CANOSSA COLLEGE

College of Nursing

A Self Learning Module on Related Learning Experience

Focus: Nursing Process

MODULE 1

Course Code: NCM 109

Level Offering: 2nd Semester, SY 2021 -2022
Clinical Area of Assignment: Skills Lab
Date: February 4-5, 2022, 6am-2pm
Topics:
• Nursing process
• Phases of Nursing Process
• Nursing Care Plan

Module Overview:

This module is designed to assess your understanding about the component

parts of the nursing process. It will show you how the cyclical nature of the
process encourages you to critically think, problem solve, and make
decisions about patient care. It focuses on the caring component of nursing
and the importance of developing good psychomotor and intellectual skills
in order to meet client’s need.

Nursing Process

The cornerstone of the nursing profession is nursing process. Skill in

utilizing the nursing process is essential for the clinical application of
knowledge and theory in nursing practice.
Nursing process is synonymous with the problem – solving approach for
discovering the healthcare and nursing care needs of clients. Therefore,
through the nursing process, nursing was able to build its own scientific
body of knowledge. This elevated Nursing from a vocation into a profession.
The nursing process is client centered. That means you will need to
individualize what you do for one client, that is, the one client with whom
working at that particular time. You will need to read about things that
should be done for clients with particular problems. But even if your client
has the same problem, you may not be able to use this information in its
solution. There may be developments in the client situation that prohibit
its use. To put it briefly, the nursing process is a tool that you, the nursing
student. will use to systematically analyze client care data, make
inferences, and draw conclusions about existing problems, and determine
what you can do about them. It is cyclical and sequential in that it includes
assessment, which leads to nosing, outcome identification/planning,

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implementing, evaluating, and revision. It shows to stop a process when the
problem is solved (goals are met), and how rework the entire cycle when the
problem is not solved (goals are not met).

The nursing process also provides you with an organized way of collecting
and analyzing information about clients. It will guide you through specific
and alternate ways of meeting client needs. It involves several elements
that are crucial to effective nursing care. The processes of critical
thinking, decision making, and problem-solving help you work through the
phase the nursing process.

Phases of Nursing Process

Assessment

Evaluation Diagnosis
Individual
Family
Community

Outcome
Implementation Identification
and Planning

Five Phases of the Nursing Process (ADPIE)

The nursing process consists of the following phases: assessment, diagnosis

outcome identification/planning, prioritizing, implementation, evaluation,
revision of the plan of care, and recording the plan. The nursing process is
a dynamic structure that guides nursing care.
Assessment
Assessment is the first part of the nursing process. It is the data
collection aspect. When the client enters the health-care setting, you
begin this assessment because in some way it is conveyed to you that a
problem exists. You collect data from a variety of sources-client, family,
chart, and health-care team. This data provides information for all the
other parts of the nursing process. You will dissect this data and analyze it
in its entirety in order to arrive at the client's problem(s). This requires
in-depth thinking. You will put the puzzle together and arrive at what you
think is the nursing diagnosis that you then verify by standard defining
characteristics. Nursing diagnoses are those problems and needs that you

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find by examining (critically analyzing) the assessment data. An example of
a nursing diagnosis is "constipation."

Diagnosis
The diagnosis is the client's problem that you identify. You give it a name
selected from a list of diagnoses developed by the North American Nursing
Diagnosis Association (NANDA). Some nursing diagnoses are actual; that is,
the signs and symptoms are readily evident. Others are potential (the
treatment plan may cause the patient to develop new problems). You will
need to list all diagnoses in order to develop a plan to treat and a plan to
prevent. Some nursing diagnoses you will be able to treat following the
standard protocol. Others will require collaboration with other disciplines
and your instructor.

Planning
Planning consists of those things that you do to help the client now that
the diagnosis has been identified. You will do this by working on these
areas: goal setting, priority setting, identifying the nursing interventions,
developing plan of care, putting it all together, and reassessing the client
before implementing the plan of care. Always reassess the client before
performing actions you choose. Continue your assessment throughout the
process and report significant changes that might cause you not to do what
you originally intended. Once you have identified the problems, you ask
intuitively as would be appropriate for my client to accomplish?" From
your answer, you formulate your goals. An example of a goal that relates to
the identified diagnosis of constipation is, “The client will have a bowel
movement before noon on 02/04/2021.” There will be many goals. You will
need to decide which on needs first attention, so you prioritize.

Prioritizing
Prioritizing is putting the goals in order of urgency. You will number them
one through ten (for example) and you will deal with them in this order. The
tasks you perform in order to accomplish the goals are called nursing
interventions. You implement your nursing interventions.

