West Visayas State University

COLLEGE OF NURSING
GRADUATE SCHOOL
La Paz, Iloilo City

Overview of the Nursing Process

In Partial Fulfillment

in

NAD 502 Nursing Administration & Supervision

Submitted & Reported by:

Ma. Risa Auro, R.N.

Ann Ross Erebaren, R.N.

Joanne Careah Cabalfin, R.N.

John Ian L. Lamasan, R.N.

Tia Mogato, R.N.

Submitted and Presented to:

Rosana Grace Belo-Delariarte, R.N., M.P.H., M.N., Ed.D.

 NURSING PROCESS
Nursing Process is a sysytematic, problem-solving approach used to identify, prevent
and treat actual or potential health problems and promote wellness. It provides the framework
in which nurses use their knowledge and skills to express human caring. (Wilkinson,J. 1996,
p.4)

Nursing Process is an orderly, systematic manner of determining the client’s problems,

making plans to solve the problems, initiating the plan or assigning other to implement the
solution, and evaluating the extent to which the plan has effectively resolved the problems
identified. (Yura,H. & M. Welsh)

Nursing Process is a method for organizing and delivering nursing car. It provides the
creative and organizational structure and framework for nursing care. (Potter, P. & A.G. Perry
1993, p.148)

HISTORICAL PERSPECTIVE

Lydia Hall first referred to nursing as a “process” in a 1955 journal article, yet
the term was not widely used until the late 1960s (Edelman &Mandle, 1997). Referring
to the “nursing process” as a series of steps, Johnson (1959), Orlando (1961),
and Wiedenbach (1963) further developed this description of nursing. At this time, the
nursing process involved only three steps: assessment, planning, and evaluation. In
their 1967 book The Nursing Process, Yura and Walsh identified four steps in the
nursing process:
• Assessing
• Planning
• Implementing
• Evaluating

The Standards of Practice, first published in 1973 by the American Nurses

Association (ANA), included eight standards. These standards identified each of the
steps, including nursing diagnosis, that are now included in the nursing process.

Fry (1953) first used the term nursing diagnosis, but it was not until 1974, after the
first meeting of the group now called the North American Nursing Diagnosis Association
(NANDA), that Gebbie and Lavin added nursing diagnosis as a separate and distinct
step in the nursing process. Prior to this, nursing diagnosis had been included as a
natural conclusion to the first step, assessment.

Following publication of the ANA standards, the nurse practice acts of many states
were revised to include the steps of the nursing process specifically. The ANA made
revisions to the standards in 1991 to include outcome identification as a specific part of
the planning phase. Currently, the steps in the nursing process are:
• Assessment
• Diagnosis
• Outcome identification and planning
• Implementation
• Evaluation

The American Nurses Association practice standards address each step of the nursing
process.

OVERVIEW OF THE NURSING PROCESS

A process is a series of steps or

acts that lead to accomplishment of
some goal or purpose. The purpose
of the nursing process is to provide care
for clients that is individualized, holistic,
effective, and efficient. The
steps of the nursing process build upon
each other, but they are not linear.
There is overlap of each step with
the previous and subsequent steps
(Figure 5-1).

The nursing process is dynamic

and requires creativity for its application.
The steps remain the same, but the application and results will be different in
each client situation. The nursing process is designed to be used with clients
throughout the life span and in any setting in which a nurse provides care for
clients. It is also a basic organizing system for the National Council Licensure
Examination for Registered Nurses (NCLEX-RN).

PURPOSES OF NURSING PROCESS

 to identify a client's health care status and actual or potential health problems,
 to determine priorities of care goals and expected outcomes,
 to establish nursing intervention to meet client-centered needs,
 to meet the identified needs,
 to deliver specific nursing interventions to address those needs, and
 to evaluate the effectiveness of nursing care in achieving client goals.
NATURE OF THE NURSING PROCESS

1. The nursing process is dynamic and cyclic. Each step may be reviewedand revised
according to changing client responses to nursing interventions wich may necessitate
revisions in the plan of care. There is no absolute beginning or end.
2. It is client-centered. The plan of care is based on the individual’s need. The client is
motivated and assisted to assume primary responsibility for his own health care.
3. It is planned and goal-directed. The plan of care and nursing intervention is
organized and carefully chosen to meet the client’s goals of care.
4. It is universally acceptable. The process is applicable to any client regardless of age,
medical diagnosis, social status, any setting, across specialities and at any point in the
illness-wellness continuum.
5. It is an intellectual process. Nurses utilize knowledge in problem solving, decision
making, and critical thinking as they assess their client’s problems, plan their care,
implement this plan and evaluate the effectiveness of the care they provide.

