THEORIES OF NURSING  Defines Health as a dynamic state in the life
Florence Nightingale (1960/1969)
 Often considered the first nurse theorist
 Defined nursing as “the act of utilizing the
environment of the patient to assist him in his
recovery”.
 Nightingale’s theory remains an integral parts
of nursing and healthcare today.
 5 Environmental Factors:
 Pure or fresh air
 Pure water
 Efficient drainage
 Cleanliness
 Light, especially direct sunlight
 Nightingale’s general concepts are:
1.Ventilation 4.Warmth
2.Cleanliness 5.Diet
3.Quiet
Dorothy E. Johnson (1980)
The Behavioral System Model for Nursing
 Focuses on how the client adapt to illness; the
goal of nursing is to reduce stress so that the
client can move easily through recovery.
 Viewed the patient’s behavior as a system that
is a whole with interacting parts. The nursing
process is viewed as a major tool.
 Purpose: To reduce stress so the client can
recover as quickly as possible.
View of components
 Person: A system of interdependent parts with
patterned, repetitive, and purposeful ways of
behaving.
 Environment: All forces that affect the person
and that influence the behavioral system.
 Health: Focus on person, not illness. Health is a
dynamic state influenced by biologic,
psychological, and social factors.
 Nursing: Promotion of behavioral system,
balance, and stability. An art and science
providing external assistance before and during
system balance disturbances.
Myra Estrin Levin(1973)
Conservation Model
 Described the Four Conservation Principles.
She advocated that nursing is a human
interaction and proposed four conservation
principles of nursing which are concerned with
the unity and integrity of the individual. The
four principles are as follows:
1. Conservation of Energy – The human body
functions by utilizing energy. The human body
needs energy producing input (food, oxygen,
fluids) to allow energy utilization as output.
2. Conservation of Structural Integrity- the
human body has physical boundaries (skin, and
mucous membranes) that must be maintained
to facilitate health and prevent harmful agents
from entering the body.
3. Conservation of Personal Integrity- the
nursing interventions are based on the
conservation of the individuals personality.
Every individual has a sense of identity, self-
worth and self-esteem, which must be
preserved and enhanced by the nurses.
4. Conservation of Social Integrity- the social
integrity of the clients reflects the family and
the community in which the clients functions.
Health care institutions may separate
individuals form their family. It is important for
nurses to consider the individual in the context
of a family.
Imogene King (1971)
Goal Attainment Theory
 Highlights the importance of the participation
of all the individuals in decision making & deals
with the choices, alternatives, & outcomes of
nursing care
 This theory offers insights into nurses’
interactions with individuals & groups within
the environment
cycle; illness is an interference in the life cycle.
Health implies a continuous adaptation to
stress
 Described nursing as a helping profession that
assists individuals and groups in society to
attain, maintain and restore health. If this is not
possible, nurses help individuals to die with
dignity.
 Viewed nursing as an interaction between the
client and the nurse whereby perceiving,
setting goals and acting on them, transaction
occurs and goals are achieved.
Faye Glenn Abdellah (1960)
Patient-Centered Approaches to Nursing
 Purpose: To deliver nursing care for the whole
individual.
 Abdellah described nursing as a service to
people, families and society. The nurse helps
people, sick or well, to cope with their health
needs. In Abdellah’s model, nursing care
means providing information to the client or
doing something to the client with the goal of
meeting needs or alleviating an impairment.
View of components
 Person: The recipient of nursing care having
physical, emotional, and sociologic
 needs that may be overt or covert.
 Environment: Not clearly defined. Some discussion
indicates that client interact
 with their environment, of which the nurse is a
part.
 Health: Implicitly defined as a state when the
individual has no unmet needs and
 no anticipated or actual impairments.
 Nursing: Broadly grouped in “21 nursing
problems.”
21 NURSING PROBLEMS
1. To maintain good hygiene.
2. To promote optimal activity: exercise, rest, and
sleep.
3. To promote safety.
4. To maintain good body mechanics.
5. To facilitate the maintenance of supply of
oxygen.
6. To facilitate maintenance of nutrition.
7. To facilitate maintenance of elimination.
8. To facilitate the maintenance of fluid and
electrolytes balance.
9. To recognize the physiologic response of the
body to disease conditions.
