THE NURSING PROCESS

Richard Deo Rox R. Alave, RN

LEARNING OUTCOMES

After completing this enhancement class, you will

be able to:
1. Describe the phases of the nursing process.
2. Identify the major process in assessing
3. Formulate nursing diagnoses and appropriate
planning based on the latest updates
4. Choose and apply correct nursing intervention
and the process of evaluation.
5. Discuss and formulate the proper way of
documenting
THE NURSING PROCESS
 systematic, rational method of planning and
providing individualized nursing care.
 Purposes:
 identify a client’s health status and actual or
potential health care problems or needs,
 to establish plans to meet the identified needs

 to deliver specific nursing interventions to meet

those needs.
 Client: an individual, a family, a community, or a
group.
THE NURSING PROCESS
 is cyclical
 follow a logical sequence,
 more than one component may be
involved at one time.
 care may be terminated if goals are
achieved
 cycle may continue with reassessment
 the plan of care may be modified.
THE NURSING PROCESS
 The Standards of Practice within the most
current Scope and Standards of Nursing
Practice include six phases of the nursing
process: assessment, diagnosis,
outcomes identification, planning,
implementation, and evaluation (ANA,
2010).
THE NURSING PROCESS
 The national licensure examination for
registered nurses(NCLEX) uses five phases:
assessment, analysis, planning,
implementation, and evaluation.
 This discussion, uses five phases: assessing,
diagnosing (which includes outcomes
identification and analysis), planning,
implementing, and evaluating.
CHARACTERISTICS OF THE NURSING PROCESS
 Data from each phase provide input into the
next phase.
 The nursing process is client centered.
 The nursing process is an adaptation of
problem solving and systems theory.
 Decision making is involved in every phase of
the nursing process.
CHARACTERISTICS OF THE NURSING PROCESS
 The nursing process is interpersonal and
collaborative.
 The universally applicable: used in all types of
health care settings
 Nurses must use a variety of critical thinking
skills to carry out the nursing process
ASSESSMENT
 is the systematic and continuous collection,
organization, validation, and documentation of
data (information).
 continuous process carried out in all phases of NP
 For example, in the evaluation phase, assessment
is done to determine the outcomes of the nursing
strategies and to evaluate goal achievement.
 All phases of the nursing process depend on the
accurate and complete collection of data.
TYPES OF ASSESSMENT
COLLECTING DATA

 Data collection :
 process of gathering information about a
client’s health status.
 systematic and continuous to prevent the
omission of significant data and reflect a
client’s changing health status.
DATABASE
 contains all the information about a
client;
 nursing health history
 physical assessment
 primary care provider’s history

 physical examination
 results of laboratory and diagnostic tests,

 material contributed by other health

personnel.
TYPES OF DATA
 Subjective data
 symptoms or covert data
 apparent only to the person affected
 described or verified only by that person.

 E.g. Sensations(pain), feelings(sad/worry),

values, beliefs, attitudes, and perception of
personal health status and life situation.
TYPES OF DATA
 Objective data
 signs or overt data
 detectable by an observer
 can be measured or tested against an accepted
standard.
 Seen(cyanosis), heard(heart/lung sounds),
felt(cold/warm), smelled(body odor), and they are
obtained by observation or physical examination.
 the nurse obtains objective data to validate
subjective data
TYPES OF DATA
 Constant data :does not change over time
(race or blood type)
 Variable data :change quickly, frequently,
or rarely (blood pressure, level of pain,
age)
SOURCES OF DATA
 primary or secondary.
 The client is the primary source of data.
 Secondary or indirect sources.
 Family members or other support persons,
 other health professionals,
 records and reports,
 laboratory and diagnostic analyses,
 relevant literature
 In fact, all sources other than the client are
considered secondary sources.
 All data from secondary sources should be
validated if possible.
DATA COLLECTION METHODS

 observing, interviewing, and examining.

 Observing occurs whenever the nurse is in
contact with the client or support persons.
Observing has two aspects:
(a) noticing the data and (b) selecting, organizin
g, and interpreting the data.
DATA COLLECTION METHODS

 Interviewing is used mainly while taking the

nursing health history.
 There are two approaches to interviewing:
directive and nondirective.
 TYPES OF INTERVIEW QUESTIONS :
• Questions are often classified as closed or
open ended, and neutral or leading.
DATA COLLECTION METHODS

 Factors affecting interview:

 Time
 Place

 seating arrangement

 Distance

 language.

 An interview has three major stages:

 the opening or introduction
 the body or development

 closing.
DATA COLLECTION METHODS

 techniques are commonly used to close an

interview
 1. Offer to answer questions
 2. Conclude
 3. Thank the client
 4. Express concern for the person’s welfare and
future
 5. Plan for the next meeting, if there is to be one, or
state what will happen next. Include the day, time,
place, topic, and purpose
 6. Provide a summary to verify accuracy and
agreement.
DATA COLLECTION METHODS

 Examining :major method used in the physical

health assessment.
 physical examination or physical :systematic
data collection method that uses observation
(i.e., the senses of sight, hearing, smell, and
touch) to detect health problems
 techniques : inspection, auscultation, palpation,
and percussion
SYSTEM OF PE
 General impression about the client’s overall appearance
and health status: for example, age, body size, mental and
nutritional status, speech, and behavior.
 Then measurements: vital signs, height, and weight.
 The cephalocaudal :head; progresses to the neck, thorax,
abdomen, and extremities; and ends at the toes.
 The body systems approach investigates each system
individually
 During the physical examination, the nurse assesses all
body parts and compares findings on each side of the body
(e.g., lungs).
 Ascreening examination, also called a review of systems a
brief review of essential functioning of various body parts or
systems.
DATA COLLECTION METHODS

