FUNDAMENTALS OF NURSING

Module 6

NURSING as a SCIENCE: PROBLEM SOLVING PROCESS and the NURSING PROCESS

This learning guide is designed to provide an overview and discussion related to the concept
of Nursing as a Science. It aims to increase a student’s theoretical knowledge of the
terminologies, roles and functions, concepts of the problem solving process as well as the
nursing process. It gives emphasis on the significance of developing critical thinking abilities
in order to practice safe, effective, and professional nursing care by identifying method of
assessment, diagnosis, and appropriate planning.

Learning Outcomes: On successful completion of this module, students will be able to:
1. Apply knowledge of physical, social, natural, health sciences and humanities in the
practice of nursing.
2. Provide safe, appropriate, and holistic care to individuals, families, population groups,
and community utilizing nursing process
3. Apply guidelines and principles of evidence-based practice in the delivery of care
4. Document properly to include reporting an up-to-date client care accurately and
comprehensively
5. Communicate effectively using therapeutic and culturally sensitive language in the
nurse/ patient/family interactions

Objectives: This learning module addresses and provide an overview, description, and
fundamental concepts related to the nursing process. Upon completion of this module, the student
will:
1. Describe and explain concepts related to Nursing Process.
2. Describe the significance of developing critical thinking abilities in order to practice
safe, effective, and professional nursing care.
3. Integrate strategies to enhance critical thinking and clinical reasoning as the provider
of nursing care in terms of assessment, diagnosis and planning.
4. Perform appropriate and effective assessment techniques
5. Create appropriate nursing diagnoses intended for a specific client/patient
6. Make a Plan of care based on the result of assessment findings.

Methods/Instructional Technique
Questioning
Video recording and simulation
Research work and analysis
Self-Evaluation/Supply Type of Test
Materials

Electronic gadgets, Paper and Pen, Power point Presentation, learning and teaching guide
Reference books/journals/articles/websites

Duration: 3 hours

Lessons

Topic 1: Critical Thinking and Clinical Reasoning

Topic 2: Problem Solving Process
Topic 3: Nursing Process
3.1. Assessing
3.2 Planning
3.3 Diagnosing

LECTURE GUIDE/ DISCUSSION

Topic 1: CRITICAL THINKING AND CLINICAL REASONING

Nurses are essential members of the healthcare team, collaborating with professionals from a
variety of disciplines to ensure the provision of quality healthcare. Professional nursing requires
innate qualities such as caring and compassion as well as a broad educational foundation, thus
the art and science of nursing.

The science of nursing is the application of theory to practice. The educational foundation of
Nursing education includes liberal arts and sciences.

Through liberal arts, nurses learn to analyze, problem-solve, think critically, and communicate.
Through science, nurses bring forward knowledge of anatomy & physiology, chemistry,
microbiology, psychology, and sociology and the like.

Nurses base the practice on evidences, perform different roles and functions and serve as an
advocate, researcher, administrators and educators. Nurses are known to be a lifelong learner.

Electronic Resource: https://www.youtube.com/watch?v=C8aSpwkf4QA&t=2s

The practice of nursing requires critical thinking and clinical reasoning.

Critical thinking is the process of intentional higher level thinking to define a client’s problem,
examine the evidence-based practice in caring for the client, and make choices in the delivery of
care.
Clinical reasoning is the cognitive process that uses thinking strategies to gather and analyze
client information, evaluate the relevance of the information, and decide on possible nursing
actions to improve the client’s physiological and psychosocial outcomes.

Clinical reasoning requires the integration of critical thinking in the identification of the most
appropriate interventions that will improve the client’s condition. The concept of clinical reasoning
“evolved from the application of decision-making to the health care professions”
(Simmons, 2010, p. 1153).

