Nursing Process

MA. RONELA PAGLINAWAN MENDOZA, RN, MAN

HEALTH ASSESSMENT

NURSING PROCESS

It is a systematic, rational method of

planning and providing
individualized nursing care.

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION
INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING

The Nursing Process

Is the underlying scheme that provides order and
direction to nursing care.
It is the essence of professional nursing practice.
It has been conceptualized as a systematic
series of independent nursing actions directed
toward promoting an optimum level of wellness
for the client.
It is cyclical; the components follow a logical
sequence, but more than one component may be
involved at any one time.

Purpose of Nursing Process

To identify a clients health status,
actual or potential health care problems
or needs, to establish plans to meet the
identified needs, and to deliver specific
nursing interventions to meet those
needs.
It helps nurses in arriving at decisions and in
predicting and evaluating consequences.
It was developed as a specific method for
applying a scientific approach or a problem
solving approach to nursing practice.

Characteristics of the Nursing Process

Dynamic
Client-centered
Planned
Interpersonal and collaborative
Universally applicable
Can focus on problems or strengths
Open, flexible
Humanistic and individualized
Cyclical
Outcome focused ( results oriented)
Emphasizes feedback and validation

Nursing Process...

Organized

Systematic
Goal-Oriented
Humanistic Care

Efficient Effective

NURSING PROCESS
Phases:
Assessment
Diagnosis
Planning
Implementation
Evaluation

ASSESSMENT
systematic & continuous collection,
organization, validation & documentation of
data (information)-(Potter and Perry, 2006)
Establish a data base
Update data as needed
Organize data
Validate data
Communicate/document data

Types of Assessment
Initial Assessment
Nursing admission assessment

Problem-Focused Assessment
Hourly assessment of clients fluid intake & urinary output
in an ICU

Time-Lapsed Reassessment
Reassessment of a clients functional health patterns in a
home care or OPD, or in a hosp, at a shift change

Emergency Assessment
Rapid assessment of persons ABC during a cardiac arrest

Activities of Assessment
1) COLLECT DATA
2) ORGANIZE DATA
3) VALIDATE DATA
4) DOCUMENT DATA

 COLLECTION OF DATA

ASSESSMENT

TYPES OF DATA
Assessment involves reorganizing
and collecting CUES:
Objective Data (overt) - Signs
Subjective Data (covert) - Symptoms

ASSESSMENT
SOURCES OF DATA
Primary
Secondary (Indirect)

DATA COLLECTION METHODS

OBSERVATION
INTERVIEWING
PHYSICAL EXAMINATION

OBSERVATION
Using the senses to
observe client data
2 ASPECTS:
Noticing the data
Selecting, organizing
and interpreting the
data

INTERVIEW
A planned
communication or a
conversation w/ a
purpose, for example,
to get or give
information, identify
problems of mutual
concern, evaluate
change, teach, provide
support or provide
counseling or therapy.

Four Phases of a Nursing Interview

Preparatory phase
Introduction
Working phase
Termination

COMPONENTS OF A
NURSING HEALTH HISTORY
BIOGRAPHIC DATA
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST HISTORY
FAMILY HISTORY OF ILLNESS

COMPONENTS OF A NURSING
HEALTH HISTORY

LIFESTYLE
SOCIAL DATA
PSYCHOLOGIC DATA
PATTERNS OF HEALTH CARE

GORDONS FUNCTIONAL
HEALTH PATTERNS
1. Health Perception Health
Management Pattern
.describes clients perceived pattern of health and well
being and how health is managed.

2. Nutritional Metabolic Pattern

.describes pattern of food and fluid consumption relative to
metabolic need and pattern indicators of local nutrient
supply.

3. Elimination Pattern
.describes pattern of excretory function (bowel, bladder,
and skin)

GORDONS FUNCTIONAL
HEALTH PATTERNS
4. Activity Exercise Pattern
.describes pattern of exercise, activity, leisure, and recreation.

5. Cognitive Perceptual Pattern

.describes sensory, perceptual, and cognitive pattern

6. Sleep Rest Pattern

.describes patterns of sleep, rest, and relaxation.

7. Self-perception Self-concept Pattern

.describes self-concept and perceptions of self (body comfort,
image, feeling state)

GORDONS FUNCTIONAL
HEALTH PATTERNS
8. Role Relationship Pattern
.describes pattern of role engagements and relationships.

9. Sexuality Reproductive Pattern

.describes clients pattern of satisfaction and dissatisfaction with
sexuality pattern, describes reproductive patterns.

