The Nursing Process

• The Nursing Care Plan

  1. Cues

  2. Nursing diagnosis

  3. Background Knowledge

  4. Goals of Care

  5. Interventions

  6. Rationale

  7. Evaluation
• Background of the Nursing Process
• ADPIE

  1. Collect data

  2. Analyze

  3. Prioritize

  4. Problem

  5. Reassess

  6. Organize

  7. Identify the problem

  8. Formulate Goals

  9. Implement

  10. Compare

  11. Validate

  12. Formulate Nursing Dx

  13. Select Interventions

  14. Supervise

  15. Relate to Goals

  16. Document

  17. Write Interventions

  18. Assist

  19. Conclude

  20. Continue

  21. Modify

  22. Terminate
• Problem-Focused Assessment

  1. Time performed: Ongoing process integrated with nursing care

  2. Sample: Period of confinement

  3. Purpose: To determine status of a specific problem identified in an earlier assessment
• Types of Assessment

  • Initial Assessment
  • Problem-Focused Assessment
• Processes involved in the Nursing Process

  1. Critical-thinking

  2. Problem Solving

  3. Decision Making
• Assessment

  1. To establish data base

  2. First step of the Nursing process

  3. Collection, organization, validation, and documentation of data

  4. Begins during the first meeting of the nurse and the client
• The Nursing Process

  1. Systematic, rational, dynamic, and cyclic process for planning and providing care for the client

  2. Series of phases describing the practice of nursing

  3. Systematic, chronological, step-by-step procedure of ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation)

  4. To diagnose and treat human responses to actual or potential health problems
• Advantages of Nursing Process
• Initial Assessment

  1. Time performed: After admission

  2. Purpose: Establish complete data base

  3. Sample: Nursing admission assessment
• Time-lapsed assessment


  1. Time performed

  2. Purpose

  3. Sample

  4. Several months after initial assessment

  5. To compare the client’s current status to baseline data previously obtained

  6. Reassessment of a client’s functional health patterns in a home care or outpatient settings
• Types of assessments

  • Problem-focused assessment
  • Time-lapsed assessment
  • Emergency assessment
• Problem-focused assessment

  1. Time performed

  2. Purpose

  3. Sample

  4. Ongoing process

  5. Integrated with nursing care
• Types of data

  • Subjective: From the client
  • Objective: Observable Data
• Sources of data
• Sources of data

  • Primary source: Client or Family
  • Secondary source: Physical exam, nursing history, team members, lab reports, diagnostic tests
• The Nursing Process is a structured method used by nurses to provide patient care
• Emergency assessment

  1. Time performed

  2. Purpose

  3. Sample

  4. During any physiological or psychological crisis of the client

  5. To identify life-threatening problems

  6. To identify new or overlooked problems

  7. Rapid assessment of individual’s airway, breathing and circulation during a cardiac arrest

  8. Assessment of suicidal tendencies
• Types of data
• Methods of collecting data

  • Make sure information is complete & accurate
  • Validate prn
  • Interpret and analyze data and compare to “Standard norms”
  • Organize and cluster data
  • Methods: Nursing interview, Health assessment, Physical exam
• Components of nursing health history

  1. Biographic data

  2. Chief of complaint

  3. History of the present illness

  4. Past history

  5. Family history of illness

  6. Lifestyle

  7. Social data
• Methods of collecting data
• The difference between Nursing and Medical Diagnosis

  • Nursing Diagnosis: Within the scope of nursing practice
  • Medical Diagnosis: Within the scope of medical practice
• Diagnosis


  1. Second step of the nursing process

  2. Interpret and analyze clustered data

  3. Identify client’s problems and strengths

  4. Formulate Nursing Diagnosis (NANDA: North American Nursing Diagnosis Association)
• The difference between Nursing and Medical Diagnosis
• Class 1: Health Promotion


  • Decreased diversional activity engagement
  • Readiness for enhanced health literacy
  • Sedentary lifestyle
• Class 2: Health Management

  • Frail elderly syndrome
  • Risk for frail elderly syndrome
  • Deficient community health
• Types of Nursing Diagnosis

  • Actual
  • Risk
  • Wellness
  • Possible
  • Syndrome
• Nursing Diagnosis focuses on identifying responses to health and illness, while Medical Diagnosis focuses on curing pathology
• Domains of NANDA

  • DOMAIN 1: Health Promotion
  • DOMAIN 2: Nutrition
  • DOMAIN 3: Elimination and Exchange
  • DOMAIN 4: Activity/Rest
  • DOMAIN 5: Perception/Cognition
  • DOMAIN 6: Self-Perception
• Class 1: Sleep/Rest

  • Insomnia
  • Sleep deprivation
  • Readiness for enhanced sleep
• Class 2: Gastrointestinal Function


  • Constipation
  • Risk for constipation
  • Perceived constipation
• Class 1: Urinary Function

  • Impaired urinary elimination
  • Functional urinary incontinence
  • Overflow urinary incontinence
• Class 1: Ingestion

  • Insufficient breast milk
  • Ineffective breastfeeding
  • Imbalanced nutrition: less than body requirements
• Class 4: Metabolism

  • Risk for unstable blood glucose level
  • Neonatal hyperbilirubinemia
  • Risk for neonatal hyperbilirubinemia
• Nursing Diagnosis can change from day to day, whereas Medical Diagnosis stays the same as long as the disease is present
• Class 3: Energy Balance


  • Imbalanced energy field
  • Fatigue
  • Wandering
• Class 2: Activity/Exercise

  • Risk for disuse syndrome
  • Impaired bed mobility
  • Impaired physical mobility
• Class 1: Attention

  • Unilateral neglect
• Class 5: Self-care


  • Impaired home maintenance
  • Bathing self-care deficit
  • Dressing self-care deficit