W8k9ko90z Overview of The Nursing Process

Evolve.
Adapt.
Overcome.
CEFI is now ready.
Overview of the Nursing

Process
FRANCISCO JAVIER J. RANOLA, RN

College of Nursing
COLLEGE OF NURSING
Calayan Educational Foundation, Inc.
INTRODUCTION TO HEALTH ASSESSMENT

A. Overview of Nursing
Process (ADPIE)
A ssessment
D iagnosis
P lanning
I mplementation
E valuation
COLLEGE OF NURSING
A. OVERVIEW OF NURSING PROCESS (ADPIE)
ADPIE process helps medical professionals remember

the process and order of the steps they need to take to
provide proper care for the individuals they are treating.
COLLEGE OF NURSING
NURSING PROCESS
• is a series of organized steps designed for nurses to

provide excellent care. It consist of 5 dynamics and
interrelated phases: ADPIE
• a systematic method of providing nursing care

COLLEGE OF NURSING
NURSING PROCESS
• It provides a framework for planning and implementing

nursing care
• This involves a problem-solving approach that enables

the nurse to identify patient problems and potential at-
risk needs (problems) and to plan, deliver, and evaluate
nursing care in an orderly, scientific manner.
COLLEGE OF NURSING
How the Nursing Process applies to the scientific Method
Scientific Method Nursing Process

State an observed problem Assessment
Form a hypothesis Nursing Diagnosis
about the problem
Develop a method Outcome identification and

to test the hypothesis Planning
Collect the data Implementation

and analyze the data
Draw conclusions Evaluation
about the hypothesis
COLLEGE OF NURSING
NURSING PROCESS: ASSESSMENT

• basis for accurate diagnosis
• provides basis for effective nursing care
• helps in effective decision making

COLLEGE OF NURSING

• promotes holistic nursing care
• provides effective and innovative nursing care
• collects data for nursing research
• evaluates the nursing care

COLLEGE OF NURSING

• Involves a systematic, collection of patient data (collect data,
validate data, organize data, document data).
1. Data Collection from a primary source (patient) secondary

sources (family, friends, health care professionals, medical
records, etc.)
COLLEGE OF NURSING

Nursing Health History:
• Biographic data
• chief complaint/ present illness
• past medical history- surgery, medications, habits and lifestyle
patterns (alcohol, tobacco, caffeine, drugs, etc), sleep pattern,
exercise, nutrition
• family history
• spiritual health
• review of systems
COLLEGE OF NURSING

1. Data Collection
• both subjective and objective data
• subjective data: collected through interview
• objective data: collected through Physical Assessment, review of

laboratory and diagnostic test results, review other available
Health Information
COLLEGE OF NURSING

1. Data Collection
Types of Data
• Subjective data
ex. “ Masakit ang ulo ko.” as
verbalized by the patient.
• objective data
ex. BP= 140/90
Facial grimace
COLLEGE OF NURSING

2. Data Validation
• The information gathered during the assessment phase must
be complete, factual, and accurate. Because the nursing
Diagnosis interventions are based on this information.
• Validation is the act of “double-checking” or verifying data to

confirm that it is accurate and factual.
COLLEGE OF NURSING

3. Organization of Data
• The nurse uses a written or computerized format that

organizes the assessment data systematically.
• The format may be modified accordingly to the client's

physical status.
COLLEGE OF NURSING

4. Data Documentation
• 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.
COLLEGE OF NURSING

4. Data Documentation
* Data are recorded in a factual manner and not interpreted by

the nurse
E.g. : the nurse record the client's breakfast intake as “coffee

240ml, juice 120 ml, 1 egg”. Rather than as “ meal taken with
good appetite”.
COLLEGE OF NURSING
NURSING PROCESS: DIAGNOSIS

• Nursing Diagnosis is a clinical judgment about individual,
family, or community responses to actual or potential health
problems
• Nursing Diagnosis provide the basis for selection of nursing

interventions to achieve outcomes to which the nurse is
accountable (NANDA, 1997)
COLLEGE OF NURSING

Nursing Diagnosis has 3 components:
1. Label an actual or potential health problems that nursing

care can affect
2. Related factors: factors that may precede, contribute to or be

associated with the human response
3. Evidence - Signs/Symptoms that point to the Nursing

Diagnosis.
COLLEGE OF NURSING

Types of Nursing Diagnosis (NANDA-I Approved):
Problem -focused Nsg. Dx/ (Actual) is a statement about a

health problem that the client has, and could benefit from nursing
care. It includes a related factor (causative) and the as exhibited
by.
COLLEGE OF NURSING

