Nursing

Process
 History
 1955- Hall originates the team care, cure,
core:
3 steps observation, administration,
validation.
 1959- Johnson, “nursing seen as fostering
the behavioral functioning of the client”.
 1961- Oralando identifies three steps:
client behavior, nurse’s reaction and
action.
 History Conti….
 1963- Weidenbach was the first to use a
series of phases describing the process.
 1967- Wiche identifies 4 steps:
Perception, Communication,
Interpretation, Evaluation.
 1967- Yura and Walsh published first
comprehensive book on nursing process
suggested 4 steps: Assessment, Planning,
Intervention, Evaluation.
 History Conti….

 1973—ANA Congress for Nursing

Practice developed Standard of
Practice
 1982—state board examinations for
professional nursing uses nursing
process as organizing concept
 Nursing Process

 The nursing process is a deliberate,

problem-solving approach to meeting the
health care and nursing needs of patients.
It involves assessment (data collection),
nursing diagnosis, planning,
implementation, and evaluation, with
subsequent modifications used as feedback
mechanisms that promote the resolution of
the nursing diagnoses.
 Nursing Process
 Nursing Process: Systematic method
of giving humanistic care that
focuses on achieving outcomes in a
cost effective manner.
 Characteristics of the
Nursing Process
 Systematic:
Part of an ordered sequence of activities
 Dynamic:
Great interaction and overlapping
among the five steps
 Interpersonal:
Human being is always at the heart of
nursing
 Characteristics of the
Nursing Process
 Outcome oriented:
Nurses and patients work together
to identify outcomes

 Universally applicable:
A framework for all nursing
activities
Advantages of Nursing Process
 Provides individualized care
 Promotes continuity of care
 Provides more effective communication
among nurses and healthcare
professionals
 Develops a clear and efficient plan of care
 Provides personal satisfaction as you see
client achieve goals
 Professional growth as you evaluate
effectiveness of your interventions
 Question
Which of the following characteristics
of the nursing process describes the
interaction and overlapping of steps
within the process itself?
A. Systematic
B. Dynamic
C. Interpersonal
D. Universally Applicable
 Answer
Answer: B. Dynamic
Rationale:
The nursing process is dynamic in that
there is much interaction and overlapping
of the steps.
It is systematic since it is an ordered
sequence of activities.
Interpersonal refers to the human being
at the heart of nursing.
The nursing process is universally
applicable in that it is a framework for all
nursing activities.
 Assessment
 It is systematic, dynamic way to
collect and analyze data about a
client, the first step in delivering
nursing care. Assessment includes
not only physiological data, but also
psychological, sociocultural,
spiritual, economic, and life-style
factors as well.
 Example
 A nurse’s assessment of a
hospitalized patient in pain includes
not only the physical causes and
manifestations of pain, but the
patient’s response—an inability to
get out of bed, refusal to eat,
withdrawal from family members,
anger directed at hospital staff, fear,
or request for more pain mediation.
Purpose of Assessment

 To establish a database concerning a

client’s physical, psychosocial, and
emotional health.
 To identify health-promoting
behaviors as well as actual and/or
potential health problems.
 Assessment
When assess a patient, think
critically about what to assess. Make
a quick observational overview
using:
 Cues
 Inferences
 Cue:
is information that you obtain through
use of the senses.
e.g. assumes slumped posture, patient
states “I am so tired”.
 Inferences:
is your judgment or interpretation of
those cues.
e.g. feeling fatigue, generalized
weakness,
 Approaches for comprehensive
assessment
 1. Gordon’s 11 functional health
pattern.
 2. Problem focused approach:

 Gordon’s 11 functional health pattern:

an assessment moves from general to
specific. When assess Gordon’s 11
functional health patterns and then
determine if there is any problem in any
pattern ask more focused questions about
those health patterns.
 Approaches for comprehensive
assessment cont’d
1. Gordon’s 11 functional health pattern.

 Health perception-  Cognitive-

health management perceptual pattern.
pattern.  Self –perception
 Nutritional pattern.
metabolic pattern.  Role-relationship
 Elimination pattern.
pattern.  Sexuality-
 Activity exercise reproductive
pattern.
pattern.
 Sleep rest pattern.  Copping stress
pattern.
 Approaches for comprehensive
assessment cont’d
2. Problem focused approach:
it focus on the patient’s situation and
begin with problematic areas such
bas patient’s report of feeling tired.
Example:
 Pain
 Nature of pain.
 Precipitating factors.
 Relieving factors.
 Types of Data

 Subjective data:
data from client’s point of view, and
include perceptions, feelings, and
concerns. Collected by interview.
 Objective data:
observable and measurable, obtained
through both physical examination and
the results of lab and diagnostic testing.
 Sources of Data
 Primary Source
 The client
 Secondary Sources
 All other sources of data
 Family and significant others.
 Medical record.

 Health care team.

 Nurse’ s experience.

Copyright 2008 by Pearson Education, Inc.