Supplemental Reading: Kozier and Erbs Fundamentals of Nursing, Concepts, Process and
Practice 10th edition, chapter 10)

Topic 2: PROBLEM SOLVING PROCESS

Problem solving is a mental activity in which a problem is identified that represents an

unsteady state. It requires the nurse to obtain information that clarifies the nature of the problem
and suggests possible solutions. Throughout the problem-solving process the implementation of
critical thought may or may not be required in working toward a solution (Wilkinson, 2012).
Commonly used approaches to problem solving include trial and error, intuition, and the
research process.
One way to solve problems is through trial and error, in which a number of approaches are
tried until a solution is found. However, without considering alternatives systematically, one
cannot know why the solution works. The use of trial-and-error methods in nursing care can be
dangerous because the client might suffer harm if an approach is inappropriate. However,
nurses often use trial and error in the home setting due to logistics, equipment, and client
lifestyle.
Intuition is a problem-solving approach that relies on a nurse’s inner sense. It is a legitimate
aspect of a nursing judgment in the implementation of care (Wilkinson, 2012). Intuition is the
understanding or learning of things without the conscious use of reasoning. It is also known as
sixth sense, hunch, instinct, feeling, or suspicion. As a problem-solving approach, intuition is
viewed by some people as a form of guessing and, as such, an inappropriate basis for nursing
decisions. However, others view intuition as an essential and legitimate aspect of clinical
judgment acquired through knowledge and experience.
Although the intuitive method of problem solving is gaining recognition as part of nursing
practice, it is not recommended for novices or students, because they usually lack the
knowledge base and clinical experience on which to make a valid judgment.
Research process, is a formalized, logical, systematic approach to problem solving. The
classic quantitative research process is most useful when the researcher is working in a
controlled situation. Health professionals, often working with people in uncontrolled situations,
require a modified approach for solving problems.
PROBLEM SOLVING PROCESS
The problem solving process involves:
1) The systematic identification of a problem

2) Determination of goals related to the problem

3) Identification of possible solutions to achieve the goals

4) Implementation of selected solutions

5) Evaluation of goal achievement.

Topic 3. NURSING PROCESS

The nursing process is a systematic, rational method of planning and providing

individualized nursing care. Its purposes are to identify a client’s health status and actual or
potential health care problems or needs, to establish plans to meet the identified needs, and to
deliver specific nursing interventions to meet those needs. The client may be an individual, a
family, a community, or a group.

Hall originated the term nursing process in 1955, and Johnson (1959), Orlando (1961), and
Wiedenbach (1963) were among the first to use it to refer to a series of phases describing the
practice of nursing. Since then, various nurses have described the process of nursing and
organized the phases in different ways.

Characteristics of the Nursing Process

The nursing process has distinctive characteristics that enable the nurse to respond to the
changing health status of the client. These characteristics include its cyclic and dynamic nature,
client centeredness, focus on problem solving and decision making, interpersonal and
collaborative style, universal applicability, and use of critical thinking and clinical reasoning.

Data from each phase provide input into the next phase. Findings from the evaluation phase
feed back into assessment. Hence, the nursing process is a regularly repeated event or
sequence of events (a cycle) that is continuously changing (dynamic) rather than staying the
same (static).

The nursing process is client centered. The nurse organizes the plan of care according to client
problems rather than nursing goals.

The nursing process is an adaptation of problem solving and systems theory and is directed
toward a client’s responses to real or potential disease and illness.

