Learning Objectives
- Apply the nursing process to deliver effective patient care.
- Identify accurate nursing diagnoses using evidence-based resources.
- Detail the creation and implementation of a patient-centered nursing care plan.
- Prioritize nursing care based on patient needs and acuity.
- Document each stage of the nursing process thoroughly and professionally.
- Differentiate the roles of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) within the nursing process.
Have you ever wondered how nurses seamlessly manage patient care, even when stepping in mid-shift? The secret lies in the nursing process, a systematic approach that provides a structured framework for care. This method enables nurses to quickly assess, plan, implement, and evaluate patient care, ensuring consistent and optimal health outcomes. This chapter will explore the nursing process in detail, demonstrating how it serves as the cornerstone of professional nursing practice, guiding safe and patient-centered care. Understanding and applying the principles outlined in resources like “Nursing Care Plan Nursing Diagnosis And Intervention 6th Edition” is crucial for every aspiring and practicing nurse.
Basic Concepts of the Nursing Process
Before diving into the specifics of the nursing process, it’s essential to grasp the fundamental concepts that underpin effective nursing practice: critical thinking and clinical reasoning. These cognitive skills are the engines that drive the nursing process, ensuring thoughtful and responsive patient care.
Critical Thinking and Clinical Reasoning in Nursing
Critical thinking in nursing goes beyond simply following protocols. It’s a multifaceted skill encompassing “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[1] A critical thinker in nursing validates patient information, ensures patient safety is paramount, and bases care plans on individual patient needs, the latest clinical guidelines, and evidence-based research.
Certain attitudes are hallmarks of a critical thinker, fostering a rational and patient-centered approach:
- Independence of Thought: Thinking autonomously and forming your own judgments.
- Fair-mindedness: Approaching every viewpoint with impartiality and without prejudice.
- Insight into Egocentricity and Sociocentricity: Balancing personal perspectives with the broader good, recognizing when self-interest (egocentricity) or group bias (sociocentricity) might influence decisions.
- Intellectual Humility: Acknowledging the limits of your knowledge and expertise.
- Nonjudgmental Attitude: Applying professional ethics and standards rather than personal biases or moral judgments.
- Integrity: Maintaining honesty and strong ethical principles in all actions.
- Perseverance: Committing to tasks despite challenges and difficulties.
- Confidence: Trusting in your ability to perform tasks effectively and safely.
- Interest in Exploring Thoughts and Feelings: Being open to different perspectives and ways of understanding.
- Curiosity: Questioning assumptions, asking “why,” and seeking deeper understanding.
Clinical reasoning, a more focused cognitive process, is 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] Effective clinical reasoning enables nurses to generate and evaluate care options, weigh evidence, and select the most appropriate course of action for each patient. This ability is honed with experience and a robust knowledge base, often developed through resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition.”[3]
Inductive and Deductive Reasoning in Clinical Judgment
Inductive and deductive reasoning are vital components of critical thinking, forming the foundation for sound clinical judgment within the nursing process.
Inductive reasoning is about moving from specific observations to broader generalizations. It involves noticing cues—data that deviate from expected findings, hinting at potential patient problems. Nurses gather these cues, identify patterns, and form generalizations, much like assembling pieces of a puzzle. From these generalizations, nurses develop hypotheses, proposed explanations for a patient’s situation, addressing the “why” behind a problem. Understanding the “why” is crucial for devising effective solutions.
Sharp observational skills are essential for inductive reasoning. Nurses, much like detectives (Figure 4.1), must be attentive to patient details, the environment, and family interactions.[4] Engage all five senses—sight, hearing, touch, smell, and even taste when appropriate—to gather comprehensive cues. Strong inductive reasoning is particularly critical in emergency situations, enabling rapid pattern recognition and quick action.
Figure 4.1 Inductive Reasoning: Looking for Cues
Example: A nurse assessing a post-operative patient observes redness, warmth, and tenderness at the incision site. Recognizing these cues as a pattern indicative of infection, the nurse hypothesizes a surgical site infection. This leads to notifying the provider, who then prescribes antibiotics, demonstrating inductive reasoning in practice.
Deductive reasoning, in contrast, is “top-down thinking.” It starts with a general rule or standard and applies it to a specific situation. Nurses use established protocols, standards of practice (like those in “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition”), and institutional policies to guide patient care decisions and problem-solving.
