2. • Nursing process is a systematic method of
providing care to clients.
• The nursing process is a systematic
method of planning and providing
individualized nursing care.
NURSING PROCESS
3. NURSING PROCESS
Purposes of nursing process
• To identify a client’s health status and
actual or potential health care
problems or needs.
• To establish plans to meet the
identified needs.
• To deliver specific nursing
interventions to meet those needs.
4. Components of nursing process:
The nursing process consists of five dynamic and
interrelated phases:
1. Assessment
2. diagnosis
3. planning
4. implementation
5. evaluation.
7. Definition
Assessment is the systematic and
continuous collection, organization,
validation, and documentation of
data (information).
NURSING ASSESSMENT
Assessment – First Step in the Nursing Process
8. The purposes of Assessment is
• To validate a diagnosis
• To provide basis for effective nursing care.
• It helps in effective decision making
• Basis for accurate diagnosis
• It promote holistic nursing care
• To collecting data for nursing research
• To evaluation of nursing care
PURPOSE OF
ASSESSMENT
9. The four different types of assessments
are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
Types of assessment
10. 1. Initial nursing assessment:
Performed within specified time after admission,
To establish a complete database for problem
identification.
EG:-
• Patient history
• General appearance
• physical examination
• Vital signs (HR, TEMP, RR, BP, AND PAIN).
Types of assessment
11. Problem Focus Assessment
• A problem focus assessment collects data about a
problem that has already been identified.
• This type of assessment has a narrower scope and
a shorter time frame than the initial assessment.
• In focus assessments, nurse determine whether
the problems still exists and whether the status of
the problem has changed (i.e. improved,
worsened, or resolved).
• This assessment also includes the appraisal of any
new, overlooked, or misdiagnosed problems.
• In intensive care units, may perform focus
assessment every few minute
Types of assessment
12. Emergency Assessments
• During emergency procedures, a nurse is focused
on rapidly identifying the root causes of concern
for the patient and assessing the airway,
breathing and circulation (ABCs) of the patient.
• Once the ABCs are stabilized, the emergency
assessment may turn into an initial or focused
assessment, depending on the situation.
Types of assessment
13. Time-Lapsed Assessment
• Time-lapsed assessment – reassessment of
client’s functional health pattern done
several months after initial assessment to
compare the client’s current status to
baseline data previously obtained
• The time-lapsed assessment may also
include lab work, X-rays or other diagnostic
medical testing
Types of assessment
16. Collect Data
Data collection is the process of gathering
information about a client’s health status.
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, meds or treatment
the client is taking now)
17. 1.Subjective data
• also referred to as Symptom/Covert data
• Information from the client’s point of view or are
described by the person experiencing it.
• Information supplied by family members, significant
others; other health professionals are considered
subjective data.
• Example: pain, dizziness, Itching and feelings of
worry
2.Objective data
• also referred to as Sign/Overt data
• Those that can be detected observed or
measured/tested using accepted standard or norm.
• Example: diaphoresis, BP=150/100, yellow
discoloration of skin
Types of Data Collection
18. 1.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
2.Observation
• Use to gather data by using the 5 senses and instruments.
3.Examination
• Systematic data collection to detect health problems using unit of
measurements, physical examination techniques (IPPA),
interpretation of laboratory results.
• should be conducted systematically:
a. Cephalocaudal approach – head-to-toe assessment
b. Body System approach – examine all the body system
c. Review of System approach – examine only particular area
affected
Methods of Data Collection
19. A.Primary source – data directly gathered from
the client using interview and physical
examination.
B.Secondary source – data gathered from client’s
family members, significant others, client’s
medical records/chart, and other members of
health team.
• In the Assessment Phase, obtain a Nursing
Health History – a structured interview
designed to collect specific data and to obtain
a detailed health record of a client.
SOURCE OF DATA
20. COMPONENTS OF A NURSING HEALTH HISTORY:
• Biographic data – name, address, age, sex, martial status,
occupation, religion.
• Reason for visit/Chief complaint – primary reason why client seek
consultation or hospitalization.
