UNIT 1:

Assessment, Diagnosis, Intervention, Evaluation and

Documentation

Mrs.Ana.Loki.Kotoimatuku
Personal Professional Development
Updated December 2022
 Learning Outcomes
At the end of the lecture the student will be able to:
1.Describe the nursing assessment of spiritual needs.
2.Demonstrate the use of the spiritual assessment scale
used for patients.
3. Discuss the various nursing diagnoses on Alterations in
Spiritual Integrity.
4. Formulate a nursing care plan for spiritual care.
5. Evaluate the spiritual nursing care that was
implemented.
6. Demonstrate the documentation of the implemented
spiritual care.
 Introduction
 There is a need for assessing and planning for
spiritual care for the client admitted in the
hospital.
 According to Taylor, Lillis and LeMone( 1993),
spirituality assessments of a patient should be
included in any nursing history.
 According to the authors, it influences every aspect
of being in a person’s spirituality and religious
beliefs. ( Taylor, Lillis, LeMone, 1993).
 Nursing Assessment of Spiritual Needs
 Viewing nursing as a vocation,
 Helps us nurses to assess the patient as a whole being
(physically, mentally and spiritually).
 1st step in planning spiritual care for any patient who is ill,
is conducting a spiritual need assessment.
 Either done by nursing research context or through
interaction with the patient and family.( Taylor, 2013)
 Assessment tools vary depending on the care of setting, for
example, intensive care versus a general ward.( Taylor,
2013)
 Some nurses may feel uncomfortable or unprepared to
discuss spiritual or religious topic with patient.( Ameling &
Provilonis, 2001).
Nursing Assessment of Spiritual needs
Spiritual Assessment in Healthcare
 Spiritual Assessment Scale
 Spiritual Assessment Guide was revised and retitled
Spiritual Assessment Scale(SAS).
 Standard instruments measures the construct of
Spiritual Well Being(SWB)
 Contains 21 items.
3 subscales i.e. Personal Faith(PF) includes 7 items,
Religious Practice(RP) includes 7 items and Spiritual
Contentment(SC) includes 7 items.
 The 21 item scale is organized with Likert type scale
response categories:
 SA – Strongly Agree, A – Agree, U – Uncertain, D –
Disagree, SD - Strongly Disagree
SPIRITUAL ASSESSMENT SCALE INSTRUCTIONS:
Please check the response category that best identifies your personal belief about the item:
• SA – Strongly Agree • A – Agree • U – Uncertain • D – Disagree • SD – Strongly Disagree

•A. PERSONAL FAITH:

1. There is a Supreme Being, or God, who created humankind and who cars for all creatures.
SA_____ A_____ U_____ D____ SD_____

2. I am at peace with God.

SA_____ A_____ U_____ D____ SD_____

3. I feel confident that God is watching over me.

SA_____ A_____ U_____ D____ SD_____

4. I receive strength and comfort from my spiritual beliefs.

SA_____ A_____ U_____ D____ SD_____

5. I believe that God is interested in all the activities of my life.

SA_____ A_____ U_____ D____ SD_____

6. I trust that God will take care of the future.

SA_____ A_____ U_____ D____ SD_____

7. My spiritual beliefs support a positive image of myself and of others as members of God’s family.
SA_____ A_____ U_____ D____ SD_____
B. RELIGIOUS PRACTICE:

8. Belonging to a church or faith group is an important part of my life.

SA_____ A_____ U_____ D____ SD_____

9. I am strengthened by participation in religious worship services.

SA_____ A_____ U_____ D____ SD_____

10. I find satisfaction in religiously motivated activities other than attending worship services, for example, volunteer work or
being kind to others.
SA_____ A_____ U_____ D____ SD_____

11. I am supported by relationships with friends or family members who share my religious beliefs.
SA_____ A_____ U_____ D____ SD_____

12. I receive comfort and support from a spiritual companion, for example, a pastoral caregiver or friend.
SA_____ A_____ U_____ D____ SD_____

