UNIVERSITY OF THE CORDILLERAS

COLLEGE OF NURSING
INSTRUCTOR: Beverly B. Santos – Bentres

MODULE 1: NURSING PROCESS

Let Us Set Our Objectives!

After this activity, the students will be able to:

✓ Explain the elements of the six steps of nursing process
✓ Discuss the use of each of the six steps of the nursing process
✓ Be familiar with the responsibilities of nurses
✓ Demonstrate the nursing process by preparing a nursing care plan.

INTRODUCTION

Nursing is considered an art and a science. It does only focus on giving care to ill
patient, but also stressed on the promotion of health.

We can say that the first meeting of a nurse and the patient sets the tone for a
successful relationship. Our objective is to discover the details regarding the
patient’s concern, identify underlying concerns and deal with them, display
genuine interest, and partnership.

So, what do we do? Where do we begin?

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 NURSING PROCESS Assess
 This is a systematic process in which
the nurse plans and provide care for
patients. Evaluate Diagnose
 This involves a problem – solving
approach to meet the health care
and nursing needs of the patient. Plan and
Implement Identify
Hence, it allows you to identify Outcome
actual and potential health
problems of the patient.
 Once you identify these problems, you are then able to plan, deliver, and
evaluate nursing care in an orderly and scientific manner.
 Nursing process is composed of six dynamic and interrelated steps:

1. ASSESSMENT
 The first step and most important step in the nursing process as it sets the
tone for the rest of the process.
 This is the systematic collection, validation, and clustering of data to
determine the health status of the patient.
 You do not perform this only once, but throughout the nursing process.

2. NURSING DIAGNOSIS
 This process involves the identification and prioritization of actual or
potential problems or responses.
➢ We analysed the collected data (through assessment), then identify
actual and potential health problems or responses to life process
and state them as nursing diagnoses.
 Nursing diagnosis can be:
a. Actual Nursing Diagnosis
➢ Identifies occurring health problem of the patient.
b. Potential Nursing Diagnosis
➢ Identifies a high-risk problem that is most likely will occur unless
preventive measures have been done.
c. Possible Nursing Diagnosis
➢ This needs further data to support it.
d. Collaborative Problem
➢ A potential medical complication that needs medical and nursing
interventions.
e. Wellness diagnosis
 This focuses in promoting or enhancing the level of wellness of the
patient.

 Once you have identified the diagnoses, then prioritize them in order so
you can develop a plan of care.
 NANDA Nursing Diagnosis

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 3. PLANNING
 In this stage, we set our goals and outcomes to assist our patient in solving
the nursing diagnosis.
 We stablish goals and desirable measurable outcomes.
 Specific, Measurable, Attainable, Realistic, Timely/Time-bound
o Short-term
o Long-term

4. IMPLEMENTATION
 AKA Intervention
 This is the “doing” phase of the nursing process since you carry out your
plan to achieve your goals and outcomes.
 As you implement your plan, you continue to assess your patient and
modify the plan if necessary.
 Make sure to document your care.

5. EVALUATION
 This determines the effectiveness of your plan. Hence, you assess the
responses of the patient to your nursing interventions based on the criteria
you set for the outcome.
o Were you able to meet your goals and outcomes?
 If your goals were not met, you have to rethink your plan and work
through the process again and develop a more effective plan of care for
your patient.

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 NURSING CARE PLAN

Ms. Kurdapia was earning Php 40,000.00 monthly but lost her job six months ago due to the pandemic. She entered the psychiatric unit
two days ago with the diagnosis of major depression. Upon admission, she states that “I just can’t live like this anymore… I missed the life
that I used to have. I messed up. I cannot even sleep like I used to. I just want to die”. Ms. Kurdapia lost 15 kg in the past 6 months, she
weighs 40 kg and is 5 feet 6 inches tall. She is often tearful, sighs often, ignore question at times, keeps repeating that she is a loser and
has poor eye contact during the interview. She becomes restless and irritable when asked about her previous job and is not oriented to
time, place and date.

Ms. Kurdapia stays in her room all day and refuse to join any activities, including her personal hygiene. She is no longer interested in
baking and cooking like she used to. She has unkempt hair and clothes; she was unable to fix her bed and her books were scattered on
the floor. When asked, she admits of having thoughts of killing herself. She states that she attempted to do so by taking the whole bottle
of multivitamins, but she was caught by her sister who stopped the incident. Hence, they take her to the emergency department.

Assessment Nursing Expected Interventions Rationale Evaluation

Diagnosis Outcome
Ineffective STO: o Assess factors contributing To gain understanding of After your
Subjective: “I just Coping At the end of to ineffective coping such the patient’s current interventions,
can’t live like this related to the shift: as poor self-concept, lack situation and to help her were you able to
anymore… I missed major o the patient of social support or lack of with effective coping meet your
the life that I used depression in will be able problem solving. strategies. goals/objectives?
to have. I messed response to to engage
up. I can’t even stressors in reality – o Assess the level of Serves as a baseline and Met, Unmet,
sleep like I used to. associated based understanding of the to plan for relevant Partially Met
I just want to die” with loss of interactions. patient and her readiness interventions.

