NCM103: FUNDAMENTALS OF NURSING PRACTICE | THEORY

MODULE 4: The Nursing Process

2ND SEMESTER |FINALS | S.Y. 2021-2022 TRANS BY: MA. CARMELLA G. MALUSAY
LECTURER: Phoebe Kates Mangarin, RN

TOPIC approach is inappropriate because success and treatment

SUB TOPIC is unknown ànot used in emergency/life-threatening
SUB-SUB TOPIC situations

CONCEPTUAL FRAMEWORK Intuition research process: act of guessing based on nurse’s

past experience but not recommend for novice/student
MAN
• Individual Modified scientific method: based on evidence-based
• Family research that prove new management.
• Community
DECISION MAKING
Nurses use the 5 phases of the nursing process. These • critical thinking process is applied for choosing the
stages can overlap and can occur at once best action to meet the goal
• must explore the following considerations:
NURSING PROCESS 1. Advantages and disadvantages: determines that
à Assessment advantages outweigh the disadvantages (benefits
o Collecting & Validating data vs risk)
à Diagnosis 2. Maslow’s Hierarchy of Needs
o Identify problem list; NANDA 3. Tasks that can be delegated to others: tasks can
à Outcome Identification and Planning be delegated to accommodate more serious
o Goals and objectives; NOC and NIC conditions
à Implementation
o Safe quality nursing actions; plan is put into Example:
action
à Evaluation vital signs can be done by nursing aide
o Determines whether the outcomes have been while the registered nurse administers
met; modify/revise care plan; reevaluate parenteral medication

à Systematic, rational method of planning and providing CHARACTERISTICS OF NURSING PROCESS

individualized nursing care Enables nurse to respond to client’s needs
• Nursing care is rendered to the particular need of the A. Cyclic and Dynamic in nature
client; rather than a routine applied to all patients o Data from each phase provides input for the next
suffering from the same disease phase and provides feedback on regularly repeated
events that continually change
CRITICAL THINKING B. Client-oriented or centered
• Setting priorities o Nurse organizes care according to client’s problems
• Solving Problems C. Focus on problem solving and decision making
• Making decisions o Medical models are used to come up with sound
interventions that directly address client’s
Purpose: identify the client’s health status; provide the physiologic responses
basis for critical thinking in nursing in accordance to the D. Interpersonal & collaborative style
professional standards o Therapeutic communication skills are needed;
collaboration with other HCP to validate data
PROBLEM SOLVING E. Universal
• Nurse obtains information that clarifies the nature of o Nursing process can be used in various healthcare
the problem and suggests possible solutions (options) settings and across age groups and cultural
backgrounds
Trial and Error: helpful for nurse researchers for medical
treatments and technologies; potentially harmful when
NCP | 1
F. Continuous APPROACHES IN ASSESSMENT
o Life and health individuals change; reassessment of
needs are done frequently; make new goals, Structured Database
implement new plans, add new interventions, • Based on accepted theoretical framework or standard
reevaluate success of overall process of practice
G. Uses critical thinking and clinical reasoning • Gordon’s functional health pattern
NURSE Example:
o Rationalize the tasks o Self-Perception
NURSE AIDES o Activity and exercise pattern
o Completion of task
Problem-Oriented
NURSING ASSESSMENT • Based on presenting situation or patient’s complaints
à RN uses systematic/dynamic way to collect, analyze, (identified problem) nursing
and validate data from patient and other source.
• Collection & organization TYPES OF DATA
• Data Validation
• Documentation of client data SUBJECTIVE
à First step in delivering nursing care; types of data • Patient’s feelings, perception, and self-report of
collected symptoms
• Physiological • Covert data
• Psychological
• Sociocultural OBJECTIVE
• Economic • Used to validate subjective data sign
• Lifestyle factors • Overt data