Example: Based on research showing improved patient recovery with adequate rest, a hospital implements a “quiet zone” policy at night (Figure 4.2).[5] This policy includes measures like reduced overhead paging, staff speaking softly, and dimmed hallway lights. A nurse then uses deductive reasoning to organize patient care to ensure uninterrupted nighttime rest, applying the general policy to all patients, regardless of their individual sleep patterns.
Figure 4.2 Deductive Reasoning: Quiet Zone Policy Implementation
Clinical judgment, the outcome of effectively using critical thinking and both inductive and deductive reasoning, is defined by the National Council of State Boards of Nursing (NCSBN) as “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”[6] Clinical judgment is fundamental to safe nursing practice and is a key component evaluated in the NCLEX exam.
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, enhancing patient outcomes. Resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition” are instrumental in promoting EBP by providing up-to-date, evidence-based guidelines for nursing practice.
The Nursing Process: ADOPIE
The nursing process is a systematic, patient-centered approach to care, guided by the Standards of Professional Nursing Practice from the American Nurses Association (ANA). It’s a critical thinking model that structures how nurses apply clinical reasoning and judgment. The ANA standards are authoritative guidelines for competent nursing practice across all roles and settings.[8] The mnemonic ADOPIE helps remember the six core components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
The nursing process is dynamic and cyclical, constantly adapting to the patient’s evolving health status (Figure 4.3).[9]
Figure 4.3 The Nursing Process Cycle
Consider Scenario A to see the nursing process in action.
Patient Scenario A: Applying the Nursing Process[10]
A hospitalized patient is prescribed Lasix 80mg IV daily for heart failure. During the morning assessment, the nurse notes a blood pressure of 98/60, heart rate of 100, respirations of 18, and temperature of 98.7°F. Reviewing the patient’s chart, the nurse sees a baseline blood pressure around 110/70 and heart rate in the 80s. Recognizing these vital signs as cues indicating potential fluid imbalance, the nurse hypothesizes dehydration. Further investigation reveals a 4-pound weight loss since the previous day and patient reports of a dry mouth and lightheadedness. Applying clinical judgment, the nurse identifies the nursing diagnosis of Fluid Volume Deficit and sets goals to restore fluid balance. The nurse appropriately withholds the Lasix, contacts the provider to discuss the patient’s fluid status, and implements interventions to increase oral fluid intake and closely monitor hydration. By shift end, the patient’s fluid balance is restored.
In Scenario A, the nurse demonstrates clinical judgment by not simply administering Lasix as prescribed. Instead, by using the nursing process—assessing, diagnosing, planning, implementing, and evaluating—the nurse ensures patient safety and optimal care.
The ANA Standards of Professional Nursing Practice for each step of the nursing process are detailed below.
Assessment
The “Assessment” Standard of Practice is defined 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 of physiological, psychological, sociocultural, spiritual, economic, and lifestyle data. For instance, assessing a hospitalized patient in pain includes not only the pain level but also its impact on mobility, appetite, social interaction, and emotional state.[12]
For a more detailed exploration of the assessment phase, refer to the “Assessment” section in this chapter.
Diagnosis
The “Diagnosis” Standard of Practice states, “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 a patient’s response to health conditions or needs. It forms the basis of the nursing care plan and differs from a medical diagnosis.[14] Resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition” are invaluable for accurately formulating nursing diagnoses.
The “Diagnosis” section provides a comprehensive guide to this step.
Outcomes Identification
According to the “Outcomes Identification” Standard of Practice, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[15] This involves setting measurable, achievable short- and long-term goals in collaboration with the patient, based on assessment data and nursing diagnoses.
The “Outcomes Identification” section further elaborates on this stage.
Planning
The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”[16] Using assessment data, diagnoses, and goals, nurses select evidence-based interventions tailored to each patient’s needs. These plans, documented as nursing care plans, ensure continuity of care by providing a roadmap for all healthcare professionals involved.[17]
The “Planning” section offers more insight into care plan development.
NURSING CARE PLANS
Nursing care plans, a product of the “Planning” phase, are crucial for documenting and delivering individualized patient care using the nursing process. A nursing care plan is a dynamic document that outlines patient-specific care, ensuring consistency across shifts and among healthcare personnel. Registered Nurses (RNs) are responsible for creating these plans, which may include interventions delegable to Licensed Practical Nurses (LPNs) or Unlicensed Assistive Personnel (UAPs) under RN supervision. The “Planning” and “Implementing” sections further discuss care plan development and delegation.
