Nursing Process

- a systematic, rational method of planning and providing individualized nursing care.

- Involves a lot of critical thinking and decision making.
- It is cyclical but it does not mean it needs to be in order. There are times we need to go
back to reassessment. We do assessment in every phase. At the end of the first cycle,
care may be terminated if goals are achieved
- more than one component may be involved at one time
Purposes:
➢ To identify a client’s health status and actual or potential health care problems or
needs.
Method of planning and providing individualized nursing care because not all clients are the
same.
➢ To establish plans to meet the identified needs .
Set goals and know what to implement to be able to achieve the goal to provide individualized
nursing care.
➢ To deliver specific nursing interventions to meet those needs. The client may be an
individual, a family, a community, or a group.
Nursing interventions are activities that a nurse does to provide care. Client may not only be an
individual, it can be a family, community or a group.

CHARACTERISTICS OF NURSING PROCESS:

- Cyclic and dynamic
Nursing process is different from one client to another that’s why it has to be customized.
- Client centeredness
Important component- client is the focus in the nursing process.
- Focus on problem solving and decision making
Nursing process is logical and rational. It involves problem solving and decision making. .
- Interpersonal and collaborative style
You cannot always do it alone. We also talk to patients and significant others. We build a
rapport. We will also need the help of our co-healthcare team.
- Universal applicability
Nursing process is not just focused on one target population, it can be an adult, a child, and an
elderly. We use this process to all age groups.
- Use of critical thinking and clinical reasoning (allows the nurse to reflect on the care
delivered throughout the phases of the nursing process.)
5 OVERLAPPING PHASES OF NURSING PROCESS: ADPIE
Each phase depends on the accuracy of the other phases. Each phase involves critical thinking.

1. Assessment
Involves active participation by the client and nurse and when assessing, the nurse uses critical
thinking and clinical reasoning when gathering subjective and objective data.
2. Diagnosing
Based the data collected on the nursing dx from NANDA International.
Examples of Critical Thinking:
Assessing:
Making reliable observations.
Distinguishing relevant from irrelevant data.
Distinguishing important from unimportant data.
Validating data.
Organizing data.
Categorizing data according to a framework.
Recognizing assumptions.
Identifying gaps in the data.

Diagnosing:
Finding patterns and relationships among cues.
Making inferences.
Suspending judgment when lacking data.
Stating the problem.
Examining assumptions.
Comparing patterns with norms.
Identifying factors contributing to the problem.

Planning:
Forming valid generalizations
Transferring knowledge from one situation to another.
Developing evaluative criteria.
Hypothesizing.
Making interdisciplinary connections.
Prioritizing client problems.
Generalizing principles from other sciences.

Implementing:
Applying knowledge to perform interventions.
Testing hypothesis.

Evaluating:
Deciding whether hypotheses are correct.
Making criterion-based evaluations.

ASSESSING: Collect, Organize, Validate and Document client data.

Purpose:
To establish a database about the client’s response to health concerns or illness and the ability
to manage health care needs.
Each client has a database as it serves as a bank of everything you have contained from your
client.
Activities of Assessing
 ● Establish a database:
Obtain a nursing health history.
Conduct a physical assessment.
Review client records.
Review nursing literature.
Consult support persons.
Consult health professionals.
● Update data as needed.
● Organize data.
● Validate data.
● Communicate/document data

DIAGNOSING: We already obtained data from collection, validation and documentation. Now
we will Analyze and Synthesize data.
Purpose:
To identify client strengths and health problems that can be prevented or resolved by
collaborative and independent nursing interventions and to develop a list of nursing and
collaborative problems.
Dependent Nursing Intervention that we cannot do on our own and needs to be directed
to us by a physician- Doctors Order

Activities of Diagnosing
● Interpret and analyze data:
Compare data against standards.
Cluster or group data (generate tentative hypotheses).
Identify gaps and inconsistencies.
● Determine client’s strengths, risks, and problems.
● Formulate nursing diagnoses and collaborative problem statements.
● Document nursing diagnoses on the care plan.

