Review of the Nursing Process

The nursing process is a systematic and rational method of planning and

providing individualized nursing care using the following steps: assessing, diagnosing, planning,
implementing and evaluating. It aims to identify a client's health status, actual or potential health
care problems or needs and deliver specific nursing interventions to meet those needs.
Hall originated the term nursing process in 1955, and Johnson (1959), Orlando (1961), and
Wiedenbach (1963) were among the first to use it to refer to a series of phases describing the practice
of nursing. Since then, various nurses have described the process of nursing and organized the phases
in different ways.
The use of the nursing process in clinical practice gained additional legitimacy in 1973 when
the phases were included in the American Nurses Association (ANA) Standards of Nursing Practice.
In order to carry out the nursing process successfully, it is very important that one must “think like a
nurse” as introduced by Dr. Christine Tanner in 2006, which means that critical thinking and critical
reasoning on the care of clients must be defined and understood.

• Critical thinking is the process of intentional higher level of thinking used to define a client’s
problem, examine the evidence based practice in caring for the client and making choices in the
delivery of care. Nurses used critical thinking in the process of solving problems and decision making
for a safe, efficient and skillful nursing intervention. Critical thinking fuels the intellectual
artistic activity of creativity. When nurses incorporate creativity , they are able to find solutions
unique to the problem.
• On the other hand , critical reasoning is the cognitive process that uses thinking strategies to
gather and analyze client information, evaluate relevance of the information, and decide on possible
nursing actions to improve psychological and psychosocial outcomes.

• Critical thinking, critical reasoning and the nursing process

o Through the nursing process, the nurse is able to respond to the changing health
status of the client in a systematic and rational way. Nursing process is a cyclical process that follows
a logical sequence, but more than one component may be involved at one time. It is action oriented,
client centered and outcome directed.
• Five Phases of the Nursing Process:

I. Assessing– the systematic and continuous collection, organization, validation and documentation of
data. It is carried out in all phases of the nursing process.
II. Diagnosing – nursing uses critical thinking skills to interpret assessment data and identify client
strengths and problems.
III. Planning – deliberate and systematic process that involves decision making and problem-solving.
IV. Implementing – is the action phase where the nurse delivers nursing interventions.
V. Evaluating– is a planned, ongoing, purposeful activity in which the clients and health care
professionals determine the client’s progress toward achievement of goals and outcomes and the
effectiveness of the nursing care plan.
NURSING ASSESSMENT
Assessment is a systematic, dynamic, and continuous way of data collection, organization,
validation and documentation about a client's health status or condition. This includes
physiological, psychosocial, sociocultural, spiritual, economic and life-style factors as well. It is a
continuous process that is involved in all phases of the nursing process.
 There are four (4) different types of assessment namely:
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed assessment

Nurses’ Role in Health Assessment

To accomplish this pertinent and comprehensive data collection, the nurse:
• Collects data in a systematic and ongoing process
• Involves the patient, family, other health care providers, and environment, as appropriate, in
holistic data collection
• Prioritizes data collection activities based on the patient’s immediate condition, or anticipated
needs of the patient or situation
• Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent
data
• Uses analytical models and problem-solving tools
• Synthesizes available data, information, and knowledge relevant to the situation to identify patterns
and variances
• Documents relevant data in a retrievable format (ANA, 2010, p. 21)
Steps of Assessment

1. Data Collection
2. Data Organization
3. Data Validation
4. Documentation
I. Data Collection
Data collection is the systematic and continuous process of gathering information about a
client’s health status or condition which prevents omission of significant data and reflects a client’s
changing health status. A client database contains all the information about a client which includes
nursing health history, physical assessment, primary care provider’s history, and physical
examination, results of laboratory and diagnostics tests, and material contributed by other health
personnel.
Clients data should include past history and current problems. Past history is the total sum of
the client's health status prior to the presenting problem. For example a history of allergic reaction
to penicillin, past surgical procedures, healing practices and chronic diseases. Current data relate to
the present circumstance, such as pain, nausea, sleep patterns and religious activities or practices.
Type of Data
• Subjective data, is also known or referred to as covert data or symptoms, which is
apparent and can be described or verified only by the person affected.
• Objective data, is also known or referred to as overt data or signs, which is detectable by
an observer and can be measured or tested against an accepted standard. These data can be
seen, heard, felt, or smelled.
 Sources of data
Sources of data can be primary or secondary. Client is the primary and best source of data. All
sources other than the client such as family members, friends, caregivers, and other members of
the healthcare team are considered secondary sources of data and must be validated if possible.