5 STEPS IN THE NURSING PROCESS

ASSESSMENT

 First step of the Nursing Process

 A systematic, dynamic way to collect and analyze data about a client, the first step in
delivering nursing care. Assessment includes not only physiological data, but also
psychological, sociocultural, spiritual, economic, and life-style factors as well. For
example, a nurse’s assessment of a hospitalized patient in pain includes not only the
physical causes and manifestations of pain, but the patient’s response—an inability to
get out of bed, refusal to eat, withdrawal from family members, anger directed at
hospital staff, fear, or request for more pain mediation.
 Gather Information/Collect Data
- Primary Source - Client / Family
- Secondary Source - physical exam, nursing history, team members, lab
reports, diagnostic tests…..
- Subjective -from the client (symptom)
- Objective - observable data (sign)

 Nursing Interview (history)

 Health Assessment - Review of Systems

 Physical Exam

◦ Inspection

◦ Palpation
 ◦ Percussion

◦ Auscultation

 Make sure information is complete & accurate

 Validate PRN
 Interpret and analyze data
- Compare to “standard norms”
 Organize and cluster data

Example of Assessment

Obtain information from nursing assessment, history and physical (H&P) etc…...

Client diagnosed with hypertension B/P 160/90 2 Gm Na diet and antihypertensive medications
were prescribed Client statement “ I really don’t watch my salt” “ It’s hard to do and I just
don’t get it”

NURSING DIAGNOSIS

 Second step of the Nursing Process

 Interpret & analyze clustered data
 Identify client’s problems and strengths
 Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-
Statement of how the client is RESPONDING to an actual or potential problem that
requires nursing intervention
 It is the nurse’s clinical judgment about the client’s response to actual or potential health
conditions or needs. The diagnosis reflects not only that the patient is in pain, but that
the pain has caused other problems such as anxiety, poor nutrition, and conflict within
the family, or has the potential to cause complications—for example, respiratory
infection is a potential hazard to an immobilized patient. The diagnosis is the basis for
the nurse’s care plan.

Formulating a Nursing Diagnosis: Composed of 3 parts

Problem statement- the client’s response to a problem

Etiology- what’s causing/contributing to the client’s problem

Defining Characteristics- what’s the evidence of the problem

Problem ( Diagnostic Label)-based on your assessment of client (gathered information),

pick a problem from the NANDA list.
Etiology- determine what the problem is caused by or related to (R/T).

Defining characteristics- then state as evidenced by (AEB) the specific facts the problem is
based on.

Example of Nursing Diagnosis

Ineffective therapeutic regimen management R/T difficulty maintaining lifestyle changes and
lack of knowledge AEB B/P= 160/90, dietary sodium restrictions not being observed, and client
statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.

Types of Nursing Diagnoses

 Actual
Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and
pain AEB height 5’5” weight 105 lbs.

 Risk
Risk for falls RT altered gait and generalized weakness

 Wellness
Family coping: potential for growth RT unexpected birth of twins.

 Collaborative Problems
Require both nursing interventions and medical interventions

EXAMPLE: Client admitted with medical dx of pneumonia

Collaborative problem = respiratory insufficiency

Nursing Interventions: Raise HOB, Encourage C&DB

Medical Interventions: IV Antibiotics , O2 therapy

PLANNING

 Third step of the Nursing Process

 This is when the nurse organizes a nursing care plan based on the nursing diagnoses.
 Nurse and client formulate goals to help the client with their problems
 Based on the assessment and diagnosis, the nurse sets measurable and achievable
short- and long-range goals for this patient that might include moving from bed to chair
at least three times per day; maintaining adequate nutrition by eating smaller, more
frequent meals; resolving conflict through counseling, or managing pain through
adequate medication. Assessment data, diagnosis, and goals are written in the patient’s
 care plan so that nurses as well as other health professionals caring for the patient have
access to it.
 Expected outcomes are identified
 Interventions (nursing orders) are selected to aid the client reach these goals.

