - structured and elicits specific information

- used to gather and to give information in a limit amount of time

Non-directive - rapport building interview

- uses open- ended questions, used for problem- solving counseling and
performance appraisal
(Rapport- is an understanding between 2 or more people)

Kinds of Interview Questions:

1. Closed question- used in directive interview, restrictive and generally require only
short answers- giving specific information
2. Open-ended questions - non-directive interview
- lead clients to explore their thoughts and feelings
disadvantages. The client may spend time conveying
irrelevant information.
3. Neutral Questions question that the client can answer without direction or
pressure from the nurse
- is open-ended, and is used in non-directive interviews
4. Leading Questions is usually closed, used in directive interview and thus directs
clients answer

Some hints to make patient comfortable before beginning the nursing history:

a. Assess for pain

b. Offer the patient an opportunity to go to the bathroom or make a call
c. Offer some beverages is medically permitted
d. Sit-down- during interview- eye level

Planning the Interview and Setting:

 1. Time
2. Place- privacy
3. Seating arrangement- 45 degree angle to the bed
4. Distance-3 to 4 ft. apart
5. Language

Stages of Interview

1. The opening /introduction

steps: a. establishing rapport
b. orienting the interviewee
2. The body
3. The closing

Examination
- major method used in the physical health assessment
- done systematically, according to examiners preference (head to toe or
body systems)
a. Cephalo-caudal- head, neck, thorax, abdomen, and extremities and ends at the
toes
b. Body System approach- respiratory, circulatory, etc.
- datas obtained are measured against norms or standards (ideal height/weight,
temperature, Blood Pressure)

Techniques Used: Preparation:

1. inspection Client, environment and equipment
2. auscultation
3. palpation
4. percussion

INSPECTION- systematic- head to toe

PALPATION - the nurse uses the hands and sense of touch to gather data
- used to detect tenderness, temp., texture, vibration, pulsations, masess
- rules out/confirms suspicious raised during interview and inspection

PERCUSSION- is the tapping of the bodys surface to produce vibration and sound
- sounds indicates the density of the underlying tissue

tympany-high-pitched-like sound over a hallow organ

dullness-low-pitched,thud-like soun over a dense organ

Technique: place the palmar surface of one hand against the clients body while tapping with
the other.
AUSCULTATION the process of listening to sounds produced by the body
- Systems involved:
Cardiovascular System
Respiratory System
Gastro-intestinal System
- Use: Stethoscope- an instrument that amplifies sounds produced by i
nternal organs

ORGANIZING DATA
- nurse uses written format that organizes the assessment data systematically

Nursing Conceptual Models/Framework which can be used to structure the nursing admission
assessments:
1. Maslows Hierarchy of basic needs
2. Hendersons 14 components of nursing care
3. Gordon;s 11 functional health pattern
4. NANDAs response pattern

VALIDATING DATA

- information gathered during assessment phase must be complete, factual, and

accurate

THE NURSING HEALTH HISTORY

Purpose:
1. To elicit information about all variables that may effect that clients health
status.
2. To obtain data that help the nurse understand and appreciate the clients life
experiences
3. To initiate a non judgmental, trusting interpersonal relationship with the
client.

Components:
1. Biographic data
2. Chief complaints or reason of visit
3. History of present illness
4. Past history
5. Family history of illness
6. Review of system (ROS)
7. Life style
 8. Social data
9. Psychological data
10. Patterns of health care

NURSING DIAGNOSIS- is a clinical Judgment about individual, family or community

responses to Actual or Potential health problems/ life process.
- It provides a basis for selection of nursing interventions to achieve outcomes for
which the N is Accountable

Advantages:

1. Ng Dx facilitates communication among Nurses and other health team

members.
2. Strengthen the Ng. Process and provide Direction for Planning independent Ng.
Actions
3. Health the nurse focus on independent Nursing Actions.
4. Help identify the focus of a Nursing Activity and thus facilitates peer review and
quality assurance program.
5. Facilitate Nursing intervention when a client moves from one hospital unit to
another.
6. They facilitate comprehensive health care by identifying, validating and
responding to specific health problems.

