NURSING PROCESS- central core to nursing actions in any -Coordination of care

setting, basis of nursing actions/essence of nursing -Health teachings and health promotion
1. Assessment
-Consultation
2. Nursing diagnosis
3. Planning -Prescriptive authority and treatment
4. Implementation EVALUATION- The registered nurse evaluates progress
5. Evaluation toward attainment of goals
PROCESS- a series of planned actions or operations directed Purpose of Nursing Process:
toward a particular result.
 To provide a systematic methodology for nursing
NURSING PROCESS- is a systematic, rational method of
practice.
planning, and providing nursing care. Its goal is to identify a
 To unify standardize and direct nursing care.
clients health status, actual or potential health problems, to
establish plans to meet the identified needs and to deliver  Defines nurse’s role and function.
specific nursing interventions to meet those needs.  Enhances communication, collaboration and
synchronization of health team members.
EVOLUTION
 To emphasize health promotion, maintenance and
1955- nursing process was introduced by Lydia Hall restoration or enhance peaceful death, depending
Early 1960s- Dorothy Johnson, Orlando Ida, and Weidenbach on the patient’s situation.
introduced 3 steps in nursing model: assess, implement, and  May be used to demonstrate of the cost
evaluate effectiveness when resources are scarce.
1966- Virginia Henderson identified Nursing Process model as:  To evaluate the efficiency and effectiveness of the
Observing, measuring, gathering data, and analyzing the care.
findings  Give direction, guidance and meaning and to the
1967- 4 step model was proposed: Assessment, Planning, nursing care.
Intervention, And Evaluation  Provide for continuity of care and to reduce
1973- use of nursing process in clinical practice continue to omissions.
gain additional accuracy and recognition when ANA published  Individualized patient participation in care.
the standard of the clinical nursing practice  Promote creativity and flexibility in nursing practice.
 Facilitate documentation of data, diagnosis patient
1973- classification of Nursing Diagnosis began by the NANDA
response.
1980- ANA published a policy of statement which provided
guidelines(standard) for individual professional nurses to Characteristics of Nursing Process
follow in practice 1. Problem oriented- It is comparable with scientific
1982- NCLEX (National Council Licensure Examination) was problem-solving approach.
revised to include the Nursing Process as a basis for 2. Goal oriented; client centered.
organization
3. Orderly, planned step by step and systematic.
1984- JCAHO (Joint commission on accreditation of Health
Organization launched the requirement for accredited 4. Open to accepting new information during its
hospitals to use the Nursing Process as a means of application to meet the unique needs of the patient,
documenting all phases of client care family, group or community.
CURRENT- the nursing process is a five steps process: (A, Dx, 5. It is flexible to meet the unique needs of patients,
PI, E) family group or community.
Scope of Standard Practice: 6. Interpersonal and collaborative, it requires that the
nurse communicate directly and consistently with
ASSESSMENT- The registered Nurse collects comprehensive
the patient.
data pertinent to the patient health of the situation
7. Permits creativity among nurses and patient in
DIAGNOSIS- The registered Nurse analyzes the Assessment
devising ways to the health problems.
data to determine the diagnosis on issues.
8. Cyclical and dynamic- steps may overlap because thy
PLANNING- or outcome Identification, the registered Nurse
are interrelated.
identified expected outcomes from a plan individualized to
patient or situation 9. Universal-applicable to any setting. It is a framework
for nursing care in all types of health care setting
IMPLEMENTATION- the registered nurse implements the
with patient’s of all groups.
identified plan:
ADVANTAGES OF NURSING PROCESS 5. EVALUATION- ( appraisal of results) – the nurse
(for nurses and student nurses) determine if the client goals were met, partially met
1. Consistent and systematic nursing practice. or not met.
2. Confidence Medical care plan - formulate by the physician:
3. Job satisfaction - In treating the patients
4. Professional growth
5. Aid in Staff Assignments -to ensure consistent responsible management of
6. Meeting standards of accredited hospital/health care diseases
institution. Nursing Care Plan- formulate by nurses through the utilization
7. Meeting the standard of Nursing Care of nursing process to:
8. Aid in Staff Assignments. -ensure consistent and responsible nursing
9. Avoidance of legal action. management of patient’s problems.
ADVANTAGES OF NURSING PROCESS INTER RELATIONSHIP OF THE NURSING PROCESS,NURSE,AND
(FOR THE PATIENT) THE PATIENT
1. Quality client care
2. Continuity of care
NURSE PATIENT
3. Participation of the client in their health care.

