Comprehensive Guide to Nursing Care Plans: Diagnosis & Interventions [PDF]

Learning Objectives

• Apply the nursing process to deliver effective patient care.
• Identify and utilize evidence-based nursing diagnoses.
• Understand the development and components of a nursing care plan.
• Prioritize nursing care based on patient needs.
• Accurately document each stage of the nursing process.
• Differentiate the roles of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) in care planning.

Have you ever considered how nurses seamlessly transition between patients, providing immediate and informed care even with minimal prior knowledge? The answer lies in the nursing process, a systematic framework that serves as their roadmap. This process is a critical thinking model, guiding nurses’ actions and interventions to enhance patient well-being and achieve optimal health outcomes. This chapter will delve into the nursing process, illustrating its use as a standard of professional nursing practice to ensure safe and patient-centered care. We will also explore how to effectively utilize nursing care plans as a central tool in this process, and where to find PDF resources for nursing care plans, nursing diagnoses, and interventions.

Basic Concepts: Critical Thinking and Clinical Reasoning in Nursing

Before diving into the specifics of the nursing process, it’s crucial to grasp the foundational concepts of critical thinking and clinical reasoning in nursing practice. Let’s examine how nurses think and make decisions in dynamic healthcare settings.

Critical Thinking and Clinical Reasoning Defined

Nurses employ critical thinking and clinical reasoning continuously when providing patient care, making complex decisions in real-time. Critical thinking in nursing goes beyond simply following protocols; it’s about “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow,”[1] ensuring patient safety is paramount and not just a secondary concern. This involves validating patient information for accuracy and tailoring care plans to individual needs based on current best practices and research.

Effective critical thinkers in nursing adopt specific attitudes that promote rational and effective decision-making:

• Independence of Thought: Formulating your own judgments and not blindly accepting others’ opinions.
• Fair-mindedness: Approaching every situation and viewpoint with impartiality and without preconceived biases.
• Insight into Egocentricity and Sociocentricity: Recognizing when decisions are influenced by personal biases (egocentricity) versus the greater good of the patient or community (sociocentricity).
• Intellectual Humility: Acknowledging the limits of one’s knowledge and skills, and seeking further learning when necessary.
• Nonjudgmental Attitude: Applying professional and ethical standards in decision-making, rather than personal or moral biases.
• Integrity: Maintaining honesty and strong ethical principles in all aspects of nursing practice.
• Perseverance: Continuing to pursue the best course of action for the patient, even when faced with challenges.
• Confidence: Trusting in one’s ability to provide safe and effective care.
• Interest in Exploring Thoughts and Feelings: Being open to different perspectives and approaches to patient care.
• Curiosity: Continuously asking “why” and seeking deeper understanding to improve care delivery.

Clinical reasoning is further defined as “a 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 between knowledge and action. Nurses must generate possible solutions, weigh the evidence, and select the optimal path forward to ensure sound clinical judgment. This ability develops through ongoing learning and practical experience.[3] For further resources, consider searching for “clinical reasoning in nursing PDF” to deepen your understanding.

Inductive and Deductive Reasoning and Clinical Judgment in Nursing

Inductive and deductive reasoning are essential critical thinking skills that underpin clinical judgment in the nursing process. These methods help nurses analyze information and make informed decisions about patient care.

Inductive reasoning, sometimes referred to as “bottom-up thinking,” involves observing specific cues, forming generalizations, and developing hypotheses. Cues are pieces of patient data that deviate from expected findings, signaling potential issues. Nurses organize these cues into patterns to create a generalization, which is a summary judgment based on collected data. This process is akin to piecing together a jigsaw puzzle, where individual pieces (cues) form patterns leading to a clearer picture (generalization). From these generalizations, nurses develop a hypothesis, a proposed explanation for the patient’s condition, attempting to answer “why” a problem is occurring. Identifying the “why” is crucial for exploring effective solutions.

Observing cues is the foundation of inductive reasoning. Nurses must be highly attentive to patient details, the environment, and interactions with family, much like a detective seeking clues, as illustrated in Figure 4.1. Sharpen your inductive reasoning by focusing on your five senses: hearing, touch, smell, taste, and sight. Strong inductive reasoning is vital for nurses, especially in emergencies where rapid action is needed. Recognizing patterns in seemingly disparate objects or events allows nurses to identify common problems and formulate appropriate responses.

Figure 4.1: Inductive Reasoning Includes Looking for Cues

Example of Inductive Reasoning: A nurse assessing a surgical site observes redness, warmth, and tenderness. Recognizing these cues as a pattern indicative of infection, the nurse hypothesizes a surgical site infection. Notifying the provider leads to a prescription for antibiotics, demonstrating inductive reasoning in practice.