PLANNING: Determining how to prevent, reduce, or resolve the identified priority client
problems; how to support client strengths; and how to implement nursing interventions in an
organized, individualized, and goal-directed manner.
Purpose:
To develop an individualized care plan that specifies client goals/desired outcomes, and related
nursing interventions.

Activities of Planning
● Set priorities and goals/outcomes in collaboration with clients.
● Write goals/desired outcomes.
● Select nursing strategies/interventions.
● Consult other health professionals.
● Write nursing interventions and nursing care plans.
● Communicate care plans to relevant health care providers.
IMPLEMENTING: Carrying out (or delegating) and documenting the planned nursing
interventions.
You as a nurse will be the one responsible in doing the activities or interventions for your client.
Delegating- it involves asking for help from other members of the healthcare team such as your
fellow nurse. A nurse can ask an unlicensed nurse/personnel to help but ensure or check the
client’s identity by letting them state their complete name and birth date. There will be
accountability.
Purpose:
To assist the client to meet desired goals/ outcomes; promote wellness; prevent illness and
disease; restore health; and facilitate coping with altered functioning.

Activities of Implementing
● Reassess the client to update the database.
● Determine the nurse’s need for assistance.
● Perform planned nursing interventions.
● Communicate what nursing actions were implemented:
Document care and client responses to care.
Give verbal reports as necessary.

EVALUATING: Measuring the degree to which goals/outcomes have been achieved and
identifying factors that positively or negatively influence goal achievement.
Has the goal met? If not, we will need to reassess the client.
Purpose:
To determine whether to continue, modify, or terminate the plan of care.

Activities of Evaluating
● Collaborate with clients and collect data related to desired outcomes.
● Judge whether goals/outcomes have been achieved.
● Relate nursing actions to client goals/outcomes.
● Make decisions about problem status.
● Review and modify the care plan as indicated or terminate nursing care.
● Document achievement of outcomes and modification of the care plan.

ASSESSING:
- Systematic and continuous collection, organization, validation, and documentation of
data (information)
- Continuous process.
- All phases of the nursing process depend on the accurate and complete collection of
data.
Assessments vary according to their PURPOSE, TIMING, TIME AVAILABLE, and CLIENT
STATUS.
Four Different Types of Assessments

1. Initial Nursing Assessment

Performed within specified time after admission to a health care agency.
Purpose: To establish a complete database for problem identification, reference and future
comparison.
Examples: Nursing admission assessment.

2. Problem-Focused Assessment
Ongoing process integrated with nursing care.
Purpose: To determine the status of a specific problem identified in an earlier assessment.
Examples: Hourly assessment of client’s fluid intake and urinary output in an ICU.

3. Emergency Assessment
During any physiological or psychological crisis of the client.
Purpose: identity problems.
To identify life-threatening problems.
To identify new or overlooked problems.
Examples:
Rapid assessment of an individual’s airway, breathing status and circulation (ABC) during a
cardiac arrest.
Assessment of suicidal tendencies or potential for violence.

4. Time-Lapsed Assessment
Several months after initial assessment.
Purpose: To compare the client’s current status to baseline data previously obtained.
Examples: Reassessment of a client’s functional health patterns in a home care or outpatient
setting or, in a hospital, at shift change.

Nursing Assessment
➢ Nursing assessments focus on a client’s responses to a health problem.
➢ A nursing assessment should include:
Client’s perceived needs
Health problems
Related experience
Health practices
Values
Lifestyles

In 2008 The Joint Commission established a nursing practice guideline stating that each client
should have an initial nursing assessment consisting of a history and physical
examination performed and documented within 24 hours of admission as an inpatient.
- Nursing assessment should be completed and documented within 24 hours of admission
as an inpatient which includes the history and physical examination.
 - The RN also has the responsibility for developing the client’s plan of care.

ANA 2010 Revision:

The registered nurse is responsible for the collection of comprehensive data, including
physical, functional, psychosocial, emotional, cognitive , sexual , cultural , age - related ,
environmental, spiritual/transpersonal, and economic assessments.

