NURSING PROCESS
Prepared by:
DR. JACQUELINE GUERRA – POLANCOS
Associate Professor, College of Nursing
Adventist University of the Philippines
▪ A process is a series of steps that follow a
logical sequence.
▪ The term nursing process is widely accepted to
designate a series of steps that the nurse takes
in planning and giving nursing care. ...
It is defined as a systematic problem-solving
approach for giving comprehensive nursing care.
Purpose
▪ To identify a client's health care status, and
actual or potential health problems,
▪ To establish plans to meet the identified needs,
▪ To deliver specific nursing interventions to
address those needs.
The client may be an individual, a family, a
community, or a group.
Page 181 Assessing
▪ Individual diagnosis (Individualized Nursing Care Plan)
▪ Family diagnosis (Family Care plan)
▪ Community diagnosis
▪ Group diagnosis
Why
✓ provides individual-centered care given in accordance
to a plan
✓time is used in a more effective way
✓promotes communication between team members
✓increases the quality of nursing care
✓provide written resources and evidence
for nursing education and research
IMPORTANCE
▪ The demand for high quality nursing care
increases with each passing day. ...
▪ Nursing process, is the most important tool
for putting nursing knowledge into practice,
▪ Systematic method of providing nursing care.
Components
Five dynamic and interrelated phases:
assessment
diagnosis
planning
implementation
evaluation
OVERLAPPING PHASES
Page 185 (Assessing)
The five phases of the nursing process are not
discrete entities but overlapping, continuing sub
process.
Nursing Process
▪ provides nurses with a
framework for care planning,
which is systematic and
methodical
Characteristics
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NP has distinctive characteristics that enable the nurse to
respond to the changing health status of the client.
These include its:
▪ Cyclical & dynamic nature
▪ Client centeredness
▪ Focus on problem solving & decision making
▪ Interpersonal and collaborative style
▪ Universal applicability
▪ Use of critical thinking & clinical reasoning
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
The nursing
process
in action.
Page 182 (Assessing)
▪ Margaret O’Brien is a 33 –year-old nursing student.
She is married and has a 13-year-old daughter and
5-year-old son. She is admitted to the hospital with
an elevated temperature, a productive cough, and
rapid, labored respirations.
▪ While taking a nursing history, Mary Medina, RN,
finds that Margaret has had a “chest cold” for 2
weeks and has been experiencing shortness of
breath upon exertion.
▪ Yesterday she developed an elevated temperature
and began to experience “pain” in her “lungs.”
ASSESSING
Nurse Medina’s physical assessment reveals that Margaret’s
vital signs are:
Temperature: 39.4 C (103 F)
Pulse: 92 beats/min
Respiration: 28/min
Blood Pressure: 122/80 mmHg
Skin: Dry, flushed cheeks, chills (+)
Auscultation: (+) inspiratory crackles with diminished Page 182 (Assessing)
breath sounds (R lung)
DIAGNOSING
After analysis, Nurse Medina formulates a nursing
diagnosis:
Ineffective Airway Clearance related to
accumulated mucus obstructing airways.
Page 182 (Assessing)
Page 182 (Assessing)
PLANNING
Nurse Medina formulates and Margaret
collaborate to establish goals (e.g. restore
effective breathing pattern and lung ventilation);
set outcome criteria ( e.g. have a symmetrical
respiratory excursion of at least 4 cm, and so on);
and develop a care plan that includes, but is not
limited to, coughing and deep breathing
exercises q3h, fluid intake of 3,000 mL day, and
daily postural drainage.
Page 182 (Assessing)
IMPLEMENTING
Margaret agrees to practice the deep-breathing
exercises q3h during the day. In addition, she
verbalizes awareness of the need to increase her
fluid intake and to plan her morning activities to
accommodate postural drainage.
Page 182 (Assessing)
EVALUATING
Upon assessment of respiratory excursion, Nurse
Medina detects failure of the client to achieve
maximum ventilation. She and Margaret
reevaluate the care plan and modify it to increase
coughing and deep-breathing exercises to q2h.
Page 182 (Assessing)
Data from each phase provide input into the next phase.
Findings from the evaluation phase feed back into
assessment. Hence, the nursing process if a regularly repeated
event or sequence of events (a cycle) that is continuously
changing (dynamic) rather than staying the same (static).
Nursing process
include an
evaluative component
APPLICATION
Assessment Nursing Objectives Planning Rationale Implementation Evaluation
Diagnosis
Assessment Nursing Goals/ Planning Implementation Rationale Evaluation
Diagnosis Objectives
Assessment Goals/ Planning Implementation Rationale Evaluation
Nursing Diagnosis Objectives
Status:
✓ Actual diagnosis
✓ Health promotion diagnosis
✓ Risk nursing diagnosis
✓ Syndrome diagnosis
Qualifiers used for the diagnostic statement
✓ Deficient
✓ Impaired
✓ Decreased
✓ Ineffective
✓ Compromised
Example:
It represents client’s
• Activity Intolerance related to decreased
cardiac output.
health problems
Assessment Nursing Goals/ Planning Rationale
Diagnosis Objectives Implementation Evaluation
Independent Interventions
Activities that nurses are licensed to initiate on
the basis of their knowledge and skills
Effectiveness of Dependent Interventions
Activities carried out under the orders or
the interventions supervision of a licensed physician or other
health care provider authorized to write
is the orders to nurses
determining
factor in the Collaborative interventions
The actions the nurse carries out in
revision of the collaboration with other health team
nursing care plan members, such as physical therapist, social
workers, dietitians, and primary care
providers
Nursing process can be defined as the:
A.Implementation of nursing care by the nurse
B. Steps the nurse employs to provide nursing care
C.Process the nurse uses to determine nursing goals
D.Activities a nurse employs to identify a nursing
problem
Nursing process can be defined as the:
A.Implementation of nursing care by the nurse
B. Steps the nurse employs to provide nursing care
C.Process the nurse uses to determine nursing goals
D.Activities a nurse employs to identify a nursing
problem
To utilize the nursing process,
the nurse must FIRST:
A. Identify goals for nursing care
B. State the client’s nursing needs
C.Obtain information about the client
D.Evaluate the effectiveness of nursing actions
To utilize the nursing process,
the nurse must FIRST:
A. Identify goals for nursing care Assessment: client’s
demographic profile
B. State the client’s nursing needs
C.Obtain information about the client
D.Evaluate the effectiveness of nursing actions
The nurse who collaborates directly with
the client to establish and implement a
plan of care is the:
A. Primary Nurse
B. Nurse clinician
C. Clinical specialist
D. Nurse coordinator
Implements the Nursing process
Top Chief Nurse/ Director of Ns. Service/
Administrator
Middle Supervisors
Head Nurses/ Senior Nurses
First Line
Operating Level Staff Nurses/ RNs / Unlicensed
Assistive Personnel (UAP)
The nurse who collaborates directly with
the client to establish and implement a
plan of care is the:
A. Primary Nurse
B. Nurse clinician
C. Clinical specialist
D. Nurse coordinator
Implements the Nursing process
NURSING PROCESS
Prepared by:
DR. JACQUELINE GUERRA – POLANCOS
Associate Professor, College of Nursing
Adventist University of the Philippines
