Nursing Process

NURSING PROCESS
FGV Jaminit, RN, CNN, MA
Diabetes Care Specialist
HIV/AIDS Counselor
Lecturer, Foundations of Nursing
Pamantasan ng Lungsod ng Pasig

Nursing Process
 An

organizational framework for the
practice of nursing
 An organized sequence of problemsolving steps used to identify and to
manage the health problems of
clients
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

2

Nursing Process Dev’t
 It

is a systematic rational method of
planning and providing individualized
nursing care
 Lydia Hall, originated the term Nursing
Process in 1955. she introduced 3
steps: Note observation, Administration
of care, Validation
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Nursing Process Dev’t
 Dorothy

Johnson’s 3 steps
Assessment, Decision, Nursing
Action (1959)
 Ida Jean Orlando (1961): client’s
behavior, nurse’s reaction, nurse’s
actions
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

4

Nursing Process Dev’t
 Walsh

(1967), 4 components:
Assessing , Planning,
Implementing, Evaluating
 Knowles (1967), 5 D’s: Discover,
Delve, Decide, Do, Discriminate

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Nursing Process Dev’t
 ANA

introduced innovations:
 Diagnosis distinguished as separate
step (1973)
 Diagnosis of actual and potential
health problems delineated as
integral part of the nursing practice
(1980)
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Assessm
ent

Evaluati
on

Clientel
e

Implementi
ng
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

Diagnosi
ng

Planning
7

Characteristics of NP
1.
2.
3.
4.
5.

Problem oriented
Goal oriented
Orderly, planned, step by step, and
systematic
Open in accepting new information
during its application
It is flexible to meet the unique needs of
patient

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Characteristics of NP
Interpersonal and collaborative
7. Permits creativity among nurses an
patient
8. Cyclical and dynamic
9. Universal
10. Beneficial to the nurse and the client
6.

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

9

Case


Mr. Lucky Chan, 58 year-old male,
was admitted at Jaminit Medical
Center’s Acute and Emergency
Department. He is complaining of
chest pain with pain score of 8/10.
He looks pale and with some DOB
upon Examination, oxygen
saturation was 89%.

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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ASSESSMENT
Collecting, validating organizing, and
recording data about the patient’s health
status
 Its purpose is to establish database
 In the collection of data, the nurse does not
make an interference but forces on
establishing a comprehensive database
that reflects the health status of the patient


NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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ASSESSMENT
 Goal

is to establish baseline
 Activity on assessment: Data
Collection

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Types of Data
1.
2.

ASSESSMENT

Subjective
Objective

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Sources of Data
1.
2.

ASSESSMENT

Primary Source
Secondary Source

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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ASSESSMENT

Methods of Collecting Data
1.
2.
3.

Interview
Observation
Physical Assessment

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

15

Diagnosing
 Is

a process which results to a
diagnostic statement or nursing
diagnosis
 Clinical act of identifying problems
 Analyze assessment information
and derive meaning from this
analysis
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing
 Goal

is to identify the client’s health
care needs and to prepare
diagnostic statements

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Nursing Diagnosis



Is a statement of client’s potential
or actual alteration of health status
It is a clinical judgment about an
individual, family, or community in
response to actual and potential
health problems and life process
(NANDA, 1990)

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Nursing Diagnosis
A

statement of a patient’s potential or
actual health problems which nurses,
by virtue of their education and
experience are capable and licensed
to treat (Gordon, 1976)

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Activities during diagnosing
 Organize

cluster or group data
 Compare data against standards
 Analyze data after comparing to
standards
 Identify gaps and inconsistencies in
data
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Activities during diagnosing
 Determine

the client’s health
problems, risks, and strengths
 Formulate nursing diagnoses
statements (refer to NANDA’s list)

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

21

Diagnosing

Types of Nursing Diagnoses
1.
2.
3.
4.
5.

Actual nursing diagnosis
Risk nursing diagnosis
Possible nursing diagnosis
Syndrome nursing diagnosis
Wellness nursing diagnosis

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Actual Nursing Diagnosis


Client problem that is present at the
time of the nursing assessment

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Risk Nursing Diagnosis


A clinical judgment that a problem
does not exist, but the presence of
risk factors indicates that a problem
is likely to develop unless nurses
intervene

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Possible Nursing Diagnosis



Evidence about health problem is
unclear or incomplete
It requires more data, either to
support or refute it

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Wellness Nursing Diagnosis


Describes human responses to
levels of wellness in an individual,
family, or community that have a
readiness for enhancement
(NANDA, 2003)

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Wellness Nursing Diagnosis


2 cues must pre present:
1.
2.

A desire for higher level of wellness
An effective present status or function

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Syndrome Nursing Diagnosis



Associated with a cluster of
diagnoses
Comprised a cluster of actual or
risk nursing diagnoses that are
predicted to be resent because of a
certain event or situation

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing

Wellness Nursing Diagnosis




Diagnostic statement for wellness
diagnoses if one part statement that
contains the label readiness for
enhanced, followed by the desired
higher level wellness
Related factors are not included

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Formula in diagnosing


Actual nursing diagnosis




Risk nursing diagnosis




P+Risk factors

Possible nursing diagnosis




P+E+S

Data but inadequate and with need for further
investigation

Wellness diagnosis


Healthy response, high level of wellness

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Components of a Nursing
Diagnoses
 Problem

 Deficient,

impaired, decreased,
ineffective, compromised

 Etiology

 Defining

characteristics

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Diagnosing
Formulating Diagnostic Statements




One-part statement
Two-part statement
Three-part statement

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Guidelines for setting priorities
1.
2.
3.
4.

Take care of immediate
life-threatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on
the overall picture, the patient as a
whole person, and availability of
time and resources.

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Planning
 Involves

determining beforehand the
strategies or course of actions to be
taken before implementation of
nursing care
 To be effective, involve the client
and his family in planning.
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

34

Planning
 Nursing

plan of care is a written
summary of the care that a client is
to receive
 It is the blue print of the nursing
process

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Purposes






Planning

To identify the client’s goals and
appropriate nursing interventions
To direct client car activities
To promote continuity of care
To focus charting requirements
To allow delegation of spec. acts.

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Characteristics


Planning

S-M-A-R-T

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Case (Remember Mr. Chan?)
 After

assessment, oxygen therapy
was started at 4 LPM via nasal
cannula; Isosorbide dinitrate 10mg SL
was given as stat dose. One hour
after the intervention chest pain was
relieved with pain score of 3/10,O2 sat
of 95% and non-pale looking skin.

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

38

Implementation
 Is

putting the nursing care plan into
action
 Purpose: carry out planned nursing
interventions to help the client goals
and achieve optimal level of health

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Activities





Implementation

Reassessing
Set priorities
Perform nursing interventions
Record actions

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Evaluation
 Assessing

the client’s response to
nursing interventions and then
comparing the response to
predetermined standard or outcome
criteria



Purpose: appraise the extent to w/c goals and
outcome criteria have been achieved
NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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Activities






Evaluation

Collect data about the client’s
response
Compare the client’s response to
goals and outcome criteria
Judgment
Analyze reasons of outcome
Modify care plan as needed

NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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NCM 100 - Nursing Process
FGV Jaminit, BSN, RN, CNN, MA

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