Nursing Care Plan: Evidenced by Medical Diagnosis for Enhanced Patient Outcomes

Introduction to Nursing Care Planning

Have you ever considered how healthcare professionals ensure every patient receives personalized and effective care? The answer lies significantly in the meticulous process of nursing care planning. Imagine a scenario where a patient is admitted with a complex medical condition. How do nurses quickly understand their needs and develop a strategy for their care? The answer is through a systematic approach that begins with understanding the patient’s medical diagnosis and culminates in a comprehensive nursing care plan.

Nurses are adept at synthesizing information, often starting from a medical diagnosis, and using the nursing process as a framework to deliver patient-centered care. This chapter will delve into how a nursing care plan, evidenced by a medical diagnosis, becomes the cornerstone of nursing practice, guiding interventions and optimizing patient well-being. We will explore how this structured approach ensures that care is not only responsive to the medical condition but also holistic, addressing the patient’s unique responses to illness.

Foundational Concepts: Critical Thinking and Clinical Reasoning in Nursing

Before we explore the intricacies of nursing care plans, it’s essential to understand the cognitive processes that underpin effective nursing practice: critical thinking and clinical reasoning.

Critical Thinking in Nursing Practice

Critical thinking in nursing is more than just following protocols; it’s a dynamic process of analyzing, evaluating, and synthesizing information to make sound clinical judgments. It encompasses “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow,”[1] ensuring patient safety and optimal care delivery. Critical thinkers in nursing do not merely execute orders; they validate patient information, tailor care plans to individual needs, and base their actions on current best practices and research.

Key attitudes that cultivate critical thinking include:

• Independent Thinking: Formulating your own judgments and not blindly accepting others’ views.
• Fairness: Approaching all viewpoints with impartiality and without bias.
• Insight into Self-centeredness: Recognizing and mitigating personal biases and focusing on the patient’s needs above personal preferences.
• Intellectual Humility: Acknowledging the limits of one’s knowledge and expertise, and being open to learning.
• Non-Judgmental Approach: Applying ethical standards of practice rather than personal moral codes when making clinical decisions.
• Integrity: Upholding honesty and strong ethical principles in all aspects of nursing care.
• Perseverance: Continuing to seek solutions and provide care despite challenges.
• Confidence: Trusting in one’s ability to deliver competent and effective care.
• Exploring Thoughts and Feelings: Being open to diverse perspectives and methods of knowing.
• Curiosity: Inquiring deeply and seeking comprehensive understanding by asking “why” and “how.”

Clinical Reasoning and Clinical Judgment: Connecting Medical Diagnosis to Nursing Care

Clinical reasoning is the “complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[2] It’s the bridge that connects a medical diagnosis to a patient-centered nursing care plan. For instance, a medical diagnosis of pneumonia provides a starting point. Clinical reasoning enables a nurse to gather patient-specific data, understand how pneumonia is affecting this patient, and then determine the most appropriate nursing actions.

Inductive reasoning plays a crucial role in this process. It involves observing specific cues, forming generalizations, and creating hypotheses. Cues are deviations from expected patient findings that signal potential issues. Nurses identify these cues, cluster them into patterns (generalizations), and then propose explanations (hypotheses) about the patient’s condition.

Consider a patient with a medical diagnosis of heart failure. Through inductive reasoning, a nurse might notice cues like increased edema, shortness of breath, and weight gain. These cues lead to a generalization of fluid overload, and a hypothesis that the patient is experiencing Excess Fluid Volume, a nursing diagnosis that directly stems from understanding the implications of heart failure.

Figure 4.1

Inductive Reasoning: Observing Cues to Understand Patient Conditions

Deductive reasoning, or “top-down thinking,” is equally important. It involves applying general rules or standards to specific situations. Nurses use established protocols, guidelines, and standards of care (derived from sources like the Nurse Practice Act or hospital policies) to guide their interventions. For example, a hospital policy based on evidence that early ambulation reduces post-operative complications (a general rule) can be deductively applied to a post-surgical patient’s care plan, including specific interventions to encourage mobility.

Clinical judgment, the outcome of critical thinking and clinical reasoning, is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” [6] It’s the ability to synthesize knowledge, experience, and patient data to make informed decisions about patient care. A nursing care plan is a formalization of clinical judgment, providing a structured pathway for care that is both evidence-based and tailored to the patient’s medical diagnosis and individual needs.

Evidence-based practice (EBP) is integral to both clinical reasoning and the nursing process. It is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.”[7] EBP ensures that nursing care plans are not based on tradition or intuition, but on the most current and reliable evidence, enhancing the effectiveness and safety of patient care.

The Nursing Process: A Framework for Patient-Centered Care

The nursing process is the systematic, patient-centered approach that nurses use to deliver care. It’s a dynamic and cyclical process, constantly adapting to the patient’s evolving health status. The mnemonic ADOPIE represents the six steps: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. This framework is aligned with the Standards of Professional Nursing Practice established by the American Nurses Association (ANA), acting as “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[8]

Figure 4.3

The Continuous and Cyclical Nature of the Nursing Process

Let’s illustrate the nursing process in action with a scenario:

Patient Scenario A: Nursing Process in Action

Consider a patient hospitalized with a medical diagnosis of heart failure, prescribed Lasix 80mg IV daily.

• Assessment: During the morning assessment, the nurse finds: BP 98/60, HR 100, RR 18, Temp 98.7F. Reviewing the patient’s baseline, the nurse notes typical BP around 110/70 and HR in the 80s.
• Diagnosis: Recognizing the pattern of low BP and increased HR as cues related to fluid imbalance, the nurse hypothesizes potential dehydration. Gathering more data, a 4-pound weight decrease since yesterday is noted, and the patient reports a dry mouth and lightheadedness. Based on these findings, the nurse formulates the nursing diagnosis: Fluid Volume Deficit. This diagnosis is directly evidenced by the patient’s medical diagnosis of heart failure, which predisposes patients to fluid imbalances, especially with diuretic therapy.
• Outcomes Identification: The nurse sets outcomes focused on restoring fluid balance.
• Planning: The nurse plans to withhold the scheduled Lasix and consult the healthcare provider. Interventions to increase oral fluid intake and closely monitor hydration are also planned.
• Implementation: The nurse withholds Lasix, contacts the provider, encourages oral intake, and monitors hydration status.
• Evaluation: By shift’s end, the patient’s fluid balance is evaluated as restored based on improved vital signs and patient report.

In this scenario, the nurse’s actions are driven by clinical judgment, not just routine medication administration. The nursing process allows for a dynamic response to patient changes, ensuring safety and effective care. The medical diagnosis of heart failure is the initial context, but the nursing process allows for individualized care based on the patient’s specific presentation and response to their condition.

Each component of the nursing process is further defined by the ANA’s Standards of Professional Nursing Practice, ensuring a consistent and high-quality approach to patient care.