Deductive reasoning, or “top-down thinking,” starts with a general rule or standard to guide specific actions. Nurses apply established standards from sources like Nurse Practice Acts, federal regulations, professional nursing associations (e.g., ANA), and employer policies to guide patient care decisions.

Example of Deductive Reasoning: Based on research showing that rest promotes patient recovery, a hospital implements a “quiet zone” policy with reduced noise levels at night, as depicted in Figure 4.2. Nurses then use deductive reasoning to apply this policy to all patients by clustering care activities to ensure uninterrupted nighttime rest, regardless of individual sleep patterns.

Figure 4.2: Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment is the culmination of critical thinking and clinical reasoning, utilizing both inductive and deductive approaches. The National Council of State Boards of Nursing (NCSBN) defines clinical judgment 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] The NCLEX exam, which all prospective nurses must pass, assesses clinical judgment and decision-making skills to ensure competent and safe entry-level nursing practice.

Evidence-based practice (EBP), as defined by the American Nurses Association (ANA), is “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 is informed by the most current and reliable evidence available. For more information, search for “evidence based nursing practice PDF”.

The Nursing Process: A Systematic Approach to Patient Care

The nursing process is a structured, critical thinking model that provides a systematic approach to patient-centered care. Nurses utilize this process for clinical reasoning and judgment in all patient interactions. It’s grounded in the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are definitive statements outlining the expected actions and behaviors of all registered nurses, regardless of their role, patient population, specialty, or practice setting.[8] The mnemonic ADOPIE is a helpful way to remember the six components of the nursing process, corresponding to the ANA Standards: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

The nursing process is not linear but rather a continuous, cyclical process, constantly adapting to the patient’s evolving health status, as illustrated in Figure 4.3.

Figure 4.3: The Nursing Process Cycle

Let’s consider Scenario A to see the nursing process in action.

Patient Scenario A: Applying the Nursing Process[10]

A patient hospitalized for heart failure is prescribed Lasix 80mg IV daily. During the morning assessment, the nurse records vital signs: BP 98/60, HR 100, RR 18, Temp 98.7°F. Reviewing the patient’s chart, the nurse notes a baseline BP around 110/70 and HR in the 80s. Recognizing these cues as a pattern of potential fluid imbalance, the nurse hypothesizes dehydration. Further data reveals a 4-pound weight loss since the previous day, and the patient reports a dry mouth and lightheadedness.

Using clinical judgment, the nurse identifies the nursing diagnosis of Fluid Volume Deficit and sets goals for fluid balance restoration. The nurse withholds the Lasix, contacts the provider to discuss fluid status, and implements interventions to increase oral fluid intake and monitor hydration closely. By shift end, the nurse evaluates that fluid balance has been effectively restored.

In this scenario, the nurse demonstrates clinical judgment by not simply administering Lasix as prescribed. Instead, through assessment, cue recognition, hypothesis formation, and intervention, the nurse ensures patient safety and optimal care.

The ANA Standards of Professional Nursing Practice for each component of the nursing process are detailed below.

Assessment: The Foundation of the Nursing Process

The first step, Assessment, is defined by the ANA as: “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”[11] This involves a systematic collection and analysis of patient data, including physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors. For example, assessing a patient in pain includes not just the pain level, but also its impact on mobility, appetite, social interactions, and emotional state.[12] For more detailed information, you might search for “nursing assessment PDF”.

Diagnosis: Identifying Patient Needs

The Diagnosis phase is defined as: “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”[13] A nursing diagnosis is a nurse’s clinical judgment about the patient’s response to health conditions or needs. It forms the basis of the nursing care plan and differs from medical diagnoses.[14] Understanding “nursing diagnosis PDF” resources can be invaluable in this step.

Outcomes Identification: Setting Patient Goals

Outcomes Identification is defined as: “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[15] Nurses set measurable, achievable goals in collaboration with patients, based on assessment data and nursing diagnoses. These include both short-term and long-term goals. Resources on “nursing outcomes PDF” can assist in formulating effective goals.

Planning: Charting the Course of Care

The Planning stage is defined as: “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”[16] This involves selecting evidence-based nursing interventions tailored to each patient’s needs, documented in a nursing care plan. This plan ensures consistent care across the healthcare team.[17]

NURSING CARE PLANS: A Detailed Blueprint for Care

Nursing care plans are essential documents in the planning phase, detailing individualized care for each patient using the nursing process. Registered Nurses (RNs) develop these plans to ensure consistent, shift-to-shift care delivery. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or Unlicensed Assistive Personnel (UAPs) under RN supervision. More information on planning and delegation can be found by searching “nursing care plan template PDF”.

