Nursing Process

SERIES OF PLANNED ACTIONS OR OPERATIONS DIRECTED

TOWARD A PARTICULAR RESULT OR GOAL.

A SYSTEMATIC, RATIONAL METHOD OF PLANNING AND

PROVIDING INDIVIDUALIZED NURSING CARE.
ITS PURPOSE IS TO IDENTIFY A CLIENT’S HEALTH STATUS,
ACTUAL OR POTENTIAL HEALTH CARE PROBLEMS OR NEEDS,
AND TO DELIVER SPECIFIC NURSING INTERVENTIONS TO
MEET THOSE NEEDS.
IT IS ALSO CYCLICAL. THAT IS, THE COMPONENTS OF THE
NURSING PROCESS FOLLOW A LOGICAL SEQUENCE, BUT MORE
THAN ONE COMPONENT MAYBE INVOLVED AT ANY ONE TIME.
 ASSESSMENT

COLLECTING, ORGANIZING, VALIDATING AND RECORDING

DATA ABOUT A CLIENT’S HEALTH STATUS. DATA ARE
OBTAINED FROM A VARIETY OF SOURCES AND ARE THE
BASIS FOR ACTIONS AND DECISIONS TAKEN IN
SUBSEQUENT PHASES. NO CONCLUSIONS ABOUT THE
DATA ARE DRAWN IN THIS PHASE.

DIAGNOSING
A PROCESS WHICH RESULTS IN A DIAGNOSTIC
STATEMENT OR NURSING DIAGNOSIS. IN THIS PHASE,
THE NURSE SORTS, CLUSTERS, AND ANALYZES THE DATA
AND ASKS, “WHAT ARE THE ACTUAL AND POTENTIAL
HEALTH PROBLEMS FOR WHICH THE CLIENT NEEDS
NURSING ASSISTANCE?” AND “WHAT FACTORS
CONTRIBUTED TO THIS PROBLEM?” RESPONSES TO THOSE
QUESTIONS ESTABLISH THE NURSING DIAGNOSES.
 PLANNING
A SERIES OF STEPS IN WHICH THE NURSE AND THE
CLIENT SET PRIORITIES AND GOALS OR EXPECTED
OUTCOMES TO RESOLVE OR MINIMIZE THE IDENTIFIED
PROBLEMS OF THE CLIENT. IN COLLABORATION WITH
THE CLIENT, THE NURSE DEVELOPS SPECIFIC
INTERVENTIONS FOR EACH NURSING DIAGNOSIS. THE
PRODUCT OF PLANNING PHASE IS A WRITTEN CARE PLAN
USED TO COORDINATE THE CARE PROVIDED BY ALL THE
HEALTH TEAM MEMBERS.

IMPLEMENTING
PUTTING THE NURSING CARE PLAN INTO ACTION.
DURING THE IMPLEMENTATION PHASE, THE NURSE
CARRIES OUT PRESCRIBED NURSING ACTIVITIES OR
DELEGATES THE CARE TO AN APPROPRIATE PERSON, AND
VALIDATES THE NURSING CARE PLAN. THIS PHASE ENDS
WHEN THE NURSE RECORDS THE CARE GIVEN AND THE
CLIENT’S RESPONSES TO CARE IN THE CLIENT RECORD.
 EVALUATING

ASSESSING THE CLIENT’S RESPONSE TO NURSING

INTERVENTIONS AND THEN COMPARING THE RESPONSE
TO THE GOALS OR OUTCOME CRITERIA WRITTEN IN THE
PLANNING PHASE. THE NURSE DETERMINES THE EXTENT
TO WHICH THE OUTCOMES/ GOALS OF CARE HAVE BEEN
ACHIEVED. THE CARE PLAN IS REASSESSED IN THIS
PHASE, WHICH MAY INVOLVE CHANGES IN ANY OR ALL
OF THE PREVIOUS PHASES OF THE NURSING PROCESS.
 ASSESSING
EACH PHASE
DEPENDS ON THE
DIAGNOSING
ACCURACY OF
THE PRECEDING
PHASE.
EVALUATING
PLANNING
INVOLVES
EXAMINATION OF
ALL PREVIOUS
PHASES.
IMPLEMENTING

EVALUATION
 The system is open and flexible to meet the unique
needs of the client, family, group or community.
It is cyclic and dynamic. Because all steps are
interrelated, there is no absolute beginning or end.

It is client centered; it individualizes the approach to

each client’s particular needs.