OVERVIEW OF PHASES OF NURSING PROCESS

INTERDEPENDENT PHASES OF NURSING PROCESS(ADPIE)
1. Assessment- provide significant information,
assembled to form the client data base. 1. Assessment (collection of data)
2. 2. Diagnosis- is the classification of disease, 2. Diagnosing (processing of data)
condition or human response based on specific 3. Planning
evaluation of signs and symptoms, history and 4. Implementation
diagnostic study. 5. Evaluation
-Analyzes the collected data.
-After analysis, a list of nursing diagnosis describing
the clients problem.
COMPARISON OF MEDICAL DIAGNOSIS AND THE NURSING
DIAGNOSIS:

3. PLANNING and Outcome Identification- involves

formulating and documenting the care plan.
-Organizes and propose course of action for
resolution of actual problems and prevention of risk
problems.
4. Implementation- execution of Nursing Care Plan
 -factual data that are observed by the nurse and could be
noted by any other skilled observer.
-seen, heard, felt or smelled by observer
EXAMPLES: pallor, diaphoresis, BP=120/80, reddish urine

COLLECTING DATA
1. INTERVIEW- planned purposeful conversation
 APPROACHES OF INTERVIEW
a. directive- highly structured and elicits specific
ASSESSMENT information. (e.g., emergency situation)
 The collection of data about the health status of the b. non directive- (rapport building interview
client/patient is systematic and continuous. The data
are accessible, communicated, and recorded. KINDS OF INTERVIEW
( Standard of Nursing Practice, American Nurses a. closed questions- restrictive, generally
Association, 1973) requiring short answer.
 Data collection b. open-ended questions- lead patient to
 Process of collecting data for the purpose of discover, explore their thoughts and feelings.
identifying actual or potential patient health c. neutral questions-patient can answer without
problems which the professional nurse licensed to direction or pressure from the nurse. (ex. How
treat. do you feel about that?)
 It is the basis of the patient care plan and later d. leading questions- directs the patients answer.
assessments contribute to revisions and updates in  FACTORS THAT INFLUENCE INTERVIEW?
the plan as the patient’s condition changes. a. time
 To establish a data base. b. place
 Collecting, validating, organizing, and recording data c. seating arrangement (45 degrees angle to the
about the patient’s health status. bed)
 d. distance(3-4ft)
 STAGES OF INTERVIEW
THREE METHODS OF COLLECTING DATA
a. opening
ASSESSMENT= OBSERVATION+INTERVIEW+EXAMINATION b. the body
(data collection) c. the closing
Sources of data collection:  USING A FORMAT
a. Henderson’s components of nursing care
Primary source= patient b. Gordon’s functional health pattern
Secondary sources= records(chart), family members, and c. Human Growth and development
other persons giving care to patient, laboratory results d. NANDA assessment tool (North American
TYPES OF DATA Nursing Diagnosis Association)
SUBJECTIVE DATA= (symptoms, or covert data) can be 2. OBSERVATION- a systematic selection, watching or
described only by the person experiencing it using their own noticing and recording of the patient’s
words which includes the individual’s perceptions. characteristics, behaviors, objectives events and the
environment.
=client’s sensations, feelings, values, beliefs, thoughts,
-use senses (sight, hearing, touch and smell)
attitudes.
-Physical examination techniques
EXAMPLES: pain, nervousness, vertigo, tinnitus *cephalocaudal (head to toe)
This are information given verbally by the patient. *body system
*focus assessment
EXAMPLES: “I feel nervous”
3. MEASUREMENT: used to ascertain the extent,
“I want to be alone” dimensions, rate, rhythm, quantity, size
“my stomach is burning” - use of measures-V/S;I & O
-results of laboratories and diagnostic examinations
OBJECTIVE DATA- (SIGNS,OR OVERT)
-can be observed and measured, qualitatively and
quantitatively.
THE ASSESSMENT PROCESS=involves 4 closely related  is a clinical judgment that an individual, family, or
activities: community is more vulnerable to develop the
a. collecting data problem than are others in the same or similar
b, organize the data situation.
c. validate the data  EXAMPLE: people admitted to a hospital have more
d. recording of data possibility of acquiring infection, High risk for
infection
POSSIBLE NURSING DIAGNOSIS
DIAGNOSING
 the nurse may decide to formulate a tentative or
DIAGNOSING
possible Nursing Diagnosis
 second phase of the nursing process  evidence about a health problem is unclear;
 interpret assessment data causative factor is unknown; this requires more data.
 identify client’s strength  this is compared to “rule out” of Medical Diagnosis
 identify client’s problems  EX: A woman lives alone-admitted to hospital-nurse
 it involves the: notice nobody visits the patient. Possible social
a. classification of disease isolation.
b. condition of human response WRITING A NURSING DIAGNOSIS
base on scientific evaluation of s/s, 1. ACTUAL NURSING DIAGNOSIS
history and diagnostic studies.
Actual nursing diagnosis= Patient problem + cause if
 it is also referred to as analysis, problem known
identification, or NURSING DIAGNOSIS 2. PES FORMAT (PROBLEM, ETIOLOGY, SIGNS and
 it is a process of data analysis and problem SYMPTOMS)
identification.
Nursing diagnosis= Problem + Etiology + S/S
NURSING DIAGNOSIS
PROBLEM
 is the specific result of diagnosing and in the problem
statement that the nurse use to communicate  identified label of client’s health condition or
professionally. response to the medical illness or therapy for which
 can describe actual health problems or potential nursing may intervene.
health problems.  also known as “NURSING DIAGNOSIS”
 it is a judgment made only after thorough systematic  QUALIFIERS:
data collection. o Acute- less than 6 months
 The nursing diagnosis is the basis for the selection of o Chronic- more than 6 months
nursing intervention. o Intermittent- stopping or starting at
 NANDA (NORTH AMERICAN NURSING DIAGNOSIS intervals
ASSOCIATION)- official working definition of Nursing ETIOLOGY
Diagnosis  or cause;
TYPES OF NURSING DIAGNOSIS  one or more probable causes of health problem.
1. Actual Nursing diagnosis  the etiology reflects the following:
2. Risk Nursing diagnosis o Environmental- odors, lighting, and noises
3. Possible Nursing diagnosis o Sociological-language, finances, support
system
ACTUAL NURSING DIAGNOSIS
o Physiological- fluid deficit/excess
 refer to a problem that exist at the present moment o Spiritual- rituals, practices, and beliefs
in reality. o Psychological- fear, anxiety, and low self
 client’s response to a health problem that is present esteem
at the time of the nursing assessment. It is based on
actual presence of signs and symptoms. DEFINING CHARACTERISTICS
 EX: Ineffective breathing pattern  clusters of cues (signs and symptoms) as EVIDENCED
BY(AEB) or AS MANIFESTED BY(AMB)
 clinical s/s which confirm the problem exist.

RISK NURSING DIAGNOSIS (POTENTIAL PROBLEM)

