HEALTH ASSESSMENT | NCM 101
NURSES ROLE IN HEALTH ASSESSMENT AND NURSING PROCESS
INTRODUCTION
A. INTRODUCTION TO HEALTH ASSESSMENT IN NURSING
• American Nurses Association (ANA) defines nursing as “the
protection, promotion, and optimization of health and abilities,
prevention of illness and injury, alleviation of suffering through
the diagnosis and treatment of human responses and advocacy
in the care of individuals, families, communities and
populations.”
• Emphasis is placed on “diagnosis and treatment of human
responses” based on “accurate client assessments,” including
how effective nursing interventions are “to promote health and
prevent illness and injury.”
B. TO ACCOMPLISH THIS PERTINENT AND COMPREHENSIVE
DATA COLLECTION, THE NURSE:
• Collects data in a systematic and ongoing process.
• Involves the patient, family, other health care providers (HCP),
and environment, as appropriate, in holistic data collection.
• Prioritizes data collection activities based on the patient’s
immediate condition, or anticipated needs of the patient or
situation.
• Uses appropriate evidence-based assessment techniques and
instruments in collecting pertinent data.
• Uses analytical models and problem-solving tools.
• Synthesizes available data, information, and knowledge relevant
to the situation to identify patterns and variances.
• Documents relevant data in a retrievable format.
C.CRITICAL THINKING AND CLINICAL REASONING
• The practice of nursing requires critical thinking and clinical
reasoning.
A. Critical thinking
- Process of intentional higher-level thinking to define a
client’s problem, examine the evidence-based
practice in caring for the client, and make choices in
the delivery of care.
B. Clinical reasoning
- Cognitive process that uses thinking strategies to
gather and analyze client information, evaluate the
relevance of the information, and decide on possible
nursing actions to improve the client’s physiologic and
psychosocial outcomes.
D. CRITICAL THINKING
• Purpose of Critical Thinking
o Critical thinking involves the differentiation of statements
of fact, judgment, and opinion.
o The process of critical thinking requires the nurse to think
ahead, to apply thinking while acting, and think back,
known as reflective thinking.
o In critical thinking, a nurse critiques his or her thoughts to
ascertain an appropriate outcome.
• Nurses use critical thinking skills in a variety of ways:
1. Nurses use knowledge from other subjects and fields.
2. Nurses deal with change in stressful environments.
3. Nurses make important decisions.
• Critical thinking cognitively fuels the intellectual, artistic activity
of creativity. When nurses incorporate creativity, they are able
to find unique solutions to unique problems.
o Creativity is thinking that results in the development of
new ideas and products.
• Applying Critical Thinking to Nursing Practice
1. Problem Solving
- A mental activity in which a problem is identified that
represents an unsteady state.
- The nurse carefully evaluates the possible solutions
and chooses the best one to implement.
- Commonly used approaches to problem-solving
include trial and error, intuition, and research process.
A. Trial and Error
- A number of approaches are tried until a
solution is found.
- Can be dangerous because the client might
suffer harm if an approach is inappropriate.
B. Intuition
- A problem-solving approach that relies on a
nurse’s inner sense.
- It is the understanding or learning of things
without the conscious use of reasoning.
- It is also known as sixth sense, hunch,
instinct, feeling, or suspicion.
- Clinical experience allows the nurse to
recognize cues and patterns and begin to
reach correct conclusions.
C. Research Process
- A formalized, logical, systematic approach
to problem-solving.
• Attitudes That Foster Critical Thinking
- A critical thinker works to develop the following nine
attitudes or traits:
1. Independence
- Nurses are open-minded about considering
different methods of performing technical skills –
not just the single way they may have been
taught in school.
2. Fair-Mindedness
- Critical thinkers are fair-minded and make
impartial judgments and do not base their
judgments on personal or group bias or
prejudice.
3. Insight and Egocentricity
- Critical thinkers are open to the possibility that
their personal biases or social pressures and
customs could unduly affect their thinking.
4. Intellectual Humility
- Intellectual humility means having an awareness
of the limits of one’s own knowledge.
- Critical thinkers are willing to admit what they do
not know; they are willing to seek new
information and to rethink their conclusions in
light of new knowledge.
5. Intellectual Courage to Challenge the Status Quo and
Rituals
- With an attitude of courage, a nurse is willing to
consider and examine fairly his or her own ideas
or views, especially those to which the nurse
may have a strongly negative reaction.