10. To facilitate the maintenance of regulatory
mechanisms and functions.
11. To facilitate the maintenance of sensory
function.
12. To identify and accept positive and negative
expressions, feelings and reactions.
13. To identify and accept the interrelatedness of
emotions and illness.
14. To facilitate the maintenance of effective
verbal and non-verbal communication.
15. To promote the development of productive
interpersonal relationship.
16. To facilitate progress toward achievement of
personal spiritual goals.
17. To create and maintain a therapeutic
environment.
18. To facilitate awareness of self as an individual
with varying needs.
19. To accept the optimum possible goals.
20. To use community resources as an aid in
resolving problems arising from illness.
21. To understand the role of social problems as
influencing factors.
Betty Neuman (1972)
Health Care Systems Model
 Views client as an open system consisting of a
basic structure or central core of energy
resources (physiologic, psychologic,
sociocultural, developmental, & spiritual)
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 surrounded by lines of resistance that defends
client against stressors
 She asserted that nursing is a unique
profession in that it is concerned with all the
variables affecting an individual’s response to
stresses which are intra (within), inter
(between one or more people) and extra-
personal ( outside the individual) in nature.
 The concern of nursing is to prevent stress
invasion, to protect the client’s basic
structure and obtain or maintain maximum
level of wellness.
 The nurse helps the client, through primary,
secondary, and tertiary prevention modes, to
adjust to environmental stressors and
maintain client system stability.
Sister Callista Roy (1979)
Adaptation Model
 Focuses on the individual as a biopsychosocial
adaptive system. Both the individual & the
environment are sources of stimuli that require
modification to promote adaptation, an on-
going purposive response
 The individual receives inputs or stimuli from
both the self & the environment
 She contended that the person is an adaptive
system, function as a whole through
interdependence of its parts.
 The system consist of input, control process,
output and feedback.
 In addition, she advocated that all people have
certain needs which they endeavor to meet in
order to maintain integrity
 These needs are divided into four different
modes, the physiological, self concept, role
function, and interdependence.
 Accordingly Roy believed that adaptive human
behavior is directed toward an attempt to
maintain homeostasis or integrity of the
individual by conserving energy and promoting
the survival, growth, reproduction and mastery
of the human system.
Ida Jean Orlando (1961)
The Dynamic Nurse-Patient Relationship
 Three elements – Client behavior, nurse
reaction and nurse actions – compose the
nursing situation.
 Purpose: To interact with clients to meet
immediate needs by identifying client
behaviors, nurse’s reactions, and nursing
actions to take.
Views of Components
 Person: Unique individual behaving verbally
and nonverbally. Assumption is that
 individuals are at times able to meet their own
needs and at other times unable to do so.
 Health: Not defined. Assumption is that being
without emotional or physical
 discomfort and having a sense of well-being
contribute to a healthy state.
 Nursing: Professional nursing is conceptualized
as finding out and meeting the
 client’s immediate need for help. Medicine and
nursing are viewed as distinctly different.
 The concept of need is central to Orlando’s
theory, which focuses on clients and their
unmet needs. Orlando believed that the
purpose of nursing is to provide the assistance
that a client requires to meet his or her needs.
Virginia Henderson (1955)
Definition of Nursing
 Nursing as a discipline separate from medicine.
 Described nursing in relation to the client and
the client’s environment
 Concerned with both healthy and ill individuals
even when recovery may not be feasible
 Teaching and advocacy roles of the nurse
 The unique function of the nurse is to assist the
individual sick or well to perform his/her
activities contributing to health, its recovery, or
to a peaceful death, the client would perform, if
he had the necessary strength, will and
knowledge.
The 14 Fundamental Needs
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body waste
4. Moving and maintaining a desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal
range by adjusting clothing and modifying the
environment
8. Keeping the body clean and well groomed to
protect the integument.
9. Avoiding dangers in the environment and
avoiding injuring others.
10. Communicating with others in expressing
emotions, needs, fears, or opinions
11. Worshipping according to one’s faith
12. Working in a such way that one feels a sense of
accomplishment
13. Playing or participating in various forms of
recreation
14. Learning, discovering, or satisfying the
curiosity that leads to normal development and
health, and using available health facilities
Hildegard Peplau (1952)
Interpersonal Relations Model
 The use of a therapeutic relationship between
the nurse and the client.