WRITING NURSING DIAGNOSIS

1. ACTUAL NURSING DIAGNOSIS

a. Ng. Dx = PATIENT PROBLEM AND ETIOLOGY

Ex. Impaired skin integrity r/t immobility
Prental role conflict r/t divorce
Impaired verbal r/t cultural
Communication differences

b. Ng. Dx = P + E + S

Impaired skin integrity r/t immobility

Manifested by disruption of skin
Surface over the elbows and coccyx

Prental role conflict r/t divorce as manifested by statement or unsatisfactory

child care during working hours

Impaired verbal r/t cultural differences as Communication manifested by

inability to Speak English.
2. POTENTIAL (High Risk) Ng. PROBLEMS:

HIGH RISK = PROBLEM + RISK FACTOR + NG DX

High risk for skin r/t physical immobilization
Breakdown in totoal body cast

High risk for skin r/t diarrhea, age 3 years, low oral
Fluid vol. Intake, temperature
Deficit

High risk for injury r/t disorientation and division after cataract surgery
3. POSSIBLE NG.DX

Possible sensory- perceptual alteration

Possible nutritional deficit
Possible fluid vol. Deficit

NURSING MEDICAL DX

Describe an individuals response to a as Describe a specific do Process

Is oriented to the individual Is oriented to pathology

Changes as the clients responses change Remains constant throughout

the duration of illness

Guides independent Ng. Guides medical

Activities: planning management, some of
Intervention and evaluation which may be carried out by
the nurse.

Is complementary to the MEDICAL Dx Is complementary to the Ng. Dx

Has no universally accepted classification Has well developed

System classification system consist
Consist of two-part of 2 or 3 words
Statement of etiology
When known
 STEPS OF DIAGNOSE PROCESS
NG-DX= DATA PROCESSING + DETERMINING THE CLIENTS HEALTH
PROBLEMS, HEALTH RISKS AND STRENGTHS
+ FORMULATION OF NURSING DIAGNOSE

1. Organized Data
2. Compare data against standard -------- normal health patterns
-------- normal vital signs
-------- lab values
3. Cluster data
4. Identify gaps & inconsistencies in data

STANDARD/NORM- general accepted rule, model, pattern or measure used in comparing

which must be relevant & reliable
CUE- a piece of information or data that influence decisions

GUIDELINES FOR CHARTING

GUIDELINES RATIONALE CORRECT ACTION

1. Entries should be legible
and written in ink
2. Do not erase, apply
correction fluid or scratch
out an error
Illegible entries can be
misinterpreted. Ink cannot be
erased
Charting becomes illegible
apperas the N is attempting
to deface the record
Write legibly. Do not use
pencil. Use correct color of
ink.
Draw a straight line across
the erro, wriote the word
error above and sign or
initials

3. Record only facts Records must be accurate Be certain entry is factuial.

4. Entries should begin with
date and time and end
with you signature
5. Do not leave blank spaces
in the nurses notes
6. Chart only for yourself
7. Avoid using generalized
empty phrases
and reliable Do not speculate or guess
Ensure that the correct
sequence of events us
recorded. Signature
documents who is
accountable for care Draw a horizontal line
delivered. through the unused space at
the end of recording
A nurse is accountable for Never chart for someone
into she enters into the chart. else.
Specific information a clients
condition can be accidentally Use complete, concise
missed if information is description of care. Only
general approved observations and
symbols should be used

8. Each page of the record
should be identified on
the patients name or
case no.
9. Entries should be kept
confidential
GUIDELINES FOR WRITING AN NG DX
1. State in terms of a
problem
2. State so that it is legally
advisable
3. Use nonjudgmental
statement
4. Both elements of the
statement must not say
the same thing
5. The clients response
precedes the contributing
or caused factor
6. Use statements provide
guidance planning
independent nursing
interventions
7. Word Dx specially and
precisely to provide
direction for planning
nursing intervention
8. Use nursing terminology
to describe clients
response
Sheets patients name maybe
misplaced in other charts. Be sure to write patients
name when adding a new
page.
Patients health care is
another matter
(/)
Actual fluid volume deficit r/t
fever
Impaired Skin r/t immobility
Spiritual distress r/t inability
to attend church services due
to immobility
Potential impaired skin
integrity r/t immobility
Non compliance with diet r/t
lack of knowledge
Social isolation r/t loss of
speech
Altered oral mucous
membrane r/t decrease
salivation secondary to
radiation of neck
Potential ineffective airway
clearance
Be sure only authorized
pwerson have access to
patients records.
(X)
Fluid replacement relate to
fever
Impaired skin integrity r/t
improper positioning
Spiritual distress r/t strict
rules necessitating church
attendance
Impaired skin integrity r/t
ulceration of sacral area
Knowledge deficit r/t
noncompliance with diet
Social isolation r/t
laryngectomy
Altered oral mucous
membrane r/t noxious agent
Potential pneumonia
9. Use nursing terminology Potential ineffective airway Potential ineffective airway
to describe probable clearance r/t accumulation of clearance r/t emphysema
cause of clients response secretions in lungs