It is interpersonal and collaborative. It requires the nurse

to communicate directly and consistently with clients to
meet their needs.
 It is planned.

It is goal directed.

It permits creativity for the nurse and client in devising

ways to solve the stated health problem.

It emphasizes feedback, which leads either to

reassessment of the problem or to revision of the care
plan.
It is universally applicable. The nursing process is used
as a framework for nursing care in all types of health
care settings, with clients of all age groups.
TO ESTABLISH A DATABASE ABOUT THE ESTABLISH A DATABASE
CLIENT’S RESPONSE TO HEALTH * OBTAIN HEALTH HISTORY
CONCERNS OR ILLNESS AND THE
ABILTY TO MANAGE HEALTH CARE * CONDUCT PHYSICAL ASSESSMENT
NEEDS * REVIEW CLIENT RECORDS
* REVIEW LITERATUIRE
* CONSULT SUPPORT PERSONS
* CONSULT HEALTH PROFESSIONALS

UPDATE DATA AS NEEDED

ORGANIZE DATA
VALIDATE DATA
COMMUNICATE/DOCUMENT DATA
OBSERVATION EXAMINING

INTERVIEWING
 Gathering data using
the five senses… OBSERVATION

INTERVIEWING Planned communication or conversation

with a purpose to identify problems of
mutual concern…

Physical examination is a
systematic data-collection
method that uses
EXAMINING
observational skills to detect
the health problems…
Gathering information about a client’s
health status. It must be both
systematic and continuous to prevent
the omission of significant data and
reflect a client’s changing health
status.
SUBJECTIVE DATA
Data belong under subjective if…
The patient or family member tells the history.
The patient or family member tells about lifestyle or home
situation.
The patient or family member tells emotions or attitudes.
The patient states his or her goals.
The patient voices a complaint.
The patient reports a response to treatment.

It is anything that the patient tells which is relevant to his case

or present condition.
OBJECTIVE DATA
Data belong under objective if…
It is part of the patient’s history taken from medical record and
relevant to the current problem.

Hx: ASHD, CHF, COPD, S/P fx L Hip ĉ prosthesis insertion

It is a result of the therapist’s objective measurements or

observations.
AROM: WNL throughout UEs & LEs except 120° L
shoulder flexion noted

It is part of the treatment given to a patient.

Tolerated 3 repetitions of ROM exercises of UEs & LEs
Types of data: SUBJECTIVE DATA OBJECTIVE DATA

SUBJECTIVE OBJECTIVE
“ I feel pain at my right BP – 90/50
knee.”
Apical Pulse – 104
Skin pale and diaphoretic

“ I have difficulty Lung sounds are diminished in the

breathing.” left lower lobe of the lung
RR – 25/min
Leans forward
Sources of data:

Primary data: patient

Secondary data: support people, other health

professionals, records and reports,
literature
 Using an organized assessment
framework, often referred to as a
nursing history or nursing assessment.
FRAMEWORKS
NURSING CONCEPTUAL MODELS
WELLNESS MODELS
NONNURSING MODELS
 NURSING CONCEPTUAL MODELS

HEALTH PERCEPTION-HEALTH MANAGEMENT

PATTERN. Describes client’s perceived pattern of
health and well-being and how health is managed.

NUTRITIONAL-METABOLIC PATTERN. Describes

PATTERN OF FOOD AND FLUID CONSUMPTION
RELATIVE TO METABOLIC NEED AND
PATTERN INDICATORS OF LOCAL NUTRIENT
SUPPLY.
ELIMINATION PATTERN. Describes patterns of
excretory function (bowel, bladder, skin)

ACTIVITY-EXERCISE PATTERN. Describes pattern

of exercise, activity leisure, and recreation

COGNITIVE-PERCEPTUAL PATTERN. Describes

sensory- perceptual and cognitive pattern.
SLEEP-REST PATTERN. Describes patterns of sleep,
rest and relaxation.
SELF-PERCEPTION-SELF-CONCEPT PATTERN.
Describes self-concept pattern and perceptions of self
(eg, body comfort. Body image, feeling state).

ROLE RELATIONSHIP PATTERN. Describes the

pattern of role-engagements and relationships.
SEXUALITY-REPRODUCTIVE PATTERN. Describes
client’s patterns of satisfaction and dissatisfaction with
sexuality; describes reproductive patterns.

