INTRODUCTION

Assessment is the first and most critical phase of the nursing process. If data collection is
inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the
remaining phases of the process: diagnosis, planning, implementation, and evaluation. They
are closely interrelated. Although the assessment phase of the nursing process precedes the
other phases in the formal nursing process, nurses are always aware that assessment is
ongoing and continuous throughout all the phases of the nursing process. The nursing process
should be thought of as circular, not linear.

REVIEW OF THE NURSING PROCESS

- A systematic, client-centered method for structuring the delivery of nursing care.

- A goal-oriented method of caring that provides a framework for nursing practice.
- Provides a structure for the nursing practice - a framework in which nurses use
knowledge and skills to express human caring.
- The nurse considers the patients as the central figure in the plan of care and confirms
the appropriateness of all aspects of nursing care by observing the patients responses.
- Entails gathering and analyzing data in order to identify client strengths and potential or
actual health problems, and continually reviewing a plan of nursing interventions to
achieve mutually agreed outcomes.
- Designed to help the nurse form thinking habits that can help him/her gain the
confidence and skills needed to think critically in the clinical setting

PURPOSES OF THE NURSING PROCESS

1. To identify a client’s health status

2. To identify actual or potential health care problems or needs
3. To establish plans to meet the identified needs.
4. To deliver/execute specific nursing interventions to meet those needs.

PHASES OF THE NURSING PROCESS

1. ASSESSMENT - collecting, organizing, validating and documenting client’s data. The

purpose is to establish a database about the client’s response to health concerns and
illness and the ability to manage health needs.

2. DIAGNOSIS - analyzing and synthesizing data. Its purpose is to identify client’s

strengths and health problems that can be prevented or resolved by collaborative and
independent nursing interventions. To develop a list of nursing and collaborative
problems.

3. PLANNING - determining how to prevent, reduce, or resolve the identified priority

client’s problems; how to support client’s strength; and how to implement nursing
interventions in an organized, individualized and goal-directed manner. Its purpose is to
develop an individualized care plan that specifies client’s goals/desired outcomes, and
related nursing interventions.

4. IMPLEMENTATION - carrying out or delegating and documenting the planned nursing

interventions. Its purpose is to assist the client to meet the desired goals/outcomes;
promote wellness; prevent illness and disease; restore health; and facilitate coping with
altered functioning.

5. EVALUATION - measuring the degree to which goals/outcomes have been achieved

and identifying factors that positively and negatively influence goal achievements. The
purpose is to determine whether to continue, modify, or terminate the plan of care.
 NOTE: In each phase of the process, the nurse and patient work together as partners; the
patient’s health state and resources influence the patient’s level of participation. For the
infant or unconscious or uncooperative patient, the phases of the process are worked
through the help of the family member or support person.

PHASES OF THE NURSING PROCESS

A. HEALTH ASSESSMENT (ASSESSING)

- the systematic and continuous collection, organization, validation, and

documentation of data
- a continuous process carried out during all phases of the nursing process
- focuses on how the client’s health status affects his activities of daily living and
how the client’s activities of daily living affect his/her health and is therefore client-
centered

STEPS OF HEALTH ASSESSMENT

The assessment phase of the nursing process has four major steps:

1. Collection of subjective data

2. Collection of objective data
3. Validation of data
4. Documentation of data

CHARACTERISTICS OF THE STEPS:

Although there are four steps, they tend to overlap and you may perform two or three steps
concurrently.

PREPARING FOR THE ASSESSMENT:

1. Review the medical record, if available, because it provides background about chronic
diseases and gives clues to how a present illness may impact the client’s activities of daily
living.

2. Remember to keep an open mind and to avoid premature judgments that may alter your
ability to collect accurate data.

3. Educate self about the client’s medical diagnosis and tests performed. The client may have
a medical diagnosis that you have never heard of or that you have not dealt with in the
past, or a test result that is abnormal and that you are not familiar with this test. At that
time, you should consult the necessary resources (textbook or laboratory manual) to learn
about the test and the implications of its findings.

4. Reflect on your own feelings regarding your initial encounter with the client. You need to
take time to examine your own feelings so you avoid biases, judgment, and the tendency
to project your own feelings onto the client.

