St.

Paul College of Ilocos Sur

( Member, St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

NCM 101: Health Assessment

Module 1

Overview of the Nursing Process

Melanio P. Rojas Jr, MAN

Clinical Instructor

2025

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 Module No. 1
OVERVIEW OF NURSING PROCESS

Learning Objectives:

After completing this module, the students will be able to:

1. Discuss the five step of the nursing process.

2. Define the different categories of nursing diagnoses and collaborative problems.

3. Describe the development of measurable client outcomes.

4. Select nursing interventions that assist in the achievement of client outcomes.

5. List the steps necessary for the evaluation process.

St. Paul College of Ilocos Sur

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 (Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

PRE-LEARNING ACTIVITY

PRE-TEST EXAMINATION: MODULE 1

NCM 101: Health Assessment

Second Semester A.Y. 2023-2024

Melanio P. Rojas Jr. MAN

Lec
(Clinical Instructor)

Name: _______________________________ Score: ___________________

Course/Year: __________________________ Date: ____________________

1. Which of the following is true regarding evaluating? Select all that apply:
A. Compare data related to outcomes C. Collect data related to outcomes
B. Organize data D. Relate nursing actions to client
2. The nurse documents the following outcome goal on the care plan.” Anxiety will be relieved
within 20 to 40 minutes following administration of lorazepam.” The nurse has just
performed an activity in which of the following phases of the nursing process?
A. Assessment C. Implementation
B. Planning D. Evaluation
3. It is the nurse’s clinical judgement about the client’s responses to actual or potential health
problems or state of wellness is called_____________.
A. Nursing process C. Diagnosis
B. Nursing diagnosis D. Medical diagnosis
4. What activities can be expected in assessing the patient?
A. Validate data
B. Determine the client’s strengths, risks and problems
C. Communicate what nursing actions were implemented
D. Make decisions about problem status
5. Which of the following is considered a high-risk nursing diagnosis?
A. Client demonstrates defining characteristics of a problem
B. Nurse intervenes to resolve or help client cope with the problem
C. Nurse intervenes to reduce risk factors or increase protective factors
D. Nurse intervenes to promote growth or maintenance of the healthy response
6. Which of the following behaviors is most representative of the nursing diagnosis?
A. Identifying major problems or needs
B. Organizing data in the client’s family history
C. Establishing short-term and long-term goals
D. Administering an antibiotic
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7. The nurse wishes to determine the client’s feelings about a recent diagnosis. Which
interview questions is most likely to elicit this information?
A. “What did the doctor tell you about your diagnosis?”
B. “Are you worried about how the diagnosis will affect you in the future?”
C. “Tell me about your reactions to the diagnosis?”
D. “How is your family responding to the diagnosis?”
8. Which of the following nursing theorists that can be correlated to the nursing process?
Select all that apply.
A. Dorothy Johnson C. Lyda Hall
B. Ida Jean Orlando D. Betty Neuman
9. Which of the following is not a subjective data?
A. Anxiety C. Dizziness
B. Chest pain D. Bluish discoloration of the skin
10. When comparing cues and clusters of cues with defining, which of the following is a correct?
Select all that apply.
A. Nurses compare client data to standards and norms to identify significant and relevant
cues.
B. Significant cues is the same from the norms of the client population; they point to a
change in client’s status or indicate a development delay.
C. Data clustering involves making inferences about the data, it is a process of determining
relatedness of facts and whether patterns are present.
D. Data may be clustered inductively by combining all the data collected to form a pattern,
or deductively by using a framework and clustering fata into defined categories.
Part II. Write S- If subjective and O- Objective
__________________________1. Shortness of breath
__________________________2. Cried during interview
__________________________3. Skin and pale
__________________________4. Diaphoretic
__________________________5. Weakness
__________________________6. Lungs sounds clearly bilaterally
__________________________7. Active bowel sounds auscultated in all 4 quadrants
__________________________8. Apical pulse 104
__________________________9. Blood pressure 90/60
_________________________10. Abdomen firm and slightly distended

Part III. Alternate Response. Write TRUE if the statement is correct; False if the statement
is incorrect. (10 points)
_________________________1. Nursing process is universal because it is applicable to individuals,
families and communities.
_________________________2. The nursing process is composed of sequential and interrelated
process.
_________________________3. The primary source of data during assessment is the patient’s chart.