COPING-STRESS-TOLERANCE PATTERN. Describes

general coping pattern and effectiveness of the pattern
in terms of stress tolerance.
VALUE-BELIEF PATTERN. Describes patterns of
values, beliefs (including spiritual), or goals that guide
choices or decisions.
 Universal Self-Care Deficits

1. The Maintenance of a sufficient intake of air.

2. The Maintenance of a sufficient intake of water.

3. The Maintenance of a sufficient intake of food.

4. The Provision of care associated with elimination
processes and increments.
5. The Maintenance of a balance between activity and rest.

6. The Maintenance of a balance between solitude and social

interaction
7. The prevention of hazards to human life, human
functioning, and human well-being.

8. The promotion of human functioning and development within

social groups in accord with human potential, known human
limitations, and human desire to be normal.
 WELLNESS MODELS

GENERALLY INCLUDES:

^^^ HEALTH HISTORY^^^

^^^ PHYSICAL FITNESS EVALUATION^^^
^^^ NUTRITIONAL ASSESSMENT^^^
^^^ LIFE-STRESS ANALYSIS^^^
^^^ LIFE-STYLE AND HEALTH HABITS^^^
^^^ HEALTH BELIEFS^^^
^^^ SEXUAL HEALTH^^^
^^^ SPIRITUAL HEALTH^^^
^^^ RELATIONSHIPS^^^
^^^ HEALTH RISKS APPRAISALS^^^
 NONNURSING MODELS

BODY SYSTEMS MODEL

MASLOW’S HIERARCHY OF NEEDS

DEVELOPMENTAL THEORIES
1. Physiologic Needs

* Activity and rest

* Nutrition
* Elimination
* Fluid and Electrolytes
* Oxygenation
* Protection
* Regulation: temperature
* Regulation: the senses
* Regulation: endocrine system
2. Self-concept
* Physical Self
* Personal Self

3. Role Function

4. Interdependence
Act of “double-checking” or verifying
data (cues) to confirm that they are
accurate and factual.
 Data are documented in factual
manner and are not interpreted by the
nurse.
TO IDENTIFY CLIENT STRENGTHS AND INTERPRET & ANALYZE DATA
HEALTH PROBLEMS THAT CAN BE
* COMPARE DATA AGAINST STANDARDS
PREVENTED OR RESOLVED BY
COLLABORATIVE AND INDEPENDENT * CLUSTER OR GROUP DATA
NURSING INTERVENTIONS
* IDENTIFY GAPS AND INCONSISTENCIES

TO DEVELOP A LISTING OF NURSING

DETERMINE CLIENT’S STRENGTHS, RISKS AND
DIAGNOSES AND COLLABORATIVE
PROBLEMS
PROBLEMS

FORMULATE NURSING DIAGNOSIS AND

COLLABORATIVE PROBLEM STATEMENTS
 A CLINICAL JUDGEMENT ABOUT
INDIVIDUAL, FAMILY OR COMMUNITY
RESPONSES TO ACTUAL AND
POTENTIAL HEALTH PROBLEMS/LIFE
PROCESSES.

IT PROVIDES THE BASIS FOR

SELECTION OF NURSING
INTERVENTIONS TO ACHIEVE
OUTCOMES FOR WHICH THE NURSE IS
ACCOUNTABLE.
STATEMENT OF NURSING JUDGMENT AND REFERS TO
A CONDITION THAT NURSES ARE LICENSED TO
TREAT; DECRIBES A CLIENT’S PHYSICAL,
SOCIOCULTURAL, PSYCHOLOGIC AND SPIRITUAL
RESPONSES TO AN ILLNESS OR POTENTIAL HEALTH
PROBLEM.

MADE BY THE PHYSICIAN AND REFERS TO A

CONDITION ONLY A PHYSICIAN CAN TREAT; REFERS
TO DISEASE PROCESSES THAT ARE FAIRLY UNIFORM
FROM ONE CLIENT TO ANOTHER.
PROBLEM STATEMENT (DIAGNOSTIC LABEL)

ETIOLOGY (RELATED FACTORS & RISK FACTORS)

DEFINING CHARACTERISTICS
1. PROBLEM (P) --- STATEMENT OF THE CLIENT’S
RESPONSES
2. ETIOLOGY (E) --- FACTORS CONTRIBUTING TO OR
PROBABLE CAUSES OF THE RESPONSE