1. Client – primary and best source of data unless the client is too ill, young, or disoriented to
communicate clearly. Clients can provide subjective data that no one else can offer. Most often
statements made by the client and objective data obtained by the nurse from the client consist of
primary data.
2. Support people – Family members, friends and caregivers are considered as secondary sources of
data if the client is unable to provide information. These are people who know the client enough to
verify or supplement information provided by the client. They are an important source of data for
clients who are very young, unconscious, or confused. Information provided is considered subjective
if it is not based on facts.
3. Client records – this include information documented by various health care professionals involved
in client’s care. This may include information such as the client's occupation, religion and marital
status. Medical records are often a source of a client's past health and illness pattern. This can give
nurses information about client’s coping behaviors, health practices, previous illness and allergies.
Record of therapies provided by other health care practitioners like physical therapists, social
workers, nutritionists and other member of the healthcare team can provide relevant data not
expressed by clients. Laboratory records also provide important health information. Any laboratory
data about a client must be compared to the agency or performing laboratory’s norm for that
particular test. The nurse must always check the information in the client records in light of the
current situation.
4. Health Care Professionals – verbal reports from other health care professionals serve as other
potential sources of information about a client’s health. Health care professionals involved in a
previous client’s care may have information from previous or current contact with the client. This is
important to ensure continuity of care when clients are transferred to and from home and health
care agencies.
5. Literature – review of nursing and related literature, such as professional journals and reference
texts, can provide additional information for the database. A literature review includes but is not
limited to the following information:
o Standard or norms against which to compare findings
o Cultural and social practices
o Spiritual beliefs
o Assessment data needed for specific client conditions
o Nursing interventions and evaluation criteria relevant to a client's health problem.
o Information about medical diagnosis, treatment and prognosis
o Current methodologies and research findings
Data collection method
Observing, interviewing and examining are the principal methods used in data
collection. A nurse uses all three methods simultaneously when assessing clients. During
client interviews, for example, the nurse observes, listens, asks questions and mentally
retains information to explore in the physical examination.
1. Observing
To observe is to use the senses in gathering data or information. It is a conscious,
deliberate skill that is developed through effort and with an organized approach and involves
distinguishing data in a meaningful manner. Nursing observations must be organized to
ensure that nothing is missed out.
2. Interviewing
An interview is a planned communication or conversation with a purpose. In a focused
interview, the nurse asks specific questions to the client to collect information related to the
client’s problem.
There are two approaches to interviewing: directive and non-directive. Directive
interview is highly structured and elicits specific information. At least at the outset,
the nurse establishes the purpose of the interview and controls it. In a directive interview,
the client answers the questions but may have limited time to ask questions and discuss
concerns. This is usually used by the nurse to give or get information at a limited time such
as in emergency situations. Non-directive interview on the other hand is also known as
rapport building interview as the nurse allows the client to control the purpose, subject
matter and pacing of the interview. Rapport is an understanding between two or more people.
During information gathering interviews, a combination of directive and non-
directive approaches is usually appropriate.