6. Integrity
- Intellectual integrity requires that individuals
apply the same rigorous standards of proof to
their own knowledge and beliefs as they apply to
the knowledge and beliefs of others.
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7. Perseverance
- Nurses who are critical thinkers show
perseverance in finding effective solutions to
client and nursing problems.
8. Confidence
- Critical thinkers believe that well-reasoned
thinking will lead to trustworthy conclusions.
9. Curiosity
- The mind of the critical thinker is filled with
questions: Why do we believe this? What causes
that? Does it have to be this way? Could
something else work?
NURSING PROCESS
• First used and mentioned by Lydia Hall in 1955 introducing the
3 steps: OBSERVATION, ADMINISTRATION and VALIDATION.
• It is a systematic, organized method of planning, and providing
quality and individualized nursing care.
• It is synonymous with the PROBLEM-SOLVING APPROACH that
directs the nurse and the client to determine the need for
nursing care, to plan and implement the care and evaluate
result.
• It is GOSH approach (goal-oriented, organized, systematic and
humanistic care) for efficient and effective provision of nursing
care.
•
1ST STEP: ASSESSMENT
• An orderly collection of information concerning the patient’s
health status.
• The 1st and most critical phase of the nursing process.
• If data collection is inadequate or inaccurate, incorrect nursing
judgments may be made that adversely affect the remaining
phases of the process.
• Be aware that assessment is ONGOING and CONTINUOUS
throughout all phases of the nursing process.
• It is analyzing and synthesizing the data, making judgments
about the effectiveness of nursing interventions, and evaluating
client care outcomes.
FOCUS OF HEALTH ASSESSMENT IN NURSING
• A comprehensive HA consists of both a health history and
physical examination.
• The purpose of nursing HA is to collect holistic subjective and
objective data to determine a client’s overall level of
functioning to make a professional clinical judgment.
• The nurse focuses on how the client’s health status affects
activities of daily living (ADLs) and how those ADLs affect the
client’s health.
• In contrast, the physician performing a medical assessment
focuses primarily on the client’s physiologic status.
TYPES OF ASSESSMENT
STEPS OF HEALTH ASSESSMENT
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data
A. COLLECTING DATA
• Data collection is the process of gathering information about a
client’s health status. Data collection must be both systematic
and continuous to prevent the omission of significant data and
reflect a client’s changing health status.
• A database contains all the information about a client; it
includes the nursing health history, physical assessment,
primary care provider’s history and physical examination,
results of laboratory and diagnostic tests, and material
contributed by other health personnel.
• Client data should include past history as well as current
problems. Current data relate to present circumstances, such as
pain, nausea, sleep patterns, and religious practices. To collect
data accurately, both the client and nurse must actively
participate.
o TYPES OF DATA:
1. Subjective data (symptoms or covert data)
- Apparent only to the person affected and can be
described or verified only by that person.
- Itching, pain, and feelings of worry are examples
of subjective data.
- Includes the client’s sensations, feelings, values,
beliefs, attitudes, and perception of personal
health status and life situation.
2. Objective data (signs or overt data)
- Detectable by an observer or can be measured
or tested against an accepted standard.
- They can be seen, heard, felt, or smelled, and
they frequently, or rarely and include such data
as blood pressure, level of pain, and age.
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- A complete database provides a baseline for
comparing the client’s responses to nursing and
medical interventions.
o COLLECTING SUBJECTIVE DATA
- Major areas include:
1. Biographical information (name, age, religion,
occupation)
2. History of present health concern: Physical
symptoms related to each body part or system
3. Personal health history
4. Family history
5. Health and lifestyle practices (health practices
that put the client at risk, nutrition, activity,
relationships, cultural beliefs or practices, family
structure and function, community environment
o COLLECTING OBJECTIVE DATA
- These data include:
1. Physical characteristics (skin, color, posture)
2. Body functions (heart rate, respiratory rate)
3. Appearance (dress and hygiene)
4. Behavior (mood, affect)
5. Measurements (BP, temperature, height, weight)
6. Results of laboratory testing (platelet count, x-ray
findings)
o SOURCES OF DATA
- Sources of data are primary or secondary.
- The client is the primary source of data.
- Family members or other support persons, other
health professionals, records and reports, laboratory
and diagnostic analyses, and relevant literature are
secondary or indirect sources.
