Chapter 4

The Nursing Process

• The nursing process functions as a systematic guide to client-centered care with 5
sequential steps. These are assessment, diagnosis, planning, implementation, and
evaluation.
• Critical thinking skills will play a vital role in the development of patient care.
• The nursing Process is considered a scientific approach in patient care as it employs a
problem solving method of responding to the health care needs of the patients.

Advantages of the 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

The ADPIE in the nursing process

• The nursing process is a scientific five-step approach that nurses use to safeguard the
levels of care that patients receive.
• ADPIE stands for ASSESSMENT, DIAGNOSIS, PLANNING, IMPLEMENTATION, AND
EVALUATION.

1. ASSESSMENT
• This is the first stage of the nursing process which involves systematic and continuous
collection, validation and communication of client data as compared to what is
standard/normal.
• It includes the client’s perceived needs, health problems, related experiences, health
practices, values and lifestyles.
• The main purpose of the assessment is to have a record of the client’s health
information.
• Four types of Assessment
1. Initial assessment – assessment performed within a specified time on admission
▪ Ex: nursing admission assessment
1. Problem-focused assessment – use to determine status of a specific problem
identified in an earlier assessment
▪ Ex: problem on urination-assess on fluid intake & urine output hourly
2. Emergency assessment – rapid assessment done during any physiologic/physiologic
crisis of the client to identify life threatening problems.
▪ Ex: assessment of a client’s airway, breathing status & circulation after
a cardiac arrest.
 3. Time-lapsed assessment – reassessment of client’s functional health pattern done
several months after initial assessment to compare the client’s current status to
baseline data previously obtained.

• Activities during assessment

a. Collection of Data
b. Validation of data
c. Organization of data
d. Analyzing of data
e. Recording/documentation of data

1. Collection of data
• gathering of information about the client
• includes physical, psychological, emotion, socio-cultural, spiritual factors that
may affect client’s health status
• includes past health history of client (allergies, past surgeries, chronic diseases,
use of folk healing methods)
• includes current/present problems of client (pain, nausea, sleep pattern,
religious practices, meds or treatment the client is taking now)
• Methods of data collection
o Observation of the patient
o Use to gather data by using the 5 senses and instruments.
o Interview of patient, family & SO
o A planned, purposeful conversation/communication with the client
to get information, identify problems, evaluate change, to teach,
or to provide support or counseling.
o it is used while taking the nursing history of a client
o examination of the patient
o Systematic data collection to detect health problems using unit of
measurements, physical examination techniques (IPPA),
interpretation of laboratory results.
o should be conducted systematically:
▪ Cephalocaudal approach – head-to-toe assessment
▪ Body System approach – examine all the body system
▪ Review of System approach – examine only particular area
affected
o Review of medical record
• Types of Data
1. Subjective data
o also referred to as Symptom/Covert data
o Information from the client’s point of view or are described by the person
experiencing it.
o Information supplied by family members, significant others; other health
professionals are considered subjective data.
o Example: pain, dizziness, ringing of ears/Tinnitus
2. Objective data
o also referred to as Sign/Overt data
 o Those that can be detected observed or measured/tested using accepted
standard or norm.
o Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin
• Sources of Data
1. Primary source – data directly gathered from the client using interview
and physical examination.
2. Secondary source – data gathered from client’s family members,
significant others, client’s medical records/chart, other members of
health team, and related care literature/journals.
• In the Assessment Phase, obtain a Nursing Health History – a structured
interview designed to collect specific data and to obtain a detailed health
record of a client.

• Components of a Nursing Health History:

▪ Biographic data – name, address, age, sex, martial status, occupation, religion.
▪ Reason for visit/Chief complaint – primary reason why client seek consultation or
hospitalization.
▪ History of present Illness – includes: usual health status, chronological story, family
history, disability assessment.
▪ Past Health History – includes all previous immunizations, experiences with illness.
▪ Family History – reveals risk factors for certain disease diseases (Diabetes,
hypertension, cancer, mental illness).
▪ Review of systems – review of all health problems by body systems
▪ Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily
living, recreation or hobbies.
▪ Social data – include family relationships, ethnic and educational background,
economic status, home and neighborhood conditions.
▪ Psychological data – information about the client’s emotional state.
▪ Pattern of health care – includes all health care resources: hospitals, clinics, health
centers, family doctors.

2. Validation of data
• The act of “double-checking” or verifying data to confirm that it is accurate
and complete.
• Purposes of data validation
1. ensure that data collection is complete
2. ensure that objective and subjective data agree
3. obtain additional data that may have been overlooked
4. avoid jumping to conclusion
5. differentiate cues and inferences
• Cues- Subjective or objective data observed by the nurse; it is what the
client says, or what the nurse can see, hear, feel, smell or measure.
• Inferences- The nurse interpretation or conclusion based on the cues.
• Example:
▪ Red swollen wound = infected wound
▪ Dry skin = dehydrated
 3. Organization of Data
• Uses a written or computerized format that organizes assessment data
systematically.
• Organization of data may be based on the following
1. Maslow’s basic needs
2. Body System Model
3. Gordon’s Functional Health Patterns:
Gordon’s Functional Health Patterns
1. Health perception-health management pattern.
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern

4. Analyze data
▪ Compare data against standard and identify significant cues. Standard/norm are
generally accepted measurements, model, pattern:
▪ Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic
values, normal growth and development pattern

5. Communicate/Record/Document Data
▪ nurse records all data collected about the client’s health status
▪ data are recorded in a factual manner not as interpreted by the nurse
▪ Record subjective data in client’s word; restating in other words what client says
might change its original meaning.