Types of Interview Questions

Interview questions can be classified as closed or open-ended and neutral or leading.
• Closed questions generally require a “yes” or “no” answer or short factual answers that
provide specific information. This is usually used in directive interviews where information
is needed quickly such as in emergency situations. Closed questions often begin with
“when,” “where,” “who,” “what,” “do (did, does),” or “is (are, was).” For example: What
medication did you take?
• Open-ended questions are often associated with non-directive interviews as they allow
clients to discover and explore, elaborate, clarify or illustrate their thoughts or
feelings. Open-ended questions give clients the freedom to choose what information to
divulge if and when they are ready to disclose the information. This is very useful at the
beginning of the interview or to change topics and to elicit attitudes. It may begin with
“what,” or “how.” For example: What would you like to talk about today?
• Neutral questions is a question that the client can answer without direction or pressure
from the nurse, is open-ended and is used in non-directive interviews. For example: How do
you feel about that?
• Leading question is usually closed, used in a direct interview and directs the client’s answer.
This type of question can lead to problems if the client, in an effort to please the nurse, gives
inaccurate responses. For example: You will take the medicine, won’t you?
• It is important to note NOT to ask questions starting with “why” as it can be perceived as an
interrogation by the client. Anything that puts the client on the defensive will interfere with
getting as much purposeful information as possible.
Stages of the interview
• The Opening can be the most important part of the interview as it sets the tone for the
remainder of the interview. The purpose is to establish rapport and orient the interviewee.
 • The Body is where the clients communicate with what he or she thinks, feels, knows and
perceives in response to the question of the nurse .Effective communication techniques
must be used by the nurse for effective development of the interview.
• The Closing is where the nurse terminates the interview . It is done once the needed
information has been obtained already. The closing is important in maintaining rapport and
trust and for facilitating future interactions.
3. Examining
Physical examination or physical assessment is a systematic data collection method that uses
observation to detect health problems and utilizes the techniques of inspection, auscultation,
palpation and percussion.

Physical examination can be done using the following approach:

• Cephalocaudal or head-to-toe approach begins examination at the head, progresses to the neck,
thorax, abdomen, extremities and ends at the toes.
• Body system approaches investigate each system individually, that is the respiratory system, the
circulatory system, the nervous system and so on.
• A screening examination or review of systems may also be done to check the essential functioning of
the body parts and systems. An example of this is the nursing admission assessment form.
Data gathered from this examination are measured against standard and norms such as body
temperature and blood pressure.
II. Organizing Data
In organizing data, the nurse uses a written or electronic format that organizes the
assessment data systematically. This is referred to as a nursing health history, nursing assessment or
nursing database form.
Most nursing schools and health care agencies have developed their own structured
assessment format. Many of these are based on selected nursing models or frameworks. Some of the
frameworks used are as follows:
i.Conceptual Model or Framework:
• Gordon’s Functional Health Pattern Framework
This provides a framework of 11 functional health patterns. Gordon uses the word
pattern to signify a sequence of recurring behavior. By using this framework, nurses
are able to discern emerging patterns by collecting functional and dysfunctional
behavior.
• Nursing Models
• Wellness Models
To assist clients to identify health risks and explore lifestyle habits and health behaviors,
beliefs, values and attitudes that influence wellness. Include: Health Hx, Physical Examination,
Nutritional assessment, Life-stress analysis, Lifestyle and health habits, Health beliefs, Sexual
health, Spiritual health, Relationships, Health risk appraisal
• Non-Nursing Models which include models like Body Systems Models, Maslow’s Hierarchy of
Needs, Developmental Theories
 III. Validating Data
Complete, factual, and accurate information must be ensured during data gathering or
assessment phase because the nursing diagnosis and interventions are based on this
information. Validation is the act of double-checking or verifying data to confirm that it is
accurate and factual.
Validation is important as it helps the nurse complete the following:
• Ensure that assessment information is complete.
• Ensure that objective and related subjective data agree.
• Obtain additional information that may have been overlooked.
• Differentiate between cues and inferences. Cues are data that can be observed directly
by a nurse. It can be subjective or objective. Inferences are the nurse's interpretation or
conclusion based on the cues.
• Avoid jumping to conclusions and focusing in the wrong direction to identify the
problem.
To build an accurate database, nurses must validate assumptions regarding the client’s
physical and emotional behavior. Data validation is necessary if there are discrepancies
obtained in the nursing interview (subjective data) and physical examination (objective
data). However, not all data must be validated. Information such as height, weight, birthday
and most laboratory results or studies that can be measured with an accurate scale can be
accepted as factual.
IV. Documenting Data
It is important to record the client’s data in a factual manner and not interpreted by the nurse
to complete the assessment phase. Accurate documentation is essential and should
include all the data collected about the client’s health status. To ensure accuracy, the nurse
records subjective data in the client’s own words, using quotation marks.

