Introduction to the Nursing Process and Care Planning
Have you ever considered how nurses seamlessly transition between patients, providing informed and effective care even when encountering a case for the first time? The answer lies in the nursing process, a systematic, critical thinking framework that serves as the cornerstone of modern nursing practice. This process is not just a set of steps; it’s a dynamic, patient-centered approach that guides nurses in delivering optimal healthcare.
The nursing process allows nurses to quickly assess, strategize, and act, ensuring patient safety and promoting well-being. It’s the roadmap that transforms complex patient information into actionable interventions and personalized care plans. For those seeking to deepen their understanding of this vital framework, resources like the “Nursing Care Plans Nursing Diagnosis And Intervention 7th Edition Pdf” offer invaluable insights and practical guidance. This guide delves into the essentials of the nursing process, emphasizing the crucial role of nursing diagnoses and interventions in crafting effective care plans, and how resources like the 7th edition PDF can enhance your practice.
Core Concepts: Critical Thinking and Clinical Reasoning in Nursing
Before we dive into the nursing process, it’s essential to understand the cognitive skills that underpin it: critical thinking and clinical reasoning. These are not just buzzwords in nursing education; they are the intellectual tools that enable nurses to make sound judgments and provide safe, effective care.
Critical Thinking: The Foundation of Nursing Judgment
Critical thinking in nursing is more than just following protocols. It’s about actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion. In a healthcare setting, this involves everything from problem-solving complex patient cases to improving team collaboration and workflow efficiency. Critical thinkers in nursing are proactive, not reactive. They validate patient information, base care plans on individual needs and current best practices, and are always vigilant about patient safety.
Key attitudes of a critical thinker include:
- Independence of Thought: Forming your own judgments based on evidence rather than passively accepting others’ views.
- Fair-mindedness: Approaching every situation and viewpoint with impartiality and without prejudice.
- Insight into Egocentricity and Sociocentricity: Recognizing personal biases and societal influences to ensure patient-centered decisions.
- Intellectual Humility: Acknowledging the limits of one’s knowledge and being open to learning and new perspectives.
- Nonjudgmental Attitude: Applying professional ethics and standards, avoiding personal biases in patient care decisions.
- Integrity: Maintaining honesty and strong moral principles in all aspects of nursing practice.
- Perseverance: Continuing to seek solutions and provide care even when faced with challenges.
- Confidence: Trusting in one’s ability to provide competent care and make informed decisions.
- Interest in Exploring Thoughts and Feelings: Being open to diverse ways of understanding and approaching patient care.
- Curiosity: Constantly asking “why” and seeking deeper understanding of patient conditions and best practices.
Clinical Reasoning: Applying Knowledge to Patient Care
Clinical reasoning takes critical thinking a step further. It’s 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.” Clinical reasoning is the bridge between knowledge and action. It’s how nurses collect patient data, interpret its significance, and decide on the best course of action. This ability grows with experience and a solid foundation of nursing knowledge, often enhanced by resources like “Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF,” which provides structured approaches to common clinical scenarios.
Inductive and Deductive Reasoning in Clinical Judgment
Nurses utilize both inductive and deductive reasoning to make clinical judgments within the nursing process.
Inductive Reasoning: This is a “bottom-up” approach. It starts with observing specific cues – unusual data that deviate from expected findings. Nurses then organize these cues into patterns and form a generalization, a judgment based on these observations. Finally, they create a hypothesis, a proposed explanation for the patient’s problem. Inductive reasoning is crucial for recognizing emerging issues and formulating initial understandings of a patient’s condition. It’s like being a detective, piecing together clues to understand the bigger picture, as illustrated in Figure 4.1.
Figure 4.1: Inductive Reasoning Includes Looking for Cues
For example, noticing redness, warmth, and tenderness at a surgical incision (cues) leads to recognizing a pattern of infection signs (generalization) and hypothesizing a surgical site infection.
Deductive Reasoning: This is “top-down” thinking, starting with a general rule or standard and applying it to a specific situation. Nurses use established standards like Nurse Practice Acts, hospital policies, and evidence-based guidelines to guide their actions. For instance, a hospital implementing a “quiet zone” policy based on research (general rule) expects nurses to apply this policy to all patients (specific application), promoting rest regardless of individual sleep issues. Figure 4.2 illustrates this.