3. RISK NURSING DIAGNOSIS body requirements
Nursing diagnosis= problem + factors Disorientation R/T Sleep pattern disturbance
sleep pattern R/T disorientation
disturbance
GUIDELINES FOR WRITING A NURSING PROBLEM OR
NURSING DIAGNOSIS:
1. Write the problem in terms of the persons response 6. The medical diagnosis should not be included in the
rather than nursing need. statement of the nursing problems.
Incorrect Correct Incorrect Correct
Needs suctioning because High risk for aspiration Diabetes Mellitus Knowledge deficit (foot
she has many secretions. R/T excessive oral care) R/T inability to retain
secretions information
Needs frequent periods Fatigue R/T persistent Cancer Altered oral mucous
because of SOB SOB membranes R/T effects of
chemotherapy
Myocardial infarction Ineffective denial R/T fear of
2. Use “related to” rather than “due to” or “caused by”
disability
to connect two parts of the statement.
Ineffective breathing Ineffective breathing
Incorrect Correct
pattern R/T pattern R/T retained
High risk for injury High risk for injury R/T emphysema secretions
caused by change of change in mental status
CHF R/T failure to take Non compliance (cardiac
mental status
medicine medication) R/T lack of
Alteration in nutrition Alteration in nutrition R/T knowledge about action
due to nausea and nausea and vomiting and correct dosages
vomiting