10. Do not start with a Altered nutrition: less than Provide high protein diet
nursig intervention body requirements r/t because of potential altered
inadequate intake of protein. nutrition

11. Avoid using a symptom Nausea related to medication

such as nausea. A
symptom does not reflect
a pattern & requirements
additional data collection

BENEFITS:
A. Client:
1. quality client care
 2. continuity of care
3. participation by the client in their health care

B. Nurse:
1. consistent and systematic nursing education
2. job satisfaction
3. professional growth
4. avoidance of legal action
5. meeting professional nursing standards

Characteristics:

1. the NCP focuses on actions which are designed to solve or alleviate an existing problem.
2. The NCP is a prodcut of a deliberate systematic process.
3. The NCP relates to the future. It utilizes events in the past and what is happening in the
present to determine trends.
4. The NCP revolves around identified healtgh and nursing problem
5. The NCP is a means to an end, not end in itself.
6. Nursing care planning is a continuous process.

DESIRABLE QUALITIE OF NCP

1. should be based on a clear definition of the problem

2. is realistic
3. consistent with the goals and philosophy of the health agency
4. NCP is drawn with the family
5. Is best kept in written form

NCP-Importance

1. they individualize care to clients

2. Healps in setting priorities by providing information about the client as well as the nature
of his problems
3. Promotes systematic communication among those involved in the health care effort
4. Continuity of care facilitated
5. Facilitates the coordination of care

STEPS IN DEVELOPING FNCP:

1. the problem definition

2. the goals and objectives of care
3. the plan of intervention
4. the plan for evaluating care

ESTABLISHING GOALS:
Goal - is a general statement of purpose
- it is the end toward which all efforts are directed

S - specific
M - measurable
A - attainable
R - realistic
T - time bounded

DIAGNOSING- is the process of making a clinical judgement (nursing diagnosis) about a

clients potential or actual health problem that nurses are licensed and able to treat.

PLANNING- inv9olves setting priorities, writing goals, and establishing a written plan for
nursing interventions designed to prevent, resolve or identify problems or potential
problems.
IMPLEMENTING- is carrying out or delegating the nursing interventions

EVALUATING- involves the nurse and the client in determining whether that clients goals
or predetermined outcomes of care have been met
- identifying factors that facilitated or inhibited goal achievement
- and modifying or terminated the care plan accordingly

METHOD DISCHARGE PLANNING

F. Medication
The client will know:
Drug name
What dosage to take and when
Purpose of drug
Effect (s) the drug should have
Symptoms of possible adverse effects, and which ones to report (repeat for
each drug prescribed)

A. ENVIRONMENT
The client will be assured of:
Adequate instruction in necessary homemaking skills
Investigation and correction of any physical hazards in the home
environment
Adequate emotional support
Investigation of sources of economic support
 Investigation of transportation means to appointment and/ or clients

T. Treatment
The client and family will:
Know the purpose of any treatment to be continued at home
Be able to demonstrate correct performance of treatment

H. Health Teaching
The client will:
Describe how his or her disease or condition affects body function
Describe the means necessary to maintain present level of health, or achive
a higher level of health

O. Outpatient Referral/ Observable Signs and Symptoms

The client will:
Know when and where of his or her prescribed diet
Know when and whom to call for medical help
Take home written discharge instructions

D. Diet
The client will be able to:
Describe the purpose of his or her prescribed diet
Plan several typical menus using prescribed diet

PLANNING

Definition- is the process of designing the Ng. Strategies or interventions required to

prevent, reduced opr eliminate those client health problems identified and validated during
the diagnostic phase.

- the process in which problem solving and decision- making are carried out.

Uses:
1. data obtained during assessing
2. the diagnostic statements that present clients health problem

6 Compaonents of P:
1. setting priorities
2. establishing client goals and outcome criteia
3. planning Ng Strategies
4. writing Ng orders
5. writing the NCP
6. Consulting
I. Setting Priorities
Determined by the following factors:

1. clients health values and belief

2. clients priorities
3. resource available to the N. and C.
4. time needed for the nursing strategies
5. urgency of the health problems
6. medical treatment plan

II. Establishing clients goal and criteria

Clients goal- is a desired outcome or change in client behavior in the direction of the
health

Purposes:
1. provide direction of planning nursing intervention
2. provide direction for establishing evaluation

Types of Goals

a. long term- client living at home or having chronic health problems, in NG. Homes and
rehab center.
b. short term- clients requiring short term care
- persons who are frustrated by long term goals

Establishing goals for Fr Ng Dx

Nursing Diagnosis- Impaired Physcial Mobility r/t pain

Client problems- Impaired physical mobility
Client goals- client will demonstrate increase in physical

Ng. Dx - SELF CARE DEFICIT: inability to feed self r/t depression

Client problems - Self- care deficit: inability to feed self.