Figure 4.2: Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy
Clinical Judgment, the outcome of effective 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.” Resources like “Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF” can significantly enhance clinical judgment by providing a structured approach to diagnoses and interventions, grounded in evidence-based practice.
Evidence-based practice (EBP) is integral to clinical judgment and the nursing process. The American Nurses Association (ANA) defines EBP 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.”
The Nursing Process: A Step-by-Step Guide to Patient-Centered Care
The nursing process is a systematic, patient-centered approach to care, guided by the Standards of Professional Nursing Practice established by the ANA. It’s a cyclical process, constantly adapting to the patient’s evolving health status. The mnemonic ADOPIE helps remember the six core components: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. Figure 4.3 visually represents this continuous cycle.
Figure 4.3: The Nursing Process
Let’s illustrate the nursing process with Scenario A:
Patient Scenario A: Applying the Nursing Process
A patient in the hospital is prescribed Lasix 80mg IV daily for heart failure. During the morning assessment, the nurse finds a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. Reviewing the patient’s chart, the nurse notes a typical BP around 110/70 and HR in the 80s. Recognizing these vital sign changes as cues related to fluid imbalance, the nurse hypothesizes dehydration. Further assessment reveals a 4-pound weight loss since yesterday. The patient confirms feeling light-headed and having a dry mouth.
Using critical thinking and clinical judgment, the nurse identifies the nursing diagnosis as Fluid Volume Deficit and sets goals for fluid balance restoration. The nurse wisely withholds the Lasix, contacts the provider to discuss the patient’s fluid status, and implements interventions to increase oral fluid intake and monitor hydration closely. By shift’s end, the patient’s fluid balance is improved.
In this scenario, the nurse’s actions exemplify clinical judgment in action, moving beyond routine order execution to patient-centered, safe care. Each step of the nursing process is crucial, and the ANA Standards of Professional Nursing Practice provide the framework for each component, detailed below.
Step 1: Assessment – Gathering Patient Data
Assessment, the first step, 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.” This goes beyond just physical data; it includes psychological, sociocultural, spiritual, economic, and lifestyle factors. For instance, assessing a patient’s pain involves not just the pain score but also their emotional response, coping mechanisms, and impact on daily life.
The “Assessment” phase is detailed further in the “Assessment” section, offering a deeper dive into data collection methods and considerations.
Step 2: Diagnosis – Identifying Patient Problems
Diagnosis, the second step, is defined as: “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” A nursing diagnosis is a nurse’s clinical judgment about a patient’s response to health conditions or needs. It’s the foundation for the care plan and differs significantly from a medical diagnosis, which focuses on the disease itself.
The “Diagnosis” phase is explored in detail in the “Diagnosis” section, which provides guidance on formulating accurate and effective nursing diagnoses. Resources like “Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF” are particularly useful here, offering a structured list of diagnoses and guidance on their application.
Step 3: Outcomes Identification – Setting Goals
Outcomes Identification, the third step, is: “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” This involves setting measurable, achievable short- and long-term goals in partnership with the patient. Outcomes must be patient-centered and realistically attainable.
The “Outcomes Identification” section further elaborates on this step, emphasizing the importance of patient collaboration in setting meaningful and achievable goals.
Step 4: Planning – Developing the Care Plan
Planning, the fourth step, is: “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” This stage involves selecting evidence-based nursing interventions tailored to the patient’s diagnoses and goals. These are documented in a nursing care plan, ensuring consistent care across the healthcare team. Resources like “Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF” are invaluable for selecting appropriate interventions aligned with specific nursing diagnoses.
The “Planning” section provides a more detailed explanation of this critical phase, emphasizing the development of individualized and evidence-based care strategies.
Nursing Care Plans: The Blueprint for Patient Care
Nursing care plans are the tangible outcome of the planning phase. They are documented strategies that outline individualized care for each patient, guided by the nursing process. Registered Nurses (RNs) are responsible for creating these plans to ensure consistent, high-quality care across all shifts and among all healthcare providers. Care plans may include interventions delegable to Licensed Practical Nurses (LPNs) or Unlicensed Assistive Personnel (UAPs) under RN supervision.
Step 5: Implementation – Putting the Plan into Action
Implementation, the fifth step, is defined as: “The nurse implements the identified plan.” This is where nursing interventions are carried out, or delegated with appropriate supervision, according to the care plan. Documentation of interventions as they are performed is also crucial.
The “Implementation” section further details this step, including important subcategories such as “Coordination of Care” and “Health Teaching and Health Promotion.”
