Nursing Process

“To you, O Lord, I lift up

my soul. In you, I trust ,
Oh my God.”
Psalm 25:1
 NURSING PROCESS

• systematic, rational method of

planning and providing individualized
nursing care
• Is a problem-solving framework for
planning and delivering nursing care
to patients and their families
NURSING PROCESS
 NURSING PROCESS
• A way of thinking as a nurse.
• A framework of interrelated activities
resulting in competent nursing care.
• Dynamic and cyclical in nature.
• A scientific, problem-oriented
approach to patient care.
 Assessing –
collecting, organizing and communicating /
recording client data
Purpose: to establish data base
about the client’s response to
health concerns or illness and
the ability to manage health care
needs
 Assessment
Activities:
• Obtain health hx
• Perform P.A.
• Review records, e.g. lab records,
other health care records
• Interview support persons
• Review literature
• Validate assessment data
Nursing Process
 Assessment

Assessment (Data
Collection)
= Observation +
Interview +
Examination
Observation
Interview
Examination
 Data Collection – process of
gathering information about the
client’s health status
TYPES OF DATA :
• Subjective – symptoms or covert
data
e.g. – itching pain, feelings of worry
• includes client’s sensations, feelings,
values, beliefs, attitudes and
perception of personal health status
and life situations.
Problem : Fever  subjective cue:
“Mainit ang pakiramdam ko.”
 Assessment

“Let me look at that.”

“Tell me about it.”
 Types of Data
• Objective data –signs or
overt data; detectable by an
observer or can be tested
against an accepted standard
• e.g. – discoloration of the
skin
• Problem: fever-objective cue
: skin is warm to touch;
temp. is 38.9 C/ax
 Objective data
Caput medusae BP reading
 SOURCES OF DATA:

• Primary
source -
client (best
source of
data)
 SOURCES OF DATA:
• Secondary sources –
indirect sources
e.g. – family members,
-support people,
-client records
(medical records,
records of therapies by
other health
professionals and
laboratory records),
-health care
professionals,
 METHODS OF DATA
COLLECTION:
• Observing 
using the five
senses; a
conscious
deliberate skill
that is
developed only
through effort
and with an
organized
approach
 METHODS OF DATA
COLLECTION
• Interview 
a planned
communicati
on or
conversation
with a
purpose
Interview
Interview
2 approaches: • b.
• a. direct nondirective 
interview  highly the nurse allows
structured and the client to control
elicit specific the purpose,
information by subject matter and
asking closed pacing
questions that
call for a specific Requirement:
amount of data. RAPPORT - the
understanding between
two or more people.
 Kinds of interview questions:
• Closed • Open-ended
questions  questions 
restrictive and lead or invite
generally clients to
require only explore their
short answers thoughts or
giving specific feelings
information;
often begin with
when, where,
who, what, do,
does, did
 PLANNING THE INTERVIEW AND
SETTING:
• Time  need to be scheduled when the client is comfortable and free of
pain
• Place  must have adequate privacy to promote communication
• Seating arrangement
• Distance  most people feel comfortable 3 to 4 ft apart during an interview
 STAGES OF AN INTERVIEW:
• Opening  sets the tone of the remainder of
the interview.
a.1. Establish rapport  process of creating
good will and trust
a.2 Orientation  explaining the purpose and
nature of the interview
• Body  client communicates what he or she
thinks, feels, knows and perceives in response
to questions from the nurse
• Closing  important in facilitating future
interactions.
 ASSESSMENT TOOLS:
GORDON’S FUNCTIONAL HEALTH
PATTERN FRAMEWORK

• pattern -signifies a sequence

of recurring behavior
• dysfunctional as well as
functional behavior
• to discern emerging patterns.
TYPOLOGY OF 11 FUNCTIONAL
HEALTH PATTERNS:
1.Health – perception – health –
management – pattern:
• describes client’s perceived pattern
of health and well-being and how
health is managed
• How does the person describe her/
• his current health?
• What does the person do to improve or
maintain her/ his health?
 1.Health – perception – health –
management – pattern:
• What does the person know about links
between lifestyle choices and health?
• How big a problem is financing health care
for this person?
• Can this person report the names of current
medications she/he is taking and their
purpose?
 1.Health – perception –
health – management –
pattern:
• If this person has • Have there
allergies, what
does s/he do to been any
prevent important
problems?
illnesses or
• What does this
person know injuries in this
about medical person's life?
problems in the
family?
1.Health – perception – health – management –
pattern: Nsg. Dx

• Ineffective health
maintenance
• Ineffective therapeutic
regimen management
• Ineffective family therapeutic
regimen management
• Ineffective community
therapeutic regimen
management
1.Health – perception – health – management – pattern:

Nsg. Dx
• Risk for infection
• Risk for injury (trauma)
• Risk for falls
TYPOLOGY OF 11 FUNCTIONAL HEALTH
PATTERNS:
2.Nutritional – metabolic
pattern:
• pattern of food and fluid
consumption relative to metabolic
need and pattern indicators of local
nutrient supply
• Is the person well nourished?
• How do the person's food choices
compare with recommended food intake?
 2.Nutritional – metabolic pattern:
Nsg. Dx
• Imbalanced nutrition: more than
body requirements
• Risk for imbalanced nutrition:
more than body requirements
• Imbalanced nutrition: less than
body requirements
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
3.Elimination – pattern:
• describes pattern of excretory
function ( bowel, bladder and skin)
• Are the person's excretory functions
within the normal range?
• Does the person have any disease of
the digestive system, urinary system or
skin?
 3.Elimination – pattern:
Nsg. Dx
• Constipation
• Diarrhea
• Risk for constipation
• Bowel incontinence
• Impaired urinary elimination
• Functional urinary incontinence
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
4.Activity – exercise pattern
:
• describes pattern of exercise,
activity, leisure and recreation
• How does the person describe
her/ his weekly pattern of activity
and leisure, exercise and
recreation?
• Does the person have any disease
that affects her/ his cardio-
 4. Activity – exercise
pattern :
Nsg. Dx
• Activity intolerance
• Risk for activity intolerance
• Fatigue
• Deficient diversonal activity
• Impaired physical mobility
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
5.Cognitive – perceptual pattern :
• describes sensory perceptual and
cognitive pattern
-make a quick neurological assessment
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
6.Sleep – rest pattern:
• describes patterns of sleep, rest and
relaxation
• Descri bes person' s sle ep -wak e
cycl e.
• Does this person appear physically
rested and relaxed?
 6.Sleep – rest pattern:
Nsg. Dx
• Disturbed sleep pattern
7.Self – perception – self –
concept – pattern:
• describes self-concept pattern and
perceptions of self (body comfort, body
image, feeling state)
• Is there anything unusual about this person's
appearance?
• Does this person seem comfortable with her/ his
appearance?
• Describe person's feeling state
 7.Self – perception – self – concept
– pattern:
Nsg. Dx
• Fear • Situational low self-esteem
• Anxiety • Risk for situational low self-
• Risk for loneliness esteem
• Hopelessness • Chronic low self-esteem
• Powerlessness • Body image disturbed
• Risk for • Disturbed personal identity
powerlessness • Risk for violence, self-
directed
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
8.Role – relationship
pattern :
• describes patterns of role
engagements and relationships
• How does this person describe her/ his
various roles in life?
• Has, or does this person now have positive
role models for these roles?
 8.Role – relationship
pattern :
• Which relationships are most
important to this person at
present?
• Is this person currently going
though any big changes in role
or relationship? What are
they?
 8.Role – relationship
pattern :
Nsg. Dx
• Anticipatory grieving
• Dysfunctional grieving
• Risk for dysfunctional
grieving
• Ineffective role performance
• Social isolation
• Impaired social interaction
• Relocation stress syndrome
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
9.Sexuality – reproductive
pattern:
• describes client’s patterns of
satisfaction and dissatisfaction
with sexuality; describes
reproductive pattern
• Do you have regular menstruation?
• When was the last sexual
intercourse?
• Sexual activities?
 9.Sexuality – reproductive pattern:
Nsg. Dx
• Sexual dysfunction
• Rape-trauma syndrome
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
10.Coping – stress –
tolerance – pattern:
• describes general coping pattern and
effectiveness of the pattern in terms of
stress tolerance
• How does this person usually cope with
problems?
• Do these actions help or make things worse?
• Has this person had any treatment for
emotional distress?
10.Coping – stress – tolerance – pattern:
Nsg. Dx.
• Ineffective coping
• Disabled family coping
• Ineffective community coping
• Post-trauma syndrome
• Risk for post-trauma syndrome
• Risk for suicide
 TYPOLOGY OF 11
FUNCTIONAL HEALTH
PATTERNS:
11. Value – belief pattern:
• describes patterns of values, beliefs
or goals that guide choices or
decisions

• E.g reads bible everyday

 REVIEW OF SYSTEMS

goal : to gather data from the client in each

of the major body systems.