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_________________________4. Priority setting primarily considers ranking of nursing diagnosis in terms
of importance to client.
_________________________5. When providing care, psychosocial needs are given priority over
physiologic needs
OVERVIEW OF THE NURSING PROCESS
1. Assessment
2. Diagnosis ( Nursing)
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Six Phases of the Nursing Process
1. ASSESSMENT. Is a collecting, organizing, and recording
data about the patient’s health status.
 Purpose: To establish data
 Activities: during assessment
1. Collecting data. This involves gathering information about
the patient considering the physical, psychological,
emotional, socio-cultural and spiritual factors that may
affect his/her health status.
2. Types of Data
a. Subjective data (symptoms). Those that can be
described only by the person experiencing it.
Examples: vertigo (dizziness), tinnitus (ringing of the
ears), pain, nausea, anxiety, weakness, fatigue,
anorexia (loss of appetite to eat), thirst, nervousness,
patient reports falling down the stairs.
b. Objective data (signs). Those that can be observed
and measured. Examples: pallor (paleness),
diaphoresis (excessive sweating); BP- 176/100,
Temperature= 37.9-degree Celsius, reddish urine,
jaundice (yellow discoloration of the skin); rbc= 4.5
million/cu.mm, edema, chills, bladder distention, weight
loss, poor skin turgor, tachycardia (rapid pulse rate)
tachypnea (rapid breathing).
Methods of Collection of Data
a. Interview: It is planned, purposeful conversation
Examples:
 Collection of data for health history
 Admission of a patient to a health history
b. Observation:
Examples
 Use of senses ( vision, hearing, touch, smell)
 Units of units measure ( mmHg for BP, lbs, or kg. for weight, degree Celsius
for temperature
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  Interpretation of laboratory results (urinalysis, shows presence of rbc, wbc,
pus and bacteria, complete blood count ( cbc) shows rbc=4.5
million/cu.mm., wbc=7,000/cu.mm, platelets=250,000/cu.mm.).
 Physical examination techniques= ( IPPA- Inspection, Palpation,
Percussion, Auscultation)
Sources of Data
a. Primary source: Patient
b. Secondary sources: Family members, friends, and significant others, Patient records or
chart, health team members, related literature (books, journals, researches and
brochures).
2. Make sure your information is accurate
1. The patient’s urine is dark in color. This may indicates dehydration or the patient
may had taken certain medication or food.
II. DIAGNOSING. Is a process which results to a diagnostic statement or nursing diagnosis. To
diagnosis. It is the clinical act of identifying problems. To diagnose in nursing it means you
analyze assessment information and derive meaning from this analysis.
1. Purpose: to identify the patient’s health care needs and to prepare diagnostic
statements.
2. Nursing diagnosis. Is a statement of patient’s potential or actual alteration of health
status. It uses the critical-thinking skills of analysis and synthesis.
3. Nursing Diagnosis uses PRS/PES format

P-problem P- problem
R-related to factors E- etiology
S-S/S S- Signs and symptoms
Activities During Diagnosing
1. Organizing data. Clustering facts into group of
information:
Examples
(1) Data about patient’s nutritional status
Subjective
“I have no appetite to eat.”
“Foods and fluids taste bitter.”
Objective data
Weight loss
Pallor
Walks slowly and holds unto furniture
(2) Data about patient’s fluid balance status
Subjective data
“I had 15 watery stools since last night until
morning.”
“I feel very thirsty.”
Objective data

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 Increased BUN
Urine output is 20-25 ml/hour (oliguria-low urine output)

2. Comparing data gathered during assessment against standards.

 Standards are accepted norms, measures, or patterns for purposes of
comparison
Examples:
The standard color of the skin is pinkish.
The standard urine output is 30-60 mls/hour.
The standard consistency of a stool is well-formed.
3. Analyzing data after comparing with standards.
Examples:
Passage of frequent watery stool may lead to dehydration and loss of electrolytes like
potassium and sodium.
Poor appetite to eat, weight loss of 10 lbs. weakness indicate nutritional intake.
Pallor, dyspnea, weakness, fatigue, RBC=4 million/cu.mm., Hgb (hemoglobin)= 10 g/dl
indicate inadequate oxygenation.
4. Identifying gaps and inconsistencies in data.
Example:
Patient claims she is gaining too much weight but actually, she is underweight.
5. Determining the patient’s health problems, health risks and strengths.
Examples:
Inadequate nutrition
Altered body image
6. Formulating Nursing Diagnoses statements:
Examples:
Fluid volume deficit related to frequent passage of watery stool.
Alteration in nutrition: less than body requirements related to poor appetite
Inadequate oxygenation related to poor oxygen –carrying capacity of the blood.
Ineffective airway clearance related to: (a) weak respiratory muscles (b) thick mucous
secretions.
SUMMARY OF STEPS OF NURSING DIAGNOSIS
A. Cluster Data ( recognize pattern or trend)
- Diarrhea for 10 days
- Distended abdomen
- Cramping before and during each bowel movement
- Family history of colon cancer
B. Compare with standards
- Soft, abdomen stool, daily
- Abdomen soft, non-distended
- Defecation non-painful
C. Make a reasoned conclusion
- Bowel elimination problem
D. Nursing Diagnosis
- Alteration in bowel elimination ( diarrhea) related to: (a) food intolerance, (b)
irritation