Step 6: Evaluation – Assessing Effectiveness
Evaluation, the final step, is: “The registered nurse evaluates progress toward attainment of goals and outcomes.” This involves continuous assessment and comparison against initial findings to determine the effectiveness of interventions and the overall care plan. The plan is adjusted as needed based on this ongoing evaluation.
The “Evaluation” section provides a deeper understanding of this step, highlighting its iterative nature and its importance in ensuring patient progress and care plan efficacy.
Benefits of the Nursing Process
Utilizing the nursing process offers numerous benefits for nurses, patients, and the entire healthcare team:
- Promotes Quality Patient Care: Ensures a systematic and comprehensive approach to care.
- Reduces Errors and Duplication: Decreases omissions and redundancies in care delivery.
- Provides Consistent Care: Guides all staff to deliver uniform and responsive care.
- Encourages Collaboration: Fosters a team approach to patient health management.
- Improves Patient Safety: Proactive planning and evaluation minimize risks.
- Enhances Patient Satisfaction: Patient-centered and individualized care improves the patient experience.
- Clarifies Goals and Strategies: Defines patient goals and the paths to achieve them.
- Increases Positive Outcomes: Improves the likelihood of achieving desired health results.
- Saves Time and Resources: Streamlines care delivery, saving energy and reducing frustration.
By employing the nursing process, nurses can customize interventions, plan effective outcomes, and critically assess the impact of their actions, leading to more effective and patient-centered care. Resources like “Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF” are instrumental in this process, offering a wealth of knowledge to support each step.
Holistic Nursing Care: Integrating Art and Science
The ANA emphasizes that nursing is both an art and a science. Holistic nursing care embodies this by addressing the patient’s emotional, spiritual, psychosocial, cultural, and physical needs. It considers the individual within the context of their family and community, ensuring a comprehensive approach to well-being.
The art of nursing is “unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” It’s about connecting with patients on a human level, understanding their experiences, and providing care with empathy and respect.
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 discovers the family’s financial constraints prevent them from affording the medication and accessing follow-up care. A holistic approach prompts the nurse to involve social services, explore affordable insurance options, and advocate for a more cost-effective treatment plan. This goes beyond just treating the ear infection; it addresses the family’s broader health and social needs.
Caring and the Nursing Process
The ANA underscores that “The act of caring is foundational to the practice of nursing.” A care relationship, built on mutual trust and rapport, is essential for the nursing process to be truly effective. This relationship allows for a deeper understanding of the patient’s beliefs, values, and attitudes, acknowledging their vulnerability and dignity. Caring interventions can be as simple as active listening, eye contact, gentle touch, and verbal reassurance, always respecting cultural nuances in expressing care, as shown in Figure 4.4.
Figure 4.4: Touch as a Therapeutic Communication Technique
Dr. Jean Watson’s theory of human caring further emphasizes the importance of authentic presence and creating a healing environment. Her work advocates for balancing the medical focus on cure with nursing’s unique role in caring and healing.
Assessment in Detail: Subjective and Objective Data
Assessment is the initial and foundational step of the nursing process. It’s a continuous process of collecting and analyzing patient data, which can be broadly categorized into subjective and objective data.
Subjective Assessment Data: The Patient’s Perspective
Subjective data is information provided by the patient and/or their family. It’s invaluable because it offers insights directly from their perspective. When documenting subjective data, it’s crucial to use quotation marks and phrases like “The patient reports…” to indicate it’s the patient’s own words. Building rapport is key to obtaining accurate and meaningful subjective data, especially concerning emotional, mental, and spiritual aspects of health.
Primary data comes directly from the patient, while secondary data is gathered from other sources like family members, medical charts, or previous healthcare providers. Secondary data is particularly important when patients cannot communicate for themselves. Figure 4.5 illustrates a nurse effectively gathering subjective data while building rapport.
Figure 4.5: Obtaining Subjective Data in a Care Relationship
Example of documented subjective data: “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”
Objective Assessment Data: Observable and Measurable Facts
Objective data is what the nurse observes, measures, and verifies through senses – sight, sound, touch, and smell. It’s reproducible, meaning another healthcare provider should be able to obtain the same data. Examples include vital signs, physical examination findings, and lab results. Figure 4.6 shows a nurse performing a physical examination.