- All sources other than the client are considered
secondary sources.
- All data from secondary sources should be validated
if possible.
a. CLIENT
- The best source of data is usually the client,
unless the client is too ill, young, or
confused to communicate clearly.
- In the acute care setting, nurse–client
relationships will develop due to the close
and frequent contact with the client.
- They can provide subjective data that no
one else can offer.
- Most often, primary data consist of
statements made by the client but also
include those objective data that can be
directly obtained by the nurse from the
client such as gender.
- Some clients cannot or do not wish to
provide accurate data. Family members or
significant others can be secondary sources
of data if the client cannot speak for
themselves, is a poor historian, or is a young
child.
- If the client is hesitant to provide data,
remind the client that the privacy of all data
collected is protected and can only be
shared with persons who have a legitimate
health-related need to know it.
- If necessary, review for yourself the
mandates of the Health Insurance
Portability and Accountability Act of 1996
(HIPAA) so you can explain this in a way that
the client can understand.
b. SUPPORT PEOPLE
- Family members, friends, and caregivers
who know the client well often can
supplement or verify information provided
by the client.
- They might convey information about the
client’s response to illness, the stresses the
client was experiencing before the illness,
family attitudes on illness and health, and
the client’s home environment.
- Support people are an especially important
source of data for a client who is very
young, unconscious, or confused.
- Before eliciting data from support people,
the nurse should ensure that the client, if
mentally able, authorizes such input.
- The nurse should also indicate on the
nursing history that the data were obtained
from a support person.
- Information supplied by family members,
significant others, or other health
professionals is considered subjective if it is
not based on act. If the client’s daughter
says, “Dad is very confused today,” that is
secondary subjective data because it is an
interpretation of the client’s behavior by the
daughter. The nurse should attempt to
verify the reported confusion by
interviewing the client directly. However, if
the daughter says, “Dad said he thought it
was the year 1941 today,” that may be
considered secondary objective data since
the daughter heard her father state this
directly.
c. CLIENT RECORDS
- Client records include information
documented by various health care
professionals.
- Client records also contain data regarding
the client’s occupation, religion, and marital
status.
- By reviewing such records before
interviewing the client, the nurse can avoid
asking questions for which answers have
already been supplied.
- Repeated questioning can be stressful and
annoying to clients and cause concern
about the lack of communication among
health professionals.
• TYPES OF CLIENT RECORDS:
1. Medical records
2. Records of therapies
3. Laboratory records
• Medical records (e.g., medical history,
physical examination, operative report,
progress notes, and consultations done
by primary care providers) are often a
source of a client’s present and past
health and illness patterns.
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• These records can provide nurses with
information about the client’s coping behaviors,
health practices, previous illnesses, and allergies.
• Records of therapies provided by other health
professionals, such as social workers,
nutritionists, dietitians, or physical therapists,
help the nurse obtain relevant data not
expressed by the client.
• Laboratory records also provide pertinent health
information.
• For example, the determination of blood glucose
level allows health professionals to monitor the
administration of oral hypoglycemic medications.
• Any laboratory data about a client must be
compared to the agency or performing
laboratory’s norms for that particular test and for
the client’s age, gender, and other
characteristics.
• The nurse must always consider the information
in client records in light of the current situation.
d. HEALTH CARE PROFESSIONALS
- Because assessment is an ongoing process,
verbal reports from other health care
professionals serve as other potential
sources of information about a client’s
health.
- Nurses, social workers, primary care
providers, and physiotherapists, for
example, may have information from either
previous or current contact with the client.
- Sharing of information among professionals
is especially important to ensure continuity
of care when clients are transferred to and
from home and health care agencies.
e. LITERATURE
- The review of nursing and related literature,
such as professional journals and reference
texts, can provide additional information for
the database. A literature review includes
but is not limited to the following
information:
✓ Standards or norms against which to
compare findings (e.g., height and
weight tables, normal developmental
tasks for an age group)
✓ Cultural and social health practices
✓ Spiritual beliefs
✓ Assessment data needed for specific
client conditions
✓ Nursing interventions and evaluation
criteria relevant to a client’s health
problems
✓ Information about medical diagnoses,
treatment, and prognoses
✓ Current methodologies and research
findings
o DATA COLLECTION METHODS
- The principal methods used to collect data are
observing, interviewing, and examining.
