NURSING PROCESS APPROACH

INTRODUCTION
Nursing process is a systematic problem-solving approach used to identify, prevent and treat actual
orpotential health problems and promote wellness. Asystematic way to plan, implement and
evaluate care for individuals, families, groups and communities.
Practice of nursing is caring which is directed by the way the nurses view the client, the client’s
environment, health and the purpose of nursing. To nurses the nursing process provides a useful
description of how nursing should be performed.
As nurses remain in constant interaction with their clients, professional colleagues, medical and
health care team members, they have the best opportunity to assess the patient’s needs and provide
evidence-based care.

HISTORY OF NURSING PROCESS

The term ‘nursing process’ was first used/mentioned by ‘Lydia hall’, a nursing theorist, in 1955
wherein she introduced 3 steps: observation, administration of care and validation.
In 1967, yura and walsh added assessment to the three steps and described a four phase process.
In the mid-1970s an addition of diagnostic phase resulted into a five step process.
The use of nursing process in clinical practice was started in 1973 by the american nurses
association (ANA ) in standards of nursing practice.
After 1980 the nursing process was added to the general nursing curriculum in India.

DEFINITIONS
The two words of nursing process are significant - nursing and process.
NURSING - Caring the clients during times of illness and assisting the client to achieve maximum
health potential throughout the life cycle.
PROCESS - A series of rational thoughts, decisions and acts to achieve a goal. It implies a
movement which has beginning, middle and an ending.
DEFINITION OF NURSING PROCESS
1. The nursing process is systematic, goal directed, client-centered method for structuring the .
delivery of nursing care.”

2. Nursing process is defined as a systematic, continuous and dynamic method of providing

care to clients. It comprises series of sequential phases built upon the preceding step. Each
phase logically leads to the next. As one step leads to the next step it results into ultimate
achievement of mutually determined nursing outcomes/goals.
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CHARACTERISTICS OF NURSING PROCESS
1. Interactive, Purposeful and systematic ..
2. Client-centered.
3. Goal-directed, outcome focused .
4. Within the legal scope of nursing
5. Prioritizing the needs.
6. The steps are interrelated and dependent on the accuracy of each of the preceding steps .
7. It is used to identify, diagnose, and treat human responses to health and illness .

PURPOSE OF NURSING PROCESS

 General objectives
 To help the nurse provide goal-directed, client-cantered care
 Specific objectives
 To identify a client’s health status; his actual/present and potential/possible health problems
or needs.
 To establish a plan of care to meet identified needs.
 To provide nursing interventions to meet those needs.
 To provide an individualized, holistic, effective and efficient nursing care.

COMPONENTS OF NURSING PROCESS:

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PHASES OF NURSING PROCESS-
Phase Title Description

1 Assessment Collecting subjective and Objective data.

2 Diagnosis Analysis subjective and objective data to make nursing diagnosis.

3 Planning Determining outcome criteria and developing a plan.

4 Implementation Carrying out a plan.

5 Evaluation Assessing whether outcome criteria have been met and revising the plan
as necessary.

1.HEALTH ASSESSMENT
It is systematic and continuous collection, validation and communication of client data as compared
to what is the standard/norm. It includes the client's perceived needs, health problems, related
experiences, health practices, values and life styles.

DEFINITION
Assessment is the systematic and continuous collection, organization, validation, and
documentation of data (information).

PURPOSE
 To establish a data base (all the information about the client):
 Nursing health history.
 Physical assessment.
 The physician's history & physical examination.
 Results of laboratory & diagnostic tests.
 Material from other health personnel

TYPES OF ASSESSMENT
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment

1. INITIAL NURSING ASSESSMENT:

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  Performed within specified time after admission.
 To establish a complete database for problem identification. Eg: nursing admission
assessment

2. PROBLEM-FOCUSED ASSESSMENT:
 To determine the status of a specific problem identified in an earlier assessment. Eg: hourly
checking of vital signs of fever patient

3. EMERGENCY ASSESSMENT:
 During emergency situation to identify any life threatening situation. Eg: rapid assessment
of an individual’s airway, breathing status, and circulation during a cardiac arrest.

4. TIME-LAPSED REASSESSMENT:
 Several months after initial assessment.
 To compare the client’s current health status with the data previously obtained.

COMPONENTS OF A HEALTH ASSESSMENT-

HEALTH HISTORY-
Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with
the patient and family.
Elements of the history include:
 Health status.
 Course of present illness including symptoms.
 Current management of illness.
 Past medical history including family's medical history.
 Social history.
 Perception of illness.
PSYCHOLOGICAL AND SOCIAL EXAMINATION-
The psychological examination may include: -
 Client's perception (why they think they have been referred are being assessed; what they
hope to gain from the meeting).
 Emotional health (mental health state, coping styles etc).
 Social health (accommodation, finances, relationships, genogram, employment status, ethnic
back ground, support networks etc).
 Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern,
diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with
comments on effectiveness).
 Spiritual health (is religion important? If so, in what way? What/who provides a sense of
purpose?). Intellectual health (cognitive functioning, hallucinations, delusions,
concentration, interests, hobbies etc).

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PHYSICAL EXAMINATION-
A nursing assessment includes a physical examination: the observation or measurement of signs,
which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by
the patient. The techniques used may include Inspection, Palpation, Auscultation and Percussion in
addition to the "vital signs" of temperature, blood pressure, pulse and respiratory rate, and further
examination of the body systems such as the cardiovascular or musculoskeletal systems.

DOCUMENTATION OF THE ASSESSMENT-

The assessment is documented in the patient's medicalor nursing records, which may be on paper or
as part of the electronic medical record which can be accessed by all members of the health care
team.

ASSESSMENT TOOLS-
A range of instruments has been developed to assist nurses in their assessment role. These include
the index of independence in activities of daily living.
1. ACTIVITIES OF DAILY LIVING (ADLS)-
Are "the things we normally do in daily living including any daily activity we perform for self care
(such as feeding ourselves, bathing, dressing, grooming), work, homemaking, and leisure."
2. THE BARTHEL INDEX-
The Barthel Index consists of 10 items that measure a person's daily functioning specifically the
activities of daily living and mobility. The items include feeding, moving from wheelchair to bed
and back, grooming, transferring to and from a toilet, bathing, walking on level surface, going up
and down stairs, dressing, continence of bowels and bladder.
3 THE GENERAL HEALTH QUESTIONNAIRE-
The General Health Questionnaire (GHQ) is a screening device for identifying minor psychiatric
disorders in the general population and within community or non-psychiatric clinical settings such
as primary care or general medical out-patients. Suitable for all ages from adolescent upwards not
children, it assesses the respondent's current state and asks if that differs from his or her usual state.
It is therefore sensitive to short-term psychiatric disorders but not to long standing attributes of the
respondent.
The self-administered questionnaire focuses on two major areas:
 The inability to carry out normal functions.
 The appearance of new and distressing phenomena.
4. MENTAL HEALTH STATUS EXAMINATION-
The Mental Status Exam (MSE) is a series of questions and observations that provide a snapshot of
a client's current mental, cognitive, and behavioural condition. Other assessment tools may focus on

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a specific aspect of the patient's care. For example, the Water low score deals with a patient's risk of
developing bedsore (decubitus ulcer) the Glasgow Coma Scale measures the conscious state of a
person.

STEPS OF ASSESSMENT:-
1) COLLECTION OF DATA
 Subjective data collection.
 Objective data collection.
2) Validation of data.
3) Organization of data.
4) Recording/documentation of data.
1) COLLECTION OF DATA
Data collection is the process of gathering information about a client’s health status. It includes the
health history, physical examination, results of laboratory and diagnostic tests, and material
contributed by other health personnel.
TYPES OF DATA
a. Subjective data and
b. Objective data.
{A} .SUBJECTIVE DATA:-
Also referred to as symptoms or covert data, are clear only to the person affected and can be
described only by that person. Itching, pain, and feelings of worry are examples of
subjective data.

{B}. 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.
For example, a discoloration of the skin or a blood pressure reading is objective data.

 SOURCES OF DATA
Sources of data are primary or secondary.
 PRIMARY :
It is the direct source of information. The client is the primary source of data.
 SECONDARY:
-It is the indirect source of information. All sources other than the client are considered
secondary sources.
-Family members, health professionals, records and reports, laboratory and diagnostic results
are secondary sources.

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 METHODS OF DATA COLLECTION
The methods used to collect data are
1. Observation,
2. Interview
3. Examination.

{1.}OBSERVATION : It is gathering data by using the senses. Vision, smell and hearing are used.
{2.}INTERVIEW : An interview is a planned communication or a conversation with a purpose.
There are two approaches to interviewing:
1) Directive
2) Nondirective.
 The directive interview Is highly structured and directly ask the questions.And the nurse
controls the interview.
 Nondirective interview, or rapport building interview
It means interviewing that avoids leading questions that indicate a particular answer as
preferred by the interviewer.

{3}EXAMINATION :
The physical examination is a systematic data collection method to detect health problems. To
conduct the examination, the nurse uses techniques of inspection, palpation, percussion and
auscultation.
1. INSPECTION-
Inspection is the visual examination of the client.
GUIDELINES FOR EFFECTIVE INSPECTION
 Be systematic
 Fully expose the area to be inspected; cover other body parts to respect the client's modesty.
 Use good light, preferably natural light.
 Maintain comfortable room temperature.
 Observe colour, shape, size, symmetry, position, and movement
 Compare bilateral structures for similarities and differences.
2. PALPATION-
Palpation uses the sense of touch to assess various parts of the body and helps to confirm findings
that are noted on inspection.
The hands, especially the finger tips are used to assess skin temperature, check pulses, texture,
moisture, lumps, tenderness, or pain. Ask the Client for permission first and explain to your client
what you intend to examine. Establish client trust with being professional. Please remember to use
warm hands. Any tender areas should be palpated last.