10. Coping Stress Tolerance Pattern

.describes general coping patterns and effectiveness of the
pattern in terms of stress tolerance.

11. Value Belief Pattern

.describes pattern of values and beliefs, including spiritual and
/or goals that guide choices or decisions.

PHYSICAL EXAMINATION
A systematic data collection
method that uses
observation to detect health
problems
TECHNIQUES/METHODS
Inspection
Auscultation
Palpation
Percussion

Problems Related to Data Collection

Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate data,
erroneous or misinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather
than observed behavior
Failure to update the database

 ORGANIZE DATA
The nurse uses a written (or computerized) format
that organizes the assessment data systematically.

 ORGANIZE DATA

 VALIDATING DATA
The act of double-checking or verifying data to
confirm that it is accurate and factual
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

 DOCUMENTING DATA
Recording of client data
Must be done accurately and should include
all data collected about the clients health
status

DIAGNOSING
Process which results to a diagnostic statement or
nursing diagnosis. Its analyze assessment
information and derive meaning from this
analysis.
Purpose:
To identify the clients health care needs and to
prepare diagnostic statements.
Nursing Diagnosis statement of clients
potential or actual alteration of health status. It
uses the critical thinking skills of analysis and
synthesis.

DIAGNOSING
TYPES OF NURSING DIAGNOSES
1) Actual diagnosis
Ineffective Breathing Pattern

2) Risk nursing diagnosis

Risk for infection

3) Wellness diagnosis
Readiness for Enhanced Spiritual Well-Being or
Readiness for Enhanced Family Coping

4) Possible nursing diagnosis

Possible Social Isolation
5) Syndrome diagnosis
Risk for disuse syndrome, Impaired Physical Mobility

OUTCOME IDENTIFICATION
Formulating and documenting
measurable, realistic, client focused
goals.
Purposes:
To provide individualized care.
To promote client participation.
To plan care that is realistic and
measurable.
To allow involvement of support

Cont.activities outcom e identifi

cation

Behavioral goals or qualifier that indicate the

level of performance that needs to be achieved.

Calculate distinguish
participate
Classify
draw
practice
Communicate explain
recall
Compare
express recite
Define
identify record
Demonstrate list
state
Construct
maintain
verbalize
Contrast
perform

Cont activities of outcom e identifi

cation

Goals may be short-term pr a long-term

Outcome criteria are specific, measurable,
realistic statement of goal attainment.

Outcome-criteria are written in a

manner that they answer the
questions: who, what actions,
under what circumstances, how
well, and when.

Cont.

Characteristics of well-stated
outcome
S MART -

specific
measureable
attainable
Realistic
Time-framed

PLANNING
Involves determining beforehand the
strategies or course of actions to be taken
before implementation phase.
Purposes:
1. To identify the clients goal and appropriate nursing
actions.
2. To direct client care activities.
3. To promote continuity of care.
4. To focus charting requirements.
5. To allow for delegation of specific activities.

PLANNING
Setting priorities
Establishing client goals/desired
outcomes
Selecting nursing interventions
Writing individualized nursing
interventions on care plans

IMPLEMENTATION
The action phase in which the nurse performs the
nursing interventions.
Activities:
Reassessing
Determining the nurses need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities
Requirements:
1. Knowledge
2. Technical Skills
3. Communication skills
4. Therapeutic use of self.

EVALUATION
a planned, ongoing, purposeful activity in which
clients & health care professionals determine:
a. Clients progress toward achievement of
goals/outcomes
b. Effectiveness of the nursing care plan

Activities:
Collect data about the clients response.
Compares the client response to goals and
outcome criteria of nursing care have been
achieved.

EVALUATION
The four possible judgment that may be
made are as follows:
1. The goal was completely met.
2. The goal was partially met.
3. The goal was completely unmet.
4. New problems or nursing diagnoses have
developed.

EVALUATION
5 COMPONENTS
Collecting data related to the desired
outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying or terminating the
NCP

Benefits of the NURSING PROCESS:

(for the Client)

QUALITY CLIENT CARE

CONTINUITY OF CARE
PARTICIPATION BY CLIENTS IN
THEIR HEALTH CARE

Benefits of the NURSING PROCESS:

(for the Nurse)

CONSISTENT AND SYSTEMATIC NURSING

EDUCATION.
JOB SATISFACTION.
PROFESSIONAL GROWTH.
AVOIDANCE OF LEGAL ACTION.
MEETING PROFESSIONAL NURSING
STANDARDS.
MEETING STANDARDS OF ACCREDITED
HOSPITALS.

HEART OF THE NURSING PROCESS

KNOWLEDGE
SKILLS
CARING