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Published by cikgu online, 2020-01-20 19:01:27

INTRODUCTION OF NURSING 1.4 The Nursing Process Part 1


1.4 The Nursing Process



Specific Learning Outcomes:

Describe Demonstrate Prepare Document

Describe the nursing Demonstrate nursing Prepare a nursing Document

process assessment. care plan base on assessment findings.
assessment findings


1. The Nursing Process

a. Overview of the nursing process

b. Stages of the Nursing Process

• Assessing

• Diagnosing

• Planning

• Implementation

• Evaluation


2. Critical thinking approaches to assessment

a. Type of assessment c. Method of data

• Initial assessment collection

• Emergency assessment • Patient interview

• Focus assessment • Physical examination
• Observation

b. Data collection
d. Data validation and
• Sources of data
• Type of data

e. Data documentation


Nursing Process

• The essential core of practice for the registered nurse to deliver

holistic, patient-focused care.

• Stages of the Nursing Process (ADPIE)

1. Assessing

2. Diagnosing

3. Planning

4. Implementation

5. Evaluation

1. Assessment

• Nurse uses 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.

1. Assessment

• Data

1. Objective data

2. Subjective data

• For example Objective data

➢Vital sign – pulse, respiration, breathing, temperature, blood pressure,


➢ECG, X-Ray, blood test, urine test etc.

1. Assessment

• For example Subjective data

➢a nurse’s assessment of a hospitalized patient in pain includes

not only the physical causes and manifestations of pain

➢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.


• You wake up on Monday morning after a late night of studying for your nursing
exam, and you know that you’re going to need an extra big cup of coffee.

• Because it took a little longer to brew, you’re running 10 minutes late to class.

• You pour that delicious, warm drink into your thermos, frantically throw it in

your backpack, and book it to school.

• When you finally make it to class, you grab your computer out of your bag and
open it up, but it won’t turn on.

• What do you do first?


• First, you’re going to assess the situation (the “A” in ADPIE).

• Why isn’t the computer turning on? Why is it all wet? And why is your thermos

empty and everything smells like coffee?

• At this stage, you are playing detective and strictly gathering data.

• Similarly, in nursing, this would be the stage when you first go in to see your

patient, the beginning of the assessment, where we collect all the data about

the patient, both objective and subjective.


• In this case, these would be things like your first impression and

vitals. What does the patient look like? Is their skin pale? Are they

groaning in pain? Are their vitals stable? Is their breathing labored?

Are they angry, scared, confused or delirious? Do they have a history

of heart problems? What kind of medication are they taking?

• These are all observations and data collection that you would take

into account when doing an assessment on a patient. As the first step

in the process, gathering all this information will allow you to proceed

with the next step: your nursing diagnosis.

2. Diagnosis

• 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

• example, respiratory infection is a potential hazard to an immobilized


• The diagnosis is the basis for the nurse’s care plan.

2. Diagnosis

• Now the “D” in ADPIE stands for diagnosis, and that brings us to our

next step after gathering that data that we were just presented with.

• “Well,” you say to yourself, “it seems to me from all my evidence

here, that my coffee must’ve leaked out onto my computer, and

therefore my computer is not working because it has gotten soaked

with coffee!”

2. Diagnosis

• So just like that, in our clinical assessment, we make a nursing

diagnosis, where we identify actual or potential medical /health risks.

• The nursing diagnosis is developed by NANDA and should be

prioritized based on Maslow’s hierarchy of needs.

• This diagnosis is key to the next step in the process: making a care


3. Planning

• 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


➢resolving conflict through counselling, or managing pain through

adequate medication.

3. Planning

• 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.

3. Planning

• Now that brings us to “P” in the acronym, which stands for planning.

• When you look at your computer and have figured out the cause, you

now have to make a quick plan.

• What are you going to do to fix the problem?

• You decide here that you need to run to get this computer fixed by a

professional. “Let’s see,” you think, “I have to call to see if the store is

open, make an appointment, find out if my computer was backed up,

leave school, take the bus to town...”

3. Planning

• When we apply that to nursing, we make a plan based on the assessment

and nursing diagnosis of our patient.

• You would then set SMART goals,





➢Timely short-and long-term goals for the patient.

• From here, we can move on to the implementation part of the process.

4. Implementation

• Nursing care is implemented according to the care plan

➢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.

4. Implementation

• Next comes the “I” in ADPIE; the implementation portion of the


• Implementation is the action part of your plan; where you actually get

up and bolt to the computer store to fix this, fast!

• Notice here the difference between the planning stage and the

implementation stage. In the planning stage, you are simply forming

the plan. The implementation stage is where you act on that specific


4. Implementation

• Similarly, when we take this back into nursing, this is where we

implement our plan for our patient.

• As the action portion of the process, this is where our plans are

carried out.

• Implementation is the step where we finally intervene to help them,

like physically giving drugs, educate, monitor, etc.

• After this step, we must evaluate the outcome.

5. Evaluation

• Both the patient’s status and the effectiveness of the nursing care

must be continuously evaluated, and the care plan modified as











a. Initial assessment

b. Emergency assessment

c. Focus assessment

d. Time-lapsed Assessment

a. Initial Assessment

• An initial assessment, also called an admission assessment, is performed when the client

enters a health care from a health care agency.

