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Nursing

Process

RN
THE NURSING PROCESS

The Nursing Process is a


systematic, client centered
method of structuring delivery of
nursing care
The Nursing Process entails
gathering and analyzing data in
order to identify client strengths
and potential or actual health
problems and developing and
continually reviewing the plan of
nursing interventions to achieve
mutually agreed outcomes
At every stage of the process,
the nurse works closely with the
client to individualize care and
build a relationship of mutual
regard and trust
Overview of Nursing Process
Lydia Hall originated the term Nursing
process in 1955, Johnson (1959), Orlando
(1961) and Wiedenbach (1963) were among
the First to use it to refer to a series of phases
describing the process of nursing
The purpose of nursing process is to identify a
clients health status and actual or potential
health care problems or needs, to establish
plans to meet the identified needs and to
deliver specific nursing interventions to meet
those needs
Nursing Process
The term Nursing Process was first
used/mentioned by Lydia Hall, a
nursing theorist, in 1955 wherein she
introduced 3 steps: observation,
administration of care and
validation.
Since then, nursing process continue to evolve: it used to be a 3-step
process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-
step process (ADOPIE)
Assessment
Diagnosis
outcome identification
Planning
Implementation
Evaluation
Overview of Nursing Process
The use of Nursing Process in clinical practice
gained additional legitimacy in 1973 when the
phases were included in the American Nurses
Association (ANA) Standards of Clinical
Practice
The standards of care within the most current
Standards of Clinical Nursing Practice include
the five phases of the nursing process:
Assessment, Diagnosis, Planning,
Implementation and Evaluation
NURSING PROCESS

is a systematic, organized method of planning, and


providing quality and individualized nursing care.

it is synonymous with the PROBLEM SOLVING


APPROACH that directs the nurse and the client to
determine the need for nursing care, to plan and
implement the care and evaluate the result.

It is a G O S H approach (goal-oriented, organized,


systematic and humanistic care) for efficient and
effective provision of nursing care.
Dorothy Johnson introduced
three steps of nursing process as
follows: assessment, decision and
nursing action (1959)

Ida Jean Orlando identified three


steps of nursing process: clients
behavior, nurses reaction and
nurses actions (1961)

Yure and Waish suggested the four components of


nursing process namely: assessing, planning,
implementing and evaluating (1967)
Knowles described nursing processes as discover,
delve, decide, do and discriminate (1967)
American Nurses Association introduced the following
innovations in the nursing process:
Diagnosis distinguished as separate step of nursing
process (1973)
Diagnosis of actual and potential health problems
delineated as integral part of nursing practice (1980)
Outcome identification differentiated as a distinct
step of the nursing process. Therefore, the six steps of
the nursing process are as follows: assessment,
diagnosis, outcome identification, planning,
implementation and evaluation
Goal-oriented nurse make her objective based on
clients health needs.
Remember: Goals and plan of care should be base
according to clients problems/needs NOT according
to your own problem as the nurse.

Organized/Systematic the nursing process is


composed of 6 sequential and interrelated steps and
these 6 phases follow a logical sequence.
Humanistic care
plan to care is developed and implemented taking
into consideration the unique needs of the
individual client.
plan of care therefore is individualized (no 2 person has the
same health needs even with same health condition/illness)
in providing care, it involves respect of human dignity
Efficient
plan of case is relevant/related to the needs of
the client thereby promoting client satisfaction
and progress.
Effective
in planning care, utilized resources wisely (staff,
time, money/cost)
Aside from GOSH, other characteristic of Nursing Process
Cyclic and Dynamic in nature data from each phase
provides the input into the next phase so that is becomes
a sequence of events (cycle) that are constantly changing
(dynamic) base on clients health status.

Involves skill in Decision-making nurse makes important


decisions related to client care, she choose the best
action/steps to meet a desired goal or to solve a problem.
She must make decisions whenever several choices or
options are available.