Implementation: Putting the Plan into Action

Implementation is defined as: “The nurse implements the identified plan.”[18] This involves carrying out or delegating nursing interventions according to the care plan, ensuring continuity across all care providers. Interventions are documented in the patient’s electronic medical record as they are performed.[19] Implementation also includes “Coordination of Care” and “Health Teaching and Health Promotion” to promote overall patient health and a safe environment.[20] For practical guides, consider downloading a “nursing interventions PDF”.

Evaluation: Assessing Effectiveness and Adjusting Care

Evaluation is defined as: “The registered nurse evaluates progress toward attainment of goals and outcomes.”[21] Nurses continuously assess the patient’s progress against expected outcomes to determine the effectiveness of interventions and the overall care plan. Both patient status and care plan effectiveness are evaluated and modified as needed.[22]

Benefits of the Nursing Process: Enhancing Patient Care and Efficiency

Utilizing the nursing process offers numerous benefits for nurses, patients, and the healthcare team, including:

• Enhanced quality of patient care.
• Reduced omissions and redundancies in care.
• Consistent and responsive care delivery by all staff.
• Improved collaboration in patient healthcare management.
• Increased patient safety.
• Higher patient satisfaction.
• Clear identification of patient goals and strategies.
• Improved likelihood of positive patient outcomes.
• Efficient use of time and resources through structured care planning.

By using the nursing process, nurses tailor interventions to patient needs, plan effective outcomes, and ensure actions are effective in meeting those needs. This structured approach forms the “science of nursing.” Let’s now consider the “art of nursing” in delivering holistic care.

Holistic Nursing Care: Integrating Art and Science

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 described as “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”[24] This involves addressing patients’ emotional, spiritual, psychosocial, cultural, and physical needs within the context of their families and communities through the nursing process.

Holistic Nursing Care Scenario

Consider a scenario where a single mother brings her child to the ER with ear pain and fever. After diagnosis and prescription, the nurse, during discharge teaching, learns of the family’s financial constraints regarding the antibiotic and lack of access to local primary care. The nurse then connects the mother with a social worker for insurance and provider options and advocates for a more affordable medication with the physician. This exemplifies holistic care, addressing not just the child’s illness, but also the family’s broader social and economic context. For further reading, search for “holistic nursing care PDF”.

Caring and the Nursing Process: The Human Connection

The ANA emphasizes that “The act of caring is foundational to the practice of nursing.”[25] Effective use of the nursing process requires a care relationship built on mutual trust, or rapport. This relationship is the essence of the art of nursing. It involves assessing the whole person—beliefs, values, attitudes—while respecting their vulnerability and dignity.[26] Caring interventions can be simple yet powerful, such as active listening, eye contact, touch, and verbal reassurance, always sensitive to cultural beliefs.[27] Figure 4.4 illustrates therapeutic touch as a caring communication technique.

Figure 4.4: Touch as a Therapeutic Communication Technique

Dr. Jean Watson, a prominent nurse theorist, has extensively written about caring in nursing, advocating for a balance between the medical focus on cure and nursing’s unique role in providing compassionate care. Her philosophy emphasizes authentic presence and creating a healing environment.[29] To learn more about her work, visit the Watson Caring Science Institute or search for “jean watson theory of caring PDF”.

With these foundational concepts in mind, let’s explore each step of the nursing process in detail.

Assessment: Gathering Patient Data

Assessment is the first and foundational step of the nursing process and the first Standard of Practice by the ANA. It’s defined as “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”[1] This includes a systematic and continuous collection of data related to health and quality of life, respecting the patient’s dignity and unique attributes, covering demographics, environment, social determinants of health, and physical, psychosocial, emotional, cognitive, spiritual, sexual, sociocultural, age-related, lifestyle, and economic factors.[1]

Nurses assess patients to identify cues, form generalizations, and diagnose human responses to health conditions. Patient data is categorized as subjective or objective, gathered from various sources.

Subjective Assessment Data: The Patient’s Perspective

Subjective data is information from the patient and/or family, providing vital insights from their perspectives. When documenting subjective data, it should be in quotation marks, attributed to the patient (e.g., “The patient reports…”). Building rapport is crucial to obtain accurate subjective data, particularly regarding mental, emotional, and spiritual aspects of health.

Subjective data is further classified into primary data, directly from the patient, and secondary data, from other sources like family or medical records. Patients are the primary source for their feelings and experiences. Secondary data is valuable for patients unable to communicate for themselves, such as infants or those with cognitive impairments.

Figure 4.5 illustrates a nurse obtaining subjective data and establishing rapport by engaging with the patient directly.