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TYPES OF PALPATION-
 Light Palpation: To check muscle tone and assess for tenderness
 Deep Palpation: To identify abdominal organs and abdominal mass.

3. PERCUSSION-
Percussion is the striking of the body surface with short, sharp strokes in order to produce palpable
vibrations and characteristic sounds. It is used to determine the location, size, shape, and density of
underlying structures; to detect the presence of air or fluid in a body space; and to elicittenderness.
TYPES OF PERCUSSION-
1. DIRECT PERCUSSION: Percussion in which one hand is used and the striking finger of the
examiner touches the surface being percussed.
2. INDIRECT PERCUSSION: Percussion in which two hands are used and the plexor strikes the
finger of the examiner's other hand, which is in contact with the body surface being percussed.
3. BLUNT PERCUSSION: Percussion which the ulnar surface of the hand or fist is used in place
of the fingers to strike the body surface, either directly or indirectly.
PERCUSSION SOUNDS-
 RESONANCE: A hollow sound.
 HYPER RESONANCE: A booming sound.
 TYMPANI: A musical sound or drum sound like that produced by the stomach.
 DULLNESS: Thud sound produced by dense structures such as the liver, and enlarged
spleen, or a full bladder.
 FLATNESS: An extremely dull sound like that produced by very dense structures such as
muscle or bone.
4. AUSCULTATION-
Auscultation is listening to sounds produced inside the body. These include breath sounds, heart
sounds, vascular sounds, and bowel sounds. It is used to detect the presence of normal and
abnormal sounds and to assess them in terms of loudness, pitch, quality, frequency andduration.

ASSESSMENT SEQUENCING
A. CEPHALO CAUDAL APPROACH-HEAD-TO-TOE ASSESSMENT:-
Physical assessment using head toe approach

GENERAL-
General health status, Vital signs and weight, Nutritional status.

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MOBILITY AND SELF CARE-
Observe posture, Assess gait and balance, Evaluate mobility, Activities of daily living.
HEAD FACE AND NECK-
Evaluate cognition, Level of Consciousness, Orientation, Mood, Language and memory, Sensory
function, Test vision, Inspect and examine ears, Test hearing, Cranial nerves, Inspect lymph nodes,
Inspect neck veins.
SKIN, HAIR AND NAILS-
Inspect scalp, hair & nails. Evaluate skin turgor. Observe skin lesion, Assess wounds.
CHEST-
Inspect and palpate breast, Inspect and auscultation lungs, Auscultate heart.
ABDOMEN-
Inspect, auscultation, and palpate four quadrants. Palpate and percusses liver, stomach, and bladder,
Bowel elimination. Urinary elimination
GENITALIA-
Inspect genitalia of male & female clients accordingly.
EXTREMITIES-
Palpate arterial pulses, Observe capillary refill, Evaluate edema, Assess joint mobility, Measure
strength, Assess sensory function, Assess circulation, movement, and sensation. Deep tendon
reflexes, Inspect skin and nails.
B. BODY SYSTEM APPROACH - EXAMINE ALL THE BODY SYSTEM-
REVIEW OF SYSTEMS
GENERAL PRESENTATION OF SYMPTOMS-
Fever, chills, malaise, pain, sleep patterns, fatigability
DIET-
Appetite, likes and dislikes, restrictions, written diary of food intake
SKIN, HAIR, AND NAILS-
Rash or eruption, itching, colour or texture change, excessive sweating, abnormal nail or hair
growth
MUSCULOSKELETAL-
Joint stiffness, pain, restricted motion, swelling, redness, heat, deformity.
HEAD AND NECK-

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  EYES-
Visual acuity, blurring, diplopia, photophobia, pain, recent change in vision
 EARS-
Hearing loss, pain, discharge, tinnitus, vertigo
 NOSE-
Sense of smell, frequency of colds, obstruction, epistaxis, sinus pain, or postnasal discharge
 THROAT AND MOUTH-
Hoarseness or change in voice, frequent sore throat, bleeding or swelling, of gums, recent
tooth abscesses or extractions, soreness of tongue or mucosa.
ENDOCRINE AND REPRODUCTIVE -
Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polyuria,
polydipsia, changes in distribution of facial hair;
 MALES-
Puberty onset, difficulty with erections, testicular pain, libido, infertility;
 FEMALES-
Menses (onset, regularity, duration and amount), Dysmenorrhoea, last menstrual period,
frequency of inter course, age at menopause, pregnancies (number. miscarriages, abortions)
type of delivery, complications, use of contraceptives; breasts (pain, tenderness, discharge,
lumps}
CHEST AND LUNGS-
Pain related to respiration, dyspnoea, cyanosis, wheezing, cough, sputum (character, and quantity),
exposure to tuberculosis (TB), at last chest X-ray.
HEART AND BLOOD VESSELS-
Chest pain or distress, precipitating causes, timing and duration, relieving factors, dyspnoea,
orthopnoea, oedema, hypertension, exercise tolerance.
GASTRO-INTESTINAL-
Appetite, digestion, food intolerance, dysphagia, heartburn, nausea or vomiting, bowel regularity,
change in stool colour, or contents, constipation or diarrhea, flatulence or haemorrhoids.
GENITO-URINARY-
Dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, loss
in force of stream, edema, sexually transmitted disease.
NEUROLOGICAL-
Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss
of memory.
PSYCHIATRIC-
Depression, mood changes, difficulty in concentrating nervousness, tension, suicidal thoughts,
irritability.

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PEDIATRICS-
Along with systemic approach in case of paediatrics, measure anthropometric measurement and
neuromuscular assessment.

2)VALIDATION OF DATA
The information gathered during the assessment is “double-checked” or verified to confirm that it
is accurate and complete.
THE STEPS OF VALIDATION INCLUDE -
 Deciding whether the data require validation.
 Determining ways to validate the data and
 Identifying areas where data are missing.
Failure to validate data may result in premature closure of the assessment or collection of inaccurate
data.
PURPOSES OF DATA VALIDATION-
a. Ensure that data collection is complete.
b. Ensure that objective and subjective data agree.
c. Obtain additional data that may have been overlooked.
d. Avoid jumping to conclusions.
e. Differentiate cues and inferences.
DATA REQUIRING VALIDATION-
Not every piece of data you collect must be verified. For example: You would not need to verify or
repeat the client's pulse, temperature, or blood pressure unless certain conditions exist Conditions
that Require Data to be Rechecked and Validated
 Discrepancies or gaps between the subjective and objective data. For example, a male client
tells you that he is very happy despite learning that he has terminal cancer.
 Discrepancies or gaps between what the client says at one time and then another time. For
example, your female patient says she has never had surgery, but later in the interview she
mentions that her appendix was removed at a military hospital when she was in the navy.
 Findings those are very abnormal and inconsistent with other findings. For example, the
client has a temperature of 104°F The client is resting comfortably. The client's skin is warm
to touch and not flushed.

METHODS OF VALIDATION-
There are several ways to validate your data .
 Recheck your own data through a repeat assessment. For example, take the client's
temperature again with a different thermometer.

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  Clarify data with the client by asking additional questions. For example: if a client is holding
his abdomen the nurse may assume he is having abdominal pain, when actually the client is
very upset about his diagnosis and is feeling anxiety.
 Verify the data with another health care professional. For example, ask a more experienced
nurse to listen to the abnormal heart sounds you think you have just heard.
 Compare your objective findings with your subjective findings to uncover discrepancies. For
example, if the client states that she nevergets any time in the sunyet has dark, wrinkled, sun
tanned skin, you need to validate the client's perception of never getting anytime in the sun.

3) ORGANIZATION OF DATA
The nurse uses a format that organizes the assessment data systematically. This is often referred to
as nursing health history or nursing assessment form.

Maslow's Basic Needs

Abraham Maslow who put forward the hierarchy ofhuman needs is the best way used for the
organization of data in the nursing process. His model got the world's attention because of its high
value in health care.

BODY SYSTEM MODEL-

The Body systems model (also called the medical model or review of systems) focuses on the
client's major mic systems. The framework allows turses to collect data about past and present
condition of each vegan er body system and to examine thoroughly all body systems for actual and
potential problems.

Gordan's Functional Health Patterns

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The client's strengths, talents and functional health patterns are an integral part of the assessment
data. An ement of functional health focuses on chent's normal function and his or her allered
function or risk for altered function.
1) Health perception health management pattern.
2) Nutritional metabolic pattern
3) Elimination pattern.
4) Activity-exercise pattern
5) Sleep-cent pattern.
6) Cognitive-perceptional pattern.
7) Self-perception-concept pattern.
8) Role-relationship pattern
9) Sexuality-reproductive pattern.
10) Coping-stress tolerance pattern.
11) Value-belief pattern.
 COMMUNICATE OR RECORD OR DOCUMENTATION OF 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.
PURPOSES OF DOCUMENTATION-
 Provides a chronological source of client assessment data and a progressive record of
assessment findings that outline the client's course of care.
 Ensures that information about the client and family is easily accessible to members
of the health care team; provides a vehicle for communication; and prevents
fragmentation, repetition, and delays in carrying out the plan of care.
 Establishes a basis for screening or validation proposed diagnoses.
 Acts as a source of information to help diagnose new problems.
 Offers a basis for determining the educational needs of the client, family, and
significant others. 6. Provides a basis for determining eligibility for care and
reimbursement. Careful recording of data can support financial reimbursement or
gain additional reimbursement for transitional or skilled care needed by the client.
 Constitutes a permanent legal record of the care that was or was not given to the
client.
 Provides access to significant epidemiologic data for future investigations and
research and educational endeavours.
GUIDELINES FOR DOCUMENTATION:-
 Document legibly or print neatly in un erasable ink.
 Use correct grammar and spelling.
 Avoid wordiness that creates redundancy.
 Use phrases instead of sentences to record data.
 Record data findings, not how they were obtained.
 Write entries objectively without making premature judgments or diagnosis.
 Record the client's understanding and perception of problems.
 Avoid recording the word-normal for normal findings.
 Record complete information and details for all client symptoms or experiences.