5. Remember to obtain and organize materials (e.g., forms for health history and PE) and
equipment (e.g., stethoscope, thermometer, otoscope) that you will need for the
assessment.
STEP 1: COLLECTION OF SUBJECTIVE DATA

These are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness),
perceptions, preferences, beliefs, ideas, values, and personal information that can be elicited
or verified only by the client. To elicit accurate subjective data, learn to use effective
interviewing skills with a variety of clients in different settings. The major areas of subjective
data include:

a. Biographical information (name, age, religion, occupation)

b. Physical symptoms related to body (e.g., eyes and ears, abdomen)
c. Past health history
d. Family history
e. Health and lifestyle practices (e.g., health practices that put the client at risk,
nutrition, activity, relationships)

STEP 2: COLLECTION OF OBJECTIVE DATA

These are directly observed by the examiner; these data include:

a. Physical characteristics (e.g., skin color, posture)

b. Body functions (e.g., heart rate, respiratory rate)
c. Appearance (e.g., dress and hygiene)
d. Behavior (e.g., mood, affect)
e. Measurements (e.g., blood pressure, temperature, height, weight)
f. Results of laboratory testing (e.g., platelet count, x-ray findings)

NOTE: Data taken from the client’s relatives are considered as OBJECTIVE DATA, upon
documentation, entries are NOT written as direct quotations… for ex: (“Nagsuka yan kanina,
mga tatlong beses” as verbalized by the client’s mother); but as... (Mother of the patient
reported that the client vomited 3x this morning) Reference: Philippine Heart Center

Rating a pain scale to measure the intensity of pain is also part of the objective data. It is
written as: (Rated felt pain at a scale of 2, wherein 3 – severe pain, 2 – moderate pain, 1- mild
pain, and 0 – no pain at all) Reference: Philippine Heart Center

STEP 3: VALIDATION OF DATA

It is a crucial part of assessment that often occurs along with data collection. It serves to
ensure that the assessment process is not ended before all relevant data is collected, and it
helps to prevent documentation of inaccurate information

STEP 4: DOCUMENTATION OF DATA

It is an important step of assessment because it forms the database (all information about a
client) for the entire nursing process and provides data for all other members of the health care
team. Thorough and accurate documentation is vital to ensure valid conclusions are made
when the data are analyzed in the second step of the nursing process.

B. DIAGNOSING

- The second phase of the nursing process

- Nurses use critical-thinking skills to interpret assessment data and identify client
strengths and problems.
- Pivotal step in the nursing process.
- Activities preceding this phase are directed toward formulating the nursing
diagnosis; the care planning activities following this phase are based on the nursing
diagnosis.
- Process of data analysis and problem identification.
 - A form of decision making that the nurse uses to arrive at judgments and
conclusion about patients responses to actual or potential health problems.

NANDA (North American Nursing Diagnosis Association)

- To define, refine and promote taxonomy of Nursing Diagnosis terminology of general
use to professional nurses.
- Taxonomy was revised and is now referred as taxonomy II

DIAGNOSIS - a statement or conclusion regarding the nature of a phenomenon

DIAGNOSTIC LABELS - standardized NANDA names for the diagnoses

NURSING DIAGNOSIS
- Refers to the client’s problem statement, consisting of the diagnostic label plus etiology
(causal relationship between a problem and its related or risk factors)
- A clinical judgment about the individual, family, or community responses to actual and
potential health problems/life processes.
- An actual or potential health problem that independent nursing intervention can prevent
or resolve.
- Provides the basis for the selection of nursing interventions to achieve outcomes for
which the nurse is accountable.
- A judgment made only after thorough systematic data collection.
- Describes a continuum of health status; deviations from health, presence of risk factors
and areas of enhanced personal growth.