 Methods of data collection

1. Interview (history)
2. Health Assessment -Review of
Systems
3. Physical Examination
1. Interviewing:
 Planned communication or a
conversation with a purpose
 Used to:
 Identify problems of mutual concern
 Evaluate change

 Teach

 Provide support

 Provide counseling or therapy

Copyright 2008 by Pearson Education, Inc.

 Interview Phases

 Preparatory
 Introduction
 Working
 Termination
 Interview Phases conti….
 Preparatory
 Nurse collects background info from
previous charts
 Ensure environment is conducive

 Arrange seating
 3 – 4 ft apart
 Interviewer at 45° angle to patient

 Allow adequate time

 Phases cont’d.
 Introduction
 Nurse introduces self
 Identifies purpose of interview

 Ensure confidentiality of information

 Working
 Nurse gathers info for subjective data
 Excellent communication skills are

needed
 Active listening
 Eye contact

 Open-ended questions
 Phases cont’d.
 Termination
 Inform patient when nearing end of
interview
 Ensure patient knows what will happen

with info
 Offer patient chance to add anything
 Interview Technique

 Close end questions.

 Open end questions.
 Closed and Open-ended
Questions
Closed Question Open-ended
 Restrictive Question
 Yes/no
 Specify broad topic to
discuss
 Factual
 Invite longer answers
 Less effort and  Get more information
information from from client
client  Useful to change
 “What medications topics and elicit
did you take?” attitudes
 “Are you having pain  “How have you been
now?” feeling lately?”
Copyright 2008 by Pearson Education, Inc.
2. Health Assessment -Review of Systems
3. Physical Examination:
 Inspection (looking at the body)
 Palpation (feeling the body with fingers or
hands)
 Percussion (producing sounds, usually by
tapping on specific areas of the body)
 Auscultation (listening to sounds)
 Nursing Health History
 In the Assessment Phase, obtain a
Nursing Health History – a structured
interview designed to collect specific
data and to obtain a detailed health
record of a client.
 Components of a Nursing Health
History:
 Biographic data – name, address, age,
sex, martial status, occupation, religion.
 Components of a Nursing
Health History cont’d
 Reason for visit/Chief complaint –
primary reason why client seek
consultation or hospitalization.
 History of present Illness –
includes: usual health status,
chronological story, family history,
disability assessment.
 Past Health History – includes all
previous immunizations, experiences
with illness.
 Components of a Nursing
Health History cont’d
 Family History – reveals risk factors
for certain disease diseases (Diabetes,
hypertension, cancer, mental illness).
 Review of systems – review of all
health problems by body systems
 Lifestyle – include personal habits,
diets, sleep or rest patterns, activities
of daily living, recreation or hobbies.
 Components of a Nursing
Health History cont’d
 Social data – include family
relationships, ethnic and educational
background, economic status, home
and neighborhood conditions.
 Psychological data – information
about the client’s emotional state.
 Pattern of health care – includes all
health care resources: hospitals,
clinics, health centers, family doctors.
 1. Initial assessment
 is performed within a specified time
after admission to a health care
agency for the purpose of
establishing a complete database
for problem identification,
reference, and future comparison.
 2. Problem-focused
assessment
 In this nurse determine whether the
status of the problem still exists &
whether the status of the problem has
changed i.e. improves, worsened or
resolved. It is use to determine status
of a specific problem identified in an
earlier assessment
 Ex: problem on urination-assess on
fluid intake & urine output hourly
 3. Emergency
assessment
 occurs during any physiologic or
psychologic crisis of the client to
identify the life-threatening
problems and to identify new or
overlooked problems.
 4. Time-lapsed
assessment
 occurs several months after the
initial assessment to compare the
client’s current status to baseline
data previously obtained.
Assessment Activities
 Collecting data
 Organizing data
 Validating data
 Analysis and Interpreting
data
 Documenting data
 Assessment Activities
Cont…
 Collecting data:
is the process of gathering information
about a client’s health status.
 Organizing data:
is categorizing data systematically using a
specified format.
 Validating data:
is the act of “double-checking” or
verifying data to confirm that it is
accurate and factual.
 Assessment Activities
Cont…
 Analysis & Interpreting data:
three critical component:
 Distinguish between relevant, irrelevant.
 Determine whether and where there are

gaps in the data.

 Identify patterns of cause and effect.

 Documenting:
is accurately and factually recording
data.
 Data Characteristics

 Complete
 Factual
 Accurate
 Relevant
 Concept mapping
 Concept mapping is effective learning
strategy to understand the
relationship that exist between client
problem.
 To organize the assessment data.
 Placing all the cues together into
those clusters that lead into next step
nursing diagnosis.
Nursing Diagnosis
 Nsg Dx vs MD Dx
 Within the scope of  Within the scope of
nursing practice medical practice
 Identifies situations  Identifies conditions
the nurse is licensed the MD is licensed
& qualified to treat & qualified to treat
 Identify responses  Focuses on curing
to health and illness pathology
 Can change from  Stays the same as
day to day long as the disease
is present
Nsg Dx vs MD Dx
 Nursing diagnoses are different
from medical diagnoses in
 Purpose.
 Goals.