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  Support objective data with specific observations obtained during the physical examination.

NURSING DIAGNOSIS-
Diagnosis is the second phase of the nursing process. In this phase, nurses use critical thinking skills
to interpret assessment data to identify client problems.
• North American nursing diagnosis association (NANDA) define or refine nursing diagnosis.
DEFINITION -
The official NANDA definition of a nursing diagnosis is: “a clinical judgment concerning a human
response to health conditions/life processes.
STATUS OF THE NURSING DIAGNOSIS
The status of nursing diagnosis are actual, health promotion and risk.
1. An actual diagnosis is a client problem that is present at the time of the nursing
assessment.
2. A health promotion diagnosis relates to clients’ preparedness to improve their health
condition.
3. A risk nursing diagnosis is a clinical judgement that a problem does not exist, but the
presence of risk factors indicates that a problem may develop if adequate care is not
given. What is Not a Nursing Diagnosis?
The nursing diagnosis statement is written in terms of a client problem, alteration in health state for
which the nursing provides the primary therapy. The following are not nursing diagnosis:
 Medical diagnosis.
 Medical pathology.
 Diagnostic tests.
 Treatments.
 Equipment.

TYPES OF DIAGNOSTIC STATEMENTS

TYPE CONSTRUCTION EXAMPLE

Actual nursing diagnosis Three part statement includes Acute pain related to
diagnostic lable,related factors, surgical trauma and
defining characteristics inflammation, as evidenced
by grimacing and verbal
reports of pain

Risk nursing diagnosis Two part statement includes Risk for infection related to

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 diagnostic label, risk factors surgery and
immunosupperession

Possible nursing diagnosis Two part statement includes Possible self esteem
diagnostic lable,related factors disturbance related to
(unknown) unknown etiology

Wellness diagnosis One part statement includes Readiness for enhanced

diagnostic label spiritual wellbeing

TYPES OF DIAGNOSTIC STATEMENTS

1. ACTUAL NURSING DIAGNOSIS-
Three part statement includes diagnostic label, related factors, defining characteristics Eg: Acute
pain related to surgical trauma and inflammation, as evidenced by grimacing and verbal reports of
pain.
2. RISK NURSING DIAGNOSIS-
Two part statement includes diagnostic label, risk factors.
Eg:Risk for infection related to surgery and immune suppression
3. POSSIBLE NURSING DIAGNOSIS-
Two part statement includes diagnostic label, related factors (unknown)
Eg: Possible self esteem disturbance related to unknown etiology.
4. WELLNESS DIAGNOSIS-
One part statement includes diagnostic label Eg: Readiness for enhanced spiritual well being.

ANALYSIS AND INTERPRETATIONS OF DATA -

Analysis of subjective and objective data to make nursing diagnosis.
After completing the nursing assessment, the nurse proceeds to the process of forming appropriate
nursing diagnosis. A nursing diagnosis is a clinical judgement about individual, family or
community responses to actual health problem or life processes. (NANDA} In the assessment
phase, data are initially collected from a variety of source and validated. The nurse then applies
reasoning and begins to look for patterns in the assessment data. To arrive at nursing diagnosis we
must go through the steps of data analysis. Thisprocess requires diagnostic reasoning skills, often
called critical thinking.
STEPS OF DATA ANALYSIS-
1. Identify abnormal data and strengths.

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2. Cluster the data.
3. Draw inferences and identify the problem.
4. Propose possible nursing diagnosis.
5. Check defining characteristics.
6. Confirm or rule out.
7. Document conclusion.
IDENTIFY ABNORMAL DATA AND STRENGTHS -
Identifying abnormal findings and strengths requires the nurse to have and use a knowledge base of
anatomy and physiology, psychology and sociology. In addition the collected data should be
compared with findings in reliable charts and reference sources that provide standards and values
for physical and psychological norms (i.e. height, nutritional requirement, growth and development)
additionally the nurse should have a basic knowledge of risk factors for the client. Risk factors are
based on client data such as gender, age, cultural background, and occupation. The nurse's
knowledge of anatomy and physiology, psychology and sociology, use of reference materials and
attention to risk factors help to identify strengths, risks and abnormal findings. Identified strengths
are used to in formulating wellness diagnosis. Identified potential weaknesses are used in
formulating risk diagnosis and abnormal findings are used in formulating actual nursing diagnosis.

CLUSTERING THE DATA-

In this step the nurse looks at the identified abnormal findings and strengths for cues that are
related. Both abnormal cues and strength cues should be clustered and a particular nursing
framework should be used as a guide when possible. The following is the example of how to cluster
the data after assessing a client who reports the subjective information defined below and whose
physical examination discloses the objective findings listed below:

Identified abnormal data and strengths: Subjective .

 Hair falling out in chunks.
 Red rash on face and chest.
 So ugly
Identified abnormal data and strengths: Objective
 Anxious appearing.
 Patchy alopecia.
 Red raised plaques on face, neck, shoulders, back and chest.

DRAW INFERENCES-
This Step requires writing down the hunches about each cue cluster. You will write what you think
the data is saying and determine where you can treat independently. i.e something that nurse would

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intervene and treat independently. Another purpose of this step is the referral of identified problems
for which the nurse cannot prescribe the definitive treatment. Referring can be defined as
connecting the clients with other professionals and resources. E.g. diabetic client who is having
trouble with understanding the exchange diet. Although the nurse has knowledge in this area,
referral to a dietician can provide the client with updated material and allow the nurse more time to
deal with client problems within the nursing domain.
PROPOSE POSSIBLE NURSING DIAGNOSIS-
If the situation requires primarily nursing intervention then the nursing diagnosis may be wellness
diagnosis, risk diagnosis or actual diagnosis. A wellness diagnosis indicates that the client has the
opportunity for enhancement of a health state. A risk diagnose indicate the client does not currently
have the problem but is at high risk for developing it. An Actual nursing diagnosis indicates the
client is currently experiencing the stated problem or has a dysfunctional pattern.

COMPARISON OF WELLNESS, RISK AND ACTUAL NURSING DIAGNOSIS-

Wellness diagnosis Risk diagnosis Actual diagnosis

Client status State of harmony and State of risk for State of health
balance identified diagnosis problems

Format for stating Opportunity to enhance Risk for Nursing diagnosis

Examples  Opportunity to  Risk for altered Altered body image

enhance body body image related to hand
image  Risk for altered wound that is not
 Opportunity to family process healing
enhance effective  Risk for Altered family
breast feeding ineffective breast process related to
 Opportunity to feeding hospitalization
enhance skin  Risk for impaired
Ineffective breast
integrity skin integrity
feeding related to
poor mother –infant
attachment

Impaired skin
integrity related to
immobility

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CHECK FOR DEFINING CHARACTERISTICS-
At this point the nurse must check for defining characteristics for the data clusters in order to
choose the most accurate diagnosis and delete that diagnosis which are not valid for the client. This
step is difficult because diagnostic labels overlap, making it hard to identify the most appropriate
diagnose. eg the diagnostic categories of impaired gas exchange, ineffective airway clearance and
ineffective breathing pattern, all reflect respiratory problems but each is used to describe a very
different human response pattern and set of defining characteristics.
CONFIRM OR RULE OUT-
If the cluster data do not match the defining characteristics, you can rule out that particular
diagnosis with the other health care professionals who are caring for the client. Tell the client what
you perceive his or her diagnosis to be. Often nursing diagnosis terminology is difficult for the
client to understand. e.g you would not tell the client that you believe that he has impaired nutrition
less than body requirement. Instead, that you might say that you believe that current nutritional
intake is not adequate to promote healing of body tissues. Then you ask the client if this seems to be
an adequate statement of the problem. It is essential that client understand the problem so that
treatment can be properly implemented. If the client is not in the coherent state of mind, to help
validate the problem you can consult with family members.
DOCUMENT CONCLUSIONS-
Be sure to document all your professional judgements and the data that supports those judgements.
Nursing diagnosis can be documented and worded in different formats like wellness diagnosis, risk
diagnosis, and actual nursing diagnosis.
NURSING DIAGNOSIS:- Application to Care Planning.
The use of nursing diagnosis is a mechanism for identifying the domain of nursing:
 The formulated nursing diagnosis provides direction for the planning process and the
selection of nursing interventions to achieve the desired outcome. The care plan is a
mechanism for demonstrating accountability.
 In addition, the nursing diagnosis and subsequent care plan assist in communicating to other
professionals the client centered problems through the nursing care plan, consultations, and
discharge
 Planning and client care conferences. Making accurate nursing diagnosis helps to ensure that
clients receive quality nursing care.
 Nursing diagnosis help to increase the specificity of nursing interventions for each client.
 . Coding of nursing diagnosis in computerized systems allows direct reimbursement for
nurses. Studies of specific nursing diagnosis improve understanding of nursing diagnostic
process and contribute to examination of nurse's role in health care. .
 The development of taxonomy of nursing diagnosis should significantly affect practice,
education, research, legislation, and nursing as a profession.

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  A nursing diagnosis will help to bridge a gap between knowledge and practice and will
articulate the scope of nursing practice, essential to developing nursing's professional role in
health care.

ADVANTAGES OF NURSING DIAGNOSIS

Nursing diagnosis is advantageous for both nurses and clients
1) They facilitate communication among nurse about the client's level of wellness and assist in
discharge planning.
2) Nursing diagnosis helps in prioritizing the client's needs.
3) Nursing diagnosis is also used for charting the progress notes, writing referrals and
providing effective transition of care from one unit to another, from one clinic to another or
from the hospital to community.
4) Nursing diagnosis can also serve as focus for quality improvement. When focusing the
nursing diagnosis the reviewer can determine whether nursing care was correct and
delivered according to standards of practice.
5) Nursing diagnosis is beneficial for the client and family
LIMITATIONS OF NURSING DIAGNOSIS
Nursing diagnosis has limitations and the beginning practitioner should be aware of their existence.
Because of the continuous evolution of the terms and use of nursing diagnosis, the language can
occasionally be verbose and contain jargon. This may limit the use of nursing diagnosis to only
nursing professionals and result is confusion among other members of health team.