CRITICAL THINKING IN ASSESSMENT CONSTANT

• Make reliable observation (ex. Hyperthermia) • Does not change quickly
• Distinguish relevant from irrelevant data (can be cause • Example: Race, blood type, skin color
by infection or pregnancy due to increased
progesterone level) VARIABLE
• Distinguish important and unimportant data (Lab • May change its amount, size, characteristics or level
results: Increased WBS) • Example: Urine output, blood pressure, pain
• Validate and organize data
SOURCES OF DATA
TYPE OF ASSESSMENT 1. Primary
Initial • Data directly from the patient
• Establish complete database; reference and future o Patient is the best source of information
comparison o Patient must be alert and coherent (to give
• Triage concise info)
Problem-focused 2. Secondary
• Determine the client’s status for prompt treatment • Significant others
• Based on specific problem presented • Other health care team
• It referred as “Ongoing” Assessment • Available records and reports
• Ex: GCS in neurologic assessment • Laboratory and diagnostic findings
Emergency • Literature (medical textbooks/articles)
• Identify life threatening cases
• Physiologic and psychologic crisis DATA COLLECTION METHODS
• ABC
Time-lapsed OBSERVATION
• Done several weeks or months after initial assessment • Consciously & deliberately done with appropriate skills
• Compare current status from baseline data and approach
• For ongoing and follow up consultation • Use of senses
o General Appearance
o Movement
NCP | 2
 o Posture • Complete, detailed, and accurate à communication
o Coherence when speaking other HCP
o Interaction with others
INTERVIEW INDEPENDENT LEARNING TASK 1
• Planned communication to educate and counsel Identify assessment findings and organize accordingly for
• Organized conversation about the client’s status UPPER RESPIRATORY TRACT INFECTION
o Gathering subjective data SIGNS:
• Directive or Non-Directive Approach • Coughing
o Directive à close-ended questions (yes or no) • Runny nose
o Non-Directive à open-ended questions (promotes • Presence of phlegm
building rapport) • Sneezing
SYMPTOMS:
EXAMINING • Nasal discharge
• Head-to-toe approach (IPPA) • Sneezing
• Screening examination • Sore throat
• Mild to moderate, hacking cough
VALIDATING DATA • Possible fever in children, rare in adults
• Act of double checking/verifying and comparing data • Possible malaise, fatigue and weakness
collected • Slight myalgia
• Confirms accuracy of cues and inferences made by the • Duration: 3-14 days
nurse Reference:
o INFERENCES: nurse’s formed conclusion or https://emedicine.medscape.com/article/302460-clinical#b1
*distinguish from lower respiratory tract infection*
opinion based on evidence LRTI infect below the voice box (includes lungs) and include pneumonia, bronchitis, and TB
Cough is the primary symptom for LRTI
• Requires prompt questioning to validate assumption Sneezing, headaches, and sore throat are primary symptoms for URTI
Reference: https://www.medicalnewstoday.com/articles/324413#upper-vs-lower-r espiratory-tract-infections
Illnesses caused by acute infection of Upper Respiratory Tract: nose, sinuses, pharynx, and larynx
Includes: tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold
VALIDATING PAIN Reference:
https://nursing-diagnosis-nanda.blogspot.com/2011/04/nursing-diagn osis-for-upper-respiratory.html
• Many cues can be validated in different ways
• For example: pain or discomfort
• Pain score
• The nurse verifies this by using the pain assessment
tool where 0 is without pain, 1-3 as mild pain, 4-6 is
moderate, 7-10 severe to worst pain
• Other pain assessment will include the use of
mnemonics like the OLDCART
O - Occurrence
L - Location
D - Duration
C - Characteristic
A - Aggravated by
R - Relieved
T - Treatment
• Objective cues: This data can further be verified when
the nurse observes for facial grimace and body /
guarding movements
o Other observations that may suggest pain is loss
of appetite which is seen as the patient has not NURSING DIAGNOSIS
consumed her meal à Second phase of nursing process; allows the nurse to
know the cause of the client’s condition based on the data
DOCUMENTING DATA from the assessment phase
• Assessment are taken from primary and secondary • Clinical judgment concerning human response to
sources health conditions and the vulnerability response by
• Essential to make basis of comparison to check any clientele
progress/deterioration of client