- Observing occurs whenever the nurse is in contact
with the client or support persons.
- Interviewing is used mainly while taking the nursing
health history.
- Examining is the major method used in the physical
health assessment.
- In reality, the nurse uses all three methods
simultaneously when assessing clients. For example,
during the client interview the nurse observes, listens,
asks questions, and mentally retains information to
explore in the physical examination.
1. OBSERVING
- To observe is to gather data by using the
senses. Observing is a conscious, deliberate
skill that is developed through effort and
with an organized approach.
- Although nurses observe mainly through
sight, most of the senses are engaged
during careful observations.
- Observing has two aspects: (a) noticing the
data and (b) selecting, organizing, and
interpreting the data. A nurse who observes
that a client’s face is flushed must relate
that observation to findings such as body
temperature, activity, environmental
temperature, and blood pressure.
- Errors can occur in selecting, organizing,
and interpreting data.
- Nursing observations must be organized so
that nothing significant is missed. Most
nurses develop a particular sequence for
observing events, usually focusing on the
client first. For example, a nurse walks into a
client’s room and observes, in the following
order:
1. Clinical signs of client distress (e.g.,
pallor or flushing, labored breathing,
and behavior indicating pain or
emotional distress)
2. Threats to the client’s safety, real or
anticipated (e.g., a lowered side rail)
3. The presence and functioning of
associated equipment (e.g.,
intravenous equipment and oxygen)
4. The immediate environment, including
the people in it.
2. INTERVIEWING
- An interview is a planned communication or
a conversation with a purpose, for example,
to get or give information, identify problems
of mutual concern, evaluate change, teach,
provide support, or provide counseling or
therapy.
- One example of the interview is the nursing
health history, which is a part of the nursing
admission assessment. In a focused
interview the nurse asks the client specific
questions to collect information related to
the client’s problem. This allows the nurse
to collect information that may have
previously been missed and yields more in-
depth information.
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NURSES ROLE IN HEALTH ASSESSMENT AND NURSING PROCESS

3. EXAMINING influence levels of wellness. Such models generally

- The physical examination or physical include the following:
assessment is a systematic data collection ✓ Health history
method that uses observation (i.e., the ✓ Physical fitness evaluation
senses of sight, hearing, smell, and touch) ✓ Nutritional assessment
to detect health problems. ✓ Life-stress analysis
- To conduct the examination, the nurse uses ✓ Lifestyle and health habits
techniques of inspection, auscultation, ✓ Health beliefs
palpation, and percussion. ✓ Sexual health
- The physical examination is carried out ✓ Spiritual health
systematically. It may be organized ✓ Relationships
according to the examiner’s preference, in a ✓ Health risk appraisal
head-to-toe approach or a body systems o NONNURSING MODELS
approach. - Frameworks and models from other disciplines may
- Usually, the nurse first records a general also be helpful for organizing data. These frameworks
impression about the client’s overall are narrower than the model required in nursing;
appearance and health status: for example, therefore, the nurse usually needs to combine these
age, body size, mental and nutritional with other approaches to obtain a complete history.
status, speech, and behavior. Then the A. BODY SYSTEMS MODEL
nurse takes such measurements as vital - The body systems model focuses on
signs, height, and weight. abnormalities of the following anatomic systems:
B. ORGANIZING DATA 1. Integumentary system
• The nurse uses a written (or electronic) format that organizes 2. Respiratory system
the assessment data systematically. This is often referred to as a 3. Cardiovascular system
nursing health history, nursing assessment, or nursing database 4. Nervous system
5. Musculoskeletal system
form.
6. Gastrointestinal system
• The format may be modified according to the client’s physical
7. Genitourinary system
status such as one focused on musculoskeletal data for
8. Reproductive system
orthopedic clients.
9. Immune system
o CONCEPTUAL MODELS/FRAMEWORKS
B. MASLOW’S HIERARCHY OF NEEDS
- Most schools of nursing and health care agencies
- Maslow’s hierarchy of needs clusters data
have developed their own structured assessment
pertaining to the following:
format. Many of these are based on selected nursing
1. Physiological needs (survival needs)
models or frameworks Three examples are Gordon’s
2. Safety and security needs
functional health pattern framework, Orem’s self-
3. Love and belonging needs
care model, and Roy’s adaptation model.