 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.
ORGANIZING DATA

 Conceptual Models/Frameworks:
 Gordon’s functional health pattern framework
 Orem’s self-care model
 Roy’s adaptation model.
 Non-Nursing Models
 Body Systems Model
 Maslow’s Hierarchy of Needs
 Developmental Theories
VALIDATING DATA

 Validation is the act of “double-checking” or

verifying data to confirm that it is accurate and
factual
DOCUMENTING DATA

 To complete the assessment phase, the nurse

records client data.
 Accurate documentation is essential and
should include all data collected about the
client’s health status.
ASSESSMENT SUMMARY
DIAGNOSIS
 diagnosing :reasoning process
 Diagnosis: statement or conclusion regarding
the nature of a phenomenon.
 The standardized NANDA names for the
diagnoses are called diagnostic labels; and the
client’s problem statement, consisting of the
diagnostic label plus etiology (causal
relationship between a problem and its related
or risk factors), is called a nursing diagnosis.
STATUS OF THE NURSING DIAGNOSES

 “Status refers to the actuality or potentiality of

the diagnosis or the categorization of the
diagnosis”
 The kinds of nursing diagnoses according to
status are actual, health promotion, risk, and
syndrome.
ACTUAL DIAGNOSIS
 An actual diagnosis is a client problem that is
present at the time of the nursing assessment.
 Examples are IneffectiveBreathing Pattern and
Anxiety.
 An actual nursing diagnosis is based on the
presence of associated signs and symptoms.
HEALTH PROMOTION DIAGNOSIS
 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.
WELLNESS DIAGNOSIS
 A wellness diagnosis “describes human
responses to levels of wellness in an individual,
family or community,” (NANDA International,
2009, p. 420).
 As with health promotion diagnoses, these
diagnosis labels begin with the phrase
Readiness for Enhanced.
 Examples of wellness diagnoses would be
Readiness for Enhanced Spiritual Well-Being or
Readiness for Enhanced Family Coping.
RISK NURSING DIAGNOSIS
 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.
SYNDROME DIAGNOSIS
 A syndrome diagnosis is assigned by a
nurse’s clinical judgment to describe a
cluster of nursing diagnoses that have similar
interventions (Herdman & Kamitsuru, 2014,
p. 23).
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.
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 Problem (Diagnostic Label) and Definition

 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.
 It direct the formation of client goals and
desired outcomes.
 Suggest some nursing interventions.
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 Qualifiers are words that have been added to

some NANDA labels to give additional meaning
to the diagnostic statement; for example:
 Deficient (inadequate in amount, quality, or
degree; not sufficient; incomplete)
 Impaired (made worse, weakened, damaged,
reduced,deteriorated)
 Decreased (lesser in size, amount, or degree)
 Ineffective (not producing the desired effect)
 Compromised (to make vulnerable to threat).
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 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.
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 Defining characteristics: cluster of signs and

symptoms that indicate the presence of a
particular diagnostic label.
 For actual nursing diagnoses, the defining
characteristics are the client’s signs and
symptoms.
 For risk nursing diagnoses, no subjective and
objective signs are present. Thus, the factors
that cause the client to be more vulnerable to
the problem form the etiology of a risk nursing
diagnosis.
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 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.
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 Differentiating Nursing Diagnoses from

Collaborative Problems
 A collaborative problem is a type of potential problem
that nurses manage using both independent and
physician-prescribed interventions.
 Independent nursing interventions for a collaborative
problem focus mainly on monitoring the client’s
condition and preventing development of the potential
complication. Definitive treatment of the condition
requires both medical and nursing interventions.
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 Collaborative problems are present when a

particular disease or treatment is present; that is,
each disease or treatment has specific
complications that are always associated with it.
 For example, a statement of collaborative problems
is “Potential complications of pneumonia:
atelectasis, respiratory failure, pleural effusion,
pericarditis, and meningitis.”
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 Nursing diagnoses, by contrast, involve human

responses, which vary greatly from one person to
the next. Therefore, the same set of nursing
diagnoses cannot be expected to occur with all
persons who have a particular disease or condition;
moreover, a single nursing diagnosis may occur as
a response to any number of diseases.
COMPONENTS OF A NANDA NURSING DIAGNOSIS

 For example, all postpartum clients have similar

collaborative problems, such as “Potential complication
of childbearing: postpartum hemorrhage,” but not all
new mothers have the same nursing diagnoses.
 Some might experience Impaired Parenting (delayed
bonding), but most will not; some might have Deficient
Knowledge, whereas others will not.
 Thus, the nurse uses nursing diagnoses rather than
collaborative problems whenever possible, since
nursing diagnoses are more individualized to a specific
client and emphasize human responses to which the
nurse can independently take action.
THE DIAGNOSTIC PROCESS

 The diagnostic process has three steps:

 Analyzing data
 Identifying health problems, risks, and
strengths
 Formulating diagnostic statements.
THE DIAGNOSTIC PROCESS

 Analyzing Data
 In the diagnostic process, analyzing involves the
following steps:
 1. Compare data against standards (identify
significant cues).
 2. Cluster the cues (generate tentative
hypotheses).
 3. Identify gaps and inconsistencies.
THE DIAGNOSTIC PROCESS