Assessment: The Foundation of the Nursing Process

The “Assessment” Standard of Practice directs nurses to collect “pertinent data and information relative to the health care consumer’s health or the situation.”[11] This involves a systematic collection of physiological, psychological, sociocultural, spiritual, economic, and lifestyle data. For example, in a patient with a medical diagnosis of chronic pain, the nursing assessment goes beyond pain scores to include the pain’s impact on daily living, emotional well-being, and social interactions.

Diagnosis: Evidencing Nursing Needs from Medical Conditions

The “Diagnosis” Standard requires nurses to “analyze the assessment data to determine actual or potential diagnoses, problems, and issues.”[13] A nursing diagnosis is a clinical judgment about the patient’s response to health conditions or life processes. It is distinct from a medical diagnosis, focusing on the patient’s needs that nurses can address. Nursing diagnoses provide the basis for the nursing care plan. They are evidenced by the medical diagnosis because the medical condition often creates specific physiological and psychological challenges that become the focus of nursing care.

For example, a patient with a medical diagnosis of stroke may have nursing diagnoses like Impaired Physical Mobility or Impaired Swallowing. These nursing diagnoses are evidenced by the stroke’s neurological impact, but they are framed in terms of patient function and needs that nursing interventions can directly target.

Outcomes Identification: Setting Patient-Centered Goals

The “Outcomes Identification” Standard states that nurses must “identify expected outcomes for a plan individualized to the health care consumer or the situation.”[15] Outcomes are measurable, patient-centered goals, developed in collaboration with the patient, based on assessment data and nursing diagnoses. For a patient with a nursing diagnosis of Impaired Physical Mobility evidenced by stroke, an outcome might be: “Patient will ambulate 50 feet with a walker by day 3.” This outcome is directly linked to the nursing diagnosis, which in turn is evidenced by the medical diagnosis of stroke.

Planning: Designing the Nursing Care Plan

The “Planning” Standard directs nurses to develop “a collaborative plan encompassing strategies to achieve expected outcomes.”[16] This involves selecting evidence-based nursing interventions tailored to the patient’s needs and nursing diagnoses. The nursing care plan documents these interventions, goals, and expected outcomes, ensuring consistent care. For the Impaired Physical Mobility diagnosis, planned interventions might include physical therapy consultations, scheduled ambulation sessions, and assistive device training – all aimed at achieving the mobility outcome.

NURSING CARE PLANS: The Blueprint for Individualized Care

Nursing care plans are the tangible output of the planning phase. A nursing care plan is a formal document that “demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process.” Registered Nurses (RNs) create these plans to ensure consistency and coordination of care across shifts and among healthcare team members. The care plan becomes a living document, reflecting the patient’s journey and the nursing strategies to support their recovery and well-being. The interventions within the care plan are always directly related to the nursing diagnoses, which are, again, evidenced by the patient’s medical condition.

Implementation: Putting the Plan into Action

The “Implementation” Standard mandates that “the nurse implements the identified plan.”[18] This involves carrying out or delegating nursing interventions as outlined in the care plan, always ensuring continuity of care. Interventions are also meticulously documented in the patient’s electronic medical record as they are performed. For the patient with Impaired Physical Mobility, implementation includes carrying out the planned ambulation exercises, coordinating with physical therapy, and documenting the patient’s progress.

Evaluation: Assessing Effectiveness and Adapting Care

The “Evaluation” Standard requires nurses to “evaluate progress toward attainment of goals and outcomes.”[21] This is a critical step where nurses assess the patient’s response to interventions and compare the outcomes against the initial goals. The care plan is continuously evaluated and modified based on the patient’s progress and changing needs. If the patient with Impaired Physical Mobility does not achieve the ambulation goal by day 3, the care plan must be re-evaluated. Perhaps the interventions need to be intensified, or the goals need to be adjusted.

Benefits of the Nursing Process: Enhancing Patient Care and Outcomes

The nursing process offers numerous benefits:

• Promotes Quality Patient Care: Ensures care is systematic, organized, and patient-centered.
• Reduces Errors: Decreases omissions and duplications in care.
• Provides Consistent Guidance: Offers a clear roadmap for all staff involved in patient care.
• Encourages Collaboration: Facilitates a team-based approach to patient health management.
• Improves Patient Safety and Satisfaction: By focusing on individualized needs and proactive problem-solving.
• Clarifies Goals and Strategies: Clearly defines patient goals and the steps to achieve them.
• Enhances Positive Outcomes: Increases the likelihood of achieving desired patient health improvements.
• Improves Efficiency: Saves time and reduces frustration by providing a structured care pathway.

The nursing process, therefore, is not just a set of steps, but a dynamic, critical thinking model that empowers nurses to provide responsive, effective, and personalized care, always starting with an understanding of the patient’s medical context.

Holistic Nursing Care: Integrating Art and Science

While the nursing process provides the scientific structure for care, the art of nursing brings in the humanistic element. The American Nurses Association (ANA) defines nursing as integrating “the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.”[23]

The art of nursing is “unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”[24] This holistic approach means considering the patient in their entirety – emotional, spiritual, psychosocial, cultural, and physical needs – within the context of their family and community.

Holistic Nursing Care Scenario

Consider a single mother bringing her child to the ER with an ear infection. The medical diagnosis is straightforward, and the physician prescribes antibiotics. However, a nurse practicing holistic care doesn’t stop there. During discharge teaching, the nurse discovers the mother’s struggles: inability to afford the medication and lack of accessible primary care. The nurse then connects the mother with social work resources for insurance and community providers and advocates with the physician for a more affordable antibiotic. This exemplifies holistic care – addressing not just the medical diagnosis, but the broader life context affecting the patient’s health.

Caring and the Nursing Process: Building Therapeutic Relationships

“The act of caring is foundational to the practice of nursing,” states the ANA.[25] Effective use of the nursing process hinges on establishing a care relationship – a mutual relationship built on trust, or rapport. This relationship acknowledges the patient’s vulnerability and dignity, and involves assessing and caring for the whole person. Caring interventions can be as simple as active listening, eye contact, touch, and verbal reassurance, always respecting cultural beliefs and preferences.

Figure 4.4

Touch as a Therapeutic Communication Technique: Demonstrating Care

Dr. Jean Watson’s theory of human caring emphasizes the importance of being authentically present with patients and creating a healing environment. Her philosophy encourages nurses to balance the medical focus on cure with a nursing focus on care, establishing nursing as a distinct and valuable profession.

In summary, the nursing process, deeply rooted in critical thinking and clinical reasoning, provides the scientific backbone of nursing practice. When combined with holistic caring and therapeutic relationships, it enables nurses to deliver truly patient-centered care, effectively addressing health needs evidenced by medical diagnoses and beyond.