 Therapeutic interventions.
Example
 For example, if the medical diagnosis for
Sheila Barrington is breast cancer, appropriate
nursing diagnoses may include Fear, Deficient
Knowledge related to treatment measures,
Anticipatory Grieving, Body Image
Disturbance, Powerlessness, and Ineffective
Coping. In addition, the goals (aims, intent, or
ends) that accompany these nursing diagnoses
differ, as do the specific, individualized
therapeutic nursing interventions (nursing
actions to promote or restore health and
enhance general well-being).
 Diagnosis
Nursing diagnosis Medical diagnosis

Breathing patterns, Chronic obstructive

ineffective pulmonary disease
Activity intolerance Cerebrovascular
accident
Pain Appendicectomy

Body image disturbance Amputation

Body temperature, risk Strep throat

for altered
 Formulating a Nursing
Diagnosis
Composed of 2 parts:
 Part one–problem statement or
diagnostic label describing the
client’s response to actual or risk
health problem or wellness condition.
 Part two–etiology or the related
cause or contributor to the problem.
 Linked by the term related to (r/t).
 Examples of nursing diagnoses
are:
 Disturbed Body Image RT loss of left
lower extremity.
 Activity Intolerance RT decreased oxygen-

carrying capacity of cells.

 Descriptive words or terms may be added

to clarify specific nursing diagnoses such

as Decreased, Deficient, Depleted,
Disturbed, Dysfunctional, Excessive,
Impaired, Increased, Ineffective etc.
 Formulating a Nursing
Diagnosis
Composed of 3 parts:
 Problem statement- the client’s

response to a problem
 Etiology- what’s causing/contributing

to the client’s problem

 Defining Characteristics- subjective

and objective data, or clinical

manifestations.
 Third part linked to the first two by

the term as evidenced by (AEB).

Types of Nursing Diagnosis

 Actual
 Risk
 Wellness
 Possible
 Syndrome
 Types of Nursing Diagnosis
cont’d
 Actual Diagnosis:
 Problem present at the time of the

assessment
 Presence of associated signs and symptoms
(ineffective breathing pattern)
Types of Nursing Diagnosis
cont’d
 Risk Diagnosis:
 Problem does not exist

 Presence of risk factors

Types of Nursing Diagnosis
cont’d
 Wellness:
 Readiness for enhancement
 describes human responses to levels of
wellness in an individual, family, or
community that have a readiness
enhancement.”
 Examples: readiness for enhanced
spiritual well- being or
readiness for enhanced family coping
 is written as readiness to/for action.
 Types of Nursing Diagnosis
cont’d
 Possible Diagnosis:
 Evidence about a health problem
incomplete or unclear
 Requires more data to either support or

to refute it
 (possible social isolation)
Types of Nursing Diagnosis
cont’d
 Syndrome Diagnosis:
 Associated with a cluster of other
diagnoses
 Example: is Rape Trauma Syndrome.

 is written as problem/diagnosis related to (r/t)

x factor/cause.
 DIAGNOSTIC AXES

 Axis
An axis is operationally defined as a
dimension of the human response
that is considered in the diagnostic
process. There are seven axes which
parallel the International Standards
Reference Model for a Nursing
Diagnosis.
 Axis 1: the diagnostic focus
 Axis 2: subject of the diagnosis (individual,
caregiver, family, group, community)
 Axis 3: judgment (impaired, ineffective, etc.)
 Axis 4: location (bladder, auditory, cerebral,
etc.)
 Axis 5: age (infant, child, adult, etc.)
 Axis 6: time (chronic, acute, intermittent)
 Axis 7: status of the diagnosis (problem-
focused, risk, health promotion).
 Axis 1 The Diagnostic Focus
 The diagnostic focus is the principal
element or the fundamental and essential
part, the root, of the diagnostic concept. It
describes the “human response” that is
the core of the diagnosis.
 The diagnostic focus may consist of one or
more nouns.
for example, Activity intolerance.
Axis 2 Subject of the Diagnosis
 The person(s) for whom a nursing
diagnosis is determined. The values in
Axis 2 which represent the NANDA-I
definition of “patient” are:
Individual: a single human being distinct
from others, a person.
 Axis 3 Judgment

 A descriptor or modifier that limits

or specifies the meaning of the
diagnostic focus. The diagnostic
focus together with the nurse’s
judgment about it forms the
diagnosis.
 Axis 4 Location