3. SIGNS & SYMPTOMS (S) --- DEFINING

CHARACTERISTICS MANIFESTED BY THE CLIENT

P E
“Activity Intolerance / related to / prolonged
S
bed rest / as manifested by / body weakness
and fatigue”
“Alteration in comfort, pain / associated
with / abdominal incision / as
manifested by / muscle guarding and
grimace”
“Altered thermoregulation, / related to
infection / as manifested by / high
grade fever and excessive perspiration”
TO DEVELOP AN INDIVIDUALIZED CARE SET PRIORITIES AND GOALS/OUTCOMES IN
PLAN THAT SPECIFIES CLIENT COLLABORATION WITH THE CLIENT
GOALS/EXPECTED OUTCOMES AND
WRITE GOALS/OUTCOME CRITERIA
RELATED NURSING INTERVENTIONS
SELECT NURSING STRATEGIES/INTERVENTIONS
CONSULT OTHER HEALTH PROFESSIONALS
WRITE NURSING ORDERS AND NURSING CARE
PLAN
COMMUNICATE CARE PLAN TO RELEVANT
HEALTH CARE PROVIDERS
TO ASSIST THE CLIENT TO MEET REASSESS THE CLIENT TO UPDATE THE
DESIRED GOALS/OUTCOMES, PROMOTE DATABASE
HEALTH AND WELLNESS; PREVENT
DETERMINE THE NEED FOR NURSING
ILLNESS AND DISEASE; AND FACILITATE
ASSISTANCE
COPING WITH HEALTH PROBLEMS.
PERFORM OR DELEGATE PLANNED NURSING
INTERVENTIONS
COMMUNICATE NURSING ACTIONS
IMPLEMENTED
* DOCUMENT CARE AND CLIENT RESPONSES
TO CARE
* GIVE VERBAL REPORTS AS NECESSARY
TO DETERMINE THE EXTENT TO WHICH COLLABORATE WITH THE CLIENT AND COLLECT
CLIENT GOALS/OUTCOMES HAVE BEEN DATA RELATED TO EXPECTED OUTCOMES
ACHIEVED AND TO DETERMINE
JUDGE WHETHER GOALS/OUTCOMES HAVE
WHETHER TO CONTINUE, MODIFY OR
BEEN ACHIEVED
TERMINATE THE PLAN OF CARE
RELATE NURSING ACTIONS TO CLIENT
OUTCOMES
MAKE DECISIONS ABOUT PROBLEM STATUS
REVIEW AND MODIFY THE CARE PLAN AS
INDICATED OR TERMINATE NURSING CARE
 CUES NURSING RATIONALE EXPECTED
DIAGNOSIS OUTCOME

(Subjective (Using
NANDA list) (JUSTIFIES THE USE OF (S.M.A.R.T. GOALS
and objective
THE NURSING DIAGNOSIS) OF CARE)
cues)

INTERVENTION/ RATIONALE EVALUATION

IMPLEMENTATION

(PRIORITIZED) (JUSTIFIES THE USE OF (EXAMINES THE

THE NURSING DIAGNOSIS) PREVIOUS PHASES)
 CUES NURSING RATIONALE EXPECTED INTERVE RATIONA EVALUATI
DIAGNOS OUTCOMES NTIONS LE ON
IS
Subjective: Altered Invasion of the At the end of 8 •Perform TSB lowers Afebrile –
thermoreg body by the hours nursing TSB down body 37.6°C
“I have been
ulation Corona virus intervention, temperatur
feeling so compromised the the patient will e
related to Ate two full
weak and body’s immune be able to:
infection •Give small meals, no
exhausted system as it •Gradually
frequent leftovers
for the last attacks the •Have lowered increasing
respiratory feedings,
four days” temp to 37 - then the intake
system. The body Was able to
• Decreased 37.5°C gradually will
attempts to get rid take a bath,
•Eat at least 3 increase promote move around
appetite; of these
tolerance of
microorganisms times during
have eaten the day in foods
by releasing Appeared
only small pyrogens causing satisfactory
•Encourage
amounts cheerful and
•Fluidshelp
amounts the elevation of increased conversant
body temperature •Resume lower down
during meal fluid intake
ADL’s body
time temperatur
e
Objective:
Temp = 38 •Loosen •Promoting
°C clothings airflow
•Pulse = assist in
85/min lowering
body
temperatur
e
 CUES NURSING RATIONALE EXPECTED INTERVE RATIONA EVALUATI
DIAGNOSIS OUTCOMES NTIONS LE ON

•Provide * Isolation
• flushed
ventilation prevents
face
but kept on spread of
• diaphoretic isolation the virus
• teary-eyed thereby
minimizing
contaminati
on
Thank you!