Planning – Begin by prioritizing client problems

 Prioritize list of client’s nursing diagnoses using Maslow

 Rank as high, intermediate or low

 Client specific

 Priorities can change

Planning: Developing a goal and outcome statement

 Goal and outcome statements are client focused.

 Worded positively
 Measurable, specific observable, time-limited, and realistic
 Goal = broad statement
 Expected outcome = objective criterion for measurement of goal
 Utilize NOC as standard

EXAMPLE

Goal: Client will achieve therapeutic management of disease process….

Outcome Statement:

AEB B/P readings of 110-120 / 70-80 and client statement of understanding importance
of dietary sodium restrictions by day of discharge.

Types of goals

Long term goal: Expected to be achieved over weeks or months

Short-term goal: Expected to be achieved in shorter time period (hour, day, week). It is
often stepping stone on way to reaching long-term goal

Goals are patient-centered and SMART

Specific

Measurable
 Attainable

Relevant

Time Bound

PLANNING-select interventions

 Interventions are selected and written.

 The nurse uses clinical judgment and professional knowledge to select appropriate
interventions that will aid the client in reaching their goal.
 Interventions should be examined for feasibility and acceptability to the client
 Interventions should be written clearly and specifically.

Interventions – 3 types

 Independent ( Nurse initiated )- any action the nurse can initiate without direct
supervision
 Dependent ( Physician initiated )-nursing actions requiring MD orders
 Collaborative- nursing actions performed jointly with other health care team members


IMPLEMENTATION

 The fourth step in the Nursing Process

 This is the “Doing” step
 Carrying out nursing interventions (orders) selected during the planning step
 This includes monitoring, teaching, further assessing, reviewing NCP, incorporating
physicians orders and monitoring cost effectiveness of interventions
 Nursing care is implemented according to the care plan, so continuity of care for the
patient during hospitalization and in preparation for discharge needs to be assured. Care
is documented in the patient’s record.
 Utilize NIC as standard

Implementing- “Doing”

 Monitor VS q4h

 Maintain prescribed diet (2 Gm Na)

 Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels,
food preparation and sodium substitutes

 Teach potential complications of hypertension to instill importance of maintaining Na

restrictions

 Assess for cultural factors affecting dietary regime

  Teach the client- hypertension can’t be cured but it can be controlled.

 Remind the client to continue medication even though no S/S are present.

 Teach client importance of life style changes: (weight reduction, smoking cessation,
increasing activity)

 Stress the importance of ongoing follow-up care even though the patient feels well.

EVALUATION- To determine effectiveness of NCP

 Final step of the Nursing Process but

also done concurrently throughout client care

 A comparison of client behavior and/or response to the established outcome criteria

 Continuous review of the nursing care plan

 Examines if nursing interventions are working

 Determines changes needed to help client reach stated goals.

 Both the patient’s status and the effectiveness of the nursing care must be continuously
evaluated, and the care plan modified as needed.

 Outcome criteria met? Problem resolved!

 Outcome criteria not fully met? Continue plan of care- ongoing.
 Outcome criteria unobtainable- review each previous step of NCP and determine if
modification of the NCP is needed.
 Were the nsg interventions appropriate/effective?

FACTORS THAT IMPEDE GOAL ATTAINMENT

 Incomplete database
 Unrealistic client outcomes
 Nonspecific nursing interventions
 Inadequate time for clients to achieve outcomes.

Benefits in Utilizing the Nursing Process

For the Clients, it provides individualized, continuous and coordinated nursing care.
Documentation of the process prevents omissions or duplications in providing care. Since the
thrust of healthcare is health in the hands of the people, nursing care is provided to the patient
when he does not have the necessary strength, will or knowledge to do these things for
himself. However, as he gains strength, he is motivated, assisted and taught how to assume
primary responsibility for his own self-care.

