NURSING PROCESS

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

-refers to a series of phases describing the practice of nursing.

PURPOSES:
1. To identify client’s health status and actual or potential health care problems or needs.
2. To establish plans to meet the identified needs, and to
3. Deliver specific nursing intervention to meet those needs.

5 PHASES/ STEPS OF NURSING PROCESS (ADPIE)

1. A-SSESSMENT
2. D-IAGNOSIS/ ANALYSIS
3. P-LANNING
4. I- MPLEMENTATION/ INTERVENTION/ INTERVENING
5. E-VALUATION

CHARACTERISTICS OF NURSING PROCESS

A) KOZIER (C2 UFI U)
*C-yclic and Dynamic- each phase provide input into the next phase
>CYCLIC- regularly repeated events
>DYNAMIC- continuously changing
*C-lient centered- organize plan of care according to client’s problem
*U-niversally Applicable- used as framework for nursing care
*F-ocus on problem solving
*I- nterpersonal collaborative- communicate in client, families, etc.
*U-se of critical thinking- very important in nursing process

B) UDAN (GOSH EE)

*G-oal oriented
*O-rganized
*S-ystematic composed of sequential and interrelate steps
*H-umanistic- individualized plan of care
 EFFICIENT AND EFFECTIVE NURSING CARE

1. ASSESSMENT (COVD)
-collection, organization, validation and documentation of data.
-is a continuous process carried out during all phases of the nursing process.
* 4 TYPES OF ASSESSMENT (IPET)

TYPE TIME PURPOSE EXAMPLE

I-NITAL ASSESSMENT-after admission -complete database -nursing admission
assessment

P-ROBLEM FOCUSED-ongoing process -determine specific -hourly I&O in pt

problem status in ICU

E-MERGENCY –during physiologic/ -identify life -assess ABC

psychologic crisis threatening problems -suicidal tendencies

T-IME LAPSED-several months after -compare current -reassessment

initial assessment status to baseline data

a) C-ollection of Data
-gathering info. about a client’s health status
*DATABASE- all information about a client
includes: -nursing health history (Biographical Data, Present Health/ Illness, Past History,
Family History, Psychosocial History, Review of Body Systems)
-physical assessment
-primary care providers history and physical examination
-results of laboratory and diagnostic tests
-material contributed by other health personnel

*TYPES OF DATA (SOCV)

1. S-UBJECTIVE DATA- also called as Symptoms/ Covert Data
-verified only by the patient
ex. pain, itching, feelings of worry, sensation, feelings, values, beliefs, attitudes
2. O-BJECTIVE DATA- also called as Signs/ Overt Data
-measurable and observable
ex. discoloration of the skin, BP 120/80, Temperature 41 degree Celsius
3. C-ONSTANT DATA- does not change over time
ex. blood type, race
4. V-ARIABLE DATA- can change quickly
ex. vital signs, age, level of pain

*SOURCES OF DATA
1. Primary Source- client best source of data
2. Secondary support people, client records, healthcare professionals, literature
*Support People- useful if pt is too young, too ill, confused
*Client Records-medical records, therapy and laboratory records
*Healthcare professionals- nurses, social workers, primary health providers <sharing
information among professionals ensure continuity of care
*Literature- review of nursing/ related literature, journals

*DATA COLLECTION METHODS (OIE)

1. O-bservation –gather data by using senses
Vision- overall appearance, facial/ body gestures, skin color/lesions
Smell- body/ breathe odors
Hearing- lung sounds, heart sounds, bowel sounds, ability to communicate
Touch- skin temperature, skin moisture, muscle strength, pulse rate, palpatory lesions

2. Interviewing -planned communication

-conversation with a purpose  get information, identify problem, teach,
provide support and therapy and counseling

*2 TYPES OF INTERVIEW
1. Directive- nurse controls, get specific information
- used when time is limited (emergency situation)
2. Non Directive- rapport building interview
- client control the interview
*RAPPORT- understanding between two or more people

*TYPES OF INTERVIEW QUESTION (CONL)

1. Closed Questions- require only yes or no
-give short, factual answers giving specific information
>W questions Who? What? When? Where?
2. Open Ended Question- invite client to discover, explore, elaborate feelings and thoughts
>What? How?
3. Neutral Question-client can answer without direction and pressure; open-ended and non
directive
>How? Why?
4. Leading Question-client has less opportunity to decide weather the answer is true or not;
closed ended/directive
>Aren’t you? Won’t you?