• General Health. Weight loss, weakness,

feelings of fatigue, mood changes, night
sweats, or bleeding tendencies?
 REVIEW OF SYSTEMS
Skin.
• Skin diseases such as eczema, psoriasis,
• acne; change in pigmentation;
• tendency toward bruising;
• excessive dryness or moisture; jaundice;
• itching, rashes, hives;
• change in color or size of moles;
• or open sores that are slow to heal?
• Hair. Itchy scalp, loss of hair, excessive body
hair? Does the client wear a wig?
 Nails. color changes, biting, clubbing, splitting?
 REVIEW OF SYSTEMS
Head
• Frequent or severe headaches,
• fainting,
• dizziness,
• accident resulting in unconsciousness
 REVIEW OF SYSTEMS
Eyes.
Difficulty seeing,
eye infection, eye pain, excessive tearing,
double vision, blurring, sensitivity to light,
cataracts, itching, spots in front of eyes?
• Does the client wear glasses (for near or
far vision) or contact lenses?
• When was the client’s last eye
examination?
 REVIEW OF SYSTEMS
Ears
• Any infection,
• loss of hearing, pain, discharge, ringing in the
ears?
• Does the client wear a hearing aid?

 Nose.
Frequent colds,
nosebleeds,
allergies, pain,
tenderness,
postnasal drip?
 REVIEW OF SYSTEMS
• Mouth and throat.
• Sore gums; bleeding gums; sores, lumps
or white spots on the mouth, lips or
tongue;
• toothaches, cavities,
• difficulty swallowing;
• voice change or hoarseness?
• Does the client wear dentures (upper,
lower, partial)?
• When was the client’s last dental
appointment?
 REVIEW OF SYSTEMS
Neck.
Pain, swelling, stiffness, limited movements,
swollen glands?

Breasts.
Nipple discharge, Scaling or cracks around
nipples, dimples, lumps,
• pattern of self breast examination?
• Last mammogram?
 REVIEW OF SYSTEMS
Respiratory system.
• Chest pain; cough; shortness of breath;
wheezing; coughing up blood;
• lung disease such as tuberculosis, emphysema,
asthma, bronchitis?
• Has the client ever had a chest x-ray? When?
Results?
 REVIEW OF SYSTEMS
Cardiovascular system.
• Heart disease,
• palpitations, heart murmur,
• high blood pressure,
• anemia,
• varicose veins,
• leg swelling or ulcer?
 REVIEW OF SYSTEMS
Gastrointestinal system.
• Nausea, vomiting, loss of appetite,
indigestion,
• heartburn,
• bright blood in stools,
• diarrhea, constipation,
• abdominal pain; excessive gas,
• hemorrhoids, rectal pain,
• colostomy, ileostomy?
 REVIEW OF SYSTEMS
Genitourinary system.
Frequency, dribbling, urgency,
urination at night,
difficulty starting stream,
blood in urine,
incontinence,
pain or burning upon urination, urinary tract
infection,
sexually transmitted disease such as
gonorrhea or syphilis?
 REVIEW OF SYSTEMS
Females:
• Age of menarche, last menstrual period
(LMP),
• duration, amount of flow, regulatory of
cycle?
• Any problems with painful menstruation,
bleeding within periods,
• pain during intercourse,
• vaginal discharge, vaginal itching, vaginal
infection?
 REVIEW OF SYSTEMS
Males:
• Penile discharge,
• swelling, masses or lesions,
• difficulty in sexual functioning?
 REVIEW OF SYSTEMS
Musculoskeletal system:
• Muscular pain,
• swelling or weakness;
• joint swelling,
• soreness, or stiffness;
• leg cramps;
• bone defects?
 REVIEW OF SYSTEMS
Neurologic system:
• Difficulty of walking;
• unconsciousness;
• seizures;
• tremors;
• paralysis; numbness, tingling; or burning
sensations in any body part;
• weakness on one side of body; speech
problems; unclear thinking; changes in
emotional state?
 REVIEW OF SYSTEMS
• Endocrine system:
• History of goiter;
• heat or cold;
• intolerance;
• diabetes;
• excessive thirst;
• excessive eating?
 NURSING DIAGNOSIS :
• statement of the client’s health status
• clinical judgment about individual, family or
community responses to actual and potential
health problems / life processes.
Purpose: Provides the basis for selections of
nursing interventions to achieve outcomes for
w/c the nurse is accountable
 NURSING DIAGNOSIS :