Uses Critical Thinking skills the nurse may encounter


new ideas or less-than-routine or non-ordinary situations
where decisions must be made using critical thinking.
Purpose of Nursing Process:
To identify a clients health status; his Actual/Present and
potential/possible health problems or needs.
To establish a plan of care to meet identified needs.
To provide nursing interventions to meet those needs.
To provide an individualized, holistic, effective and efficient
nursing care.
Critical Thinking in Nursing
Process
Critical Thinking is the intellectually
disciplined process of actively and skillfully
conceptualizing, applying, analyzing and
evaluating information gathered from
observation, experience, reasoning or
communication
Nurses are expected to use critical thinking to
solve client problems and make better
decisions
Steps/Phases of the Nursing Process:
Assessment
involves data collection about the patient from a variety of sources
Diagnosis
allows for the formulation of diagnostic statements that identify the
prioritized client's actual and potential health problems and
strengths and the factors contributing to the problem
Outcome Identification
refers to formulating and documenting measurable, realistic and
client-focused goals that will provide the basis for evaluating nursing
diagnosis
Planning
involves the formulation of the nursing care plan wherein the nurses
work with the client to set goals and outcomes
Implementation
is the action sage of the nursing process
Evaluation
helps determine the clients progress towards meeting the expected
outcomes and goal
ASSESSMENT
Assessment
it is systematic and continuous collection, validation,
organization and documentation of data
(information)
It is a continuous process carried out during all
phases of nursing process
it includes the clients perceived needs, health
problems, related experiences, health practices,
values and lifestyles.
Purpose: To establish a Data base (all the information
about the client):
Sources of Database
Nursing health history
physical Assessment
Physicians history & physical examination
Results of laboratory & diagnostic tests
Material from other health personnel
4 Types of Assessment:

1. Initial assessment assessment performed within


a specified time on admission
Example: nursing admission assessment

2. Problem-focused assessment use to determine


status of a specific problem identified in an
earlier assessment.
Example: problem on urination-assess on fluid intake
& urine output hourly
3. Emergency assessment rapid assessment done
during any physiologic/physiologic crisis of the
client to identify life threatening problems.
Example: assessment of a clients airway, breathing
status & circulation after a cardiac arrest.

4. time-lapsed assessment reassessment of clients


functional health pattern done several months after
initial assessment to compare the clients current
status to baseline data previously obtained.
Activities during Assessment Phase:
Collection of data
Organization of data
Validation of data
Recording/documentation of data

Assessment = Observation of the patient + Interview


of patient, family & SO + examination of the patient +
Review of medical record
Assessing is a continues process carried out during the
all phases of the nursing process.
A. Collection of data
gathering of information about the client
includes physical, psychological, emotion,
socio-cultural, spiritual factors that may affect
clients health status

includes past health history of client


(allergies, past surgeries, chronic diseases,
use of folk healing methods)

includes current/present problems of


client (pain, nausea, sleep pattern,
religious practices, meds or treatment the
client is taking now)
Types of Data:
Subjective data
also referred to as Symptom/Covert data
those that can be described only by the person experiencing
it
Includes clients sensations, feelings, values, beliefs,
attitudes and perception of personal health status
information supplied by family members, significant
others, other health professionals are considered
subjective data.
Example: pain, dizziness, ringing of ears/Tinnitus, vertigo,
itching, feelings of worry
Objective data
also referred to as Sign/Overt data
those that can be detected, observed or measured/tested
using accepted standard or norm.
They can be seen, heard, felt, or smelled
Obtained by observation or physical examination
Example: pallor, diaphoresis, BP=150/100, yellow
discoloration of skin, blood pressure
Methods of Data Collection:
A. Interview
a planned, purposeful conversation/communication
with the client to get information, identify problems,
evaluate change, to teach, or to provide support or
counseling
it is used while taking the nursing history of a client
it is the first step in nursing assessment in which its
purpose are to obtain a nursing health history, identify
the health needs and risk factors
Methods of Data Collection:
A. Interview
Approaches to Interviewing:
Directive Interview
highly structured and elicits specific information
Frequently used to gather and to give information when
time is limited e.g. emergency situation

Nondirective Interview
Aka. Rapport building interview
Nurse allows the client to control the purpose, subject
matter and pacing
Rapport is an understanding between two or more people
Methods of Data Collection:
A. Interview
Types of Interview Questions:
Closed questions
Used in directive interview
Require only yes or no or short factual answers giving
specific information

Open-ended questions
Associated with the nondirective interview
Invite clients to discover and explore, elaborate, clarify or
illustrate their feelings or thoughts
Invite answers longer than one or two words
B. Observation
use to gather data by using the 5 senses and instruments
Sense of vision, smell, hearing and tourch
Is a conscious, deliberate skill that is developed through
effort and with an organized approach

C. Physical Examination
systematic data collection to detect health problems using
unit of measurements, physical examination techniques
inspection, palpation, percussion, auscultation (IPPA), and
interpretation of laboratory results.
should be conducted systematically:
Cephalocaudal approach head-to-toe assessment, begins assessment of
the head, neck, thorax, abdomen, extremities
Body System approach examine all the body system individually
Review of System approach examine only particular area affected
Source of data:
Primary source
data directly gathered from the client using
interview and physical examination
client is the primary source of data