*PLANNING THE INTERVIEW AND SETTING (TP SA DL)

CONSIDER: TIME, PLACE, SEATING ARRANGEMENT, DISTANCE, LANGUAGE

1. TIME- when client is physically comfortable and free from pain
-minimal interruptions

2. PLACE- well lighted, well ventilated

-free of distractions
-place where others cannot overhear or see client

3. SEATING ARRANGEMENT- *client in bed- 45 degree angle to bed

*initial admission- overbed table between
*standing and looking down at a client can be intimidating

4. DISTANCE- neither too small or too far

-pts feel uncomfortable when talking to someone who is too close or too far away
-2 to 3 feet during interview
-also varies in ethnicity
8-12 inches- Arab 24 inches- Britain
18 inches- US 36 inches- Japan

5. LANGUAGE-convert medical terminology into common English usage

-interpreters/ translators if nurse don’t speak the same language or dialect

*STAGES OF AN INTERVIEW (OB C)

1. Opening-most important part

-establish RAPPORT that will create trust and goodwill (greeting, self-introduction)
-orient the interviewee (purpose, what info. needed, how long it will take, how info. will be
used)

2. Body- client communicates what he/she thinks, feels, knows, perceives

-nurse use communication techniques that make both parties feel comfortable

3. Closing-terminates interview when needed information has been obtained

-important for maintaining trust/ rapport and for facilitating future interactions

TECHNIQUES TO CLOSE THE INTERVIEW

1. Offer to answer questions (do you have any questions?)
2. Conclude ( Well, that’s all I need to know for now)
3. Thank the client (Thank you for your time and help)
4. Express concern (Take care of yourself)
5. Plan for next meeting (I’ll be here to see you on Monday)
6. Summary/ Summarize (Lets review what we have just covered in this interview…)
3. Examining-systematic data collection method that uses observation to detect health
problems
-major method used in physical health assessment

TECHNIQUES: (IPPA)

I-nspectionassessing by the use of sense of sight

P-alpationexamining by sense of touch using fatpads of the finger
P-ercussiontapping body part to produce sounds
A-uscultationlistening to body sounds with the use of stethoscope

3 WAYS OF EXAMINING

1. Cephalocaudal- “head to toe approach”

head-neck-thorax-abdomen-extremities-toes
2. Body System- respiratory system, circulatory system, nervous system, etc.
3. Screening examination- “review of systems”
-brief review of essential functioning (nursing admission assessment form)

b) O-rganizing data
-nurses use an organized assessment framework.

*11 Typology of Functional Health Pattern (Gordon)

1.Health perception/ Health Management-describes the clients perceived pattern of health
and well-being and how health is managed.
2.Nutritional/ Metabolic Pattern-describes client’s pattern of food and fluid consumption.
3.Elimination Pattern-describes pattern of excretory function (bowel, bladder and skin).
4.Activity-Exercise Pattern-describes pattern of exercise, activity, leisure and recreation.
5.Sleep-Rest Pattern-describes pattern of sleep, rest and relaxation
6.Cognitive-Perceptual Pattern-describes sensory-perceptual and cognitive patterns.
7.Self Perception/ Self Concept Pattern-describes client’s self concept and perception of self
pattern (self-worth, comfort, body image, feeling state).
8.Role-relationship Pattern-describes pattern of participation and relationship.
9.Sexuality-reproductive Pattern-describes client’s pattern of satisfaction and dissatisfaction
with sexuality patterns; describes reproductive patterns.
10.Coping/ Stress- tolerance Pattern-describes client’s general coping pattern and
effectiveness of pattern in terms of stress tolerance.
11.Values-beliefs Pattern-describes patterns of values, beliefs and goal that guide the client’s
choices or decisions.

*Abraham Maslow’s Hierarchy of Needs

Self-actualization

Self esteem

Love and belongingness

Safety and Security

Physiologic Needs- FONBERS

(fluid, oxygen, nutrition, body temperature, elimination, rest & sleep)

c) V-alidating Data- double checking or verifying data to ensure that it is accurate and
factual
(C2 D2 R)
C-ompare- subjective vs. objective
C-larify- ambiguous/ vague statement
D-ouble check- extremely abnormal data
D-etermine factors that may interfere accurate measurement
R-eferences- explain phenomena
*differentiate CUES from INFERENCES!
CUES- are subjective or objective data that can be directly observed by the nurse
INFERENCES-are the nurse’s interpretation or conclusion based on the cues

d) D-ocumenting Data
-data are recorded in a factual manner and not interpreted by the nurse.
-for example, the nurse must record the client’s intake as “coffee 240 ml, juice 120 ml, 1 egg
and 1 slice of toast” rather than as “appetite good” or “normal appetite” a judgment.
F-actual
A-ctual
T-imely
2. DIAGNOSIS/ DIAGNOSING
- statement or conclusion regarding the nature of phenomena.
- provides basis for the selection of nursing intervention.