Decision making is involved in every phase of the nursing process. Nurses can be highly
creative in determining when and how to use data to make decisions.
The nursing process is interpersonal and collaborative. It requires the nurse to communicate
directly and consistently with clients and families to meet their needs. It also requires that
nurses collaborate, as members of the health care team, in a joint effort to provide quality client
care.
Overview of the Nursing Process
Phase and Description
ASSESSING
Collecting, organizing,
validating,
and documenting client data
DIAGNOSING
Analyzing and synthesizing data
PLANNING
Determining how to prevent,
reduce, or resolve the identified
priority client problems; how to
support client strengths; and
how
to implement nursing
interventions in an organized,
individualized, and goal-directed
manner
IMPLEMENTING
Carrying out (or delegating) and
documenting the planned
nursing
interventions
Purpose
To establish a database about
the client’s
response to health concerns or
illness
and the ability to manage health
care
needs
To identify client strengths and
health problems that can be
prevented or resolved by
collaborative and independent
nursing interventions
To develop a list of nursing and
collaborative problems
To develop an individualized
care plan
that specifies client
goals/desired out-
comes, and related nursing
interventions
To assist the client to meet
desired goals/
outcomes; promote wellness;
prevent
illness and disease; restore
health; and
facilitate coping with altered
functioning
Activities
Obtain a nursing health history.
• Conduct a physical
assessment.
• Review client records.
• Review nursing literature.
• Consult support persons.
• Consult health professionals.
Update data as needed.
Organize data.
Validate data.
Communicate/document data.
Interpret and analyze data:
• Compare data against
standards.
• Cluster or group data
(generate tentative
hypotheses).
• Identify gaps and
inconsistencies.
Determine client’s strengths,
risks, and problems.
Formulate nursing diagnoses
and collaborative
problem statements.
Document nursing diagnoses on
the care plan.
Set priorities and
goals/outcomes in collaboration
with client.
Write goals/desired outcomes.
Select nursing
strategies/interventions.
Consult other health
professionals.
Write nursing interventions and
nursing care plan.
Communicate care plan to
relevant health care
providers.
Reassess the client to update
the database.
Determine the nurse’s need for
assistance.
Perform planned nursing
interventions.
Communicate what nursing
actions were

EVALUATING
Measuring the degree to which
goals/outcomes have been
achieved and identifying factors
that positively or negatively
influence goal
achievement
implemented:
• Document care and client
responses to care.
• Give verbal reports as
necessary.
To determine whether to Collaborate with client and
continue, collect data related to desired
modify, or terminate the plan of outcomes.
care Judge whether goals/outcomes
have been
achieved.
Relate nursing actions to client
goals/outcomes.
Make decisions about problem
status.
Review and modify the care
plan as indicated or
terminate nursing care.
Document achievement of
outcomes and modification of
the care plan.

Examples of Critical Thinking in the Nursing Process

Nursing Process Phase Critical Thinking Activities

Assessing Making reliable observations
Distinguishing relevant from irrelevant data
Distinguishing important from unimportant data
Validating data
Organizing data
Categorizing data according to a framework
Recognizing assumptions
Identifying gaps in the data
Diagnosing Finding patterns and relationships among cues
Making inferences
Suspending judgment when lacking data
Stating the problem
Examining assumptions
Comparing patterns with norms
Identifying factors contributing to the problem
Planning Forming valid generalizations
Transferring knowledge from one situation to
another
Developing evaluative criteria
Hypothesizing
Making interdisciplinary connections
Prioritizing client problems
Generalizing principles from other sciences
Implementing Applying knowledge to perform interventions
Testing hypotheses
Evaluating Deciding whether hypotheses are correct
Making criterion-based evaluations
Wilkinson, Judith M., Nursing Process and Critical Thinking, 5th Ed., © 2012. Reprinted and Electronically
reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.
 3.1. ASSESSING

-is the systematic and continuous collection, organization, validation, and documentation of data
(information)
- is a continuous process carried out during all phases of the nursing process.
-All phases of the nursing process depend on the accurate and complete collection of data. The
four different types of assessments are the initial nursing assessment, problem-focused
assessment, emergency assessment, and time-lapsed reassessment

-Assessments vary according to their purpose, timing, time available, and client status.
- Nursing assessments focus on a client’s responses to a health problem. A nursing assessment
should include the client’s perceived needs, health problems, related experience, health
practices, values, and lifestyles. To be most useful, the data collected should be relevant to a
particular health problem.

- The registered nurse is responsible for the collection of comprehensive data, including
physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related,
environmental, spiritual/transpersonal, and economic assessments. The nursing assessment
also involves the elicitation of clients’ own perspectives on their condition; identifying barriers to
communication; recognizing the impact of the nurse’s own attitudes, values, and beliefs on the
assessment process; including family dynamics; and increased emphasis on protection of the
privacy of data (ANA, 2010, p. 32).

TYPES OF ASSESSMENTS
Type Time Performed Purpose Example
Initial Performed within To establish a complete Nursing admission assessment
assessment specified time after database for problem
admission to a health identification, reference,
care agency and future comparison
Problem- Ongoing process To determine the status of Hourly assessment of client’s
focused integrated a specific problem identified fluid intake and urinary output in
assessment with nursing care in an earlier assessment an ICU
Assessment of client’s ability to
perform self-care while
assisting a
client to bathe
Emergency During any To identify life-threatening Rapid assessment of an
assessment physiological or problems individual’s airway, breathing
psychological crisis of To identify new or status, and
the client overlooked problems circulation during a cardiac
arrest
Assessment of suicidal
tendencies or potential for
violence
Time-lapsed Several months after To compare the client’s Reassessment of a client’s
reassessment initial assessment current status to baseline functional health patterns in a
data previously obtained home care or outpatient setting
or, in a hospital, at shift change
COLLECTING DATA

-Data collection is the process of gathering information about a client’s health status. Data
collection must be both systematic and continuous to prevent the omission of significant data
and reflect a client’s changing health status.
- A database contains all the information about a client; it includes the nursing health history,
physical assessment, primary care provider’s history and physical examination, results of
laboratory and diagnostic tests, and material contributed by other health personnel.
- Client data should include past history as well as current problems.
- Data can be of the subjective or objective and constant or variable types, and from a primary
or secondary source. The collection of data allows the nurse, client, and health care team to
identify health-related problems or risk factors that could cause changes in a client’s health
status.

TYPES OF DATA

Subjective data, also referred to as symptoms or covert data, are apparent only to the person
affected and can be described or verified only by that person. Itching, pain, and feelings of worry
are examples of subjective data.
Subjective data include the client’s sensations, feelings, values, beliefs, attitudes, and
perception of personal health status and life situation.

Objective data, also referred to as signs or overt data, are detectable by an observer or can
be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled,
and they are obtained by observation or physical examination.
During the physical examination, the nurse obtains objective data to validate subjective data
and to complete the assessment phase of the nursing process.

Constant data is information that does not change over time such as race or blood type.
Variable data can change quickly, frequently, or rarely and include such data as blood
pressure, level of pain, and age.

EXAMPLES OF SUBJECTIVE AND OBJECTIVE DATA

SUBJECTIVE OBJECTIVE
“I feel weak all over when I exert myself.” Blood pressure 90/50 mmHg*
Apical pulse 104 beats/min
Skin pale and diaphoretic
Vomited 100 mL green-tinged fluid
“I feel sick to my stomach.” Abdomen firm and slightly distended
Active bowel sounds auscultated in all four
quadrants
“I’m short of breath.” Lung sounds clear bilaterally; diminished in right
lower lobe
Wife states: “He doesn’t seem so sad today.” Client cried during interview
(This is subjective and secondary source data.)
“I would like to see the chaplain before surgery.” Holding open Bible
Has small silver cross on bedside table
SOURCES OF DATA

Sources of data are primary or secondary. The client is the primary source of data. Family
members or other support persons, other health professionals, records and reports, laboratory
and diagnostic analyses, and relevant literature are secondary or indirect sources. In fact, all
sources other than the client are considered secondary sources. All data from secondary
sources should be validated if possible.

DATA COLLECTION METHOD

The principal methods used to collect data are observing, interviewing, and examining.
Observing occurs whenever the nurse is in contact with the client or support persons.
Interviewing is used mainly while taking the nursing health history. Examining is the major
method used in the physical health assessment.

1. OBSERVING
To observe is to gather data by using the senses. Observing is a conscious, deliberate skill that
is developed through effort and with an organized approach. Although nurses observe mainly
through sight most of the senses are engaged during careful observations.

Observing has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting
the data.

Nursing observations must be organized so that nothing significant is missed. Most nurses
develop a particular sequence for observing events, usually focusing on the client first. For
example, a nurse walks into a client’s room and observes, in the following order:

1. Clinical signs of client distress (e.g., pallor or flushing, labored breathing, and behaviour
indicating pain or emotional distress)
2. Threats to the client’s safety, real or anticipated (e.g., a lowered side rail)
3. The presence and functioning of associated equipment (e.g., intravenous equipment and
oxygen
4. The immediate environment, including the people in it.

2. INTERVIEWING

An interview is a planned communication or a conversation with a purpose, to get or give

information, identify problems of mutual concern, evaluate change, teach, provide support, or
provide counseling or therapy.

In a focused interview the nurse asks the client specific questions to collect information related
to the client’s problem. This allows the nurse to collect information that may have previously
been missed and yields more in-depth information (D’Amico & Barbarito, 2013).

TYPES OF INTERVIEW QUESTIONS

Questions are often classified as closed or open ended, and neutral or leading. Closed
questions, used in the directive interview, are restrictive and generally require only “yes” or “no”
or short factual answers that provide specific information.
Closed questions often begin with “when,” “where,” “who,” “what,” “do (did, does),” or “is (are,
was).”
Examples of closed questions are “What medication did you take?” “Are you having pain now?
Show me where it is.” “How old are you?” “When did you fall?”

Closed questions are often used when information is needed quickly, such as in an emergency
situation. The highly stressed person and the person who has difficulty communicating will find
closed questions easier to answer than open ended questions.

Open-ended questions, associated with the nondirective interview, invite clients to discover
and explore, elaborate, clarify, or illustrate their thoughts or feelings. An open-ended question
specifies only the broad topic to be discussed, and invites answers longer than one or two
words. Such questions give clients the freedom to divulge only the information that they are
ready to disclose.
The open-ended question is useful at the beginning of an interview or to change topics and to
elicit attitudes.

Open-ended questions may begin with “what” or “how.” Examples of open-ended questions are
“How have you been feeling lately?”
“What brought you to the hospital?” “How did you feel in that situation?” “Would you describe
more about how you relate to your child?” “What would you like to talk about today?”

A Neutral question is a question the client can answer without direction or pressure from the
nurse, is open ended, and is used in nondirective interviews. Examples are “How do you feel
about that?” “What do you think led to the operation?”

A leading question, by contrast, is usually closed, used in a directive interview, and thus
directs the client’s answer. Examples are “You’re stressed about surgery tomorrow, aren’t you?”
“You will take your medicine, won’t you?”

The leading question gives the client less opportunity to decide whether the answer is true or
not. Leading questions create problems if the client, in an effort to please the nurse, gives
inaccurate responses. This can result in inaccurate data.

Try to avoid asking “why” questions. These questions can be perceived as a form of
interrogation by the client (Kneisl & Trigoboff, 2013). Because the goal of questioning is to elicit
as much purposeful information as possible, anything that puts the client on the defensive will
interfere with reaching that goal.

PLANNING THE INTERVIEW AND SETTING Before beginning an interview, the nurse reviews
available information about the current illness, or literature about the client’s health problem.

Both nurses and clients are made comfortable in order to encourage an effective interview by
balancing several factors. Each interview is influenced by time, place, seating arrangement or
distance, and language.

TIME- Nurses need to plan interviews with clients when the client is physically comfortable and
free of pain, and when interruptions by friends, family, and other health professionals are
minimal.
PLACE -A well-lighted, well-ventilated room that is relatively free of noise, movements, and
distractions encourages communication.

SEATING ARRANGEMENT - a seating arrangement in which the parties sit on two chairs
placed at right angles to a desk or table or a few feet apart, with no table between, creates a
less formal atmosphere, and the nurse and client tend to feel on equal terms.
In groups, a horseshoe or circular chair arrangement can avoid a superior or head-of-the-table
position.

