THEORIES OF NURSING

Florence Nightingale
 Florence Nightingale (1960/1969)

 Often considered the first nurse

theorist
 Defined nursing as “the act of utilizing
the environment of the patient to assist
him in his recovery”.
 Nightingale’s theory remains an
integral parts of nursing and healthcare
today.
5 Environmental Factors:
Pure or fresh air
Pure water
Efficient drainage
Cleanliness
Light, especially direct sunlight

 Nightingale’s general concepts are:

1.Ventilation 4.Warmth
2.Cleanliness 5.Diet
3.Quiet
Dorothy Johnson
 Dorothy E. Johnson (1980)
The Behavioral System Model for
Nursing
 Focuses on how the client adapt to illness;
the goal of nursing is to reduce stress so
that the client can move easily through
recovery.
 Viewed the patient’s behavior as a system
that is a whole with interacting parts. The
nursing process is viewed as a major tool.
 Purpose: To reduce stress so the client
can recover as quickly as possible.
View of components
 Person: A system of interdependent parts
with patterned, repetitive, and purposeful
ways of behaving.
 Environment: All forces that affect the person
and that influence the behavioral system.
 Health: Focus on person, not illness. Health is
a dynamic state influenced by biologic,
psychological, and social factors.
 Nursing: Promotion of behavioral system,
balance, and stability. An art and science
providing external assistance before and
during system balance disturbances.
 Myra Estrin Levin(1973)
Conservation Model
Described the Four Conservation
Principles. She advocated that
nursing is a human interaction and
proposed four conservation
principles of nursing which are
concerned with the unity and
integrity of the individual. The four
principles are as follows:
1. Conservation of Energy – The human
body functions by utilizing energy. The
human body needs energy producing
input (food, oxygen, fluids) to allow
energy utilization as output.
2. Conservation of Structural Integrity- the
human body has physical boundaries
(skin, and mucous membranes) that must
be maintained to facilitate health and
prevent harmful agents from entering the
body.
3.Conservation of Personal Integrity- the
nursing interventions are based on the
conservation of the individuals personality.
Every individual has a sense of identity,
self-worth and self-esteem, which must be
preserved and enhanced by the nurses.
4.Conservation of Social Integrity- the social
integrity of the clients reflects the family
and the community in which the clients
functions. Health care institutions may
separate individuals form their family. It is
important for nurses to consider the
individual in the context of a family.
Imogene King
 Imogene King (1971)
Goal Attainment Theory
 Highlights the importance of the
participation of all the individuals in
decision making & deals with the
choices, alternatives, & outcomes of
nursing care
 This theory offers insights into
nurses’ interactions with individuals
& groups within the environment
 Defines Health as a dynamic state in
the life cycle; illness is an interference in
the life cycle. Health implies a continuous
adaptation to stress
Described nursing as a helping
profession that assists individuals and
groups in society to attain, maintain and
restore health. If this is not possible,
nurses help individuals to die with
dignity.
 Viewed nursing as an interaction
between the client and the nurse
whereby perceiving, setting goals
and acting on them, transaction
occurs and goals are achieved.
 Social Systems
(Society)