ERRORS IN NURSING DIAGNOSIS STATEMENT

3. Write the nursing diagnosis in legally advisable
1. Do not state the nursing diagnosis in medical terms,.
terms.
2. Do not state the nursing diagnosis as a medical
Incorrect Correct diagnosis.
Ineffective airway Ineffective airway clearance 3. Do not state the two problems at the same time.
clearance R/T R/T sedation 4. Do not the statement in such a way that it may
excessive sedation legally incriminating.
5. Do not rename a medical problem to make it a
High risk for injury R/T High risk injury R/T hazards
nursing diagnosis.
inadequate of skin traction
6. Do not write a nursing diagnosis based on value
maintained skin
judgments.
traction
7. Do not write the etiology as the same meaning of the
nursing diagnosis.
4. Write the problem stated without value judgements.
Incorrect Correct PLANNING
Altered parenting R/T Altered parenting R/T  involves determining beforehand the strategies or
poor bonding with longed separation from the course of actions to be taken before implementation
child child of nursing care.
 is a mental formulation of a proposed method of
doing or making something in achieving a given end.
5. Avoid reversing the clauses.
ACTIVITIES:
Incorrect Correct
1. SETTING PRIORITIES: the nurse and the patient
Decreased caloric Altered nutrition: less than mutually determine which problems may be dealt
intake R/T altered body requirements R/T later.
nutrition: less than decreased caloric intake
  List
A. Maslow’s Hierarchy of Needs  Demonstrate
 High priority- life threatening problems (loss of  Share
cardiac or respiratory functions)  Express
 Medium priority- health threatening problems
 Walk
(acute illness)
 low priority- one that arises from normal Non measurable verbs
development al needs or that requires only  Know
minimal nursing support.  Understand
B. Focus on the problems the patient feels are most  Appreciate
important. This will involve the patient in planning  Think
their own care and will enhance cooperation  Accept
between nurse and the patient.  Feel
C. Consider the culture, values, and beliefs of the 4. Identify the appropriate nursing interventions.
patient. NURSING INTERVENTIONS-are activities that the
D. Consider the effect of potential problems. nurse plans and must be implemented to help the
E. Consider the cost, resources and available patient to achieve goals.
personnel. The nurse should select interventions that are:
F. Consider the time needed to plan for and  safe
treatment of the patient.  specific
2. Set goals in collaboration with the patient.  realistic and feasible
 GOAL: is a general statement indicating the interest FACTORS IN SELECTION OF NURSING INTERVENTION
or desired change in the client’s health status,  Desired goal
function or behavior.  Client abilities
 SHORT TERM GOAL: is a statement identifying a  Client preference
change in behavior that can be achieved fairly,  Available resources
quickly, usually within a few hours or days (2-3 days)  Nursing knowledge
 LONG TERM GOAL: indicates an objective to be
TYPES OF NURSING INTERVENTIONS
achieved a longer period usually over a week or
months. 1. INDEPENDENT NURSING INTERVENTIONS
 these are those activities that nurses is
3. Set objectives in collaboration with the patient.
licensed to initiate on the basis of their
 Well stated behavioral objective is a SMART knowledge and skills.
objective. (Specific, Measurable, Attainable, Realistic,  EX: physical care, ongoing assessment,
time bound/time frame) emotional support, and comfort, teaching,
EXAMPLE: counselling, environmental management.
2. DEPENDENT NURSING INTERVENTIONS
A. BEHAVIORAL/PERFORMANCE
 is those activities carried out under the
 WILL DRINK physician’s order or supervision or according