For the Nurses, the utilization of the nursing process becomes the vehicle through which they
establish rapport with the patient and his family and in providing quality nursing care. The
utilization of various approaches, knowledge, skills and attitudes is enhanced, thus giving the
nurses self-confidence and job satisfaction. It enables them to meet the standards of safe
practice for which they are accountable.

To the Nursing Profession, the utilization of the nursing process establishes that nursing
process is based on a well-defined and well-organized body of specialized knowledge. Thus it
helps people understand what nurses do. It also maximizes collaboration and coordination with
members of health team and the various services thus enhancing quality of service. The use of
the nursing process demonstrates that nurses contribute to better patient outcomes and
decreased cost in terms of allocating resources.

BASES FOR UTILIZING THE NURSING PROCESS

The Philippine Nursing Law, the Standards of Nursing Practice, and the Code of Ethics
for Filipino Nurses form the bases of nursing practice in the country. Collectively they emphasize
the following provisions.

1. Qualification – Nurses should be graduates of Bachelor of Science in Nursing and

licensed in the country to practice the profession.
2. Professional competence- Nurses should have the knowledge, skills and the right
attitude to perform their functions specified in their job.
3. Quality of care- Nurses should perform nursing care that are appropriate, adequate,
effective, efficient, and safe. They should use the nursing process in providing care with
genuine interest, sincere concern, compassion, commitment, and willingness to work
and learn with the clients and the health team in any setting. Nurses are accountable for
their own practice.
4. Collaboration- In providing nursing care, nurses should collaborate with the members
of the health team ( Physicians, other nurses, and allied health workers), the clients, the
client’s family and/or significant others, and the community.
5. Ethics- The nurse’s professional actions must be ethical. The must act as client
advocates, safeguard their client’s rights and privileges, perform their duties in accord
with existing code of ethics and generally accepted principles of moral conduct and
proper decorum.
6. Research- Nurse must initiate/participate in studies/researches designed to improve
the quality of nursing care rendered and consequently disseminate results.
7. Performance appraisal- Nurses should evaluate their performance and the outcomes
of nursing interventions. These may be in terms of structure (facilities and personal);
 the utilization of the nursing process , or in terms of outcomes wherein actual
improvement and stabilization of the client’s functional status and alleviation of the
effects of his environment is determined.
8. Professional development- Nurses should acquire and/or maintain current knowledge
in nursing practice through continuing education programs.
9. Resource utilization- Nurses should establish linkages with community resources and
other agencies.
10. Documentation- A written record of the assessment, plans of care, nursing
interventions rendered and the patient’s response should be documented thoroughly
and accurately.

References:

 Venzon, L. & Nagtalon, J. (2006) Nursing Management Towards Quality care (3rd Edition), page
142-147, C&E Publishing,Inc.
 Funnell, R., Koutoukidis, G.& Lawrence, K. (2009) Tabbner's Nursing Care (5th Edition), page 72,
Elsevier Pub, Australia.
page 432, Marriner-Tomey & Allgood (2006) Nursing Theorists and their work
 Reed, P. (2009) Inspired knowing in nursing. Pg 63 in Loscin & Purnell (Eds) (2009)
Contemporary Nursing Process.Springer Pub
 Kim, H (2010) The Nature of Theoretical Thinking in Nursing. page 6.
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Professions.
 Funnell, R., Koutoukidis, G.& Lawrence, K. (2009) Tabbner's Nursing Care (5th Edition), page
222, Elsevier Pub, Australia.
 http://rogeriannursingscience.wikispaces.com/Chapter+7+Practice+Methods
 http://intranet.tdmu.edu.ua/data/kafedra/internal/magistr/classes_stud./English/First%20year/Nu
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 Kozier, Barbara, et al. (2004) Assessing, Fundamentals of Nursing: concepts, process and
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 Barbara Kuhn Timby (2008-01-01), Fundamental Nursing Skills and Concepts, p. 114, ISBN 978-
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