2. Diagnosis
▪ Is the 2nd step of the nursing process.
▪ the process of reasoning or the clinical act of identifying problems
▪ Purpose
o To identify health care needs and prepare a Nursing Diagnosis.
o To diagnose in nursing
o It means to analyze assessment information and derive meaning from this
analysis.

o Nursing Diagnosis
o Is a statement of a client’s potential or actual health problem resulting from
analysis of data.
o Is a statement of client’s potential or actual alterations/changes in his health
status.
 o A statement that describes a client’s actual or potential health problems that
a nurse can identify and for which she can order nursing interventions to
maintain the health status, to reduce, eliminate or prevent
alterations/changes.
o Is the problem statement that the nurse makes regarding a client’s condition
which she uses to communicate professionally.
o It uses the critical-thinking skills analysis and synthesis in order to identify
client strengths & health problems that can be resolves/prevented by
collaborative and independent nursing interventions.
▪ Analysis – separation into components or the breaking down of the
whole into its parts.
▪ Synthesis – the putting together of parts into whole

Three Activities in Diagnosing:

1. Data Analysis
2. Problem Identification
3. Formulation of Nursing Diagnosis

Characteristics of Nursing Diagnosis

1. It states a clear and concise health problem.
2. It is derived from existing evidences about the client.
3. It is potentially amenable to nursing therapy.
4. It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE)

1. Problem statement/diagnostic label/definition = P
2. Etiology/related factors/causes = E
3. Defining characteristics/signs and symptoms = S
*Therefore may be written as 2-Part or a 3-Part statement.

• Types of Nursing Diagnosis

1. Actual Nursing Diagnosis – a client problem that is present at the time of the
nursing assessment. It is based on the presence of signs and symptoms.
a. Examples:
▪ Imbalanced Nutrition: Less than body requirements r/t
decreased appetite nausea.
▪ Disturbed Sleep Pattern r/t cough, fever and pain.
▪ Constipation r/t long term use of laxative.
▪ Ineffective airway clearance r/t to viscous secretions
▪ Noncompliance (Medication) r/t unknown etiology
▪ Noncompliance (Diabetic diet) r/t unresolved anger about
Diagnosis
▪ Acute Pain (Chest) r/t cough 2nrdary to pneumonia
▪ Activity Intolerance r/t general weakness.
▪ Anxiety r/t difficulty of breathing & concerns over work
2. Potential Nursing diagnosis – one in which evidence about a health problem is
incomplete or unclear therefore requires more data to support or reject it; or the
causative factors are unknown but a problem is only considered possible to occur.
 a. Examples:
▪ Possible nutritional deficit
▪ Possible low self-esteem r/t loss job
▪ Possible altered thought processes r/t unfamiliar
surroundings
3. Risk Nursing diagnosis – is a clinical judgment that a problem does not exist,
therefore no S/S are present, but the presence of RISK FACTORS is indicates that a
problem is only is likely to develop unless nurse intervene or do something about it.
No subjective or objective cues are present therefore the factors that cause the
client to be more vulnerable to the problem are the etiology of a risk nursing
diagnosis.
a. Examples:
▪ Risk for Impaired skin integrity (left ankle) r/t decrease
peripheral circulation in diabetes.
▪ Risk for interrupted family processes r/t mother’s illness &
unavailability to provide child care.
▪ Risk for Constipation r/t inactivity and insufficient fluid
intake
▪ Risk for infection r/t compromised immune system.
▪ Risk for injury r/t decreased vision after cataract surgery.

• Formula in writing nursing diagnosis (PES or PE)

1. Actual nursing diagnosis = Patient problem + Etiology – replace the (+) symbol
with the words “RELATED TO” abbreviated as r/t. = Problem + Etiology + S/S
2. Risk Nursing diagnosis = Problem + Risk Factors
3. Possible nursing diagnosis = Problem + Etiology

• Qualifiers – words added to the diagnostic label/problem statement to gain

additional meaning.
▪ “deficient” – inadequate in amount, quality, degree, insufficient, incomplete
▪ “impaired” – made worse, weakened, damaged, reduced, deteriorated
▪ “decreased” – lesser in size, amount, degree
▪ “ineffective” – not producing the desired effect

• Activities during diagnosis:

1. Compare data against standards
2. Cluster or group data
3. Data analysis after comparing with standards
4. Identify gaps and inconsistencies in data
5. Determine the client’s health problems, health risks, strengths
6. Formulate Nursing Diagnosis – prioritize nursing diagnosis based on what problem
endangers the client’s life