 Describes the parts/regions of the

body and/or their related functions –
all tissues, organs, anatomical sites,
or structures.
 Axis 5 Age
 Refers to the age of the person who is the subject of the
diagnosis (Axis 2). The values in Axis 5 are noted below
Fetus: an unborn human more than eight weeks after
conception, until birth
 Neonate: a child < 28 days of age
 Infant: a child > 28 days and <1 year of age
 Child: person aged 1 to 9 years, inclusive
 Adolescent: person aged 10 to 19 years, inclusive
 Adult: a person older than 19 years of age unless
national law defines a person as being
an adult at an earlier age
 Older adult: a person > 65 years of age
 Axis 6 Time

 Describes the duration of the

diagnostic concept (Axis 1). The
values in Axis 6 are:
 Acute: lasting <3 months
 Chronic: lasting >3 months

 Intermittent: stopping or starting again

at intervals, periodic, cyclic

 Continuous: uninterrupted, going on

without stop.
Axis 7 Status of the Diagnosis

 Refers to the actuality or potentiality

of the problem/syndrome or to the
categorization of the diagnosis as a
health promotion diagnosis. The
values in Axis 7 are:
 Problem-focused.
 Health Promotion.

 Risk & syndrome.

 COMPONENTS OF A NURSING
DIAGOSIS

 Diagnosis Label.
 Definition
 Defining Characteristics
 Risk Factors
 Related Factors
 COMPONENTS OF A NURSING
DIAGNOSIS cont’d

 Diagnosis Label
Provides a name for a diagnosis that
reflects, at a minimum, the diagnostic
focus (from Axis 1) and the nursing
judgment (from Axis 3). It is a concise
term or phrase that represents a pattern
of related cues. It may include modifiers.
 COMPONENTS OF A NURSING
DIAGNOSIS cont’d
 Definition:
Provides a clear, precise description; delineates
its meaning and helps differentiate it from
similar diagnoses.
 Defining Characteristics:
Observable cues/inferences that cluster as
manifestations of a problem-focused, health-
promotion diagnosis or syndrome. This does not
only imply those things that the nurse can see,
but things that are seen, heard (e.g., the
patient/family tells us), touched or smelled.
 COMPONENTS OF A NURSING
DIAGNOSIS cont’d

 Risk Factors:
Environmental factors and physiological,
psychological, genetic, or chemical
elements that increase the vulnerability of
an individual, family, group, or community
to an unhealthy event. Only risk diagnoses
have risk factors.
 COMPONENTS OF A NURSING
DIAGNOSIS cont’d

 Related Factors:
Factors that appear to show some type of
patterned relationship with the nursing diagnosis.
Such factors may be described as antecedent to,
associated with, related to, contributing to, or
abetting. Only problem-focused nursing diagnoses
and syndromes must have related factors; health-
promotion diagnoses may have related factors, if
they help to clarify the diagnosis.
 PROCESS OF A NURSING DIAGNOSIS

 Data analysis.
 Clusters and interpret cues.
 Generate Hypotheses.
 Validation & Prioritization.
 Planning.
 Intervention.
 Evaluation.
 PROCESS OF A NURSING DIAGNOSIS
cont’d
 Data analysis:
Conduct a nursing assessment collection
of subjective and objective data relevant
to the care recipient's (person, family,
group, community) human responses to
actual or potential health problems / life
processes.
 Cluster and interpret cues:
data must be clustered and interpreted
before the nurse can plan, implement or
evaluate a plan to support patient care
 PROCESS OF A NURSING DIAGNOSIS
cont’d
 Generate Hypotheses:
possible alternatives that could represent the
observed cues/patterns.
 Validation & Prioritization:
of Nursing Diagnoses taking necessary steps
to rule out other hypotheses, to confirm with
the patient(s) the validity of the hypotheses,
and to prioritize the list of diagnoses. A
focused assessment may be needed to obtain
data for one or more diagnoses
 PROCESS OF A NURSING DIAGNOSIS
cont’d
 Planning :
Determining appropriate (realistic)
patient outcomes.
 Interventions:
most likely to support attainment of those
outcomes through evidence-based
practice Implementation Putting the plan
of care (nursing diagnoses - outcomes -
interventions) into place, preferably in
collaboration with the care recipient(s)
 Question
A patient who admits to smoking two
packs of cigarettes a day is diagnosed
with lung cancer based on his symptoms
and a series of test results. Which of the
following is the etiology in this scenario?
A. Lung cancer
B. Test results
C. Smoking cigarettes
D. The subjective and objective data
 Answer
Answer: C. Smoking cigarettes
Rationale:
The etiology is the factor that
maintains the unhealthy condition
(smoking cigarettes). Lung cancer is
the problem, and the remaining
factors are the distinguishing
characteristics.
 Question
Which of the following nursing diagnoses
would most likely be considered a high
priority?
A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance
 Answer
Answer: B. Impaired gas exchange
Rationale:
Impaired gas exchange poses a threat to
the patient’s well-being.
Disturbed personal identity and risk for
powerlessness are non–life-threatening
and are ranked as medium priorities.
Activity intolerance, if not specifically
related to the current health problem, is a
low priority.
PROCESS OF A NURSING DIAGNOSIS
cont’d