Secondary source
data gathered from clients family members,
significant others, clients medical
records/chart, other members of health team,
and related care literature/journals.
NURSING HEALTH HISTORY
a structured interview designed to collect specific data and to
obtain a detailed health record of a client.
The objective in taking the nursing health history is to identify
patterns of health and illness, risk factors, physical and
behavioral problems and deviations from normal
Its components include:
Biographical data
Chief complaint
History of present illness
Family History
Past Health History
Lifestyle
Social Data
Psychological Data
Patterns of Health Care
Components of a Nursing Health History

1. BIOGRAPHIC DATA
Clients name , address, age, sex, marital status,
occupation, religious preferences, health care
financing and usual source of medical care

2. CHIEF COMPLAINT OR REASON FOR VISIT


The answer given to the question what is troubling
you? or what brought you to the hospital or clinic?
Should be recorded in the clients own words
3. HISTORY OF PRESENT ILLNESS (HPI)
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)
Activity in which the client was involved when the
problem occurred
Symptoms associated with the chief complaint
Factors that aggravate or alleviate the problem
4. PAST HISTORY
Children illnesses, such as chicken pox, mumps,
measles, rubella, rubeola and other significant illness
Childhood immunizations and the date of the last
tetanus shot
Allergies to drugs, animals, insects or other
environmental agents and the type of reaction that occurs
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 and over-the-
counter medications, such as aspirin, nasal spray,
vitamins or laxatives
5. FAMILY HISTORY OF ILLNESS
To ascertain risk factors for certain diseases
Also includes the ages of siblings, parents and
grandparents and their current state of health or if
they are deceased, the cause of death
Particular attention should be given to disorders such
as heart disease, cancer, diabetes, hypertension,
obesity, allergies, arthritis, tuberculosis, bleeding,
alcoholism
Best illustrated through a Genogram
6. LIFESTYLE
Personal habits: the amount, frequency and duration
of substance use (tobacco, alcohol, coffee, cola, tea,
and illicit 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
Seep/rest patterns: usual daily sleep/wake times,
difficulties sleeping and remedies for difficulties
Activities of daily living (ADLs): any difficulties
experienced in the basic activities of eating,
grooming, dressing, elimination and locomotion
Recreation/hobbies: exercise activity and tolerance,
hobbies and other interests and vacations
7. SOCIAL DATA
Family relationships/friendship: clients support system
in terms of stress
Ethnic affiliations: health customs and beliefs, cultural
practices that may affect health care
Educational history: data about the clients highest level
of education attained
Occupational history: current employment status, the
number of days missed from work because of illness, any
history of accidents from job, any occupational health
hazards
Economic status: information about how the clicent is
paying for medical care and whether the clients illness
presents financial concerns
Home conditions: home safety measures and
adjustment in physical facilities
8. PSYCHOLOGIC DATA
Major stressors experienced and the client's
perception of them
Usual coping pattern with a serious problem or a high
level of stress
Communication style: ability to verbalize
appropriate emotion, non-verbal communication i.e.
eye movements, gestures, use of touch and posture;
interaction with support persons
9. PATTERNS OF HEALTH CARE
All health care resources the client is currently
using and has used in the past i.e. family
physician, specialists, dentist, folk practitioners,
health clinic or health center
PHYSICAL ASSESSMENT
involves a detailed
examination of the body from
head to toe using the
techniques of
observation/inspection,
palpation, percussion and
auscultation
Methods of Physical Assessment
1. Inspection/visualization
involves the use of sight occupied with
hearing, touching and smelling to a lesser
degree
the examiner notes general behavior, the size
of the body and its contour, posture, body
movement, gait, state of nutrition, skin color,
presence of rashes/lesions, swellings, scars.
the walls of an orifice or the organ may be
seen by the examiner with the use of
scopes such as otoscope, opthalmoscope,
laparoscope etc.
2. Palpation
the examiner uses the hand and his/her sense of
touch to detect tenderness, temperature, texture
vibrations, pulsations, masses and changes in
structural integrity
3. Percussion
is the tapping of the bodys surface to produce
vibrations and sound. The sounds determine the
density of the underlying tissues whether they are
air filled, fluid filled or solid
it also determines the location of body organs and
structures
4. Auscultation
is the process of listening to sounds produced by
the body. The cardiovascular system, respiratory
system and gastrointestinal system produce
sounds for the examiner to auscultate with the
use of stethoscope
Nursing Responsibilities during Physical
Assessment
1. the nurse should introduce herself and explains the
purpose of the examination
2. the safety and comfort of the patient should be
given primary consideration
3. if the examiner is a male and the patient is a female,
a female nurse or nursing aide should be present for
protection of the patient and the examiner, especially if
a pelvic examination is to be done
4. minimal exposure of the patient should be observed,
only the area to be examine should be exposed.
Proper draping must be done for privacy
5. the bell of the stethoscope is warmed first in the
hands of the examiner
6. the room should ensure privacy
7. the patient is assisted to and from the
examining table to prevent accidents
8. parents and guardians usually stay with
children as latter are examined to reduce any fear
and anxiety
Diagnostic or Laboratory Data
it is the final source of assessment data. The findings
are used to complete the data base and identify
actual or potential health problems
Common Laboratory Examinations:
Blood analysis complete blood count (CBC), arterial
blood gas (ABG) , fasting blood sugar (FBS), Glucose
tolerance test (GTT);
Urine analysis urinalysis (UA), urine culture and
sensitivity test
Radiological Examination chest, upper GI, lower
GI, intravenous pyelography, body scans
Stool analysis ova and parasites
Sputum analysis culture and sensitivity tests, acid
fast bacilli
for other test electrocardiograms, stress test,
electro-encephalograms
Organization of Data
uses a written or computerized format that
organizes assessment data systematically.
Often referred to as a nursing health history, nursing
assessment, or nursing database form
Also includes structured assessment format i.e.
Gordons functional health pattern, Body system
model, Maslows Hierarchy of needs
Gordons Functional Health Patterns:
Provides a framework of 11 functional health patterns
Gordon uses word pattern to signify a sequence of recurring
behavior

