6 STEPS / PHASES
OF
NURSING PROCESS
ASSESSMENT
Systematic and continuous collection, validation and
communication of client data
Purpose: To establish a data base (all the information
about the client):
• nursing health history
• physical assessment
• the physician’s history & physical examination
• results of laboratory & diagnostic tests
• material from other health personnel
4 Types of Assessment:
• Initial assessment – assessment performed within a
specified time on admission
• Problem-focused assessment – use to determine status
of a specific problem identified in an earlier assessment
• Emergency assessment – rapid assessment done during
any physiologic/physiologic crisis of the client to
identify life threatening problems.
• time-lapsed assessment – reassessment of client’s
functional health pattern done several months after
initial assessment to compare the clients current status
to baseline data previously obtained.
Activities:
I. Collection of data
• gathering of information about the client
• includes physical, psychological, emotion, socio-
cultural, spiritual factors that may affect client’s
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
• information from the client’s point of view or
are described by the person experiencing it.
Objective data
• also referred to as Sign
• those that can be detected, observed or
measured /tested
Methods of Data Collection:
• Interview
• Observation
• Examination
• Cephalocaudal approach – head-to-toe
assessment
• Body System approach – examine all the body
system
• Review of System approach – examine only
particular area affected
Sources of data:
• Primary source – data directly gathered
from the client using interview and
physical examination.
• Secondary source – data gathered from
client’s family members, significant
others, client’s medical records/chart,
other members of health team, and
related care literature/journals.
• II. 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
III. Organization of Data – uses a written or computerized
format that organizes assessment data systematically.
IV. Analyze data – compare data against standard and
identify significant cues.
V. Communicate/Record/Document Data
• nurse records all data collected about the client’s health
status
• data are recorded in a factual manner not as
interpreted by the nurse
• record subjective data in client’s word; restating in
other words what client says might change its original
meaning.
DIAGNOSIS
• Nursing Diagnosis: is a statement of a client’s
potential or actual health problem resulting from
analysis of data.
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:
• P = Problem statement/diagnostic
label/definition
• E = Etiology/related factors/causes
• S = Defining characteristics/signs
and symptoms
OUTCOME IDENTIFICATION
• 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. Establishing priorities
• Life threatening situation
• Maslow’s Hierarchy of needs
• Patient’s condition
2. Establishing goals
•States what the patient will be after interventions
have been implemented
• Short Term Goal or Long Term Goal
• Use S-M-A-R-T
QUALIFIERS
• Criteria for achieving a goal
• Examples:
Demonstrate Express
Perform Verbalize
Explain Ambulate
State Maintain
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 2
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.
PLANNING
involves determining before and the strategies or
course of actions to be taken before
implementation of nursing care.
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.
PLANNING
1. Establish/Set priorities
[Link] nursing interventions/nursing orders to direct
activities to be carried out in the implementation
phase.
Nursing interventions
• 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.
• Independednt, Dependent and
Collaborative Nursing Ineteventions
3. Write a Nursing Care Plan
> it is the “blueprint” of the nursing
process.
> nursing centered
> step-by-step process
IMPLEMENTATION
• putting the nursing care plan into
action.
Activities:
1. Reassessing
2. Setting priorities
3. Perform nursing interventions
4. Record actions
Requirements for Implementation
• Knowledge
• Technical skills
• Communications skills
• Therapeutic use of self
EVALUATION
• assessment the client’s response
to nursing interventions and then
comparing that response to
predetermined standards or outcome
criteria.
Activities:
• Collect data about the client’s response.
• Compare the client’s response to goals and
outcome criteria.