PLANNING

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Planning involves decision making and problem solving. It is the process of formulating client goals
and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health
problems.

PURPOSES OF PLANNING
 Direct client care activities.
 Promote continuity of care.
 Focus charting requirements.
 Allow for delegation of specific activities.

TYPES OF PLANNING
 Initial Planning
 Ongoing Planning
 Discharge Planning

INITIAL PLANNING
It should be initiated as soon as possible after the initial assessment.
ONGOING PLANNING
It occurs at the beginning of a shift as the nurse plans the care to be given that day.
DISCHARGE PLANNING RIBELL RGE
It begins at first client contact and involves comprehensive and ongoing assessment to obtain
information about the patients ongoing needs.

THE PLANNING PROCESS

The planning process includes the following activities:
 Setting priorities.
 Establishing client goals/expected outcomes.

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  Selecting nursing strategies.
 Developing nursing care plans.

SETTING PRIORITIES
Priority setting is a process of establishing a preference order for nursing strategies. The nurse and
the client begin planning by deciding which nursing diagnosis requires attention first, which second,
and so on. Instead of rank ordering diagnoses, nurses can group them as having high, medium and
low priority.
Life threatening problems such as loss of respiratory and cardiac functioning, are designated as high
priority, for example high risk for aspiration. Health threatening problems, such as acute illness and
decreased coping ability, may result in delayed development or cause destructive physical or
emotional changes; thus, they are usually assigned medium priority, e.g. impaired physical
mobility. A low priority problem is one that arises from normal developmental needs or that
requires only minimal nursing support. Using a framework makes priority setting easier. Although
it is not a nursing framework, nurses frequently use Maslow's hierarchy of needs when setting
priority. In Maslow's hierarchy, physiological needs such as air, food and water, are basic to life and
receive higher priority than the need for security and activity. Growth needs, such as self esteem,
are not perceived as basic in this framework. Thus, when the nurse plans care for a client with
unmet physiological needs and unmet growth needs, the physiological needs receive first priority.
Priority setting does not require that all the high priority diagnoses be resolved before the nurse
addresses any others. The nurse may partially address a high priority diagnosis and then deal with a
diagnosis of lesser priority. The priorities assigned to problems do not remain fixed; rather, they
change as the clientresponses, problems and therapies change. The nurse assigns priorities on the
basis of nursing judgement and, insofar as possible, client preference. The nurse must consider a
variety of factors, for example, the client's values and priorities and the available resources. Nursing
diagnoses provide the framework for establishing outcomes for care.

 ESTABLISHING CLIENT GOALS OR EXPECTED OUTCOMES

After establishing priorities, the nurse sets goals for each nursing diagnosis. A goal is a desired
outcome or change in client behavior. Goal attainment is the resolution of the problem specified in
the nursing diagnosis. On a care plan, the goals describe, in terms of observable client responses,
what the nurse hopes to achieve by implementing the nursing orders. A distinction is made between
the goals and expected outcomes, Goals are the broad statements about what the client's state will
be after the nursing intervention is carried out e.g. nutritional status will improve. Expected
outcomes are the more specific, measurable, realistic statements of goal attainment e.g. Will gain 5
lb by the end of the week. They may restate the goal, but they also present information that will
guide the evaluation phase of the nursing process. Some sources also use the terms outcome criteria,
objective and predicted outcome. When goals are defined broadly, the client's care plan must
include both goals and expected outcomes. In fact, they are sometimes combined into one statement
linked by the words as evidenced by, for e.g. Nutritional status will improve, as evidenced by
weight gain of 5 lb by end of the week. Writing the broad goals first may help to think of the
specific outcomes that are needed but even though broad goals can be a starting point for planning,
it is the specific, measurable outcome that must be written on the care plan. For example, Goal is to
improve mobility; expected outcome is Client will ambulate with crutches by the end of the week.

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CRITERIA FOR EXPECTED OUTCOME
According to ANA:- The nurse identifies expected outcomes individualized to the client.
1. Outcomes are derived from the diagnoses.
2. Outcomes are documented as measurable goals.
3. Outcomes are mutually formulated with the client and health care providers, when possible.
4. Outcomes are attainable in relation to resources available to the client.
5. Outcomes are realistic in relation to the client's present and potential capabilities.
6. Outcomes include a time estimate for attainment.Outcomes provide direction for continuity
of care.

PURPOSE OF GOALS OR EXPECTED OUTCOMES

 Provide direction for planning nursing interventions that will achieve the desired
changes in the client. Ideas for interventions come more easily if the goals state clearly
and specifically what the nurse hopes to achieve.
 Provide a time span for planned activities.
 Serve as criteria for evaluation of client progress. Although developed in the planning
step of the nursing process, the expected outcomes serve as criteria for judging nursing
interventions and client progress in the evaluation step.
 Enable the client and nurse to determine when the problem has been resolved.
 Help motivate the client and nurse by providing a sense of achievement.

LONG-TERM AND SHORT-TERM GOALS

Goals may be short term or long term. A short term goal can be met in a relatively short period
(within days or less than 1 week). A long term goal requires more time, perhaps several weeks
or months. A short term goal might be "client will raise right arm to shoulder height by Friday"
In the same context, a long term goal might be, "client will regain full use of right arm in 6
weeks". In the acute care setting, much of nurse's time is spent on the client's immediate needs,
so most goals are short term. Short term goals also enable the nurse to evaluate client progress
more accurately. Long term goals are often used for clients who live at homes and have chronic
health problems and for clients in nursing homes, extended care facilities, and rehabilitation
centres.

SHORT TERM GOALS ARE USEFUL

a) For clients who require health care for short time.
b) For those who are frustrated by long term goals that seem difficult to attain and who
need the satisfaction for achieving a short term goal.

RELATIONSHIP OF GOALS OR EXPECTED OUTCOMESTO NURSING

DIAGNOSES
Goals/expected outcomes are derived from and relate to the client's nursing diagnoses- primarily
from the first clause (problem). The problem clause contains the unhealthy response; it states
what should change. Therefore, the essential client goals are derived from the problem clause.
For example, if the nursing diagnosis is High risk for fluid volume deficit related to diarrhoea
and inadequate intake secondary to nausea, the essential goal statement might be "client's fluid

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balance will be maintained, as evidenced by urinary and stool output in balance with fluid
intake, normal skin turgor, and moist mucus membranes". In this, a general goal (fluid balance)
is stated as the opposite of the problem (Fluid volume deficit) and then followed by list of
measurable expected outcome. If achieved, the expected outcomes would be evidence that the
problem has been prevented. Goals may occasionally be derived from second clause (etiology of
the diagnosis), but they are different from those derived from the problem. Their achievement
may help to resolve the problem, but they might also be achieved without resolving the
problem. In the above example, the following expected outcome can be derived from the
etiology: Client will have daily fluid intake of 1500ml. Note that drinking 1500ml of fluid
would help the client achieve fluid balance; however, if the nurse discontinued the care plan on
the basis of achieving this outcome, then the client's needs would not be met. The fact that the
client intake was 1500ml does not prove that the problem was prevented. For e.g. continued
diarrhoea or a high fever that cause the client to lose more than 1500ml of fluid could still create
a problem of Fluid volume deficit. For every nursing diagnosis, the nurse must write at least one
outcome criterion that, when achieved, directly demonstrates resolution of the problem clause.
When developing outcome criteria, ask the following questions:
 What is the problem clause?
 What is the opposite, healthy response? .
 How will the client look or behave if the healthy response is achieved?
 What must the client do and how well must the client do it to demonstrate problem
resolution orfor demonstrate the capability of resolving the problem?

COMPONENTS OF GOAL OR EXPECTED OUTCOME STATEMENTS

Goal or expected outcome statements generally have the following four components:-
a) Subject
The subject, is the client, or some attribute of the client, such as client's pulse or urinary output.
Often the subject is omitted in nursing care plan goals; it is assumed that the subject is the client
unless indicated otherwise.

b) Verb
The verb denotes an action the client is to perform, for e.g. what the client is to do, learn, or
experience. Verbs that denote directly observable behaviours, such as administer, demonstrate,
show, walk, and so on are used. Examples of Verb Actions
Apply, Arrange, Assemble, Breathe, Choose, Communicate, Compare, Construct, Calculate,
Classify, Define, Demonstrate, Describe, Design, Differentiate, Discuss, Draw, Drink, Explain,
Express, Help, Identify, Inject, List Maintain, Move, Name, Prepare, Perform, Practice, Report,
Recall, Recite, Share, Stand, Sleep, State, Show, Talk, Take Transfer, Turn, Use, Verbalize,
Walk.
c) Conditions or Modifiers

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Conditions or modifiers may be added to the verb to explain the circumstances under which the
behaviour is to be performed. They explain what, where, when, or how. For e.g.
 Walks with the help of walker (how).
 After attending two group diabetes classes, list sign and symptoms of diabetes (when).
 When at home maintains weight at existing level (where).
 Discusses four food groups recommended daily servings (what).
Conditions need not be included if the criterion of performance clearly indicates what is
expected.
d) Criterion of Desired Performance
The criterion indicates the standard by which a performance is evaluated or the level at
whichthe client will perform the specified behaviour. These criteria may specify time or speed,
accuracy, distance, and quality. To establish a time achievement criterion, the nurse needs to
ask,
 How long? To establish an accuracy criterion,
 How well?
 How far?
 What is the expected standard? to establish distance and quality criteria, respectively.
For e.g.
 Weighs 75kg by April (time).
 Lists five out of six signs of diabetes (accuracy).
 Walks one block per day (time and distance).
 Administers insulin using aseptic technique (quality).