Assessment: Gathering Data to Inform the Nursing Care Plan

Assessment, the first step of the nursing process and the first Standard of Practice by the ANA, is defined as “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”[1] This initial step is crucial for understanding the patient’s condition and forms the basis for all subsequent steps in the nursing process. The assessment is directly influenced by the patient’s medical diagnosis, as it guides the nurse in focusing on specific areas relevant to that condition.

Nurses collect data to identify cues, make generalizations, and formulate nursing diagnoses. Patient data is categorized as either subjective or objective, and it’s gathered from various sources.

Subjective Assessment Data: Understanding the Patient’s Perspective

Subjective data is information obtained from the patient and/or their family, offering valuable insights from their perspectives. This type of data is essential for understanding the patient’s experience of their illness. When documenting subjective data, it’s important to use quotation marks and phrases like “The patient reports…” to indicate it’s the patient’s own account.

There are two types of subjective data:

• Primary Data: Information directly from the patient. Patients are the most reliable source about their feelings, symptoms, and experiences. Active listening by the nurse is key to obtaining valuable primary data and building rapport.
• Secondary Data: Information from sources other than the patient, such as family members, medical records, or previous healthcare providers. Secondary data is particularly important for patients who cannot communicate effectively themselves, such as infants, children, or adults with cognitive impairments.

Figure 4.5

Building Rapport While Gathering Subjective Data

Example of Subjective Data Documentation: “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data: Verifiable and Measurable Information

Objective data includes observations that can be seen, heard, felt, or smelled by the nurse, and can be verified by others. It is reproducible and factual, forming the measurable aspects of the patient’s condition. Examples include vital signs, physical examination findings, and laboratory results.

Figure 4.6

Performing a Physical Examination to Collect Objective Data

Example of Objective Data Documentation: “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data: Methods for Data Collection

Nurses use three primary methods to gather assessment data:

1. Interview: Involves asking patients questions, active listening, and observing both verbal and nonverbal cues. Reviewing the patient’s chart beforehand can streamline the interview by avoiding redundant questions and focusing on key areas. The interview should start with introductions and explaining the purpose of the interview. Asking about the patient’s understanding of their medical diagnoses early in the interview can provide context and guide further questioning.

2. Physical Examination: A systematic method of collecting objective data using techniques of inspection, auscultation, palpation, and percussion.

   • Inspection: Observation of the patient’s body and appearance.
   • Auscultation: Listening to body sounds (heart, lungs, bowels) using a stethoscope.
   • Palpation: Using touch to assess organ size, location, tenderness, etc.
   • Percussion: Tapping body parts to assess size and presence of fluid (typically done by advanced practitioners).
     Vital signs collection is also a key component of the physical examination. Registered Nurses (RNs) typically perform the initial comprehensive physical examination, while Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) or Unlicensed Assistive Personnel (UAP) may collect follow-up data like vital signs under RN supervision.

3. Review of Laboratory and Diagnostic Test Results: Provides crucial objective data related to the patient’s health status. Understanding normal and abnormal results is vital for planning care and implementing medical orders. Nurses are responsible for reviewing these results, noting any concerns, and communicating with the provider as needed.

Types of Nursing Assessments: Tailoring Assessments to Patient Needs

Different situations call for different types of nursing assessments:

• Primary Survey: A rapid assessment used in emergencies to evaluate life-threatening conditions related to airway, breathing, and circulation (ABCs), and level of consciousness.
• Admission Assessment: A comprehensive assessment performed upon a patient’s admission to a healthcare facility, gathering extensive data using an organized approach.
• Ongoing Assessment: Regular reassessments in acute care settings, often a head-to-toe assessment done at least once per shift to monitor patient status and detect changes.
• Focused Assessment: In-depth assessment of a specific problem or condition that has already been identified.
• Time-Lapsed Reassessment: Used in long-term care, performed at intervals (e.g., every 3 months) to evaluate progress toward long-term goals.

Putting It Together: Scenario C and Data Collection

Let’s apply these assessment concepts to a patient scenario:

Scenario C

Ms. J., 74 years old, admitted for shortness of breath, ankle/calf swelling, and fatigue. Medical history: hypertension, coronary artery disease, heart failure, type 2 diabetes. Medications: aspirin, metoprolol, furosemide, metformin.

Admission vital signs: BP 162/96, HR 88, SpO2 91% (room air), RR 28, Temp 97.8F. Weight up 10 lbs since last visit 3 weeks ago.

Patient statements: “I am so short of breath,” “My ankles are so swollen,” “I’m so tired and weak,” “Sometimes I’m afraid to get out of bed because I get so dizzy,” “I would like to learn more about my health.”

Physical findings: Bilateral basilar crackles in lungs, 2+ pitting edema ankles/feet. Lab result: Potassium 3.4 mEq/L (low).

Patient’s daughter shares: “We are so worried about mom living at home alone when she is so tired!”

Critical Thinking Questions (Assessment):

1. Identify subjective data: Patient reports of shortness of breath, swollen ankles, fatigue, dizziness, desire to learn about health; daughter’s worry.
2. Identify objective data: Vital signs (elevated BP, HR, RR, low SpO2), weight gain, crackles in lungs, edema, low potassium.
3. Example of secondary data: Daughter’s statement about concerns.

In summary, the assessment phase is a comprehensive data-gathering process, using subjective and objective information from various sources and methods. This data is crucial for the next step in the nursing process: diagnosis. The medical diagnosis provides the initial framework, but the nursing assessment expands on this to understand the patient’s unique response to their health condition.

Diagnosis: Formulating Nursing Diagnoses Evidenced by Medical Conditions

Diagnosis, the second step of the nursing process and the second ANA Standard of Practice, involves “analyzing assessment data to determine actual or potential diagnoses, problems, and issues.”[1] In this phase, nurses move from data collection to clinical judgment, identifying nursing diagnoses that will guide the care plan. These diagnoses are often directly evidenced by or related to the patient’s medical diagnosis, as the medical condition creates the context for the patient’s health challenges.

Analyzing Assessment Data: Identifying Relevant Cues

After collecting assessment data, the nurse analyzes it to differentiate between expected and unexpected findings, or normal and abnormal data, based on the patient’s age, development, and baseline health status. This analysis helps identify “clinically relevant” data that requires nursing attention.

Example: In Scenario C, the nurse analyzes Ms. J.’s vital signs and identifies elevated blood pressure, respiratory rate, and heart rate, along with decreased oxygen saturation. These are deemed “relevant cues” in the context of her medical history of heart failure.

Clustering Information and Forming Hypotheses: Pattern Recognition

Once relevant cues are identified, the nurse clusters them into patterns. Assessment frameworks like Gordon’s Functional Health Patterns can help organize this information. These patterns represent common human responses to health conditions.

Example: In Scenario C, the nurse clusters cues like elevated BP, RR, lung crackles, edema, weight gain, shortness of breath, and heart failure history. These cluster into a pattern related to fluid balance, aligning with Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse hypothesizes Excess Fluid Volume. This nursing diagnosis is directly related to and evidenced by Ms. J.’s medical diagnosis of heart failure, which is known to cause fluid retention issues.