 Evaluation:
Movement toward identified outcomes is
continually evaluated, with changes made
to interventions as necessary. When no
positive movement is occurring,
reassessment to reevaluate
appropriateness of diagnoses and/or
achievability of outcomes must occur.
 Question
Which of the following nursing diagnoses
is written correctly?
A. Child Abuse related to maternal
hostility
B. Breast Cancer related to family history
C. Deficient Knowledge related to
alteration in diet
D. Imbalanced Nutrition related to
insufficient funds in meal budget
 Answer
Answer: D. Imbalanced Nutrition related
to insufficient funds in meal budget
Rationale:
Answer A makes legally inadvisable
statements, answer B is a medical
diagnosis, and answer C reverses the
clauses in the statement.
 Common Sources of Error in
Nursing Diagnoses
 Premature diagnoses based on
incomplete database
 Erroneous diagnoses resulting from
inaccurate or faulty database
 Error in interpretations and analysis
 Errors in data clustering
 Errors of omission
 BARRIERS TO NURSING
DIAGNOSIS
1. Nurses are more overworked than
ever and have less time to spend with
clients.
2. Care is still organized around the
medical diagnosis and nurses are
involved in the completion of tasks
based on this focus.
3. Nurses are afraid they may be
ridiculed for using nursing diagnoses.
 Cont’d….
4. Nurses may also be unable and
unwilling to use nursing diagnoses
because of incomplete knowledge
about the process and
disagreements about wording. The
nursing diagnosis list does not
always fit the client situation.
 OVERCOMING BARRIERS TO
NURSING DIAGNOSIS
 According to Carlson-Catalano (1993), the
only way society will understand
professional nursing is through the
language used by nurses.
 Effective communication, in turn, improves
the accuracy in nursing diagnoses.
 Administrators and medical staffs need to
be more supportive of the use of nursing
diagnoses in their respective settings.
 Cont’d
 Nurses collaborate on the
refinement of nursing diagnoses.
 Enhanced communication among
nurses in everyday settings and
among professionals.
 Experienced nurses need
opportunities to review principles of
nursing diagnoses,
 Culture relevance of nursing
diagnosis
 A patient’s culture influences the type of
health care problems.
 Nurse should consider how culture
influences the related factor for diagnostic
statement.
 Foe example, impaired verbal
communication related to culture differences
or non compliance related to patient’s value
system reflect diagnostic conclusions that
considers patient’s unique cultural needs.
Maslow’s Hierarchy of Human
Needs
 Planning
 Based on the assessment and diagnosis,
the nurse sets measurable and achievable
short- and long-range goals for this
patient that might include moving from
bed to chair at least three times per day;
maintaining adequate nutrition by eating
smaller, more frequent meals; resolving
conflict through counseling, or managing
pain through adequate medication.
 Assessment data, diagnosis, and goals are
written in the patient’s care plan so that
nurses as well as other health
 Planning
Third step of the Nursing Process
 This is when the nurse organizes a

nursing care plan based on the

nursing diagnoses.
 Nurse and client formulate goals to

help the client with their problems

 Expected outcomes are identified

 Interventions (nursing orders) are

selected to aid the client reach these

goals.
Purposes of planning
Advantages f planning
Steps of planning
 Identify factors that the nurse
must consider when setting
priorities.
 Setting Priorities
 High priority (life-threatening)
 Medium priority (health-threatening)

 Low priority (developmental needs)

 How to Make a Plan That
Works
Track
Track
Develop
Develop Progress
Progress
Set
Set Develop
Develop Effective
Effective Maintain
Maintain
Toward
Toward
Goals
Goals Commitment
Commitment Action
Action Flexibility
Flexibility
Goal
Goal
Plans
Plans Achievement
Achievement

Revise
Revise existing
existing plan
plan
or
or
Begin
Begin new
new planning
planning process
process

2
118
 Setting Goals
Specific
Specific
S.M.A.R.T.
Measurable
Measurable

Attainable
Attainable

Realistic
Realistic

2.1 Timely
Timely
119
 Planning- Types of goals

 Short term goals

 Long term goals

 Cognitive goals

 Psychomotor goals

 Affective goals
 Planning- Types of goals

 Long-term—requires a longer period to

be achieved and may be used as discharge
goals
 Short-term—may be accomplished in a
specified period of time
 Planning- Types of goals

 Cognitive: mental skills (knowledge)

 Affective: growth in feelings or emotional
areas (attitude or self)
 Psychomotor: mantal or physical skills
(skills)
 Question
Which one of the following examples is a
psychomotor outcome?
A. A patient learns how to control his
weight using the MyPyramid Food Guide.
B. A patient is able to test for glucose
levels and inject insulin as needed.
C. A patient values his health enough to
decide to quit smoking.
D. A patient is able to ambulate the
hallway following knee surgery.
 Answer
Answer: B. A patient is able to test for glucose
levels and inject insulin as needed.
Rationale:
Psychomotor outcomes involve the patient’s
achievement of a new skill, such as controlling
diabetes.
Cognitive outcomes involve an increase in patient
knowledge (Answer A).
Affective outcomes pertain to changes in patient
values (Answer C).
Physiologic outcomes target physical changes in
the patient (Answer D).
 Three Elements of
Comprehensive Planning

 Initial
 Ongoing
 Discharge
 Initial Planning
 Developed by the nurse who performs the
nursing history and physical assessment
 Addresses each problem listed in the
prioritized nursing diagnoses
 Identifies appropriate patient goals and
related nursing care
 Ongoing Planning
 Carried out by any nurse who interacts
with patient
 Keeps the plan up to date
 States nursing diagnoses more clearly
 Develops new diagnoses
 Makes outcomes more realistic and
develops new outcomes as needed
 Identifies nursing interventions to
accomplish patient goals
 Discharge Planning

 Carried out by the nurse who worked

most closely with the patient
 Begins when the patient is admitted for
treatment
 Uses teaching and counseling skills
effectively to ensure home care behaviors
are performed competently
Factors to Consider When
Setting Priorities
 Client’s health values and beliefs
 Client’s priorities
 Resources available to the nurse
and client
 Urgency of the health problem
 Medical treatment plan
 Common Errors in Writing
Patient Outcomes

 Expressing patient outcome as nursing

intervention
 Using verbs that are not observable or
measurable
 Including more than one patient behavior
or manifestation in short-term outcomes
 Writing vague outcomes
 Problems Related to Outcome
Identification and Planning
 Failure to involve patient
 Insufficient data collection
 Nursing diagnoses developed from
inaccurate or insufficient data
 Outcomes stated too broadly
 Outcomes derived from poorly developed
nursing diagnoses
 Failure to write nursing order clearly
 Nursing orders that do not solve problems
 Failure to update the plan of care
 Planning Developing a goal and
outcome statement

 Goal and outcome statements are client

focused.
 Worded positively
 Measurable, specific observable, time-limited,
and realistic
 Goal = broad statement
 Expected outcome = objective criterion for
measurement of goal
 Guidelines for Writing
Goal/Outcome Statements
 Patient centered.
 Singular goal or outcome.
 Observable.
 Measurable.
 Time limited.
 Mutual factors.
 Realistic.
 Guidelines for Writing
Goal/Outcome Statements
cont’d
 Patient centered:
Outcomes & goals reflect the patient behavior
or responses expected as a result of nursing
intervention.
Example: a correct outcome statement is
“patient will ambulate 3 times a day”.
A common error is to write
“ambulate patient 3 times a
day”.
 Guidelines for Writing
Goal/Outcome Statements
cont’d
Singular goal or outcome:
to ensure precise evaluation of care,
each goal and outcome addresses only
one behavior or response.
Example: if outcome reads “patient’s lungs
will be clear to auscultation and respiratory
rate will be 22 breaths / minute, consider the
outcomes when you evaluate that the lungs
are clear but RR is 28 breaths / min. it will be
difficult to determine whether the expected
outcome has been achieved. Singularity allow
to decide the need to modify the plan of care.
 Guidelines for Writing
Goal/Outcome Statements
cont’d
 Observable:
observable changes occur in physiological
findings and the patient's knowledge,
perception and behavior perception and
behaviors.
 Measureable:
set standards against which to measure
the patient’s response to nursing care. Do
not use vague qualifiers such as normal,
acceptable, stable or sufficient.
 Guidelines for Writing
Goal/Outcome Statements
cont’d
 Time limited:
the time frame for each goal and expected outcome
indicates when you expect the response to occur.
 Mutual factors:
mutual goal setting increases the patient’s
motivation and cooperation.
 Realistic:
when establishing realistic goals, be sure to know
the resources of health care facility, family and
patient.
 Critical thinking in planning
nursing care
 Choosing suitable nursing
interventions involves critical
thinking. Its need competency in
three areas:
1. Knowing the scientific rationale.

2. Possessing the necessary

psychomotor and interpersonal skills.
3. Being able to function within a
particular setting to use the available
resources effectively.
 Types of intervention
1. independent interventions.
2. dependent interventions.
3. collaborative intervention.
 independent interventions:
those activities that nurses are
licensed to initiate on the basis of
their knowledge and skills;
Types of intervention cont’d
 dependent interventions:
activities carried out under the primary
care provider’s orders or supervision,
or according to specified routines.
 collaborative interventions:
actions the nurse carries out in
collaboration with other health team
members. The nurse must choose
interventions that are most likely to
achieve the goal/desired outcome.
 Nursing intervention
classifications
 It includes three levels and 7 domains.
 Level 1:
 Domain 1: physiological: basic
 Domain 2: physiological: complex
 Domain 3: behavioral
 Domain 4: safety
 Domain 5: family
 Domain 6: health system
 Domain 7: community
 Nursing intervention
classifications cont’d
 Level 2:
 Activity & exercise management.
 Elimination management.