Figure 4.5: Obtaining Subjective Data in a Care Relationship

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

Objective Assessment Data: Observable and Measurable Information

Objective data is observable and measurable through senses: hearing, sight, smell, and touch. It’s reproducible, meaning consistent findings can be obtained by different observers. Examples include vital signs, physical exam findings, and lab results. Figure 4.6 shows a nurse performing a physical examination.

Figure 4.6: Physical Examination

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: Interview, Physical Exam, and Diagnostic Tests

Assessment data is gathered from three primary sources: patient interviews, physical examinations, and review of laboratory and diagnostic test results.

Interviewing: Engaging with the Patient

Interviewing involves questioning, listening, and observing verbal and nonverbal communication. Reviewing the patient chart beforehand can streamline interviews, focusing on key areas or needed clarifications. However, always verify chart data with the patient to ensure accuracy.

Start by introducing yourself, explaining your role and the interview’s purpose and duration. Begin with questions about medical diagnoses and their impact on the patient’s life. Active listening and clarification are crucial. Patients may not realize certain details are relevant to their care, so probing questions can uncover valuable cues. Be attentive to both verbal and nonverbal cues; inconsistencies may indicate areas needing further investigation. Validate any inferences to avoid misinterpretations, such as cultural differences in eye contact.

Physical Examination: Systematic Data Collection

A physical examination is a structured method of collecting body system data using inspection, auscultation, palpation, and percussion. Inspection is visual observation. Auscultation involves listening to body sounds with a stethoscope. Palpation uses touch to assess organ size, location, and tenderness. Percussion, typically by providers, involves tapping body parts to assess size and fluid presence. Detailed procedures can be found in nursing skills textbooks, such as the Open RN Nursing Skills resource. Physical examination also includes vital signs.

Registered Nurses (RNs) conduct initial physical exams and analyze findings. Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) and Unlicensed Assistive Personnel (UAPs) may collect follow-up data like vital signs, but RNs remain responsible for analysis and documentation.

Physical exams can be comprehensive (head-to-toe) or focused on specific problems. Data is documented in the patient’s Electronic Medical Record (EMR).

Reviewing Laboratory and Diagnostic Test Results

Laboratory and diagnostic results provide crucial objective data. Nurses must understand normal and abnormal ranges and their implications for patient care. Abnormal results may necessitate provider notification and prescription verification before implementation.

Types of Assessments: Tailoring to Patient Needs and Settings

Different types of nursing assessments are used based on the clinical situation:

• Primary Survey: Rapid initial assessment (level of consciousness, airway, breathing, circulation) for every patient encounter, especially in emergencies.
• Admission Assessment: Comprehensive assessment upon admission to a healthcare facility, gathering extensive baseline data.
• Ongoing Assessment: Regular head-to-toe assessments, often shift-based in acute care, with changes reported to providers.
• Focused Assessment: In-depth assessment of a specific problem, re-evaluating its status.
• Time-lapsed Reassessment: Used in long-term care settings at intervals (e.g., every 3+ months) to track progress on long-term outcomes.[4]

Scenario C: Applying Assessment Concepts

Consider Scenario C to integrate assessment concepts.

Scenario C

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

Admission vital signs:

• BP: 162/96 mm Hg
• HR: 88 bpm
• SpO2: 91% on room air
• RR: 28 breaths/min
• Temp: 97.8°F orally

Weight is up 10 lbs in 3 weeks. Patient states, “I am so short of breath,” “My ankles are so swollen,” “I am so tired and weak,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She also expresses a desire to learn more about her health.

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

Patient’s daughter shares, “We are so worried about mom living at home alone.”

Critical Thinking Questions:

1. Identify subjective data.
2. Identify objective data.
3. Provide an example of secondary data.

Answers are in the Answer Key.

Diagnosis: Analyzing Data and Identifying Nursing Diagnoses

Diagnosis, the second step of the nursing process and ANA Standard, is defined as: “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.”[1] This step involves prioritizing diagnoses based on patient needs and documenting them to facilitate outcome development and care planning.

Analyzing Assessment Data: From Cues to Hypotheses

After assessment, nurses analyze data to identify “expected” versus “unexpected” findings based on patient norms and baseline status. This analysis helps determine “clinically relevant” cues, which guide care prioritization.[3]

Example: In Scenario C, elevated BP, RR, heart rate, and decreased oxygen saturation are “relevant cues” for Ms. J.

Clustering Information, Recognizing Patterns, and Forming Hypotheses

Following data analysis, nurses cluster relevant cues into patterns. Frameworks like Gordon’s Functional Health Patterns help organize information into categories of human responses.