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 COMPARISON OF CORRECT AND INCORRECT IN NURSING DIAGNOSIS
1. Correct: Acute Pain related to physical exertion.
Incorrect: Acute Pain related to myocardial
infarction.
2. Correct: Ineffective breathing pattern related to
increase secretions.
Incorrect: Ineffective breathing pattern related to
pneumonia.
3. Correct: impaired physical mobility related to
pain in right knee. Anxiety related to difficulty in
ambulating.
Incorrect: Pain and anxiety related to difficulty in
ambulating
4. Correct: High risk injury related to disorientation.
Incorrect: High risk injury related to absence of
side rails.
III. OUTCOME IDENTIFICATION. Refers to formulating and documenting measurable realistic,
patient-focused goals. It provides the basis for evaluating nursing diagnosis.
 Purposes
 To provide individualized care.
 To promote patient participation.
 To plan care that is realistic and measurable.
 To allow involvement of support people.
 Activities during outcome identification
1. Establishing priorities.
A priority is something takes precedence in position, deemed the most important
among several items. Priority setting is a decision making process the ranks the
order of nursing diagnoses in terms of importance to the patient.
 Priority setting involves the following:
a. Life- threatening situations should be given highest priority, e.g., difficulty
in breathing, chest pain, hemorrhage, suicidal tendencies.
b. Patient with unstable condition should be given priority over the stable
conditions. E.g., attended to the patient with nausea and vomiting before
the patient who is anxious.
c. Actual problems take precedence over potential problems. E.g., fluid
volume deficit (actual problem) should be given priority before high risk
for infection (potential problem).
d. Consider the amount of materials, equipment required to care for
patients. E.g., attended to the patient with fever before attending to the

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 patient who is scheduled for physical therapy in the afternoon. Teaching
requires more time and it should not be done in a hurried matter.
e. Use Maslow’s hierarchy of needs. Physiologic needs are given priority
over psychosocial needs. E.g., attended to the patient with nausea and
vomiting before the patient who is anxious.
f. Consider something that is very important to the patient. e.g. pain,
anxiety, (before giving health teachings).
g. Use the principle of ABC’s (airway, breathing, circulation); airways
should be the highest priority.
 Nursing diagnoses are classified as high- priority, medium-priority, and low
priority.
 High-priority nursing diagnoses are those that are potentially life-
threatening and require immediate action. Examples include: impaired gas
exchange, ineffective breathing pattern, self- directed risk for violence.
 Medium-priority nursing diagnoses are those that could result in unhealthy
consequences, such as physical or emotional impairment, but are not life
threatening. Examples include: Fatigue, Activity Intolerance, Ineffective
Coping and Dysfunctional Grieving.
 Low-priority nursing diagnoses involve problems that usually can be
resolved easily with minimal interventions and are unlikely to cause
significant dysfunction. Examples include: sensation of hunger in a patient
who is on NPO (nothing per orem), in preparation for a diagnostic procedure;
minimal pain on the third postoperative day, related to ambulation.
2. Establishing patient’s goals and outcome criteria.
 A patient goal is an educated guess, made as broad statement, about what the
patient’s state will be after nursing intervention is carried out.
 Behaviors goas are written to indicate a desired state. They contain an action
verb and a qualifier that indicate the level of performance that needs to be
achieved.
 Examples of behavioral verbs used in patient goals are as follows:
Calculate Distinguish Participate
Classify Draw Practice
Communicate Explain Recall
Compare Express Recite
Define Identify Record
Demonstrate List State
Describe Name Use
Construct Maintain Verbalize
Contrast Perform
 The qualifier is a description of the parameter for achieving the goal:
Examples:
“Ambulate safely with one-person assistance.”
“Demonstrate signs sufficient rest before surgery.”
“Identifies actual and high-risk environment hazards.”
“States the importance of adopting appropriate health maintenance
behaviors.”