3. PLANNING
▪ Involves determining before and the strategies or course of actions to be taken
before implementation of nursing care. To be effective, the client and his family
should be involve in planning.
▪ Purpose
o To determine the goals of care and the course of actions to be undertaken
during the implementation phase.
o To promote continuity of care.
o To focus charting requirements.
o To allow for delegation of specific activities.

o Activities during planning

1. Establish/Set priorities
o Priority – is something that takes precedence in position, and considered
the most important among several items. It is a decision making process
that ranks the order of nursing diagnosis in terms of importance to the
client.
o Guideline for setting priorities:
1. Life-threatening situations should be given highest priority.
2. Use the principle of ABC’s (airway, breathing, circulation)
3. Use Maslow’s hierarchy of needs.
4. Consider something that is very important to the client.
5. Actual problems take precedence over potential concerns.
6. Clients with unstable condition should be given priority over those with stable
conditions. Ex: attend to client with fever before attending to client who is
scheduled for physical therapy in the afternoon.
7. Consider the amount of time, materials, equipment required to care for clients. Ex:
attend to client who requires dressing change for postop wound before attending to
client who requires health teachings & is ready to be discharged late in the
afternoon.
8. Attend to client before equipment. Ex: assess the client before checking IV fluids,
urinary catheter, and drainage tube

2. Plan nursing interventions/nursing orders to direct activities to be

carried out in the implementation phase.
o Nursing interventions
▪ Any treatment, based upon clinical judgment and knowledge, that a
nurse performs to enhance client outcomes.
▪ They are used to monitor health status; prevent, resolve or control a
problem; assist with activities of daily living; or promote optimum
health and independence.
▪ Types of Interventions
▪ Independent Nursing Intervention – those activities that the nurse
is licensed to initiate as a result of the nurse’s own knowledge and
skills.
▪ Dependent Nursing Intervention – those activities carried out on
the order of a physician, under a physician’s supervision, or according
to specific routines.
▪ Interdependent/Collaborative – those activities the nurse carries out in
collaboration or in relation with other members of the health care team.
 3. Write a Nursing Care Plan
• Nursing Care Plan (NCP)
• A written summary of the care that a client is to receive.
• It is the “blueprint” of the nursing process.
• It is nursing centered in that the nurse remains in the scope of
nursing practice domain in treating human responses to actual or
potential health problems.
• It is s step-by-step process as evidence by:
1. Sufficient data are collected to substantiate nursing diagnosis.
2. At least one goal must be stated for each nursing diagnosis.
3. Outcome criteria must be identified for each goal.
4. Nursing interventions must be specifically designed to meet the
identified goal.
5. Each intervention should be supported by a scientific rationale, which is
the justification or reason for carrying out the intervention.
6. Evaluation must address whether each goal was completely met,
partially met or completely unmet.

4. Implementation
▪ Is putting the nursing care plan into action.
▪ Purpose
To carry out planned nursing interventions to help the client attain goals and
achieve optimal level of health.
▪ Activities
1. Reassessing – to ensure prompt attention to emerging problems.
2. Set priorities – to determine the order in which nursing interventions are carried
out.
3. Perform nursing interventions – these may be independent. Dependent or
collaborative measures.
4. Record actions – to complete nursing interventions, relevant documentation should
be done. Remember: Something that is NOT written is considered as NOT done at
all.
▪ Requirements of Implementation
1. Knowledge – include intellectual skills like problem-solving, decision-making and
teaching.
2. Technical skills – to carry out treatment and procedures.
3. Communication skills – use of verbal and non-verbal communication to carry out
planned nursing interventions.
4. Therapeutic use of self – is being willing and being able to care.

5. 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
▪ Step of the nursing process that measures the client’s response to nursing actions
and the client’s progress toward achieving goals
▪ Data collected on an on-going basis
▪ Supports the basis of the usefulness and effectiveness of nursing practice
 ▪ Involves measurement of Quality of Care
▪ Evaluation of individual plan of care includes determining outcome achievement
▪ Identify variables/factors affecting outcome achievement
▪ Decide where to continue/modify/terminate plan
▪ Continue/modify/terminate plan based on whether outcome has been met (partially
or completely)

Evaluation of Goal Achievement:

-Measures and Sources: Assessment skills and techniques
-As goals are evaluated, adjustments of the care plan are made
-If the goal was met, that part of the care plan is discontinued
-Redefines priorities

Reflection in Action:
Once you deliver an intervention, you continuously examine results by gathering
subjective and objective data from the patient, family, and health care team members.
At the same time you review knowledge regarding a patient's current condition, the
treatment, and the resources available for recovery.
By reflecting on previous experiences caring for similar patients, you are in a better
position to know how to evaluate your patient.

Perform the following steps to objectively evaluate the degree of success in achieving
outcomes of care:
1.Examine
2.Evaluate
3.Compare
4.Judge
5. What is/are the barriers? why did they not agree?

When do you discontinue a care plan?

- if the patient has met all goals and outcomes
Modifying a care plan
• Reassessment
• Redefining diagnoses
• Goals and expected outcomes