Figure 4.6: Physical Examination
Example of documented objective data: “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”
Sources of Assessment Data
Assessment data is primarily gathered through:
Interviewing: This involves asking questions, active listening, and observing verbal and nonverbal cues. Reviewing the patient’s chart beforehand can streamline the interview, focusing on key areas. Starting with questions about medical diagnoses helps understand their impact on the patient’s life. Observing nonverbal cues and validating inferences are also crucial.
Physical Examination: A systematic method using inspection, auscultation, palpation, and percussion to collect objective data. Inspection involves observation; auscultation uses a stethoscope to listen to body sounds; palpation uses touch to assess organs; and percussion, often by providers, involves tapping body parts to assess size and fluid presence. Vital signs are also a key component.
Reviewing Laboratory and Diagnostic Test Results: These results provide crucial objective data related to the patient’s health status and are essential for informed care planning and intervention. Nurses must understand normal and abnormal results and their implications for patient care.
Types of Nursing Assessments
Different situations call for different types of assessments:
- Primary Survey: A rapid assessment in emergency situations focusing on consciousness, airway, breathing, and circulation (ABCs).
- Admission Assessment: A comprehensive, head-to-toe assessment when a patient is admitted to a healthcare facility.
- Ongoing Assessment: Regular assessments, often shift-based in acute care, to monitor patient status and detect changes.
- Focused Assessment: Detailed assessment of a specific problem or condition already identified.
- Time-lapsed Reassessment: Interval assessments, especially in long-term care, to evaluate progress over time.
Scenario C: Putting Assessment Together
Scenario C
Ms. J., 74, is admitted for shortness of breath, ankle swelling, and fatigue. Her history includes hypertension, coronary artery disease, heart failure, and type 2 diabetes. Medications include aspirin, metoprolol, furosemide, and metformin.
Admission vital signs: BP 162/96, HR 88, SpO2 91% (room air), RR 28, Temp 97.8°F. Weight is up 10 pounds in three 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 exam findings: Bilateral lung crackles and 2+ pitting edema in ankles/feet. Lab results: Potassium 3.4 mEq/L (low).
Her daughter adds, “We are so worried about mom living at home alone when she is so tired!”
Critical Thinking Questions:
- Identify subjective data.
- Identify objective data.
- Provide an example of secondary data.
(Answers in Answer Key)
Diagnosis in Detail: Analyzing Data and Identifying Nursing Diagnoses
Diagnosis, the second step of the nursing process, involves analyzing collected assessment data to identify patient problems. The ANA defines it as: “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” This step is crucial for prioritizing care and developing targeted interventions.
Analyzing Assessment Data: From Cues to Hypotheses
After assessment, nurses analyze data to differentiate between expected and unexpected findings for a particular patient. Data analysis involves comparing patient data to norms and baselines, identifying “relevant cues”—data that deviate from the expected and are clinically significant.
Example: In Scenario C, elevated BP, RR, and decreased SpO2 are relevant cues.
Clustering Information, Seeing Patterns, and Forming Hypotheses
Relevant cues are then clustered into patterns. Frameworks like Gordon’s Functional Health Patterns help organize this data. These patterns represent common human responses to health conditions. Clustering helps in forming a generalization about the patient’s overall health status and then developing a hypothesis about potential nursing diagnoses.
Example: In Scenario C, cues like elevated BP, RR, lung crackles, edema, weight gain, and heart failure history cluster into a pattern of fluid imbalance, fitting under Gordon’s Nutritional-Metabolic pattern. The hypothesis is Excess Fluid Volume.
Gordon’s Functional Health Patterns
- Health Perception-Health Management: Patient’s view of their health and its management.
- Nutritional-Metabolic: Food and fluid intake relative to needs.
- Elimination: Bowel, bladder, and skin excretory functions.
- Activity-Exercise: Exercise, activity levels, and mobility.
- Sleep-Rest: Sleep patterns, rest, and energy levels.
- Cognitive-Perceptual: Sensory and cognitive functions.
- Self-perception and Self-concept: Self-esteem, body image, and mood.
- Role-Relationship: Social roles and relationships.
- Sexuality-Reproductive: Sexual function and reproductive health.
- Coping-Stress Tolerance: Stress management and coping mechanisms.
- Value-Belief: Values, beliefs, and spiritual considerations.
Identifying Nursing Diagnoses: NANDA-I and Resources
A nursing diagnosis is a clinical judgment about a patient’s response to health conditions. It guides care planning and is distinct from a medical diagnosis. Resources like “Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF” are essential for this step. They provide comprehensive lists of NANDA-I diagnoses, definitions, and defining characteristics.