Implementation
Implementation is putting the plan into action, that is, carrying out the
nursing interventions. These are what you said you would do in order to
create a change in the client's condition. Before you do this, however, you
are to determine if what you planned to do is still necessary. Remember
that so time will have passed since you developed your plan. It might be
just several minutes, but the situation might have changed within that
short time. For example, you might have diagnosed “Fluid Volume Deficit in
your client. Your plan might have been to measure urinary output every
hour from a Foley catheter and to give two ounces or 60 mL of water every
hour. Between the time you developed your plan and your implementation,
the physician writes an order to remove the Foley catheter. Your action
would now change to “measure each voided specimen, record time of voiding
and consistency of urine." You are to perform this continuous reassessment
(evaluation) throughout the implementation of the plan of care. Then, at the
end of your implementation phase, you are to perform your final evaluation.

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These "what to do” tasks for a specific problem in order to realize your
client's goal will be listed in your Nursing Care Plan Book. These are
nursing skills that you should practice before implementing. Remember to
seek help with these if you are uncertain.

Evaluation
During your evaluation you determine if your goals are met. You critically
analyze whether what you wanted to happen in this client's behalf has
actually taken place. Imagine the personal satisfaction for both you and
the client if it has. If it has not, don't be discouraged. Support the client,
analyze your formulas, and ask why it didn't work. Begin to gather more
data, use other resources, and ask your instructor or other experts for
help. Probably you need to formulate a new diagnosis. Regardless of what
you need to do, remember the plan is cyclical and continuous and continues
to be fun, demanding, and challenging. Good luck.

Revision of the Plan of Care

If the goals have not been met after the evaluation, then you may need to
collect new data, form a new nursing diagnosis, formulate new goals, use
new interventions, and reevaluate. Remember that nursing process is
cyclical. Consider if things have changed since you did your first
assessment. Do you have a new goal? Do you need to change your priorities?
For example, you had planned to sit your client up in a chair
for breakfast, as ordered by the physician. When you take the tray into the
room, your client is complaining of severe pain. The pain medication that
was given four hours earlier is no longer effective. You decide to give
another dose medication (according to the physician's order), and allow the
client to eat in bed until the pain subsides. You make a decision to sit the
client up about an hour later when he is more comfortable. Remember that
assessment is continuous throughout all of your activities. You should be
continuously asking if the planned goal is being realized. Do you need to do
something else? An overall evaluation follows your interventions.

Recording the Plan

Recording the plan will help you organize and will help others understand
your sequencing of events. The sequencing (documentation), for example,
can be done in six columns. Column one is the portion of the data that you
used to support your nursing diagnosis. Column two is your nursing
diagnosis, three is for goals, four for interventions, and column five is for
your rationale or scientific reason for using these interventions. Column
six will be saved for your evaluation. Record legibly so that it can be easily
read and understood.

RLE Learning Process

This module has 4 parts:

1. Desired Learning Outcome
2. Learning Activities

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3. Explore and Apply
4. Feedback

Desired Learning Outcome: at the end of 16-hour virtual learning exposure,

you are expected to:

1. Explain nursing process.

2. List and define the five steps of nursing process in sequence.
3. Describe the interrelatedness of each step.
4. Make a nursing care plan.

How will you be graded? Check what’s in the Box

Papers not turned in on or before the due date will lose one-half grade per
day late--no exceptions.

A Paper: This paper does not just fulfill the assignment; it also has
something original and important to say and the points it makes are
supported well. It is organized effectively, develops smoothly, and it is
written clearly and correctly. It is based on data, or a review of the
literature clearly related to the points it must make. The sources cited are
authoritative, current, and appropriate in scope and quantity.

B Paper: This paper fulfills the assignment well. Its general idea is clear,
and it is effectively presented. It handles its sources well, it reports on
adequate literature, but sources are not as authoritative or current as they
should be. Generally, the paper is correct in usage, appropriate in style,
and correct in mechanical standards of writing citation.

C Paper: This paper is adequate to fulfill the assignment, but it might be

better described as an annotated bibliography. Points may be hard to
follow, and the paper may be poorly organized (e.g., unbroken narrative with
no headings or clear relationships; literature review that summarize
sources in sequence instead of synthesizing points supported by
references). Sources of information are poorly chosen.

D Paper. This paper meets only the minimum requirement of the assignment.
The paper may lack adequate focus and instead attempt to cover too broad a
topic. There may be serious error of fact or interpretation. Cited
information comes from no authoritative sources in this field. Citations
are incomplete or inaccurate or are formatted incorrectly.

F Paper: This paper does not fulfill the assignment. It may omit important
material lying within its declared scope or make repeated errors of fact or
interpretation.

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 Ms. Girlie

Meanwhile, you may write down some of your questions, comments in the box
provided. Before we proceed with Module 1, I want you to rest for 15
minutes and have some stretching after.

Learning Task 1

Problem Solving Using the Nursing Process

Directions:
Read the scenario below and provide answers to the following:
a. List all problem(s) (Subjective data and Objective data)
b. From the problem list, identify one priority nursing diagnosis.
c. Locate and write the definition of the nursing diagnosis.
d. What are related to and as evidenced by criteria?