Interpersonal
System
(Groups)
Personal
Systems Imogene King
(Individuals) A conceptual framework
for nursing:Dynamic
interacting systems.
Nursing process is defined as
dynamic interpersonal process
between nurse, client and health
care system.
Faye Glenn Abdellah
 Faye Glenn Abdellah (1960)
Patient-Centered Approaches to
Nursing
 Purpose: To deliver nursing care for the
whole individual.
 Abdellah described nursing as a service to
people, families and society. The nurse
helps people, sick or well, to cope with
their health needs. In Abdellah’s model,
nursing care means providing information
to the client or doing something to the
client with the goal of meeting needs or
alleviating an impairment.
View of components
 Person: The recipient of nursing care having
physical, emotional, and sociologic
 needs that may be overt or covert.
 Environment: Not clearly defined. Some
discussion indicates that client interact
 with their environment, of which the nurse
is a part.
 Health: Implicitly defined as a state when
the individual has no unmet needs and
 no anticipated or actual impairments.
 Nursing: Broadly grouped in “21 nursing
problems.”
1. To maintain good hygiene.
2. To promote optimal activity: exercise, rest,
and sleep.
3. To promote safety.
4. To maintain good body mechanics.
5. To facilitate the maintenance of supply of
oxygen.
6. To facilitate maintenance of nutrition.
7. To facilitate maintenance of elimination.
8. To facilitate the maintenance of fluid and
electrolytes balance.
9. To recognize the physiologic response of the
body to disease conditions.
10. To facilitate the maintenance of regulatory
mechanisms and functions.
11. To facilitate the maintenance of sensory
function.
12. To identify and accept positive and negative
expressions, feelings and reactions.
13. To identify and accept the interrelatedness
of emotions and illness.
14. To facilitate the maintenance of effective
verbal and non-verbal communication.
15. To promote the development of
productive interpersonal relationship.
16. To facilitate progress toward achievement
of personal spiritual goals.
17. To create and maintain a therapeutic
environment.
18. To facilitate awareness of self as an
individual with varying needs.
19. To accept the optimum possible goals.
20. To use community resources as an aid in
resolving problems arising from illness.
21. To understand the role of social problems
as influencing factors.
Betty Neuman
 Betty Neuman (1972)
Health Care Systems Model
Views client as an open system
consisting of a basic structure or
central core of energy resources
(physiologic, psychologic,
sociocultural, developmental, &
spiritual) surrounded by lines of
resistance that defends client against
stressors
 She asserted that nursing is a unique
profession in that it is concerned with all
the variables affecting an individual’s
response to stresses which are intra
(within), inter (between one or more
people) and extra-personal ( outside the
individual) in nature.
 The concern of nursing is to prevent
stress invasion, to protect the client’s
 basic structure and obtain or
maintain maximum level of wellness.
 The nurse helps the client,
through primary, secondary, and
tertiary prevention modes, to adjust
to environmental stressors and
maintain client system stability.
Sister Calista Roy
 Sister Callista Roy (1979)
Adaptation Model
 Focuses on the individual as a
biopsychosocial adaptive system. Both
the individual & the environment are
sources of stimuli that require
modification to promote adaptation, an
on-going purposive response
 The individual receives inputs or stimuli
from both the self & the environment
 She contended that the person is an
adaptive system, function as a whole
through interdependence of its parts.
 The system consist of input, control
process, output and feedback.
 In addition, she advocated that all
people have certain needs which
they endeavor to meet in order to
maintain integrity
These needs are divided into four
different modes, the physiological,
self concept, role function, and
interdependence.
Accordingly Roy believed that
adaptive human behavior is directed
toward an attempt to maintain
homeostasis or integrity of the
individual by conserving energy and
promoting the survival, growth,
reproduction and mastery of the
human system.
Ida Jean Orlando
 Ida Jean Orlando (1961)
The Dynamic Nurse-Patient
Relationship
 Three elements – Client behavior,
nurse reaction and nurse actions –
compose the nursing situation.
 Purpose: To interact with clients to
meet immediate needs by identifying
client
 behaviors, nurse’s reactions, and
nursing actions to take.
Views of Components
 Person: Unique individual behaving
verbally and nonverbally. Assumption is
that
 individuals are at times able to meet
their own needs and at other times
unable to do so.
 Health: Not defined. Assumption is that
being without emotional or physical
 discomfort and having a sense of well-
being contribute to a healthy state.
 Nursing: Professional nursing is
conceptualized as finding out and
meeting the
 client’s immediate need for help.
Medicine and nursing are viewed as
distinctly different.
 The concept of need is central to
Orlando’s theory, which focuses on
clients and their unmet needs. Orlando
believed that the purpose of nursing is
to provide the assistance that a client
requires to meet his or her needs.
Virginia Henderson
 Virginia Henderson (1955)
Definition of Nursing
 Nursing as a discipline separate from medicine.
 Described nursing in relation to the client and
the client’s environment
 Concerned with both healthy and ill individuals
even when recovery may not be feasible
 Teaching and advocacy roles of the nurse
 The unique function of the nurse is to assist the
individual sick or well to perform his/her
activities contributing to health, its recovery, or
to a peaceful death, the client would perform,
if he had the necessary strength, will and
knowledge.
The 14 Fundamental Needs

 Breathing normally
 Eating and drinking adequately
 Eliminating body waste
 Moving and maintaining a desirable
position
 Sleeping and resting
 Selecting suitable clothes
 Maintaining body temperature within
normal range by adjusting clothing
and modifying the environment
 Keeping the body clean and well groomed to
protect the integument.
 Avoiding dangers in the environment and
avoiding injuring others.
 Communicating with others in expressing
emotions, needs, fears, or opinions
 Worshipping according to one’s faith
 Working in a such way that one feels a sense of
accomplishment
 Playing or participating in various forms of
recreation
 Learning, discovering, or satisfying the curiosity
that leads to normal development and health,
and using available health facilities
Hildegard Peplau
 Hildegard Peplau (1952)
Interpersonal Relations Model
 The use of a therapeutic relationship between the
nurse and the client.
 Nursing as a therapeutic, interpersonal process
which strives to develop a nurse-patient
relationship in which the nurse serves as a
resource person, counselor and surrogate.