 Identifying Health Problems, Risks, and

Strengths
 After data are analyzed, the nurse and client
can together identify strengths and problems.
This is primarily a decision making process
THE DIAGNOSTIC PROCESS

 Determining Problems and Risks

 After grouping and clustering the data, the nurse
and client together identify problems that support
tentative actual, risk, and possible diagnoses. In
addition the nurse must determine whether the
client’s problem is a nursing diagnosis, medical
diagnosis, or collaborative problem.
THE DIAGNOSTIC PROCESS

 Determining Strengths
 At this stage, the nurse and client also establish the
client’s strengths, resources, and abilities to cope.
Most people have a clearer perception of their
problems or weaknesses than of their strengths
and assets, which they often take for granted. By
taking an inventory of strengths, the client can
develop a more well-rounded self-concept and self-
image. Strengths can be an aid to mobilizing health
and regenerative processes.
THE DIAGNOSTIC PROCESS

 Formulating Diagnostic Statements

 Most nursing diagnoses are written as two-
part or three-part statements, but there are
variations of these.
THE DIAGNOSTIC PROCESS

 Basic Two-Part Statements: PE/PRE

 1. Problem (P): statement of the client’s response
(NANDA label)
 2. Etiology (E): factors contributing to or probable
causes of the responses.
 The two parts are joined by the words related to
rather than due to. The phrase due to implies that
one part causes or is responsible for the other part.
By contrast, the phrase related to merely implies a
relationship.
THE DIAGNOSTIC PROCESS

 For NANDA labels that contain the word Specify, the

nurse must add words to indicate the problem more
specifically. The format is still a two-part statement. For
example, Noncompliance (Specify) would be
Noncompliance (Diabetic Diet) related to denial of
having disease. For ease in alphabetizing, many NANDA
lists are arranged with qualifying words after the main
word (e.g., Infection, Risk for). Avoid writing diagnostic
statements in that manner; instead, write them as they
would be stated in normal conversation (e.g., Risk for
Infection).
THE DIAGNOSTIC PROCESS

 BASIC THREE-PART STATEMENTS: PES format

 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.
THE DIAGNOSTIC PROCESS
 To minimize long problem statements, the nurse can
record the signs and symptoms in the nursing notes
instead of on the care plan
 recommended for students, is to list the signs and
symptoms on the care plan below the nursing
diagnosis, grouping the subjective (S) and objective
(O) data
 Noncompliance (Diabetic Diet) related to
unresolved anger about diagnosis as manifested
by
 S— “I forget to take my pills.”
---“I can’t live without sugar in my food.”
 O— Weight 98 kg (215 lb) (gain of 4.5 kg [10 lb])
THE DIAGNOSTIC PROCESS
 ONE-PART STATEMENTS
 Some diagnostic statements, such as health
promotion diagnoses and syndrome
nursing diagnoses, consist of a NANDA
label only.
 Refined
 more specific
 nursing interventions can be derived from the
label itself.
 etiology may not be needed.
THE DIAGNOSTIC PROCESS
 Currently seven syndrome diagnoses are on the
NANDA International list.
 Risk for Disuse Syndrome, for example,may be
experienced by long-term bedridden clients.
 Clusters of diagnoses associated with this syndrome
include:
 Impaired Physical Mobility,
 Risk for Impaired Tissue Integrity
 Risk for Activity Intolerance
 Risk for Constipation
 Risk for Infection
 Risk for Injury
 Risk for Powerlessness,
 Impaired Gas Exchange, and so on..
VARIATIONS OF BASIC FORMATS
 1. Writing unknown etiology when the defining
characteristics are present but the nurse does
not know the cause or contributing factors.
 E.g. Noncompliance (Medication Regimen)
related to unknown etiology.
 2. Using the phrase complex factors when there
are too many etiologic factors or when they are
too complex to state in a brief phrase.
 E.g.Chronic Low Self-Esteem related to complex
factors.
VARIATIONS OF BASIC FORMATS
 3. Use possible to describe either the
problem or the etiology. When the nurse
believes more data are needed about the
client’s problem or the etiology.
 E.g. Possible Low Self-Esteem related to loss of
job and rejection by family;
 Altered Thought Processes possibly related to
unfamiliar surroundings.
VARIATIONS OF BASIC FORMATS
 4. Use secondary to to divide the etiology into two
parts, thereby making the statement more descriptive
and useful. The part following secondary to is often a
pathophysiologic or disease process or a medical
diagnosis
 Risk for Impaired Skin Integrity related to decreased
peripheral circulation secondary to diabetes.
 5. Adding a second part to the general response or
NANDA label to make it more precise.
 E.g. Impaired Skin Integrity (Left Lateral Ankle) related to
decreased peripheral circulation.
COLLABORATIVE PROBLEMS

 Carpenito-Moyet (2013) has suggested that

all collaborative (multidisciplinary) problems
begin with the diagnostic label Potential
Complication(PC). Nurses should include in
the diagnostic statement both the possible
complication they are monitoring and the
disease or treatment that is present to
produce it.
 E.g. Potential Complication of Head Injury:
increased intracranial pressure
COLLABORATIVE PROBLEMS