DISTANCE- The distance between the interviewer and interviewee should be neither too small
nor too great, because people feel uncomfortable when talking to someone who is too close or
too far away. Proxemics is the study of use of space. As a species, humans are highly
territorial but we are rarely aware of it unless our space is somehow violated. Most people feel
comfortable maintaining a distance of 2 to 3 feet during an interview. Some clients require more
or less personal space, depending on their cultural and personal needs.

LANGUAGE- Failure to communicate in language the client can understand is a form of

discrimination. The nurse must convert complicated medical terminology into common word
usage, and interpreters or translators are needed if the client and the nurse do not speak the
same language or dialect.

STAGES OF AN INTERVIEW An interview has three major stages: the opening or introduction,
the body or development, and the closing.
THE OPENING- The opening can be the most important part of the interview because what is
said and done at that time sets the tone for the remainder of the interview. The purposes of the
opening are to establish rapport and orient the interviewee.

THE BODY- In the body of the interview, the client communicates what he or she thinks, feels,
knows, and perceives in response to questions from the nurse. Effective development of the
interview demands that the nurse use communication techniques that make both parties feel
comfortable and serve the purpose of the interview.

THE CLOSING -The nurse terminates the interview when the needed information has been
obtained. In some cases, however, a client terminates it, when deciding not to give any more
information or when unable to offer more information for some other reason. The closing is
important for maintaining rapport and trust and for facilitating future interactions.

3. EXAMINING

The physical examination or physical assessment is a systematic data collection method that
uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.
To conduct the examination, the nurse uses techniques of inspection, auscultation, palpation,
and percussion.

The physical examination is carried out systematically. It may be organized according to the
examiner’s preference, in a head-to-toe approach or a body systems approach.
DOCUMENTING DATA

To complete the assessment phase, the nurse records client data. Accurate documentation is
essential and should include all data collected about the client’s health status. Data are
recorded in a factual manner and not interpreted by the nurse.

Validating Data - act of double checking or verifying data to confirm that they are accurate and
factual
Validating data helps nurse to:
 ensure that the assessment is complete
 ensure that objective and related subjective data agree
 obtain additional data that may have been overlooked
 differentiate between cues and inferences
 avoid jumping to conclusions and focusing in the wrong direction to identify problem

3.2. DIAGNOSING

-Diagnosing is the second phase of the nursing process. In this phase, nurses use critical
thinking skills to interpret assessment data and identify client strengths and problems. -
Diagnosing is a pivotal step in the nursing process. Activities preceding this phase are directed
toward formulating the nursing diagnoses; the care planning activities following this phase are
based on the nursing diagnoses

The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement
or conclusion regarding the nature of a phenomenon. The standardized NANDA names for the
diagnoses are called diagnostic labels; and the client’s problem statement, consisting of the
diagnostic label plus etiology (causal relationship between a problem and its related or risk
factors), is called a nursing diagnosis.

Purpose: to identify health care needs and prepare a Nursing Diagnosis

Nursing Diagnosis is a statement of a client’s potential or actual health problem resulting from
analysis of data

A nursing diagnosis is a judgment made only after thorough, systematic data collection.
Nursing diagnoses describe a continuum of health states: deviations from health, presence of
risk factors, and areas of enhanced personal growth.

Health problems or potential health problems are identified and formulated into nursing
diagnosis.
Nursing Diagnosis is the basis for planning nursing interventions that help prevent, minimize or
alleviate specific health issues.

Activities:
 Data Clustering
 Comparing data against standards
 Data analysis
 Identify gaps and inconsistencies
 Determine health problems
 Formulation of Nursing Diagnosis
TYPES OF NURSING DIAGNOSES

1. Actual Nursing Diagnosis- problem that is present at the time of assessment

Also known as the problem-focused diagnosis

Eg. Ineffective breathing pattern

Acute Pain
Impaired skin integrity

2. Potential Nursing Diagnosis- also known as Risk nursing diagnosis

These are clinical judgment that a problem does not exist, but the presence of risk
factors indicates that the problem is likely to develop

