Mastering Nursing Care Plan Diagnosis: A Comprehensive Guide to the Nursing Process

The nursing process, pioneered by Ida Jean Orlando in 1958, remains the cornerstone of modern nursing practice. This systematic approach to patient care integrates critical thinking, patient-centered methodologies, goal-oriented interventions, evidence-based practice (EBP) guidelines, and seasoned nursing intuition. By weaving together holistic principles and scientific rigor, the nursing process ensures compassionate and high-quality care delivery.[1][2][3]

The 5 Steps of the Nursing Process: A Functional Overview

The nursing process is a cyclical, five-step framework designed to deliver patient-centered care. These steps are: Assessment, Diagnosis, Planning, Implementation, and Evaluation, each building upon the last to create a comprehensive and adaptable care strategy.

1. Assessment: Gathering Patient Data

The initial step, assessment, is the foundation of the nursing process. It requires astute critical thinking and comprehensive data collection, encompassing both subjective and objective information. Subjective data includes the patient’s or caregiver’s verbal descriptions of their health concerns and experiences. Objective data, conversely, is measurable and observable, such as vital signs, fluid intake and output, and physical measurements.

Data sources can vary, ranging from direct patient input to insights from primary caregivers, who may include family members or close friends. Electronic health records (EHRs) are invaluable tools for consolidating patient data and streamlining the assessment phase.

Crucially, strong critical thinking skills are paramount during assessment. Modern nursing education emphasizes concept-based curricula to cultivate these essential analytical abilities.

2. Diagnosis: Identifying Patient Needs with Nursing Diagnoses

Formulating a precise nursing diagnosis is pivotal, as it provides the clinical judgment necessary to guide subsequent planning and implementation of patient care.

The North American Nursing Diagnosis Association International (NANDA-I) is the definitive resource for standardized nursing diagnoses. NANDA-I defines a nursing diagnosis as a “clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes.”

Nursing diagnoses are intrinsically linked to Maslow’s Hierarchy of Needs, a psychological theory that prioritizes human needs in a hierarchical manner. Developed by Abraham Maslow in 1943, this hierarchy posits that basic physiological needs must be satisfied before individuals can pursue higher-level needs such as self-esteem and self-actualization. In nursing, Maslow’s Hierarchy provides a framework for prioritizing patient care, with physiological and safety needs forming the bedrock of nursing interventions and care planning.[4][5]

Maslow’s Hierarchy of Needs in Nursing Practice

• Physiological Needs (Base of the Pyramid): These are the most fundamental needs for survival: nutrition (food and water), elimination, airway management (suctioning), breathing (oxygenation), circulation (monitoring pulse, cardiac function, blood pressure), sleep, sex, shelter, and exercise. Addressing these needs is paramount for patient stability.
• Safety and Security Needs: Once physiological needs are met, safety and security become priorities. This includes injury prevention (using side rails, call lights, practicing hand hygiene, implementing isolation protocols, suicide and fall precautions, car seat and helmet use, seat belt encouragement), fostering a secure and trusting environment through therapeutic relationships, and patient education on preventative measures (e.g., modifiable risk factors for stroke and heart disease).
• Love and Belonging Needs: These social needs encompass fostering supportive relationships, implementing strategies to combat social isolation (addressing bullying), employing active listening and therapeutic communication techniques, and supporting healthy sexual intimacy.
• Self-Esteem Needs: Self-esteem relates to feelings of accomplishment and self-worth. Nursing interventions in this area focus on promoting community acceptance, supporting workforce participation, recognizing personal achievements, fostering a sense of control and empowerment, and encouraging acceptance of one’s body image.
• Self-Actualization Needs (Peak of the Pyramid): Self-actualization represents reaching one’s full potential. In healthcare, this involves creating an empowering environment, supporting spiritual growth, encouraging the ability to understand diverse perspectives, and facilitating the patient’s journey toward maximizing their capabilities.

3. Planning: Constructing the Nursing Care Plan

The planning stage is dedicated to formulating patient-specific goals and desired outcomes. These plans are meticulously developed using evidence-based practice guidelines to ensure the highest quality of care. Nursing care plans are the central output of this phase, serving as roadmaps for individualized care tailored to each patient’s unique circumstances. A patient’s overall health status and any co-existing conditions are carefully considered when constructing a care plan. Well-structured care plans are essential for enhancing communication among healthcare team members, ensuring accurate documentation, facilitating reimbursement processes, and promoting continuity of care across the entire healthcare spectrum.

Effective goals within a nursing care plan are characterized by the acronym SMART:

1. Specific: Goals should be clearly defined and unambiguous.
2. Measurable: Progress toward goals should be quantifiable and trackable.
3. Attainable: Goals must be realistic and achievable for the patient.
4. Relevant: Goals should be pertinent to the patient’s needs and health condition, also referred to as Results-Oriented.
5. Time-bound: Goals should have a defined timeframe for achievement, also referred to as Time-Oriented.

4. Implementation: Putting the Care Plan into Action

Implementation is the action-oriented phase where nursing interventions, as detailed in the care plan, are put into practice. This step encompasses a wide range of nursing actions, including direct care (e.g., applying a cardiac monitor, administering oxygen), indirect care (e.g., managing the patient’s environment), medication administration, adherence to standard treatment protocols, and application of evidence-based practice standards.