 When monitoring for a group of complications

associated with a disease or pathology:
 E.g. Potential Complication of Pregnancy-Induced
Hypertension: seizures, fetal distress, pulmonary edema,
hepatic/renal failure, premature labor, CNS hemorrhage
 In some situations, an etiology might be helpful in
suggesting interventions. Nurses should write the
etiology when (a) it clarifies the problem statement,
(b) it can be concisely stated, and (c) it helps to
suggest nursing actions.
GUIDELINES IN WRITTING DX
TAXONOMY II
 Taxonomy II has three levels: domains, classes, and nursing
diagnoses
 The diagnoses are no longer grouped by Gordon’s patterns but
coded according to seven axes:
 diagnostic concept
 subject of diagnosis
 Judgment
 location
 Age

 Time

 status of diagnosis

 In addition, diagnoses are now listed alphabetically by concept, not

by first word.
DX SUMMARY
PLANNING

 deliberative, systematic phase of the nursing

process
 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
PLANNING

 NURSING INTERVENTION
 “any treatment, based upon clinical
judgment and knowledge, that a nurse
performs to enhance patient/client
outcomes”
TYPES OF PLANNING

 Initial Planning
 The nurse who performs the admission
assessment usually develops the initial
comprehensive plan of care.
TYPES OF PLANNING

 Ongoing Planning
 All nurses who work with the client do
ongoing planning.
 occurs at the beginning of a shift as the
nurse plans the care to be given that day
TYPES OF PLANNING

 Purpose:
 1. To determine whether the client’s health status
has changed
 2. To set priorities for the client’s care during the
shift
 3. To decide which problems to focus on during the
shift
 4. To coordinate the nurse’s activities so that more
than one problem can be addressed at each client
contact.
TYPES OF PLANNING

 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.
 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.
 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.”
 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.
DEVELOPING NURSING CARE PLANS
 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).
 An individualized care plan is tailored to meet the
unique needs of a specific client—needs that are
not addressed by the standardized plan.
DEVELOPING NURSING CARE PLANS
 During planning phase:
 (a) decide which of the client’s problems
need individualized plans and which
problems can be addressed by standardized
plans and routine care,
 (b) write individualized desired outcomes and
nursing interventions for client problems that
require nursing attention beyond preplanned,
routine care.
DEVELOPING NURSING CARE PLANS
 Standard of care, standardized care plans,
protocols, policies, and procedures are
developed and accepted by the nursing staff
in order to:
 (a) ensure that minimally acceptable criteria
are met and
 (b) promote efficient use of nurses’ time by
removing the need to author common
activities that are done repeatedly for many
of the clients on a nursing unit.
DEVELOPING NURSING CARE PLANS
 Protocols are predeveloped to indicate the actions
commonly required for a particular group of clients
 Policies and procedures are developed to govern
the handling of frequently occurring situations.
 A standing order is a written document about
policies, rules, regulations, or orders regarding
client care.
 Standing orders give nurses the authority to carry
out specific actions under certain circumstances,
often when a primary care provider is not
immediately available.
FORMATS FOR NURSING CARE PLANS
 (1) problem/nursing diagnoses,
 (2) goals/desired outcomes,
 (3) nursing interventions, and
 (4) evaluation.
STUDENT CARE PLANS
 a learning activity as well as a plan of care, more
lengthy and detailed than care plans used by
working nurses.
 To help students learn to write care plans,
educators may require that more of the plan be
original work. They may also modify the plan by
adding “Rationale” after the nursing interventions.
 A rationale is the evidence-based principle given as
the reason for selecting a particular nursing
intervention.
 Students may also be required to cite supporting
literature for their stated rationale.
FORMATS FOR NURSING CARE PLANS
 concept map is a visual tool in which
ideas or data are enclosed in circles or
boxes of some shape, and relationships
between these are indicated by
connecting lines or arrows
 COMPUTERIZED CARE PLANS
 computer can generate both
standardized and individualized care
plans
MULTIDISCIPLINARY (COLLABORATIVE) CARE PLANS

 multidisciplinary care plan is a standardized

plan that outlines the care required for
clients with common, predictable—usually
medical— conditions. Such plans, also
referred to as collaborative care plans and
critical pathways, sequence the care that
must be given on each day during the
projected length of stay for the specific type
of condition.
GUIDELINES FOR WRITING NURSING CARE PLANS
 1. Date and sign the plan.
 2. Use category headings. “Nursing Diagnoses,”
“Goals/Desired Outcomes,” “Nursing Interventions,” and
“Evaluation” are the common
 3. Use standardized/approved medical or English symbols
and key words rather than complete sentences to
communicate your ideas unless agency policy dictates
otherwise.
 “Turn and reposition q2h” rather than “Turn and reposition
the client every two hours.” Or, write “Clean wound −c H2O2
bid” rather than “Clean the client’s wound with hydrogen
peroxide twice a day, morning and evening.”
GUIDELINES FOR WRITING NURSING CARE PLANS
 4. Be specific.
 5. Refer to procedure books or other sources of information
rather than including all the steps on a written plan.
 6. Tailor the plan to the unique characteristics of the client
by ensuring that the client’s choices, such as preferences
about the times of care and the methods used, are included.
 7. Ensure that the nursing plan incorporates preventive and
health maintenance aspects as well as restorative ones.
 For example,carrying out the intervention “Provide active-
assistance ROM (range-of-motion) exercises to affected
limbs q2h” addresses the goal of preventing joint
contractures and maintaining muscle strength and joint
mobility.
GUIDELINES FOR WRITING NURSING CARE PLANS
 8. Ensure that the plan contains ongoing assessment of the
client (e.g., “Inspect incision q8h”).
 9. Include collaborative and coordination activities in the
plan.
 For example, the nurse may write interventions to ask a
nutritionist or physical therapist about specific aspects of the
client’s care.
 10. Include plans for the client’s discharge and home care
needs.
 The nurse begins discharge planning as soon as the client
has been admitted. It is often necessary to consult and
make arrangements with the community health nurse, social
worker, and specific agencies that supply client information
and needed equipment.
THE PLANNING PROCESS
 Setting priorities
 Establishing client goals/desired
outcomes
 Selecting nursing interventions and
activities
 Writing individualized nursing
interventions on care plans.
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.
SETTING PRIORITIES
 factors to consider when assigning
priorities:
 1. Client’s health values and beliefs.
 2. Client’s priorities.
 3. Resources available to the nurse and
client
 4. Urgency of the health problem.
 5. Medical treatment plan
ESTABLISHING CLIENT GOALS/DESIRED OUTCOMES
 what the nurse hopes to achieve by
implementing the nursing interventions.
 Some references also use the terms
expected outcome, predicted outcome,
outcome criterion, and objective.
 Goal (broad): Improved nutritional status.
 Desired outcome (specific): Gain 5 lb by April 25.
 Improved nutritional status as evidenced by weight
gain of 5 lb by April 25.
PURPOSE OF GOALS/DESIRED OUTCOMES

 1. Provide direction for planning nursing

interventions.
 2. Serve as criteria for evaluating client
progress.
 3. Enable the client and nurse to
determine when the problem has been
resolved.
 4. Help motivate the client and nurse by
providing a sense of achievement.
SHORT-TERM AND LONG-TERM GOALS
 A short-term goal might be “Client will raise
right arm to shoulder height by Friday.”
 a long-term goal/outcome might be “Client will
regain full use of right arm in 6 weeks.”
 Short-term goals are useful for clients who (a)
require health care for a short time or (b) are
frustrated by long-term goals that seem difficult
to attain and who need the satisfaction of
achieving a short-term goal.
RELATIONSHIP OF GOALS/DESIRED OUTCOMES
TO NURSING DIAGNOSES
COMPONENTS OF GOAL/DESIRED
OUTCOME STATEMENTS
 1. Subject. The subject, a noun, is the client, any
part of the client, or some attribute of the client,
such as the client’s pulse or urinary output.
 2. Verb. The verb specifies an action the client is
to perform, for example, what the client is to do,
learn, or experience. Verbs that denote directly
observable behaviors, such as administer, show,
or walk, must be used.
COMPONENTS OF GOAL/DESIRED
OUTCOME STATEMENTS
 3. Conditions or modifiers. Conditions or
modifiers may be added to the verb to explain the
circumstances under which the behavior is to be
performed. They explain what, where, when, or
how. For example: Walks with the help of a cane
(how). After attending two group diabetes classes,
lists signs and symptoms of diabetes (when). When
at home, maintains weight at existing level (where).
Discusses food pyramid and recommended daily
servings (what). Conditions need not be included if
the criterion of performance clearly indicates what
is expected.
COMPONENTS OF GOAL/DESIRED
OUTCOME STATEMENTS
 4. Criterion of desired performance. The criterion
indicates the standard by which a performance is evaluated
or the level at which the client will perform the specified
behavior. 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, the nurse asks “How
well?” Similarly, the nurse asks “How far?” and “What isthe
expected standard?” to establish distance and quality
criteria, respectively. Examples are:
 Weighs 75 kg by April (time).
 Lists five out of six signs of diabetes (accuracy).
 Walks one block per day (distance and time).
 Administers insulin using aseptic technique (quality).
GUIDELINES FOR WRITING
GOALS/DESIRED OUTCOMES
 1. Write goals and outcomes in terms of client
responses, not nursing activities. Beginning each
goal statement with The client will may help focus
the goal on client behaviors and responses. Avoid
statements that start with enable, facilitate, allow,
let, permit, or similar verbs followed by the word
client. These verbs indicate what the nurse hopes
to accomplish, not what the client will do.
 Correct: The client will drink 100 mL of water per
hour (client behavior).
 Incorrect: Maintain client hydration (nursing action).
GUIDELINES FOR WRITING
GOALS/DESIRED OUTCOMES
 2. Be sure that desired outcomes are realistic for the
client’s capabilities, limitations, and designated time
span, if it is indicated. Limitations refers to finances,
equipment, family support, social services, physical and
mental condition, and time. For example,the outcome
“Measures insulin accurately” may be unrealistic for a
client who has poor vision due to cataracts.
 3. Ensure that the goals and desired outcomes are
compatible withthe therapies of other professionals.
For example, the outcome “The client will increase the
time spent out of bed by 15 minutes each day” is not
compatible with a primary care provider’s prescribed
therapy of bed rest.
GUIDELINES FOR WRITING
GOALS/DESIRED OUTCOMES
 4. Make sure that each goal is derived from only
one nursing diagnosis.
 For example, the goal “The client will increase the
amount of nutrients ingested and show progress in
the ability to feed self ” is derived from two nursing
diagnoses: Imbalanced Nutrition: Less Than Body
Requirements and Feeding Self-Care Deficit.
Keeping the goal statement related to only one
diagnosis facilitates evaluation of care by ensuring
that planned nursing interventions are clearly
related to the diagnosis.
GUIDELINES FOR WRITING
GOALS/DESIRED OUTCOMES
 5. Use observable, measurable terms for
outcomes.
 Avoid words that are vague and require interpretation
or judgment by the observer. For example, phrases
such as increase daily exercise and improve
knowledge of nutrition can mean different things to
different people. If used in outcomes, these phrases
can lead to disagreements about whether the
outcome was met. These phrases may be suitable for
a broad client goal but are not sufficiently clear and
specific to guide the nurse when evaluating client
responses.
GUIDELINES FOR WRITING
GOALS/DESIRED OUTCOMES
 6. Make sure the client considers the
goals/desired outcomes important and
values them.
 Some outcomes, such as those for problems
related to self-esteem, parenting, and
communication, involve choices that are best
made by the client or in collaboration with the
client.
SELECTING NURSING INTERVENTIONS
AND ACTIVITIES
 Nursing interventions and activities are the actions that
a nurse performs to achieve client goals.
 nurse chooses interventions to treat the signs and
symptoms or the defining characteristics
 Interventions for risk nursing diagnoses should focus
on measures to reduce the client’s risk factors
 Correct identification of the etiology during the
diagnosing phase provides the framework for choosing