Data Collection
➢ Process of gathering information about a client’s health status.
➢ Must be both systematic and continuous to prevent the omission (lack) of significant
data and reflect a client’s changing health status.

A DATABASE contains all the information about a client.

Includes:
Nursing health history
Physical assessment
Primary care provider’s history and physical examination
Results of laboratory and diagnostic tests, and materials contributed by other health personnel.
Client data should include:
Past history as well as current problems. The collection of data allows the nurse, client, and
health care team to identify health-related problems or risk factors that could cause changes in
a client’s health status.

Components of a Nursing Health History

1. Biographic data
2. Chief complaint or reason for visit
3. History of present illness
4. Past history
5. Family history of illness
6. Lifestyle
7. Social data
8. Psychological data
9. Patterns of Health Care

Biographic Data:
1. Client’s name
2. Address
3. Age
4. Sex
5. Marital status
6. Occupation
7. Religious preference
8. Health care financing
 9. Usual source of medical care - This is important to take note because not all patients are
self-paying, they don’t pay for their hospital bills because most of the patients have
private insurances. Sometimes there are certain procedures or equipment that we
nurses give to patients and we don’t know that the patient is not covered with health
insurance. So we have to be keen.

Chief Complaint or Reason for Visit:

“What is troubling you?”
“Describe the reason you came to the hospital or clinic today.”
The chief complaint should be recorded in the client’s own words. (verbatimly)
~ Avoid terms that client’s won’t understand.

History of Present Illness(HPI)- reasons why patient sought or health consultation.

Ex: Difficulty of breathing
● When the symptoms started
● Whether the onset of symptoms was sudden or gradual
● How often the problem occurs
● Exact location of the distress
● Character of the complaint (e.g., intensity of pain or quality of sputum, emesis, or
discharge) Activity in which the client was involved when the problem occurred
● Phenomena or symptoms associated with the chief complaint
● Factors that aggravate (pinapalala) or alleviate (pinapabuti) the problem

Past History
● Illnesses
● Immunizations and the date
● Allergies to drugs, animals, insects, or other environmental agents, the type of reaction
that occurs, and how the reaction is treated. (Red tags in patients usually indicates they
have allergies.)
● Accidents and injuries: how, when, and where the incident occurred, type of injury,
treatment received, and any complications
● Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery
performed, course of recovery, and any complications
● Medications: all currently used prescription, over-the-counter medications, such as
aspirin, nasal spray, vitamins, or laxatives, and herbal supplements

Family History of Illness

● To ascertain risk factors for certain diseases, the ages of siblings, parents, and
grandparents and their current state of health or, if they are deceased, the cause of
death are obtained.
● Particular attention should be given to disorders such as heart disease, cancer, diabetes,
hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and any
mental health disorders.
Lifestyle
● Personal habits: the amount, frequency, and duration of substance use (tobacco,
alcohol, coffee, cola, tea, and illegal or recreational drugs)
● Diet: description of a typical diet on a normal day or any special diet, number of meals
and snacks per day, who cooks and shops for food, ethnic food patterns, and allergies
● Sleep patterns: usual daily sleep/wake times, difficulties sleeping, and remedies used
for difficulties
● Activities of daily living (ADLs): any difficulties experienced in the basic activities of
eating, grooming, dressing, elimination, and locomotion
● Instrumental ADLs: any difficulties experienced in food preparation, shopping,
transportation, housekeeping, laundry, and ability to use the telephone, handle finances,
and manage medications. (these are other activities that are not basic and done by the
patient kumbaga EXTRA).
● Recreation/hobbies: exercise activity and tolerance, hobbies and other interests, and
vacations

Social Data- support system.