• History of present Illness – includes: usual health status,
chronological story, family history, disability assessment.
• Past Health History – includes all previous immunizations,
experiences with illness.
• Family History – reveals risk factors for certain disease diseases
(Diabetes, hypertension, cancer, mental illness).
• Review of systems – review of all health problems by body systems
• Lifestyle – include personal habits, diets, sleep or rest patterns,
activities of daily living, recreation or hobbies.
• Social data – include family relationships, ethnic and educational
background, economic status, home and neighborhood conditions.
• Psychological data – information about the client’s emotional state.
• Pattern of health care – includes all health care resources: hospitals,
clinics, health centers, family doctors.
23. ORGANIZING DATA
The nurse uses a written or computerized
format that organizes the assessment data
systematically. The format may be modified
according to the client's physical status.
26. Validation of Data
• The act of “double-checking” or verifying data to
confirm that it is accurate and complete.
Purposes of data validation
1.ensure that data collection is complete
2.ensure that objective and subjective data agree
3.obtain additional data that may have been overlooked
4.avoid jumping to conclusion
Validation of Data
27. • Recheck your own data through a repeat assessment. For example,
take the client’s temperature again with a different thermometer.
• Clarify data with the client by asking additional questions. For
example: if a client is holding his abdomen the nurse may assume he
is having abdominal pain,
• Verify the data with another health care professional. For example,
ask a more experienced nurse to listen to the abnormal heart
sounds you think you have just heard.
• Compare you objective findings with your subjective findings to
uncover discrepancies. For example, if the client state that she
“never gets any time in the sun” yet has dark, wrinkled, suntanned
skin, you need to validate the client’s perception of never getting
any time in the sun
METHODS OF VALIDATION
30. • To complete the assessment phase, the nurse
records client's data.
• Accurate documentation is essential and should
include all data collected about the client's health
status.
• Data are recorded in a factual manner and not
interpreted by the nurse.
DOCUMENTING DATA
33. • Nursing Diagnosis is the second Step of
nursing process.
• In this phase, nurses use critical thinking skills
to interpret assessment data to identify client
problems.
• North American Nursing Diagnosis Association
(NANDA) define or refine nursing diagnosis.
NURSING DIAGNOSIS
Purpose
•To identify health care needs and prepare a
Nursing Diagnosis.
•It means to analyze assessment
information and derive meaning from this
analysis
34. Three Activities in Diagnosing:
1.Data Analysis
2.Problem Identification
3.Formulation of Nursing Diagnosis
Characteristics of Nursing Diagnosis
1. It states a clear and concise health
problem.
2. It is derived from existing evidences
about the client.
3. It is potentially amenable to nursing
therapy.
4. It is the basis for planning and carrying
out nursing care.
35. COMPONENTS OF A NANDA
NURSING DIAGNOSIS
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
36. • The problem statement describes the
client’s health problem.
• The etiology component of a nursing
diagnosis identifies causes of the health
problem.
• Defining characteristics are the cluster
of signs and symptoms that indicate the
presence of health problem.
COMPONENTS OF A NANDA NURSING
DIAGNOSIS
37. Types of Nursing Diagnoses
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:
1.Imbalanced Nutrition: Less than body requirements r/t
decreased appetite nausea.
2.Disturbed Sleep Pattern r/t cough, fever and pain.
3.Constipation r/t long term use of laxative.
4.Ineffective airway clearance r/t to viscous secretions
5.Noncompliance (Medication) r/t unknown etiology
6.Noncompliance (Diabetic diet) r/t unresolved anger
about Diagnosis
7.Acute Pain (Chest) r/t cough 2nrdary to pneumonia
8.Activity Intolerance r/t general weakness.
9.Anxiety r/t difficulty of breathing & concerns over work
38. 1. 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 job
• Possible altered thought processes r/t unfamiliar
surroundings
Types of Nursing Diagnoses
39. 1. 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 is indicates that a problem is
only is 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 are the etiology of a risk nursing
Diagnosis Examples:
a. Risk for Impaired skin integrity (left ankle) r/t decrease
peripheral circulation in diabetes.
b. Risk for interrupted family processes r/t mother’s illness &
unavailability to provide child care.
c. Risk for Constipation r/t inactivity and insufficient fluid
intake
d. Risk for infection r/t compromised immune system.
e. Risk for injury r/t decreased vision after cataract surgery.