The nurse-client relationship evolves four

phases:
Orientation
 The client seeks help
 The nurse assist the client to understand the
problem and the extent of the need for help.
Identification
 The client assumes a posture of dependence,
interdependence, or independence in relation to
the nurse.
 The nurse’s focus is to assure the person that
the nurse understands the interpersonal
meaning of the client’s situation.
Exploitation
 The client derives full value from what the nurse
offers through the relationship.
 The client uses available services based on self-
interest and needs.
 Power shifts from the nurse to the client.
Resolution
 Old needs and goals are put aside and new
ones adopted. Once older needs are resolved,
newer and more mature ones emerge.
 Nurses’ Roles:
 Stranger
 Teacher
 Resource Person
 Surrogate
 Leader
 Counselor
Martha Rogers
 Martha Rogers (1970)
Science of Unitary Human Beings
 Views person as an irreducible whole, the
whole being greater than the sum of its
parts. Whole is differentiated from holistic.
 States that the humans are dynamic energy
fields in continuous exchange with
environmental fields, both of which are
infinite.
 Both human and environmental fields are
characterized by pattern, a universe of open
systems, and four dimensionality.
 Considers man as a unitary human being co-
existing within the universe, views nursing
primarily as a science and is committed to
nursing research.
What is an unitary man? Unitary
man :
Is an irreducible, four-dimensional
energy field identified by pattern
Manifests characteristics different
from the sum of parts
Interacts continuously and creatively
with the environment
Behaves as a totality
As a sentient being, participates
creatively in change.
Nurses applying Roger’s theory in practice:
 focus on the person’s wholeness
 seek to promote symphonic interaction
between the two energy fields to strengthen
the coherence and integrity of the person
 coordinate the human field with the
rhythmicities of the environment field
 direct and redirect patterns of interaction
between the two energy fields to promote
maximum health potential.
Non-therapeutic touch:
 based on human energy fields
 affected by pain and illness
 can assess and feel the energy field
and manipulate it to enhance the
healing process of people who are ill
or injured.
 Dorothea Orem (1971)
General Theory of Nursing
 Emphasizes the client’s self-care needs,
nursing care becomes necessary when
client is unable to fulfill biological,
psychological, developmental or social
needs.
 Three related concepts
 Self-care
 Self-care deficit
 Nursing systems
Self-care theory is based on four
concepts:
 Self-care – activities an individual
performs independently to promote
and maintain personal well-being.
 Self-care agency – individual’s ability
to perform self-care activities.
Consists of two agents
 A self care agent – an individual who
performs self-care independently
 A dependent care agent – a person other
than the individual who provides the
care
Self– care requisites (self-care needs) – actions
or measures taken to provide care. There are
three categories:
Universal requisites – includes: Intake and
elimination of air, water and food; balancing rest,
solitude, and social interaction; preventing hazards
to life and well-being; and promoting normal human
functioning.
Developmental requisites – results from maturation
or are associated with conditions and events.
Health deviation requisites – result from illness,
injury or disease or its treatment. (eg. Seeking health
care assistance, carrying out prescribed therapies,
and learning to live with the effects of illness or
treatment)
Therapeutic self- care demand – all self-care
activities required to meet existing self-care
requisites. ( Actions to maintain health and
well-being Self-care deficit results when
self-care agency is not adequate to meet
the known self-care demand.)
5 Methods in helping:
 a. Acting or doing for
 b. Guiding
 c. Teaching
 d. Supporting
 e. Providing an environment that promotes
abilities to meet current demands
3 Types of Nursing Systems:
 Wholly compensatory systems are
required for individuals who are unable to
control and monitor their environment and
process information.
 Partly compensatory systems are designed
for individuals who are unable to perform
some, but not all, self-care activities
 Supportive-educative (developmental)
systems are designed for persons who
need to learn to perform self-care
measures and need assistance to do so.
Basic Conditioning Factors for Self-care
Agency and Therapeutic Self Care
Demand:
 Age
 Gender
 Developmental state
 Sociocultural orientation
 Health State
 Family system factors
 Health care system factors
 Patterns of living
 Environmental factors
 Resource availability and adequacy
Basic Conditioning Factors for
Nursing Agency
 Age
 Gender, race
 Physical and constitutional
characteristics
 Health state
 Family/Community roles
 Nursing educational preparation
 Nursing experience
 Maturity/Status as a person
 R R
Self-care