Example: In Scenario C, cues like elevated BP/RR, lung crackles, edema, weight gain, shortness of breath, heart failure history, and diuretic use cluster into a pattern related to fluid balance, under Gordon’s Nutritional-Metabolic pattern. The nurse hypothesizes excess fluid volume.

Gordon’s Functional Health Patterns[5]

• Health Perception-Health Management: Patient’s perception of health and management.
• Nutritional-Metabolic: Food and fluid intake relative to needs.
• Elimination: Bowel, bladder, and skin excretory functions.
• Activity-Exercise: Exercise and daily activities.
• Sleep-Rest: Sleep, rest, and daily routines.
• Cognitive-Perceptual: Perception and cognition.
• Self-perception and Self-concept: Self-esteem, body image, mood.
• Role-Relationship: Role engagements and relationships.
• Sexuality-Reproductive: Reproduction and sexual satisfaction.
• Coping-Stress Tolerance: Stress management and coping mechanisms.
• Value-Belief: Values, beliefs, and spiritual practices guiding decisions.

Identifying Nursing Diagnoses: NANDA-I and Beyond

After analysis and clustering, nurses ask, “What are my patient’s human responses (nursing diagnoses)?” A nursing diagnosis is “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] They are individualized and drive care plan development. Nurses use care planning resources and review diagnostic definitions to ensure accurate diagnosis selection.

NANDA International (NANDA-I) provides a standardized nursing terminology, with over 220 diagnoses regularly updated based on research. Common NANDA-I diagnoses are in Appendix A, and comprehensive lists are in nursing care plan references. NANDA-I diagnoses are grouped into 13 domains, similar to Gordon’s patterns, to aid in selection.

Nursing Diagnoses vs. Medical Diagnoses: Focusing on Patient Responses

Nursing diagnoses differ from medical diagnoses. Medical diagnoses, made by physicians or advanced practitioners, focus on diseases. Nursing diagnoses focus on the human response to health conditions, made independently by RNs. Patients with the same medical diagnosis may have different nursing diagnoses due to varied responses. For example, heart failure patients may have different nursing diagnoses based on their individual responses to the condition, such as knowledge deficit or anxiety. Nursing diagnoses consider patient and family needs to personalize holistic care.

Example: Ms. J.’s medical diagnosis is heart failure. This isn’t a nursing diagnosis but an “associated condition.” The nursing diagnosis will address her response to heart failure.

NANDA-I Terminology: Patient, Age, and Time

NANDA-I uses specific definitions for terms like patient, age, and time in diagnoses:

Patient includes:

• Individual
• Caregiver
• Family
• Group (ethnic group)
• Community (neighborhood, city)[8]

Age categories:

• Fetus
• Neonate (under 28 days)
• Infant (28 days to 1 year)
• Child (1-9 years)
• Adolescent (10-19 years)
• Adult (over 19 years)
• Older adult (over 65 years)[9]

Time or duration:

• Acute (less than 3 months)
• Chronic (over 3 months)
• Intermittent (stopping and starting)
• Continuous (uninterrupted)[10]

New Terms: At-Risk Populations and Associated Conditions

The 2018-2020 NANDA-I edition introduced “at-risk populations” and “associated conditions” to refine diagnoses.[11]

At-Risk Populations are groups sharing traits increasing vulnerability to specific responses (e.g., demographics, health history).

Associated Conditions are medical diagnoses or treatments that, while not nurse-modifiable, inform nursing diagnosis accuracy.[12]

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

NANDA-I categorizes nursing diagnoses into four types:[13]

• Problem-Focused: Undesirable response to health conditions. Requires related factors and defining characteristics.
• Health Promotion-Wellness: Desire to enhance well-being. Expressed as readiness to improve health behaviors.
• Risk: Vulnerability to developing undesirable responses. Supported by risk factors.
• Syndrome: Cluster of diagnoses best addressed together with similar interventions.

Establishing Nursing Diagnosis Statements: PES Format

NANDA-I recommends nursing diagnosis statements include the diagnosis, related factors, and defining characteristics. Accuracy is confirmed by linking these components from patient assessment data.[20]

Creating these statements was traditionally known as “PES format,” though NANDA-I terminology has evolved, the components remain the same.

• Problem (P): Nursing diagnosis.
• 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.”

Problem-Focused Nursing Diagnosis Example

For Ms. J. in Scenario C, “Excess Fluid Volume” is a problem-focused diagnosis.

• P: Fluid Volume Excess
• E: Related to excessive fluid intake
• S: As manifested by lung crackles, edema, weight gain, patient report of swollen ankles.

Full statement: Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis Example

For Ms. J., “Readiness for Enhanced Health Management” is a health-promotion diagnosis.

• P: Readiness for Enhanced Health Management
• S: Expressed desire to “learn more about my health so I can take better care of myself.”