Gordon’s Functional Health Patterns: A Framework for Clustering Data

• Health Perception-Health Management: Patient’s perceived health status and health management practices.
• Nutritional-Metabolic: Food and fluid intake in relation to metabolic needs.
• Elimination: Bowel, bladder, and skin excretory functions.
• Activity-Exercise: Exercise levels and daily activities.
• Sleep-Rest: Sleep patterns, rest, and relaxation.
• Cognitive-Perceptual: Sensory functions, cognition, and pain perception.
• Self-perception and Self-concept: Self-esteem, body image, and emotional state.
• Role-Relationship: Social roles and relationships.
• Sexuality-Reproductive: Sexual function and reproductive health.
• Coping-Stress Tolerance: Stress response and coping mechanisms.
• Value-Belief: Values, beliefs, and spiritual practices guiding health decisions.

Identifying Nursing Diagnoses: NANDA-I and Standardized Terminology

After data analysis and clustering, the nurse identifies nursing diagnoses, defined as “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”[6] Nursing diagnoses are patient-specific and drive the nursing care plan. Nurses use resources like NANDA International (NANDA-I) to select standardized nursing diagnoses. NANDA-I provides a comprehensive list of diagnoses, regularly updated based on research.

NANDA-I diagnoses are organized into 13 domains, similar to Gordon’s Functional Health Patterns, aiding nurses in selecting appropriate diagnoses based on clustered data. These domains include areas like health promotion, nutrition, activity/rest, safety/protection, and comfort.

Nursing Diagnoses vs. Medical Diagnoses: Distinct but Related

It’s crucial to distinguish between nursing diagnoses and medical diagnoses. Medical diagnoses (made by physicians or advanced practitioners) identify diseases or medical conditions (e.g., heart failure, pneumonia). Nursing diagnoses, in contrast, describe the patient’s response to these conditions (e.g., Excess Fluid Volume, Impaired Gas Exchange). Patients with the same medical diagnosis can have different nursing diagnoses because their responses and needs vary.

Example: Ms. J.’s medical diagnosis is heart failure. This isn’t a nursing diagnosis. However, heart failure is an “associated condition” that helps contextualize and evidence potential nursing diagnoses like Excess Fluid Volume, which is a response to heart failure’s physiological effects.

Key Terms in NANDA-I Diagnoses: Patient, Age, and Time

NANDA-I uses specific definitions for terms like “patient,” “age,” and “time” to standardize diagnoses:

• Patient: Can be an individual, caregiver, family, group, or community.
• Age: Categories include fetus, neonate, infant, child, adolescent, adult, and older adult.
• Time: Duration of the diagnosis can be acute (less than 3 months), chronic (more than 3 months), intermittent, or continuous.

New Terms: At-Risk Populations and Associated Conditions

The 2018-2020 NANDA-I updates introduced “at-risk populations” and “associated conditions” to refine diagnoses:

• At-Risk Populations: Groups with shared characteristics making them susceptible to certain responses (e.g., older adults are at higher risk for falls).
• Associated Conditions: Medical diagnoses, treatments, or circumstances that contribute to or evidence a nursing diagnosis (e.g., heart failure is an associated condition for Excess Fluid Volume).

Types of Nursing Diagnoses: Problem-Focused, Health Promotion, Risk, Syndrome

NANDA-I identifies four types of nursing diagnoses:

• Problem-Focused: Describes an existing undesirable response to a condition (e.g., Impaired Gas Exchange related to pneumonia). Requires related factors (causes) and defining characteristics (signs/symptoms).
• Health Promotion-Wellness: Focuses on a patient’s desire to improve well-being (e.g., Readiness for Enhanced Nutrition). Used when a patient is willing to enhance specific health behaviors.
• Risk: Describes vulnerability to developing a problem (e.g., Risk for Falls related to dizziness). Supported by risk factors.
• Syndrome: A cluster of nursing diagnoses occurring together (e.g., Frail Elderly Syndrome). Addressed with similar interventions.

Constructing Nursing Diagnosis Statements: PES Format and Beyond

NANDA-I recommends structuring nursing diagnosis statements to include the nursing diagnosis, related factors, and defining characteristics. This is often referred to as the PES format (though NANDA-I terminology has evolved, the structure remains valuable):

• Problem (P): The nursing diagnosis itself.
• Etiology (E): Related factors, phrased as “related to” (R/T).
• Signs and Symptoms (S): Defining characteristics, phrased as “as manifested by” or “as evidenced by.”

Examples of Nursing Diagnosis Statements:

• Problem-Focused: For Ms. J. in Scenario C, based on assessment data (crackles, edema, weight gain) and her medical diagnosis of heart failure, a diagnosis is: Excess Fluid Volume related to heart failure as manifested by bilateral basilar crackles, 2+ pitting edema, and 10-lb weight gain. The medical diagnosis of heart failure is the underlying condition evidencing the nursing diagnosis.
• Health-Promotion: For Ms. J., expressing a desire to learn more about her health leads to: Readiness for Enhanced Health Management as manifested by expressed desire to “learn more about my health so I can take better care of myself.”
• Risk: Ms. J.’s dizziness and weakness, linked to her medical conditions, lead to: Risk for Falls as evidenced by dizziness and decreased lower extremity strength.
• Syndrome: Ms. J.’s activity intolerance and social isolation (related to her overall frail condition and heart failure) contribute to: Risk for Frail Elderly Syndrome related to activity intolerance and social isolation.

Prioritization of Nursing Diagnoses: Addressing Urgent Needs First

After identifying multiple nursing diagnoses, prioritization is essential. This involves ranking diagnoses based on urgency and patient needs. Prioritization frameworks include:

• Maslow’s Hierarchy of Needs: Prioritizing basic physiological needs (like breathing, circulation) and safety needs before higher-level needs.
• ABCs (Airway, Breathing, Circulation): Addressing immediate life-threatening issues first.
• Acute vs. Chronic Conditions: Acute, uncompensated problems usually take priority over chronic, stable conditions.
• Actual vs. Potential Problems: Actual problems generally prioritized over risk problems, but high-risk situations can be a priority.

Example: For Ms. J., Fluid Volume Excess and Risk for Falls are high priorities. Fluid Volume Excess impacts basic physiological needs (breathing), while Risk for Falls concerns safety. While Readiness for Enhanced Health Management is positive, it’s a lower priority than addressing her immediate physiological and safety needs.

In conclusion, the diagnosis phase of the nursing process is where nurses synthesize assessment data, consider the medical diagnosis as context, and formulate nursing diagnoses that are evidenced by the medical condition and the patient’s unique responses. These diagnoses then become the foundation for individualized nursing care planning.