NANDA International (NANDA-I) is the leading organization for developing and standardizing nursing diagnoses. They offer a continually updated taxonomy of diagnoses, grouped into 13 domains similar to Gordon’s patterns. While specific NANDA-I diagnoses aren’t tested on the NCLEX, the underlying clinical judgment skills are.
Nursing Diagnoses vs. Medical Diagnoses
Medical diagnoses identify diseases, made by physicians or advanced practitioners. Nursing diagnoses focus on the patient’s response to these conditions, made independently by RNs. Patients with the same medical diagnosis can have different nursing diagnoses based on their unique responses.
Example: Two patients with heart failure (medical diagnosis) might have different nursing diagnoses: one might have Deficient Knowledge about their condition, while another experiences Anxiety related to their prognosis. Nursing diagnoses are holistic, considering the patient’s individual needs and responses.
NANDA-I Terminology: Key Definitions
- Patient: NANDA-I’s definition includes individual, caregiver, family, group, and community.
- Age: Categories range from fetus to older adult.
- Time: Duration is defined as acute (less than 3 months), chronic (more than 3 months), intermittent, or continuous.
New Terms in NANDA-I (2018-2020)
- At-Risk Populations: Groups sharing characteristics that increase vulnerability to specific responses.
- Associated Conditions: Medical diagnoses, injuries, or treatments that are not nurse-modifiable but inform the nursing diagnosis.
Types of Nursing Diagnoses
NANDA-I recognizes four types:
- Problem-Focused: Describes an existing undesirable response. Requires related factors and defining characteristics.
- Health Promotion-Wellness: Describes a desire to enhance well-being. Focuses on readiness to improve.
- Risk: Describes vulnerability to developing a problem. Supported by risk factors.
- Syndrome: A cluster of nursing diagnoses occurring together. Addressed with similar interventions.
Formulating Nursing Diagnosis Statements
A nursing diagnosis statement typically includes the nursing diagnosis and related factors as evidenced by defining characteristics. Accurate statements link these components clearly, reflecting the patient’s assessment data. The traditional PES format is still helpful for structuring these statements:
- P (Problem): The nursing diagnosis itself.
- E (Etiology): Related factors, phrased as “related to” (R/T).
- S (Signs and Symptoms): Defining characteristics, phrased as “as manifested by” or “as evidenced by.”
Examples of Nursing Diagnosis Statements
Problem-Focused: Excess Fluid Volume related to excessive fluid intake as manifested by bilateral basilar crackles, 2+ pitting edema, 10-pound weight gain, and patient report of “swollen ankles.”
Health-Promotion: Readiness for Enhanced Health Management as manifested by expressed desire to “learn more about my health.”
Risk: Risk for Falls as evidenced by dizziness and decreased lower extremity strength.
Syndrome: Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling.
Prioritization of Nursing Diagnoses
After identifying diagnoses, prioritization is crucial. It involves determining the most urgent problems and interventions. Life-threatening issues take immediate priority. Tools for prioritization include:
- Maslow’s Hierarchy of Needs: Prioritizes physiological needs and safety first.
- ABCs (Airway, Breathing, Circulation): Essential for immediate life support.
- Acute vs. Chronic Conditions: Acute, uncompensated conditions often take precedence.
- Actual vs. Potential Problems: Actual problems generally prioritized, but significant risks may be higher priority.
Example: For Ms. J., Fluid Volume Excess is a high priority due to its impact on physiological needs, closely followed by Risk for Falls due to safety concerns.
Outcome Identification in Detail: Setting SMART Goals
Outcome Identification is the third step, where the RN “identifies expected outcomes for a plan individualized to the health care consumer or the situation.” Outcomes are measurable patient behaviors resulting from nursing interventions. This step involves setting both broad goals and specific, measurable expected outcomes.
Short-Term and Long-Term Goals
Nursing care must be patient-centered and individualized. Goals should be tailored to each patient’s needs, values, and cultural beliefs, involving patients and families in the process. Goals are broad statements of desired change, either short-term or long-term, depending on the care setting.
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
Expected outcomes are specific, measurable statements of patient behavior within a timeframe. They should be guided by the Nursing Outcomes Classification (NOC), a standardized system linked to NANDA-I diagnoses. Outcomes must be SMART:
- Specific: Clearly defined action.