1. Health perception-health management pattern


Describes the clients perceived pattern of health and well-
being and how health is managed
E.g. aware of medical diagnosis, complied with treatment
regimen
2. Nutritional-metabolic pattern
Describes the clients pattern of food and fluid consumption
relative to metabolic need
E.g. height, weight, vital signs, eating pattern
3.Elimination pattern
Describes the patterns of excretory function i.e. bowel,
bladder, skin
4. Activity-exercise pattern
Describes the pattern of exercise, activity, leisure and
recreation
E.g. patterns of exercise or physical activity
5. Sleep-rest pattern
Describes the patterns of sleep, rest and relaxation
6. Cognitive-perceptual pattern
Describes sensory-perceptual and cognitive patterns
7. Self-perception-concept pattern
Describes the clients concept pattern and
perceptions of self i.e. worth, comfort, body image,
feeling state
8. Role-relationship pattern
Clients pattern of role participation and relationships
9. Sexuality-reproductive pattern
Describes the clients patterns of satisfaction and
dissatisfaction with sexuality pattern
Describes reproductive patterns
10.Coping-stress tolerance pattern
Describes the clients general coping pattern and
effectiveness of the pattern in terms of stress
tolerance
11. Value-belief pattern
Describes the patterns of values, beliefs including
spiritual
BODY SYSTEM MODEL
Focuses on abnormalities of the following
anatomic systems:
Integumentary system
Respiratory system
Cardiovascular system
Central Nervous system
Musculoskeletal system
Gastrointestinal system
Genitourinary system
Reproductive system
Immune system
MASLOWS HIERARCHY OF NEEDS
clusters data pertaining to the following:
Physiologic needs
Safety and security needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
Validation of Data
the act of double-checking or verifying data to
confirm that it is accurate and complete.
Purposes of data validation:
ensure that data collection is complete
ensure that objective and subjective data agree
obtain additional data that may have been overlooked
avoid jumping to conclusion
differentiate cues and inferences
o Cues subjective or objective data observed by the
nurse; it is what the client says, or what the nurse
can see, hear, feel, smell or measure.
o Inferences the nurse interpretation or conclusion
based on the cues.
o Example: red, swollen wound = infected wound
Dry skin = dehydrated
Record/Document Data
nurse records all data collected
about the clients health status
Documentation serves as a
permanent record of client
information and care
Purposes of Clients Record/Chart:
Communication. Provides efficient and effective method
of sharing information. It allows to convey meaningful
data about the client
Legal Documentation. It is admissible as evidence in a
court of law
Research. Provides valuable health relate data for
research
Statistics. Provides statistical information that can be
utilized for planning peoples future needs
Education. Serves as an educational tool for students in
health discipline
Audit and Quality assurance. Monitors the quality of
care received by the client and the competence of health
care givers
Types of Records:
1. Source Oriented medical record (Traditional Client
Record)
Each person or department makes notations in a separate sections of the
clients chart
Information about a particular problem is distributed throughout the record
Care providers from each discipline can easily locate the forms on which tor
record data
Basic components of the Traditional Client Record
1. Admission sheet
2. Graphic record Vital sign sheet
3. Diagnostic reports laboratory report
4. Special flow sheet e.g. Intake/Output record
5. Physicians order
6. Medical history
7. Nurses notes
8. Special records and reports (referrals, x-ray reports, laboratory
findings, report of surgery, anesthesia record, flow sheets, vital signs, I
& O, medications)
9. Discharge plan and summary
2. Problem Oriented medical record (POMR or
POR)
Data about the client are recorded and arranged
according to the source of the information
The records integrates all data about the problem,
gathered by the members of the health team
Basic components of POMR/POR
1. Database. Contains all the initial information about
the client
2. Problem list. Contains all the aspects of the
persons life requiring health care
3. Initial list of orders or care plans
4. Progress notes
Type of Nurses Notes:
Nurses or narrative notes (SOAPIE format)
S subjective data
O objective data
A assessment/analysis
P planning
I intervention
E evaluation