Outcome Identification: Setting SMART Goals for Patient Care

Outcome Identification, the third step in the nursing process and ANA Standard of Practice, focuses on “identifying expected outcomes for a plan individualized to the health care consumer or the situation.”[1] This step is crucial for setting the direction of care and defining what success looks like for the patient. Outcomes are directly linked to the nursing diagnoses, which are in turn evidenced by the medical diagnosis, creating a clear pathway from medical condition to desired patient results.

An outcome is “a measurable behavior demonstrated by the patient responsive to nursing interventions.”[2] Outcomes are established before planning interventions. They serve as benchmarks for evaluating the effectiveness of the care plan.

Short-Term and Long-Term Goals: Tailoring Timeframes to Patient Needs

Nursing care is always individualized. Goals and outcomes must be tailored to each patient’s unique needs, values, and cultural beliefs. Patient and family involvement in goal setting is essential, promoting buy-in and realistic expectations.

Goals are broad statements describing the desired overall change in patient status. They can be short-term or long-term, with timeframes varying based on the care setting. In acute care, short-term goals might be for hours; in outpatient settings, they could be for weeks or months.

A nursing goal is the overall aim of care, often directly addressing or reversing the nursing diagnosis.

Example: For Ms. J.’s nursing diagnosis of Fluid Volume Excess, a broad goal is: “Ms. J. will achieve a state of fluid balance.” This goal directly counters the identified problem.

Expected Outcomes: SMART Criteria for Measurable Success

While goals are broad, expected outcomes are specific, measurable, and time-bound. They are statements of observable patient behavior that indicate progress toward the goal. Nurses may develop outcomes independently or use standardized systems like the Nursing Outcomes Classification (NOC), which provides a list of over 330 standardized nursing outcomes linked to NANDA-I diagnoses.

Effective outcome statements are patient-centered and follow the SMART criteria:

• Specific
• Measurable
• Attainable/Action-oriented
• Relevant/Realistic
• Time-bound

Figure 4.9

SMART Components of Effective Outcome Statements

SMART Criteria Explained:

• Specific: Outcomes should clearly define what needs to be achieved. Vague outcomes make evaluation difficult.
  • Not specific: “The patient will increase exercise.”
  • Specific: “The patient will walk for 30 minutes daily.”
• Measurable: Outcomes must be quantifiable, using numbers or observable criteria to determine if they’ve been met. Avoid vague terms like “adequate” or “normal.”
  • Not measurable: “The patient will drink enough fluids.”
  • Measurable: “The patient will drink 1500ml of fluids per day.”
• Attainable/Action-Oriented: Outcomes should involve patient actions (using action verbs) and be achievable given the patient’s condition and resources.
  • Not action-oriented: “The patient will have better mobility.”
  • Action-oriented: “The patient will demonstrate correct use of crutches.”
• Relevant/Realistic: Outcomes should be pertinent to the patient’s nursing diagnoses, medical condition, values, and overall goals. They must also be realistically achievable given the patient’s current health status, prognosis, and available resources.
  • Not realistic: “The patient will run a marathon by next week.”
  • Realistic: “The patient will walk 100 feet by discharge.”
• Time-bound: Each outcome should have a specific timeframe for achievement and evaluation. Timeframes depend on the nature of the outcome and the care setting.
  • Not time-bound: “The patient will manage their blood sugar.”
  • Time-bound: “The patient will demonstrate blood glucose self-monitoring by discharge.”

Figure 4.10

Measurable Verbs vs. Non-Measurable Verbs in Outcome Statements

Figure 4.11

Action Verbs for Outcome Statements

Putting It Together: SMART Outcomes for Scenario C

For Ms. J.’s nursing diagnosis Fluid Volume Excess related to heart failure, a SMART expected outcome could be: “The patient will exhibit clear bilateral lung sounds as auscultated by the nurse within 24 hours.” This outcome is:

• Specific: Focuses on lung sounds.
• Measurable: “Clear bilateral lung sounds” is objectively assessed by auscultation.
• Attainable/Action-oriented: Related to a nursing assessment.
• Relevant/Realistic: Directly addresses Fluid Volume Excess and is achievable in her condition.
• Time-bound: “Within 24 hours.”

In summary, outcome identification is about setting clear, measurable, achievable, relevant, and time-bound goals for patient care. These outcomes are derived from the nursing diagnoses, which are evidenced by the patient’s medical condition, ensuring that the entire care plan is focused on achieving positive and tangible results for the patient.

Planning: Designing Nursing Interventions Based on Medical Diagnosis

Planning, the fourth step of the nursing process and ANA Standard of Practice, involves developing “a collaborative plan encompassing strategies to achieve expected outcomes.”[1] In this phase, nurses select specific nursing interventions designed to help the patient reach the previously defined outcomes. These interventions are directly linked to the nursing diagnoses, which are evidenced by the patient’s medical diagnosis, creating a clear and logical flow from understanding the medical condition to implementing targeted nursing actions.

Nursing interventions are evidence-based actions that nurses perform to achieve patient outcomes. They are the “prescriptions” nurses use to address patient problems, much like medical prescriptions from providers address medical conditions. Effective nursing interventions aim to eliminate or reduce the related factors (etiology) of the nursing diagnoses whenever possible. The nursing care plan documents these interventions, along with goals and outcomes, to ensure consistent and coordinated care.

Selecting Nursing Interventions: Evidence-Based Practice

How do nurses choose the right interventions? Evidence-based practice is key. Nurses can use several resources:

• Agency Care Planning Tools: Many healthcare facilities provide standardized care plan templates within electronic health records (EHRs), often including pre-approved interventions.
• Nursing Care Planning Books and Resources: Textbooks and online databases offer lists of evidence-based interventions for various nursing diagnoses.
• Nursing Interventions Classification (NIC): NIC is a standardized classification system that categorizes and describes nursing interventions based on research and professional consensus. It’s a valuable tool for identifying evidence-based interventions.

The nurse’s clinical judgment is crucial in selecting the most appropriate interventions for an individual patient, considering their specific needs, preferences, and the context of their medical diagnosis.

Direct and Indirect Care Interventions: Different Modes of Delivery

Nursing interventions can be categorized as:

• Direct Care: Interventions involving direct patient interaction. Examples: wound care, medication administration, patient teaching, counseling, physical therapy exercises, and emotional support.
• Indirect Care: Interventions performed away from the patient but on their behalf. Examples: consulting with other healthcare team members, documenting care, participating in care conferences, advocating for the patient’s needs, managing the patient’s environment to ensure safety and comfort.

Classification of Nursing Interventions: Independent, Dependent, and Collaborative

Nursing interventions are further classified based on the level of autonomy and collaboration required:

Independent Nursing Interventions: Nurse-Initiated Actions

Independent nursing interventions are actions nurses can initiate autonomously, without needing a physician’s order. These are based on nursing knowledge and scope of practice. Examples include:

• Patient education and counseling
• Repositioning and mobility assistance
• Monitoring vital signs and patient status
• Implementing comfort measures
• Encouraging deep breathing and coughing exercises
• Providing emotional support
• Adjusting the patient’s environment for safety and comfort

Example: For Ms. J.’s Fluid Volume Excess diagnosis, an independent intervention is: “The nurse will elevate the patient’s legs while sitting to promote venous return and reduce edema.” This intervention is within the nurse’s scope of practice and directly addresses a symptom of fluid overload.