NANDA (North American Nursing Diagnosis Association)

-define, refine and promote a taxonomy of nursing diagnostic terminology of general use to
professional nurses. A taxonomy is a classification system or set of categories arranged based
on a single principle or set of principles.

*DIAGNOSTIC LABELS-standardized NANDA names for diagnoses

*DIAGNOSING-reasoning process
*NURSING DIAGNOSIS- diagnostic label + etiology

***TYPES OF NURSING DIAGNOSIS (WARPS)

TYPE DESCRIPTION EXAMPLE

W-ellness Dx -describes human responses to -Readiness for Enhanced Spriritual
level of wellness in an Well-being
individual, family or -Enhanced Family Coping
community that have a
readiness for enhancement
A-ctual Dx -problem is present -Ineffective Breathing Pattern
(+) signs/ symptoms -Anxiety
R-isk Dx -problem does not exist, but -Risk for infection
the present of risk factors
indicates a problem is likely to
develop unless nurses
intervene
P-ossible Dx -health problem is incomplete -Possible Social Isolation r/t
or unclear unknown etiology
S-yndrome Dx -associated with a cluster of -Impaired Physical Mobility
other diagnosis -Risk for Disuse Syndrome
-Risk for Impaired Tissue Integrity
***COMPONENTS OF NURSING DIAGNOSIS (PED)

P-roblem (diagnostic label)

- describes client’s health problem or response for nursing theraphy given.

PURPOSE: to direct the formation of client’s goals and desired outcomes.

Qualifiers- word that have been added to NANDA labels to give additional meaning.
(DIDIC)

D-eficient (inadequate in amount, quality or degree; not sufficient; incomplete)

I- mpaired (made worse, weakened, damaged, reduced, deteriorated)
D- ecreased ( lesser in size, amount, degree)
I- neffective ( not producing the desired effect)
C- ompromised ( to make vulnerable to threat)

E-tiology (related factors/ risk factors)

-identifies one or more probable causes of health problem, gives direction to the required
nursing theraphy and enables the nurse to individualized nursing care.

D-efining Characteristics
-cluster of signs and symptoms that indicate the presence of a particular diagnostic label

***DIAGNOSTIC PROCESS
-uses critical thinking skills of analysis and synthesis
*Critical Thinking- cognitive process during which a person reviews data and considers
explanation before forming an opinion.
*Analysis- separation into components; breaking down of the whole into its parts ( deductive
reasoning)
*Synthesis- putting together parts into whole (inductive reasoning)

3 STEPS OF DIAGNOSTIC PROCESS ( AIF)

1. A-nalyze Data
2. I-dentifying health problems, risk, strengths
3. F-ormulating Diagnostic Statements

1. A-nalyzing Data
A) Compare data against standards
B) Cluster Cues
C) Identify gaps and inconsistencies
A) Compare data against standard and norms

TYPE OF CUE CLIENT CUES STANDARD/NORM

Deviation from population F- 5’2 in height, 240 lbs F- 5’2 in height -108-121 lbs
norms (ideal weight)
Dysfunctional behavior Teen (16 y/o) not left the Adolescents usually liked to
room for 2 days as be with their peers
verbalized by the mother
Developmental Delay Child 17 months old, still Children usually speak their
cannot speak as verbalized first word by 10-12 months
by the parent
Changes in usual health States “I’m not hungry these Client usually eats three
status days” balanced meals per day
Changes in usual behavior Reports that his husband Husband usually relaxed and
angers easily easygoing

B) Cluster Cues
- combining data from different assessment areas to form a pattern and organizing subjective
and objective data into appropriate categories
- nurse interprets meaning of cues, label the cue clusters with tentative diagnostic hypothesis

C) Identifying Gaps and Inconsistencies in Data

- Final check to ensure that data are complete and correct.
Possible sources: measurement error, expectations, and inconsistent or unreliable reports.
E.g. Nursing history- not seen doctor in 15 years, stated my doctor takes my BP every year