ANALYSIS OF ASSESSMENT DATA

To arrive at nursing diagnoses, collaborative problems, or referral, you must go through the steps of
data analysis. This process requires diagnostic reasoning skills, often called critical thinking. The
process can be divided into seven major steps:

1. Identify abnormal data and strengths.

2. Cluster the data.
3. Draw inferences and identify problems.
4. Propose possible nursing diagnoses.
5. Check for defining characteristics of those diagnoses.
6. Confirm or rule out nursing diagnoses.
7. Document conclusions.

WEEK 2 MODULE: LEARNING CONTENT

There are two aspects of assessing client’s health status namely (1) nursing health history and (2)
physical examination.
 Obtaining health history is an excellent way to start the assessment process. It paves a way for
identifying nursing problems and gives direction to the physical examination. This will also assist the
primary care provider or the examiner in identifying the areas of strength and limitation of an
individual’s lifestyle and current health status.
Physical assessment or examination has three types: (1) a complete assessment, (2) examination of
the body system, and (3) examination of the body area. A complete assessment may be done from
head-to-toe which is a systematic manner downward. However, the procedure can vary according to
the age of the individual, the severity of of the illness, the preference of the nurse, the location of the
examination and the agency’s priorities and procedures.
This module will focus on nursing health history.
Taking health history should begin with an explanation to the client of why the information is being
requested. The health history has 8 sections:

1. Biographic data
2. Reasons for seeking health care
3. history of present health concern
4. Personal health history
5. Family health history
6. Review of body systems for current health problems.
7. Lifestyle and health practices
8. Developmental levels
Biographic Data:
This includes information which will identify the client such as name, address, phone number,
gender, date of birth and who provided the information. Other information such as medical data
record number (if any) or any similar identifying data may be included. Client is considered as the
primary source of information and the all other sources are considered secondary sources.
To determine the client’s culture, ethnicity and subculture, collecting information such as date and
place of birth, nationality, ethnicity, marital status, religious and spiritual beliefs and practices,
primary and secondary language spoken, written and read is important. This will help the nurse
identify special needs and practices that may affect the care plan that will be given to the client.
Gathering information about the client’s level of understanding such as educational background and
working status aids the nurse and medical practitioner if communicating effectively.
Knowing the people or family members and/or significant others living with the client provide
information of the availability of possible caregivers and support person for the client.
Reasons for Seeking Health Care
This may involve two basic but important question. First, “What is you major health problem or
concerns at this time?” This will also provide information of the client’s chief complaint (CC), which
is also the reason why the client is seeking medical help. A more holistic approach in phrasing and
delivering the question may lead out to further information that goes beyond the physical complaint
and stress on lifestyle changes. Second, “How do you feel about having to seek health care?” This
question encourages the client to discuss fears and /or other feelings about having to see a heath care
provider.
History of the Present Health Concern
This takes into account several aspects of the health problem. Encouraging the client to explain the
health problem or symptom by giving as much details as possible by focusing on the onset,
progression, duration of the problem, signs and symptoms and what the client perceives caused the
problem is By assessing the Character, Onset, Location, Duration, Severity, Pattern and Associated
factors (COLDSPA) or Provocation, Quality/Quantity, Region/Radiation, Severity Scale and Timing
(PQRST) helps the nurse complete this assessment effectively.
Note: COLDSPA and PQRST are some of the mnemonic used to help the nurse remember the process
easily.

Mnemonic Question

Describe the sign or symptom (feeling, appearance, sound,

Character
smell, or taste). “What does the pain like?”

When did it begin?

Onset
When did this pain start?

Location Where is it? Does it radiate? Does it occur anywhere else?

Duration How long does it last? Does it come and go or is it constant?

How bad is it? How much does it bother you? How intense is
Severity
the pain?

What makes it better or worse?Are there any treatment

Pattern
you’ve tried and relieve the pain?