Dependent Nursing Interventions: Prescription-Required Actions

Dependent nursing interventions require an order or prescription from a primary healthcare provider (physician, advanced practice nurse, or physician assistant). These are typically medical treatments or actions outside the nurse’s independent scope of practice. Examples include:

• Medication administration
• Oxygen therapy
• Dietary orders
• Wound care treatments prescribed by a physician
• Diagnostic tests

Example: For Ms. J.’s Fluid Volume Excess, a dependent intervention is: “The nurse will administer furosemide (Lasix) 40mg IV daily as prescribed by the physician to reduce fluid volume.” This intervention directly addresses the fluid overload issue, but requires a medical order.

Collaborative Nursing Interventions: Team-Based Actions

Collaborative nursing interventions are carried out in coordination with other members of the healthcare team, such as physicians, therapists (physical, occupational, respiratory), dietitians, social workers, etc. These interventions require interprofessional communication and shared decision-making. Examples include:

• Physical therapy and occupational therapy regimens
• Respiratory therapy treatments
• Nutritional plans from a dietitian
• Social work consultations for discharge planning or resource needs
• Pain management strategies involving multiple disciplines

Figure 4.12

Collaborative Nursing Interventions: Working with the Healthcare Team

Example: For Ms. J.’s Fluid Volume Excess, a collaborative intervention might be: “The nurse will consult with a respiratory therapist to optimize oxygen therapy and breathing treatments to improve gas exchange.” This requires collaboration to ensure coordinated respiratory care.

Individualization of Interventions: Patient-Centered Approach

It’s crucial that planned interventions are individualized to the patient. What works for one patient may not work for another, even with the same medical diagnosis and nursing diagnosis. Patient preferences, cultural considerations, lifestyle, and available resources must be considered. For example, suggesting increased fluid intake for a patient with dehydration is a standard intervention, but the type of fluids and how they are offered must be tailored to the patient’s preferences and abilities.

Creating Nursing Care Plans: Formalizing the Plan

Nursing care plans are documented by Registered Nurses (RNs). They are legally required in many settings, like long-term care facilities and hospitals, to ensure quality and consistent care. Care plans can be standardized (with pre-set interventions) or fully customized, but they should always be individualized to the patient’s needs.

Figure 4.13

Example of a Standardized Nursing Care Plan

Nursing care plans, regardless of format (standardized, concept map, table), serve as a blueprint for care. They ensure that all healthcare providers are working towards the same patient outcomes and using consistent, evidence-based interventions. The interventions are always selected to address the nursing diagnoses, which are, in turn, evidenced by the patient’s medical condition. This interconnectedness ensures that the care plan is both medically informed and patient-centered.

Implementation of Interventions: Putting the Nursing Care Plan into Action

Implementation, the fifth step of the nursing process and ANA Standard of Practice, is where the nursing care plan comes to life. It involves “implementing the identified plan.”[1] This step requires nurses to use critical thinking and clinical judgment to execute interventions effectively and safely. Implementation is guided by the nursing care plan, which is evidenced by the patient’s medical diagnosis, ensuring that actions are targeted and relevant to the patient’s health condition.

Continual reassessment is crucial during implementation. The patient’s condition is dynamic, and the care plan must be flexible enough to adapt to changes. This step involves prioritizing interventions, ensuring patient safety, delegating appropriately, and documenting all actions.

Prioritizing Implementation: Addressing the Most Urgent Needs First

Prioritizing interventions follows similar principles as prioritizing nursing diagnoses, using frameworks like Maslow’s Hierarchy of Needs and the ABCs (Airway, Breathing, Circulation). Life-threatening issues take immediate precedence. Least invasive interventions are generally preferred initially, progressing to more invasive options if needed.

The timing of interventions is also critical. Some actions must be completed at specific times to be effective or to prevent complications. Understanding the patient’s daily schedule, planned procedures, and medication timings is important for prioritization.

Patient Safety During Implementation: Minimizing Risks and Errors

Patient safety is paramount during intervention implementation. Nurses must constantly assess for changes in patient condition that might make a planned intervention unsafe or inappropriate. Clinical judgment dictates when to modify or withhold an intervention based on real-time patient assessment.

Example: If a care plan includes “ambulate patient twice daily,” but the patient suddenly becomes dizzy and hypotensive, the nurse would not implement the ambulation intervention without further assessment and modification of the plan.

Preventable medical errors are a serious concern in healthcare. Reports like “To Err Is Human” and “Preventing Medication Errors” have highlighted the scope of the problem and the need for system-wide improvements and vigilant nursing practice. Nurses are on the front lines of patient safety, acting as crucial error preventers.

The Quality and Safety Education for Nurses (QSEN) project emphasizes the importance of quality improvement (QI) in nursing education and practice. Nurses are expected to participate in QI initiatives to identify gaps in care and implement changes to improve patient outcomes and system performance.

Delegation of Interventions: Utilizing the Healthcare Team

During implementation, RNs often delegate tasks to other members of the healthcare team, such as Licensed Practical Nurses (LPNs) or Unlicensed Assistive Personnel (UAP). Delegation is the assignment of tasks to qualified individuals while the RN retains accountability for the outcome.

RNs must consider the “Five Rights of Delegation”:

1. Right Task: Is the task appropriate for delegation based on patient needs and team member skills?
2. Right Circumstance: Is the patient stable enough for delegation?
3. Right Person: Is the team member competent to perform the task?
4. Right Communication: Is the delegation clear, concise, and understood?
5. Right Supervision: Will appropriate monitoring and feedback be provided?

RNs cannot delegate tasks requiring clinical judgment or those outside the scope of practice of the delegatee. Understanding state Nurse Practice Acts and agency policies is essential for safe delegation.

Documentation of Interventions: Creating a Legal and Clinical Record

Accurate and timely documentation of implemented interventions is crucial. Documentation in the patient’s medical record serves as:

• Legal Record: Proof that care was provided. Lack of documentation can be legally interpreted as lack of care.
• Communication Tool: Informs other healthcare team members about the care provided and the patient’s response.
• Data for Evaluation: Provides evidence for evaluating the effectiveness of the care plan and making necessary revisions.

Interventions should be documented as soon as possible after they are performed to ensure accuracy and prevent errors.