Full statement: Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis Example

For Ms. J., “Risk for Falls” is a risk diagnosis.

• P: Risk for Falls
• As Evidenced By: Dizziness and decreased lower extremity strength

Full statement: Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis Example

For Ms. J., “Risk for Frail Elderly Syndrome” is a syndrome diagnosis.

• P: Risk for Frail Elderly Syndrome
• S: Activity Intolerance and Social Isolation diagnoses
• Related Factor: Fear of falling

Full statement: Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling.

Prioritization of Nursing Diagnoses: Addressing Urgent Needs First

Prioritization involves determining the most significant nursing problems and interventions. Life-threatening issues are addressed immediately. Prioritization concepts include Maslow’s Hierarchy of Needs, ABCs (Airway, Breathing, Circulation), and acute vs. chronic conditions. Figure 4.7 provides a guide to prioritization.

Figure 4.7: The How To of Prioritization

Maslow’s Hierarchy of Needs categorizes needs from basic physiological needs (bottom) to self-actualization (top). Basic needs (physiological and safety) are highest priority. Figure 4.8 illustrates this hierarchy.

Figure 4.8: Maslow’s Hierarchy of Needs

Acute, uncompensated conditions generally take priority over chronic ones. Actual problems are usually prioritized over potential problems, though risk diagnoses can be high priority depending on vulnerability.

Example: For Ms. J., “Fluid Volume Excess” is the top priority due to its impact on physiological needs, followed by “Risk for Falls” due to safety concerns.

Outcome Identification: Setting SMART Goals

Outcome Identification, the third step of the nursing process and ANA Standard, is defined as: “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[1] This involves setting measurable, time-bound goals in collaboration with the patient and healthcare team.

An outcome is a “measurable behavior demonstrated by the patient responsive to nursing interventions.”[2] Outcomes should be set before planning interventions and evaluated post-implementation.

Outcome identification includes setting short- and long-term goals and creating specific expected outcome statements for each nursing diagnosis.

Short-Term and Long-Term Goals: Patient-Centered and Time-Bound

Nursing care should be patient-centered and individualized. Goals should be tailored to patient needs, values, and cultural beliefs, involving patients and families in the goal-setting process. Goals are broad statements of purpose, either short- or long-term, depending on the care setting.

A nursing goal describes the desired direction of patient progress to resolve the nursing diagnosis, often the opposite of the problem.

Example: For Ms. J.’s “Fluid Volume Excess” diagnosis, a broad goal is: “Ms. J. will achieve a state of fluid balance.”

Expected Outcomes: SMART Criteria for Measurable Results

Expected outcomes are specific, measurable actions for the patient within a set timeframe, responsive to nursing interventions. Nurses can create these independently or use resources like the Nursing Outcomes Classification (NOC), which lists over 330 standardized outcomes linked to NANDA-I diagnoses.[3]

Outcome statements are always patient-centered, starting with “The patient will…” and aimed at resolving defining characteristics of the diagnosis. They must be achievable and patient-agreed.

Outcome statements should be SMART:

• Specific
• Measurable
• Attainable/Action-oriented
• Relevant/Realistic
• Timeframe

Figure 4.9 outlines the SMART components.

Figure 4.9: SMART Components of Outcome Statements

Specific Outcomes: Clear and Focused

Outcomes must clearly state what will be achieved.

• Not specific: “The patient will increase exercise.”
• Specific: “The patient will bicycle for 30 minutes daily.”

Each outcome should address only one action for clear evaluation.

Measurable Outcomes: Quantifiable Progress

Measurable outcomes use numeric or concrete criteria. Objective data is key. Avoid vague terms like “acceptable.” Figure 4.10 lists measurable and non-measurable verbs.

Figure 4.10: Measurable Outcomes Verbs

• Not measurable: “The patient will drink adequate fluids.”
• Measurable: “The patient will drink 24 ounces of fluids per day shift (0600-1400).”

Action-Oriented and Attainable Outcomes: Patient-Driven Actions

Outcomes should specify patient actions, using action verbs. Figure 4.11 provides examples.

Figure 4.11: Action Verbs for Outcome Statements

• Not action-oriented: “The patient will increase physical activity.”
• Action-oriented: “The patient will list three aerobic activities they will do weekly.”

Realistic and Relevant Outcomes: Considering Patient Context

Realistic outcomes consider patient physical and mental state, cultural and spiritual values, and socioeconomic factors. Re-evaluate and adjust outcomes for attainability as needed.

• Not realistic: “The patient will jog a mile daily from day one.”
• Realistic: “The patient will walk ½ mile three times weekly for two weeks.”