Focus charting (FDAR) intended to make the client


and client concerns and strengths the focus of care
F focus (problem/nursing diagnosis/behavior/sign or
symptom, acute change in the clients condition)
D data (Subjective/objective)
A actions (Interventions)
R response (evaluations)
3. Kardex
provides a concise method of
organizing and recording data about a
client, making information readily
accessible to all members of health
team
it is a series of flip cards usually kept in
portable file
it is a way to ensure continuity of care
from one shift to another and from one
day to the next
it is a tool for change of shift reports.
But endorsement is not simply reciting
content of Kardex
The health care need of the client is still
primary basis for endorsement
Kardex usually includes the following data:
Personal data
Problem list
Allergies
Diagnostic tests
Daily nursing procedures
Medications and intravenous fluids
Treatments like oxygen therapy, steam inhalation,
suctioning, change of dressings, mechanical
ventilation
entries are usually in pencil so that they can be
changed as clients condition changes
This implies the Kardex is for planning and
communication purposes only
Characteristics of Good Recording
1. Brevity

entries are concise


complete sentences are not required
start each entry with a capital letter
end the entry with a period even if the entry is a
single word or phrase
2. Use of ink/Permanence
avoid felt pen or pencil for permanence of data,
because the clients chart can be used as an
evidence in a legal court

3. Accuracy
chart objective facts, not your interpretations or
opinion
e.g.
Correct ate 50% of the food served.
Incorrect ate with poor appetite
Correct refused medications.
Incorrect uncooperative.
Correct seen crying.
Incorrect depressed.
Place complaint of the client in quotation marks to
indicate that it is statement.
E.g. complained of chest pain radiating down the left arm

Objective data are also to be charted.


E.g. skin cold and clammy. Diaphoretic. Prefers to sit up.
Vital signs taken as follows: Temp=37.6 C, PR=110/min,
RR=26/min, BP=146/90 mmhg

Describe behaviors rather than feelings to allow other


health team members to determine the actual
problems of the client

Refusal of medications and treatment must be


documented
4. Appropriateness
Only information that pertain to the clients health
problems and care are recorded
Any other personal information that is conveyed to the
nurse is inappropriate for the record

5. Completeness and
Chronology/organization/sequence/timing
notes should appear on each succeeding line
continuous charting is done for each entry unless a time
change occurs. No need for a new line for each new idea
or entry
date is entered in the date column on the first line of every
page of nurses notes and whenever the date changes
time is entered in the time column whenever a new time
entry occurs

avoid time changes in the text of the nurses notes

avoid double chart. If something appears on particular


sheet, it does need to appear on the nurses notes,
unless there is an alteration from the normal e.g. body
temperature and blood pressure

avoid squeezing information into a space because you


forgot to chart it earlier. Add the information on the first
available line. Write the event occurred, not the time
you entered the information
The following information should be charted:
Physicians visit
Time the patient leaves and returns to the unit, mode
of transportation and destination
Medications should be charted immediately after
administered
Treatments should be charted immediately after
given
6. Use of standard terminology

use only those abbreviations and symbols approved


by the institutions; spell correctly; use proper grammar

7. Signed
affix signature, place at the end of the charting, at
the right hand margin of the nurses notes
sign each entry with your full name and status e.g.
SN for student nurse. RN for registered nurse
script, not printing is used for the signature
8. In case of ERROR

correct errors by drawing a single (horizontal) line


through the ERROR
write the word error above the line and then affix
your signature
no ink eradication, erasures or use of occlusive
materials