Types of Nursing Diagnosis (NANDA-I Approved):
Problem -focused Nsg. Dx/ (Actual):

Problem: Impaired Physical Mobility
Etiology: Incisional Pain
Symptoms: as evidenced by restricted turning and
positioning
Example:
Impaired Physical Mobility related to Incisional Pain
as evidenced by restricted turning and positioning
COLLEGE OF NURSING

Types of Nursing Diagnosis:
A Risk Dx is a statement about a health problem that the client

doesn't have yet, but is at a higher than normal risk of developing
in the near future. They do not have related factors because they
have not yet occured. Instead, risk diagnosis has risk factors
Example:
Risk for Injury, Risk for Loneliness, Risk for Ineffective
peripheral Tissue Perfusion
COLLEGE OF NURSING

Comparison of selected Nursing Dx and Medical Dx
Nursing Dx Medical Dx
• Ineffective Breathing Pattern • Chronic Obstructive

• Activity Intolerance Pulmonary
• Acute Pain Disease (COPD)
• Body Image Disturbance • Cerebrovascular Accident
• Risk for Altered Body • Appendectomy
Temperature • Amputation
• Strep Throat
COLLEGE OF NURSING
NURSING PROCESS: PLANNING

This includes the formulation
of guidelines that establish the
proposed course of nursing action
in the resolution of nursing Dx
and the development of the
client's plan of care.
COLLEGE OF NURSING

The four Critical Elements of Planning
1. Establishing priorities
• The nurse examines the client's nursing Dx and ranks them in
order of physiological or psychological importance
• one of the most common methods of selecting priorities is the
consideration of Maslow's hierarchy of needs.
*life threatening vs. non-life threatening diagnosis.
What are those needs?
COLLEGE OF NURSING
Prioritizing nursing Dx with Accompanying Nursing Implications

PRIORITY DIAGNOSIS NURSING IMPLICATION
High > Ineffective Breathing * Assess breath sounds
Pattern * Auscultate lungs
* Monitor Vital signs
* Reposition client
Moderate > Risk for impaired skin * Perform comprehensive skin assessment
integrity * Keep skin clean and dry
* Provide turning schedule
Low > Ineffective coping * Assist to identify problem
* Encourage keeping daily journal
* Teach client strategies for expressing
feelings/diversional activities
COLLEGE OF NURSING

The four Critical Elements of Planning:
2. Setting goals
3. Developing expected outcomes
4. Planning nursing Interventions (with collaboration and
consultation as needed)
COLLEGE OF NURSING

2. Setting goals
• A goal is a specific and measurable objective designed to reflect

the patient highest level of wellness and independence in
function
• a goal should be SMART.....

COLLEGE OF NURSING

2. Setting goals
A goal should be SMART.....
• Specific
• Measurable
• Attainable
• Realistic
• Time-bound
COLLEGE OF NURSING

2. Setting goals
There are 2 categories in goals:

* Short term - can be met fairly and quickly (hours or days)
* Long term - cover a long time span (months or years)
COLLEGE OF NURSING

2. Setting goals
e.g.
The patient's lung will remain clear from day 1 post operatively
upto discharge.
COLLEGE OF NURSING

3. Developing Expected Outcomes
• defines when a patient goal has been met and assist in
evaluating the extent to which the nursing dx has been
resolved.
e.g.
Goal: The patient lung will remain clear from day 1 post
operatively upto discharge.
Expected outcomes:
• the sputum will remain white
• The lungs will be clear to auscultation
COLLEGE OF NURSING
Example of Goals/Outcomes to Relieve Problems

Problem Statement of the Related Patient Goal/Outcome
Nursing Diagnosis
Pain within 8 hours, patient will report pain is absent

or diminished
Imbalanced nutrition: By 01/17/19, patient will reach target weight of
More than Body 122 lb./ 55.45 klgs.
Requirements
Impaired Physical Before discharge, patient will ambulate length of

Mobility hallway independently.
COLLEGE OF NURSING

4. Planning Nursing Intervention (with Collaboration &
• Nursing Interventions are treatment, based upon clinical

judgment and knowledge that a nurse performs to enhance
patient (client outcomes)
COLLEGE OF NURSING

• Dependent - a nursing action based on the instruction of

another professional like physician
• Independent - requires no supervision
• Interdependent - actions carried out by the nurse in
collaboration with another health care professional like
Radiologist, Dietician, Midwife, etc.
COLLEGE OF NURSING

Dependent - a nursing action based on the instruction of
another professional like physician.
e.g.
medication administration
intravenous fluids
COLLEGE OF NURSING

4. Planning Nursing Intervention (with
Collaboration & consultation as
needed)
Independent - requires no
supervision
e.g. tepid sponge bath

COLLEGE OF NURSING

4. Planning Nursing Intervention (with Collaboration & consultation
as needed)
Interdependent - actions carried out by the nurse in
collaboration with another health care professional like Radiologist,
Dietician, Midwife, etc.
e.g. assist patient with physical therapy exercises

COLLEGE OF NURSING

• Nursing Interventions must be specifically designed to meet

the identified goal
• Each intervention should be reported by a scientific rational.

