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1. Assessment
2. Nursing Diagnosis (What’s the problem? What are the patient’s needs?)
3. Planning (What needs to be done?)
4. Implementation (Do what needs to be done to meet the patient’s needs.)
5. Evaluate / Reassess (Have the patient’s needs been met?)
6. Documentation (If you don’t write it, you didn’t do it!!)
- documentation allows for thorough assessments to be passed to
others and followed up

subjective data (covert) – information that the patient gives to the care

objective data (overt) – information that you gather from assessing (looking,
touching, hearing) the patient
- may better define patient’s condition and help in planning care

- gather data that is individualized to the patient

- continuous collection, validation, and communication of patient data
- includes all pertinent patient information collected by the nurse and
other healthcare professionals
- enables a com0prehensive and effective plan of care to be
designed and implemented for
the patient
- collection of patient data is a vital step in the nursing process
because the remaining steps
depend on complete, accurate, factual and relevant data
- initial comprehensive nursing assessment results in baseline data that
enable the nurse to:
• make a judgement about patient’s health status, ability to manage
his/her healthcare, and need for nursing
• refer the patient to physician or other healthcare professional
• plan and deliver individualized, holistic nursing care
- sources for data include patient, patient’s family and significant others,
patient record, patient’s
healthcare professional, and literature
- medical assessments target data pointing to pathologic conditions,
whereas nursing assessments
focus primarily on the patient’s responses to health problems and
functional abilities
- purpose for which an assessment is being performed offers the best
guideline about what type and
how much data to collect
- priorities are influenced by patient’s health orientation,
developmental stage, and need for
- include appraisal of health status, identification of health
problems, and establishment of
data for nursing intervention
- methods used to collect data are inspection, palpation, percussion, and
- data needs to be:
• complete – as much as possible
• factual and accurate – allows other healthcare professionals to
explore causes of the behavior
• relevant – only experience teaches nurses what data is needed in
specific cases
- observation is key – observation of the conscious and deliberate, use
the five senses
• what are the patient’s current responses – be alert to signs of
distress and things out of the ordinary
• what is the patient’s current ability to manage his/her care
• what is the immediate environment – safety, people, temperature,
• what is the larger environment – hospital or community
- begin the work of interpreting and analyzing data while still collecting
- group data or cues that point to the existence of a patient health problem
(separating into “like piles”)
- nursing diagnoses should always be derived from clusters of significant data
rather than from a single cue
- when the nurse recognizes a cluster of significant patient data
indicating a health problem that can
be treated by independent nursing interventions, a nursing
diagnosis should be written
- nursing diagnosis is written either as two-part statements listing the
patient’s problem and its cause
or as three-part statements that also include the problem’s defining

- classifying
- purpose is to identify how an individual responds to actual or potential health
and life processes, identify
factors that contribute to or cause health problems (etiologies), and
identify resources or strengths that
can be drawn on to prevent of resolve problems

nursing diagnoses – actual or potential health problems that can be

prevented or resolved by
independent nursing intervention
- clinical judgment about individual responses to actual or potential
health problems/life
- provides the basis for selection of nursing interventions to achieve
- NEVER a medical diagnosis

- medical diagnoses identify diseases, whereas nursing diagnoses focus on

unhealthy responses to health and
- medical diagnoses remains the same for as long as the disease is
present, whereas nursing
diagnosis may change from day to day as the patient’s responses
- nurses monitor certain physiologic complications to detect onset or changes
in status
- involves potential complications that must be identified early so that
preventive nursing care can be
instituted early

Documentation Format: P – problem = what is it related to ***

- identifies what is unhealthy about the patient,
indicating the need for change
- clear, concise statement of patient’s health problem
- suggests patient outcomes
E – etiology = what is causing it as manifested by ***
- identifies factors (physiologic, psychological,
sociologic, spiritual,
environmental) that are maintaining the
unhealthy state or response
- contributing or causative factor
- directs nursing intervention
S – signs and symptoms gathered from objective and
subjective assessment
- identify the subjective and objective data that signal
the existence of the

***Linking words that must be used in care plan to link potential

complications and problem***

Guidelines for Writing Nursing Diagnoses

1. Phrase nursing diagnosis as patient problem or alteration in health state
rather than as patient need
2. Check to ensure patient problem precedes etiology and the two are
linked by the phrase “related to”
3. Defining characteristics in nursing diagnosis should follow etiology and
linked by the phrase “as
manifested by” or “as evidenced by”
4. Use nonjudgmental language
5. Be sure problem state indicates what is unhealthy about patient or what
needs to be changed
6. Avoid defining characteristics, medical diagnoses, or something that
cannot be changed in the
problem statement
7. Ensure problem statement suggests patient outcomes and that etiology
direct selection of nursing


goal – aim or end

patient outcome – expected conclusion to patient health problem, or in the

event of a wellness diagnosis, an
expected conclusion to patient’s health expectation

plan of nursing care (patient care plan) – written guide that directs the
efforts of the nursing team as nurses
work with patients to meet their health goals
- specifies nursing diagnoses, outcomes, and associated nursing

- patient centered to keep the patient and patient’s interest and

preferences central in every aspect of
planning and outcome identification
- goals are indicated by phrases like “The patient will _______”
- measurable (something that can be counted or scaled) criteria used to
evaluate the extent to which a
goal has been met within the specified time limits
- if outcomes specified are not valued by the patient or do not
contribute to the prevention,
resolution, or reduction of the patient’s problems or the
achievement of the patient’s
health expectations, the plan of care may be meaningless
- parameters of definition are indicated by phrases like “as
evidenced by”
- primary purpose of outcome identification and planning is to design a
plan of care for and with the
patient that, once implemented, results in the prevention,
reduction, or resolution of patient
health problems and attainment of patient’s health expectations, as
identified in outcomes
- broad aims are to promote wellness, prevent disease and illness,
promote recovery, and
facilitate coping with altered functioning
- because basic needs must be met before a person can focus on higher
ones, patient needs may be
prioritized according to Maslow’s Hierarchy of Human Needs
• physiologic
• safety
• love and belonging
• self-esteem
• self-actualization
- it is best to first meet the needs the patient thinks are most important,
if this order does not interfere
with other vital therapies
- evaluative statements (patient has met, partially met, or not met)
include a statement about
achievement of desired outcome and list actual patient behavior as
evidence supporting the
- if plan is not met, recommendations for revising the plan of care
are included in the
evaluative statement

Guidelines for Writing Outcomes

1. Each set of outcomes is derived from only one nursing diagnosis
2. At least one of the outcomes shows a direct resolution of the problem
statement in the nursing
3. Both long-term and short-tem outcomes are identified as necessary
4. Cognitive, psychomotor, and affective outcomes appropriately signal the
type of change needed by
5. Patient and family value the outcomes
6. Each outcome is brief and specific (clearly describes one observable,
measurable patient
behavior/manifestation) is phrases positively, and specifies a time
7. Outcomes are supportive of total treatment plan

To be measurable, outcomes should have:

• subject – patient or some part of the patient
• verb – indicates the action the patient will perform
- helpful verbs: define, prepare, identify, design, list,
verbalize, describe, choose, explain, select, apply,
• conditions – specifies particular circumstances in or by which the
outcome is to be achieved
• performance criteria – describe in observable, measurable term the
expected patient behavior
or other manifestation
• target time – specifies when the patient is expected to be able to
achieve outcomes

Commonly Encountered Problems: failure to involve the patient in the planning

process, insufficient data
collection, use of inaccurate or insufficient data to
develop nursing
diagnoses, outcomes that are stated too broadly
- give the goal (activity) and rationale for nursing interventions
- educate and/or offer ways to meet outcomes / goals

- nursing actions planned in previous step are carried out
- patient is primary in determining how nursing interventions are implemented
- successful nurses modify actions according to patient’s changing ability
and willingness to participate
in the plan of care and previous responses to nursing interventions
and progress toward
goal/outcome achievement

nurse-initiated interventions – carrying out nurse-prescribed interventions

resulting from assessment of
patient needs written on nursing plan of care, as well as any other
actions that nurses initiate without
the direction or supervision of another healthcare professional

physician-initiated interventions – carrying out physician-prescribed orders

- nurses are responsible for not only nurse-prescribed interventions but
also for the clarification of any
questionable order

collaborative interventions – actions performed jointly by nurses and other

members of the healthcare team

- nurse and patient together measure how well the patient has achieved the
outcomes specified in the plan of
care; however, the patient is always the nurse’s primary concern
- functions to determine whether the outcomes have been or are being met and
then identifying the
appropriate nursing response
* Goal Met
* Goal Partially Met
* Goal Not Met
- based on the patient’s responses to the plan of care (feedback), the nurse
decides to
• terminate plan when each expected outcome is achieved
• modify the plan if there are difficulties achieving the outcomes
• continue the plan if more time is needed to achieve the outcomes