Coordination of Care and Health Teaching/Health Promotion: Expanding the Nurse’s Role

The ANA’s Implementation Standard also includes “Coordination of Care” and “Health Teaching and Health Promotion.” These expand the scope of implementation beyond just task completion:

• Coordination of Care: Involves organizing all aspects of the patient’s care, ensuring seamless transitions, engaging the patient in self-care, and advocating for holistic care.
• Health Teaching and Health Promotion: Includes educating patients and families about their health conditions, treatments, self-management techniques, and preventive measures. Patient education should be integrated into every patient interaction.

Putting It Together: Implementation in Scenario C

In Scenario C (Ms. J. with heart failure and Fluid Volume Excess), implementation would involve:

• Prioritizing: Administering diuretic medication (dependent intervention) first to address Fluid Volume Excess, then implementing independent interventions like leg elevation and fluid restriction education.
• Safety: Continuously monitoring vital signs, lung sounds, and edema to assess response to diuretic and adjust interventions as needed.
• Delegation: Delegating tasks like daily weights to UAP.
• Documentation: Recording medication administration, lung sound assessments, edema levels, patient education provided, and any changes in patient status in the EHR.
• Coordination: Communicating with the physician about Ms. J.’s fluid status and response to treatment, coordinating with respiratory therapy if needed, and involving social work for discharge planning.
• Health Teaching: Educating Ms. J. about her medications, fluid and sodium restrictions, self-monitoring for fluid overload symptoms, and when to seek medical attention.

In summary, implementation is the action phase of the nursing process. It requires careful prioritization, unwavering attention to patient safety, effective delegation, thorough documentation, and a commitment to coordination of care and health promotion. All implementation actions are driven by the nursing care plan, which is ultimately evidenced by the patient’s medical diagnosis and individual needs.

Evaluation: Assessing the Effectiveness of the Nursing Care Plan

Evaluation, the sixth and final step of the nursing process and ANA Standard of Practice, is defined as “evaluating progress toward attainment of goals and outcomes.”[1] This step is crucial for determining the effectiveness of the nursing care plan and making necessary adjustments. Evaluation is directly linked back to the nursing care plan, which is evidenced by the patient’s medical diagnosis, ensuring that the care remains relevant and effective in addressing the patient’s health needs.

Evaluation is an ongoing process, not just a final step. Nurses continuously evaluate patient status and the effectiveness of interventions, modifying the care plan as needed. This dynamic process ensures that care remains patient-centered and responsive to changing conditions.

Assessing Outcome Achievement: Met, Partially Met, or Not Met

During evaluation, nurses compare the patient’s current status to the expected outcomes established in the planning phase. The goal is to determine if outcomes have been:

• Met: The patient has achieved the desired outcome within the specified timeframe.
• Partially Met: The patient has made some progress toward the outcome, but not fully achieved it within the timeframe.
• Not Met: The patient has made little or no progress toward the outcome within the timeframe.

This evaluation requires critical thinking and analysis of reassessment data. It’s not just about checking off a list; it’s about understanding why outcomes were or were not achieved.

Revising the Care Plan: Adapting to Patient Progress and Challenges

If outcomes are not met or only partially met, the nursing care plan must be revised. Evaluation is the trigger for re-planning. Revision involves revisiting all steps of the nursing process:

• Re-Assessment: Is the original assessment data still accurate and complete? Are there new cues or changes in patient status that need to be considered?
• Re-Diagnosis: Are the nursing diagnoses still appropriate? Have new diagnoses emerged? Do any diagnoses need to be modified or reprioritized?
• Re-Outcome Identification: Were the original outcomes realistic and achievable? Do they need to be revised based on the patient’s progress or lack thereof? Are the timeframes still appropriate?
• Re-Planning of Interventions: Were the interventions effective? Do different interventions need to be selected? Are there barriers to implementation that need to be addressed?

Guiding questions for care plan revision:

• Did anything unexpected happen during implementation?
• Has the patient’s condition changed significantly?
• Were the expected outcomes and timeframes realistic?
• Are the nursing diagnoses still accurate and relevant?
• Were the planned interventions appropriate and effective?
• What barriers hindered outcome achievement?
• What does ongoing assessment data suggest about needed changes to diagnoses, outcomes, interventions, or implementation strategies?
• Are different or additional interventions required?

Putting It Together: Evaluation in Scenario C

In Scenario C (Ms. J.), let’s evaluate the outcomes for the nursing diagnosis Fluid Volume Excess. The expected outcomes were:

1. Patient will report decreased dyspnea within 8 hours.
2. Patient will have clear lung sounds within 24 hours.
3. Patient will have decreased edema within 24 hours.
4. Patient’s weight will return to baseline by discharge.

Evaluation on Day 1:

• Outcome 1 (Dyspnea): Met. Ms. J. reported decreased shortness of breath within 8 hours.
• Outcome 2 (Lung Sounds): Met. Clear lung sounds auscultated within 24 hours.
• Outcome 3 (Edema): Partially Met. Weight decreased by 1 kg, but 2+ edema in ankles/calves persisted.
• Outcome 4 (Weight Baseline): Not Met. Baseline weight not expected to be met until discharge.

Revision based on Evaluation:

Outcomes 1 and 2 were met, indicating positive response to interventions. Outcome 3 was partially met, showing improvement but ongoing issue. Outcome 4 is long-term. Care plan revision should focus on:

• Maintaining current interventions: Continue diuretic administration, fluid restriction, monitoring.
• Adding new interventions to address persistent edema: Consider adding TED hose (prescription needed) and leg elevation when sitting (independent intervention).

The care plan would be updated with these revisions. For the Risk for Falls diagnosis, if the outcome “Patient will remain free from falls” is evaluated as “Met,” then that aspect of the care plan would continue to be implemented and evaluated.

Documentation of the evaluation is essential, noting whether outcomes were met, partially met, or not met, and any revisions made to the care plan.

In conclusion, evaluation is the critical step that closes the loop in the nursing process. It ensures that nursing care is effective, patient-centered, and continuously improving. By rigorously evaluating outcomes and revising care plans based on patient response, nurses ensure that the care remains aligned with the patient’s needs, as evidenced by their medical diagnosis and their individual journey toward health and well-being.

Summary of the Nursing Process: A Dynamic Cycle of Care

You have now journeyed through each step of the nursing process – Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation – guided by the ANA Standards of Professional Nursing Practice. This systematic approach, often remembered by the mnemonic ADOPIE, is the cornerstone of modern nursing practice.

Critical thinking, clinical reasoning, and sound clinical judgment are the threads that weave through every step. The nursing process is not linear but cyclical and dynamic, requiring constant reassessment and adaptation to the patient’s ever-changing health status. Frequent reassessment and care plan revision are not signs of failure, but hallmarks of effective, patient-centered care.

Throughout the entire process, the patient remains at the center. The nursing care plan, evidenced by the medical diagnosis, ensures that care is both medically informed and deeply personalized. It is through this integrated approach – blending the science of nursing with the art of caring – that nurses optimize patient outcomes and provide truly professional, safe, and compassionate care.