9. Confidentiality

only the health personnel who participate in the


care of the client are allowed to read the chart
10. Legal awareness
chart only what you personally have done,
observed, heard, smelled or felt
do not discard any part of the client record

12. Legibility
writing must be clear and easily read by the others
If writing is not legible, then print
a horizontal line is drawn to fill up a partial line. This
is to prevent other persons from adding information
in the nurses notes.
DIAGNOSING
is the 2nd step of the nursing process.
Is a process which results to a diagnostic
statement or nursing diagnosis
Purpose: To identify clients health care needs
and to prepare diagnostic statements
To diagnose in nursing: it means to analyze
assessment information and derive meaning
from this analysis.
Nursing Diagnosis
is a statement of a clients potential or actual health
problem resulting from analysis of data.
is a statement of clients potential or actual
alterations/changes in his health status.
A statement that describes a clients actual or
potential health problems that a nurse can identify
and for which she can order nursing interventions to
maintain the health status, to reduce, eliminate or
prevent alterations/changes.
Nursing Diagnosis
Is the problem statement that the nurse
makes regarding a clients condition which she
uses to communicate professionally.
It uses the critical-thinking skills analysis and
synthesis in order to identify client strengths &
health problems that can be
resolve/prevented by collaborative and
independent nursing interventions.
Nursing Diagnosis
Analysis separation into components or the
breaking down of the whole into its parts.
Synthesis the putting together of parts into
whole
3 activities in Diagnosing:
DIAGNOSING = Data Analysis + Problem
Identification + Formulation of Nursing
Diagnosis
Characteristics of Nursing
Diagnosis:
It states a clear and concise health problem.
It is derived from existing evidences about the
client.
It is potentially amenable to nursing therapy.
It is the basis for planning and carrying out
nursing care.
Components of a nursing
diagnosis: PES format
Problem statement/diagnostic label/definition
=P
Etiology/related factors/causes = E
Defining characteristics/signs and symptoms =
S
Types of Nursing Diagnosis:
1. Actual Nursing Diagnosis a client problem that is present at the
time of the nursing assessment. It is based on the presence of signs
and symptoms.
Examples:
Imbalanced Nutrition: Less than body requirements r/t decreased appetite
nausea.
Disturbed Sleep Pattern r/t cough, fever and pain.
Constipation r/t long term use of laxative.
Ineffective airway clearance r/t to viscous secretions
Noncompliance (Medication) r/t unknown etiology
Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
Acute Pain (Chest) r/t cough 2 to pneumonia
Activity Intolerance r/t generalize weakness.
Anxiety r/t difficulty of breathing & concerns over work
Types of Nursing Diagnosis:
2. Potential Nursing diagnosis one in which evidence
about a health problem is incomplete or unclear
therefore requires more data to support or reject it; or
the causative factors are unknown but a problem is
only considered possible to occur.
Examples:
Possible nutritional deficit
Possible low self-esteem r/t loss of job
Possible altered thought processes r/t unfamiliar
surroundings
Types of Nursing Diagnosis:
3. Risk Nursing diagnosis is a clinical judgment that a problem does not
exist, therefore no S/S are present, but the presence of RISK FACTORS
indicates that a problem is only likely to develop unless nurse intervene or
do something about it.
No subjective or objective cues are present therefore the factors that
cause the client to be more vulnerable to the problem is the etiology of
a risk nursing diagnosis.
Examples:
Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in
diabetes.
Risk for interrupted family processes r/t mothers illness & unavailability to provide
child care.
Risk for Constipation r/t inactivity and insufficient fluid intake
Risk for infection r/t compromised immune system.
Risk for injury r/t decreased vision after cataract surgery.
Formula in writing nursing
diagnosis: PES or PE
1. Actual nursing diagnosis = Patient problem +
Etiology replace the (+) symbol with the words
RELATED TO abbreviated as r/t.
= Problem + Etiology + S/S
2. Risk Nursing diagnosis = Problem + Risk
Factors
3. Possible nursing diagnosis = Problem +
Etiology
Qualifiers
Qualifiers words added to the diagnostic
label/problem statement to gain additional
meaning.
deficient - inadequate in amount, quality,
degree, insufficient, incomplete
impaired made worse, weakened, damaged,
reduced, deteriorated
decreased lesser in size, amount, degree
ineffective not producing the desired effect
Activities during diagnosis:
Compare data against standards. Standards are accepted
norms, measures, or patterns for purposes of comparison. E.g
the standard color of the sclera is white; the standard color of
urine is amber
Cluster or group data e.g. pallor, dyspnea, weakness, fatigue,
RBC=4 M/cu.mm, Hgb=10g/dl,,pertains to problems with
oxygenation
Data analysis after comparing with standards
Identify gaps and inconsistencies in data
Determine the clients health problems, health risks, strengths
Formulate Nursing Diagnosis prioritize nursing diagnosis
based on what problem endangers the clients life
Situation: Functional Health
Pattern Activity/Exercise
Aling Sylvia,35 years as a laundry woman seeks consultation at
the Ospital ng Sampaloc due to fever 2 days PTA. She
verbalizes: Bigla na lang ako giniginaw, masakit ang ulo at
mainit ang pakiramdam pagkatapos kong maglaba sa kabilang
kanto. She has 3 children she walks off to school everyday
before she goes to work
VS: T=39.2C RR = 35 P = 96; With flush skin and warm to
touch, teary eyed and with dry lips and mucous membrane.
Nsg Dx: Hyperthermia r/t environmental condition as
manifested by T = 39C, flush skin, warm to touch, teary eyed
and dry lip and mucous membrane.
Situation: Functional Health
Pattern = Nutritional/Metabolic
States, No appetite since having cough
Has not eaten today; last fluids at noon today
Has lost 8 lbs in past 2 weeks
Nauseated x 2 days
Nsg. Dx: Imbalanced Nutrition: Less than body
Requirements r/t decreased appetite and
nausea 2ndary to disease process/cough
Situation: Functional Health
Pattern = Activity/Exercise
Difficulty sleeping because of cough
States, Cant breath lying down
Report pain on chest when coughing
Nsg Dx: Disturbed Sleep Pattern r/t a disease
process, orthopnea and pain.
Acute Pain (chest) r/t pathologic condition
2ndary to pneumonia
O-U-T-C-O-M-E I-D-E-N-T-I-F-I-C-A-T-I-O-N