● Family relationships/friendships: the client’s support system in times of stress (who
helps in time of need?), what effect the client’s illness has on the family, and whether any
family problems are affecting the client
● Ethnic affiliation: health customs and beliefs; cultural practices that may affect health
care and recovery
● Educational history: data about the client’s highest level of education attained and any
past difficulties with learning
● Occupational history: current employment status, the number of days missed from
work because of illness, any history of accidents on the job, any occupational hazards
with a potential for future disease or accident, the client’s need to change jobs because
of past illness, the employment status of spouses or partners and the way child care is
handled, and the client’s overall satisfaction with the work
● Economic status: information about how the client is paying for medical care (including
what kind of medical and hospitalization coverage the client has) and whether the client’s
illness presents financial concerns
● Home and neighborhood conditions: home safety measures and adjustments in
physical facilities that may be required to help the client manage a physical disability,
activity intolerance, and activities of daily living; the availability of neighborhood and
community services to meet the client’s needs.

Psychological Data
● Major stressors experienced and the client’s perception of them
● Usual coping pattern for a serious problem or a high level of stress
● Communication style: ability to verbalize appropriate emotion; nonverbal
communication—such as eye movements, gestures, use of touch, and posture;
interactions with support persons; and the congruence of nonverbal behavior and verbal
expression.
Patterns of Health Care
● All health care resources that the client is currently using and has used in the past.
● These include the primary care provider, specialists, dentist, folk practitioners, health
clinic, or health center; whether the client considers the care being provided adequate;
and whether access to healthcare is a problem. (Sino sino na ba mga doctors ang
nakakita kay patient, they should also be noted).

TYPES OF DATA:

SUBJECTIVE DATA OBJECTIVE DATA

- Symptoms - Signs
- Covert data - Overt data
- Apparent only to the person affected - Detectable by an observer or can be
and can be described or verified measured or tested against an
only by that person accepted standard
Eg: Itching, pain, and feelings of worry, the - Can be seen, heard, felt, or smelled,
client’s sensations, feelings, values, beliefs, and they are obtained by observation
attitudes, and perception of personal health or physical examination
status and life situation. Eg: discoloration of the skin or a blood
pressure reading.

● During the physical examination, the nurse obtains objective data to validate
subjective data and to complete the assessment phase of the nursing process.
● Constant data is information that does not change over time such as race or blood
type.
● Variable data can change quickly, frequently, or rarely and include such data as blood
pressure, level of pain, and age.

Sources of Data:
➢ Client
- Best source of data.
- Provide subjective data that no one else can offer.
- Primary data consist of statements made by the client but also include those
objective data that can be directly obtained by the nurse from the client such as
gender.
- Remind them about data privacy so they won’t hesitate to provide data.
➢ Support People
- Family members, friends, and caregivers who know the client well often can
supplement or verify information provided by the client.
- Important source of subjective data for a client who is very young, unconscious,
or confused.
- Nurses should indicate on the nursing history that the data were obtained from a
support person.
 ➢ Client Records
- Include information documented by various health care professionals.
- Also contain data regarding the client’s occupation, religion, and marital status.
- Types of client records include medical records, records of therapies, and
laboratory records.
➢ Health Care Professionals
- Serve as other potential sources of information about a client’s health.
- Nurses, social workers, primary care providers, and physiotherapists, for
example, may have information from either previous or current contact with the
client.
- Sharing of information among professionals is especially important to
ensure continuity of care when clients are transferred to and from home and
health care agencies.
➢ Literature
- Standards or norms against which to compare findings (e.g., height and weight
tables, normal developmental tasks for an age group)
- Cultural and social health practices
- Spiritual beliefs
- Assessment data needed for specific client conditions
- Nursing interventions and evaluation criteria relevant to a client’s health problems
- Information about medical diagnoses, treatment, and prognoses
- Current methodologies and research findings.

Primary Data Collection Methods: Observing, Interviewing & Examining.