4. Self-esteem needs
- Gordon provides a framework of 11 functional health
5. Self-actualization needs.
patterns. The eleven functional health patterns are
C. DEVELOPMENTAL THEORIES
health perception and management, nutritional,
- Several physical, psychosocial, cognitive, and
metabolic, elimination, activity, sleep, cognitive, self-
moral developmental theories may be used by
perception and concept, role relationship, sexuality,
the nurse in specific situations. Examples include
coping and stress, and value belief systems.
the following:
- Gordon uses the word pattern to signify a sequence
1. Havighurst’s age periods and developmental
of recurring behavior. The nurse collects data about
tasks
dysfunctional as well as functional behavior. Thus, by
2. Freud’s five stages of development
using Gordon’s framework to organize data, nurses
3. Erikson’s eight stages of development
are able to discern emerging patterns.
4. Piaget’s phases of cognitive development
- Orem’s self-care model delineates eight universal
5. Kohlberg’s stages of moral development.
self-care requisites of humans. The model describes
the client’s need for adequate nutrition, normal C. VALIDATING ASSESSMENT DATA
elimination, and adequate rest to promote normal • Crucial part of assessment
human functioning and development. • It serves to ensure that the assessment process is not ended
- Roy outlines the data to be collected according to the before all relevant data have been collected, and helps to
Roy adaptation model and classifies observable prevent documentation of inaccurate data.
behavior into four categories: physiological, self- D. DOCUMENTING DATA
concept, role function, and interdependence. • It forms the database for the entire nursing process and
o WELLNESS MODELS provides data for all other members of the health care team.
- Nurses use wellness models to assist clients to
• Thorough and accurate documentation is vital.
identify health risks and to explore lifestyle habits and
health behaviors, beliefs, values, and attitudes that
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NURSES ROLE IN HEALTH ASSESSMENT AND NURSING PROCESS
2ND STEP: NURSING DIAGNOSIS
• An orderly collection of information concerning the patient’s
health status.
• 2nd phase of the nursing process
• According to NANDA, it is a clinical judgment about individuals,
family or community responses to actual and potential health
problems and life processes.
• NANDA NURSING DIAGNOSES
- To use the concept of nursing diagnoses effectively in
generating and completing a nursing care plan, the
nurse must be familiar with the definitions of terms
used and the components of nursing diagnoses.
• DEFINITIONS
o Diagnosing refers to the reasoning process
o Diagnosis is a statement or conclusion regarding the
nature of a phenomenon.
o The standardized NANDA names for the diagnoses are
called diagnostic labels; and the client’s problem
statement, consisting of the diagnostic label plus
etiology (causal relationship between a problem and
its related or risk factors), is called a nursing
diagnosis.
STATUS OF THE NURSING DIAGNOSES
• “Status of the nursing diagnosis refers to the actuality or
potentiality of the problem/syndrome or the categorization of
the diagnosis as a health promotion diagnosis”.
• The kinds of nursing diagnoses according to status are actual,
health promotion, risk, and syndrome.
✓ An actual nursing diagnosis is a client problem that is
present at the time of the nursing assessment. Examples
are Ineffective Breathing Pattern and Anxiety. An actual
nursing diagnosis is based on the presence of associated
signs and symptoms.
✓ A health promotion diagnosis relates to clients’
preparedness to implement behaviors to improve their
health condition. These diagnosis labels begin with the
phrase Readiness for Enhanced, as in Readiness for
Enhanced Nutrition.
✓ A risk nursing diagnosis is a clinical judgment that a
problem does not exist, but the presence of risk factors
indicates that a problem is likely to develop unless nurses
intervene. For example, all people admitted to a hospital
have some possibility of acquiring an infection; however, a
client with diabetes or a compromised immune system is
at higher risk than others. Therefore, the nurse would
appropriately use the label Risk for Infection to describe
the client’s health status.
✓ A syndrome diagnosis is assigned by a nurse’s clinical
judgment to describe a cluster of nursing diagnoses that
have similar interventions.
COMPONENTS OF A NANDA NURSING DIAGNOSIS
• A nursing diagnosis has three components: (1) the problem and
its definition, (2) the etiology, and (3) the defining
characteristics. Each component serves a specific purpose.