Eg. Risk for Injury

Potential for fall
Risk for Bleeding

3. Wellness Nursing diagnosis- transition from a specific level of wellness to a higher

level of wellness.
Also known as Health promotion diagnosis
Concerned in individual, family and community transition from a specific level of
wellness to a higher level of wellness

Eg. Readiness for Enhanced Spiritual Well Being

Readiness for Enhanced Family Coping
Readiness for Enhanced Parenting

4. Syndrome Diagnosis- clinical judgment concerning with a cluster of problem or risk

nursing diagnoses that are predicted to present because of a certain situation or
event
Eg. Chronic Pain Syndrome
Post Traumatic Syndrome

5. Possible Nursing Diagnosis- problem may be present

Are statements describing a suspected problem.
It provides the nurse with the ability to communicate with other nurses that a
diagnosis may be present but additional data collection is indicated to rule out or
confirm the diagnosis

Eg. Possible Chronic Low Self-esteem

Possible Social Isolation

FORMULATING DIAGNOSTIC STATEMENT

1. P.E Format (problem + (related to) etiology)

Ex: problem r/t etiology
Constipation related to prolonged laxative use
Anxiety related to threat to physiological integrity:possible cancer diagnosis
Parental role conflict r/t divorce
2. P.E.S Format (problem+etiology+ signs and symptoms)
Ex: problem r/t etiology as manifested by s/sx
Situational Low Self-Esteem related to (r/t) feelings of rejection by husband as manifested by
(a.m.b.) hypersensitivity to criticism; states “I don’t know if I can manage by myself” and rejects
positive feedback
Impaired verbal communication r/t cultural differences a.m.b inability to speak English

A Nursing Diagnosis is written in a format called "PES ", developed by NANDA

"P" stands for PROBLEM
"E "stands for ETIOLOGY or cause of problem
"S "stands SIGNS and SYMPTOMS of problem
By using all of the components of the nursing diagnosis, the problem is clearly communicated to
everyone involved in the clients care.

3.3 PLANNING

Planning is a deliberative, systematic phase of the nursing process that involves decision
making and problem solving. In planning, the nurse refers to the client’s assessment data and
diagnostic statements for direction in formulating client goals and designing the nursing
interventions required to prevent, reduce, or eliminate the client’s health problems.

Although planning is basically the nurse’s responsibility, input from the client and support
persons is essential if a plan is to be effective. Nurses do not plan for the client, but encourage
the client to participate actively to the extent possible.

Identifying beforehand the specific actions to be done before implementation of nursing

interventions

Purpose: to determine the goals of care and the course of actions to be undertaken during the
implementation phase

TYPES OF PLANNING

Planning begins with the first client contact and continues until the nurse–client relationship
ends, usually when the client is discharged from the health care agency. All planning is multidis-
ciplinary (involves all health care providers interacting with the client) and includes the client and
family to the fullest extent possible in every step.
Initial Planning

The nurse who performs the admission assessment usually develops the initial comprehensive
plan of care. This nurse has the benefit of seeing the client’s body language and can also gather
some intuitive kinds of information that are not available solely from the written
database. Planning should be initiated as soon as possible after the initial assessment.
Ongoing Planning

All nurses who work with the client do ongoing planning. As nurses obtain new information and
evaluate the client’s responses to care, they can individualize the initial care plan further.
Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be
given that day. Using ongoing assessment data, the nurse carries out daily planning for the
following purposes:

1. To determine whether the client’s health status has changed

2. To set priorities for the client’s care during the shift
3. To decide which problems to focus on during the shift
4. To coordinate the nurse’s activities so that more than one problem can be
addressed at each client contact.

Discharge Planning

Discharge planning, the process of anticipating and planning for needs after discharge, is a
crucial part of a comprehensive health care plan and should be addressed in each client’s care
plan.