2. I-dentifying Health Problems, Risk and Strengths

*Determining Health Problem and Risk
- after grouping and clustering data, nurse- client together identify problem
Ex. 1. Decreased urinary frequency and amount for two days
 possible urinary problem
2. Deficient Fluid Volume (urinary problem- eliminated)
*Determining Strengths
-when problem is already identified, taking inventory of strengths promotes self-concept and
self-image.
-this strengths aid in mobilizing health and regenerative process
Ex. normal weight/ height, absence of allergies, being a non-smoker
3. F-ormulating Diagnostic Statements
a) One- part statement (Problem)
-consist of NANDA label only
-Wellness diagnosis, Syndrome diagnosis
e.g. Rape-Trauma Syndrome, Readiness for Enhanced Spiritual Well Being

b) Two- part statement (Problem + Etiology)

-are joined by the words Related to
e.g. Constipation related to prolonged laxative use, Severe anxiety related to threat to
physiologic integrity; possible cancer

c) Three- part statement (Problem + Etiology + Signs/ Symptoms)

-are joined by the word related to; and manifested by for the signs/ symptoms
e.g. Non Compliance ( Diabetic Diet) related to unresolved anger about diagnosis as
manifested by:
S- “ I forget to take my pills”
“ I can’t live without sugar in my food”
O- Weight 98 kg (215 lbs)
BP- 190/ 100

VARIATIONS OF BASIC FORMAT

1. Unknown Etiology- does not know the cause
e.g. Noncompliance (Medication Regimen) related to unknown etiology

2. Complex Factors- too many etiologic factors

e.g. Chronic Low Self- Esteem related to complex factors

3. Possible- nurse believes more data are needed about clients problem/ needs
e.g. Possible Low Self-Esteem related to loss of job and rejection by family

4. Secondary to-divide etiology in 2 parts; more descriptive, useful; often pathophysiologic or

disease process or medical diagnosis
e.g. Risk for Impaired skin integrity related to decreased peripheral circulation secondary to
diabetes

3. PLANNING
- A deliberative, systematic phase of nursing process that involves decision making and
problem solving.
 NURSE refers  client’s assessment data and diagnostic statementsformulating client’s
goals designing interventions prevent, reduce or eliminate the client’s health problem
-product NCP “blueprint of nursing process

***TYPES OF PLANNING (IOD)

I- NITIAL PLANNING
- admission assessment
-initial comprehensive plan of care
O-NGOING PLANNING
- done by all nurses who work with the client, occurs at the beginning of the shift as the nurse
plans the care to be given that day.
PURPOSES:
1. To determine whether the client’s health status has changed
2. To set priorities for the client’s care during the shift
3. To decide which problems to focus on during the shift
4. To coordinate the nurse’s activities so that more than one problem can be addressed at each
client contact

D-ISCHARGE PLANNING
- the process of anticipating and planning for the needs after discharge

THE PLANNING PROCESS (SESI)

1. S-etting Priorities
2. E-stablishing Client’s Goal
3. S-electing Nursing Intervention
4. I-ndividualized Nursing Care Plan Writing

1. S-etting priorities
-a process of establishing a preferential sequence for addressing nursing diagnosis and
intervention.
*High Priority- life- threatening
*Medium Priority- delayed development or causes physical and emotional changes
*Low Priority-arises from normal developmental needs or that requires minimal nursing
support
Ex. Loss of cardiac function, Loss of respiratory function
Acute illness, Decreased coping ability

 Often use HIERARCHY OF NEEDS of Abraham Maslow

FACTORS TO CONSIDER:
1. Client’s Values and Beliefs- values concerning health may be more important to the nurse
than to the client.
2. Client’s Priorities- involving client in prioritizing and care planning enhances cooperation.
3. Resources Available
4. Urgency of Health problem

2. E-stablishing Client’s Goal

GOAL (broad) Improve nutritional status
DESIRED OUTCOME (specific) Gain 5 lbs by Dec. 15, 2009

GOAL (broad) Improve knowledge regarding disease

(Hypertension)
DESIRED OUTCOME (specific) Be able to discuss the factors that affect the
disease (Hypertension)
2 TYPES OF GOALS
1. SHORT TERM GOAL- can achieve in a short period of time (days/ less than a week)
(useful: pts that require healthcare for short time,pts frustrated with long term
goals)

2. LONG TERM GOAL- can achieve for weeks or months

(useful: who lives at home, with chronic problems, pts in nursing extended care
facilities, rehabilitation centers)

COMPONENTS OF GOAL/ DESIRED OUTCOME STATEMENT

1. Subject- a noun ( client, any part of client)
2. Verb- specifies an action the client is to perform
3. Conditions/ Modifiers- added to verb to explain –what, where, when, how?
4. Criterion of Desired Outcome- level at which client will perform specified behavior (time,
speed, accuracy, distance, quality)