- Measurable: Quantifiable criteria for success.
- Attainable/Action-Oriented: Realistic and patient-driven.
- Relevant/Realistic: Aligned with patient’s condition and resources.
- Time-bound: With a clear timeframe for achievement.
Figure 4.9 illustrates the SMART components.
Figure 4.9: SMART Components of Outcome Statements
Specific Outcomes
Outcomes should be precise about what will be achieved.
- Not specific: “The patient will increase exercise.”
- Specific: “The patient will bicycle for 30 minutes daily.”
Each outcome should focus on a single action for clear evaluation.
Measurable Outcomes
Outcomes must be quantifiable, using numeric parameters or concrete criteria. Avoid vague terms like “adequate” or “normal.” Figure 4.10 lists measurable and non-measurable verbs.
Figure 4.10: Measurable Outcomes
- Not measurable: “The patient will drink adequate fluids.”
- Measurable: “The patient will drink 24 ounces of fluid per shift.”
Action-Oriented and Attainable Outcomes
Outcomes should describe an action the patient will take, using action verbs. Figure 4.11 provides examples.
Figure 4.11: Action Verbs
- Not action-oriented: “The patient will have increased activity.”
- Action-oriented: “The patient will list three aerobic activities.”
Realistic and Relevant Outcomes
Outcomes must be achievable considering the patient’s condition, resources, and values. Re-evaluate and revise outcomes for realism as needed.
- Not realistic: “The patient will jog a mile daily (starting exercise).”
- Realistic: “The patient will walk ½ mile three times a week for two weeks.”
Time-Limited Outcomes
Outcomes should specify a timeframe for evaluation, ranging from shift-based 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.”
Putting it Together: SMART Outcome Example
For Ms. J.’s Fluid Volume Excess, a SMART outcome is: “The patient will have clear bilateral lung sounds within the next 24 hours.”
Planning in Detail: Selecting Nursing Interventions
Planning, the fourth step, involves developing a care plan with evidence-based nursing interventions to achieve the set outcomes. The ANA defines it as: “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” Nursing interventions should aim to resolve the related factors of the nursing diagnosis.
Planning Nursing Interventions: Evidence-Based Choices
“Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF” and similar resources are crucial for this stage. They provide evidence-based interventions linked to nursing diagnoses. The Nursing Interventions Classification (NIC) system is a standardized resource categorizing and describing nursing interventions, constantly updated with research and nursing expertise. Nurses use clinical judgment to select the most appropriate interventions for each patient.
Direct and Indirect Care Interventions
Nursing interventions can be:
- Direct Care: Involve direct patient interaction (e.g., wound care, repositioning).
- Indirect Care: Support patient care but don’t involve direct contact (e.g., care conferences, documentation).
Classification of Nursing Interventions: Independent, Dependent, Collaborative
Interventions are also classified by their nature of initiation:
-
Independent Nursing Interventions: Nurse-initiated, no prescription needed (e.g., monitoring intake/output, therapeutic communication). Example: For Fluid Volume Excess, “The nurse will reposition the patient every 2 hours.”
-
Dependent Nursing Interventions: Require a provider’s prescription (e.g., medication administration). Example: For Fluid Volume Excess, “The nurse will administer scheduled diuretics as prescribed.”
-
Collaborative Nursing Interventions: Carried out with other healthcare team members (e.g., respiratory therapy, physical therapy). Example: For Fluid Volume Excess, “The nurse will manage oxygen therapy in collaboration with the respiratory therapist.” Figure 4.12 shows collaborative planning.
Figure 4.12: Collaborative Nursing Interventions
Individualization of Interventions
Effective interventions must be tailored to the patient’s preferences and needs. Collaboration with the patient, family, and interprofessional team is key to selecting interventions that are both effective and acceptable to the patient.
Creating Nursing Care Plans: Legal and Professional Standards
RNs create nursing care plans, which are legally required in long-term care facilities (by CMS) and hospitals (by The Joint Commission). CMS guidelines emphasize patient participation in care planning. The Joint Commission sees care plans as crucial for coordinating communication and ensuring safe, effective care. Standardized care plan templates, like the one in Figure 4.13, are often used but must be individualized.
Figure 4.13: Standardized Care Plan
Nursing school care plans may vary in format but should always be patient-specific. Appendix B provides a template for creating nursing care plans.
