Nursing Process

Nursing - is an art of applying scientific principles in a humanitarian

way of care of people
Nursing Process – serves as the organizational framework for the
practice of nursing

Assessment Process
- a systematic method by which nursing, plans and provides care
for patients
- involves a problem-solving approach that enables the nurse to
identify patient problems and potential at-risk needs and to
plan, deliver and evaluate nursing care in an orderly, scientific
manner

Components of Nursing Process

- consists of five dynamic and interrelated phases (ADPIE)
o Assessment
o Diagnosis
o Planning
o Implementation
o Evaluation

Assessment
- An interactive process of information gathering and analysis
that nurses carry to identify client strengths and actual and
potential health problems and to evaluate the effectiveness of
care
- A comprehensive assessment includes data about client’s
psychosocial, spiritual, cultural, environmental and
developmental status as well as physiologic health
o Collect data
o Organize data
o Validate data
o Documenting data
- The nurse gathers information to identify the health status of the

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 patient
- Assessments are made initially and continuously throughout
patient care
- The remaining phases of the nursing process depend on the
validity and completeness of the initial data collection

Purposes of Assessment
- To establish database
o All the information about a client
▪ Nursing health history
▪ Physical examinations
• Physician’s history
• Results of laboratory and diagnostic tests

Types of Assessments
- Initial Assessment
o Also called an admission assessment, is performed
when the client enters a health care from a health care
agency
o Very thorough and includes detailed health history and
physical examination and examine the client’s overall
health status
o Purpose: to provide an in-depth, comprehensive
database, which is critical for evaluating changes in the
client’s health status in subsequent assessments
- Problem-focused Assessment
o 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
o Nurse determines whether the problems still exists and
whether the status of the problem has changed (i.e
improved, worsened or resolved).
o Includes the appraisal of any new, overlooked, or
misdiagnosed
- Time-lapsed Assessment
o Or on-going reassessment, another type of assessment,
takes place after the initial assessment to evaluate any

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 changes in the clients functional health
o Nurses perform time-lapsed reassessments when
substantial periods of time have elapsed between
assessments (e.g. periodic output, patient clinic visits,
home health visits, health and development screenings)

- Emergency Assessment
o Takes place in life-threatening situations in which the
preservation of life is the top priority. Time is ofd the
essence rapid identification of an intervention for the
client’s health problems. Ofter the client’s difficulties
involve airway, breathing, and circulatory problems (the
ABCs). Abrupt changes in self-concept (suicidal thoughts)
or roles or relationships (social conflict leading to violent
acts) can also initiate an emergency
o Focuses on few essential health patterns and is not
comprehensive

Types of Data
Subjective Data (symptoms or covert data)
- Verbal statements provided by the patient, statements about
nausea and descriptions of pain and fatigue are examples of
subjective data
Objective Data (signs or overt data)
- Are detectable by an observer or can be measured or tested
against an accepted standard. They can be seen, heard, felt,
or smelt, and they are obtained by observation or physical
examination. For example: discoloration of the skin

Sources of Data
Primary Source – client or the major provider of information about
a client
Secondary Source – sources of data other than client and include
family members, other health care providers, and medical records

Data Collection Methods

1. Observing – to observe is to gather data by using the senses
2. Interviewing – an interview is a planned communication or

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 conversation with a purpose
3. 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

The Interview Process

1. Establish rapport
2. Invite the patient’s story
3. Establish the agenda of the interview
4. Expand and clarify the health history
5. Identify the possible nursing diagnoses
6. Crate a shred understanding of the nursing problem
7. Plan for follow-up and closing

Interview
- Is a planned communication or conversation with a purpose
- 2 approaches:
Directive Interview
- highly structured and elicits specific information
- The nurse establishes the purpose of the interview and controls
the interview
- The client responds to questions but have limited opportunity to
ask questions and discuss concerns
- Frequently use by nurses to gather and give information when
time is limited as in emergency situation
Non-directive Interview
- Rapport-building interview
- The nurse allows the client to control the purpose, subject
matter and pacing
- Rapport – an understanding between two or more people
- The combination of the two approaches is usually appropriate
during the information gathering interview
- The nurse begins by determining areas of concerns for the
client