Contributi Contributi
ng R ng
Self-care
Factors agency Self-care Factors
< demands
Deficit

R
R
Nursing
Contributi Agency
ng
Factors
 Jean Watson (1979)
Human Caring Theory
Believes the practice of caring is central
to nursing: it is the unifying focus for
practice
Carative factors – nursing intervention
related to human care.
Redefining nursing as a caring-healing
health model
10 Factors
 Forming a humanistic-altruistic system of values
 Instilling faith and hope
 Cultivating sensitivity to one’s self and others
 Developing a helping-trust (human care) relationship
 Promoting and accepting the expression of positive and
negative feelings
 Systematically using the scientific problem-solving
method for decision making.
 Promoting interpersonal teaching-learning
 Providing a supportive, protective, or corrective mental,
physical, socio-cultural, and spiritual environment
 Assisting with the gratification of human needs
 Allowing for existential-phenomenologic forces
Watson’s Assumptions of Caring
 Human caring is not just an emotion, concern,
attitude or benevolent desire. Caring connotes a
personal response.
 Caring is an intersubjective human process and is
the moral ideal of nursing.
 Caring can be effectively demonstrated only
interpersonally.
 Effective caring promotes health and individual
or family growth.
 Caring promotes health more than does curing.
 Caring responses accept a person not only as
they are now, but also for what the person may
become.
 A caring environment offers the development of
potential while allowing the person to choose the
best action for the self at a given point in time.
 Caring occasions involve action and choice by
nurse and client. If the caring occasion is
transpersonal, the limits of openness expand, as
do human capacities.
 The most abstract characteristic of a caring person
is that the person is somehow responsive to
another person as a unique individual, perceives
the other’s feelings, and sets one person apart
from another.
 Human caring involves values, a will and a
commitment to care, knowledge, caring actions,
and consequences.
 The ideal and value of caring is a starting point, a
stance, and an attitude that has to become a will,
an intention, a commitment, and a conscious
judgment that manifests itself in concrete acts.
THE NURSING PROCESS
Systematic problem - solving approach toward
giving individualized nursing care.

STEPS:
 Assessment
 Nursing Diagnosis
 Planning
 Intervention
 Evaluation
 ASSESSING PATIENT’S HEALTH STATUS

Assessment
 A systematic collection of subjective
and objective data with the goal of
making a clinical nursing judgment
about an individual, family or
community.
 1st phase of nursing process which
involves data collection , organization
and validation.
 Purpose of Nursing Assessment
 To establish the client-nurse relationship.
 To obtain information about the client’s health,
including physiologic, socio-cultural, cognitive,
developmental & spiritual aspects.
 To identify the client’s strength.
 To identify actual & potential problems.
 To establish a data base from w/c the subsequent
phases of the nursing process evolve.
 Methods used in Nursing
Assessment
Observation
Interview
Physical Examination
 OBSERVATION
 To gather data by using the 5 senses
 Is a conscious deliberate skill that is
developed only through effort and
with organized approach
 Observational Skills
 Vision
 Overall appearance (body size, weight,
posture); signs of distress or discomfort; facial &
body gestures; skin color & lesions;
abnormalities of movement; non-verbal
demeanor
 Smell - Body or breath odors
 Hearing - Breath & heart sounds, bowel sounds,
ability to communicate, language spoken,
orientation to time person & place
 Touch - Skin temp, pulse rate, rhythm; muscle
strength;
 INTERVIEW
 Planned communication or
conversation wherein its primary
purpose is to gather data.
 This will give information, identify
problems of mutual concern,
evaluate change, teach, provide
support, counseling & therapy
 APPROACHES FOR INTERVIEW

DirectiveInterview
Nondirective Interview
Directive Interview
 Is a highly structured and elicits specific
information.
 The nurse establishes the purpose of the
interview & controls the interview by asking
closed type of questions
Nondirective Interview
 This is a rapport-building interview w/c
allows the client to control the purpose,
subject matter, and pacing of the interview.
 The nurse usually used an open-ended
questions
 KINDS OF INTERVIEW QUESTIONS
Closed questions
 Used in directive interview, usually restrictive
& generally require only short answers giving
specific information. Thus, the amount of the
information gained is limited.
 Often begins with 4WH.