GUIDELINES FOR WRITING GOALS OR EXPECTED OUTCOMES

 Write goals or outcome criteria in terms of client behaviour. Begin each goal and
outcome criteria with the client. Outcome criteria should focus on what the client will
accomplish, not what the nurse will do.
 Avoid statements that start with enable, facilitate, allow, let, permit, or similar verbs
followed by the work client. These words indicate what the nurse hopes to accomplish
not what the client will do.
 Make sure that the goal statement is appropriate to the nursing diagnosis. Validate the
outcomes. If the outcomes are accomplished, will the client's nursing diagnosis be
resolved?
 Be sure that the outcomes are realistic for the client's capabilities, limitations, and
designated life span, if it is indicated. Limitations refer to finances, equipment, family
support, social services, physical and mental condition, and time.
 Make sure that the client considers the goals or outcome important and values them.
Some outcome 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.
 Ensure that the goals and outcome are compatible with the work and therapies of other
professionals. Make sure that each goal is derived from only one nursing diagnosis.

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  When writing expected outcome, use observable, measurable terms; avoid words that are
vague and require interpretation or judgement by the observer.

CHARACTERISTICS OF A WELL STATED GOALS OR EXPECTED

OUTCOMES
A well stated expected outcome is:
 Derived primarily from the first clause of the nursing diagnosis.
 Possible to achieve.
 Stated in terms of client responses rather than nursing activities.
 Statement of one specific client behaviour. Specific and concrete.
 Appraisable or measurable.
 Valued by the client and family.
 Compatible with the therapies of other professionals.

 SELECTING NURSING STRATEGIES

This involves selecting action that enables the person to achieve the outcomes and to resolve the
related factors in the nursing diagnosis. These selected actions or strategies are called nursing
interventions. The specific strategies chosen should focus on eliminating or reducing the
etiology of the nursing diagnosis, which is the second clause of the diagnostic statement.
Correct identification of the etiology during the diagnostic phase provides the framework for
choosing successful nursing interventions.
Often the nurse and the client can establish a number of nursing strategies for each problem
statement. Too many alternatives can be confusing. Usually three to five alternative nursing
strategies for each health problem are satisfactory.

CONSIDERING THE CONSEQUENCES OF EACH STRATEGY

Once the nurse identifies a number of possible strategies to implement, the next step is to
consider the risks and benefits of each action. Often, an action will have more than one
consequence. Determining the consequences of each strategy requires nursing knowledge and
experience.

CRITERIA FOR CHOOSING NURSING STRATEGIES

The following criteria can help the nurse choose the best nursing strategy. The planned action
must be:
 Safe and appropriate for the individual's age, health, and so on.
 Achievable with the resources available.
 Congruent with the client's values and beliefs.
 Congruent with other therapies.
 Based on nursing knowledge and experience or knowledge from relevant sciences
(based on rationale).
 With in established standards of care as determined by state laws, professional
associations, and the policies of the institution.

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TYPES OF NURSING STRATEGIES
Nursing strategies are identified and written during the planning step of the nursing process;
however, they are actually performed during the implementing step. A nursing intervention is
any direct care treatment that a nurse performs on the behalf of a client, whether nurse initiated
or physician initiated.

i) Independent Interventions
These are those activities that nurses are licensed to initiate on the basis of their knowledge and
skills. They include physical care, ongoing assessment, emotional support and comfort,
teaching, counselling, environmental management, and making referrals to other health care
professionals. McCloskey and Bulechek refer to these as nurse initiated treatments. Mundinger
prefers the term autonomous nursing practice. She states Knowing why, when, and how to
position clients and doing it skilfully makes the function an autonomous therapy.

ii) Dependent Interventions

These are those activities carried out under the physician's order or supervision, or according to
specific routines. McCloskey and Bulechek call these physician initiated treatments. Medical
orders commonly include orders for medications, intravenous therapy, diagnostic tests,
treatments, diet and activity. The nurse is responsible for explaining, assessing the need for, and
administering the medical orders. Dependent interventions are usually directly related to the
client's disease, and their importance should not be minimized.

iii) Collaborative Interventions

These are actions the nurse carries out in collaboration with other health team members, such as
physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities
reflect the overlapping responsibilities of, and collegial relationships between, health personnel.
To achieve collaborative nursing practice, nurses must be clinically competent, feel confident in
their knowledge and skills, and assume responsibility for their own actions.

WRITING NURSING ORDERS

After choosing the appropriate nursing interventions, the nurse writes them on the care plan as
nursing orders. Nursing orders are instructions for the specific activities the nurse performs to
help the client meet established health care goals. The term order connotes a sense of
accountability for nurse who gives the order and for the nurse who carries it out. Carnevali and
Thomas used the term nursing directives.

A complete well-written nursing order is composed of five components:

 Date: Nursing orders are dated when they are written and reviewed regularly at intervals
that depend on the individual's needs.

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  Specific action verb, such as instruct, place, supervise, and observe. Sometimes a
modifier, such as actively, softly, firmly helps clarify the verb.
 Content area: The content is the where and what of the order.
 Time element: The time element answers when, how long, or how often the nursing
action is to occur.
 Signature: The signature of the nurse prescribing the order shows the nurses
accountability and has legal significance.

 DEVELOPING NURSING PLANS

The nursing care plan is a written guide that organizes information about a client's care into a
meaningful whole. It includes the actions nurses must take to address the client's nursing
diagnosis and meet the stated goals. The nurse starts the care plan as soon as the client is
admitted to the health care agency and constantly updates it throughout the client's stay, in
response to changes in the client's condition and evaluations of goal achievement.

Purposes of a Written Care Plan

 To provide direction for individualized care of the client.
 To provide for continuity of care.
 To provide direction about what needs to be documented on the client's progress notes.
 To serve as a guide for assigning staff to care for the client.
 To serve as a guide for reimbursement from medical insurance companies, often called
third party reimbursement.
 To provide for individual and family participation in the nursing care plan.
 To outline a program for health education of individuals and significant others.
 To encourage adequate discharge planning.
 To provide a source of information for quality improvement and research.

WRITING A NURSING PLAN OF CARE

A nursing plan of care documents the problem-solving process. The ability to create the nursing
plan of care has become a standard expected of every nurse. The plan is a critical element in
focusing nursing activity. To serve as evaluation criteria and meet the standards of the Joint
Joint Commission for Accreditation of Health care Organizations (JACHO; 1996), the plan
must be developed by a registered nurse, it must be documented in the client's health record, and
it must reflect the standards of care establ institution and the profession.

Two Important Concepts Guide a Nursing Plan of Care

 The plan of care is nursing centred.
 The plan of care is a step by step process.
Keeping the plan of care nursing centred is essential to identify the scope and depth of nursing
practice. By focusing on the treatment of human resources to actual or potential health
problems, the nurse remains in the nursing practice domains.

A step-by-step process is evidenced by the following

 Sufficient data are collected to substantiate nursing diagnosis.

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  At least one goal must be stated for each nursing diagnosis.
 Outcome criteria must be identified for each goal.
Nursing interventions must be specifically designed to meet the identified goal.
 Each intervention should be supported by a scientific rationale.
 Evaluation must address whether each goal was completely met, partially met, or
completely met.

Guidelines for Writing Nursing Care Plans

1) Date and sign the plan.
2) Use the category headings
 Nursing Diagnosis,
 Goals/outcome criteria,
 Nursing orders and
 Evaluation and include a date for the evaluation of each goal
3) Use standardized medical or English symbols and key words rather than complete
sentences to communicate your ideas.
4) Refer to procedure books or other sources of information rather than including all the
steps on a written plan.
5) Tailor the plan to the unique characteristics of the client by ensuring that the client's
choices, such as preferences about the time of care and the methods used, are included.
This reinforces the client's individuality and sense of control.
6) Ensure that the nursing plan incorporates preventive and health maintenance aspects as
well as restorative.
7) Ensure that the plan contains orders for ongoing assessment of the client.
8) Include collaborative and coordination activities in the plan.
9) Include plans for the client's discharge and home care needs.

Types of Nursing Care Plans

As you care for people in various health care facilities, you will discover a variety of nursing
care plan formats. The documentation of the plan of care is also changing as federal, state, and
accrediting agencies examine and modify their standards. It can be written in various ways. The
most common formats for care plans include student nursing care plan, individually developed
nursing care plan, practice guidelines, critical path or case management plans, and computerized
nursing care plans.
1. Student Nursing Care Plans
Each school of nursing has a care plan format adopted by or developed by the faculty for
student use. Because student plans are used as learning tools, they are usually more
comprehensive and detailed than the care plans utilized by graduate staff nurses. Student care
plans focus heavily on documenting signs and symptoms and proving the rationale for specific
nursing interventions. This information is no less important to the graduate nurse. However, the
experienced nurse is capable of high level assessment and synthesis of data, which are still step
by- step for the student. The components usually include nursing diagnoses, client goals,
outcome criteria, nursing interventions, scientific rationale, and evaluation.