NCP | 3
• Statement about actual or potential health concerns • When there is one or more domain of health affected
that can be managed through independent nursing (ie, physical, psychological, functional, or social)
function (ie, patient education and symptom relief) • Example: frail elderly syndrome
POSSIBLE
à Make use of NANDA-I (North American Nursing • NOT a type of nursing diagnosis
Diagnosis Association - International) • Provides opportunity for communication with other
• Standardized terminologies for nursing diagnosis nurses to rule out possible diagnoses
• Statements describing a suspected problem for which
PURPOSE OF DIAGNOSIS - NANDA additional data are needed to confirm or rule out
• Provides a precise definition with the use of common • Example: possible social isolation in a newly diagnosed
language in understanding client’s needs cancer patient
• Allows nurse to communicate both written and COMPONENTS OF NURSING DIAGNOSIS
electronic
• Distinguishes the nurse’s role from other HCPs PROBLEM & DEFINTION
• Guides the nurse in formulating expected outcomes • Describes client’s health problem/response
• Diagnostic label
DIAGNOSIS • Example: impaired mobility, deficient fluid volume,
Both must complement each other// decreased cardiac output, ineffective airway clearance
NURSING (care-focused)
• Statement of nursing judgment ETIOLOGY (RELATED FACTORS)
• Describes client’s response to illness or health Parts:
problems 1. Qualifier
• Changing depending on the client’s physical, mental, à Example: impaired, deficient, decreased,
spiritual response ineffective, compromised
MEDICAL (illness-focused) à Exemption to qualifiers = one-word diagnosis
• Statement made by physician (anxiety, fatigue, hyperthermia, nausea, pain)
• Refers to the disease process 2. Focus of the diagnosis
• Fairly uniform from one client to another àDescribes patient’s identified problem
à One or more probable causes of the problem
TYPE OF NURSING DIAGNOSIS à Gives direction to required nursing therapy
PROBLEM-FOCUSED (ACTUAL) à Example: impaired mobility related to insufficient
• Client problem that is present at the time of nursing strength to ambulate using crutches
assessment
• Based on signs and symptoms DEFINING CHARACTERISTICS
• Example: increased body temperature = hyperthermia • Cluster of signs and symptoms that indicate the
• May be equally important as the risk diagnosis presence of a particular diagnostic label
RISK • For risk nursing, no signs & symptoms are identified
• Clinical judgment that a problem does not exist
• But the present of risk factors indicates that a problem HOW TO DIAGNOSE
is likely to develop 1. Analyzing Data
• Prioritizes HIGH to LOW a. Example: eating very small meal (little appetite)
• Example: risk for increased bleeding seemed to be normal for the patient
HEALTH PROMOTION (WELLNESS) i. Guided by growth and development patterns,
• Clinical judgment about motivation and desire to vital signs and laboratory values
increase well being ii. Accept measure, rule, model, and pattern
• Concerns the individual, family, or community from a b. Purpose:
specific level of wellness to a higher level of wellness i. Cluster clues - grouping the cues to determine
• Example: readiness for enhanced parenting (pattern relatedness of facts
of providing an environment which nurtures growth ii. Identify gaps and inconsistencies - gaps and
and development of child(ren)); readiness for inconsistencies create conflict (measurement
enhanced breastfeeding error, unreliable reports)
SYNDROME Example: patient reported moderate pain score of 6/10
• Clinical judgment concerning a cluster of problems or but is smiling
risk nursing diagnosis