Open-ended questions
 Associated in nondirective interview.
 Allow the clients to elaborate, clarify &
illustrate their thoughts & feelings. (e.g. Why
did you come to the hospital tonight?; How did
you feel in that situation?
Neutral question
 It is a question the client can answer without
direction or pressure from the nurse.
(e.g., How do you feel about that?; Why do
you think you had an operation?)

Leading question
 Directs the client’s answer. The phrasing of the
question suggests what answer is expected.
e. g. You are stressed about the surgery
tomorrow, aren’t you?; You will take your
medicine, won’t you?
 POINTS TO REMENBER IN AN
INTERVIEW
 Select a quiet private setting (time, place,
seating arrangement, distance).
 Choose terms carefully and avoid using
jargon.
 Use appropriate body language.
 Confirm patient statements to avoid
misunderstanding.
 Use open-ended question.
 COMMUNICATION
a. Silence STRATEGIES
 - Moments of silence during the interview encourage
the pt. to continue talking & give a nurse a chance to
assess the clients ability to organize thoughts.
b. Facilitation
 -Facilitation encourages the pt. to continue with his
story. (e.g. “please continue”, “go on” and “uh-huh)
c. Confirmation
 - Ensures that both the nurses & the pt. are on the
same track.
 (e.g. If I understand you correctly, you said…..)
d. Reflection
 - Repeating something the pt. has just said can help
you obtain more specific information.
e. Clarification
 is used when an information given is vague.
 e.g. client: I can’t stand this!
 Nurse : What do you mean by I cant stand
this?
f. Summarization
 -restating the information that the pt. gave you. It
ensures that the data collected is accurate &
complete.
g. Conclusion
 Signals the pt. that the nurse is ready to conclude
the interview. It provides the pt. the opportunity to
gather his thoughts and make any pertinent final
statements.
 e.g. nurse: I think I have all the information I need
now. Is there anything you would like to add.
 NURSING HEALTH HISTORY
 One example of an interview.
 1st part of the assessment of the
client’s health status.
 Used to gather subjective data about
the pt. & explore the past & the
present health problems.
uniqueness of
the client in his
or her situation
that brings a
Nursing Care
Plan to life. Be
sure to match
your
assessment,
priority
diagnoses,
goals and
evaluative
measures to the
personality, life
style and needs
 COMPONENTS OF THE NURSING
HISTORY
Biographic data
 Includes the client’s name, address, age,
sex, telephone no., race, marital status,
b-day, occupation, religion, nationality.

Chief complaint or reason for visit

 The c/c should be recorded in the client’s
own words. (‘What is troubling you?”)
History of present illness

P-rovocative/Palliative
 ask the patient: what triggers & relieves the
symptom?

Q-uality or Quantity
 What the symptom feels like, look like?
 Are you having the symptom right now? If so , is it
more or less severe than usual?

R-egion or Radiation
 Where in the body does the symptom occur?
 - Does the symptom appear in other regions? If so,
where?
S-everity
 How severe is the symptom? How would you rate
it on a scale of 1-10, with 10 being the most
severe.
 Does the symptom seem to diminishing,
intensifying, or staying about the same?

T-iming
 When did the symptom begin?
 Was the onset sudden or gradual?
 How often does the symptom occur?
 How long does the symptom last?
Family History
 The family nursing history reveals risk factors for
certain diseases
 This information should include the ages of
siblings, parents & grandparents & their current
state of health or cause of death.
 Particular attention should be given to disorders
such as heart disease, cancer, diabetes,
hypertension, obesity, allergies, arthritis , TB,
jaundice, bleeding, ulcers, migraine & alcoholism.
Review of systems (ROS)
 It’s a review of all health problems by body
system to prevent omission of data related to the
present illness and to discover any other
problems that might have been blessed.
 Head to Toe approach is used and often an
agency checklist is available.
Medical History
 Past and current medical problems such as
hypertension, diabetes, and back pain.