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 Types of Interview Questions
Closed Questions
- Used in the directive interview
- Are restrictive and generally require only “yes” or “no” or short
factual answers giving specific information
- Questions oft en begin with ‘what, when, where, who, do, or is’
- Highly stressed individual and a person who has difficulty
communicating find closed questions easier to answer than
open-ended questions
Open-ended Questions
- Associated with the non-directive interview
- Invite client to discover and explore, elaborate, clarify, or
illustrate their thoughts and feelings
- Specifies only the broad topic to be discussed and invites
answers longer than one or two words
- Useful at the beginning of an interview or to change topic and to
elicit attitudes
- Often begin with what, or how
- Example: ‘What brought you to the hospital?” “How have you
been feeling today?”
Neutral Questions
- A questions the client can answer without direction or pressure
from the nurse, is open-ended question and is used in non-
directive interview
- Example: “How do you feel about that?” “Why do you think you
had the operation?”
Leading Questions
- Is usually closed, used in a directive interview and directs the
client’s answer
- Gives the client less opportunity to decide whether the answer
is true or not
- May create problems if the client, in an effort to please the
nurse, gives inaccurate responses that results to inaccurate
data
- Example: “You’re stressed about surgery tomorrow, aren’t you?”
“You will take your medicine, won’t you?”
An interview is influenced by:
1. Time – physically comfortable and free of pain, interruption by

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 friends, family, and other health team members are minimal
2. Place – well-lighted, well-ventilated, moderate sized room, free
of noise, movements, and interruption
3. Seating Arrangements – less formal atmosphere when seated
in two chairs placed at right angles to the desk or to the table;
standing and looking down at a client in bed or in a chair perceive
the nurse as having greater status
4. Distance – the distance between the interviewer and the
interviewee should be neither too small or too great because
people feel uncomfortable to someone who is too closer or too far;
people are comfortable maintaining a distance of 2-3 feet ; some
require more or less personal space depending on their cultural and
personal needs
5. Language – the nurse must convert complicated medical terms
into common English usage or may have interpreter or translator if
the client and the nurse do not speak the same language

Major Stages of Nursing Interview

1. Introductory Phase / The Opening
- Introduce yourself and explains the purpose of the interview to
the client
- Before asking questions, let client to feel comfort, privacy and
confidentiality
2. Working Phase / The Body
- The nurse must listen and observe cues in addition to using
critical thinking skills to validate information received from the
client. The nurse identify client’s problems and goals
3. Termination Phase
- The nurse summarizes information obtained during the working
phase
- Validates problems and goals with the client
- Making plans to resolve the problems (nursing diagnosis and
collaborative problems are identified and discussed with the
client)

Guidelines: Communication During an Interview

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 1. Listen attentively, using all your senses, and speak slowly and
clearly
2. Use language the client understands, and clarify points that are
not understood
3. Plan questions to follow a logical sequence
4. Ask only one question at a time. Double questions limit the
client to one choice and may confuse both nurse and the client
5. Allow the client the opportunity to look at things the way they
appear to him or her and not the way they appear to the nurse
or someone else
6. Do not impose your own values on the client
7. Avoid using personal examples such as saying “if I were
you…”
8. Nonverbally convey respect, concern, interest, and acceptance
9. Use and accept silence to help the client search for more
thoughts or to organize them
10. Use eye contact and be calm, unhurried and sympathetic

Techniques of Interviewing
1. Active Listening – requires listening closely to what your
client is communicating
2. Adaptive Questioning – adapt your questioning to your
client’s verbal and nonverbal cues
3. Non-verbal Communication – be sensitive to nonverbal
messages of your client
4. Facilitation – encourage patient to say more about the topic
without you specifying the topic
5. Echoing – repetition of the client’s words will encourage the
patient to express
6. Empathic Responses – acknowledge how the client feels and
inquire about his/her feelings
7. Validation – legitimize or validate his/her emotional experience
8. Reassurance – identify and accept the client’s feelings
9. Summarization – lets the client know that you are listening
10. Highlighting Transition – inform client whenever you are
changing directions during the interview

