NURSING PROCESS

 Organized and Systematic

 5 sequential and interrelated steps
 HUMANISTIC
 The plan of care is implemented with great consideration to the unique needs and
concerns of the individual client. It is individualized
 It is individualized
 It involves aspect of human dignity
 EFFICIENT
 Relevant to the needs of the client
 Promotes client satisfaction and progress
 EFFECTIVE
 Utilizes sources wisely in terms of human, time, and cost resources

THE HEART OF THE NURSING PROCESS

K — knowledge; S — skills; C - Caring

A. MANUAL B. INTELLECTUAL C. INTERPERSONAL
TECHNICAL CRITICAL THINKING TO ESTABLISH POSITIVE INTERPERSONAL
SKILLS RELATIONSHIPS, WITH CLIENT, CO-
WORKERS
• careful deliberate, goal-directed — (REQUIRES COMMUNICATION SKILLS)
to solve problems/make decisions
• check for evidence
• Keeping an open mind
• Avoid jumping into conclusions

I. The Nursing Process Overview

The nursing process is a continuous cycle centered around the client. It consists of the following
interconnected phases:
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation

II. Phase 1: Assessment

Definition: Collecting, validating, organizing, and recording data about the client’s health status
(individual, family, community).
Purpose: To establish a database.
Activities in Assessment:
 Collecting Data: Gathering information.
 Scope: Include physical, psychological, emotional, socio-cultural, and spiritual factors.
Types of Data:
 Subjective Data (Symptoms): Experienced by the client.
o Examples: Pain, dizziness.
 Objective Data (Signs): Those that can be observed and measured.
o Examples: Pallor, diaphoresis, blood pressure, reddish urine, body temperature.
Methods & Sources:
 Methods:
o Interview: Planned purposeful conversation.
o Observation: Use of senses, lab results interpretation, and physical examination.
 Sources:
o Primary: Patient / Client.
o Secondary: Family members, S.O. (Significant Other), patient’s chart/record, health team
members, related literature.
 Management:
o Verifying/Validating: Ensure information is accurate.

III. Phase 2: Diagnosing

Definition: A clinical act of identifying problems by analyzing assessment data and deriving meaning
from that analysis.
Purpose: To identify the client’s health care needs and prepare diagnostic statements.
Nursing Diagnosis:
 A statement of a client’s potential or actual alteration of health status.
 Uses critical thinking and skills analysis.
Diagnostic Formats:
1. PRS Format: Problem, Related to factors, Signs and symptoms.
2. PES Format: Problem, Etiology, Signs and symptoms.
Components of a NANDA Diagnosis:
 Problem (Diagnostic Label): Describes the client's health status clearly in a few words.
o Qualifiers: Deficient (inadequate), Impaired (made worse/weakened), Ineffective (not
producing desired effect).
 Etiology (Related & Risk Factors): Identifies probable causes and gives direction to health
needs.
 Defining Characteristics: A cluster of signs and symptoms.
o Actual DX: Based on signs and symptoms.
o High Risk/Risk: Factors that make the client more vulnerable to the problem.
IV. Clinical Examples
Activities During Diagnosing:
 Data Clustering: Grouping data (e.g., Pallor, dyspnea, weakness, fatigue = oxygenation
problems).
 Comparison: Checking data against accepted norms (e.g., Amber, clear urine VS cloudy or tea-
colored urine).
 Analysis: Identifying gaps/inconsistencies and determining health risks/strengths.
Nursing Diagnosis Examples:
 Anxiety related to insufficient knowledge regarding surgical experience.
Ineffective airway clearance related to tracheobronchial infection as manifested by weak cough,
adventitious breath sounds, and copious green sputum production.

V. PHASE 3: PLANNING
 Definition: Determining beforehand the strategies or course of action to be taken before
implementation.
 Key Aspects: Involves the client and family; begins at first contact until discharge.
 The Nursing Care Plan: A written summary of care; the "blueprint" of the nursing process.
Requires sufficient data and at least one goal for each nursing diagnosis.
Types of Planning
 Initial Planning: Starts upon admission.
 Ongoing Planning: Done by all nurses to determine changes in status, set daily priorities, and plan
shift activities.
 Discharge Planning: Anticipating needs after discharge (referrals, medications, diet, health
teachings).

VI. PHASE 4: IMPLEMENTATION

 Definition: Putting the nursing care plan into action.
 Purpose: To carry out interventions to help the client attain goals and optimal health.
 Activities:
o Set priorities for interventions.
o Perform nursing interventions.
o Record actions: SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT
DONE!!!.
VII. PHASE 5: EVALUATION
 Definition: Assessing the client’s response to interventions and comparing them to predetermined
standards or outcome criteria.
 Purpose: To appraise the extent to which goals and outcome criteria have been achieved.
 Activities:
o Collect data on client response.
o Compare response to goals.
o Assess if goals are met (partially/completely) or unmet.
o Analyze reasons for outcomes and modify the care plan as needed.