Typical question:
 Have you ever been hospitalized? When &
Why?
 What childhood illnesses did you have?
 Have you ever had a surgery? When & Why?
Lifestyle
 Personal Habits – the frequency of substance used such as,
alcohol, coffee, cola, tobacco, illicit or recreational drugs.
 Diet & elimination– food allergies, special food preparation,
prescribed diet. Frequency of bowel movement.
 Sleep/rest & exercise pattern
 Work & leisure – what he does for a living & leisure time;
hobbies.
 Religious observances
Psychosocial
 Find out how the pt. feels about himself, his place in society
& his relationship to others, occupation, educational status
& responsibilities.
 e.g. how have you coped w/ medical or emotional crises in
the past?
 how adequate is the emotional support?
 do you have a health insurance?
 do you have a fixed income, extra money for health care?
 Gordon (1987) devised a theoretical framework
for assessment of a nursing client that allows
nurses to identify obvious as well as emerging
patterns of functioning. Using this framework
nurses screen their client for functional as well
as dysfunctional patterns .
 An early step in the development of nursing
diagnoses for a client is to do a general
assessment using some selected framework.
There are many nursing frameworks from which
to choose. Gordon's 11 Functional Health
Patterns is one that is useful for a screening
assessment.
 Gordon’s Typology of 11
Functional Health Patterns
 Health Perception and Health Management. Data collection
is focused on the person's perceived level of health and well-
being, and on practices for maintaining health. Habits that may
be detrimental to health are also evaluated, including smoking
and alcohol or drug use. Actual or potential problems related to
safety and health management may be identified as well as
needs for modifications in the home or needs for continued care
in the home.
 Nutrition and Metabolism Assessment is focused on the
pattern of food and fluid consumption relative to metabolic need.
The adequacy of local nutrient supplies is evaluated. Actual or
potential problems related to fluid balance, tissue integrity, and
host defenses may be identified as well as problems with the
gastrointestinal system.
 Elimination. Data collection is focused on
excretory patterns (bowel, bladder, skin).
Excretory problems such as incontinence,
constipation, diarrhea, and urinary retention
may be identified.
 Activity and Exercise. Assessment is focused
on the activities of daily living requiring energy
expenditure, including self-care activities,
exercise, and leisure activities. The status of
major body systems involved with activity and
exercise is evaluated, including the respiratory,
cardiovascular, and musculoskeletal systems.
 Cognition and Perception. Assessment is focused on
the ability to comprehend and use information and on
the sensory functions. Data pertaining to neurologic
functions are collected to aid this process. Sensory
experiences such as pain and altered sensory input may
be identified and further evaluated.
 Sleep and Rest. Assessment is focused on the
person's sleep, rest, and relaxation practices.
Dysfunctional sleep patterns, fatigue, and responses to
sleep deprivation may be identified.
 Self-Perception and Self-Concept. Assessment is
focused on the person's attitudes toward self, including
identity, body image, and sense of self-worth. The
person's level of self-esteem and response to threats to
his or her self-concept may be identified.
 Roles and Relationships. Assessment is
focused on the person's roles in the world and
relationships with others. Satisfaction with roles,
role strain, or dysfunctional relationships may
be further evaluated.
 Sexuality and Reproduction. Assessment is
focused on the person's satisfaction or
dissatisfaction with sexuality patterns and
reproductive functions. Concerns with sexuality
may he identified.
 Coping and Stress Tolerance. Assessment is
focused on the person's perception of stress and on
his or her coping strategies Support systems are
evaluated, and symptoms of stress are noted. The
effectiveness of a person's coping strategies in
terms of stress tolerance may be further evaluated.
 Values and Belief. Assessment is focused on the
person's values and beliefs (including spiritual
beliefs), or on the goals that guide his or her
choices or decisions.
 Types of data
Subjective data
 These can be gathered solely from the patient’s own
account. Includes the pt. sensation, feelings, values,
beliefs, attitudes & perception towards health status &
life situation.
 Referred to as symptoms or covert data
 e.g. “I feel weak all over when I exert myself”
“ I have a sharp pain on my chest”
Objective data
 Can be obtained through observation and verifiable
 Referred as signs or overt data, these can be seen ,
heard, felt or smelled
 Validates the subjective data
 e.g. B.P. 90/50
 Apical pulse 104, abdomen is distended, skin is pale &
diaphoretic.
 PHYSICAL EXAMINATION
 Itis a systematic data-collection method
that uses observational skills to detect
health problems. (cephalocaudal or body
system approach)
 Uses the following techniques:

 Inspection,Palpation, Percussion,
Auscultation (IPPA)
 PURPOSE OF PHYSICAL ASSESMENT

 To obtain baseline data about the client’s

functional abilities.
 To supplement, confirm or refute the data
obtained in nursing history.
 To obtain data that will help the nurse
establish nursing dx. & plan the client’s care.
 To evaluate the physiologic outcomes of
healthcare & the progress of the client’s
health problem.
 ASSESSMENT TOOLS