Time-Limited Outcomes: Setting Evaluation Timelines

Outcomes must include a timeframe for evaluation, ranging from per shift to monthly, depending on the intervention and patient condition.

• Not time-limited: “The patient will stop smoking.”
• Time-limited: “The patient will complete smoking cessation plan by December 12, 2021.”

Scenario C Outcome Example

For Ms. J.’s “Fluid Volume Excess” diagnosis, a SMART outcome is: “The patient will have clear bilateral lung sounds within the next 24 hours.”

Planning: Developing Nursing Interventions

Planning, the fourth step and ANA Standard, is defined as: “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”[1] This involves creating an individualized, evidence-based plan in collaboration with the patient and healthcare team.

After setting outcomes, nurses plan nursing interventions, evidence-based actions to achieve patient outcomes. Interventions should aim to eliminate or reduce related factors of nursing diagnoses.[2] Nursing Interventions Classification (NIC) and agency care planning tools are valuable resources.

Planning Nursing Interventions: Evidence-Based Strategies

How do nurses select evidence-based interventions? Resources include agency care planning tools, care planning books, and the Nursing Interventions Classification (NIC) system. NIC provides a standardized, research-based categorization of nursing interventions, regularly updated. Nurses use clinical judgment to select the most appropriate interventions for individual patient needs. For more resources, search for “nursing interventions list PDF”.

Direct and Indirect Care Interventions

Nursing interventions are classified as direct care, involving patient contact (e.g., wound care), or indirect care, performed away from the patient but still supporting their care (e.g., care conferences, documentation).

Classification of Nursing Interventions: Independent, Dependent, and Collaborative

Nursing interventions are also classified as independent, dependent, or collaborative. Figure 4.12 shows nurses collaborating on care planning.

Figure 4.12: Collaborative Nursing Interventions

Independent Nursing Interventions: Nurse-Initiated Actions

Independent nursing interventions are actions nurses can perform without a provider prescription, such as monitoring intake/output or using therapeutic communication.

Example: For Ms. J.’s “Fluid Volume Excess,” an independent intervention is: “The nurse will reposition the patient with dependent edema frequently, as appropriate,” individualized to “every 2 hours.”

Dependent Nursing Interventions: Requiring Provider Prescriptions

Dependent nursing interventions require a provider prescription, like medication administration. A primary health care provider (physician, advanced practice nurse, or physician’s assistant) authorizes these.

Example: For Ms. J.’s “Fluid Volume Excess,” a dependent intervention is: “The nurse will administer scheduled diuretics as prescribed.”

Collaborative Nursing Interventions: Interdisciplinary Team Approach

Collaborative nursing interventions are carried out with other healthcare team members (physicians, therapists, social workers). These actions are planned in consultation with other professionals.[7]

Example: For Ms. J.’s “Fluid Volume Excess,” a collaborative intervention is consulting a respiratory therapist for deteriorating oxygen saturation. The nurse will “manage oxygen therapy in collaboration with the respiratory therapist.”

Individualization and Nursing Care Plans: Tailoring Care to the Patient

Interventions must be individualized to be effective. For example, prune juice for constipation only works if the patient likes it. Patient collaboration is vital. Nursing care plans, legally required in long-term care and hospitals, document individualized care. CMS and The Joint Commission mandate patient participation in care planning. Figure 4.13 shows a standardized care plan example.

Figure 4.13: Standardized Care Plan

Nursing care plans can take various formats, from concept maps to tables. Appendix B offers a care plan template. You can also find numerous “nursing care plan examples PDF” online.

Implementation of Interventions: Putting the Plan into Action Safely

Implementation, the fifth step and ANA Standard, is defined as: “The registered nurse implements the identified plan.”[1] This includes delegation, with RNs accountable for appropriate delegation based on patient condition, communication, supervision, and evaluation, adhering to Nurse Practice Acts and agency policies.

Implementation requires critical thinking and continuous reassessment to adapt the care plan to changes in patient condition.

Prioritizing Implementation: Safety and Urgency

Prioritization in implementation mirrors diagnosis prioritization, using Maslow’s Hierarchy and ABCs. Least invasive actions are generally preferred. Potential impact of delayed interventions is also considered.

Patient Safety During Implementation: Preventing Errors

Patient safety is paramount during implementation. Changes in patient condition may contraindicate planned interventions. Nurses, as frontline providers, are crucial in preventing errors.

The Institute of Medicine (IOM) reports, To Err Is Human and Preventing Medication Errors, highlighted the prevalence of preventable medical errors and medication errors in hospitals. Quality and Safety Education for Nurses (QSEN) project aims to improve nurse preparation in quality and safety. Nurses participate in quality improvement (QI) initiatives to enhance patient outcomes.

