NURSING PROCESS

Or Nursing Health History, can be defined as the systematized collection of

DATA used to determine a client’s functional health pattern status.

The nurse collects, physiologic, psychological, sociocultural,

developmental, and spiritual client data.

These data assist the nurse in identifying nursing diagnoses and/ or

collaborative problems
 DIFFERENCES BETWEEN SUBJECTIVE AND
OBJECTIVE DATA
SUBJECTIVE
DESCRIPTION Elicited and verified by the client Directly or indirectly observed
SOURCES Client, Family, Significant
Others, Client Record, Other
health care professionals
METHODS TO OBTAIN DATA Client Interview
SKILLS NEEDED TO OBTAIN Interview and THERAPEUTIC
DATA COMMUNICATION skills, Caring
skills, Empathy and Listening
skills
EXAMPLES “I have headache”
OBJECTIVE
through measurement
Observation and Physical
Assessment findings of
healthcare team members,
Documentation of assessments
made in client record
Observation and Physical
Assessment
Inspection, Palpation,
Percussion, Auscultation
BP of 180/90, X-ray film reveals
fracture of the 4th and 5th
Intercostal Ribs
COMPARISON OF NURSING DIAGNOSES AND
COLLABORATIVE PROBLEMS
NURSING DIAGNOSES
DESCRIPTION Physiological, psychosocial, or
spiritual problem
Monitor and treats
The nurse independently orders
and implements the primary
nursing interventions
FORMAT Problem + “related to” +
etiology
Write specific client goals
Write specific nursing orders
COLLABORATIVE PROBLEMS
Physiologic complication
Monitor signs and symptoms of
the complication and notifies
the physician if changes occur
(may initiate nursing
interventions in some cases)
The physician orders the
primary treatment and the
nurse collaborates with the said
implementation of orders
“Potential complication: ___”
Write nursing goals
Write which parameters the
nurse must monitor. Indicate
when the physician should be
notified.
 EXAMPLES OF MEDICAL DIAGNOSES,
COLLABORATIVE PROBLEMS, AND NURSING
DIAGNOSES
MEDICAL DIAGNOSES COLLABORATIVE NURSING DIAGNOSES
PROBLEMS

FRACTURED JAW Potential complication: Chronic Pain related to

Aspiration tissue trauma

DIABETIC FOOT Potential complication: Impaired Skin Integrity

Hyperglycemia related to poor
circulation to lower
extremities

Pneumonia Potential complication: Ineffective Airway

hypoxemia Clearance related to
presence of excessive
mucus
N.A.N.D.A
The North American Nursing Diagnoses Association

They define a NURSING DIAGNOSIS as a clinical judgment about individual,

family, or community responses to actual and potential health problems
and life processes.

It provides the basis for selection of nursing interventions to achieve

outcomes for which the nurse is accountable.
CATEGORIES OF NURSING DIAGNOSIS
WELLNESS DIAGNOSIS

RISK DIAGNOSIS

ACTUAL DIAGNOSIS
 COMPARISON OF WELLNESS, RISK, AND
ACTUAL NURSING DIAGNOSES

WELLNESS RISK ACTUAL

Human Responses to levels Human Responses that may Human Responses to health
of wellness that have a develop in a vulnerable conditions/ life processes
readiness for enhancement. individual, family, or that exist.
community.
READINESS FOR RISK FOR… (nursing diagnosis) related
ENHANCE… to (clause)

Readiness for Enhance Skin Risk for Interrupted Family Dysfunctional Family
Integrity Processes Processes: Alcoholism
THEORETICAL FRAMEWORKS OF NURSING
- Several models of nursing used to guide the nurse in data collection.

- Assists the nurse with the collecting data necessary to identify and validate
nursing diagnoses.

- The medical systems model is more useful for the physician in making medical
diagnoses. (biographical data, chief complaint, present health history, past
medical history, family history, psychosocial history and review of systems).