5. Evaluation: Assessing the Effectiveness of Interventions

Evaluation, the final step in the nursing process, is critical for ensuring positive patient outcomes. After implementing any nursing intervention, it is imperative to reassess and evaluate the patient’s response to determine if the desired outcomes have been achieved. The frequency of reassessment depends on the patient’s overall condition and stability. Based on new assessment data gathered during evaluation, the nursing care plan may need to be adapted or revised to better meet the patient’s evolving needs.

Challenges in Implementing the Nursing Process

A 2011 study conducted in hospitals within the Mekelle Zone highlighted significant challenges in the practical application of the nursing process. The study revealed that a substantial number of nurses lacked adequate knowledge and experience to consistently implement the nursing process in their daily practice. Factors such as high nurse-to-patient ratios and limited resources were identified as major barriers to effective implementation. Specifically, ninety percent of the study participants reported insufficient experience in applying the nursing process in routine care. The research concluded that resource scarcity and overwhelming workloads due to understaffing significantly hindered the consistent use of the nursing process in patient care delivery.[6][7][8]

Clinical Significance of the Nursing Process

In today’s increasingly complex and dynamic healthcare landscape, the consistent and diligent application of the nursing process is more clinically significant than ever. Aging populations often present with multiple comorbidities, increasing the risk of overlooking critical health conditions.

As highlighted by Salmond and Echevarria, the healthcare field is in constant flux, necessitating a transformation in traditional nursing roles to meet the demands of this evolving environment. Nurses are uniquely positioned to be agents of change, actively shaping future patient care delivery models.[9][10]

Adapting to the Future of Nursing: The Concept-Based Curriculum

Critical thinking skills are becoming increasingly vital as nurses navigate the complexities of care planning for patients with multiple health issues in a challenging healthcare environment. The shift towards concept-based nursing curricula is a crucial adaptation to equip nurses with the necessary cognitive tools.

Baron’s work further emphasizes the necessity of concept-based learning over traditional, content-heavy educational models, acknowledging the implementation challenges while underscoring its direct positive impact on patient care quality and outcomes. The synergy between nursing practice and education, fostering clinical knowledge and expertise, is essential for facilitating the transition of new nurses into the workforce as valuable team members and leaders in this new era of healthcare.

The focus must shift to learning as a dynamic and continuous process, nurtured within a collaborative learning environment involving educators and students, preceptors and novices, and mentors and mentees.

Looking ahead, nurses must be adept problem-solvers, capable of navigating diverse and complex situations, including challenging nurse-patient ratios, multifaceted care prioritization, resource limitations, efficient use of electronic health records, and effective teamwork and leadership.

Review Question

Where does Nursing Diagnosis fall within the steps of the nursing process?

Figure: Maslow’s Hierarchy of Needs for Nursing, illustrating the prioritization of needs in patient care planning.

References

1. Karttunen M, Sneck S, Jokelainen J, Elo S. Nurses’ self-assessments of adherence to guidelines on safe medication preparation and administration in long-term elderly care. Scand J Caring Sci. 2020 Mar;34(1):108-117. [PubMed: 31058362]

2. Younan L, Clinton M, Fares S, Samaha H. The translation and cultural adaptation validity of the Actual Scope of Practice Questionnaire. East Mediterr Health J. 2019 Apr 25;25(3):181-188. [PubMed: 31054228]

3. Epstein AS, Desai AV, Bernal C, Romano D, Wan PJ, Okpako M, Anderson K, Chow K, Kramer D, Calderon C, Klimek VV, Rawlins-Duell R, Reidy DL, Goldberg JI, Cruz E, Nelson JE. Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. J Pain Symptom Manage. 2019 Jul;58(1):72-79.e2. [PMC free article: PMC6849206] [PubMed: 31034869]

4. Shih CY, Huang CY, Huang ML, Chen CM, Lin CC, Tang FI. The association of sociodemographic factors and needs of haemodialysis patients according to Maslow’s hierarchy of needs. J Clin Nurs. 2019 Jan;28(1-2):270-278. [PubMed: 29777561]

5. Maslow K, Mezey M. Recognition of dementia in hospitalized older adults. Am J Nurs. 2008 Jan;108(1):40-9; quiz, 50. [PubMed: 18156858]

6. Raso A, Ligozzi L, Garrino L, Dimonte V. Nursing profession and nurses’ contribution to nursing education as seen through students’ eyes: A qualitative study. Nurs Forum. 2019 Jul;54(3):414-424. [PubMed: 31056754]

7. Hu J, Yang Y, Fallacaro MD, Wands B, Wright S, Zhou Y, Ruan H. Building an International Partnership to Develop Advanced Practice Nurses in Anesthesia Settings: Using a Theory-Driven Approach. J Transcult Nurs. 2019 Sep;30(5):521-529. [PubMed: 31060444]

8. Bird M, Tolan J, Carter N. Baccalaureate Nursing Students’ Perceptions of Learning in Mentored and Simulated Research Practica. J Nurs Educ. 2019 May 01;58(5):290-293. [PubMed: 31039263]

9. Salmond SW, Echevarria M, Allread V. Care Bundles: Increasing Consistency of Care. Orthop Nurs. 2017 Jan/Feb;36(1):45-48. [PubMed: 28107300]

10. Rigolosi R, Salmond S. The journey to independent nurse practitioner practice. J Am Assoc Nurse Pract. 2014 Dec;26(12):649-57. [PubMed: 24824941]

Disclosures: Tammy Toney-Butler and Jennifer Thayer declare no relevant financial relationships with ineligible companies.