Refers to formulating and documenting


measurable, realistic and client focused goals
that will provide the basis for evaluating
nursing diagnosis
Purposes:
To provide individualized care
To promote client participation
To plan care that is realistic and measurable
To allow involvement of support people
Activities during Outcome
Identification:
1. Establish clients achieved. Identify
goals and outcome Example of verbs used in List
criteria client goals: Name
Client Goal Calculate Maintain
is an educated guess Classify Perform
made as a broad Communicate
statement about what Particular
the clients state or Compare Practice
condition will be AFTER Define Recall
the nursing intervention Demonstrate Recite
is carried out. Describe Record
are written to indicate a Construct State
desired state. They Contrast
contain action Use
word/verb and a Distinguish Verbalize
qualifier that indicate Draw Ambulates
the level of performance Explain
that needs to be Express
Activities during Outcome
Identification:
QUALIFIER is a description of the parameter or criteria for achieving the goal
Example:
Ambulates safely with one-person assistance.
Identifies actual & risk environmental hazards.
Demonstrates signs of sufficient rest before Surgery.
Goals may be short term or long term:

Short Term Goal can be met in a short period (days/ less than a week)
Long Term Goal require more time (several weeks/months)
Outcome Criteria are specific, measurable, realistic statements goal attainment.
Therefore the characteristic of well-stared outcome criteria are:
S = pecific
M =easurable
A = ttainable
R = ealistic
T = ime bounded
Example of Goals and Outcome
Criteria
Goal The client will report a decreased anxiety level
regarding Surgery.
Possible Outcome Criteria
The client discusses fears & concern regarding
surgical procedure after client teaching.
After client teaching, the client verbalizes decreased
anxiety.
The client identifies a support system and strategies
to use to reduce stress and anxiety related to the
surgical experience.
Example of Goals and Outcome
Criteria
2. Goal The client will demonstrate safety habits when
performing activities of daily living.
Possible Outcome Criteria:
Immediately after instruction by the nurse, the client uses call
light system for assistance when needs to use the bathroom.
The client demonstrates safety practices when dressing and
doing personal hygiene.
The client uses over-the-bed lights, non-skid slippers when
transferring to chair or getting out of bed.
The client identifies modification for home safety (removal of
throw pillows, installation of hand rails in hallway, better
lighting of hallway and stairway), 12 hours after nurses
instruction about home safety.
Example of Goals and Outcome
Criteria
3. Goal The client will mobilize lung secretions.
Possible Out come Criteria:
After teaching session, the client demonstrates
proper coughing techniques.
The client drinks at least 6 glasses of water per day
while in the hospital.
The caregiver or significant other demonstrates
proper technique of chest physiotherapy including
percussion, vibration and postural drainage before
discharge.
Classification of Nursing
Diagnoses:
1. High priority Nursing Diagnosis
are those that are potentially life-threatening
and require immediate action.
E.g. include impaired gas exchange, ineffective
breathing pattern, self-directed risk for
violence
Classification of Nursing
Diagnoses:
2. Medium Priority Nursing Diagnosis
are those that could result in unhealthy
consequences such as physical or emotional
impairment, but are not life threatening.
E.g include fatigue, activity intolerance,
ineffective coping and dysfunctional grieving
Classification of Nursing
Diagnoses:
3. Low priority Nursing Diagnosis
involve problems that usually can be resolved
easily with minimal intervention and are
unlikely to cause significant dysfunction.
E.g include sensation of hunger in a client who
is on NPO in preparation for diagnostic
procedure, minimal pain on the third
postoperative day related to ambulation
P-L-A-N-N-I-N-G