COMPONENTS OF A NURSING DIAGNOSIS

1. Problem (diagnostic label) and definition

- Problem Statement – describes the client’s health problem/status or response
for w/c nursing therapy is given
- its purpose is to direct the formation of client goals & desired outcomes & it may
suggest some nursing interventions
- Diagnostic Label – needs to be specific; when the word SPECIFY follows a
NANDA label, the nurse states the area in which the problem occurs
oExamples: Deficient knowledge (medications)
Deficient knowledge (dietary adjustments)
oQualifiers – are words that have been added to some NANDA labels to give
additional meaning to the diagnostic statement
oExamples:
deficient – inadequate in amount, quality or degree, not sufficient, incomplete
impaired – made worse, weakened, damaged, reduced, deteriorated
decreased – lesser in size , amount or degree
ineffective – not producing the desired effect
compromised – to make vulnerable to threat
- each diagnostic label approved by NANDA carries a definition that clarifies its
meaning
oExample: Activity Intolerance - refers to insufficient physiological or psychological
energy to endure or complete required or desired daily activities

2. Etiology (related factors & risk factors)

- identifies one or more probable causes of a health problem, gives direction to the
required nursing therapy & enables the nurse to individualize the client’s care
- the probable causes of activity intolerance include: sedentary lifestyle, generalized
weakness, immobility or bed rest, imbalance bet. O2 supply /demand

Example: Constipation r/t long-term laxative use, inactivity and insufficient fluid intake

3. Defining characteristics
 - are clusters of signs & symptoms that indicate the presence of a particular
diagnostic label
- for an actual nursing diagnosis, the defining characteristics are the client’s signs &
symptoms
- for a risk nursing diagnosis, no subjective & objective signs are present
Collaborative Problems
- are multidisciplinary problems w/ a diagnostic label “potential for complication”
- a type of potential problem that nurses manage using both independent & physician-
prescribed interventions
- should include in the diagnostic statement both the possible complication they are
monitoring & the disease or treatment that is present
- include disease, complication & etiology
- independent nursing interventions focus mainly on monitoring the client’s condition &
preventing the development of the potential complication

Examples:

Potential Complication of Childbirth: hemorrhage r/t uterine atony, retained placental fragments
and bladder distension

Potential Complication of Pneumonia: atelectasis, respiratory failure, pleural effusion,

pericarditis & meningitis

C. PLANNING

* Now that you have collected data about your patient, analyzed those data, and formulated
the nursing diagnosis, you are ready to begin with the planning phase.

 Nurse’s function: developing a plan of care to assist the patient to an optimum or

improved level of functioning in the problem areas identified in the nursing diagnosis.
 The nurse analyzes the strengths and weaknesses of the patient, the patient’s family,
the nursing personnel, the health care facility and the available resources.
 Nurse works with the client to set goals/outcomes to prevent, correct or relieve health
problems and determine appropriate nursing interventions.

The Planning Process:

1. setting priorities
2. establishing client goals/desired outcomes
3. selecting nursing interventions/planning nursing interventions
4. writing individualized nursing interventions on care plans

1. Setting priorities
 The process of establishing a preferential sequence for addressing nursing diagnoses
and interventions.
 During the process, the nurse and the patient, whenever possible, determine which
problems identified during the assessment phase are in need of immediate attention
and which problems may be dealt with at a later time.
 It is not necessary to resolve all high-priority diagnoses before addressing others.
High priority diagnoses may be addressed partially and then deal with diagnoses of
lesser priority. Since clients may have several problems, the nurse often deals with
more than one diagnosis at a time.
 Priorities change as the client’s responses, problems, and therapies change.

Guides for Setting Priorities:

a. Maslow’s Hierarchy of Needs

Ex: problems identified: dyspnea, social isolation, and self-care deficit
 - Difficulty of breathing must be given attention since it is included in
Maslow’s first level needs.

b. ABC’s (airway, breathing, circulation) of Life

Ex: A patient with pneumonia finds it hard to breathe and the BP is 140/90
mmHg.
- Priority is the problem of airway clearance (since difficulty of breathing
may be alleviated if the airway is cleared) then, the problem on increase
in BP.

NOTE: The 2010 American Heart Association Guidelines for CPR stipulated an
update regarding the protocol to be followed in performing Basic Life Support
measures for patients who suffer from cardiac arrest, they reiterated for the
sequence to be changed to chest compressions first before rescue breaths (CAB
rather than ABC).