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2. Individually Developed Nursing Care
Plans The Individually developed nursing care plan is the most traditional and oldest method of
documenting the plan of care. It typically consists of three columns, which are labelled,
according to the setting, as nursing diagnoses or problems, outcomes or goals, and nursing
interventions or orders. Additional columns may be added to the format to include a spot for the
date and initials of the nurse who developed the plan, the date for the outcome achievement, and
the date the nursing diagnosis was resolved. Individual care plans are intended to focus on the
specific needs of the person and are to be updated as the person's condition changes. The
Individually developed nursing care plan, like the other formats for the plan of care, is usually
combined with a Kardex. A Kardex is an abbreviated form that contains 1) basic demographic
information about the person, such as name, age, sex, medical diagnoses, surgical procedures,
and physician's name, and 2) basic care information, such as type of bath, frequency of vital
signs, allowable activity, ordered treatments and so on.
Advantages
The advantages of individually developed nursing care plans include their specificity to a
particular person. They contain only the pertinent nursing diagnoses, outcomes and
interventions.
Disadvantages
The primary disadvantage of this is the time consuming aspect of the development process.
Also, as is true with other formats for care plans, the individually developed nursing care plan
may not accurately reflect the person's current problems if it has not been updated.
3. Standardized Nursing Care Plans
Printed care plans, known as standardized care plans, are developed commercially or by an
individual health care facility. The direct nursing care for people with specific medical
diagnoses (e.g. myocardial infarction) with certain nursing diagnoses such as pain or anxiety, or
who are undergoing special procedures such as cardiac catheterization. These care plans are
typed, pre printed, duplicated, and made available to the appropriate units in the health care
facility. The format is designed to leave space for the nurse to individualize the care plan by
filling in specific related factors associated with nursing diagnosis, adding deadlines to the
outcomes, and clarifying the interventions with additional details. For example, the
interventions could be individualized by adding frequencies, amounts, times, and the client's
preferences.
Advantages
Reduced amount of writing needed to record routine nursing interventions and help to the staff
by highlighting necessary interventions. These are usually developed by a group of nurses who
use their collective expertise and experience to produce a well-researched tool. Particularly
helpful to nurses who may be asked to work in an unfamiliar area.
Disadvantages
a. Nurses may use these care plans without individualizing them for a particular person.
b. Many of the nursing diagnoses, outcomes, and interventions may not be applicable.ch

29
c. These may tend to be long.
d. Frustrated by the amount of time it takes simply to read them, some nurses have not found
them to be helpful. This problem can be reduced by developing concise standardized care plans
that contain only the essential information.
4. Teaching Plans
Teaching plans are a specialized form of nursing care plans. Individually developed teaching
plans may be hand written or computer generated for individuals with complex teaching needs.
An agency may have a variety of standardized teaching plans prepared for people with
commonly seen teaching needs. The nurse modifies the standard teaching plan as needed and
uses the form to document the outcome of the teaching.
5. Practice Guidelines
Practice Guidelines also called protocols; specify nursing management of broad clinical issues
like maintenance of skin integrity, phases of hospitalization such as postoperative care, or
interdependent clinical issues for e.g. management of a person receiving a certain type of potent
medication, such as cardiac medication given intravenously in ICUS. Whereas the standardized
care plan or individually developed care plan contains information about a variety of nursing
diagnoses, the practice guidelines typically addresses one issue, problem, or nursing diagnosis.
Practice guidelines are usually developed by experts and reviewed by a group of nurses for
validity. When a practice guideline address an interdependent clinical issue that includes both
medical and nursing management of a particular concern, physician committee review of the
medical orders is usually needed. These plans illustrate the manner in which health care
professionals collaborately manage treatment. Practice guidelines are used commonly in short
stay areas of a hospital, such as Emergency departments and Post- Anesthesia care units. Certain
commonalities exist among people in these areas, making it possible to manage their care
according to practice guidelines.
Advantages
 They clearly specify well-researched and agreed-upon management of certain problems.
 Once the initial work of developing the practice guideline is completed, their use saves
much time by quickly transmitting information thatdoes not need to be documented for
each person for whom it is applicable.
 Practice guidelines are not considered standards.
Disadvantages
 The temptation to follow uncritically the interventions without individualizing them for
a particular person.
 No prepared plan of care, no matter what its format, replaces the judgement and critical
thinking of the nurse.
5. Case Management Care Plans
Case management is a method of delivering care that has evolved from the emphasis on
decreasing the length of stay in hospitals and the focus on achieving timely client outcomes.
Case management is designed to organize care to achieve certain specific outcome with in a
time frame permitted by the reimbursement system. The Case management plan is a
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standardized care plan that consists of nursing diagnoses, outcomes, deadlines, nursing
interventions, and physician interventions. The plan is developed collaboratively by nurses,
physicians and other health care professionals and is reviewed and individualized for a
particular person. The comprehensive case management plan is often summarized in the form of
a critical path or patient outcome time line.
Critical paths can improve quality of care by:
 Allowing health care professionals to share knowledge with each other.
 Educating clients by thoroughly explaining the treatment plan.
 Permitting comparison of outcomes or results of various treatment methods.
 Identifying and reinforcing steps critical to the desired outcome.
Advantages
 Easy to identify appropriate steps in achieving the outcomes.
 Resources of the nursing staff and hospital are used more effectively as they become
directed at moving the person through the hospitalization.
 The person is actively involved in reviewing the plan of care.
 Nurses are given more authority to make changes in the system to facilitate the
achievement of outcomes.
Disadvantages
 A great deal of planning needed to implement this method of delivering care.
 It may be difficult in some instances to gain the cooperation of physicians in defining
how to manage certain types of clients and to collaborate with nurses on a professional
level.
 Certain people will have pre-existing conditions or complications that will prevent the
achievement of outcomes at specified time periods.
6. Computerized Nursing Care Plans
Many software vendors have developed computerized nursing care plans and critical paths.
Computerized plans of care are generated from assessment data entered into a computer about a
specific client. The plan is written by experts in the area and the content is similar to that of
standardized plan of care. Once the plan is on the computer screen, the nurse has opportunity to
customize it for the client.
Advantages
 Legibility.
 Reduction in the amount of time needed to develop and update the plan.
 Access to plans developed by expert clinicians.
 Ability to collect information about patients for research.
Disadvantages
 It requires a critical analysis of a pre-existing plan to ensure that it is appropriate and
current.
 It is critical that all pertinent information be collected and entered into the system.

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 IMPLEMENTATION
The nursing process is a deliberate, problem-solving approach to meeting the health care and
nursing needs of patients. It involves assessment, diagnosis, outcome identification, planning,
implementation and evaluation, with subsequent modifications used as feedback mechanisms that
promote the resolution of the nursing diagnoses. The process as whole is cyclical, the steps being
interrelated, interdependent, and recurrent. Thenursing process is action oriented, client centered,
and goal directed. After developing a plan of care based on the assessing and diagnosing phases, the
nurse puts the plan into effect and evaluates the results. Based on this evaluation, the plan of care is
continued, modified, or terminated. As in all phases of the nursing process, clients and support
persons are encouraged to participate as much as possible. The degree of participation depends on
the client's health status. After the nurse and client identify problems and strengths, they plan
together methods of helping the client maintain or return to healthy function. Out-come criteria are
set for goals, and a plan of care is developed. Now they are ready for the implementation phase of
the nursing process, the activity that provides planned care, and the evaluation phase, in which the
client's status is measured in response to the nursing care provided.

DEFINITION
Implementation refers to the action phase of the nursing process in which nursing care is provided.
It is the actual initiation of the plan and recording of nursing actions. Its purpose is to provide
technical and therapeutic nursing care required to help the client achieve an optimal level of health.
Bulechek define nursing interventions as any direct care treatment that a nurse performs on behalf
of a client. These treatments include nurse- initiated treatments resulting from medical diagnoses
and performance of the daily essential functions for the client who that cannot do these.

IMPLEMENTATION SKILLS
The implementation phase of the nursing process draws heavily on the intellectual, interpersonal,
and technical skills of the nurse. These are also known as cognitive, affective and conative skills.
Decision making, observation, and communication are significant skills, enhancing the success of
action. These skills are utilized by the client, the nurse, nursing team members, and health team
members. Competence in intellectual, interpersonal and technical skills are required to carry out the
implementation phase.

Intellectual or Cognitive Skills

The intellectual skills used in implementation include problem solving, decision making, critical
thinking and teaching. To solve problems, nurses ask clients pertinent questions, discuss
alternatives, and open new ideas. To enrich the decision making abilities of clients, nurses give
them opportunities to choose which treatments are performed, when and in what sequence.
Teaching requires knowledge about teaching-learning principles and information to convey.

Interpersonal or Affective Skills

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The ability to work with others to accomplish goals is critical to nursing. Nurses use communiction
skills to carry out planned nursing interventions. Verbal and nonverbal communication skills are
utilized when you interact with the health care team. These skills are often crucial in the successful
implementation of nursing care. People often judge nurses not by their technical skills alone but by
whether they are kind, concerned and caring. The ability to use effective interpersonal skills when
communicating with physicians, social workers, and other personnel will also affect the success of
the implementation phase. It is essential that the nurses be able to use cognitive skills to solve
problems and make decisions and use interpersonal skills to implement those decisions.

Technical or Conative Skills

Psychomotor or technical skills are the third major category of skills used during implementation of
nursing care. These skills are used to carry out treatments and procedures. Nurses learn the specific
skills through clinical practice. Technical competence means being able to use equipment machines
and supplies in particular specialty. For example, nurses working in delivery rooms must be familiar
with foetal monitoring, positioning on delivery- room table, and neonatal resuscitation devices. On
the other hand, nurses working on medical units may need technical competence in using
hypothermia blankets, therapeutic beds or feeding pumps. Nurses often find that when technical
skills are unfamiliar, it is difficult to incorporate the cognitive and interpersonal components.

IMPLEMENTATION ACTIVITIES
The activities of implementation include the following:
 Reassessing.
 Setting priorities.
 Performing nursing intervention.
 Recording nursing actions.

Reassess
Assessing is carried out throughout the nursing process, whenever the nurse has contact with the
client. Just before implementing, the nurse must reassess whether the intervention is still needed
because a client's condition can change quickly and dramatically. For example, the client who
experiences pain may become quiet and withdraw from external stimuli. Recognizing such a
change, nurses can intervene, validate, and assist the client to become more comfortable. As they
initiate the nursing plan of care, nurses must ensure that the planned interventions are still relevant.