Eg.
• Problem : Fever 
nursing diagnosis :
Alteration in
thermoregulatory
function: or
hyperthermia related
to inflammatory
process
 TYPES OF NURSING DIAGNOSES:
• Actual Nursing Diagnosis  a judgment
about the client’s response to a health
problem w/c is present at the time of nursing
assessment
• Potential Nursing Diagnosis  a judgment
that a client is more vulnerable to develop the
problem in the same / similar situation
• Problem Statement  describes the
client’s health problem or response for
which nursing therapy is given
• Qualifiers  added words to give
additional meaning to the diagnostic
statement
• Altered  change from baseline
• Impaired  made worse, weakened,
damaged
• Decreased  smaller in size, amount or
degree
• Ineffective  not producing the desired
effect
• Acute  severe or of short duration
• Chronic  lasting a long time
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES

1.Using medical diagnosis

–INCORRECT: Self-care deficit related
to stroke
–CORRECT: Self-care deficit related to
neuromuscular impairment
2.Relating the problem to an
unchangeable situation
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES
1. Confusing the etiology or
signs/symptoms for the
problem
– INCORRECT: Post-operative
lung congestion related to bed
rest
– CORRECT: Ineffective airway
clearance related to general
weakness and immobility
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES

1. Use of a procedure instead

of a human response
– INCORRECT:
Catheterization related to
urinary retention
– CORRECT: Urinary retention
related to perineal swelling
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES
1. Lack of specificity
• INCORRECT: Constipation
related to nutritional intake
• CORRECT: Constipation related
to inadequate dietary bulk and
fluid intake
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES

1. Combining two nursing diagnosis

• INCORRECT: Anxiety and fear
related to separation from
parents
• CORRECT: Anxiety related to
change in environment and
unmet needs
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES

1. Relating one nursing diagnosis to

another
• INCORRECT: Coping, individual
ineffective related to anxiety
• CORRECT: Anxiety, severe related
to change in role functioning and
socio-economic status
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES

• Use of judgmental/value-laden
language
• Ineffective airway clearance related to
bad habit
 COMMON ERRORS IN FORMULATING
NURSING DIAGNOSES
• Making assumptions
• INCORRECT: Risk for altered
parenting related to inexperience
• CORRECT: Deficient knowledge
regarding child care issues
related to lack of previous
experience, unfamiliarity with
resources
1. Writing a Legally Inadvisable
Statement
• INCORRECT: Skin integrity
related to not being turned every
2 hours
• CORRECT: Impaired skin
integrity related to pressure and
altered circulation
 A Nursing Diagnosis
• Is • Is Not
– A statement of a – A medical diagnosis
patient problem – A nursing action
– Actual or – A physician order
potential – A therapeutic
treatment
– Within the scope
of nursing
practice
– Directive of
nursing
 Medical Dx vs.Nursing
Diagnosis
• Myocardial infarction • Fear r/t possible recurrence
of uncertain outcome
• Chronic ulcerative colitis • Diarrhea r/t dis. process
• Alteration in nutrition: less
• Chronic ulcerative colitis than body requirements r/t
altered GI absorptions
• Risk for(Potential) body
image disturbance if
• Cancer of the breast mastectomy is required

• Self-care deficit: dressing &

• Cerebral vascular grooming r/t right sided
accident flaccidity
Etiology (Related/ Risk Factors)  the
probable cause of the health problem; may
include client’s behavior, environmental
factors or the interaction of the two;
NANDA-“ related to” to describe the etiology
or likely cause
Example:
• Activity intolerance related to decreased
cardiac output.
• Ineffective breast-feeding related to first-
time experience
• Altered bowel elimination; constipation
related to insufficient fluid intake.
• Medical Diagnosis  made by a
physician refers to a
pathophysiologic responses that
are fairly uniform from one client to
another.

• Nursing Diagnosis  describes the

clients’ physical, sociocultural,
psychologic and spiritual
responses to an illness or potential
health problems; vary among
individuals.
 Nursing diagnosis
Actual nursing diagnoses
PES approach
= Problem + Etiology + S/S
• Impaired verbal communication r/t
cultural differences as manifested by
inability to speak English
 Nursing diagnosis
Potential nursing diagnosis
PRF approach (risk factor)
• Potential skin breakdown r/t physical
immobilization in total body cast
• Potential fluid volume deficit r/t
diarrhea, age 3 yrs., low oral intake,
elevated temperature
 PLANNING
• involves decision making and problem solving
Planning process includes:
A.Setting priorities  establishing a preferential order
for nursing strategies ; the nurse must consider a
variety of factors :
1.Client’s health values and beliefs  a client may
believe that being home with children is more urgent
than a health problem.
2.Client’s priorities  involving the client enhances
cooperation between nurse and client
3.Urgency of health problems  ABC’s of life (airway,
breathing, circulation)
4.Medical treatment plan  must be congruent with
treatment of other health care professionals
 PLANNING
should be S-M-A-R-T (specific, measurable,
attainable, realistic and time-bound)