Associated factors/ How it affects What other symptoms occur with it? How does it affect you?
the client What do you think caused it to start?

Components of the COLDSPA symptom analysis mnemonic. J. Weber and J. Kelly, Health Assessment
in Nursing, 5th Edition

Mnemonic Question

What were you doing when the pain started? What caused it? What
Provocation/ Palliation makes it better or worse?
What relieves and aggravates the pain?

Region/ Radiation Where is the pain located? Does the pain radiate?
 Severity scale How severe is the pain from a scale of 1-10?

Timing When or at what time does the pain start? How log did it last?

PQRST of Pain Assessment

The client answers to the questions provide the nurse with a great deal of information about the
client’s problem and how it affects client’s lifestyle and activities od daily living (ADL). This also helps
the nurse gain insight on how the client view the problem and his/her plan managing it.
Personal Health History
This will involve information about any childhood illnesses and immunization to date. Adult illnesses
including physical, emotional and psychological are being assessed. Information on past surgeries
and accidents, any prolonged episodes of pain, allergies and use of over the counter medications are
asked. These data provide information related to the client’s strength and weaknesses in relation to
his/her health history.
Information covered in this section also includes questions about birth, growth, development,
childhood diseases, immunization, allergies, medication use, previous health problems,
hospitalization, surgeries, pregnancy, births, previous accidents, injuries, pain experiences, and
emotional or psychiatric problems.
Not all clients will be very cooperative about providing their past health status. It will be helpful to
have a series of alternative questions for such clients and for those who may not understand what is
being asked.
Family Health History
Family health history plays an important role in a health of an individual. An increasing number of
health problems that seems to run in the families and are genetically based. Being exposed to these
problems may help in awareness and predisposition that may have affected the client. This should
include as many relatives genetically that the client can recall. Thorough assessment may identify
those diseases that may skip a generation like autosomal recessive disorders. Family health history
will include paternal and maternal grandparents, aunts and uncles on both sides, parent’s siblings
and client’s children. A genogram may help to organize and illustrate the family health history.
Review of Systems (ROM) for Current Health Problems
This is also called as the review of body systems. A client is asked questions that may give information
to current health problems or those experienced in the past that may still affect the client or are
recurring. Note, that in the review of body system, care must be taken only to subjective information
provided by the client. A nurse must document the client’s descriptions of his/health status for each
body system and to take note of the client’s denial of any signs, symptoms, diseases or problems that
was asked.
Here are the different body part/systems hat is involved in this assessment:

1. Skin, Hair, and Nails

2. Head and Neck
3. Eyes
4. Ears
5. Mouth, throat, nose and sinuses
6. Thorax and Lungs
7. Breast and regional lymphatics
8. Heart and Neck vessels
9. Peripheral Vascular
10. Abdomen
11. Male Genitalia
12. Female genitalia
13. Anus, rectum and prostate
14. Musculoskeletal
15. Neurologic
Lifestyle and Health Practices Profile
This section of the client’s health history deals with his/her human responses which involves
nutritional habits, activity and exercise patterns, sleep and rest patterns, self-concept and self-care
activities, social and community activities, relationship, values and belief system, education and
work, stress level, coping style and environment.
This will give a picture on how clients manage their everyday living, awareness on good and healthy
living patterns and their strength and available support system.
Description of a typical day is important to know how the client sees his usual daily activity pattern.
Note that the question should be vague enough in able for the client to give the orientation from
which the day is viewed and encourage the client to provide information on activities during a usual
day.
Q: “Please tell me what an average or typical day is for you? Start with awakening in the morning and
continue until bedtime.”
Nutrition and Weight Management involves knowing and asking the client what consist of an average
24-hour intake and give focus on the foods eaten, snacks and fluid intake and other substances
consumed and in what amount. You may also ask depending on the client who buys and prepares the
food and when or where meals are eaten. Whatever the client’s response is should be compared with
the guidelines in the food pyramid.

The messages this time around have changed slightly to emphasize different things.