1. PROBLEM (DIAGNOSTIC LABEL) AND DEFINITION
- The problem statement, or diagnostic label, describes
the client’s health problem or response for which
nursing therapy is given. It describes the client’s
health status clearly and concisely in a few words. The
purpose of the diagnostic label is to direct the
formation of client goals and desired outcomes. It
may also suggest some nursing interventions.
- To be clinically useful, diagnostic labels need to be
specific; when the word Specify follows a NANDA
label, the nurse states the area in which the problem
occurs, for example, Deficient Knowledge
(Medications) or Deficient Knowledge (Dietary
Adjustments).
o Qualifiers are words that have been added to
some NANDA labels to give additional meaning
to the diagnostic statement, for example:
a. Deficient (inadequate in amount, quality, or
degree; not sufficient; incomplete)
b. Impaired (made worse, weakened,
damaged, reduced, deteriorated)
c. Decreased (lesser in size, amount, or
degree)
d. Ineffective (not producing the desired
effect)
e. Compromised (to make vulnerable to
threat)
2. ETIOLOGY (RELATED FACTORS AND RISK FACTORS)
- The etiology component of a nursing diagnosis
identifies one or more probable causes of the health
problem, gives direction to the required nursing
therapy, and enables the nurse to individualize the
client’s care. Differentiating among possible causes in
the nursing diagnosis is essential because each may
require different nursing interventions.
- Each diagnostic label approved by NANDA carries a
definition that clarifies its meaning.
DIFFERENTIATING NURSING DIAGNOSES FROM MEDICAL
DIAGNOSES
• A nursing diagnosis is a statement of nursing judgment and
refers to a condition that nurses, by virtue of their education,
experience, and expertise, are licensed to treat. A medical
diagnosis is made by a physician and refers to a condition that
only a physician can treat.
• Medical diagnoses refer to disease processes—specific
pathophysiologic responses that are fairly uniform from one
client to another. In contrast, nursing diagnoses describe the
human response, a client’s physical, sociocultural,
psychological, and spiritual responses to an illness or a health
problem.
• A client’s medical diagnosis remains the same for as long as the
disease process is present, but nursing diagnoses change as the
client’s responses change.
FORMULATING DIAGNOSTIC STATEMENTS
• Most nursing diagnoses are written as two-part or three-part
statements, but there are variations of these.
A. BASIC TWO-PART STATEMENTS
- The basic two-part statement includes the following:
1. Problem (P): statement of the client’s response
(NANDA label)
2. Etiology (E): factors contributing to or probable
causes of the responses.
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B. BASIC THREE-PART STATEMENTS
- The basic three-part nursing diagnosis statement is
called the PES format and includes the following:
1. Problem (P): statement of the client’s response
(NANDA label)
2. Etiology (E): factors contributing to or probable
causes of the response.
3. Signs and symptoms (S): defining characteristics
manifested by the client.
STEPS IN DIAGNOSIS
1. Collecting information data collected in the assessment phase
2. Interpreting information
3. Clustering information the data are sorted in meaningful groups
according to NANDA’s HUMAN RESPONSE PATTERNS
4. Naming a cluster or problem formulation
3RD STEP: PLANNING
• The 3rd step of the nursing process that involves the
participation of nursing diagnoses and care and the selection of
nursing intervention.
• Planning is a deliberative, systematic phase of the nursing
process that involves decision making and problem solving.
• In planning, the nurse refers to the client’s assessment data and
diagnostic statements for direction in formulating client goals
and designing the nursing interventions required to prevent,
reduce, or eliminate the client’s health problems.
• Although planning is basically the nurse’s responsibility, input
from the client and support persons is essential if a plan is to be
effective.
• Nurses do not plan for the client, but encourage the client to
participate actively to the extent possible. In a home setting,
the client’s support people and caregivers are the ones who
implement the plan of care; thus, its effectiveness depends
largely on them.
TYPES OF PLANNING
• Planning begins with the first client contact and continues until
the nurse–client relationship ends, usually when the client is
discharged from the health care agency.
• All planning is multidisciplinary (involves all health care
providers interacting with the client) and includes the client and
family to the fullest extent possible in every step.
1. Initial Planning
- The nurse who performs the admission assessment
usually develops the initial comprehensive plan of
care.
- This nurse has the benefit of seeing the client’s body
language and can also gather some intuitive kinds of
information that are not available solely from the
written database.
- Planning should be initiated as soon as possible after
the initial assessment.