13. My relationship with God is strengthened by personal prayer.

SA_____ A_____ U_____ D____ SD_____

14. I am helped to communicate with God by reading or thinking about religious or spiritual things.
SA_____ A_____ U_____ D____ SD_____
C. SPIRITUAL CONTENTMENT:

15. I experience pain associated with my spiritual beliefs.

SA_____ A______ U_____ D_____ SD ______

16. I feel “far away” from God.

SA_____ A______ U_____ D_____ SD ______

17. I am afraid that God might not take care of my needs.

SA_____ A______ U_____ D_____ SD ______

18. I have done some things for which I fear God may not forgive me.
SA_____ A______ U_____ D_____ SD ______

19. I get angry at God for allowing “bad things” to happen to me, or to people I care about.
SA_____ A______ U_____ D_____ SD ______

20. I feel that I have lost God’s love.

SA_____ A______ U_____ D_____ SD ______

21. I believe that there is no hope of obtaining God’s love.

SA_____ A______ U_____ D_____ SD ______
Nursing Diagnosis: Alterations in Spiritual
Integrity
 ND - Currently used in selected health care
facilities.
 Label those patients conditions whose
treatment falls within the responsibility of
the nurse.
 7 nursing diagnosis related to “ Alterations in
Spiritual Integrity”.
 Identified by O’Brien 1982a on spirituality
and life threatening illness.
Nursing Diagnosis: Alterations in Spiritual Integrity

 Spiritual Pain:
Expression of discomfort/suffering.
e.g. a terminally ill patient experiencing spiritual
pain and states that he/she has not lived,
according to God’s will.
 Spiritual Alienation:
Expression of loneliness or God seems far away.
e.g. ill person is frustrated that God seems far
away.
Nursing Diagnosis: Alterations in Spiritual Integrity

 Spiritual Anxiety:
Expression of fear of God’s punishment.
e.g. an ill person may think that the illness is a
punishment from God.
 Spiritual Guilt:
Expressions suggesting that he\she has failed to do
the things he\she supposed to do in life.
e.g. individuals who are so religious experience guilt
relating to their failure to follow God.
Nursing Diagnosis: Alteration in Spiritual
Integrity.
 Spiritual Anger:
Expression of frustration or outrage at God for allowing one
of your loved ones to
e.g. Family members of those who are ill express anger at
God for allowing loved one to suffer.
 Spiritual Loss:
Expressions of feeling having terminated the love of God.
e.g.an individual will feel useless and powerless.
 Spiritual Despair:
Expressions of no hope of having a relationship with God.
e.g. If a patient thoughts/ feelings are expressed, nurse
needs to be alerted, can lead to suicidal attempt.
 Formulating NCP: Spiritual Care

Subjective Assessment
FICA – contains open ended
questions to ask patients about
their personal spiritual beliefs
in a way that is open and non
judgmental.
F – Faith/Beliefs
 What is your spiritual beliefs?
 Do you consider yourself
spiritual?
 What things that you believe
in that gives meaning to life?
 Formulating NCP: Spiritual Care
Continue… A – Address
I – Importance/Influence  What support can we
 Is faith/spirituality important provide to support your
to you?
spiritual beliefs/practices?
 How has your illness
and/or/hospitalization affected
your personal beliefs?
C – Community
 Are you connected to a faith
center in the community?
 Does it provide
comfort/support for you during
times of stress?
 Is there a person, group leader
who supports/ assists you in
your spirituality?
 Formulating NCP: Spiritual Care