Guidelines for Talking Nursing History

1. Private, comfortable, and quiet environment

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 2. Allow the client to state problems and expectations for the
interview
3. Orient the client the structure, purposes, and expectations of
the history
4. Communicate and negotiate priorities with the client
5. Listen more than talk
6. Observe nonverbal communications (e.g. body language, voice
tone and appearance)
7. Review information about past health history before starting
interview
8. Clarify the client’s definitions (terms & descriptors)
9. Balance between allowing a client to talk in an unstructured
manner and the need to structure requested information
10. Avoid yes or no question (when detailed information is desire)
11. Write adequate notes for recording
12. Record nursing health history soon after interview

Components of Health History

A. Biographic Data
a. Name
b. Address
c. Birth Date & Birth Place
d. Age
e. Sex
f. Race
g. Marital Status
h. Occupation
i. Religious Orientation
j. Health Care Financing
B. Chief Complaint (CC.)
a. What brought you to the clinic or hospital?
b. What is troubling you?
c. Should be recorded in the client’s own words
d. The chief complaint established the purpose of the
contact, provides direction for the assessment, and
establishes the nurse-client relationship
e. Gather information to fully describe the client’s problem
f. Ask questions that help the client describe the specific
signs and symptoms associated with the problem and

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 provide a history to the present illness
Examples of Chief Complaints:
- Chest pain for 3 days
- Swollen ankles for 2 weeks
- Fever and headache for 24 hours
- Pap smear needed
- Physical examination needed for camp
C. History of Present Illness
- What is the chronological sequence of events in reference to
the client’s chief complaint?
a. Client’s summary and usual health
b. When didd the symptoms start?
c. Whether the onset of symptoms was sudden or gradual
d. How often the problem occurs?
e. Exact location of the distress
f. Character of the complaint (e.g. intensity of pain, or quality
of sputum, emesis, or discharge)
g. Type of activity of client when problem occurred
h. Symptoms associated with the chief complaint
i. Factors that aggravate or alleviate the problem
j. Was help or consultation sought?
k. What were the medication used?
l. How has the problem interred with daily life?
D. Past Health History
a. Childhood illness (e.g. history of rheumatic fever)
b. History of accidents and disabling injuries
c. History of hospitalization (time of admission, date,
admitting complaint, discharge diagnosis and follow up
care)
d. History of operations “how and why this done”
e. History of immunization and allergy

S/P —> status post

E. Family History of Illness
a. Health and ages of patients, siblings, children or ages of
death and causes
b. Illness in the family similar to the patient’s illness
c. Family incidence of rheumatic fever, hypertension,
tuberculosis, diabetes, mental illness etc. especially as

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 suggested by the presented illness
d. Cause of death of the family members “immediate and
extended family”
F. Lifestyle
a. Personal Habits: the amount, frequency and duration of
substance used (tobacco, alcohol, coffee, cola, tea and
elicit or recreational drugs)
b. Diet: description of a typical diet on a normal day or any
special diet, number of meal and snacks per day, who
cooks and shops for food, ethnically distinct food patterns
and allergies
c. Sleep/Rest Patterns: usual daily slept wake times,
difficulties sleeping and remedies used for difficulties
d. Activities of Daily Living: any difficulties experienced in
the basic activities of eating, grooming, dressing,
elimination and locomotion
e. Recreation/Hobbies: exercise activities and tolerance,
hobbies and other interests and vacation
f. Social Data: family relationships/friendships client’s
support system at time of stress. What effect the client’s
illness has in the family and whether and family problems
are affecting the client
g. Ethnic Affiliation: health customs and beliefs, cultural
practices that may affect health care and recovery
h. Educational History: data about client’s highest level of
education attained and any past difficulties with learning
i. Occupational History: current employment status, the
number of days missed from work because of illness, any
history of accidents in the job, any occupational hazards
with a potential for future disease or accident, the client
need to change jobs because of past illness, the
employment status of spouses, partners and the way child
care is handled, and the client’s overall satisfaction at work
j. Economic Status: info about how the client is paying for
medical care (including what kind of medical and
hospitalization coverage the client has) and whether the
client’s illness presents financial concerns
k. Home and Neighborhood Conditions: home safety
measures and adjustments in physical facilities that may

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 be required to help the client manage a physical disability,
activity intolerance and activities of daily living, the
availability of neighborhood and community services to
meet the client’s needs\
l. Psychosocial Activity: how the client and his family cope
disease or stress and how they response to illness and
health; you can assess if there is psychological or social
problem and if it alters general health of the client

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