 Nursing as a therapeutic, interpersonal process
which strives to develop a nurse-patient
relationship in which the nurse serves as a
resource person, counselor and surrogate.
The nurse-client relationship evolves four
phases:
Orientation
 The client seeks help
 The nurse assist the client to understand the
problem and the extent of the need for help.
Identification
 The client assumes a posture of dependence,
interdependence, or independence in relation
to the nurse.
 The nurse’s focus is to assure the person that
the nurse understands the interpersonal
meaning of the client’s situation.
Exploitation
 The client derives full value from what the
nurse offers through the relationship.
 The client uses available services based on
self-interest and needs.
 Power shifts from the nurse to the client.
Resolution
 Old needs and goals are put aside and new
ones adopted. Once older needs are resolved,
newer and more mature ones emerge.
Nurses’ Roles:
 Stranger
 Teacher
 Resource Person
 Surrogate
 Leader
 Counselor
 Martha Rogers
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Martha Rogers (1970)
Science of Unitary Human Beings
 Views person as an irreducible whole, the
whole being greater than the sum of its parts.
Whole is differentiated from holistic.
 States that the humans are dynamic energy
fields in continuous exchange with
environmental fields, both of which are infinite.
o Both human and environmental fields
are characterized by pattern, a
universe of open systems, and four
dimensionality.
 Considers man as a unitary human being co-
existing within the universe, views nursing
primarily as a science and is committed to
nursing research.
What is an unitary man? Unitary man:
 Is an irreducible, four-dimensional energy field
identified by pattern
 Manifests characteristics different from the
sum of parts
 Interacts continuously and creatively with the
environment
 Behaves as a totality
 As a sentient being, participates creatively in
change.
Nurses applying Roger’s theory in practice:
 focus on the person’s wholeness
 seek to promote symphonic interaction
between the two energy fields to strengthen
the coherence and integrity of the person
 coordinate the human field with the
rhythmicities of the environment field
 direct and redirect patterns of interaction
between the two energy fields to promote
maximum health potential.
Non-therapeutic touch:
 based on human energy fields
 affected by pain and illness
 can assess and feel the energy field and
manipulate it to enhance the healing process of
people who are ill or injured.
Dorothea Orem (1971)
General Theory of Nursing
 Emphasizes the client’s self-care needs,
nursing care becomes necessary when client is
unable to fulfill biological, psychological,
developmental or social needs.
Three related concepts
 Self-care
 Self-care deficit
 Nursing systems
Self-care theory is based on four concepts:
 Self-care – activities an individual performs
independently to promote and maintain
personal well-being.
 Self-care agency – individual’s ability to
perform self-care activities. Consists of two
agents
 A self care agent – an individual who
performs self-care independently
 A dependent care agent – a person other
than the individual who provides the care
 Self – care requisites (self-care needs) –
actions or measures taken to provide
care. There are three categories:
o Universal requisites – includes:
Intake and elimination of air, water
and food; balancing rest, solitude,
and social interaction; preventing
hazards to life and well-being; and
promoting normal human
functioning.
o Developmental requisites – results
from maturation or are associated
with conditions and events.
o Health deviation requisites – result
from illness, injury or disease or its
treatment. (eg. Seeking health
care assistance, carrying out
prescribed therapies, and learning
to live with the effects of illness or
treatment)
 Therapeutic self- care demand – all self-care
activities required to meet existing self-care
requisites. ( Actions to maintain health and
well-being Self-care deficit results when self-
care agency is not adequate to meet the known
self-care demand.)
5 Methods in helping:
 Acting or doing for
 Guiding
 Teaching
 Supporting
 Providing an environment that promotes
abilities to meet current demands
3 Types of Nursing Systems:
 Wholly compensatory systems are required
for individuals who are unable to control
and monitor their environment and process
information.
 Partly compensatory systems are designed
for individuals who are unable to perform
some, but not all, self-care activities
 Supportive-educative (developmental)
systems are designed for persons who
need to learn to perform self-care
measures and need assistance to do so.