Video Review: Creating a Sample Care Plan

This video provides a helpful visual summary of how to create a nursing care plan, reinforcing the steps of the nursing process and demonstrating its practical application in patient care.

Learning Activities: Applying the Nursing Process

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Instructions: Apply your knowledge of the nursing process by creating a nursing care plan for the following patient scenario. Use the template in Appendix B as a guide.

Patient Scenario:

Mark S., a 57-year-old male, is admitted to the hospital with “severe” abdominal pain, unresolved in the ER. The physician informs Mark he needs diagnostic tests scheduled for the morning.

After hearing this, Mark becomes visibly anxious and begins pacing. He repeatedly asks the nurse, “How long will the tests take?” and states, “I’m so uptight, I’ll never sleep tonight.” He avoids eye contact, fidgets with the call light, and his eyes dart around the room. He appears tense, with a strained facial expression, and reports, “My mouth is so dry.”

Vital signs: T 98°F, P 104 bpm, R 30 breaths/min, BP 180/96 mmHg. Skin is diaphoretic and cool.

Critical Thinking Activity:

1. Cluster Subjective and Objective Data: Group the data into subjective (patient reports) and objective (nurse observations, vital signs) categories.
2. Formulate a Problem-Focused Nursing Diagnosis (Hypothesis): Based on the clustered data, identify a relevant NANDA-I nursing diagnosis. Consider the evidence provided by Mark’s presentation related to his medical situation.
3. Develop a Broad Goal and SMART Expected Outcome: Create a broad goal related to the nursing diagnosis, and then write a SMART expected outcome.
4. Outline Three Nursing Interventions: List three specific, evidence-based nursing interventions to address the nursing diagnosis and help achieve the outcome. Cite an evidence-based source for one intervention.
5. Evaluate Outcome Achievement: Imagine you implemented your interventions. Evaluate if the expected outcome was: Met, Partially Met, or Not Met. Explain your evaluation.

IV. Glossary of Key Terms

Advocacy: Pleading for, supporting, or recommending a cause or course of action on behalf of the patient.[1]

Art of nursing: Providing compassionate, comforting care while unconditionally accepting the humanity of others and respecting their dignity.[2]

At-risk populations: Groups sharing characteristics that increase susceptibility to specific human responses.[3]

Associated conditions: Medical diagnoses, injuries, or treatments that are not nurse-modifiable but inform nursing diagnoses.[4]

Basic nursing care: Predictable care following defined procedures with minimal modification.[5]

Caring relationship: A mutual relationship built on trust and respect, considering the patient’s vulnerability and dignity.[6]

Client: Individual, family, group, or community receiving care.[7]

Clinical judgment: Outcome of critical thinking and decision-making, using nursing knowledge for safe patient care.[8]

Clinical reasoning: Cognitive process of gathering, analyzing, and evaluating patient information for informed action.[9]

Clustering data: Grouping related assessment data into patterns.

Collaborative nursing interventions: Actions requiring cooperation among healthcare team members.

Coordination of care: Organizing care plan components, engaging patients in self-care, and advocating for holistic care.[10]

Critical thinking: Reasoning about clinical issues, teamwork, and workflow to ensure patient safety and quality.[11]

Cue: Subjective or objective data indicating a potential patient problem.

Deductive reasoning: “Top-down” thinking, applying general rules to specific situations.

Defining characteristics: Observable cues clustering as manifestations of a nursing diagnosis.[12]

Delegation: Assigning patient care tasks to qualified personnel while retaining accountability.[13]

Dependent nursing interventions: Actions requiring a prescription from a healthcare provider.

Direct care: Interventions involving personal patient contact.

Electronic Medical Record (EMR): Digital version of a patient’s medical chart.

Evidence-Based Practice (EBP): Integrating best research evidence, clinical expertise, and patient preferences in care.[14]

Expected outcomes: SMART statements of measurable patient action within a specific timeframe.

Functional health patterns: Assessment framework for identifying patient problems and risks.

Generalization: Judgment formed from a set of facts and observations.

Goals: Broad statements describing the aim of nursing care.

Health teaching and health promotion: Strategies to educate and promote patient wellness.[15]

Independent nursing interventions: Actions nurses can initiate autonomously.

Indirect care: Interventions performed on behalf of the patient but outside direct contact.

Inductive reasoning: Forming generalizations from specific observations.

Inference: Interpretation or conclusion based on cues and assumptions.

Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs): Licensed nurses with specific training, practicing under RN or provider supervision.

Medical diagnosis: Disease or illness identified by a physician or advanced practitioner.

Nursing: Integrating art and science of caring to promote health, prevent illness, and alleviate suffering.[16]

Nursing care plan: Formal documentation of individualized nursing care planning and delivery.

Nursing process: Systematic, patient-centered care approach: Assessment, Diagnosis, Outcomes, Planning, Implementation, Evaluation (ADOPIE).

Objective data: Verifiable data observed by the nurse (signs, measurements, test results).

Outcome: Measurable patient behavior responsive to nursing interventions.[17]

PES Statement: Format for nursing diagnosis statements: Problem, Etiology, Signs/Symptoms.

Prescription: Orders for interventions or treatments from an authorized healthcare provider.[18]

Primary data: Information directly from the patient.

Primary health care provider: Licensed professional authorized to prescribe treatments (physician, NP, PA).[19]

Prioritization: Deciding the order of actions based on patient needs and urgency.

Quality improvement: Efforts to enhance patient outcomes, system performance, and professional development.[20]

Rapport: Relationship of mutual trust and understanding.

Registered Nurse (RN): Licensed nurse with comprehensive education and training.

Related factors: Underlying causes (etiology) of a nursing diagnosis.

Right to self-determination: Patient’s right to make decisions about their own care.

Scientific method: Systematic approach to knowledge discovery involving problem identification, data collection, and hypothesis testing.

Secondary data: Information from sources other than the patient.

Subjective data: Patient’s reports, feelings, and perceptions.

Unlicensed Assistive Personnel (UAP): Trained, unlicensed staff assisting in supportive roles under nursing supervision.[21]

References

1.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
2.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
3.Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵
4.Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵
5.Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
6.Walivaara B., Savenstedt S., Axelsson K. Caring relationships in home-based nursing care – registered nurses’ experiences. The Open Journal of Nursing. 2013;7:89–95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf ↵
7.NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm ↵
8.NCSBN. (n.d.). NCSBN clinical judgment model. https://www.ncsbn.org/14798.htm ↵
9.Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221. ↵
10.American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association. ↵
11.Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221. ↵
12.NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/ ↵
13.American Nurses Association. (2013). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). American Nurses Association. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf ↵
14.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
15.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
16.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
17.Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵
18.NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm ↵
19.NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm ↵
20.Batalden P. B., Davidoff F. What is “quality improvement” and how can it transform healthcare?. BMJ Quality & Safety. 2007;16(1):2–3. ↵
21.NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm ↵

Figure 4.5

Obtaining Subjective Data with a Senior Patient