Client goals - client will perform self feeding

OUTCOME CRITERIA:
4 purposes:

1. provide direction for nursing intervention

2. provide a time spab for planned activities
3. serve as criteria for evaluation of progress toward goal achievement
COMPONENTS OF OUTCOME CRITERIA:

1. subject
2. verb
3. condition or modifier
4. criterion

SUBJECT VERB CONDITION DESIRED

PERFORMANCE
Standard
Client Drinks 100 ml of fluid Q 4 hours
Client List Three hazards of (three)
Smoking
Client Identifies Advance of On the next visit
Immunization
Client States The purpose of his Before discharge
medication
Cleint Identifies Importance of eating On the next visit
right kind of food

GUIDELINES:

1. Write goals and outcome criteria in term of client behavior- focus on the client not
nursing action.
2. Avoid statement that short and enable, facilitate, allow, let, permit followed by the word
client
3. Make sure the goal statement is appropriate for the NG. Dx and those outcome criteria
are appropriate for goal
4. Make sure the client considers the goals important and values them.
5. Ensure that the (goals) (client) goals and outcome criteria are compatible with the word
and therapies of other professionals
6. Make sure that each goals is derived from only on NG Dz
7. When writing outcome criteia, use observable, measurable terms (smart)

III. PLANNING NG STRATEGIES:

1. generating alternative nursing strategies
a. brainstorming
b. Hypothesizing
c. Extrapolating
2. considering the consequences of each strategies
3. choosing nursing strategies

IV. WRITING NURSING ORDERS:

 5 components:
1. date
2. action verb
3. time element
4. signature

Relationship of OC Vs CG

1. OC- outcome criteria are derived from and relate to the client goals CG from 1 st clause of
the Ng Dx

Ng Dx- POTENTIAL IMPIARED SKIN INTERITY r/t imposed bed rest.

Client goal- maintain intact ski, particular over bony prominence
Outcome Criteria- demonstrate correct techniques for positioning and turning

Note: 3-6 outcome criteia are neede to each goal

Characteristics of a well stated outcome criteria:

1. each outcome criteria related to the established goals

2. the outcome stated in the criteria is possible to achieve
3. each criteria is a specific and concrete as possible, to facilitate measurement
4. each criteria is appraisable or measurable

V. WRITING NCP

NCP- is a guide that organizes information about a Clients health into a meaningful whole

Format: 4 columns or categories

1. Ng. Dx or problem list

2. Goals
3. Ng. Strategies/ interventions/ orders
4. Outcome or evaluation criteria

Ng. Dx Goals Ng. Orders Outcome criteria

Fears r/t cardiac Experience increased Establish a trusting Verbalizes specified
catherterization, emotional comfort relationship with the concerns
possible heart and feelings of client and family to communicate
surgery and its control express feelings and thoughts clearly and
outcome concern discuss the logically facial
cardiac cath expressions, voice
procedure and what tone, and body
is expected of him posture correcpond
before and after the to verbal expressions
procedure and increased
 emotional comfort
after instruction,
describe cath
procedure and what
is expected of him.

CONSULTING- is deliberating between 2 people

7 steps:

1. identify the problem

2. collect pertinent data about the client
3. select the consultant
4. communicate the problem
5. discuss the recommendation with the consultant
6. include the recommendations in the clients NCP

Discharge Planning- the process of anticipating and planning for needs after discharge form
a Hospital or other facility.

IMPLEMENTING- Intervening
- putting the nursing strategies listed in the hrsing care plan into action

by: Belucheck and Mc Closkey

Nursing Intervention- an autonomous action based on scientific rationale that is executed to
benefit the client in a predicted way related to the Nursing diagnosis and stated goals.

TYPES OF NURSING ACTIONS:

1. Independent Nursing Action- an activity that the nurse initiates as a result of the
nurses own knowledge and skill autonomous nursing practice.
Taxonomy- is a set of classification that are ordered and arranged on the basis of a
single principle or consistent set of principle.