2. Ongoing Planning
- All nurses who work with the client do ongoing
planning. As nurses obtain new information and
evaluate the client’s responses to care, they can
individualize the initial care plan further. Ongoing
planning also occurs at the beginning of a shift as the
nurse plans the care to be given that day. Using
ongoing assessment data, the nurse carries out daily
planning for the following purposes:
• To determine whether the client’s health status
has changed
• To set priorities for the client’s care during the
shift
• To decide which problems to focus on during the
shift
• To coordinate the nurse’s activities so that more
than one problem can be addressed at each
client contact.
3. Discharge Planning
- Discharge planning, the process of anticipating and
planning for needs after discharge, is a crucial part of
a comprehensive health care plan and should be
addressed in each client’s care plan.
- Because the average stay of clients in acute care
hospitals has become shorter, people are sometimes
discharged still needing care.
- Although many clients are discharged to other
agencies (e.g., long-term care facilities), such care is
increasingly being delivered in the home.
- Effective discharge planning begins at first client
contact and involves comprehensive and ongoing
assessment to obtain information about the client’s
ongoing needs.
DEVELOPING NURSING CARE PLANS
• The end product of the planning phase of the nursing process is
a formal or informal plan of care.
A. An informal nursing care plan is a strategy for action that
exists in the nurse’s mind. For example, the nurse may
think, “Mrs. Phan is very tired. I will need to reinforce her
teaching after she is rested.”
B. A formal nursing care plan is a written or computerized
guide that organizes information about the client’s care.
The most obvious benefit of a formal written care plan is
that it provides for continuity of care.
C. A standardized care plan is a formal plan that specifies the
nursing care for groups of clients with common needs
(e.g., all clients with myocardial infarction).
D. An individualized care plan is tailored to meet the unique
needs of a specific client—needs that are not addressed by
the standardized plan.
• When nurses use the client’s nursing diagnoses to develop goals
and nursing interventions, the result is a holistic, individualized
plan of care that will meet the client’s unique needs.
• Care plans include the actions nurses must take to address the
client’s nursing diagnoses and produce the desired outcomes.
The nurse begins the plan when the client is admitted to the
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agency and updates it throughout the client’s stay in response
to changes in the client’s condition and evaluations of goal
achievement.
DURING THE PLANNING PHASE, THE NURSE MUST:
a. Decide which of the client’s problems need individualized plans
and which problems can be addressed by standardized plans
and routine care, and
b. Write individualized desired outcomes and nursing
interventions for client problems that require nursing attention
beyond preplanned, routine care.
SETTING PRIORITIES
• Priority setting is the process of establishing a preferential
sequence for addressing nursing diagnoses and interventions.
The nurse and 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, or low priority.
• Nurses frequently use Maslow’s hierarchy of needs when
setting priorities. 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 or activity. Growth needs,
such as self-esteem, are not perceived as “basic” in this
framework.
• Thus, nursing diagnoses such as Ineffective Airway Clearance
and Impaired Gas Exchange would take priority over nursing
diagnoses such as Anxiety or Ineffective Coping.
• Priorities change as the client’s responses, problems, and
therapies change. The nurse must consider a variety of factors
when assigning priorities, including the following:
1. Client’s health values and beliefs. Values concerning
health may be more important to the nurse than to the
client. For example, a client may believe that being home
for the children is more urgent than a health problem.
When such a difference of opinion arises, the client and
nurse should discuss it openly to resolve any conflict.
2. Client’s priorities. Involving the client in prioritizing and
care planning enhances cooperation. Sometimes, however,
the client’s perception of what is important conflicts with
the nurse’s knowledge of potential problems or
complications. For example, an older client may not regard
turning and repositioning in bed as important, preferring
to be undisturbed. The nurse, however, aware of the
potential complications of prolonged bed rest (e.g., muscle
weakness and pressure sores), needs to inform and work
with the client to carry out these necessary interventions.
3. Resources available to the nurse and client. If finances,
equipment, or personnel are scarce in a health care
agency, then a problem may be given a lower priority than
usual. Nurses in a home setting, for example, do not have
the resources of a hospital. If the necessary resources are
not available, the solution to that problem might need to
be postponed, or the client may need a referral. Client
resources, such as finances or coping ability, may also
influence the setting of priorities. For example, a client
who is unemployed may defer dental treatment; a client
whose husband is terminally ill and dependent on her may
feel unable to cope with nutritional guidance directed
toward losing weight.