1. Gregor Tan, 8 years old, was brought into the clinic by his mother. He
presented with multiple lesions on his face and extremities that
appeared to be erythematous, ulcerated, and moist, with honey-
colored crusts. Gregor reported that the lesions itched.
a. _______________________________________

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 b. _______________________________________
c. _______________________________________
d. _______________________________________

2. Rhonelee Flores, 40 years old, is waiting to see her OBGyne. She is in

her first trimester of pregnancy, experiencing the following
symptoms: discomfort when urinates, a sense of urgency, she is
urinating more frequently, however, voiding only small amounts or
urine. Her symptoms have lasted for more than one week and are
worsening.
a. _______________________________________
b. _______________________________________
c. _______________________________________
d. _______________________________________
Learning Task 2

Writing Diagnosis Statements

Instructions Read each case history and follow directions.
a. Highlight the abnormal subjective data in yellow and abnormal
objective data in blue.

b. Complete the three-part diagnostic statement that clearly describes

the nursing diagnosis. In other words, what is the R/T and AEB
information you will include with the nursing diagnosis?

1. Carla Jimenez was hospitalized yesterday. Today she demonstrates the

following signs and symptoms blood pressure 138/78, pulse rate 102
per minute and regular, respiratory rate 24 per minute and using
accessory muscles, restless, and irritable. Oral temperature is 99.8°F.
The pulse oximeter reading is 90%. Mrs. Jimenez is diaphoretic and
complains of a headache. Her lung sounds are clear but diminished.
She states he feels “light-headed” when she moves from her bed to the
chair.
a. __________________________________________________________________
b. __________________________________________________________________

2. Karlynn Magdayao returned from Jomalig, Quezon Province one week

ago. She has experienced nausea, vomiting and diarrhea for four days
and exhibits the following additional symptoms: inelastic skin
turgor, dry oral mucous membranes, weakness, and an elevated
temperature.
a. _________________________________________________________________
b. __________________________________________________________________

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Learning Task 3

Writing Goals

Read the case history and follow directions.

a. List all appropriate goal(s)and desired outcome.

1. Mrs. Cortez had abdominal surgery one day ago. she has a medical
history of diabetes mellitus and must take morning and evening
insulin subcutaneously. Her nurse identifies the nursing diagnosis:
Risk for Infection; R/T: inadequate primary defenses (surgical
incision/broken skin), increased environmental exposure, chronic
disease, invasive procedures.

Learning Task 4

Directions:
Read the scenario below and provide answers to the following:
1. Identify 1 nursing diagnosis.
2. Make a nursing care plan.
3. Submit and present in the group.

Rosa Rosales is a 34-year-old Ilocano woman with a 3-year history of type

2 diabetes. She was seen in her primary physician’s office because of a
missed menstrual period; a pregnancy test was positive.

Her past obstetrical history included five vaginal deliveries and six
miscarriages. All of her previous pregnancies occurred before the diagnosis
of diabetes. Her previous medical care was in Puerto Prinsesa, Palawan. She
was never told of any glucose problem during her pregnancies, and she does
not know the birth weights of her children. At the time of referral, she was
8 weeks pregnant and taking glyburide 10 mg twice daily. She was checking
her blood glucose once daily in the morning with typical readings between
180 and 220 mg/dl using glucometer. Family history was positive for
diabetes in her mother. Her height was 62 inches, and her weight was 198 lb.
Other than mild acanthosis nigricans and obesity, her physical examination
was normal. She had no retinopathy and no evidence of neuropathy. Her
glycosylated hemoglobin (HbA1c) level was 10.5%, and the capillary blood
glucose 4 h after lunch was 201 mg/dl.

She was started on insulin immediately and her glyburide was discontinued.
She began monitoring her glucose before and after each meal, making daily
adjustments in insulin. She received nutrition education with an
appropriate calorie intake plus an emphasis on frequent smaller meals and
limited carbohydrate intake. Within 1 week, her plasma glucose values were
ranging from 140 to 170 mg/dl, and in the following week she had a vaginal
bleeding and confined to the hospital with medical Diagnosis Mild Placenta
Previa.

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 1. Identify two nursing diagnosis.
2. Make a nursing care plan.
3. Submit and present in the group.

Nursing Care Plan:

Fill in the appropriate elements of the care plan for this client.

PLANNING

ASSESSMENT GOAL / EVALUATION

NURSING NURSING
DESIRED RATIONALE
DIAGNOSIS INTERVENTIONS
OUTCOME

Feedback: Before we moved on to the next module. I would gladly want to

listen to your feedback. Kindly rate each area with a scale of 1-5 as 1 as the
lowest and 5 as the highest.

Item 1 2 3 4 5

Comprehensive content

Relevance of the content

Clarity of test and message

Alignment of the assessment

activities to learning outcomes

Note: Please submit your work in Google Classroom 16 hours after duty. You
may use this document to insert your answers under each learning task.

You just finished Module 1.

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