 Immobility management.

 Nutrition support.

 Physical comfort promotion.

 Electrolyte and acid base management.

 Drug management.

 Neurological management.
 Nursing intervention
classifications cont’d
 Preoperative care.
 Skin / wound management.
 Thermoregulation.
 Tissue perfusion management.
 Behavior therapy.
 Cognitive therapy.
 communication enhancement.
 Copping assistance.
 Crisis management.
 Risk management.
 Nursing intervention
classifications cont’d
 Level 3: activity and exercise
management
 Example: fatigue falls under this
level energy management, exercise
therapy, ambulation.
 Criteria for Choosing
Appropriate Intervention

 Safe and appropriate for the client’s age,

health, and condition
 Achievable with the resources available
 Congruent with the client’s values, beliefs,
and culture
 Congruent with other therapies
 Based on nursing knowledge and experience
or knowledge from relevant sciences
 Within established standards of care
 Question
Which one of the following nursing actions would most
likely occur during the ongoing planning stage of the
comprehensive care plan?
A. The nurse collects new data and uses them to
update the plan and resolve health problems.
B. The nurse uses teaching and counseling skills to
help the patient carry out self-care behaviors at home.
C. The nurse who performs the admission nursing
history develops a patient care plan.
D. The nurse consults standardized care plans to
identify nursing diagnoses, outcomes, and
interventions.
 Answer
Answer: A. The nurse collects new data and uses
them to update the plan and resolve health problems.
Rationale:
In the ongoing planning stage, any nurse who
interacts with the patient updates the plan to
facilitate the resolution of health problems, manage
risk factors, and promote function.
Teaching and counseling are the key to discharge
planning.
The nurse performing the admission nursing history
consults standardized care plans during initial
planning to formulate the initial care plan.
 Implementation
 The performance of the nursing
interventions identified during the
planning phase.
 Carrying out (or delegating) and
documenting planned nursing
interventions.
 This step of the nursing process involves
the execution of the nursing care plan
derived during the Planning phase.

Copyright 2008 by Pearson Education, Inc.

Goals
•Assist the client to meet desired
goals/outcomes
•Promote wellness
•Prevent illness and disease
•Restore health
•Facilitate coping with altered
functioning
 Implementation cont’d

 This is the “Doing” step

 This includes:
 monitoring.
 Teaching.

 further assessing.

 reviewing NCP.

 incorporating physicians orders.

 monitoring cost effectiveness of

interventions
 Utilize NIC as standard
 Implementation cont’d
 This step of the nursing process
involves the execution of the nursing
care plan derived during the Planning
phase.
 Putting your plan into action
 Set priorities after report

 Assess and reassess

 Perform interventions

 Chart client responses

 Give report to next shift

Types of Nursing Interventions

 Direct
 Indirect
 Independent interventions
 Dependent interventions
 Collaborative
interventions
 Direct care:
is an intervention performed
through interaction with the client.
 Indirect care:
is an intervention performed away
from but on behalf of the client such
as interdisciplinary collaboration or
management of the care
environment.
 independent interventions:
those activities that nurses are
licensed to initiate on the basis of
their knowledge and skills.
 dependent interventions:
activities carried out under the
primary care provider’s orders or
supervision, or according to specified
routines;
 Implementation process

 Preparation for implementation

ensures efficient, safe and effective
nursing care. Follow these activities:
 Reassess the patient.
 Review and revise the existing nursing

care plan.
 Organize resources and care delivery.

 Anticipate and prevent complication.

 Implementing skills.
Implementation process cont’d
Reassess the patient:
Just before implementing a nursing
activity, reassess the patient.
Example:
You planned to assist a patient with
ambulation following lunch, however a
reassessment reveals shortness of breath
and increased fatigue which required to
assist the patient back to bed.
Implementation process cont’d
 Review and revise the existing
nursing care plan:
there are four steps to modifying the written
care plan:
1. Revise data:

revise data in the assessment section to reflect

the patient’s current status. Date any new data
to inform others health team members of the
time that the change occurred.
Implementation process cont’d

2. Revise the nursing diagnosis:

It is necessary to revise related factors,
as well as the client’s goals, outcomes
and priorities. Date any revision.
3. Revise specific intervention:
This should reflect the client’s present
status.
4. Determine evaluation:
If you achieved outcomes.
Implementation process cont’d