Implementation of Interventions in Detail: Action and Safety
Implementation, the fifth step, is where the care plan is put into action. The ANA defines it as: “The registered nurse implements the identified plan.” This step requires ongoing critical thinking and clinical judgment.
Prioritizing Implementation: Urgency and Safety
Prioritization during implementation mirrors diagnosis prioritization, using Maslow’s Hierarchy and ABCs. Less invasive interventions are generally preferred initially. Prioritization also considers the impact of timely intervention completion, especially for time-sensitive tasks like pre-operative NPO status.
Patient Safety During Implementation: Preventing Errors
Patient safety is paramount during implementation. Nurses must continuously reassess patients and adapt interventions as needed. An example is holding ambulation if a patient becomes dizzy, despite it being in the care plan. Nurses are frontline in preventing errors.
Reports like the Institute of Medicine’s “To Err Is Human” and “Preventing Medication Errors” have highlighted the critical need for patient safety in healthcare, emphasizing preventable medical errors and medication errors. The Quality and Safety Education for Nurses (QSEN) project aims to prepare nurses to continuously improve healthcare quality and safety. Quality improvement (QI) is a collective effort to enhance patient outcomes, system performance, and professional development.
Delegation of Interventions: RN Responsibility
RNs may delegate tasks to LPNs or UAPs but remain accountable. Delegation requires considering the “Five Rights of Delegation”: Right Task, Right Circumstance, Right Person, Right Communication, and Right Supervision/Evaluation, alongside state Nurse Practice Acts and agency policies. RNs cannot delegate tasks requiring clinical judgment. Table 4.7 outlines delegation guidelines in Wisconsin.
Table 4.7: General Guidelines for Delegating Nursing Tasks
Documentation of Interventions: Timeliness and Accuracy
Timely and accurate documentation of interventions is crucial. Lack of documentation is legally considered as “not done.” Prompt documentation, especially for medications, prevents errors and ensures continuity of care.
Coordination of Care and Health Teaching/Health Promotion
ANA’s Implementation Standard includes “Coordination of Care” and “Health Teaching and Health Promotion.” Coordination involves organizing care, engaging patients in self-care, and advocating for holistic care. Health teaching is a continuous process of educating patients about their health and self-management.
Putting it Together: Scenario C Implementation
In Scenario C, interventions for breathing were prioritized. Diuretics were administered first, lung sounds monitored, and patient weight delegated to a CNA. Patient education on medications and edema management was provided. All interventions were documented in the EMR.
Evaluation in Detail: Measuring Outcome Achievement
Evaluation, the final step, assesses the effectiveness of the care plan. The ANA defines it as: “The registered nurse evaluates progress toward attainment of goals and outcomes.” It’s a continuous process of assessing patient status and care plan effectiveness, modifying the plan as needed.
Evaluating Outcome Achievement: Met, Partially Met, Not Met
Evaluation involves comparing reassessment data to expected outcomes to determine if they were met, partially met, or not met within the specified timeframes. If outcomes are not fully met, the care plan requires revision. Reassessment is ongoing, occurring with every patient interaction and review of new data. The evaluation results and any care plan revisions must be documented.
Revising the Care Plan: Adaptive and Responsive Care
Care plan revision is essential when interventions are not effective. Questions to guide revision include:
- Were there any unexpected events?
- Has the patient’s condition changed?
- Were outcomes and timeframes realistic?
- Are diagnoses still accurate?
- Are interventions appropriately targeted?
- What barriers were encountered?
- Does new data necessitate changes to diagnoses, outcomes, interventions, or implementation?
- Are different interventions needed?
Putting it Together: Scenario C Evaluation
For Ms. J. and her Fluid Volume Excess, the nurse evaluated outcomes like reduced dyspnea, clear lung sounds, decreased edema, and weight returning to baseline. Initial evaluation showed “Partially Met” outcomes, prompting care plan revisions, including TED hose and leg elevation. Risk for Falls outcome was evaluated as “Met.” Ongoing evaluation and revision are integral to the nursing process.
Summary of the Nursing Process: Continuous Cycle of Care
The nursing process is a dynamic, six-step cycle (ADOPIE) that forms the foundation of patient-centered nursing practice. Critical thinking, clinical reasoning, and clinical judgment are interwoven throughout each step. Continuous reassessment and care plan revision ensure adaptive and effective care, always prioritizing the patient’s needs and goals. Resources like “Nursing Care Plans Nursing Diagnosis and Intervention 7th Edition PDF” are invaluable tools for mastering this process and developing effective care plans.