Basic Conditioning Factors for Self-care Agency
and Therapeutic Self Care Demand:
 Age
 Gender
 Developmental state
 Sociocultural orientation
 Health State
 Family system factors
 Health care system factors
 Patterns of living
 Environmental factors
 Resource availability and adequacy
Basic Conditioning Factors for Nursing Agency
 Age
 Gender, race
 Physical and constitutional characteristics
 Health state
 Family/Community roles
 Nursing educational preparation
 Nursing experience
 Maturity/Status as a person
Jean Watson (1979)
Human Caring Theory
 Believes the practice of caring is central to
nursing: it is the unifying focus for practice
 Carative factors – nursing intervention related
to human care.
 Redefining nursing as a caring-healing health
model
10 Factors
1. Forming a humanistic-altruistic system of
values
2. Instilling faith and hope
3. Cultivating sensitivity to one’s self and others
4. Developing a helping-trust (human care)
relationship
5. Promoting and accepting the expression of
positive and negative feelings
6. Systematically using the scientific problem-
solving method for decision making.
7. Promoting interpersonal teaching-learning
8. Providing a supportive, protective, or corrective
mental, physical, socio-cultural, and spiritual
environment
9. Assisting with the gratification of human needs
10. Allowing for existential-phenomenologic forces
Watson’s Assumptions of Caring
 Human caring is not just an emotion, concern,
attitude or benevolent desire. Caring connotes
a personal response.
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  Caring is an intersubjective human process and
is the moral ideal of nursing.
 Caring can be effectively demonstrated only
interpersonally.
 Effective caring promotes health and individual
or family growth.
 Caring promotes health more than does curing.
 Caring responses accept a person not only as
they are now, but also for what the person may
become.
 A caring environment offers the development
of potential while allowing the person to choose
the best action for the self at a given point in
time.
 Caring occasions involve action and choice by
nurse and client. If the caring occasion is
transpersonal, the limits of openness expand,
as do human capacities.
 The most abstract characteristic of a caring
person is that the person is somehow
responsive to another person as a unique
individual, perceives the other’s feelings, and
sets one person apart from another.
 Human caring involves values, a will and a
commitment to care, knowledge, caring
actions, and consequences.
 The ideal and value of caring is a starting point,
a stance, and an attitude that has to become a
will, an intention, a commitment, and a
conscious judgment that manifests itself in
concrete acts.
THE NURSING PROCESS
 Systematic problem - solving approach toward
giving individualized nursing care.
STEPS:
 Assessment
 Nursing Diagnosis
 Planning
 Intervention
 Evaluation
ASSESSING PATIENT’S HEALTH STATUS
Assessment
 A systematic collection of subjective and
objective data with the goal of making a clinical
nursing judgment about an individual, family or
community.
 First phase of nursing process which involves
data collection, organization and validation.
Purpose of Nursing Assessment
 To establish the client-nurse relationship.
 To obtain information about the client’s health,
including physiologic, socio-cultural, cognitive,
developmental & spiritual aspects.
 To identify the client’s strength.
 To identify actual & potential problems.
 To establish a data base from w/c the
subsequent phases of the nursing process
evolve.
Methods used in Nursing Assessment
 Observation
 Interview
 Physical Examination
OBSERVATION
 To gather data by using the 5 senses
 Is a conscious deliberate skill that is developed
only through effort and with organized
approach
Observational Skills
 Vision - Overall appearance (body size, weight,
posture); signs of distress or discomfort; facial
& body gestures; skin color & lesions;
abnormalities of movement; non-verbal
demeanor
 Smell - Body or breath odors
 Hearing - Breath & heart sounds, bowel sounds,
ability to communicate, language spoken,
orientation to time person & place
 Touch - Skin temp, pulse rate, rhythm; muscle
strength;
INTERVIEW
 Planned communication or conversation
wherein its primary purpose is to gather data.
 This will give information, identify problems of
mutual concern, evaluate change, teach,
provide support, counseling & therapy
APPROACHES FOR INTERVIEW
Directive Interview
 Is a highly structured and elicits specific
information.
 The nurse establishes the purpose of the
interview & controls the interview by asking
closed type of questions
Nondirective Interview
 This is a rapport-building interview w/c allows
the client to control the purpose, subject
matter, and pacing of the interview.
 The nurse usually used an open-ended
questions
KINDS OF INTERVIEW QUESTIONS
Closed questions
 Used in directive interview, usually restrictive &
generally require only short answers giving
specific information. Thus, the amount of the
information gained is limited.