2. Dependent Nursing Action- are those activities carried out in the order of the
physician, under the physicians supervision or according to specified routines.

3. Interdependent Interventions- is completed with our without a physicians order or is

written at a nurse suggestion

COLLABORATION- a ture partnership, in which power on both sides in valued by both,

with recognition and acceptance of separate and combined spheres of activity and
responsibility, mutual safe guarding of legitimate interests of each party and a
commonality of goals that is recognized by both parties.
 PROTOCOLS- is a written plan specifying the procedure to be followed in a particular
situation.

STANDING ORDER- is a written document about policies, rules, regulations or orders

regarding client care.

6 COMPONENTS OF IMPLEMENTING

1. Reassessing the client

- focuses on more specific needs
- N- determine whether planned nursing strategies are appropriate for the client.

2. Validating the NCP

N reviews the NCP in 4 areas:
a. safety
b. appropriateness
c. effectiveness
d. individualize nursing care
to validate the plan- to request another appropriate professional and patient iif possible
to give plan approved or implementation

3. Determining the Needs for Assistance

2 Reasons:

a. the N unable to implement the nursing strategies safety alone

b. the N lack the knowledge or skills to implement a particular nursing activity

4. Implementing Nursing Strategies

- to help the client meet his/her health goals
4 Areas of Nursing Practice
a. health promotion
b. health maintenance
c. health restoration
d. care of the dying

6 Important Consideration for Implementing

1. The clients individuality

2. The clients need for involvement
3. Prevention of Complication
4. Preservation of bodys defenses
5. Provision of comfort and support to the client
6. Accurate and careful implementation of all nursing activities

5. Communicating Nursing Actions:

Written and Verbal
IMPLEMENTING ACTIVITIES:
3 important skills:

a. cognitive (intellectual skills)

b. interpersonal skills
c. technical skills

IMPLEMENTING ACTIVITIES
1. Caring
2. Communicating
3. Helping
4. Teaching
5. Counseling
6. Client advocate

GUIDELINES FOR IMPLEMENTING NURSING STRATEGIES

1. Nursing action are based on scientific knowledge
2. Nursing actions resulting from a physicians order must be understood by the N
3. Nursing actions are adapted to the individual
4. Nursing actions should always be safe
5. Nursing actions often require teaching, supportive and comfort components
6. Nursing actions should be holistic
7. Nursing action should respect the dignity of the client and enhance clients self-esteem
8. The clients active participation in implementing nursing actions should be encouraged as
health permits.

EVALUATING

To evaluate- to identify whether or to what degree to clients goals have been met

6 Components

1. Identifying Outcome Criteria

2 purposes
a. establish the kind of evaluation data that need to bo collected
b. provide a standard against which data are judged

2. Collecting Data
- observation
- direct communication
- purposeful listening/ reports
3. Judging Goal Achievement
4. relating Nursing Action to Client Outcomes
5. Reexamining the clients care plan
- database
- diagnostic statement
- goal statements
- nursing strategies
6. Modifying the care plan

3 alternative on how well a goal was met

a. Goal met- if the patient was able to demonstrate the behavior by the specific time on
date
b. Goal Partially Met- if the patient was able to demonstrate the behavior but not as well
as the N had specified in the goal statement
c. Goal Not Met- if the patient was unable or willing to perform the behavior at all

Example:

Nursing Diagnosis- Activity intolerance related to prolonged bed rest

Goal Statement- Patient will walk length of hall and abck by 7/29\
Goal Evaluation- (done on 7/29 or earlier)
Goal Achieved- Patient walked length of hall but not too tired to walk back
Goal partially achieved- Patient walked length of hall but too tired to walk back
Goal not Achieved- Patient refused to walk
Goal Not Achieved- Patient unable to bear his own weight

EVALUATING QUALITY OF NURSING CARE

- is essential part of professional accountability

- other terms: QUALITY ASSESSMENT- examination of services
QUALITY ASSURANCE- implies that efforts are made to evaluate and
ensure quality health care

APPROACHES TO QUALITY EVALAUTION

1. the structure to which client care takes place

2. The process of care- activity of the nurse
How:
- talking with the client
- auditing clients record
- observing the nursing activities
3. Outcomes of care- clients change in behavior toward goal achievement prior to discharge
(concurrent audit)
- client record- reviewed (retrospective audit)

TOOLS AND METHODS USED:

Steps:
1. Defining and clarifying the nature of nursing
2. Deciding what approach to take
3. Developing standards and criteria
4. Testing criteria