Objective Assessment  Hope: “ I have nothing

 Nurse to observe patients left to hope for”.
for cues indicating  Mystery : “ Why me?”.
difficulties in finding  Isolation : “ All my
meaning, purpose, or hope
friends/family are gone”.
in life.
 Helplessness : “ I have no
 Be mindful of the
statements indicating control over my life
spiritual distress that anymore”.
should cue the nurse that
spiritual care is needed.
Examples:
 Lack of Meaning: “ I am not
the person I used to be.”
 Therapeutic Nursing Interventions:
Spiritual Support
 Provide privacy and quiet
time for spiritual activities.
 Seek consent.
 Use therapeutic
communication to establish
trust and empathetic caring.
 Be present and actively listen
to the individuals feelings
and express empathy.
 Be open to the individuals
expressions of loneliness and
powerlessness.
 Therapeutic Nursing Interventions:
Spiritual Support
 Be open to the individuals
feelings about illness/or
death.
 Pray with individual.
 Encourage forgiveness.
 Encourage forgiveness.
 Encourage participation in
interactions with friends,
family members and others.
 Encourage participation in
support groups.
Documentation of the Implemented
Spiritual Care
Nursing documentation:
 An integral part of nursing care.
 Carried out to the standard.
 Understanding and skills in applying
the standard of good.
 Large portion of the clinical records
of patients who informs certain
factors that occur during the care
exercised.
 A record that can be proved or be
used as evidence in legal matters.
(Tungpalan, 1983).
 Documentation of the Implemented Spiritual
Care
Continued…
Document information includes:
 Patients details
 Time/Date
 Patients health status
 Spiritual needs
 Nursing activities
 As well as patients response to
care it receives.
 Print your name
 Designation
 Sign and date all entries.
 Documentation of the Implemented
Spiritual Care

Nurse should abide by the policy and nursing

standard of documentation as dictated by the
nursing process.
Activity: Formulate NCP for Spiritual Care
Nursing Assessment:
Mrs. Tiko, 55yrs old I - Taukei female hospitalized, recovering from a
right mastectomy.
Due to the mastasis of the cancer, her prognosis is poor.
Nurse finds her in tears, stating she did not sleep well and does not
want to eat.
“ Why has God done this to me?”, maybe because I have sinned in my
life.
“I’m afraid of dying and what awaits me”, she asked the nurse.
 State your Spiritual Nursing Diagnosis
 Desired Outcome
 Nursing Intervention
 Evaluation Outcome
 Documentation
Activity: Formulate NCP for Spiritual Care
Assessment
Mrs. Tiko, 55yrs old I - Taukei
female hospitalized, recovering
from a right mastectomy.
Due to the mastases of the
cancer, her prognosis is poor.
Nurse finds her in tears, stating
she did not sleep well and does
not want to eat.
“ Why has God done this to
me?”, maybe because I have
sinned in my life.
“I’m afraid of dying and what
awaits me”, she asked the
nurse.
Nursing Diagnosis
Spiritual Distress – related to the
feeling of guilt and alienation from
God as evidenced by questioning
“Why God has done this?", inquires
about insomnia and no appetite.
Desired Outcomes
Spiritual health (2001) as
evidenced by:
Interacts with spiritual leader of
her religion.
Uses a type of spiritual experience
that provides her comfort.
Connects with others to share
thoughts, feelings and beliefs.
 Activity: Formulate NCP for Spiritual Care
Nursing intervention
Spiritual Support:
 Be open to Mrs. Tiko’s
feelings about illness and
death.
 Assist her to express and
relieve anger in appropriate
way.
 Observe and listen to her
communication.
Coping Enhancement
 Create an accepting non
judgmental atmosphere.
 Encourage verbalization of
feelings of perceptions
and fears, allow time for
grieving.
 Encourage her to list
values that guide behavior
in times of tragedy.
 Activity: Formulate NCP for Spiritual Care
Evaluation/Outcome
Mrs. Tiko has been visited
several occasions by her
minister(pastor).
 She read scripture each
day and has found
consolation in reading
the Book of Psalms.
 She states "God is
merciful and will help
me bear my sufferings
of death.”
 Reference

O’Brien, E.M.(2018). Spirituality in Nursing: Standing on Holy

Ground(6th ed.). Burlington, MA, UK : Jones & Bartlett.

https://www.wolterskluwer.com/en/expert-insights/nursing-documentation-how-to-avoid-the-m
ost-common-medical-documentation-errors

Giger, N. J. (2017). Transcultural Nursing: Assessment & Intervention (7th ed.)3251 Riverport Lane, St Louis,
Missouri 63043, USA: Mosby.

O’Brien, E. M. (2014). Spirituality in Nursing: Standing on holy ground (5th ed.). Burlington, MA, UK: Jones
& Bartlett.