 Often begins with 4WH.
Open-ended questions
 Associated in nondirective interview.
 Allow the clients to elaborate, clarify &
illustrate their thoughts & feelings. (e.g. Why
did you come to the hospital tonight?; How did
you feel in that situation?)
Neutral question
 It is a question the client can answer without
direction or pressure from the nurse. (e.g., How
do you feel about that?; Why do you think you
had an operation?)
Leading question
 Directs the client’s answer. The phrasing of the
question suggests what answer is expected. (e.
g. You are stressed about the surgery
tomorrow, aren’t you?; You will take your
medicine, won’t you?)
POINTS TO REMENBER IN AN INTERVIEW
 Select a quiet private setting (time, place,
seating arrangement, distance).
 Choose terms carefully and avoid using jargon.
 Use appropriate body language.
 Confirm patient statements to avoid
misunderstanding.
 Use open-ended question.
COMMUNICATION STRATEGIES
a. Silence
 Moments of silence during the interview
encourage the pt. to continue talking &
give a nurse a chance to assess the clients
ability to organize thoughts.
b. Facilitation
 Facilitation encourages the pt. to continue
with his story. (e.g. “please continue”, “go
on” and “uh-huh)
c. Confirmation
 Ensures that both the nurses & the pt. are
on the same track. (e.g. If I understand you
correctly, you said…..)
d. Reflection
 Repeating something the pt. has just said
can help you obtain more specific
information.
e. Clarification
 is used when an information given is
vague. (e.g. client: I can’t stand this! Nurse
: What do you mean by I cant stand this?)
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 f. Summarization
 restating the information that the pt. gave
you. It ensures that the data collected is
accurate & complete.
g. Conclusion
 Signals the pt. that the nurse is ready to
conclude the interview. It provides the pt.
the opportunity to gather his thoughts and
make any pertinent final statements. (e.g.
nurse: I think I have all the information I
need now. Is there anything you would like
to add.)
NURSING HEALTH HISTORY
 One example of an interview.
 1st part of the assessment of the client’s health
status.
 Used to gather subjective data about the pt. &
explore the past & the present health
problems.
COMPONENTS OF THE NURSING HISTORY
Biographic data
 Includes the client’s name, address, age, sex,
telephone no., race, marital status, b-day,
occupation, religion, nationality.
Chief complaint or reason for visit
 The c/c should be recorded in the client’s own
words. (‘What is troubling you?”)
History of present illness
P-rovocative/Palliative
 ask the patient: what triggers & relieves the
symptom?
Q-uality or Quantity
 What the symptom feels like, look like?
 Are you having the symptom right now? If so ,
is it more or less severe than usual?
R-egion or Radiation
 Where in the body does the symptom occur?
 Does the symptom appear in other regions? If
so, where?
S-everity
 How severe is the symptom? How would you
rate it on a scale of 1-10, with 10 being the
most severe.
 Does the symptom seem to diminishing,
intensifying, or staying about the same?
T-iming
 When did the symptom begin?
 Was the onset sudden or gradual?
 How often does the symptom occur?
 How long does the symptom last?
Family History
 The family nursing history reveals risk factors
for certain diseases
 This information should include the ages of
siblings, parents & grandparents & their
current state of health or cause of death.
 Particular attention should be given to
disorders such as heart disease, cancer,
diabetes, hypertension, obesity, allergies,
arthritis , TB, jaundice, bleeding, ulcers,
migraine & alcoholism.
Review of systems (ROS)
 It’s a review of all health problems by body
system to prevent omission of data related to
the present illness and to discover any other
problems that might have been blessed.
 Head to Toe approach is used and often an
agency checklist is available.
Medical History
 Past and current medical problems such as
hypertension, diabetes, and back pain.
Typical question:
 Have you ever been hospitalized? When &
Why?
 What childhood illnesses did you have?
 Have you ever had a surgery? When & Why?
Lifestyle
 Personal Habits – the frequency of substance
used such as, alcohol, coffee, cola, tobacco,
illicit or recreational drugs.
 Diet & elimination– food allergies, special food
preparation, prescribed diet. Frequency of
bowel movement.
 Sleep/rest & exercise pattern
 Work & leisure – what he does for a living &
leisure time; hobbies.