NCP | 4
2. Identification of Health Problems TYPES OF PLANNING
a. May need collaboration with other HCPs Initial
b. Example: A patient has difficulty turning to sides for • Used during admission assessment
3days since he reported 6/10 pain score after surgery • Based on intuitions
i. Acute pain: can be due to the incision site Ongoing
ii. Impaired skin integrity: occurs due to recently • Gathering of new information to set priorities for the
sutured incision shift
iii. Altered bed mobility: limited movement, not • Determines if initial plan was effective
able to change positions in bed due to pain Discharge
iv. Risk for infection • Process of anticipating needs for discharge
• Continuity of car
3. Formulation of the Diagnostic Statement
a. One-part DEVELOPING NURSING CARE PLANS
i. Problem/diagnostic label Informal
ii. Wellness & Syndrome • Health teaching
iii. CDU-CN Method: Formal
à Readiness for Enhanced Breastfeeding • Written or computerized guide that organize
b. Two-Part information
i. Problem & Etiology Standardized Care Plan
ii. Risk • Formal plan that specifies the nursing care for group
iii. CDU-CN Method: of clients with common needs
à Risk for infection related to alteration in skin integrity Individualized Care Plan
c. Three-Basic part • Tailored to meet unique needs of a client
i. Problem, Etiology and Signs & Symptoms
• Use of nursing diagnosis to develop goals and
ii. Actual interventions
iii. CDU-CN Method:
• Considerations:
1. Acute pain: a pain score of 6/10 related to presence of
o Kept with client’s individualized care plan in
surgical incision
the nursing unit (medical records)
2. Altered Bed Mobility: difficulty turning to sides related
o Provide detailed interventions and contain
to postoperative pain
additions and deletions
o Typically written
PROBLEM, SIGN AND SYMPTOM (DEFINE CHARACTERISTICS)
o Frequently includes checklist to efficiently
AND ETIOLOGY
manage time
INDEPENDENT LEARNING TASK 2
Based on your assessment findings for an UPPER
STUDENT CARE PLAN
RESPIRATORY TRACT INFECTION, formulate 3 nursing
diagnoses • Learning activity
o Be more lengthy and detailed
1. Impaired swallowing: aversion to swallowing related o Handwritten
to sore throat o Be presented in columns with a rationale
2. Risk for ineffective breathing pattern related to upper
respiratory inflammatory process PLANNING PROCESS
3. Risk for ineffective airway clearance related to
increased mucus secretions 1. SETTING PRIORITIES
4. Ineffective airway clearance: presence of thick mucus à Establishing a preferential sequence in addressing
secretions related to poor coughing reflex nursing diagnoses and interventions

PLANNING à Ranking Priority

• High (respiratory, cardiac related & safety)
Third phase (Outcome phase)
• Medium (non-life threatening)
• Deliberate, systematic phase of nursing process
• Low (focus on long term health care needs)
• Refers to client’s assessment data and diagnostic
à Use of Maslow’s Hierarchy of Needs
statements
***avoid classifying only physiological nursing diagnoses
Purpose: formulate client goals and nursing interventions
as HIGH priority always
o Prevent, reduce and eliminate health problems
NCP | 5
 à Mutually set with the client
2. ESTABLISHING GOALS AND OUTCOMES à Increase motivation
à Aim to achieve goals by implementing interventions à Attained set goals
• Goal (broad) = general objectives • REALISTIC/RELEVANT
• Desired Outcome = specific objectives à Client
Always consider the role of the client; must be alert and o Limitations
aware o Realistic goals to give them a sense of hope
Purpose: à Family
• Provide direction for planning nursing interventions o Resource available
• Serve as criteria for evaluating client progress o Healthcare facility
(effectiveness of interventions) • TIMED BASED
• Enable the client and nurse to determine when à General objective: To achieve pain relief
problem has been resolved à All HCT will aim to manage to reduce pain while being
• Help motivate the client and nurse to accomplish goal hospitalized
o Dependent on the nature of the problem
Example: malnourished client o Etiology/overall condition
à Consider the setting
GOAL: after 2 weeks of holistic nursing care, the child will have o Short term – the client’s pain is less than 5 on a
an improved nutritional status scale of 0 to 10 in 48 hours
Desired Outcome: child will gain 2 pounds after 5 days o Long term – Mr. X has decreased a pain score
Nursing interventions are implemented to achieve desired outcome below 3 by day of discharge

3. SELECTING APPROPRIATE INTERVENTIONS

Example: postoperative patient has not gotten out of bed
à Interventions are related to identified problems
GOAL: after 1 month of nursing care, patient will restore his
Example: Hyperthermia à intervention is tepid sponge
mobility function
Desired Outcome: Patient will get out of bed after 5 days with
bath to lower bad temperature
assistance from nurse with minimal signs of discomfort
Selecting interventions (NIC):
• Guided by SMART criteria of an objective 1. Domains
SMART 2. Classes
à SPECIFIC, MEASUREABLE, ATTAINABLE, 3. Interventions
RELEVANT/REALISTIC, TIME BASED
Types of Nursing interventions:
• SPECIFIC 1. Direct
à Precise • Performed by nurse through patient interaction
o The client will administer a self-injection by (administering medication, performing tepid sponge
discharge bath)
o The client will demonstrate infection control 2. Indirect
measures at home • Delegated by the nurse to another HCP;
à Singular interdisciplinary and environmental management
o The client’s lungs will be clear (nurse supervisor requests for staff nurse to change
o The client’s RR is maintained within 22 breaths per patient’s IV tubing)
minute 3. Independent
• MEASURABLE • initiated without physician’s order/autonomously
à Be guided by the standards performed by nurse (actions that provide continuous
o Body temperature = use Celsius or Fahrenheit physical care, emotional support, ongoing assessment,
o Pain score = Wong-Baker FACES pain Rating Scale comfort, teaching, and referrals)
Examples: 4. Dependent
o The child’s body temperature has decreased from • based on physician’s orders (medical orders); nurses
38.7 dC to at least 37.5 dC at the end of the shift are responsible in assessing the patient’s condition
o The client’s pain is less than 5 on a scale of 0 to 10 5. Collaborative/Interdependent
in 48 hrs • overlapping responsibilities among other HCT
• ATTAINABLE members