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  Goals may be short-term or long-term. Short-term goal can be met in a relatively
short period (within days or less than a week). A long term goal requires more
time (several weeks or months).
 Outcome criteria are specific, measurable, realistic statements of goal
attainment. Outcome-criteria are written in a manner that they answer the
questions: who, what actions, under what circumstances, how well and when.

 Therefore, the characteristics of well-stated outcome criteria are as follows:

S- Specific
M-Measurable
A-Attainable
R-Realistic
T-Time-framed
 Examples of goals and outcome criteria are as follows:
1. Goal
 The patient will report a decreased anxiety level regarding surgery.
Possible Outcome Criteria
 During health teaching, the patient discusses fears and concerns regarding
surgical procedure.
 After health teaching, the patient verbalizes decreased anxiety.
 The patient identifies a support system and strategies to use to reduce
stress and anxiety related to the surgical experience.
2. Goal
 The patient will demonstrate safety habits when performing ADL’s (activities of daily
living) and injury prevention.
Possible Outcome Criteria
 The patient uses call light system for assistance at each need to use
bathroom immediately after instruction by the nurse.
 The patient demonstrates safety practices in dressing and hygiene.
 The patient uses over-the-bed lights, non-skid slippers when transferring to
chair or out of bed.
 The patient identifies modification for home safety (removal of throw rugs,
installation of hand rails in hallway, better lighting of hallway and stairway)
12 hours after nurse’s instruction about home safety.
IV. PLANNING. Involves determining beforehand the strategies or course of actions to be taken
before implementing of nursing care. To be effective, involve the patient and
his family planning.
 Purposes
1. To identify the patient’s goals and appropriate nursing interventions.
2. To direct patient care activities.
3. To promote continuity of care.
4. To focus charting requirements.

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 5. To allow for delegation of specific activities.
 Activities During Planning
1. Planning nursing interventions.
 To direct activities to be carried out in the implementation phase. Nursing
interventions are any treatment based upon the judgement and knowledge that a
nurse performs to enhance patient outcomes.”
 Nursing interventions are also called nursing orders.
 Nursing orders are independent, dependent or interdependent/collaborative
activities that nurses carry out to provide patient care.
2. WRITING A NURSING PLAN OF CARE.
 The nursing plan of care is written summary of the care that a patient is to
receive. It is the blueprint of the nursing process.
 The plan of care is nursing centered. This is essential to identify the scope and
depth of the nursing practice. By focusing on the treatment of human responses
to actual or potential health problems, the nurse remains in the nursing practice
domain.
 The plan of care is a step-by-step process. This is evidenced by the following.
1. Sufficient data are collected to substantiate nursing diagnoses.
2. At least one goal must be started for each nursing diagnosis.
3. Outcome criteria must be identified for each goal.
4. Nursing interventions must be specifically designed to meet the identified
goal.
5. Each intervention should be supported by a scientific rationale. The
scientific rationale is the justification or reason for carrying out the
intervention.
6. Evaluation must address whether each goal was completely met, partially
met or completely unmet.
SAMPLE NURSING PLAN OF CARE
 Nursing Diagnosis
(Use the NANDA- accepted list of nursing diagnoses. List in priority order. Use the
diagnostic label and “related to (related factor), followed by manifested by (supporting
defining characteristics).

Risk for Injury related to sensory and integrative dysfunction manifested by

altered mobility and faulty judgement.

 Patient Goal
(One or more patient goals established from nursing diagnosis. A broadly stated
objective that indicates an overall picture of the state of the patient if the problem is
resolved.

Patient will demonstrate safety habits when performing ADL’s and injury
prevention.

 Patient Outcome Criteria

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 (Specific, measurable, realistic statements that can be evaluated to judge goal
attainment. Stated as behavioral objectives, they include a verb, a short phase
describing the specific measure to be accomplished, and a time reference)

 Patient uses a nurse call light system for assistance for each need to use
bathroom immediately after instruction by the nurse.
 Patient demonstrates safety practices in dressing and hygiene.
 Patient uses over-the-bed lights, nonskid slippers each time when transferring
to chair or out of bed.
 Patient identifies modification for home safety.