Types of Nursing Diagnoses
40. Formulating a Nursing
Diagnosis
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
41. Acute pain related to abdominal surgery
as evidenced by patient discomfort and
pain scale.
Problem Etiology Signs and
symptoms
Pain Surgery of
abdomen
Pain scale
and
discomfort of
patient
42. Situation: Functional Health Pattern –
Activity/Exercise
• fadumo, 35 years of laundry woman seeks
consultation at the Manhal Hospital due to fever
2 days prior to admission She verbalizes: “(“I
suddenly felt cold, headache and warm after I
done laundry”). She has 3 children she walks off
to school everyday before she goes to work
43. Vital Signs
• Temperature (T) =39.2°C Respiratory Rate (RR)
= 35 P = 96; with flush skin and warm to touch,
teary eyed and with dry lips and mucous
membrane.
Nursing Diagnosis
• Hyperthermia [related to (r/t)] environmental
condition AMB T = 39°C, flush skin, warm to touch,
teary eyed and dry lip and mucous membrane.
44. Situation: Functional Health Pattern = Nutritional
1. States, “No appetite since having cough”
2. Has not eaten today; last fluids at noon today
3. Has lost 8 lbs in past 2 weeks
4. Nauseated x 2 days
Nursing Diagnosis
• Imbalanced Nutrition: Less than body Requirements
r/t decreased appetite and nausea 2ndary to disease
process/cough
45. Situation: Functional Health Pattern Activity/Exercise
1. Difficulty sleeping because of cough
2. States, “Can’t breath lying down”
3. Report pain on chest when coughing
Nursing Diagnosis
• Disturbed Sleep Pattern r/t a disease process,
orthopnea and pain.
• Acute Pain (chest) r/t pathologic condition 2ndary
to pneumonia
46. Situation: Functional Health Pattern = Stress
1. Anxious
2. State, “I can’t breath”
3. Facial muscles tense, trembling
4. Expresses concern and worry over leaving
daughter with neighbors
5. Husband out of town, will be back next
week.
Nursing Diagnosis
• Anxiety r/t difficulty of breathing and
concerns over parenting roles.
47.
48.
49. Mang Teban is a 73-year old patient diagnosed with
pneumonia. Which data would be of greatest concern to the
nurse when completing the nursing assessment of the
patient?
A.Alert and oriented to date, time, and place
B. Buccal cyanosis and capillary refill greater than 3 seconds
C. Clear breath sounds and nonproductive cough
D.Hemoglobin concentration of 13 g/dl and leukocyte count
5,300/mm3
50. 1.Nursing diagnosis is the
A.First step of Nursing process
B.Last step of Nursing process
C.Second step of Nursing process
D.Third step of Nursing process
The correct answer is C
51. 1.Components of nursing process include
except
A.Nursing diagnosis
B.Nursing planning
C.Nursing evaluation
D.Medical diagnosis
The correct answer is D
52. 1.If the first method of Nursing Process is
nursing assessment, what is the second
method?
A.Nursing diagnosis
B.NR planning
C.NR Evaluation
D.Nursing intervention
The correct answer is A
53. 1.Components of a Nursing Diagnosis. Select all that
apply
A. planning
B. Data clustering
C. Contributing, etiologic or related factors
D. None of the above
The correct answer is C
54. 1.Which of the following are true regarding nursing
diagnosis?
A. Nurses Use Critical Thinking Skills To
Interpret Assessment Data To Identify
Client Problems.
B. First Step Of Nursing Process
C. A Nursing Diagnosis Is The Planning Of Pts
Care
D. Nursing Diagnosis And Nursing Intervention
Are Same
The correct answer is A
55. 1.Assessment is the
A.first step of nursing process
B.last step of nursing process
C.second step of nursing process
D.third step of nursing process
The correct answer is A