• Example:
• Problem : Fever  subjective cues : “Mainit ang
pakiramdam ko.”
• objective cues : skin is warm to
touch; temp. is 38.9 C
•  nursing diagnosis : Alteration in
thermoregulatory function: hyperthermia related to
inflammatory process
•  plan : After 4 hours of
continuous nursing intervention, patient’s
temperature will decrease from 38.9 C to
37.5C/ ax.
 PLANNING

Planning
= setting priorities + establishing
goals + planning interventions
 PLANNING
B. Establish Goals
Components of a goal statement
Goal statement
= pt behavior + criteria of performance +
Time + conditions (if needed)
 Components of a goal statement
• PATIENT BEHAVIOR
- an observable activity that the
patient will demonstrate
– (the patient) will void
– Decrease in ( the patient’s) BP
– (the patient) will ambulate
– (the patient) will report
– (the patient) will drink
 Components of a goal
statement
• TIME FRAME
- a designated time or date when the
patient should be able to achieve the
behavior
– Within the next hour
– By discharge
– At the end of this shift
– By Dec. 25
– In 2 months
 Components of a goal statement
• CONDITIONS
- specific aides which will facilitate the patient
performing a behavior at the level in the criteria
and within the specified time frame
– With the help of a walker
– With the use of a wheelchair
– With the help of the family
– With the use of medication
– Using oral analgesics q3-4 hrs
– Using IM Demerol q3-4 hrs
 Planning Process
C. Planning Interventions
• render continuous tepid sponge bath
• loosen tight and thick clothing
• increase fluid intake
• keep room well ventilated
• administer antipyretics as
indicated/ordered
 IMPLEM EN TATIO N /
INTERVEN TI ON
 implement the
interventions identified
in the plan of care.
• Cognitive/Intellectual
Skills  include
problem solving,
decision making,
critical thinking and
creative thinking
 IM PL EME NT ATIO N / INT ER VENT ION
• Interpersonal skills
 activities use
when
communicating
directly with one
another; include
verbal and nonverbal
activities; necessary
for caring,
comforting, referring,
counseling and
supporting clients;
 IM PL EME NT ATIO N / INT ER VENT ION
• Technical
/psychomotor skills 
‘hands-on’ skills
such as manipulating
equipment, giving
injections and
bandaging, moving,
lifting, and repositioning
clients; require
knowledge and
frequently manual
dexterity.
 The process of implementing:
1.Reassessing the client 
reassess whether the intervention is
still needed
Note:
even though an order is written on the
care plan, the situation or the client’s
condition may have changed.
The process of implementing:
2.Determining the need for
nursing assistance  the
nurse maybe unable to
implement the nursing strategies
safely alone
The process of implementing:
3.Implementing nursing
strategies  nursing activities
include caring, communicating,
helping, teaching, counseling,
acting as a client advocate and
change agent, leading and
managing.
The process of implementing
4.Communicating nursing
actions  recording the
interventions along with the
client responses in the
nursing progress notes.
 TYPES OF NURSING ACTIONS:
• Independent Nursing Actions  an activity
that the nurse initiates as a result of the nurse’s
own knowledge and skills
• Dependent nursing actions  activities
carried out on the order of the physician, under
the physician’s supervision or according to
specified routines
• Collaborative nursing actions  activities
performed either jointly with another member of
the health care team or as a result of a joint
decision by the nurse and another health care
team member
• Problem : Fever  subjective cues : “Mainit
ang pakiramdam ko.”
• objective cues : skin is
warm to touch; temp. is 38.9 C
 nursing diagnosis : Alteration in
thermoregulatory function: hyperthermia
related to inflammatory process
 plan : After 4 hours of continuous nursing
intervention, patient’s temperature will
decrease from 38.9 C to 37.5C.
 Intervention
• continuous tepid sponge bath
rendered
• tight and thick clothing loosened
• fluid intake increased
• room kept well ventilated
• antipyretics as indicated/ordered
administered
 EVALUATION
• The evaluation process has 6 components:
• Identifying the expected outcomes that the
nurse will use to measure client goal
achievement
• Collecting data related to the expected
outcomes
• Comparing the data with the expected
outcomes and judging whether the goals have
been achieved
• Relating nursing actions to client outcomes
• Drawing conclusions about problem status
• Reviewing and modifying the client’s care plan
• determine client’s progress toward goal
achievement and the effectiveness of NCP
• EVALUATION STATEMENT consist
of 2 parts : a conclusion and a
supporting data
• Example : Goal met : After 4 hours of
continuous nursing intervention,
temperature decreased from 38.9 to
37.4 C/ax