 Religious observances
Psychosocial
 Find out how the pt. feels about himself, his
place in society & his relationship to others,
occupation, educational status &
responsibilities.
 e.g. how have you coped w/ medical or
emotional crises in the past?
 how adequate is the emotional support?
 do you have a health insurance?
 do you have a fixed income, extra money
for health care?
Gordon (1987)
 devised a theoretical framework for
assessment of a nursing client that allows
nurses to identify obvious as well as emerging
patterns of functioning. Using this framework
nurses screen their client for functional as
well as dysfunctional patterns .
 An early step in the development of nursing
diagnoses for a client is to do a general
assessment using some selected framework.
There are many nursing frameworks from
which to choose. Gordon's 11 Functional
Health Patterns is one that is useful for a
screening assessment.
Gordon’s Typology of 11 Functional Health Patterns
1. Health Perception and Health
Management
 Data collection is focused on the person's
perceived level of health and well-being,
and on practices for maintaining health.
Habits that may be detrimental to health
are also evaluated, including smoking and
alcohol or drug use. Actual or potential
problems related to safety and health
management may be identified as well as
needs for modifications in the home or
needs for continued care in the home.
2. Nutrition and Metabolism
 Assessment is focused on the pattern of
food and fluid consumption relative to
metabolic need. The adequacy of local
nutrient supplies is evaluated. Actual or
potential problems related to fluid balance,
tissue integrity, and host defenses may be
identified as well as problems with the
gastrointestinal system.
3. Elimination.
 Data collection is focused on excretory
patterns (bowel, bladder, skin). Excretory
problems such as incontinence,
constipation, diarrhea, and urinary
retention may be identified.
4. Activity and Exercise.
 Assessment is focused on the activities of
daily living requiring energy expenditure,
including self-care activities, exercise, and
leisure activities. The status of major body
systems involved with activity and
exercise is evaluated, including the
respiratory, cardiovascular, and
musculoskeletal systems.
5. Cognition and Perception.
 Assessment is focused on the ability to
comprehend and use information and on
the sensory functions. Data pertaining to
neurologic functions are collected to aid
this process. Sensory experiences such as
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 pain and altered sensory input may be
identified and further evaluated.
6. Sleep and Rest.
 Assessment is focused on the person's
sleep, rest, and relaxation practices.
Dysfunctional sleep patterns, fatigue, and
responses to sleep deprivation may be
identified.
7. Self-Perception and Self-Concept.
 Assessment is focused on the person's
attitudes toward self, including identity,
body image, and sense of self-worth. The
person's level of self-esteem and response
to threats to his or her self-concept may
be identified.
8. Roles and Relationships.
 Assessment is focused on the person's
roles in the world and relationships with
others. Satisfaction with roles, role strain,
or dysfunctional relationships may be
further evaluated.
9. Sexuality and Reproduction.
 Assessment is focused on the person's
satisfaction or dissatisfaction with
sexuality patterns and reproductive
functions. Concerns with sexuality may he
identified.
10. Coping and Stress Tolerance.
 Assessment is focused on the person's
perception of stress and on his or her
coping strategies Support systems are
evaluated, and symptoms of stress are
noted. The effectiveness of a person's
coping strategies in terms of stress
tolerance may be further evaluated.
11. Values and Belief.
 Assessment is focused on the person's
values and beliefs (including spiritual
beliefs), or on the goals that guide his or
her choices or decisions.
Types of data
Subjective data
 These can be gathered solely from the
patient’s own account. Includes the pt.
sensation, feelings, values, beliefs, attitudes &
perception towards health status & life
situation.
 Referred to as symptoms or covert data
 e.g. “I feel weak all over when I exert myself”,
“ I have a sharp pain on my chest”
Objective data
 Can be obtained through observation and
verifiable
 Referred as signs or overt data, these can be
seen, heard, felt or smelled
 Validates the subjective data
 e.g. B.P. 90/50, apical pulse 104, abdomen is
distended, skin is pale & diaphoretic.
PHYSICAL EXAMINATION
 It is a systematic data-collection method that
uses observational skills to detect health
problems. (cephalocaudal or body system
approach)
 Uses the following techniques:
 Inspection, Palpation, Percussion, Auscultation
(IPPA)
PURPOSE OF PHYSICAL ASSESMENT
 To obtain baseline data about the client’s
functional abilities.