Set Priorities
Because a person's condition changes, priorities also may change. Priorities are based on
information collected during reassessment. When setting priorities, nurses rank nursing problems in
order of importance based on several factor.
 The client's condition.
 New information from reassessment.
 Time and resources available for nursing interventions.

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  Feedback from the client, family and health staff.
 The nurse's experience in assessing situations and setting priorities.
Priorities can be set every few minutes, hourly, daily, weekly or for longer periods. For example, in
the critical care unit, priorities may need to be set every few minutes for an unstable client with
multiple traumas.

Perform Nursing Interventions

Nurse carry out the nursing interventions listed on the nursing plan of care. If a nurse is caring for
several clients, he or she develops a schedule so that all clients are cared in a timely fashion.

Intervention for collaborative problems

Nurses manage collaborative problems using both nurse and physician prescribed interventions to
reducerisk of complications. Both types of interventions involve nursing judgment, because both
require legal mandates.

Record Actions
After carrying out nursing interventions, nurses record them in the client's health record. Each
institution determines the specific requirements for documentation and should prepare written
guidelines for the use of all forms.

TYPES OF NURSING INTERVENTIONS

Nursing intervention fall within three major categories: those using cognitive skills, those using
interpersonal skills and those using technical skills. Selection of the type of nursing intervention to
be used in client situations depends on the client's dysfunction and functional requirements.

1. Cognitive Interventions
Educational interventions
Nurses carry out educational nursing interventions by applying general principles about the teaching
and learning process. They develop teaching plans and provide instruction about health promotion
or specific health care problems and their management. The ability to teach clients requires
knowledge of normal anatomy and physiology, usual patterns of client response to health changes
and pathophysiology of the disease process. Once a nurse is aware of the client's readiness for
learning, he or she can implement outcome-based teaching plans, using instruction methods that
optimize successful outcomes.
Supervisory interventions
The term supervisory interventions are applied in the context of overseeing a client's overall care.
Supervisory nursing interventions include ensuring that other members of the nursing team carry
out specified aspects of the plan of care, and that those involved with the client or family show

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return demonstration of skills. Supervising the client or family in skill performance is essential, to
provide encouragement, give feedback about correct and incorrect performance and facilitate
introduction of new skills to be learned. Nurses include clients and family members in planning and
implementing initial care. They help clients and families begin to assume responsibility for self-
management.

2. Interpersonal Interventions
Coordinating interventions
Coordinating client activities serves many purposes. Coordination involves acting as a client
advocate, making referrals for follow-up care, collaborating with other health care team members
and ensuring that the client's schedule is therapeutic. In the advocacy role, the nurse presents the
client's point of view and suggests ways in which the client's requests can be met. Nurses are in a
position to know what type of nursing follow-up clients need. They make referrals to home health
agencies, visiting nurse associations or other health care providers to facilitate return to optimal
function.

3. Supportive interventions
Supportive nursing interventions emphasize use of communication skills, relief of spiritual distress
and caring behaviours. A combination of good communication and caring provides comfort and
promotes a healthy response to health problems. Nurses provide spiritual support by giving clients
time to carry out religious practices, meditate or read. Respecting the client's privacy during these
times conveys acceptance and understanding.

4. Psychosocial interventions
Psychosocial nursing interventions focus on resolving emotional, psychological or social problems.
Humour, exploring feelings are all ways of carrying out psychosocial nursing interventions.
Providing individual and group therapy is the nurse's responsibility in various setting. For example,
individual therapy is used as a means of resolving psychological problems and group therapy is
used to provide support and guidance for clients with similar needs or problems.

5. Technical Interventions
Maintenance interventions
Maintenance nursing interventions help clients retain a certain state of health, preventing
deterioration of physical or psychological functioning and preserving independence. Maintenance
interventions include basic hygiene, skin care and other routine nursing activities.
Surveillance interventions
Surveillance nursing interventions include detecting changes from baseline data and recognizing
abnormal responses. This activity also can be categorized as observation, inspection or vigilance.
Nurses rely on the senses to detect changes: observing the appearance and characteristics of client;
hearing by auscultation,; detecting odours and comparing them with past experiences and using
touch to assess body temperature and skin condition. Nurses use all these surveillance activities to
determine the status of clients and changes from previous states.

6. Psychomotor interventions
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Psychomotor nursing interventions-those requiring technical expertise-include inserting, removing,
changing, applying, administering, cleansing or any other activity that requires a psychomotor
action. The management and care of equipment, supplies, treatments and procedures also falls into
this category of nursing interventions nurses gain technical competence through practice.

Responsibilities in Implementation of Nursing Care

It is the professional responsibility to carry out the nursing care as the primary nurse, delegate
certain interventions to appropriate nursing or allied health professionals and carry out physician
orders, thereby integrating medical therapy into overall care plan. Nursing care is implemented to
assist people in achieving the outcomes established in the plan of care, to prevent disease and illness
by promoting wellness, to restore functioning and to facilitate coping with illness.
The major responsibilities in implementing nursing care include:
 Reviewing the planned interventions for appropriateness.
 Scheduling and organizing the interventions.
 Collaborating with other team members.
 Achievement of the organizational and client care goals. .
 Providing direct nursing care.
 Providing counselling.
 Involving the client in health care.
 Teaching the client and family.
 Making referrals to other health care professionals.
 Documenting nursing care provided.

REVIEWING THE PLANNED INTERVENTIONS FOR

APPROPRIATENESS
The first phase of implementation involves reviewing the planned interventions. Cognitive skills are
used to choose the appropriate nursing interventions. Developing a plan of action is a two-step
process.

1. Develop interventions
Interventions are generated through processing information and using creativity. The
considerationof numerous interventions results in a creative solution to the diagnosis. The specific
ways in which interventions are developed
 Recall ways in which you handled a similar nursing diagnosis in past.
 Consider the nursing diagnosis from various angles and in different ways.
 Imagine how you would ideally like to see the nursing diagnosis resolved.
 Discuss the interventions with the person and family, hear their ideas on solutions to
resolving the nursing diagnosis.
 Talk with colleague, or meet with a group of colleagues, and brainstorm possible solutions
to the diagnosis.
 Obtain expert advice and recommendations.
 Review current literature.

2. Select the best intervention

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The next step is to analyse the interventions and choose the one that seems best. In most nursing
care situations, the best approach is the one promising the greatest benefit with the least risk. To
select such an intervention, systematically examine all the available options. Ask yourself the
following questions and try to answer them objectively:
 Has this type of intervention been used before in a similar situation? If so, what were the
results?
 Will this particular intervention enable the person to meet outcomes within proposed time
limits?
 Does this intervention take into consideration the person's, age, sex, lifestyle, attitudes,
religious and cultural traditions, social resources, and coping abilities?
 Is this intervention acceptable to the individual and family?
 Is the intervention realistic? Are equipment, staff time, staff size and other resources
adequate?
 What might be some undesirable consequences if this intervention is selected? Would this
particular solution bring more problems in its wake?

3. Scheduling and organizing the interventions

Specific coordinating activities include meeting with other health care team members to plan and
organize care, scheduling the person's activities (scheduling appointment with dietitian, determining
the best time for physical or occupational therapy), discussing the person's progress, consulting with
the physician, arranging for discharge and long term needs. Scheduling and coordinating nursing
care requires time management skills. You will be involved in balancing the requirements of several
people, including several patients and health care practitioners. As you become more comfortable
with providing nursing care, you will be better able to organize your day and address the needs of
many people.

4. Collaborating with other team members

One should not be the primary nurse for every person in your clinical area. Therefore,
communication with and collaboration among team members are essential. These valuable resource
people are nurses prepared at the master's level who possess expertise in specific clinical specialties.
Staff nurses should also consult each other as professional colleagues, so that nursing as a
profession is strengthened. Collaboration with other professional nurse also improves the quality of
nursing care.

5. Supervising and delegating nursing care by other members of the nursing

team
As a professional, nurse will delegate appropriate responsibilities to the person, significant others
and other team members. The delegation of nursing care is based on six elements, as defined by the
Joint Commission of Accreditation of Health care Organizations.
 The complexity of the individual's condition and nursing care needs.
 The stability of the person's status.
 The complexity of the assessment required to care for the person properly, including the
knowledge and skills needed by the nursing staff member in order to complete the
assessment.

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  The type of technology or equipment employed in providing nursing care.
 The degree of supervision required by the nursing staff member based on the nurse's level of
competence.
 The availability of supervision.
Delegation of nursing care also depends on the job description and legal limitations of the scope of
practice of other team members. For example, a registered nurse could not ask a nursing assistant to
give a dose of intravenous medication.

6. Achieving of the organizational and client care goals

The nursing team carries out the nursing orders detailed in the nursing plan of care. If the plan of
care is well constructed, carrying out its orders is the most important task and should receive top
priority. The nursing actions planned to promote client goal or outcome achievement and the
resolution of health problems should be carefully executed. As the quality care provided to clients
and achieve the client's goals, ultimately the organizational goals are achieved.

7. Providing direct nursing care

The nursing interventions may be independent or interdependent. They may also be dependent and
is carried out based on the physician's orders e.g. medication administration, providing IV fluids
etc. In some instances, there are standing orders that direct the care of the client. Standing orders are
typically developed when the facility is caring for a group of people with clearly identified and
anticipated needs. Both dependent interventions and standing orders must be evaluated carefully to
be sure they are appropriate for the person. Nurses are legally responsible for questioning
physician's orders that are inappropriate or inaccurate.

8. Providing counselling
Counselling helps individuals with long-term chronic illness and disabilities to come to terms with
their condition. In this case, encourage people to verbalize fears or concerns by establishing a warm,
nonthreatening atmosphere. Counselling also involves helping people cope successfully as they pass
through the various developmentalstages of a normal life. In this case, the counsellor not only
discusses the person's problems but also talks about many normal changes that occur during
different developmental stages.