Client walks the length of the hall without cane by date of discharge.
(December 1, 2009)

Client performs leg ROM exercises as taught every 8 hours

3. S-electing Nursing Intervention

-nurse perform to achieve client’s goals

***3 TYPES OF NURSING INTERVENTIONS

1. Independent Interventions- nurses licensed to initiate
e.g. physical care, ongoing assessment, emotional support and comfort, teaching, counseling,
environmental management, making referrals to other health care professionals
2. Dependent Interventions- activities carried out under physician’s order/ supervision
e.g. medications. IV therapy, diagnostic tests, treatments, diet and activity
3. Collaborative Interventions- nurse carries with collaboration with other health team
members

CRITERIA FOR CHOOSING NURSING INTERVENTIONS

I- ndividual’s age, health, condition

T- herapies
S- afe Intervention
S- how respect (values/ beliefs)
A- chievable with resources available
F- irm adherance
E- evidenced based

4. Individualized NCP Writing

4. IMPLEMENTATION
-is putting the nursing care plan into action.
-an action phase in which nurse performs nursing intervention.
Purpose: To carry out planned nursing interventions to help the client attain goals and achieve
optimal level of health.

***Implementing Skills
1. Cognitive- include intellectual skills like problem solving, decision-making, critical thinking
and creativity.
 Crucial to safe, intelligent nursing care
2. Interpersonal- nurse ability to communicate with others.
 caring, comforting, advocacy, referring, counseling/ supporting
3. Technical skills- hands on skills, tasks, procedures, and psychomotor skills.
 manipulating equipment, giving injections, bandaging, moving, lifting
4. Therapeutic use of self – is being willing and being able to care.

PROCESS IN IMPLEMENTING (RIDDS)

R- eassessing client
I- mplementing nursing intervention
D- etermine nurse’s need for assistance
D- ocumenting nursing activities
S- upervising nursing activities

1. Reassessing the client- to ensure prompt attention to emerging problems.

>just before implementing an intervention, nurse must reassess the client to make sure the
intervention is still needed.
Ex. Diagnosis ( Disturbed Sleep Pattern r/t Anxiety)  during rounds you see that the pt is
sleeping  (X) relaxation strategy
2. Implementing nursing intervention- it is important to explain the client the ff:
 What interventions will be done?
 What sensation to expect?
 What the expected outcome is?
***Always ensure patient’s privacy!!!

>>>When implementing nursing intervention, nurses should follow these guidelines.

(ABC RE HIP).
A- dapt activities to the individual client
- client’s beliefs, values, age, health status and environment that can affect the success of a
nursing action.
B- ased on scientific knowledge, research and professional standard of care
-rationale, possible side effects or complications
C- learly understand interventions to be implemented
-intelligent implementation of medical and nursing plan
R- espect dignity of client and enhance client’s self- esteem
-providing pricay and encouraging clients to make their own decision
E- ncourage patient to participate actively
-enhances client sense of independence and control but it varies (because
some patient may want total or little involvement.
***Amount of desired involvement may be related to:
 Severity of illness
 Client’s culture
 Client’s fears
 Client’s understanding of the illness/ intervention
H- olistic
-nurse must view client as a whole and consider client’s responses in that context
I- mplement safe care
P-rovide teaching, support and comfort
-should explain purpose of intervention, what client will experience, how the client can
participate
 increase responsibility for self-care
3. Determining nurse’s need for assistance- when implementing nursing intervention, nurse
may need assistance for one or more of the following reasons:
NURSE: Unable to implement
Assistance decreases stress of clients
Lacks knowledge/ skills
4. Documenting nursing activities-part of the agency’s permanent record for the client
-after carrying out DOCUMENT!
*not done before implementation

5. Supervising nursing activities-if care is delegated to other healthcare personnel, the nurse is
responsible for client’s overall care and must ensure that activities have been implemented
according to the care plan.
COMMUNICATE- documenting the client’s record
- reporting verbally
- filling out a written form
5. EVALUATION
-assessing client’s response to nursing progress toward healthcare and effectiveness of nursing
care plan.

TYPES OF EVALUATION

1. Ongoing Evaluation- continous

2. Initial Evaluation- specific intervals

3. Terminal Evaluation- evaluation at discharge

TYPES OF OUTCOMES

 The goal was completely met.

 The goal was partially met.
 The goal was completely unmet.