Video Review: Sample Care Plan Creation
Learning Activities: Applying the Nursing Process
Learning Activities
(Answers in Answer Key)
Instructions: Create a nursing care plan for Mark S., a 57-year-old male admitted with severe abdominal pain and scheduled for diagnostic tests. Use Appendix B as a template.
Scenario: Mark S., 57, admitted for severe abdominal pain. Diagnostic tests scheduled. Pacing, repeatedly asking about test duration, stating “I’m so uptight I will never be able to sleep,” avoids eye contact, fidgets, eyes darting, tense, strained expression, “My mouth is so dry.” Vital signs: T 98, P 104, R 30, BP 180/96. Diaphoretic, cool skin.
Critical Thinking Activity:
- Cluster subjective and objective data.
- Create a problem-focused nursing diagnosis.
- Develop a broad goal and SMART outcome.
- Outline three interventions with evidence-based sources.
- Evaluate outcome achievement: Met – Partially Met – Not Met.
IV Glossary
Advocacy: Supporting or recommending a cause or action.
Art of nursing: Compassionate, dignified, and comforting care, respecting patient humanity.
At-risk populations: Groups susceptible to specific health responses due to shared traits.
Associated conditions: Medical factors not nurse-modifiable but relevant to diagnosis.
Basic nursing care: Predictable care following defined procedures.
Caring relationship: Trust-based relationship assessing the whole person.
Client: Individual, family, group, or community receiving care.
Clinical judgment: Outcome of critical thinking and evidence-based decision-making for safe care.
Clinical reasoning: Cognitive process analyzing patient data and weighing actions.
Clustering data: Grouping similar data patterns.
Collaborative nursing interventions: Interventions requiring interprofessional cooperation.
Coordination of care: Organizing and integrating care plan components.
Critical thinking: Reasoning about clinical issues, teamwork, and workflow.
Cue: Hint or indication of a potential problem.
Deductive reasoning: “Top-down” thinking from general rules to specific situations.
Defining characteristics: Observable cues manifesting a diagnosis.
Delegation: Assigning tasks to UAP or LPNs while retaining accountability.
Dependent nursing interventions: Interventions requiring provider prescriptions.
Direct care: Interventions involving direct patient contact.
Electronic Medical Record (EMR): Digital patient medical chart.
Evidence-Based Practice (EBP): Integrating research, expertise, and patient preferences in care.
Expected outcomes: Measurable, time-bound patient actions in response to interventions.
Functional health patterns: Assessment framework for identifying patient problems.
Generalization: Judgment from facts, cues, and observations.
Goals: Broad statements of nursing care aims.
Health teaching and health promotion: Strategies for patient education and wellness.
Independent nursing interventions: Nurse-initiated interventions without prescriptions.
Indirect care: Interventions performed away from direct patient contact.
Inductive reasoning: “Bottom-up” reasoning from specific incidents to generalizations.
Inference: Interpretation based on cues and personal experiences.
Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs): Licensed nurses with specific training, scope defined by state and facility.
Medical diagnosis: Disease or illness identified by a provider.
Nursing: Art and science of caring, focusing on health promotion, healing, and alleviation of suffering.
Nursing care plan: Documentation of individualized care planning and delivery.
Nursing process: Systematic approach to patient care: ADOPIE.
Objective data: Observable, measurable, and verifiable patient information.
Outcome: Measurable patient behavior responsive to interventions.
PES Statement: Nursing diagnosis statement format: Problem, Etiology, Signs/Symptoms.
Prescription: Provider-ordered interventions or treatments.
Primary data: Information from the patient directly.
Primary health care provider: Authorized prescriber within the healthcare team.
Prioritization: Deciding order of actions for optimal outcomes.
Quality improvement: Continuous efforts to enhance patient outcomes and system performance.
Rapport: Mutual trust and understanding in a relationship.
Registered Nurse (RN): Licensed nurse with extensive education and training.
Related factors: Underlying causes of a nursing diagnosis.
Right to self-determination: Patient’s right to decide their own care.
Scientific method: Systematic knowledge discovery process.
Secondary data: Information from sources other than the patient.
Subjective data: Patient-reported information and nurse inferences.
Unlicensed Assistive Personnel (UAP): Trained, unlicensed personnel assisting in supportive roles.