4. Urgency of the health problem. Regardless of the
framework used, life-threatening situations require that
the nurse assign them a high priority. Situations that affect
the integrity of the client, that is, those that could have a
negative or destructive effect on the client, also have high
priority. Such health problems as drug abuse and radical
alteration of self-concept due to amputation can be
destructive both to the individual and to the family.
5. Medical treatment plan. The priorities for treating health
problems must be congruent with treatment by other
health professionals. For example, a high priority for the
client might be to become ambulatory; however, if the
primary care provider’s therapeutic regimen calls for
extended bed rest, then ambulation must assume a lower
priority in the nursing care plan. The nurse can provide or
teach exercises to facilitate ambulation later, provided the
client’s health permits. The nursing diagnosis related to
ambulation is not ignored; it is merely deferred.
4TH STEP: IMPLEMENTATION
• The 4thstage of the nursing process wherein the nurse executes
the interventions that were devised during the planning stage.
TYPES OF NURSING INTERVENTIONS
• Nursing interventions are identified and written during the
planning step of the nursing process; however, they are actually
performed during the implementing step.
• Nursing interventions include both direct and indirect care, as
well as nurse-initiated, physician-initiated, and other provider-
initiated treatments.
• Direct care is an intervention performed by the nurse through
interaction with the client.
• Indirect care is an intervention delegated by the nurse to
another provider or performed away from but on behalf of the
client such as interdisciplinary collaboration or management of
the care environment.
A. Independent interventions
- 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, counseling,
environmental management, and making referrals to
other health care professionals.
- Nursing diagnoses are client problems that can be
treated primarily by independent nursing
interventions.
- In performing an autonomous activity, the nurse
determines that the client requires certain nursing
interventions, either carries these out or delegates
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them to other nursing personnel, and is accountable a desire not to perpetuate ineffective actions but to adopt more
or answerable for the decision and the actions. effective ones.
B. Dependent interventions
- Are activities carried out under the orders or
supervision of a licensed physician or other health
care provider authorized to write orders to nurses.
- Primary care providers’ orders commonly direct the
nurse to provide medications, intravenous therapy,
diagnostic tests, treatments, diet, and activity.
- With the client, the nurse is responsible for assessing
the need for, explaining, and administering the
medical orders.
- Nursing interventions may be written for the purpose
of individualizing the medical order based on the
client’s status.
C. Collaborative interventions
- Are actions the nurse carries out in collaboration with
other health team members, such as physical
therapists, social workers, dietitians, and primary care
providers.
- Collaborative nursing activities reflect the overlapping
responsibilities of, and collegial relationships among,
health personnel. For example, the primary care
provider might order physical therapy to teach the
client crutch-walking. The nurse would be responsible
for informing the physical therapy department and for
coordinating the client’s care to include the physical
therapy sessions.
- The nurse may assist with crutch-walking and
collaborate with the physical therapist to evaluate the
client’s progress. The amount of time the nurse
spends in an independent versus a collaborative or
dependent role varies according to the clinical area,
type of institution, and specific position of the nurse.
5TH STEP: EVALUATING
• To evaluate is to judge or to appraise. Evaluating is the 5th
phase of the nursing process. In this context, evaluating is a
planned, ongoing, purposeful activity in which clients and
health care professionals determine (a) the client’s progress
toward achievement of goals/outcomes and (b) the
effectiveness of the nursing care plan.
• Evaluation is an important aspect of the nursing process
because conclusions drawn from the evaluation determine
whether the nursing interventions should be terminated,
continued, or changed.
• Evaluation is continuous. Evaluation done while or
immediately after implementing a nursing order enables the
nurse to make on-the-spot modifications in an intervention.
• Evaluation performed at specified intervals (e.g., once a week
for the home care client) shows the extent of progress toward
achievement of goals/outcomes and enables the nurse to
correct any deficiencies and modify the care plan as needed.
• Evaluation continues until the client achieves the health goals
or is discharged from nursing care. Evaluation at discharge
includes the status of goal achievement and the client’s self-
care abilities with regard to follow-up care.
• Most agencies have a special discharge record for this
evaluation. Through evaluating, nurses demonstrate
responsibility and accountability for their actions, indicate
interest in the results of the nursing activities, and demonstrate