The NURSING

PROCESS
Jeng P. Cuevas
 Nursing process
• foundation of the nursing profession
• central to nursing actions
• a process to deliver care to patients
• supported by nursing models or
philosophies.
• systematic approach
• enhances research opportunities
• adaptable to different clients in
different care settings
• efficient method of organizing thought
processes or clinical decision-making
 CRITICAL THINKING
• It is how the • Over time the
nurse uses the nurse learns to
information to almost
reason, make simultaneously
inferences and review,
form mental interpret,
picture of what analyze and
is happening to evaluate
• Facione and Facione (1996) define
critical thinking as purposeful self-
regulatory judgment that is
centrally evident in expert clinical
 To use this process, the nurse
must demonstrate other
fundamental abilities of:

3. Knowledge
4. Creativity
5. Adaptability
6. Commitment
7. Trust
8. Leadership
9. Intelligence
10.Interpersonal and technical
ASSESSMENT
Client Data
Mr. Harold Simpson was admitted on Sunday morning with
a medical diagnosis of swollen right knee and diabetes.
Subjective Data
Four children, ages 16, 14, 12,10.
Occupation: Painter
Urinating about every two hours.
Client states that he fell that morning from a ladder that
slipped while he was painting the neighbor’s house. He
later developed a headache. He admits that he didn't sleep
well the night before and he states that he is very upset
because he was supposed to take his children to a
basketball game that day. He states that he is agnostic but
his wife and children are Protestants who go to church
regularly and they are trying to
Data According to
FUNCTIONAL HEALTH
PATTERNS
Data According to
MASLOW’S HIERARCHY OF
NEEDS
DIAGNOSIS
 Actual VS
Risk
Is a Is a
problem problem
that is that the
identified nurse,
during the through
assessment knowledge
. It is and
supported experience,
by obvious perceives
signs and will
 Writing the Nursing
Diagnosis
• It may be written as, Patient
problem+ Cause of the problem
(etiology)

Example: >Impaired skin integrity

r/t immobility
>Parental role conflict r/t
divorce
>Impaired verbal
communication r/t

cultural differences
Or, by using the PES format; Patient
problem + Etiology + Symptoms

Example:
>Impaired skin integrity r/t
immobility as manifested by
Disruption of the skin surface over
the elbows and sacral area

>Parental role conflict r/t divorce

as manifested by statements Of
unsatisfactory child care during
working days

>Impaired verbal communication

Case Study
Mrs. Jones, 1 75-year old male, is
admitted to the unit with a medical
diagnosis of “lumbar pain”. He states
that “the pain started 2 days ago”. He
has been in a wheelchair for 1 year
following a stroke. He has had a foley
catheter in place for 3 months because of
incontinence. His urinary output is less
than 30 cc per hour and is concentrated.
He is being fed through a
gastrostomytube that has been in place
for 6 months. He has one son who lives
in Europe. He lost his wife a year ago. On
admission, his vital signs were: T-38
PLANNING
 PLANNING
The resulting plan of nursing care is
designed to help patients and their
families;

• Maintain their current level of health

and functioning if they are identified
at risk for developing problems.
• Reach an improved level of health
functioning.
• Adjust to a reduced level of health
and functioning when improvement
is not possible.
• Adjust to a progressively decreasing
 GUIDELINES FOR
SETTING PRIORITIES:
• Maslow’s hierarchy of basic needs can
guide the selection of high priority
problems.
• Focus on the problems the patient feel
are most important if this priority does
not interfere with medical treatment.
• Consider the effect of potential problems
in setting priorities.
• For an actual nursing diagnosis, the goal
statement is a patient behavior that
demonstrates reduction or alleviation of
the problem.
• For a potential nursing diagnosis, the
goal statement is a patient behavior that
IMPLEMENTATION
Interventions:
• Assessment is the FIRST
intervention!
• Independent actions before
dependent actions.
• Refer to Standing Orders.
• Refer to Physician.
• Collaborate with other
members of the health team.
• Write only when performed.
EVALUATION
It has two parts; Evaluation of
goal achievement + Review of
– Evaluation of goal statement
• The purpose of the first part is
to decide whether the patient
has achieved the goal selected
during the planning phase of
the nursing process.
• The goal is evaluated at the
time or date specified in the
goal statement.
• It is written as:
Goal met As
evidenced
Goal unmet +
 Review of the Nursing
Care plan
• Review of the NCP keeps the plan
current and responsive to the
patient’s changing needs.
• The process of nursing is cyclical
in nature with that five steps
viewed as a circle with one step
leading to another.