➢ Observing
- gather data by using the senses.
➢ Vision- overall appearance.
➢ Smell- body or breath odors.
➢ Hearing- lung and heart sounds, ability to communicate, health status,
etc.
➢ Touch- skin temperature and moisture, muscle strength (eg. hand grip),
pulse rate, palpable lesions, etc.
- Is a conscious, deliberate skill that is developed through effort and with an
organized approach.
- Has two aspects: (a) noticing the data and (b) selecting, organizing, and
interpreting the data.
- Involves distinguishing data in a meaningful manner.
- The experienced nurse is often able to attend to an intervention and at the
same time make important observations. The beginning student must learn to
make observations and complete tasks simultaneously.
- Most nurses develop a particular sequence for observing events, usually focusing
on the client first.
1. Clinical signs of client distress (e.g., pallor or flushing, labored
breathing, and behavior indicating pain or emotional distress)
 2. Threats to the client’s safety, real or anticipated (e.g., a lowered side
rail)
3. The presence and functioning of associated equipment (e.g.,
intravenous equipment and oxygen)
4. The immediate environment, including the people in it.
➢ Interviewing - health history
- a planned communication or a conversation with a purpose.
- Focused interview the nurse asks the client specific questions to collect
information related to the client’s problem. Allows the nurse to check for missed
information.
- Two Approaches:

Directive Non-directive

- Highly structured - Rapport-building interview .

- Elicits specific information - Nurse allows the client to
- Nurse establishes the purpose and controls control the purpose, subject
the interview matter, and pacing.
- Limited opportunity for clients to ask - Clients will feel more at ease,
questions or discuss concerns used in an free flowing.
emergency situation.

A combination of directive and nondirective approaches is usually appropriate during the

information-gathering interview.
- Types of Interview Questions
Closed- Ended Open- Ended

- - Directive interview - Non-directive interview

- Restrictive - Invite clients to discover, explore,
- “Yes” or “No” elaborate, clarify, and illustrate
- Short factual answers that provide thoughts/feelings
specific information - Invites answers longer than two
- “Who,” “When,” “Where,” “What,” words
“Do,” “Is” - “What” or “How”
- Used in emergency situation

Neutral Question Leading Question

- Client can answer without - Usually closed

direction or pressure from the - Used in directive interview
nurse - Directs the client’s answer
- Open-ended - Gives client less opportunity to
- Used in non-directive interviews decide whether the answer is true
“How do you feel about that?” or not
“What do you think led to the “You’re stressed about the surgery
operation?” tomorrow, aren’t you?” “You will take your
medicine, won’t you?”
Nurses often find it necessary to use a combination of closed and open-ended questions
throughout an interview to accomplish the goals of the interview and obtain needed information.

● Try to avoid asking “why” questions. These questions can be perceived as a form of
interrogation by the client.

Planning the interview and setting: balancing several factors encourage an effective
interview.
● Time
- Nurses need to plan interviews with clients when the client is physically
comfortable and free of pain.
● Place
- A well-lighted, well-ventilated room that is relatively free of noise, movements,
and distractions encourages communication.
● Seating Arrangement
DOs
- Nurse can sit at a 45-degree angle to the bed when the client is in bed.
- Overbed table between the client and the nurse during initial admission interview.
- Two chairs placed at right angles to a desk or a few feet apart with no table in
between.
- Horseshoe or circular chair arrangement.
 DON’Ts
- Standing and looking down at a client who is in bed or in a chair.
- Sitting behind a table or standing at the foot of the bed.
- Nurse behind a desk and the client seated across.

● Distance
- Distance between the interviewer and interviewee should be neither too small nor
too great, because people feel uncomfortable when talking to someone who is
too close or too far away.
- Proxemics is the study of the use of space.
- Most comfortable distance during the interview is 2 to 3 feet.
- Some clients require more or less personal space, depending on their cultural
and personal needs.
● Language
- Failure to communicate in language the client can understand is a form of
discrimination.
- The nurse must convert complicated medical terminology into common
English usage, and interpreters or translators are needed if the client and the
nurse do not speak the same language or dialect.
- Translating medical terminology is a specialized skill.