 Organize resources and care delivery:

a facility’s resources includes:
 Equipment.:
place equipment in a convenience
location to provide easy access.
Equipment should in working order to
ensure safe use.
 Personnel:

when interventions are complex or

physically difficult, nurse will probably
need assistance from colleagues.
Implementation process cont’d
 Environment:
client safety is first concern. If the
client has sensory deficits, physical
disability or an alteration in level of
consciousness, arrange the
environment to prevent injury.
 Client:

before deliver intervention, b sure the

client is an physically and
psychologically comfortable as possible.
Implementation process cont’d
 Anticipate and prevent complication:
as a nurse, be alert for recognize risks,
adapt choice of intervention to the
situation, evaluate the relative benefits of
the treatment versus the risk and finally
initiate risk prevention measures.
The scientific rationale for certain
intervention e.g. pressure relief devices,
repositioning or wound care help to
prevent or minimize complications.
Implementation process cont’d
 Implementing skills:
nursing practice includes:
 Cognitive skills (involves the application of critical
thinking)
 Interpersonal skills (communication is critical for
keeping client informed, provide individualize client
teaching and effectively supporting clients with emotional
needs).
 Psycho motor skills (integration of cognitive and motor
activities).
 EVALUATION

 Fifth step in the nursing process.

 Determines whether client goals
have been met, partially met, or not
met.
 Ongoing evaluation is essential for
the nursing process to be
implemented appropriately.
Explain how evaluating relates to
other phases of the nursing
process.
 Nursing Process—Evaluating
 Depends on the effectiveness of phases that
precede
 Assessing and nursing diagnosis must be
accurate
 Goals/desired outcomes must be stated
behaviorally to be useful for evaluating
 Without implementing phase, there would be
nothing to evaluate
Components of the Evaluation
Process
 Collecting data related to the desired
outcomes
( nursing outcomes classifications NOC
indicators)
 Comparing the data with outcomes

 Relating nursing activities to outcomes

 Drawing conclusions about problem status

 Continuing, modifying, or terminating the

nursing care plan

 Question
Tell whether the following statement is
true or false.
The purpose of evaluation is to allow the
patient’s achievement of expected
outcomes to direct future nurse–patient
interactions.
A. True
B. False
 Answer
Answer: A. True
The purpose of evaluation is to allow the
patient’s achievement of expected
outcomes to direct future nurse–patient
interactions.
 Question
Which of the following actions should the
nurse take when a patient has achieved
each expected outcome in the plan of
care?
A. Terminate the plan of care
B. Modify the plan of care
C. Continue the plan of care
 Answer
Answer: A. Terminate the plan of care
Rationale:
The plan of care is terminated when the
patient has achieved all of its goals.
The plan of care is modified when there
are difficulties achieving outcomes.
The plan of care is continued if more time
is needed to achieve the outcomes.
 Nursing care plan
Elevated Body Temperature

 Assessment:
umer is 35 years old school teacher
who arrives at out patient clinic with
the complain of malaise. His medical
history includes a past urinary tract
infection.
 Nursing care plan cont’d
Assessment activities: Findings/defining
Characteristics
 Palpate skin. Skin warm & dry to
touch.
 Clients behavior while labored breathing &
face
talking & resting. Flushed.
 Obtain vital signs. Pulse 128/minute.
Respiration
36/minute.
Temp 102 F.
 Nursing care plan cont’d
 Review medical Smoking one pack
of history. cigarettes per
day.
Expectorating yellow
sputum.
tired for past three
days.
Upon rising in the
morning
has been dizzy.
 Nursing care plan cont’d
 Nursing diagnosis:
 Elevated body temperature related to
infection.
 Planning:
 Goals:
 Patient will gain normal body temperature
within 24 hours.
 Attain sense of comfort and rest within 24 hours.

 Fluid and electrolyte balance maintain during

next 3 days.
 Nursing care plan cont’d
 Expected outcomes:
 Temperature will decline at least 1 degree F

within next 6 hours.

 Increased satisfaction with rest and sleep.

 Increase in energy level within next 3 days.

 Intake will equal output within next 24 hours.

 Implementation:
 Reduce external covering.

 Monitor temperature.

 Administer medication as ordered.

 Limit physical activity and increase frequency of

rest.
 Increase oral fluids.
 Nursing care plan cont’d

 Rationale:
 Promotes heat lost through conduction
& convection.
 Antipyretics reduce fever.

 Activity & stress increase metabolic

rate.
 Intake fluid prevent water loss.
 Nursing care plan cont’d

 Evaluation:
 Body temperature normal.
 Denies dizziness.

 Patient responds “I am sleeping much

better and have returned to work with

lot of energy.
 DOCUMENTATION

 Any printed or written record of

activities.
 Recording and reporting are the
major ways health care providers
communicate.
 The client’s medical record is a
legal document of all activities
regarding client care.
 PRINCIPLES OF EFFECTIVE
DOCUMENTATION

1. Document accurately, completely,

and objectively, including any
errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.
 PRINCIPLES OF EFFECTIVE
DOCUMENTATION (continued)

7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10. Write on every line.
11. Chart omissions.
12. Sign each entry.
 SOAP, SOAPI, AND
SOAPIER
 S: subjective data
 O: objective data
 A: assessment data
 P: plan
 I: implementation
 E: evaluation
 R: revision
 PIE CHARTING

 P: problem
 I: intervention
 E: evaluation