• The purposes

➢to evaluate the client’s health status

➢to identify functional health patterns that are problematic

➢to provide an in-depth, comprehensive database, which is critical for evaluating changes in

the client’s health status in subsequent assessments.

b. Emergency Assessment

• Emergency assessment takes place in life-threatening situations in which the
preservation of life is the top priority.

• Time is of the essence rapid identification of and intervention for the client’s

health problems.

• Often the client’s difficulties involve airway, breathing and circulatory problems

(the ABCs).

b. Emergency Assessment

• Abrupt changes in self-concept (suicidal thoughts) or roles or

relationships (social conflict leading to violent acts) can also initiate

an emergency.

• Emergency assessment focuses on few essential health patterns and

is not comprehensive.

c. Focus Assessment / Problem-

focused Assessment

• A problem focus assessment collects data about a problem that has already

been identified.

• This type of assessment has a narrower scope and a shorter time frame than

the initial assessment.

• In focus assessments, nurse determine whether the problems still exists and

whether the status of the problem has changed (i.e. improved, worsened, or


c. Focus Assessment / Problem-

focused Assessment

• This assessment also includes the appraisal of any new, overlooked,

or misdiagnosed problems.

• In intensive care units, may perform focus assessment every few


d. Time-lapsed Assessment /

Ongoing Assessment

• Time lapsed reassessment, takes place after the initial assessment

to evaluate any changes in the clients functional health.

• Nurses perform time-lapsed reassessment when substantial periods

of time have elapsed between assessments (e.g., periodic output

patient clinic visits, home health visits, health and development


Steps Of Assessment

a. Collection of data

• Subjective data collection

• Objective data collection

b. Validation of data

c. Organization of data

d. Recording/documentation of data


• gathering of information about the client

includes physical, psychological, emotion, socio-

cultural, spiritual factors that may affect client’s

health status

2. DATA ➢includes past health history of client

(allergies, past surgeries, chronic diseases,
COLLECTION use of folk healing methods)

➢includes current/present problems of client

(pain, nausea, sleep pattern, religious

practices, medication or treatment the client

is taking now)

• When performing an assessment the nurse

gathers subjective and objective data

a. Subjective data (symptoms or covert data):
Types of data ➢are the verbal statements provided by the


➢Statements about nausea and descriptions of

pain and

➢fatigue are examples of subjective data

b. Objective data (signs or overt data):

➢detectable by an observer or can be

measured or tested against an accepted

Types of data standard.

➢They can be seen, heard, felt, or smelt, and

they are obtained by observation or physical


➢For example: discoloration of the skin

• Data can be obtained from primary or secondary sources.

• The primary source of data is the patient.

➢In most instances the patient is considered to be the
Sources Of most accurate reporter.

➢The alert and oriented patient can provide information
Data about past illness and surgeries and present signs,

symptoms, and lifestyle.

• When the patient is unable to supply information because

of deterioration of mental status, age, or seriousness of
illness, secondary sources are used.

• The Secondary sources of data include family

members, significant others, medical records,

diagnostic procedures,

Sources Of ➢Members of the patient's support system
may be able to furnish information about the

Data patient's past health status, current illness,

allergies, and current medications.

➢Other health team professionals are also

helpful secondary sources (Physicians, other




a. Observing: to observe is to gather data by using the


Data b. Interviewing: an interview is a planned

communication or conversation with a purpose.

methods c. Examining: Performance of a physical examination.

The physical examination is often guided by data

provided by the patient. A head-to-toe approach is
frequently used to provide systematic approach

that helps to avoid omitting important data

Data • Comprise of 2


a. Patient interview

methods b. Physical examination

• Biographical data

• Reason for Seeking Care

• History of Present Illness

➢Past Health

Patient ➢Accidents and Injuries

➢Hospitalizations and Operations
Interview ➢Family History

• Review of Systems

➢Functional Assessment ( Activities of Daily


➢Perception of Health

Physical a. Head – to - Toe Assessment

Assessment b. Body Systems Assessment

1. Inspection

Assessment 2. Palpation

Techniques 3. Percussion

4. Auscultation

Physical Assessment Using Head Toe Approach

General Mobility and self care

• General health status • Observe posture

• Vital signs and weight • Assess gait and balance

• Nutrional status • Evaluate mobility

• Activities of daily living

Physical Assessment Using Head Toe Approach

Head face and neck Chest

• Evaluate cognition • Inspect and palpate breast

• LOC • Inspect and auscultate lungs

• Orientation • Auscultate heart

• Mood

• Language and memory

• Sensory function

• Test vision

• Inspect and examine ears

• Test hearing

• Cranial nerves

• Inspect lymph nodes

• Inspect neck veins

Physical Assessment Using Head Toe Approach

Abdomen Skin, hair and nails

• Inspect, auscultate, palpate four • Inspect scalp, hair & nails

quadrants • Evaluate skin turgor

• Palpate and percuss liver, • Observe skin lesion

stomach, bladder

• Assess wounds
• Bowel elimination

• Urinary elimination

Physical Assessment Using Head Toe Approach

Genitalia Extremities

• Inspect female client Inspect male • Palpate arterial pulses
• Observe capillary refill

• Evaluate edema

• Assess joint mobility

• Measure strength

• Assess sensory function

• Assess circulation, movement, &

• sensation

• Deep tendon reflexes

• Inspect skin and nails

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