Stages of an Interview:
● Opening - Introduction
- Establish rapport (process of creating goodwill and trust) and orient the
interviewee.
● Body - Development of the interview.
- Client communicates what he or she thinks, feels, knows, and perceives in
response to questions from the nurse.
● Closing
- The nurse terminates the interview when the needed information has been
obtained. It is important for maintaining rapport and trust and for facilitating
future interactions.
- Following techniques commonly used to close an interview:
1. Offer to answer questions: “Do you have any questions?”“I would be
glad to answer any questions you have.” Be sure to allow time for the
person to answer, or the offer will be regarded as insincere.
2. Conclude by saying “Well, that’s all I need to know for now” or “Well,
those are all the questions I have for now.” Preceding a remark with the
word “well” generally signals that the end of the interaction is near.
3. Thank the client: “Thank you for your time and help. The questions you
have answered will be helpful in planning your nursing care.” You may
also shake the client’s hand.
4. Express concern for the person’s welfare and future: “I hope all goes
well for you.”
 5. Plan for the next meeting, if there is to be one, or state what will happen
next. Include the day, time, place, topic, and purpose.
6. Provide a summary to verify accuracy and agreement. Summarizing
serves several purposes: It helps to terminate the interview, it reassures
the client that the nurse has listened, it checks the accuracy of the nurse’s
perceptions, it clears the way for new ideas, and it helps the client to note
progress and a forward direction.
- Summaries are particularly helpful for clients who are anxious or
who have difficulty staying with the topic.

➢ Examining
- Physical examination or physical assessment is a systematic data collection
method that uses observation to detect health problems. It is carried out
systematically.
- Nurses use techniques of inspection, palpation, percussion and auscultation
(IPPA).
- Cephalocaudal or head-to-toe approach begins the examination at the head;
progresses to the neck, thorax, abdomen, and extremities; and ends at the toes.
- Use of body systems approach investigates each system individually.
- A screening examination, also called a review of systems, is a brief review of
essential functioning of various body parts or systems.
Organizing Data:
The nurse uses a written (or electronic) format that organizes the assessment data
systematically. (nursing health history, nursing assessment, or nursing database form.)

Non-nursing Models: are narrower than the model required in nursing; therefore, the nurse
usually needs to combine these with other approaches to obtain a complete history
➢ Body Systems Model
- focuses on abnormalities of the following anatomic systems.
➢ Maslow’s Hierarchy of Needs
- clusters data pertaining to Physiological needs (survival needs), Safety and
security needs, Love and belonging needs, Self-esteem needs, and
Self-actualization needs.
➢ Developmental Theories
- Physical, psychosocial, cognitive, and moral developmental theories may be
used by the nurse.
Conceptual Models/Framework
➢ Gordon’s 11 Functional Health Pattern Framework
The nurse collects data about dysfunctional as well as functional behavior.
Nurses are able to discern emerging patterns.

➢ Orem’s Self-Care Model

Eight universal self- care requisites of humans.
 ➢ Roy’s Adaptation Model
physiological, self concept, role function, and interdependence.

Wellness Models
- assist clients to identify health risks and to explore lifestyle habits and health
behaviors, beliefs, values, and attitudes that influence levels of wellness.

Validation is the act of “double-checking” or verifying data to confirm that it is accurate and
factual.

Validating data helps the nurse complete these tasks:

➢ Ensure that assessment information is complete.
➢ Ensure that objective and related subjective data agree.
➢ Obtain additional information that may have been overlooked.
➢ Differentiate between cues and inferences.
- Cues are subjective or objective data that can be directly observed Inferences
are the nurse’s interpretation or conclusions made based on the cues.
➢ Avoid jumping to conclusions and focusing in the wrong direction to identify problems.

Not all data require validation. For example, data such as height, weight, birth date, and most
laboratory studies that can be measured with an accurate scale can be accepted as factual.

Documenting Data:
● Accurate documentation is essential and should include all data collected about the
client’s health status.

● Data is recorded in a factual manner and not interpreted by the nurse.

● A judgment or conclusion such as “appetite good” or “normal appetite” may have

different meanings for different people.

● To increase accuracy, the nurse records the client's subjective data verbatimly using
quotation marks. Restating in other words what someone says increases the chance of
changing the original meaning.