Delegation of Interventions: Appropriate Task Assignment

RNs may delegate tasks to LPNs or UAPs, remaining accountable for outcomes. Delegation must be appropriate to the delegatee’s training, patient condition, and circumstance, with clear communication, supervision, and evaluation. RNs cannot delegate tasks requiring clinical judgment. Table 4.7 outlines delegation guidelines.

Table 4.7: General Guidelines for Delegating Nursing Tasks

Documentation of Interventions: Timely and Accurate Records

Interventions must be documented promptly in the patient record. Lack of documentation is legally considered as not done. Timely documentation prevents errors and ensures accurate communication.

Coordination of Care and Health Teaching/Promotion: Holistic Implementation

ANA’s Implementation Standard includes “Coordination of Care” and “Health Teaching and Health Promotion.” Coordination involves organizing care components and engaging patients in self-care. Health teaching is integral to every patient encounter, including medication education and self-management strategies.

Scenario C Implementation Example

For Scenario C, care is implemented as per Appendix C. Breathing-related interventions are prioritized, diuretic administration is first, lung sounds are monitored, weight measurement is delegated to CNA, and patient education on medications and edema management is provided. All interventions are documented in the EMR.

Evaluation: Assessing Outcome Achievement and Care Plan Effectiveness

Evaluation, the sixth and final step, and ANA Standard, is defined as: “The registered nurse evaluates progress toward attainment of goals and outcomes.”[1] It involves continuous assessment of patient status and care plan effectiveness, with modifications as needed.[2]

Evaluation assesses intervention effectiveness by reviewing expected outcomes against set timeframes. Nurses use critical thinking to determine if outcomes are met, partially met, or unmet. Unmet or partially met outcomes require care plan revision. Reassessment is ongoing, informing care plan updates. Evaluation results are documented in the patient’s medical record.

When outcomes are not met, consider:

• Unanticipated events?
• Changes in patient condition?
• Outcome realism?
• Diagnosis accuracy?
• Intervention appropriateness?
• Barriers to implementation?
• Need for revised diagnoses, outcomes, interventions, or strategies?
• Need for different interventions?

Scenario C Evaluation Example

For Scenario C and Appendix C, the nurse evaluates progress on expected outcomes for “Fluid Volume Excess”:

1. Decreased dyspnea within 8 hours.
2. Clear lung sounds within 24 hours.
3. Decreased edema within 24 hours.
4. Weight return to baseline by discharge.

Evaluation data on Day 1: “Patient reports less shortness of breath, lung crackles resolved in lower bases. Weight down 1 kg, but 2+ edema persists.” Outcomes are “Partially Met.” Care plan revised with new interventions: TED hose prescription and leg elevation.

“Risk for Falls” outcome evaluated as “Met“: “Patient verbalizes understanding, calls for assistance. No falls.”

Care plan revisions and ongoing evaluations are documented in the patient’s medical record.

Summary of the Nursing Process: A Cycle of Patient-Centered Care

You have now explored each step of the nursing process, aligned with ANA Standards. Critical thinking, clinical reasoning, and judgment are essential throughout assessment, planning, and implementation. Continuous reassessment and care plan revisions are crucial for achieving patient outcomes. The patient remains central to this process, ensuring individualized, patient-centered care and effective outcomes, fundamental to safe, professional nursing practice.

Video Review: Creating a Sample Care Plan[1]

Nursing Care Plan Tutorial Video

Learning Activities: Apply Your Knowledge

Learning Activities

Apply your learning by creating a nursing care plan for the following scenario, using the template in Appendix B.

Scenario: Mark S., 57-year-old male, admitted for “severe” abdominal pain, diagnostic tests scheduled.

After hearing about tests, Mark paces, repeatedly asks about test duration, states, “I’m so uptight I will never be able to sleep tonight.” Avoids eye contact, fidgets, eyes darting, tense expression, dry mouth. Vital signs: T 98, P 104, R 30, BP 180/96. Diaphoretic, cool skin.

Critical Thinking Activity:

1. Cluster subjective and objective data.
2. Create a problem-focused nursing diagnosis.
3. Develop a broad goal and SMART outcome.
4. Outline three interventions with evidence-based sources.
5. Evaluate outcome achievement: Met, Partially Met, or Not Met.

Interactive Learning Activity 1

Interactive Learning Activity 2

Interactive Learning Activity 3

Glossary of Nursing Process Terms

Glossary of Nursing Process Terms

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Appendices:

Appendix A: Common NANDA-I Diagnoses

Appendix B: Nursing Care Plan Template

Appendix C: Sample Abbreviated Care Plan for Scenario C

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References:

References

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