 Sphygmomanometer  Scale with height

 Cotton balls measurement
 Gloves  Skin calipers
 Visual acuity charts  Speculum
 Ophthalmoscope  Stethoscope
 Otoscope  Tape measure
 Penlight  Thermometer
 Percussion Hammer  Tuning fork
 Safety pins  Tongue depressor
 NURSING DIAGNOSIS
A clinical judgment about an
individual, family or community
responses to actual or potential
health/life processes.
 Provides the basis for selection of
nursing intervention to achieve
outcomes for which the nurse is
accountable.
 Nursing Diagnosis
 Diagnosing is a process which results
to a diagnostic statement.
 Nursing Diagnosis – is a statement of
a client’s potential or actual
alteration of health status. It results
from analysis and synthesis.
 Purpose: To identify the client’s
health care needs and to prepare
diagnostic statements.
 NURSING DIAGNOSIS
 Medical diagnosis
 describes a disease or pathology of specific
organs or body system
 Provide convenient means for communicating
treatment requirements
 Nursing Diagnosis
- describes an actual, risk or wellness human
response to a health problem that nurses are
responsible for treating independently.
 Nursing Diagnosis
 EXAMPLE:
Medical Dx: Pneumonia
Nursing Dx: Ineffective airway
clearance r/t tracheobronchial
secretions

Medical Dx: Tonsillitis

Nursing Dx: Elevated body temperature
related to presence of pyrogens.
 NURSING DIAGNOSIS
TAXONOMY
 Taxonomy
Method for ordering complex
information
Classification system to provide
structure for nursing practice.
Purpose: to provide vocabulary for
classifying phenomena in a discipline
 Components of Nursing Dx
 Diagnostic Label/Problem - this describes the
client’s health status clearly and concisely in
a few words. - name of the nursing diagnosis
as listed in the taxonomy
 E.g. Impaired mobility; activity intolerance
 Descriptors – words used to give additional
meaning to a nursing diagnosis. They
describe changes in condition, state of the
client or some qualification
 E.g.altered, impaired, decreased, ineffective,
acute, chronic, excessive, delayed
 Components of Nursing Dx
 Related factors/Etiology – describes the conditions,
circumstances that contribute to the problem. Terms used:
associated with, related to or contributing to.
 Defining characteristics/Signs and symptoms – observable
cues that cluster as manifestation of an actual or wellness
nursing diagnosis.
 Risk factors – describe clinical cues in risk nursing diagnosis.
They are environmental, physiological, psychological,
genetic, or chemical factors that increase the vulnerability of
pt. leading to unhealthful event.
Formulating Nursing Diagnosis
A. Collect Valid and pertinent data
B. Cluster the Data
C. Differentiate Nursing Dx from
Collaborative problems
D. Formulate Nursing Dx correctly
select priority diagnosis.
 Use Nursing Diagnosis Decision Tree
Is there a problem in a specific area?

Yes No

Collect more focused If no problem, is the

data. Is a problem person at risk for
present? developing a problem?

Yes Yes No

Actual Nsg Dx Risk Nsg Dx Although there is no

actual problem or risk
factors to actual problem,
does the person desire to
improve

Well Nursing Diagnosis

 Types of Nursing Diagnosis
A. Actual
Describes a clinical judgment that the nurse has
validated because of the presence of major
defining characteristics.
Ex. Ineffective Airway Clearance related to
excessive and tenacious secretions.