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as verbalised by job during o The patient to learn necessary lifestyle
the patient on the will be changes
admission. pandemic. oriented to
person, o Assess strengths such as To verbally praise the
Objective: place, and her acknowledgement on patient for her strengths
o Disorientation time. the source of stress. and used these strengths
o Ruminating to help in coping with
thoughts such LTO: stress.
as repetitive After five days
verbalisation of of working with o Monitor risk of harming Most patients who feel
being a loser. the patient: herself or others and helpless and unable to
o Anhedonia o she will be intervene appropriately. solve their problems often
characterised able to
by her lack of express or o Assess available support Some patients may lack
interest in daily verbalise systems sufficient support system
activities emotions outside the hospital
o Sleep with the facility
disturbances: nurse and o Provide a safe
early the environment for the Physical safety of the
awakening, significant patient patient
insomnia other
o Generalised without o Encourage patient to This will allow the patient
restlessness or being express or verbalise to express negative
agitation restless or feelings feelings regarding her
o Poor eye irritable. current situation
contact

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o Suicidal ideas o She will be To assess the coping
or behaviour able to abilities of the patient in
o Poor self-care identify and o Actively listen to the understanding her current
o Poor initiates patient’s concerns and situation
communication effective identify her perceptions of
by patterns like coping current situation Spending time with the
ignoring strategies in patient will convey a
questions and adapting to o Encourage significant caring attitude and shows
giving bizarre situational others to spend time with a good support system.
answers at crisis or stress. the patient
times This creates a supportive
o Decrease used environment and
o Support effective coping
of social enhance coping
strategies – give patient a
support mechanisms.
time to relax.
characterised
by lack of Relaxation techniques
interest in can help the patient
o Encourage the use of
socialising. cope, increase her sense
relaxation techniques such
of control, and alleviate
as music or exercise.
anxiety.

This creates a supportive

environment that
o Use verbal and non-verbal
enhance effective coping
therapeutic
strategies
communication
approaches

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 Involving patients in
decision-making will help
o Assist the patient in setting them move toward
realistic goals and identify independence.
personal skills and
knowledge.

o Assist client in taking her

medications and in doing
her daily activities.

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 ROLES OF NURSES
1. PRACTITIONER
 We are directly involved in meeting the health care and
nursing needs of our patients, families, and significant others.
 This includes staff nurses at all rungs, advanced-practice
nurses and community-based nurses.

a. Coordinator
❑ Coordinate and plans care
❑ Liaison in the health care team

b. Communicator
❑ Establish rapport with our patient
❑ Use therapeutic communication – verbal or nonverbal cues

c. Teacher
❑ We educate our patient for them to move toward independence and
develop self – care abilities.
❑ We provide knowledge to enable our patients to make informed
decisions.
❑ Through our health teachings, we promote health, prevent illness, restore
health and facilitate coping.

d. Counsellor
❑ We assist patients in solving their problems or in making informed
decisions.

e. Advocate
❑ We are the representative of the patient. Hence, we protect and support
our patient.
❑ We promote self determination
❑ Assertiveness

2. LEADER
 This involves deciding, relating, influencing or facilitating that affects the
actions of others and is directed toward the determination and
achievement of our goals.
 This can be formal leadership or informal roles that are regularly assumed
by nurses.

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 3. RESEARCHER
 This involves the implementation of studies in determining the
actual effects of nursing care to expand scientific-based nursing
practice.
 It can be done bay all nurses, not just academicians, nurse
scientist and graduate nursing students.

4. TEAM PLAYER
❑ We are part of the team, and do not work alone.

5. CRITICAL THINKER
❑ “Think Outside the Box”
❑ Open to new ideas

6. INNOVATOR
❑ We initiate change
❑ We take actions to make things happen.
❑ We see problems and look for solutions

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 REFERENCES:

Chadcha, P. (2014 June 4) Roles of the Nurse.

https://www.slideshare.net/ParveenKumarChadha1/roles-of-the-nurse

Dillon, P. (2007). Nursing Health Assessment: A Critical Thinking, Case Studies

Approach (2nd ed.). Philadelphia. F.A. Davis Company

Female Researcher or Scientist Using a Powerful Microscope in the laboratory.

[image] (n.d.). Clipart Guide. https://www.clipartguide.com/_pages/0511-1108-
1012-0266.html

Christensen, B.L., Kockrow, C. (2011). Foundations of Nursing (6th ed). Missouri.

Mosby Elsevier

Nettina, S. (2013). Lippincott Manual of Nursing Practice (10th ed.). Pennsylvania.

Lippincott Williams & Wilkins

Nurse Clipa Art. [image]. (n.d.) Clipartix.com. https://clipartix.com/nurse-clip-art/

Wayne, G. (2017 September 24) Ineffective Coping Nursing Care Plan.

https://nurseslabs.com/ineffective-coping/

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