NCP | 6
Criteria for Choosing Nursing Interventions: b) When the intervention is not needed at the time
• Safety of assessment
• Achievable resources o defer the plan of care
• Congruent to patient’s beliefs and culture c) New data may indicate a need to change the
• Based on nursing knowledge and relevant science priorities of care
• Within law 2. Determining the need for assistance
a) Safely implement nursing
4. WRITING INDIVIDUALIZED NURSING CARE PLAN b) Reduce patient’s stress
à Clients are individuals with unique needs c) Support a nurse who lacks the knowledge or skills
• Based on the individual patient needs 3. Implementing nursing interventions
• Requires update, regular review as indicated a) Explain to client what interventions will be done
Must include: b) Ensure client’s privacy
à Subject c) Coordinate client care
à Verb 4. Supervising delegated care
à Condition a) The nurse is responsible for overall care
à Time b) Activities are implemented according to the care
OUTCOME = PATIENT CARE PLAN plan
IMPLEMENTATION PHASE c) Maintains an open communication through
CHARACTERISTICS: documentation
• Action oriented 5. Documenting nursing activities
• Client centered a) Must complete necessary recording after carrying
• Outcome directed out the nursing activities
b) Must not be recorded in advance
GUIDING PRINCIPLES OF IMPLEMENTATION: c) Recording must be up to date and accurate
1. Performed based on the first three phases of nursing d) Immediate recording helps safeguard the client
process e) Hand-off/Endorsement: the transfer of essential
2. Nurse continually reassesses the patient every contact info and care
3. Expect to modify (tailoring interventions) when the
patient manifests different symptoms, or as the patient EVALUATING PHASE
progress deteriorates à Phase of nursing process that compares the data with
the desired outcomes
IMPLEMENTING SKILLS à Planned, ongoing, and purposeful activity
COGNITIVE SKILLS
• Nurse intellectually understands problem Purpose:
• Critical analysis • Determine the patient progress based on achievement
• Creative of goals
• Assess the effectiveness of the nursing care plan
INTERPERSONAL SKILLS
• Activities that require nonverbal/verbal approaches Concludes whether the nursing interventions are:
• Therapeutic communication techniques • Terminated
• Building rapport and trust • Continued
• Changed or Modified
TECHINICAL/PSYCHOMOTOR SKILLS
• Purposeful hands-on skill PROCESS
• Nurse’s actual skills in handling equipment and the 1. Collecting data
client 2. Comparing data with desired outcomes
a. Goal was met
PROCESS OF IMPLEMENTING b. Goal was partially met (short-term is
1. Reassessing the client achieved, but long-term may not have been
a) Ascertain that intervention is still needed: achieved)
Example: Disturbed Sleeping Pattern → nurse goes to c. Goal was not met
administer sleeping pill but finds that patient is already 3. Relating nursing activities to outcomes
asleep → no more need for intervention 4. Drawing conclusion
5. Continuing, modifying, or terminating nurse care plan

NCP | 7
 HOSPITAL REQUIREMENTS NURSING CARE PLAN
à Nursing assessment
à Nursing care plan
à Drug therapeutic record
à Health teaching plan
à Play therapy (for infants to school-age)

à Sample BLM

Physiologic overload = pain is too much for body to handle

Physiologic deficit = “ineffective”

OLDCART = onset, location, duration, characteristics,

aggravating factors, relieving factors, treatment

SCIENTIFIC BASIS/SIGNIFICANCE supports the NURSING

DIAGNOSIS (source in APA format)

NCP | 8