successful nursing interventions.
 For example, the diagnostic label Activity Intolerance
may have several etiologies: pain, weakness,
sedentary lifestyle, anxiety, or cardiac arrhythmias.
TYPES OF NURSING INTERVENTIONS
 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.
TYPES OF NURSING INTERVENTIONS
 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,
counselling, environmental management, and
making referrals to other health care professionals.
TYPES OF NURSING INTERVENTIONS
 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
 1. Dangle for 5 min, 12 hours postop.
 2. Stand at bedside 24 hours postop; observe for
pallor, dizziness, and weakness.
 3. Check pulse before and after ambulating. Do not
progress if pulse is greater than 110.
TYPES OF NURSING INTERVENTIONS
 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.
CONSIDERING THE CONSEQUENCES OF
EACH INTERVENTION
 Safe and appropriate for the individual’s age, health, and
condition.
 Achievable with the resources available. For example, a
home care nurse might wish to include an intervention for an
older client to“Check blood glucose daily.”
 Congruent with the client’s values, beliefs, and culture.
 Congruent with other therapies (e.g., if the client is not
permitted food, the strategy of an evening snack must be
deferred until health permits).
 Based on nursing knowledge and experience or knowledge
from relevant sciences (i.e., based on a rationale).
 Within established standards of care as determined by state
laws,professional,accrediting organizations, and the policies
of the institution.
CRITERIA FOR CHOOSING NURSING
INTERVENTIONS
 The nurse’s task is to choose those that are most likely to
achieve the desired client outcomes.
 The nurse begins by considering the risks and benefits of
each intervention.
WRITING INDIVIDUALIZED NURSING
INTERVENTIONS
 Date nursing interventions on the care plan
when they are written and review regularly at
intervals that depend on the individual’s
needs.
 The format of written interventions is similar
to that of outcomes: verb, conditions, and
modifiers, plus a time element.
WRITING INDIVIDUALIZED NURSING
INTERVENTIONS
 The action verb starts the intervention and must be
precise. For example, “Explain (to the client) the
actions of insulin” is a more precise statement than
“Teach (the client) about insulin.” “Measure and
record ankle circumference daily at 0900” is more
precise than “Assess edema of left ankle daily.”
Sometimes a modifier for the verb can make the
nursing intervention more precise. For example,
“Apply spiral bandage firmly to left lower leg” is
more precise than “Apply spiral bandage to left leg.”
WRITING INDIVIDUALIZED NURSING
INTERVENTIONS
 The time element answers when, how long, or how
often the nursing action is to occur. Examples are
“Assist client with tub bath at 0700 daily” and
“Administer analgesic 30 minutes prior to physical
therapy.”
 In some settings, the intervention (and other
segments of the nursing care plan) is signed. The
signature of the nurse prescribing the intervention
shows the nurse’s accountability and has legal
significance.
RELATIONSHIP OF NURSING
INTERVENTIONS TO PROBLEM STATUS
 Depending on the type of client problem, the nurse
writes interventions for observation, prevention,
treatment, and health promotion.
 Observations include assessments made to determine
whether a complication is developing, as well as
observation of the client’s responses to nursing and other
therapies. The nurse should write observations for both
real problems and those for which the client is at risk.
Some examples are “Auscultate lungs q8h,” “Observe
for redness over sacrum q2h,” and “Record intake and
output hourly.”
RELATIONSHIP OF NURSING
INTERVENTIONS TO PROBLEM STATUS
 Prevention interventions prescribe the care needed to
avoid complications or reduce risk factors. They are
needed mainly for potential nursing diagnoses and
collaborative problems. Examples are “Turn, cough, and
deep breathe q2h” (prevents respiratory complications)
and “Keep bed rails raised and bed in low position”
(minimizes chances of clients falling out of bed or
injuring themselves should they fall over the rails).
RELATIONSHIP OF NURSING
INTERVENTIONS TO PROBLEM STATUS
 Treatments include teaching, referrals, physical care,
and other care needed for an actual nursing diagnosis.
Some interventions may accomplish either prevention or
treatment functions, depending on the status of the
problem. In the preceding examples, “Turn, cough, and
deep breathe q2h” can also be intended to treat an
existing respiratory problem.
RELATIONSHIP OF NURSING
INTERVENTIONS TO PROBLEM STATUS
 Enhancement or promotion interventions are
appropriate when the client has no health problems or
when the nurse makes a health promotion nursing
diagnosis. Such nursing interventions focus on helping
the client identify areas for improvement that will lead to
a higher level of wellness and actualize the client’s
overall health potential. Examples are “Discuss the
importance of daily exercise” and “Explore infant
stimulation techniques.”
THE NURSING INTERVENTIONS CLASSIFICATION
 This taxonomy consists of three levels: level 1, domains;
level 2, classes; and level 3, interventions.
SUMMARY
IMPLEMENTING
 the action phase in which the nurse performs the nursing
interventions
 Consists of doing and documenting the activities that are
the specific nursing actions needed to carry out the
interventions.
 The nurse performs or delegates the nursing activities for
the interventions that were developed in the planning