NURSING INTERVENTIONS AND SCIENTIFIC RATIONALE

Nursing Interventions Scientific Rationale

(Write nursing interventions/nursing orders that (Gives reason for carrying out the intervention.
are related to the goal. Interventions include Demonstrates synthesis of physiologic, psychologic
who, what, when, and how the order is to be and pathophysiological concepts).
carried out.)
1. Position bed in the lowest position. 1. Low bed position minimizes distance to floor if
patient falls.
2. Place patient call light system within reach 2. A call light allows patient to call for help.
of hand and give instruction.
3. Perform frequent visual checks of patient. 3. Patient may attempt to get of bed or chair without
calling for assistance.
4. Use safety belt in all transfers if the patient 4. A safety belt allows for control/monitoring of
is unsteady or has difficulty with balance. patient movement without trauma to any body part.
5. Assist patient to perform hygiene at sink 5. Mirror provides patient with visual reinforcement of
with large mirror, encourage patient to activity.
scan the whole visual field.
6. Evaluate the patient’s ability to use toilet; 6. Patients with hip muscle weakness may be unable
obtain raised toilet seat or grab bars if to rise from low toilet seat. Grab bars may assist
indicated. the weak person to move slowly and safely.

V. IMPLEMENTATION. Is putting the nursing care plan into action.

 Purpose: To carry out planned nursing interventions to help the patient attain goals and
achieve optimal level of health.
 Activities:
 Reassessing: To ensure prompt attention to emerging problems.
 Set priorities: To determine the order in which nursing interventions are carried
out.
 Perform nursing interventions: These may be independent, dependent or
interdependent/collaborative measures.
 Record actions: To complete nursing interventions, relevant documentation
should be done.

CRITICAL TO REMEMBER: SOMETHING THAT

IS NOT WRITTEN IS CONSIDERED AS NOT DONE!

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  Requirements of Implementation
1. Knowledge. Includes intellectual skills like problem- solving, decision making-
making and teaching.
2. Technical skills. To carry out treatments and procedures.
3. Communications skills. Use of verbal and non-verbal communication to carry out
planned nursing interventions.
4. Therapeutic use of self. It is being willing and being able to care.
VI. EVALUATION. Is assessing the patient’s response to nursing interventions and then
comparing the response to predetermined standards or outcome criteria.
 Purpose: To appraise the extent to which goals and outcome criteria of nursing care
have been achieved.
 Activities:
 Collect data about the patient’s response.
 Compare the patient’s response to goals and outcome criteria
 The four possible judgments that may be made are as follows:
1. The goal was completely met.
2. The goal was partially met.
3. The goal was completely unmet.
4. New problems or nursing diagnoses have developed
 Analyzed the reason for the outcomes
 Modify care plan as needed

NURSING DIAGNOSIS MEDICAL DIAGNOSIS

Decreased Cardiac Output Congestive heart failure
Ineffective Breathing Pattern Meniere’s disease
Risk for Imbalanced Volume Lung cancer
Impaired Physical Mobility COPD
Anxiety

TYPES OF NURSING DIAGNOSIS

Actual diagnosis Perceived constipation R/T faulty appraisal AEB
expectation of passage of stool at the same time
every day.
Risk diagnosis Risk for aspiration R/T decreased cough and
gag reflexes.
Wellness diagnosis Readiness for Enhanced Spiritual Wellbeing

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Sample Nursing Care Plan

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 St. Paul College of Ilocos Sur
(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

POST-LEARNING ACTIVITY

POST-TEST EXAMINATION: MODULE 1

NCM 101: Health Assessment

2nd Semester A.Y. 2022-2023

Melanio P. Rojas Jr. MAN

(Clinical Instructor)

Name: _______________________________________________ Score: ________________________________

Course/Year: _________________________________________ Date: _________________________________

I. Create a nursing care plan the following given situations:

Situation: S.J. has just arrived on the nursing unit from the post-anesthesia care unit (PACU) following a hysterectomy this
morning. She is complaining of pain and nausea. You are the nurse assigned to care for her.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

S-

O-

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P.S has just arrived in the ER with the chief complaint of body malaise, flush skin and T- 39.8 degree Celsius.

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
S-

O-

Reminders:
1. Place it in a long coupon bond
2. Font- Arial 10
3. No “cut tables/ separate per NCP
4. Per NCP is graded - 100%

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