PLANNING PROCESS

Setting Priorities
Establishing client goals
Selecting nursing interventions
Writing individualized nursing interventions on care plan

Setting Priorities
Determine which problems identified during the assessment phase are in need of IMMEDIATE
attention and which problems may be dealt with a later time

CONSIDER- The most important problems to the patient

Effect of potential problems
Costs, resources available, personnel, time needed

Establishing client goals

Describes a change in the patient’s health status or functioning
Expected outcome, predicted outcome, outcome criterion, objective

Example:
“After 4 hours of nursing interventions, the patient’s temperature will decrease from 38.9 to a
range of 37.0 – 37.5”
GUIDELINES FOR WRITING GOALS

1. Write goals and outcomes in terms of client responses, not nursing activities. Beginning
each goal statement with The client will may help focus the goal on client behaviors and
responses. Avoid statements that start with enable, facilitate, allow, let, permior similar
verbs followed by the word client. These verbs indicate what the nurse hopes to
accomplish, not what the client will do.
Correct: The client will drink 100 mL of water per hour (client behavior).
Incorrect: Maintain client hydration (nursing action).

2. Be sure that desired outcomes are realistic for the client’s capabilities, limitations, and
designated time span, if it is indicated. Limitations refers to finances, equipment, family
support, social services, physical and mental condition, and time.

3. Ensure that the goals and desired outcomes are compatible with the therapies of other
professionals. For example, the outcome “The client will increase the time spent out of
bed by 15 minutes each day” is not compatible with a primary care provider’s pre-scribed
therapy of bed rest.

4. Make sure that each goal is derived from only one nursing diagnosis. For example, the
goal “The client will increase the amount of nutrients ingested and show progress in the
ability to feed self ” is derived from two nursing diagnoses: Imbalanced Nutrition Less
Than Body Requirements and Feeding Self-Care Deficit. Keeping the goal statement
related to only one diagnosis facilitates evaluation of care by ensuring that planned
nursing interventions are clearly related to the diagnosis.

5. Use observable, measurable terms for outcomes. Avoid words that are vague and
require interpretation or judgment by the observer.

6. Make sure the client considers the goals/desired outcomes important and values them.
Some outcomes, such as those for problems related to self-esteem, parenting, and
communication, involve choices that are best made by the client or in collaboration with
the client.

The Planning Phase Involves Several Tasks:

 The list of nursing diagnosis is prioritized
 Client centered long and short term goals and outcomes are identified
 Specific interventions are developed
 The entire plan of care is recorded in the client’s chart

Activities: Priority setting

Setting goals and objectives: Goals may be short-term or long term; the characteristics of a well-
stated behavioral objectives are as follows:

C- client centered
S – specific
M – measurable
A – attainable
R – realistic
T – time-framed
Examples of Goal Statements

Nursing Diagnosis: Goals:

Imbalanced Nutrition: more than body
requirements r/t poor eating habits
Impaired physical mobility r/t general
muscle weakness
Will lose 20 lbs. within 12 weeks
Will reach target wt. of 122 lbs. by December. 20, 2020
Will identify 10 low-calorie snacks he is willing to try within 3 days
One day before discharge, patient will ambulate length of hallway
independently

Alteration in thermoregulatory function:
Hyperthermia r/t increased metabolic
rate secondary to infectious process
Alteration in comfort: Acute pain r/t post
surgical incision
Risk for infection r/t presence of open
wound on the right forearm
Body temperature will decrease from 38.5 C to 36.5 C – 37.5 C
within 3 hours
Verbalization of decreased pain from a scale of 2 to 1 (where
3=severe, 2=moderate, 1=mild, 0=no pain) within the shift
Will not manifest any sign of infection during hospitalization

Electronic Resources: https://www.youtube.com/watch?v=zSNkHbm_t00

https://www.youtube.com/watch?v=am9zN5calho

References:

https://nursing.lsuhsc.edu/AcademicSuccessProgram/StrategiesProblemSolving.aspx
https://nursing-course.blogspot.com/2014/11/problem-solving-and-nursing-process.html
Kozier and Erbs Fundamentals of Nursing, Concepts, Process and Practice 10 th edition
https://www.youtube.com/watch?v=zSNkHbm_t00
https://www.youtube.com/watch?v=am9zN5calho