B. Risk
Describes a clinical judgment that an
individual/group is more vulnerable to develop
the problem than others in the same or similar
situation
Ex. Risk for Impaired Skin Integrity related to
immobility secondary to fractured hip.
C. Possible
An option to indicate that some data are
present to confirm a diagnosis but are
insufficient as of this time.
Ex. Possible Self Care Deficit related to
impaired ability to use left hand secondary
to presence of intravenous therapy.
D. Wellness
Diagnostic statement that describes the
human response to level of wellness.
From a specific level of wellness to a higher
level of wellness.
Ex. Readiness for enhanced spiritual well
being
 Diagnostic Statements
A. One-Part
Just the label or the problem
Ex. Readiness for enhanced parenting
B. Two-Part
Problem r/t to etiology or risk factors
Ex. Risk for impaired skin integrity related to
immobility secondary to fractured hip
C. Three-Part
Diagnostic label + contributing factors + signs
and symptoms.
Ex. Anxiety related to unpredictable nature of
operative procedure as evidenced by
statements of: “Natatakot akong hindi
makahinga.”
 Nursing Diagnosis
 To use NANDA (2003 edition)
 Use the 2-part Diagnostic
Statements
Problem r/t etiology or risk factors
+ secondary to
 Don’ts
 Using medical diagnosis
ex. Self care deficit related to stroke
Self care deficit related to neuromuscular impairment
 Relating the problem to an unchangeable situation
ex. paralysis
 Confusing etiology or s/sx for the problem
ex. Post op lung congestion related to bedrest
Ineffective airway clearance related to general weakness and
immobility
 Use of procedure instead of a human response
ex. Catheter related to urinary retention
Urinary retention related to perineal swelling
 Lack of specificity
ex. Constipation related to nutritional imbalance
 Combining two nursing dx
ex. Anxiety and fear related to separation from parents
 Relating one nursing dx to another
ex. Ineffective coping related to anxiety
 Use of judgmental / value laden language
ex. Pain related to monetary gain
 Making assumptions
ex. Risk for altered parenting related to inexperience
 Writing a legally inadvisable statements
ex. Impaired skin integrity related to not being turned
2 hourly
 PLANNING
 Involves determining beforehand the
strategies or course of actions to be taken
before implementation of nursing care.
 To be effective, involve the client and his
family in planning.
 Purpose: To identify the client’s goal and
appropriate nursing interventions.
 PLANNING
1. Set priorities in collaboration with
the patient

E.g. Lessened pain scale from 9

–5
Increase weight from 110 lbs
– 115 lbs
 PLANNING
2. Set goals and objectives in
collaboration with the client. Short-term
goal (STG) or Long-term goal (LTG)
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time-framed
 PLANNING
 Example: STG
At the end of 8 hrs of nursing
interventions, the patient’s temperature
will be equal to or less than 37.8 C per
axilla.
At the end of 4 hrs of nursing
interventions, the patient’s pain will be
relieved if not lessened as manifested by
decrease in pain scale from 9-5 and
presence of unguarded behavior.
 PLANNING
 Example: LTG
After one week of nursing
interventions, the
patient’s body temperature will
remain under
normal range of =/> 37.8 C per axilla.
After 2 weeks of nursing intervention, the
patient’s weight will increased from 110 lbs
– 115 lbs.
 IMPLEMENTATION
 Putting the nursing care plan into action
 Purpose: To carry out planned nursing
interventions to help the client attain goals
Requirements:
1. Knowledge
2. Technical skills
3. Communication Skills
 IMPLEMENTATION
STEPS:
1. Reassess the client
2. Set priorities
a. ABC
b. Maslow’s hierarchy of needs
3. Implement nursing interventions
4. Documentation
 IMPLEMENTATION
 Implementing
Nursing interventions
1. Assessment – for baseline data
ex: Assess breath sounds, assess wt
2. Independent nursing interventions
ex: Positioned pt to high-fowlers position
Encouraged slow but deep breathing
Instructed to small but frequent feeding
 IMPLEMENTATION
3. Dependent nursing interventions
ex: Administered pain reliever as ordered.
4. Interdependent nursing interventions
ex: Secured specimen for urinalysis as
ordered
5. Psychosocial interventions
ex: Encouraged verbalization of feelings
 EVALUATION
 Assessing the client’s response to
nursing interventions and then
comparing the response to
predetermined standards or outcome
criteria.
 Purpose: To determine the extent to
which goals if nursing care have
been achieved.
 EVALUATION
 STEPS:

1. Collect data about client’s

response
2. Compare the client’s response
to outcome criteria
3. Analyze the reasons for the
outcomes
4. Modify care plan as needed.
 EVALUATION
 Example:
After 8 hours of nursing
intervention, the patient verbalizes
relief of pain with Pain scale from 9 –
5. Patient manifests relaxed and
unguarded behavior.
After 8 hrs of nursing intervention,
the pt’s body temperature was 37.8
C per axilla.
 Characteristics . . . . .
 Problem-oriented – it is comparable with scientific
problem solving approach
 Goal oriented
 Orderly, planned, step by step
 Open to accepting new information during its
application
 Interpersonal
 Permits creativity among nurses and clients in
devising ways to solve the health problems
 Cyclical
 Universal
 Benefits for clients
 Quality of care

 Continuity of care

 Participation by the clients in their

health care
 Benefits for the Nurse
 Consistent and systematic nursing
education
 Job satisfaction
 Professional growth
 Avoidance of legal action
 Meeting professional nursing standards
 Meeting standards of accredited hospitals