involves determining beforehand the strategies or
course of actions to be taken before implementation
of nursing care. To be effective, the client and his
family should be involve in planning.
Purpose:
To determine the goals of care and the course of
actions to be undertaken during the implementation
phase.
To promote continuity of care.
To focus charting requirements.
To allow for delegation of specific activities.
Activities during Planning:
1. Establish/Set priorities
Priority is something that takes precedence in position, and
considered the most important among several items.
Guideline for setting priorities:
Life-threatening situations should be given highest priority.
Use the principle of ABCs (airway, breathing, circulation)
Use Maslows hierarchy of needs.
Consider something that is very important to the client.
Actual problems take precedence over potential concerns.
Clients with unstable condition should be given priority over
those with stable conditions. Ex: attend to client with fever
before attending to client who is scheduled for physical
therapy in the afternoon.
Activities during Planning:
Consider the amount of time, materials,
equipment required to care for clients. Ex:
attend to client who requires dressing change
for postop wound before attending to client
who requires health teachings & is ready to be
discharged late in the afternoon.
Attend to client before equipment. Ex: assess
the client before checking IV fluids, urinary
catheter, drainage tube.
Activities during Planning:
2. Plan nursing interventions/nursing orders to direct
activities to be carried out in the implementation phase.
to direct activities to be carried out in the implementation
phase
nursing interventions are any treatment, based upon clinical
judgment and knowledge, that a nurse performs to enhance
client outcomes
they are used to monitor health status; prevent, resolve or
control a problem; assist with activities of daily living; or
promote optimum health and independence
nursing interventions are also called nursing orders
nursing interventions are independent, dependent and
interdependent activities that nurses carry out to provide
client care
Activities during Planning:
3. Write a Nursing Care Plan or NCP
NCP
a written summary of the care that a client is to receive.
It is nursing centered in that the nurse remains in the scope of nursing
practice domain in treating human responses to actual or potential health
problems.
It is s step-by-step process as evidence by:
Sufficient data are collected to substantiate nursing diagnosis.
At least one goal must be stated for each nursing diagnosis.
Outcome criteria must be identified for each goal.
Nursing interventions must be specifically designed to meet the identified
goal.
Each intervention should be supported by a scientific rationale, which is
the justification or reason for carrying out the intervention.
Evaluation must address whether each goal was completely met, partially
met or completely unmet.
I-M-P-L-E-M-E-N-T-A-T-I-O-N
Is putting nursing care plan into action
Purpose: To carry out planned nursing interventions to help the
client attain goals and achieve optimal level of health.
Activities:
Reassessing ensure prompt attention to emerging problems
Set priorities determine the order in which nursing
interventions are carried out
Perform nursing interventions these may be independent.
Dependent or collaborative measures.
Record actions to complete nursing interventions, relevant
documentation should be done. Remember: Something that is
NOT written is considered as NOT done at all.
Requirements of Implementation:
Cognitive Skills (Knowledge)
include intellectual skills like problem solving,
decision making, critical thinking, creativity and
teaching
Technical skills
Hands on skills to carry out treatment and
procedures such as manipulating equipment, giving
injections and bandaging, moving, lifting and
repositioning clients
Interpersonal (Communication) skills
use of verbal and non verbal communication to carry
out planned nursing interventions