REFERENCE: http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S685

c. Life Preservation
Ex: convulsion secondary to hyperthermia, impaired nutrition: less than body
requirements and impaired physical mobility
- Priority is convulsion, specifically the prevention of injury and lowering of body
temperature, then impaired nutrition, then the impairment in physical mobility.

When setting priorities, the following can also be considered:

 the problems the patient feels are most important if this priority does not interfere with
medical treatment

Example: A patient who needs to be repositioned every 2 hours prefers to be

undisturbed. The nurse, in this case should discuss with the patient the importance of
this therapeutic regimen to resolve the conflict.

 effect of potential problems

Example: A need to start a routine frequent turning and positioning of a bed ridden
patient to prevent bedsores and contractures; even though the patient may not see
this as important, prevention of the potential complications of prolonged bed rest is a
high priority.

 costs, resources available, personnel, time needed to plan for and treat each of the
patient’s identified problem

2. Establishing Client Goals / Desired Outcomes

 A goal describes a change in the patient’s health status or functioning, a desired
outcome of nursing care that which you hope to achieve with your patient. It
demonstrates a direct resolution of the problem statement.
 Other terms: expected outcome, predicted outcome, outcome criterion, objective
 Goals can be classified as whether short or long term goals.

a. Short-term Goals
 Identify outcomes in patient’s status or behavior that can be achieved fairly
quickly in a matter of hours or days
 Especially appropriate to acute care settings such as ICU, ER, and RR
wherein the patient’s conditions are unstable and their physical status is often
changing rapidly.

Examples:
1. The patient will pass out flatus within 24 hours post-operatively.
 2. Patient’s temperature will decrease from 38.5 ºC to 37 ºC within 1
hour.

b. Long-term Goals
 Give direction for nursing care over time, usually more than a week.
 Often used for clients who have chronic health problems

Example: The patient will demonstrate the ability to care for his colostomy
within 1 month after surgery.

Situation: Frail elderly man with a pressure ulcer

Long-term goal:

The patient’s sacral area will exhibit no evidence of a pressure ulcer after a month

Short-term goals:

Patient’s sacral pressure ulcer will demonstrate absence of purulent drainage within
a week of initiating wound care.

At the end of the first week, the patient’s pressure ulcer would have decreased in
size by a quarter inch.

Other Examples:

Short -term goal: Client will raise right arm to shoulder level.
Long-term goal: Client will regain full use of right arm in 6 weeks.

Guidelines for Writing Goals:

S – Specific
M – Measurable
A – Attainable
R – realistic
T – Time bounded

 The goal statement should be specific. The goal statement is a patient behavior that
demonstrates reduction of the problem identified in the nursing diagnosis.

Nursing Dx: bathing self-care deficit r/t presence of cast in the left leg
Goal: The patient will bathe with assistance within period of hospitalization.

 The goal statement should be measurable. Write goals in observable or measurable

terms whenever possible. Avoid terms such as good, normal, adequate, and improve,
increase. These words make the goal unclear/vague.

VAGUE GOAL: The patient’s breathing will improve within the shift.
OBSERVABLE/MEASURABLE GOAL: The patient will breathe without using his
accessory muscles for breathing by tomorrow.

VAGUE GOAL: The patient will ambulate by tomorrow.

OBSERVABLE/MEASURABLE GOAL: The patient will ambulate with assistance from
bed to bathroom by tomorrow.

 The goal statement should be attainable and realistic.

a. It is realistic for the patient’s capabilities in the time span you designate your goal.

Example:
 The patient will be able to drink fluid amounting to 1200mL within an 8-hour
period.

It may be impossible to state that the patient will be able to drink fluid amounting
to 1200 mL within an hour.

b. It is realistic for the nurse’s level of skill and experience. (If the nursing diagnosis is
dealing with a problem beyond the nurse’s role, the best course of action is to refer
the problem to the appropriate professional.)

Example: Nursing Dx: imbalanced nutrition: less than body requirements r/t
refusal to eat hospital food

This case may be referred to the dietitian, since the etiology of the problem is not
modified through the nurse’s action.

 The goal statement should be time bounded. All goals include a time at which point the
patient is to be evaluated for goal achievement.