step and then concludes the implementing step by
recording nursing activities and the resulting client
responses.
IMPLEMENTING SKILLS
 Cognitive-(intellectual skills) include:
 problem solving,
 decision making,
 critical thinking,
 clinical reasoning,
 creativity.
IMPLEMENTING SKILLS
 Interpersonal-
 verbal
 nonverbal,
 ability to communicate with others,
 therapeutic communication
IMPLEMENTING SKILLS
 technical skills-purposeful “hands-on” skills:
 manipulating equipment,
 giving injections,
 bandaging,
 moving, lifting, and repositioning clients.
 tasks,
 procedures,
 psychomotor skills.
PROCESS OF IMPLEMENTING
 Reassessing the client
 Determining the nurse’s need for assistance
PROCESS OF IMPLEMENTING
 Implementing the nursing interventions-
 scientific knowledge, nursing research, and professional
standards of care
 Clearly understand the interventions to be implemented
 Adapt activities to the individual client
 Implement safe care.
 Provide teaching, support, and comfort
 Be holistic.
 Respect the dignity of the client and enhance the client’s
self-esteem.
 Encourage clients to participate actively in implementing
the nursing interventions.
PROCESS OF IMPLEMENTING
 Supervising the delegated care
 Documenting nursing activities.
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.
 Conclusions drawn from the evaluation
determine whether the nursing interventions
should be terminated, continued, or changed.
PROCESS OF EVALUATING CLIENT
RESPONSES
 The evaluation phase has five
components :
 Collecting data related to the desired
outcomes (NOC indicators)
 Comparing the data with desired outcomes
 Relating nursing activities to outcomes
 Drawing conclusions about problem status
 Continuing, modifying, or terminating the
nursing care plan.
PROCESS OF EVALUATING CLIENT
RESPONSES
 Collecting data: collects data so that
conclusions can be drawn about whether
goals have been met.
 It is usually necessary to collect both objective
and subjective data.
PROCESS OF EVALUATING CLIENT
RESPONSES
 Comparing data with desired outcomes:
 the nurse can draw one of three possible
conclusions:
 1. The goal was met; that is, the client response is
the same as the desired outcome.
 2. The goal was partially met; that is, either a short-
term outcome was achieved but the long-term goal
was not, or the desired goal was incompletely
attained.
 3. The goal was not met.
PROCESS OF EVALUATING CLIENT
RESPONSES
 Comparing data with desired outcomes:
 After determining whether or not a goal has been
met, the nurse writes an evaluation statement
(either on the care plan or in the nurse’s notes).
 An evaluation statement consists of two parts: a
conclusion and supporting data.
 conclusion: statement that the goal/desired
outcome was met, partially met, or not met.
 supporting data: list of client responses that support
the conclusion, for example:
 Goal met: Oral intake 300 mL more than output; skin
turgor resilient; mucous membranes moist.
PROCESS OF EVALUATING CLIENT
RESPONSES
 Relating nursing activities to outcomes:
 determining whether the nursing activities had any
relation to the outcomes.
 It should never be assumed that a nursing activity was
the cause of or the only factor in meeting, partially
meeting, or not meeting a goal.
DOCUMENTING
AND
REPORTING
TERMS
 discussion
 informal oral consideration of a subject
 two or more health care personnel
 to identify a problem or establish strategies to resolve a
problem.
 report
 oral, written, or computer-based communication
 intended to convey information to others
 Record
 Or a chart or client record, is a formal, legal document
 provides evidence of a client’s care
 written or computer based.
TERMS
 The process of making an entry on a
client record is called recording,
charting, or documenting.
ETHICAL AND LEGAL CONSIDERATIONS
 nurse has a duty to maintain confidentiality of all
patient information
 client’s record is also protected legally as a
private record of the client’s care.
 Access to the record is restricted to health
professionals involved in giving care to the client.
 The institution or agency is the rightful owner of the
client’s record.
 This does not, however, exclude the client’s rights to the
same records.
ETHICAL AND LEGAL CONSIDERATIONS
 For purposes of education and research, most agencies
allow student and graduate health professionals access to
client records.
 The student or graduate is bound by a strict ethical
code and legal responsibility to hold all information in
confidence.
 It is the responsibility of the student or health
professional to protect the client’s privacy by not using
a name or any statements in the notations that would
identify the client.
PURPOSES OF CLIENT RECORDS
 Communication
 Plan client care
 Auditing health agencies
 Research
 Education
 Reimbursement
 Legal documents
 Health care analysis
DOCUMENTATION SYSTEMS
 the source-oriented record;
 the problem-oriented medical record;
 the problems, interventions, evaluation (PIE)
model;
 focus charting;
 charting by exception (CBE);
 computerized documentation;
 case management.
 These documentation systems can be implemented
using the traditional paper forms or with EHRs.
DOCUMENTATION SYSTEMS
 the source-oriented record
 traditional client record
 Narrative charting is a traditional part of the
source-oriented record
 It consists of written notes that include routine
care, normal findings, and client problems.
 There is no right or wrong order to the
information, although chronologic order is
frequently used.
 Today, few institutions use only narrative
charting.