1. Chose lower sodium foods

2. Make half your plate fruits and vegetables
3. Chose low fat or no fat dairy products
4. Eat smaller portions
5. Eat whole grains
6. Drink water over sugary drinks
7. Cut back on fatty, sugary foods
8. Balance your calorie intake with exercise
Information gathered in nutritional assessment gives an insight on the overall health status of the
patient. It identifies risk factor for obesity and is also used as a guide in health promotion.
 Nutrition refers to a complex process by which nutrients are ingested, digested, absorbed, transported,
used and the excreted.
Essential nutrients includes carbohydrates, proteins, fats, vitamins, minerals, and water.
Q: What do you usually eat during a typical day? Please tell me the kind of foods you prefer and how
often you eat throughout the day and how much you eat.”
Activity level and exercise shows how active the client is during an average week either at home or
at work. Ask about client’s regular exercise and distinguish between activity done when working and
exercise which is designed to reduced stress.
Q: “What is your daily pattern of activity?”
“Do you follow a regular exercise plan? What type of exercise do you do?
Sleep and rest, will explore the client’s perception on whether he/she is getting enough sleep and
rest. It should focus on specific sleep patterns and how many hours a night a person sleeps,
interruptions, and whether the client feel rested, is there any problem sleeping, rituals to promote
sleep and any concerns the client might have regarding sleeping habbits.
Q: “Tell me about your sleeping pattern.”
“Do you have trouble falling asleep or staying asleep?”
Substance use or abused provides information concerning lifestyle and a client’s self-care ability as
substance abuse can affect the client’s health and cause loss of function or impaired senses.
Developmental Levels
Knowledge on the normal growth and development provides a nurse a framework for health
assessment and health promotion throughout lifespan. Growth and development is a dynamic
process and is often used interchangeably. GROWTH is a physical change and can be measured
quantitatively. Development on the other hand, is an increase in the complexity of function and skill
progression. Both are independent and interrelated process.

Stages of Growth and Development:

Kozier & Erb’s Fundamentals of Nursing

There are different developmental theories related to growth and development. Some of the these
are:

1. Sigmund Freud contributed the Theory of Psychosexual Development with five overlapping stages of
personality development from birth to adulthood. Here the libido changes it’s location of emphasis
from one stage to another.
Kozier & Erb’s Fundamentals of Nursing

2. Erik H. Erikson adapted and expanded Freud’s developmental theory to include the entire lifespan,
believing people continue to develop throughout life and proposes that life is a sequence of
developmental stages or levels of achievement where each stage signals a task that must be
 completed. Erikson’s theory has become known as Psychosocial Development theory.

1. Weber & J. Kelly, Health Assessment in Nursing 5th Edition

Each person can be assessed as a comparison to the developmental domains (psychosexual,

psychosocial, cognitive and moral).
Psychosocial History
A cognitive level of functioning (thinking, knowledge, problem solving) and emotional functioning
(feelings, mood, behaviors, stability)also refers to client mental status. Mental health is very
important as one cannot be totally healthy without mental health which is more than just the absence
of mental disabilities and disorders.
A healthy status is needed to think clearly and respond appropriately to function effectively in all
activities of daily living. This manifest in a person’s appearance, behavior, speech, thought patterns,
decision and relationships.
Factors affecting Mental health:
There are several factors that affect mental health which include the following:

1. Economic and social factors

2. Unhealthy lifestyle choices
3. Exposure to violence
4. Personality factors
5. Spiritual factors
6. Cultural factors
7. Changes and impairment in the structure and function of the neurologic system.
8. Psychosocial developmental levels and issues.
The nurse observation of the client’s behaviors and answers to the interview questions gives way to
the assessment of his/her mental health. It is important to note for all verbal and non-verbal ques
that reflects the client mental status from the very first interaction you have with the client. While
doing the interview the nurse may encounter a variety of emotions expressed by the client.
Appendix:

1. Nursing Health Assessment Tool Format

2. Sample Genogram
III. Mental Assessment Guide

1. Nutritional Assessment Guide

2. Developmental Level Assessment Guide
3. 24-Hour Diet Recall for Client
VII. Assessment Tool: Nutritional History
VIII. Assessment Tool: Speedy Checklist for Nutritional Health