 The goal is congruent with and supportive of other therapies. (Nursing goals for the
patient don’t contradict or interfere with the work of other professionals caring for the
patient).

EXAMPLE:

Doctor’s order: Rehydrate patient with IV therapy 500cc for 2 hours; diet is NPO

INCORRECT GOAL: “The patient will drink at least 6-8 glasses of water within the
shift” (This is not congruent with the doctor’s order – NPO.

The nurse may rather focus her goal to have fluid intake through IV)

Doctor’s order: Complete bed rest with bathroom privileges.

INCORRECT GOAL: Patient will ambulate along the corridors within the shift.

MORE APPROPRIATE GOAL: Patient will ambulate from bed to bathroom within the
shift.

 Whenever possible, the goal is important and valued by the patient, the nurses and the
physician.

Patient – will be more motivated to reach the goal

Nurse – will be more likely to carry out the care
Physician – understanding and support of nursing goals will help to assure congruence
with medical treatment.

 Write goals in terms of patient outcomes, NOT nurse activities. Avoid statements that
start with enable, facilitate, allow, let, permit, or similar verbs followed by the word client.
These verbs indicate what the nurse hopes to accomplish, not what the client will do.

EXAMPLE:

INCORRECT: Promote urinary elimination.

CORRECT: Patient will void at least once within 6 hours

INCORRECT: Maintain client hydration.

CORRECT: Client will drink 100 mL of water/hour.
  Derive each goal from only one nursing diagnosis. Keeping the goal statement
related to only one nursing diagnosis facilitates evaluation of care by ensuring that
planned nursing interventions are clearly related to the diagnosis.

 Keep the goal short.

Formula for Writing a Goal Statement:

Goal Statement = patient’s behavior + criteria of performance + time + conditions (if needed)

Patient’s behavior – an observable activity that the patient will demonstrate (The word
patient may be omitted when writing the goal, since the goal always refer to the patient.)

Criteria of performance – the level at which the patient will perform the behavior (how
well? how long? how far? how much?)

Time – designated time or date when the patient should be able to achieve the behavior

Condition – the circumstances, if important, under which the behavior will be performed

Examples of Goal Statements:

1. Nursing Diagnosis: Imbalanced nutrition: more than body

requirements r/t poor eating habits
Goals: Will lose 20 lbs. within 12 wks. (Aug. 2008)
Will reach target weight of 122 lbs. by Aug. 15, 2008
Body weight will decrease by 2 lbs after a week of regular exercise

2. Nursing Diagnosis: Impaired physical mobility r/t general muscle weakness

Goal: Before discharge, patient will ambulate length of hallway independently

3. Nursing Diagnosis: hyperthermia r/t infectious process

Goal: Body temperature will decrease from 38.5 0C to 37.50C within 2 hours after
administering TSB.

4. Nursing Diagnosis: acute pain r/t post surgical incision

Goal: verbalization of decreased pain from a scale of 2 to 1(where 3=severe, 2=moderate,
1=mild, 0=no pain) within the shift

5. Nursing Diagnosis: risk for infection r/t presence of open wound on the right forearm
Goal: will not manifest any sign of infection during hospitalization

3. Planning Nursing Interventions / Selecting Nursing Interventions

 Nursing Interventions
- activities the nurse plans and implement to help a patient achieve identified goal
- any treatment based on clinical judgment and knowledge that the nurse performs
to enhance patient outcomes
 Rationale of Nursing Interventions– based on principles and theories from various
discipline (anatomy and physiology, psychology, sociology, etc.)
- not necessary to be written in an NCP, but for student nurses, this is a sort of
practice and it is important to know the rationale because the nursing process is
incomplete and potentially unsafe unless nurses base the choices of nursing
action on appropriate rationale.

Components of a Nursing Intervention

a. PDx (Diagnostic)
ex: weighing, VS, Hgt monitoring, measuring abdominal circumference
b. PTx (Therapeutic)
ex: Administering of Paracetamol 500 mg. 1 tab. q4H as ordered by the physician,
enforce fluid intake

c. PEd (Education or Health teaching)

ex: Instruct the patient on proper wound dressing
4. Writing Individualized Nursing Interventions
 The nurse writes the chosen/planned nursing interventions on the care plan.
 Nursing interventions on the care plan should be dated when they are written and
reviewed regularly at intervals that depend on the individual’s needs.

EXAMPLES OF NURSING INTERVENTIONS

Nursing Diagnosis: impaired urinary elimination r/t previous indwelling catheterization

Short-term goal: The patient will void at least once 6 hours after the removal of catheter.

Interventions:
- Record intake and output for 24 hours.
- Apply alternate hot and cold compress for 15 minutes on hypogastric area every
2 hours.
- Offer assistance to the bathroom every 2 hours.
- Provide privacy for voiding attempts.
- Encourage fluid intake of at least 1 glass of water every hour.
- Encourage voiding attempt in sitz bath, tub bath or shower to enable to void in 6
hour.

D. IMPLEMENTING
 putting the nursing care plan into action to achieve the expected outcome; doing
phase of the nursing care plan
 The nurse performs nursing interventions to resolve or reduce the identified nursing
problem on the patient, with the patient, and for the patient.
 Implies that the patient is not a passive recipient of care but must always be regarded
as an active participant in his care
 involves:
 giving nursing care / carrying out the planned nursing activities
 delegating the care to another health care team member
 documenting and validating care
 continuing data collection

Aspects of the Nurse’s Role in Implementation of Care:

a. Care aspects
 focuses on promoting, maintaining, and restoring the patient’s physical or
psychosocial well-being
 examples: reassuring the anxious patient; placing the patient to a comfortable position
b. Curative
 activities which fall under the nurse’s dependent functions
c. Protective
 measures to reduce environmental hazards (physical, chemical, bacteriological, and
radiological)
d. Teaching
 all activities the nurse engages in to teach health maintenance and promotion,
prevention of illness, and rehabilitation to individuals and families
e. Patient advocate
 when the nurse speaks in behalf of the patient

The mentioned aspects of the nurse’s role are in no way mutually exclusive. A nursing
measure designed primarily to promote comfort can be considered as having other aspects.
Example: TSB is curative because it puts the patient in the best condition for recovery:
protective because it removes skin waste; and instructional because the nurse explains why
the patient has to keep his skin clean.

Delegating Care

If care has been delegated to other health care personnel, the nurse responsible for the client’s
overall care must ensure that the activities have been implemented according to the care plan.

Documenting Nursing Activities

 completion of the implementing phase
 The nurse records the interventions carried out and client responses and/or changes
in the client’s health status in the nursing progress notes.
 To be able to record client responses and/or changes in the client’s status,
continuing data collection is necessary.
 Routine or recurring activities may be recorded at the end of a shift.
 In some instances, certain nursing interventions should be recorded immediately after
it is implemented, i.e. administration of medications and treatments. This helps safeguard
the client, for example, from receiving a duplicate dose of the drug.

E. EVALUATION

 a planned, ongoing, purposeful activity

 determining the client’s response to nursing interventions using the goals of care as
criteria whether they were met, partially met, or not met
Goal Met – the client’s response is the same as the desired outcome
Goal Partially Met – either the short term goal was achieved but the long term goal was
not, or the desired outcome was only partially attained
 shows the extent of progress toward goal achievement and enables the nurse to
correct any deficiencies and modify the care plan as needed

Evaluation statement
 consist of 2 parts: conclusion and supporting data

EXAMPLE OF EVALUATION:

Goal statement: Will ambulate half the length of hallway w/ assistance 3x daily

Evaluative Statement:
Goal partially met: Patient refused to ambulate in the morning but walked
to the bathroom once in the afternoon w/ the
assistance of one nurse

conclusion
supporting data

Goal statement: Body temperature will decrease from 38.5 0C to a range of 36.50C - 37.50C
within 2 hours after administering TSB.

Evaluative statement: Goal met. Body temperature went down to 37.2 0C within 2 hours after
TSB administration.

Goal statement: verbalization of decreased pain from a scale of 2 to 1(where 3=severe,

2=moderate, 1=mild, 0=no pain) within the shift
Evaluative statement: Goal not met. Patient verbalized that the pain intensity remained the
same