 To supplement, confirm or refute the data
obtained in nursing history.
 To obtain data that will help the nurse establish
nursing dx. & plan the client’s care.
 To evaluate the physiologic outcomes of
healthcare & the progress of the client’s health
problem.
ASSESSMENT TOOLS
 Sphygmomanometer
 Cotton balls
 Gloves
 Visual acuity charts
 Ophthalmoscope
 Otoscope
 Penlight
 Percussion HammeR
 Safety pins
 Scale with height measurement
 Skin calipers
 Speculum
 Stethoscope
 Tape measure
 Thermometer
 Tuning fork
 Tongue depressor
NURSING DIAGNOSIS
 A clinical judgment about an individual, family
or community responses to actual or potential
health/life processes.
 Provides the basis for selection of nursing
intervention to achieve outcomes for which the
nurse is accountable.
 Diagnosing is a process which results to a
diagnostic statement.
 It is a statement of a client’s potential or actual
alteration of health status. It results from
analysis and synthesis.
 Purpose: To identify the client’s health care
needs and to prepare diagnostic statements.
NURSING DIAGNOSIS & MEDICAL DIAGNOSIS
Medical diagnosis
 describes a disease or pathology of specific
organs or body system
 Provide convenient means for communicating
treatment requirements
Nursing Diagnosis
 describes an actual, risk or wellness human
response to a health problem that nurses are
responsible for treating independently.
EXAMPLE:
 Medical Dx: Pneumonia
Nursing Dx: Ineffective airway clearance r/t
tracheobronchial secretions
 Medical Dx: Tonsillitis
Nursing Dx: Elevated body temperature related
to presence of pyrogens.
NURSING DIAGNOSIS TAXONOMY
Taxonomy
 Method for ordering complex information
 Classification system to provide structure for
nursing practice.
 Purpose: to provide vocabulary for classifying
phenomena in a discipline
Components of Nursing Dx
Diagnostic Label/Problem
 This describes the client’s health status clearly
and concisely in a few words.
 The name of the nursing diagnosis as listed in
the taxonomy
 E.g. Impaired mobility; activity intolerance
Descriptors
 words used to give additional meaning to a
nursing diagnosis. They describe changes in
condition, state of the client or some
qualification
 E.g. altered, impaired, decreased, ineffective,
acute, chronic, excessive, delayed
Related factors/Etiology
 describes the conditions, circumstances that
contribute to the problem. Terms used:
associated with, related to or contributing to.
Defining characteristics/Signs and symptoms
 observable cues that cluster as manifestation
of an actual or wellness nursing diagnosis.
Risk factors
 describe clinical cues in risk nursing diagnosis.
They are environmental, physiological,
psychological, genetic, or chemical factors that

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 increase the vulnerability of pt. leading to
unhealthful event.
Formulating Nursing Diagnosis
A. Collect Valid and pertinent data
B. Cluster the Data
C. Differentiate Nursing Dx from Collaborative
problems
D. Formulate Nursing Dx correctly select priority
diagnosis.
Use Nursing Diagnosis Decision Tree
Types of Nursing Diagnosis
Actual
 Describes a clinical judgment that the nurse
has validated because of the presence of major
defining characteristics.
 Ex. Ineffective Airway Clearance related to
excessive and tenacious secretions.
Risk
 Describes a clinical judgment that an
individual/group is more vulnerable to develop
the problem than others in the same or similar
situation
 Ex. Risk for Impaired Skin Integrity related to
immobility secondary to fractured hip.
Possible
 An option to indicate that some data are
present to confirm a diagnosis but are
insufficient as of this time.
 Ex. Possible Self Care Deficit related to
impaired ability to use left hand secondary to
presence of intravenous therapy.
Wellness
 Diagnostic statement that describes the human
response to level of wellness.
 From a specific level of wellness to a higher
level of wellness.
 Ex. Readiness for enhanced spiritual well being
Diagnostic Statements
One-Part
 Just the label or the problem
 Ex. Readiness for enhanced parenting
Two-Part
 Problem r/t to etiology or risk factors
 Ex. Risk for impaired skin integrity related to
immobility secondary to fractured hip
Three-Part
 Diagnostic label + contributing factors + signs
and symptoms.