9. Involving the client in health care

There is a strong trend towards offering the client choices to enhance the acceptability of the
outcomes and interventions. The degree considered necessary or desirable by the client, family
members have a right to be informed about and involved in the provision of nursing care.

10. Teaching the client and family

Teaching is a vital part of implementing the care plan and promoting change. Nurses assume the
role of teacher when clients have identifiable learning needs. It helps clients and family to develop
the self-care abilities that enable them to maximize their functioning and quality of life.

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11. Making referrals to other health care professionals
Most health care agencies have a referral procedure to simplify the transfer of information from one
health care facility or department to another. Referrals are written on special forms, made over the
phone, or requested in person. Clients are typically referred to dietitians, social workers,
psychiatrists, physical and occupational therapists, and various organizations.

12. Documenting nursing care provided

During and after implementation of care nurse will record information in the medical record. This
information includes data, observations, interventions and evaluation of the effectiveness of care.

EVALUATION
As a part of professional accountability, nurses are answerable to themselves as practitioners, to
individuals and significant others, to physicians and others who participate in giving care, to
agencies in which they practice, and to the community. The use of evaluation helps fulfil the nurse's
duty to act in a professionally responsible way.

Definition
To evaluate is TO JUDGE or TO APPRAISE.
Evaluation is a planned, ongoing, purposeful activity, in which client and health care professionals
determine
1) The client's progress towards goal achievement.
2) The effectiveness of nursing care plan.
Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based
on the client's behavioural responses. This phase involves a thorough, systematic review of the
effectiveness of nursing interventions and a determination of client goal achievement. Nurses use a
variety of skills to judge the effectiveness of nursing care. These skills include knowledge of
standards of care, normal client responses, and conceptual models and theories of nursing; ability to
monitor the effectiveness of nursing interventions; and awareness of clinical research. Critical
appraisal of goal attainment is determined jointly by the nurse and the client.

DIFFERENCE BETWEEN ASSESSMENT AND EVALUATION

Assessment involves data gathering for the purpose of deriving a nursing diagnosis and forming a
plan. Therefore, the assessment phase consists of gathering information about the existing problems
and strengths of the person. The evaluation step of nursing process uses your knowledge and skills
to make a clinical judgment about the achievement of outcomes. During Evaluation, you compare
the current status of the person with the expected outcome. When you evaluate the person, you
make a decision about how well the person achieved the outcome and whether the plan of care
should be continued, modified, or discontinued.

PURPOSES

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  To collect the objective and subjective data to make judgments about nursing care delivered.
 To examine the client's behavioural responses to nursing interventions.
 To compare the client's behavioural responses with predetermined outcome criteria.
 To appraise the extent to which client goals were attained or problems resolved.
 To appraise involvement and collaboration of the client, family members, nurses, and health
care team members in health care decisions.
 To provide a basis for the revision of the nursing plan of the care evaluation.
 To monitor the quality of nursing care and its effect on the client's health status.
TYPES
There are three types of evaluation:

i. Structure Evaluation
Structure evaluation focuses on the attributes of the setting or surroundings where health care is
provided. It deals with the environmental aspects that directly or indirectly influence the quality of
care provided. Availability of equipment, layout of physical facilities, nurse- client ratios,
administrative support, and maintenance of nursing staff competence are some areas of concern for
structure evaluation.

ii. Process Evaluation

Process evaluation focuses on the nurse's performance and whether the nursing care provided was
appropriate and competent. The phases of the nursing process are used as the framework for the
evaluation of nursing care. Areas of concern for this type of evaluation include the type of
information obtained by interview and physical assessment, the validity of the nursing diagnostic
statements, and the nurse's technical competence.

iii. Outcome Evaluation

Outcome evaluation, which focuses on the client and the client's function. Outcome evaluation
determines the extent to which the client's behavioral response to nursing interventionreflects the
desired client goal and outcome criteria. Outcome evaluation can take place only after standards
have been developed. An example of an outcome evaluation is to establish standards of care for a
specific diagnosis and then compare actual client outcome with that standard.

EVALUATION MAY ALSO BE ONGOING, INTERMITTENT, OR

TERMINAL:
i. Ongoing Evaluation
Ongoing evaluation is done while or immediately after implementing a nursing order, it enables the
nurse to make on the spot modifications in an intervention.

ii. Intermittent Evaluation

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It is performed at specified intervals (e.g. Once a week). It shows the extent of progress towards
goal achievement and enables the nurse to correct any deficiencies and modify the care plan as
needed. Evaluation continues (either ongoing or intermittently) until the client achieve the health
goals or is discharged from nursing care.

iii. Terminal Evaluation

It indicates the client's condition at the time of discharge. It includes the status of goal achievement
and an evaluation of the client's self care abilities with regard to follow-up care. Most agencies have
a special discharge record for the terminal evaluation.
Evaluation: The final phase of the nursing process, in which the nurse determines the client's
progress toward goal/outcome achievement and the effectiveness of the nursing care plan.

REVIEW CLIENT GOALS AND OUTCOME CRITERIA

Measuring goal attainment starts by reviewing the client goals and outcome criteria, written in
measurable terms that were developed from each nursing diagnosis. Nurses' review expected client
behaviour by examining the time frames and methods of measurement of goal fulfilment. They
evaluate client goals and outcome criteria in a variety of ways, including observing client
behaviours, using documentation of the client's responses to interventions, and receiving feedback
from the client, family members, and other health care providers, if appropriate. This review helps
nurses focus on data they need to assess the accuracy and realistic nature of goals and outcome
criteria.

Collect Data
Systematic data collection is required to determine goal achievement. Subjective data are collected
from any sources: The client, family members or significant others, nursing staff, and other health
care team members. Objective data from observation (e.g. posture, skin, colour, and behaviour),
health records (e.g. laboratory results, reports from other health care team members), physical
assessment (e.g. breath sounds, strength of extremities) and measurement devices (e.g. blood

41
pressure, temperature) are collected to judge the client's behavioural responses to nursing
interventions. Nurses also use subjective data to evaluate the effectiveness of nursing care provided.
E.g. a client with a nursing diagnosis of Acute Pain related to a recent surgical procedure may
haveas a goal, -Client will state that pain is relieved within 10 minutes after repositioning. The
client's subjective statement would be needed to judge whether this goal has been achieved or not.

Measure Goal or Outcome Achievement

After collecting data, nurses form a comprehensive picture of the client's behavioural responses to
nursing interventions. The next activity is to make a judgment about goal attainment by comparing
the client's actual behavioural responses to the predicted responses or predetermined outcome
criteria developed in the planning phase. When possible, the client is involved.
 The four possible judgments that may be made are as following:
 The goal was completely met.
 The goal was partially met.
 The goal was completely unmet.
 New problems or nursing diagnosis have developed.
The fourth judgment can exist simultaneously with any of first three. Once the judgment about the
attainment or lack of attainment of outcome criteria is made, the plan of care is revised.

Assess Facilitators of Goal Attainment

Clients, family members, significant others and other health care team members are invaluable in
facilitating or helping with goal attainment. Occasionally, only those closest to the client can
identify the subtle or elusive factors that helped or hindered goal achievement. Examples of
facilitators include audio visual materials, written handouts, repetition of material, and easily
accessible and interested nursing staff.

Assess Barriers to Goal Attainment

Several barriers to goal attainment have been identified. Barriers may involve the client, family
members or significant others, and the nurse or other health care team members. Examples of how
goal attainment may be blocked include providing incorrect information, with holding information,
having an unexpected reaction to treatment (e.g. allergic response to therapy), possessing
inadequate coping ability, and experiencing a worsened underlying pathologic condition. Family
members also may act as barriers to goal achievement in many ways. E.g. their lack of
understanding the plan of care, lack of interest in theclient etc. Nurses may unwillingly block goal
achievement.
E.g. By neglecting to collect pertinent assessment data, delegating nursing care to inappropriate
nursing staff members. Other health care team members also may be barriers. They may lack
communication among themselves, be unable to work together as a team. The evaluation phase
identifies the barriers that are interfering with the client's advancement towards goal achievement.

Record Judgment or Measurement of Goal Attainment

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Written documentation of the subjective and objective data gathered and the judgment made about
goal attainment is required on the client's health record. Judgment about goal attainment is written
clearly and concisely

Revise or Modify the Nursing Care Plan

Revision or modification of the nursing plan of care is part of evaluation phase. It provides a
feedback mechanism that starts the entire chain of events again. Nursing diagnoses that are resolved
require no further nursing intervention and may be removed from the nursing plan of care. To
maintain the client's problem free status, a nursing plan of care is developed that incorporates
potential for wellness and other health promoting nursing diagnosis and focuses nursing actions
towards maximal functioning. The levels of functioning and health status changes are periodically
reassessed to determine whether new problems or nursing diagnosis have developed.

CONCLUSION
The nursing process is the best way to provide care to the patients. Adoption of nursing process
enable nurses to safe guard her patient's life.

BIBLIOGRAPHY
 Kaur Brar N & Rawat HC. Textbook of Advanced Nursing Practice. 1 st ed. New Delhi:
Jaypee Brothers; 2015.page no. 60-65.
 Basheer SP and Khan SY. A Concise Text Book of Advanced Nursing Practice. 2 nd ed.
Bangalore: Emmess Medical Publishers; 2020. page no. 474-504.
 Potter PA and Perry AG. Fundamental of Nusing. 6th ed. Elsevier Publishers. page no. 569-
589
 Soni S. Textbook Of Advance Nursing Practice. 1st ed. Bangalore: Jaypee Medical
Publisher; 2013 . page no. 120.
 Babu. B. Nursing Process [Online]2016 Mar. 10 [cited on 2021 Dec. 08]; [83 slideshare]
available from: URL: https://www.slideshare.net>nursing...
 Manikandan T. Nursing Process [Online] 2019 Nov. 20 [cited on 2021 Dec. 09]; [173
screen] available from: URL: https://www.slideshare.net>nursing..

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