 WILL VOID to specified routines.
 DECREASE IN  EX: medications, medical treatment, and
 INCREASE IN medical procedures.
3. COLLABORATIVE
 WILL AMBULATE
Measurable verb
IMPLEMENTATION
 Identify
 This is the “DOING” phase of the nursing process.
 Describe
 Actual implementation of nursing care
 Perform
 COMPONENTS OF IMPLEMENTATION PHASE:
 Relate
A. Pre-IMPLEMENTATION:
 State
 o knowledge of the NCP 2. Problem-oriented-medical-record
o validating the NCP a. data base
o knowledge, and skills to implement the nursing b. doctor’s order sheet
intervention competently and efficiently c. progress notes
d. care plans
o technical skills- ability to perform a procedure
-nurses progress notes
competently and safely.
o interpersonal skills- communicating with the
client and to other members of the health team. DIFFERENT WAYS OF NURSES PROGRESS NOTES/CHARTING
o intellectual skills- ability to reason and 1. SOAPIE (subjective, objective, analysis, plan,
understand intervention, and evaluation)
B. POST IMPLEMENTATION EX:
 documenting the implemented  S- Mainit ang pakiramdam ko”
intervention.  O- warm to touch, redness of face
 T- 39
PURPOSE OF DOCUMENTATION:
 A- hyperthermia related to infection
1. Promote communication for the continuity of care.  P- at the end of 4 hours, patient body
2. Maintain legal records temperature will subside from 39-37
3. Meet requirements of regulatory agencies.  I—tepid sponge bath, increased fluid intake,
regulate the IVF accurately, tempra 1
CHARACTERISTICS OF DOCUMENTATION tablet/orem as per doctors order
1. organized, complete, and concise.  E-latest body temperature: 37
2. Factual-only information that pertains to the patient 2. SOAPIER (Subjective, objective, analysis, planning,
health condition and care is recorded. implementation, evaluation, revision)
3. Accurate and appropriate, do not include your 3. Narrative charting- notes written in paragraph
personal opinion and perception. EX:
Example:  6-2 shift
 Received patient with D5LR 1L infusing well
 refused medication(correct)
at 10 gtts/minute.
 was uncooperative(incorrect)
 Vital signs taken and recorded
 was crying(correct)
 Morning care done
 was very depressed(incorrect)
 Breakfast serve, ate with good appetite
4. current
 Visited and examined by attending physician
5. confidential
 12pm- vomited twice, previously taken
foods, in moderate amount
GUIDELINES IN DOCUMENTATION  referred to attending physician with orders
1. Use only standard terminologies (abbreviations, and carried out.
symbols, and terms)  maintained on NPO temporary as ordered
2. Proper grammar and spelling by AP.
3. Use ink  afebrile
4. Chart only post implementation  2pm-left patient, sleeping with D5LR 1L at
5. Do not leave spaces the level of 300cc infusing well.
6. Document in timely manner(include date and time)
7. Sign the recording FOCUS CHARTING (DAR) (DATA, ACTION, RESPONSE)
DATE/TIME FOCUS NOTES (DAR)
TYPES OF RECORDING/DOCUMENTATION May 2, 2010 Impaired skin D- presence of
1. Source-oriented medical record integrity bedsore
a. admission sheet A- wound care
b. physician orders sheet done turn patient
c. medical history sheet side to side every
d. nurse’s notes hour
e. special records and report (referral form, lab
R- improvement
diagnostic/findings)
 noted in sacral
area feeling of
comfortable after
care

EVALUATION
 is assessing the patient’s response to nursing
interventions and then comparing the response to
predetermined standards or outcome criteria.
 Activities:
1. identify the expected outcome
2. collect data about the patient response which is
related to expected outcome.
3. compare the data with the expected outcome.
4. relate nursing actions to patient outcome.
5. Observe conclusion to patient outcome.
6. review and modify NCP as needed.