 Ex. Anxiety related to unpredictable nature of
operative procedure as evidenced by
statements of: “Natatakot akong hindi
makahinga.”
Nursing Diagnosis
To use NANDA (2003 edition)
 Use the 2-part Diagnostic Statements
 Problem r/t etiology or risk factors +
secondary to
Don’ts
 Using medical diagnosis
o ex. Self care deficit related to stroke
 Self care deficit related to neuromuscular
impairment
 Relating the problem to an unchangeable
situation
o ex. paralysis
 Confusing etiology or s/sx for the problem
o ex. Post op lung congestion related to
bedrest
 Ineffective airway clearance related to
general weakness and immobility
 Use of procedure instead of a human
response
o ex. Catheter related to urinary retention
 Urinary retention related to perineal
swelling
 Lack of specificity
o ex. Constipation related to nutritional
imbalance
 Combining two nursing dx
o ex. Anxiety and fear related to separation
from parents
 Relating one nursing dx to another
o ex. Ineffective coping related to anxiety
 Use of judgmental / value laden language
o ex. Pain related to monetary gain
 Making assumptions
o ex. Risk for altered parenting related to
inexperience
 Writing a legally inadvisable statements
o ex. Impaired skin integrity related to not
being turned 2 hourly
PLANNING
 Involves determining beforehand the strategies
or course of actions to be taken before
implementation of nursing care.
 To be effective, involve the client and his family
in planning.
 Purpose: To identify the client’s goal and
appropriate nursing interventions.
1. Set priorities in collaboration with the
patient
 E.g. Lessened pain scale from 9 – 5
 ncrease weight from 110 lbs – 115 lbs
2. Set goals and objectives in collaboration
with the client. Short-term goal (STG) or
Long-term goal (LTG)
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time-framed
Example: STG
 At the end of 8 hrs of nursing interventions, the
patient’s temperature will be equal to or less
than 37.8 C per axilla.
 At the end of 4 hrs of nursing interventions, the
patient’s pain will be relieved if not lessened as
manifested by decrease in pain scale from 9-5
and presence of unguarded behavior.
Example: LTG
 After one week of nursing interventions, the
patient’s body temperature will remain under
normal range of =/> 37.8 C per axilla.
 After 2 weeks of nursing intervention, the
patient’s weight will increased from 110 lbs –
115 lbs.
IMPLEMENTATION
 Putting the nursing care plan into action
 Purpose: To carry out planned nursing
interventions to help the client attain goals
Requirements:
1. Knowledge
2. Technical skills
3. Communication Skills
STEPS:
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 1. Reassess the client
2. Set priorities
 ABC
 Maslow’s hierarchy of needs
3. Implement nursing interventions
4. Documentation

Implementing Nursing interventions

1. Assessment – for baseline data
 ex: Assess breath sounds, assess wt
2. Independent nursing interventions
 ex: Positioned pt to high-fowlers position
 Encouraged slow but deep breathing
 Instructed to small but frequent feeding
3. Dependent nursing interventions
 ex: Administered pain reliever as
ordered.
4. Interdependent nursing interventions
 ex: Secured specimen for urinalysis as
ordered
5. Psychosocial interventions
 ex: Encouraged verbalization of feelings
EVALUATION
 Assessing the client’s response to nursing
interventions and then comparing the response
to predetermined standards or outcome criteria.
 Purpose: To determine the extent to which goals
if nursing care have been achieved.
STEPS:
1. Collect data about client’s response
2. Compare the client’s response to outcome
criteria
3. Analyze the reasons for the outcomes
4. Modify care plan as needed.
Example:
 After 8 hours of nursing intervention, the
patient verbalizes relief of pain with Pain scale
from 9 – 5. Patient manifests relaxed and
unguarded behavior.
 After 8 hrs of nursing intervention, the pt’s
body temperature was 37.8 C per axilla.
Characteristics . . . . .
 Problem-oriented – it is comparable with
scientific problem solving approach
 Goal oriented
 Orderly, planned, step by step
 Open to accepting new information during its
application
 Interpersonal
 Permits creativity among nurses and clients in
devising ways to solve the health problems
 Cyclical
 Universal
Benefits for clients
 Quality of care
 Continuity of care
 Participation by the clients in their health care
Benefits 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