DOCUMENTATION SYSTEMS
DOCUMENTATION SYSTEMS
DOCUMENTATION SYSTEMS
 Problem-Oriented Medical Record
 the data are arranged according to the
problems the client has rather than the source
of the information.
 Members of the health care team contribute to
the problem list, plan of care, and progress
notes.
DOCUMENTATION SYSTEMS
 Problem-Oriented Medical Record
 Advantage:
 (a) it encourages collaboration
 (b) the problem list in the front of the chart alerts
caregivers to the client’s needs and makes it
easier to track the status of each problem.
DOCUMENTATION SYSTEMS
 Problem-Oriented Medical Record
 four basic components:
 Database
 Problem list
 Plan of care
 Progress notes.-soapie/soapier
 In addition, flow sheets and discharge
notes are added to the record as
needed.
DOCUMENTATION SYSTEMS
 PIE- problems, interventions, and
evaluation of nursing care.
 The problem statement is labeled “P” and
referred to by number (e.g., P #5). The
interventions employed to manage the
problem are labelled “I” and numbered
according to the problem (e.g., I #5). The
evaluation of the effectiveness of the
interventions is also labelled and numbered
according to the problem (e.g., E #5).
DOCUMENTATION SYSTEMS
 Focus charting -intended to make the
client and client concerns and strengths
the focus of care.
 3 columns for recording are usually used: date
and time, focus, and progress notes.
 The focus may be a condition, a nursing
diagnosis, a behaviour, a sign or symptom, an
acute change in the client’s condition, or a client
strength.
 The progress notes are organized into (D) data,
(A) action, and (R) response, referred to as DAR.
DOCUMENTATION SYSTEMS
 data -assessment phase of the nursing process
-observations of client status and behaviors,
including data from flow sheets (e.g., vital signs,
pupil reactivity). - subjective and objective
 action -planning and implementation and
includes immediate and future nursing actions-
any changes to the plan of care.
 response -evaluation phase - describes the
client’s response to any nursing and medical
care.
DOCUMENTATION SYSTEMS
 Focus charting- provides a holistic perspective of the
client and the client’s needs.
 It also provides a nursing process framework for the
progress notes (DAR).
 The three components do not need to be recorded in
order and each note does not need to have all three
categories.
DOCUMENTATION SYSTEMS
DOCUMENTATION SYSTEMS
 Charting by Exception -a documentation system in
which only abnormal or significant findings or
exceptions to norms are recorded.
 1. Flow sheets. Examples of flow sheets include
graphic records of a vital sign sheet/a head and
face assessment in a daily nursing assessments
record
 2. Standards of nursing care. Documentation by
reference to the agency’s printed standards of
nursing practice eliminates much of the repetitive
charting of routine care.
DOCUMENTATION SYSTEMS
 3. Bedside access to chart forms. In the CBE
system, all flow sheets are kept at the client’s
bedside to allow immediate recording and to
eliminate the need to transcribe data from the
nurse’s worksheet to the permanent record.
 advantages -eliminates lengthy, repetitive notes and it
makes client changes in condition more obvious.
DOCUMENTATION SYSTEMS
 Computerized Documentation
 Electronic health records (EHRs) are used to manage
the huge volume of information required in
contemporary health care. That is, the EHR can
integrate all pertinent client information into one record.
 Multiple flow sheets are not needed in computerized
record systems because information can be easily
retrieved in a variety of formats.
 Computers make care planning and documentation
relatively easy. To record nursing actions and client
responses, the nurse either chooses from standardized
lists of terms or types narrative information into the
compute
DOCUMENTING NURSING ACTIVITIES
 Admission Nursing Assessment
 Nursing Care Plans-traditional and standardized
 Kardexes -widely used, concise method of
organizing and recording data about a client,
making information quickly accessible to all health
professionals.
 Flow Sheets –graphic records, I & O record, MAR,
Skin Assessment record
 Progress Notes
 Nursing Discharge/Referral Summaries
GENERAL GUIDELINES FOR RECORDING
 Date and time  Completeness
 Timing  Conciseness
 Legality  Legal prudence
 Permanence
 Acceptable terminology
 Correct spelling
 Signature
 Accuracy-avoid error
 Sequence
 Appropriateness
REPORTING
 The purpose of reporting is to communicate specific
information to a person or group of people.
 A report, whether oral or written, be concise,
including pertinent information but no extraneous
detail.
 Change-of-Shift Reports-handoff communication
REPORTING
 Telephone Reports- The nurse receiving a
telephone report should document the date and
time, the name of the person giving the
information, and the subject of the information
received, and sign the notation.
 6/6/14 1035 G Messina, laboratory technician,
reported by telephone that Mrs. Sara Ames’s
hematocrit is 39%._____________________ B.
Ireland RN
 The person receiving the information should
repeat it back to the sender to ensure accuracy
REPORTING
 Care Plan Conference-meeting of a group of
nurses to discuss possible solutions to certain
problems of a client
 Nursing Rounds- Nursing rounds are procedures in
which two or more nurses visit selected clients at
each client’s bedside to:
 Obtain information that will help plan nursing care.
 Provide clients the opportunity to discuss their care.
 Evaluate the nursing care the client has received.