COLLEGE OF NURSING
NURSING PROCESS: IMPLEMENTATION

• The implementing phase is where the nurse follows through
on the decided plan of action. This plan is specific to each
patient and focuses on achievable outcomes
• Implementation can take place over the course of hours,

days, weeks, or even months.
COLLEGE OF NURSING

• Actions involved in a nursing care plan include monitoring the
patient for signs of change or improvement, directly caring for
the patient or performing necessary medical tasks, educating
and insructing the patient about further health management,
and referring or contacting the patient for follow-up
e.g. monitoring of intake and urine output every hr/ shift

COLLEGE OF NURSING
NURSING PROCESS: EVALUATION

• Once all Nursing Interventions/Actions have been taken place,
the nurse completes an evaluation to determine of the goals for
patient wellness have been met.
• The possible patient outcomes are generally described under

three terms:
1. patient's condition improved
2. patient's condition stabilized
3. patient's condition deteriorated, died, or discharged
COLLEGE OF NURSING

• In the event, the condition of the patient has shown no
improvement, or if the wellness goals were not met, the
nursing process begins again from the first step.
• All nurses must be familiar with the steps of the nursing

process.
COLLEGE OF NURSING
Sample chart...
Focus Data Action Response
Pain Subjective Data: • assess pain felt pain relief from
“Masakit ang ulo by the patient pain scale of
ko,” as verbalized • instructed 7/10 to 4/10
by the patient, pain patient to have
scale of 7/10 a rest
Objective Data: • administer pain
• BP=140/90 medications as
• facial grimace ordered y the
MD

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Evolve.

Overview of the Nursing

FRANCISCO JAVIER J. RANOLA, RN

INTRODUCTION TO HEALTH ASSESSMENT

ADPIE process helps medical professionals remember

• is a series of organized steps designed for nurses to

• a systematic method of providing nursing care

• It provides a framework for planning and implementing

• This involves a problem-solving approach that enables

Scientific Method Nursing Process

Develop a method Outcome identification and

Collect the data Implementation

NURSING PROCESS: ASSESSMENT

• provides basis for effective nursing care

• helps in effective decision making

NURSING PROCESS: ASSESSMENT

• provides effective and innovative nursing care

• collects data for nursing research

• evaluates the nursing care

NURSING PROCESS: ASSESSMENT

1. Data Collection from a primary source (patient) secondary

NURSING PROCESS: ASSESSMENT

NURSING PROCESS: ASSESSMENT

• subjective data: collected through interview

• objective data: collected through Physical Assessment, review of

NURSING PROCESS: ASSESSMENT

NURSING PROCESS: ASSESSMENT

• Validation is the act of “double-checking” or verifying data to

NURSING PROCESS: ASSESSMENT

• The nurse uses a written or computerized format that

• The format may be modified accordingly to the client's

NURSING PROCESS: ASSESSMENT

NURSING PROCESS: ASSESSMENT

* Data are recorded in a factual manner and not interpreted by

E.g. : the nurse record the client's breakfast intake as “coffee

NURSING PROCESS: DIAGNOSIS

• Nursing Diagnosis provide the basis for selection of nursing

NURSING PROCESS: DIAGNOSIS

1. Label an actual or potential health problems that nursing

2. Related factors: factors that may precede, contribute to or be

3. Evidence - Signs/Symptoms that point to the Nursing

NURSING PROCESS: DIAGNOSIS

Problem -focused Nsg. Dx/ (Actual) is a statement about a

NURSING PROCESS: DIAGNOSIS

Problem -focused Nsg. Dx/ (Actual):

NURSING PROCESS: DIAGNOSIS

A Risk Dx is a statement about a health problem that the client

NURSING PROCESS: DIAGNOSIS

• Ineffective Breathing Pattern • Chronic Obstructive

NURSING PROCESS: PLANNING

NURSING PROCESS: PLANNING

Prioritizing nursing Dx with Accompanying Nursing Implications

NURSING PROCESS: PLANNING

NURSING PROCESS: PLANNING

• A goal is a specific and measurable objective designed to reflect

• a goal should be SMART.....

NURSING PROCESS: PLANNING

NURSING PROCESS: PLANNING

There are 2 categories in goals: