NURSING PROCESS SYSTEM

 A systematic rational method of planning and providing individualized nursing care.

 A cognitive and intellectual process that requires a critical thinking and skills in clinical
judgments.
 Requires psychomotor skills for data collection and determining interventions to be
carried out.

 PURPOSES OF NPS
1.Identify client’s health status (actual or potential health-care problems or needs).
2.Establish plans that meet the identified needs.
3.Deliver specific nursing interventions to meet Identified needs.

 PHASES OF NURSING PROCESS

I. ASSESSMENT

 2 STEPS IN ASSESSMENT PHASE

 PROBLEM RECOGNITION
 DATA COLLECTION

 Collecting Data:
– Subjective Data (symptoms), Objective Data (signs)
– Primary source is the client
– Secondary source is family or anyone else that is not the client
– Collect data by observing which uses your senses or through an interview
○ Interview is planned communication with a purpose
○ Directive interview - Nurse directs interview, client responds to questions and has limited
chances to discuss concerns.
○ Nondirective interview – rapport-building where the client is in control of the purpose,
subject, and pace.
○ Questions :
Open-ended – invites client to discover and explore, elaborate, clarify, or illustrate their
thoughts or feelings. “How have you been feeling lately?”
Closed-ended – used in directive interviewing, and are questions that require a yes or no
answer.
Neutral question – a question that the client can answer without direction. “Why do you
think you had the operation?”
Leading question – directs the clients answer. “You’re stressed about surgery tomorrow,
aren’t you?”
 Organizing Data:
– Using a written or computerized format that organizes the assessment data.
– Most schools of nursing and health cause agencies have developed their own structured
assessment format.
– Frameworks:
○ Gordon – 11 functional health patterns
○ Orem – 8 Universal Self-Care Requisites of Humans
○ Roy’s Adaptation Model
○ Maslow’s Hierarchy of Needs
 Validating Data:
– Double checking data to ensure that the assessment info is correct, and to ensure that the
subjective and objective data agree, as well as to obtain additional info that may have been
over looked.
– Cues vs. Inferences:
○ Cues – subjective or objective data that can be directly observed by the nurse, either what
the client says or what the nurse can see.
○ Inferences – nurses interpretations or conclusions based on the cues. (A nurse observes the
cues that an incision is red, hot, and swollen; the nurse makes the inference that the
incision is infected.)

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 – You don’t have to check all data (like birth dates, height, weight and most lab studies)
 Documenting Data:
– Data is recorded in a factual manner and not interpreted by the nurse.
○ The nurse records the client’s breakfast intake (objective) as “coffee 240 mL, 1 egg, and 1
slice of toast”

II. DIAGNOSIS

 Diagnostic Labels
○ Describes the client’s health problem or response for which nursing therapy is given.
○ Qualifiers – additional info
Deficient, Impaired, Decreased, Ineffective, Compromised.
○ Etiology – Related factors and risk factors.
○ Example of Label :
Activity Intolerance related to Generalized weakness
 Defining characteristics – clusters of s/s that indicate the presence of a particular diagnostic
label.
○ Actual nursing diagnoses – signs and symptoms
○ Risk nursing diagnoses – no-subjective or objective signs are present.
 Differentiating Nursing Diagnoses from Medical Diagnoses
○ A client’s medical diagnosis remains the same for as long as the disease process is present,
but nursing diagnoses change as the client’s responses change.
○ Independent function – areas of health care that are unique to nursing and separate and
distinct from medical management.
○ Dependent function- Nurses are obligated to carry out physician-prescribed therapies and
treatments.
 Differentiating Nursing Diagnoses from Collaborative Problems
○ Collaborative – monitoring the client’s condition and preventing development of the
potential complication and using physician-prescribed interventions.
○ Nursing Diagnoses – involve the human response, which vary from one person to the next.
More individualized.
 Analyzing Data:
 Compare data against standards
○ Growth and development patterns, normal vital signs, and lab values.
 Clustering Cues
○ The process of grouping cues to determine the relatedness of facts and see if there are
any patterns.
 Identify Gaps and inconsistencies in data
○ Conflicting data: Ex. Client tells you that they haven’t been to the doctor in 15 years, but
then says that they see their doctor every year for a physical.
 Identifying Health Problems, Risks, and Strengths:
– Determining Problems and Risks
○ Client has no appetite and has not eaten today
Problem/Risk is Imbalanced Nutrition: Less than Body Requirements
– Determine Strengths
○ Anything that is at the client’s advantage
The client may be physically fit and there for may recover faster.
 Formulating Diagnostic Statements:
– Two-part Statement (PE): Problem(P) Related to Etiology(E)
– Three-part Statement (PES): Problem(P) Related to Etiology(E) as manifested by Signs and
symptoms(S).
– One-Part Statement: Nursing intervention can be derived from the label and doesn’t need a
etiology. Ex. Health-Seeking Behaviors ( Low-Fat Diet)
 Avoiding Errors in Diagnostic Reasoning:
– Verify, build a good knowledge base and acquire clinical experience, know what is normal,
consult resources, base diagnoses on patterns- that is, on behavior over time- rather than on
an isolated incident, and improve critical thinking skills.

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III. PLANNING:
 Nursing Intervention: any treatment based upon clinical judgment and knowledge, that a nurse
performs to enhance patient outcomes
 Planning :
○ Initial Planning
Done ASAP
Using client’s body language as well as intuitive kinds of information.
○ Ongoing Planning:
Done by all nurses who work with the client.
has changed

focus on during the shift

than one problem can be addressed at
each client contact
○ Discharge Planning:
Process or anticipating and planning for needs after discharge, is a crucial part of
comprehensive health case and should be addressed in each client’s care plan.
M - Medications
E - Exercise
T - Treatment
H - Health Education
O - OPD visit (when to return)
D - Diet
 Informal Nursing Care Plan
○ Strategy for action that exists in the nurse’s mind.
 Formal Nursing Care Plan
○ Written or computerized guide for organizing information
 Standardized Care Plan
○ Formal plan that specifies the nursing care for groups of clients with common needs.
○ Not for individuals
○ Preprinted guides for the nursing care of a client who has a need that arises frequently in
the agency.
○ Problem -> Goals/Desired Outcomes -> Nursing interventions -> Evaluation
Protocols – preprinted to indicate the actions commonly required for a particular group
of clients.
ncy may have a protocol for admitting a client to the intensive care unit.
Policies/procedures – are developed to govern the handling of frequently occurring
situations.

Standing orders – are written document about policies, rules, regulations, or orders
regarding client care. They also give nurses the authority to carry out specific actions
under circumstances, often when a physician is not immediately available.
 Individualized Care Plan
○ Is tailored to meet the unique needs of a specific client.
 Multidisciplinary (collaborative) Care Plans – is a standardized plan that outlines the care
required for clients with common, predictable usually medical-conditions.
 When nurses use the client’s nursing diagnoses to develop goals and nursing interventions, the
result is a holistic, individualized plan of care that will meet the client’s unique needs.
 During planning phase, the nurse must decide which of the client’s problems need
individualized plans and which problems can be addressed by standardized plans and routine
care, and write unique desired outcomes and nursing interventions for client problems that
require nursing attention beyond preplanned, routine care.
 Formats for Nursing Care Plans
○ Student – have a rationale column
○ Computerized - visual tool
 Guidelines for writing a Nursing Care Plan:
○ Date and sign the plan
○ Use category headings
“Nursing Diagnoses” “Goals/Desired Outcomes”

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 ○ Use standardized medical or English symbols and key words rather that complete
sentences to communicate your ideas.
○ Be specific when it comes to time
○ Refer to procedure books or other sources of info rather than including all steps on
something
○ Tailor plan to the client
Ask when the best time is for the client to do interventions
○ Ensure that the plan incorporates preventive and health maintenance aspects as well as
restorative ones.
○ Ensure that the plan contains interventions for ongoing assessment of the client.
○ Include collaborative and coordination activities in the plan
○ Include plans for the client’s discharge and home care needs
 Setting Priorities -establishing a preferential sequence for addressing nursing diagnoses and
interventions.
○ Clients health values and beliefs
○ Clients priorities
○ Resources available to the nurse and client
○ Urgency of the health problem
○ Medical treatment plan
 Establishing Client Goals/Desired Outcomes

GUIDELINES FOR WRITING OUTCOME STATEMENTS

1. FOR AN ACTUAL DIAGNOSIS: the outcome is focused to a patient behavior that

demonstrates reduction or alleviation of the problem.
o Alleviation or Lessening of Pain
2. FOR HIGH RISK NURSING DIAGNOSIS: the outcome is focused to the patients behavior
that demonstrates maintenance of the current status of health functioning.
o High Risk/at Risk for impaired Skin Integrity r/t casted left leg demonstrates maintenance of
intact skin)
3. Realistic for clients abilities/capabilities in the time span designated
o Infant will weigh 4.5 lbs in 7 days
4. Realistic for a nurse’s level of skills, experience and time
5. Congruent and supportive of other therapies.
6. An observable or measurable client behavior.
 Nurse can see, hear, feel or measure the response
 Observable Verbs: reports, rates, walks, drinks, eat, voids, sleeps
 Non-observable Verbs: Good, Improved, Normal, adequate.
7. Write in terms of client behavior not nursing actions.
8. Keep it SMART.
S – Short and specific
M – Measurable
A – Attainable
R – Realistic
T – Time bounded
9. Derive each outcome from only one Nursing Diagnosis

 Nursing Outcomes Classification (NOC) - Taxonomy that describes the client outcomes.
 Goals and outcomes provide direction for planning, interventions, they serve as a criteria for
evaluating client progress, enable client and nurse to determine when the problem has been
resolved, and help motivate the client and nurse by providing a sense of achievement.
 Short-term and long-term goals should be used
 Selecting Nursing Interventions and Activities:
○ Independent Interventions - Activities that the nurse is licensed to initiate on the basis of
their knowledge and skills
○ Dependent interventions - Activities carried out under the physicians’ orders or
supervision, or according to specific routines.
○ Collaborative interventions - Actions carried out by nurses and other health care providers
 Consider the consequences of each intervention
 Makes sure that the intervention is safe and appropriate for the client’s age, health, and
condition

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  Interventions must be congruent with the client’s values and beliefs.

IV. IMPLEMENTING :
 Carrying out the plan of care
 It needs the ff skills -
○ Cognitive
Intellectual skills including problem solving, decision making, critical thinking, and
creativity
○ Interpersonal
Required in all nursing activities
Verbal and nonverbal, people use when interacting directly with each other
○ Technical
Hands on skills
Using equipment, giving injections, bandaging, moving, lifting, and repositioning
clients.
 Reassessing the Client
 Determining the Nurse’s Need for Assistance
 Implementing the Nursing Intervention:
Base intervention on scientific knowledge, nursing research, and professional
standards of care
Understand the intervention
Adapt to client
Use safe care
Teach
Be holistic
Respect dignity or the client
Encourage clients to participate
 Even though you delegate care to someone else, you are responsible for making sure that the
task was done right and you are responsible for anything that goes wrong.
 Document everything

V. EVALUATING:
 Evaluation is continuous
 Evaluating and assessing phase overlap
 The desired outcomes are related to the collection of data
 Collecting Data
○ Objective
○ Subjective
 Comparing Data with Outcomes
○ Goal Met
○ Goal partially met – what changes need to be made?
○ Goal was not met – what changes need to be made?
After goal was met, writes an evaluative statement

 Conclusion
 Supporting data
 “Goal Met: Oral intake 300ml more than output; skin turgor resilient; mucous
membrane moist
 Relating Nursing Activities to Outcomes
○ Make sure that it is what you are doing that is bring any change to the client
○ Ask them if they are doing anything extra
 Drawing Conclusions about problem Status
○ Have actual or potential problems been resolved
○ Actual problem still exists even though some goals were met
 If the goals have been partially met or when goals have not been met, 2 things may be drawn
○ Care plan needs to be revised
○ Care plan doesn’t need to be revised, because the client merely needs more time to achieve
the goals.
 Continuing, Modifying, and Terminating the Nursing Care Plan

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 ○ After drawing conclusions about the state of the client’s problem, the nurse modifies the
care plan as indicated.
Discontinue, or “goal met” with the date
 Evaluating the Quality of Nursing Care
○ Quality-Assurance (QA) Program - An ongoing systematic process designed to evaluate
and promote excellence in the health care provided to clients.
valuation – focuses on the setting in which care is given. It answers this
question:
“what effect does the setting have on the quality of care.”
cess Evaluation – Focuses on how the care was given. It answers the question, “Is
the care relevant to the client’s needs? Is the care appropriate, complete, and timely?”
– focuses on demonstrable changes in the client’s health status
as result of nursing care.
○ Quality Improvement - Evaluating and improving the quality of health care based on
internal assessment by health care providers and increasing awareness by the public that
medical errors are not uncommon and can be lethal.
Sentinel Event – is an unexpected occurrence involving death or serious physical or
psychological injury.
Root cause analysis – process for indentifying the factors that bring about deviations
in practices that lead to the event.
Quality improvement (QI) – focuses on client care rather than organizational
structures, focuses on process rather than individuals, and uses a systematic approach
with the intention of improving the quality of care rather than ensuring the quality of
care.
 Nursing Audit
○ To examine or review records
○ Retrospective Audit – is the evaluation of a client’s health record after discharge from as
agency.
○ Concurrent audit – is the evaluation of a client’s health care while the client is still
receiving care from the agency.
○ Peer review – nurses reviewing other nurses
Individual peer review – focuses on the performance of an individual nurse
Nursing audits (peer review) – evaluation the nursing care through review of the
records.

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 SCIENTIFIC GOALS OBJECTIVE NURSING
PROBLEM RATIONALE EVALUATION
BASIS CRITERIA INTERVENTION

S> “Mahirap Complete or At the end of the 8 hour INDEPENDENT: >for baseline >Goal met. With
maghinga” partially obstructed shift, the client will >Monitor V/S q 4 hrs. data RR=32 c.p.m.
O>RR=40 airway can occur experience relief from >Position client at >promote lung
c.p.m. anywhere along the difficulty in breathing moderate high back rest expansion
>with O2 inh. upper and lower through the following >IOFI >Adequate
noted @ respiratory manifestations hydration,
3lpm passageways. An a. RR= 30-35 c.p.m. reduce viscosity
>Productive upper airway b. Expectorate of sputum &
cough noted obstruction-that is, phlegm & make
>Presence of in the nose, mobilization of expectoration >Goal met. Cough
crackles pharynx, larynx or secretions thru the easier productive of
noted trachea- can arise demonstration of >Teach/encourage deep >assist in thick, yellowish
>Pallor noted because of foreign proper coughing breathing & coughing emptying the sputum
>Cold clammy objects such as techniques after exercises lungs
skin noted food, or when instruction
>Nasal flaring secretions collect in
the passageways.
Lower airway
obstruction involves
Partial or complete
occlusion of the
passageways in the
bronchi or lungs.

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 GOALS OBJECTIVE NURSING
PROBLEM SCIENTIFIC BASIS RATIONALE EVALUATION
CRITERIA INTERVENTION

O>Irritability & d. Minimize crackle >Back tapping >to dislodge Goal met.
restlessness Reference: sound on mucous & Scattered
noted Kozier, 2002, auscultation mobilize inspiratory
>diff in breathing Fundamentals of secretions crackles
Nursing, 5th Ed., auscultated on
A> Ineffective pp.1135 COLLABORATIVE: >provide right anterior chest
airway  Inform / assist humidification &
clearance R/T nebulization q 4 hrs. to keep
presence of c/o pulmo dept. secretions liquid
viscous
bronchial DEPENDENT: >Liquefaction of
secretions >Administer excessive
Carbocistine viscid mucous
500mg. 1 cap. TID

Reference:
Brunner &
Suddarth, 1986,
Lippincott Manual
of Nursing
Practice 4th Ed ,
pp. 155-161

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