NURSING PROCESS
Systematic process of planning and giving nursing care
It has five components that follows a logical sequence
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Purpose: To identify the client’s health status, health problems, to
create plans to meet the identified needs and to provide the
appropriate nursing interventions to address those needs.
STEPS IN THE NURSING PROCESS
ASSESSMENT
Collection, organization, validation, and documentation of data
Types of assessment: Remember the word (TIPE) or TYPE
T = Time lapsed: Comparing the previous data (baseline data) to
current data.
I = Initial: To get a complete database for problem identification and
usually done after admission to a health care agency.
P = Problem Focused: To identify the status of a specific problem
and it is an ongoing process.
E = Emergency: To identify life threatening problems during
physiologic or psychologic crisis.
Types of Data:
a. Subjective / Covert / Symptoms
Feelings of the client, verified only by the client itself
, Example: The values, feelings, sensations, and attitudes of the client
b. Objective / Overt / Sign
Data that can be compared on an acceptable standard,
these can be smelled, heard, felt, and seen.
Example: Changes in the color of the skin, vital signs, and breath
sounds.
Sources of Data
a. Primary source – Data came from the client itself
b. Secondary source – Data came from the family members, other
members of the health team, records and reports, laboratory and
diagnostic sources and relevant literatures.
Methods of collecting Data
a. Observing – Gathering data using the different senses
Vision: Overall look of the client (posture, gait, grooming)
Smell: Odors
Hearing: Breath, Bowel, and Heart sounds
Touch: Pulse rate and Skin temperature
b. Interviewing – Planned communication to gather data
1. Planning an Interview
a. Place: Conducive environment (well lighted and ventilated),
free from any destruction like noise.
b. Seating arrangement: If the client is in bed the nurse can sit at
a 45-degree angle to the bed
c. Distance: 2 to 3 feet away
d. Language: Using simple Terms
Systematic process of planning and giving nursing care
It has five components that follows a logical sequence
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Purpose: To identify the client’s health status, health problems, to
create plans to meet the identified needs and to provide the
appropriate nursing interventions to address those needs.
STEPS IN THE NURSING PROCESS
ASSESSMENT
Collection, organization, validation, and documentation of data
Types of assessment: Remember the word (TIPE) or TYPE
T = Time lapsed: Comparing the previous data (baseline data) to
current data.
I = Initial: To get a complete database for problem identification and
usually done after admission to a health care agency.
P = Problem Focused: To identify the status of a specific problem
and it is an ongoing process.
E = Emergency: To identify life threatening problems during
physiologic or psychologic crisis.
Types of Data:
a. Subjective / Covert / Symptoms
Feelings of the client, verified only by the client itself
, Example: The values, feelings, sensations, and attitudes of the client
b. Objective / Overt / Sign
Data that can be compared on an acceptable standard,
these can be smelled, heard, felt, and seen.
Example: Changes in the color of the skin, vital signs, and breath
sounds.
Sources of Data
a. Primary source – Data came from the client itself
b. Secondary source – Data came from the family members, other
members of the health team, records and reports, laboratory and
diagnostic sources and relevant literatures.
Methods of collecting Data
a. Observing – Gathering data using the different senses
Vision: Overall look of the client (posture, gait, grooming)
Smell: Odors
Hearing: Breath, Bowel, and Heart sounds
Touch: Pulse rate and Skin temperature
b. Interviewing – Planned communication to gather data
1. Planning an Interview
a. Place: Conducive environment (well lighted and ventilated),
free from any destruction like noise.
b. Seating arrangement: If the client is in bed the nurse can sit at
a 45-degree angle to the bed
c. Distance: 2 to 3 feet away
d. Language: Using simple Terms