Implementation
The “Implementation” Standard of Practice is, “The nurse implements the identified plan.”[18] This involves carrying out or delegating nursing interventions as outlined in the care plan, ensuring consistent care delivery. Interventions are also documented in the patient’s medical record as they are performed.[19] The “Implementation” Standard also includes “Coordination of Care” and “Health Teaching and Health Promotion,” emphasizing holistic patient care.[20]
Further details on implementation can be found in the “Implementation” section.
Evaluation
The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”[21] This final step involves reassessing the patient to compare their status against the initial assessment, judging the effectiveness of interventions and the overall care plan. Evaluation is ongoing, requiring continuous adjustment of the care plan as needed.[22]
The “Evaluation” section provides a deeper understanding of this critical phase.
Benefits of the Nursing Process
Utilizing the nursing process offers numerous advantages for nurses, patients, and the entire healthcare team:
- Enhances the quality of patient care.
- Reduces errors and redundancies in care delivery.
- Provides a clear, consistent guide for all staff involved in patient care.
- Promotes collaborative management of patient health issues.
- Improves patient safety outcomes.
- Increases patient satisfaction with care.
- Clarifies patient goals and the strategies to achieve them.
- Increases the likelihood of positive patient outcomes.
- Optimizes time and resources by providing a structured care pathway.
By employing the nursing process as a critical thinking framework, nurses can tailor interventions to individual patient needs, plan effective outcomes, and evaluate the success of their actions. Mastering the nursing process, often detailed in resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition,” is fundamental to the “science of nursing.” However, nursing is also an “art,” involving holistic care delivered with compassion.
Holistic Nursing Care
The American Nurses Association (ANA) defines nursing as, “Nursing integrates 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]
Nursing is both a science and an art. The art of nursing is “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”[24]
Holistic nursing care addresses the patient’s emotional, spiritual, psychosocial, cultural, and physical needs, considering them within their family and community context. The nursing process is the vehicle for delivering this holistic care.
Holistic Nursing Care Scenario
A single mother brings her child to the emergency room with ear pain and fever. The physician diagnoses an ear infection and prescribes an antibiotic, advising a follow-up with their primary provider in two weeks. During discharge teaching, the nurse learns the mother cannot afford the prescribed antibiotic and lacks transportation to a primary care provider accessible by bus. The nurse then consults a social worker to discuss affordable health insurance and local providers, and follows up with the physician to prescribe a less expensive generic antibiotic. This demonstrates holistic care, addressing not just the child’s medical needs but also the family’s socioeconomic barriers to health.
For further understanding of culturally responsive care and reducing health disparities, refer to the “Diverse Patients” chapter.
Caring and the Nursing Process
The ANA emphasizes that “The act of caring is foundational to the practice of nursing.”[25] A care relationship, built on mutual trust and rapport, is essential for the successful application of the nursing process and embodies the art of nursing. This relationship involves assessing the patient as a whole person—considering beliefs, values, attitudes, vulnerabilities, and dignity—addressing physical, mental, emotional, and spiritual dimensions.[26] Caring interventions can be simple, like active listening, eye contact, therapeutic touch (Figure 4.4), and verbal reassurance, always respecting cultural beliefs around caring behaviors.[27]
Figure 4.4 Therapeutic Touch: Communicating Caring
For more on therapeutic communication, including active listening, see the “Communication” chapter.
Nurse theorist Dr. Jean Watson’s philosophy of caring emphasizes the importance of authentic presence and creating a healing environment, balancing the medical focus on cure with nursing’s unique caring perspective.[29] Her work and resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition” reinforce the humanistic aspects of nursing.
To learn more about Dr. Watson’s theory, visit the Watson Caring Science Institute.
With these foundational concepts in mind, let’s explore each step of the nursing process in greater detail in the following sections, using insights often found in comprehensive nursing resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition.”
References
[List of references as in the original article]
Assessment in the Nursing Process
Assessment is the first crucial step in the nursing process and the first Standard of Practice defined by the American Nurses Association. It’s defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This comprehensive data collection includes “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.”[1] This step is foundational for all subsequent steps in the nursing process and is thoroughly detailed in resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition.”
Nurses perform assessments to gather essential clues, form generalizations, and ultimately diagnose patient responses to health conditions and life processes. Patient data falls into two categories: subjective and objective, and is gathered from various sources.
Subjective Assessment Data
Subjective data is information obtained directly from the patient and/or their family, providing crucial insights from their perspectives. When documenting subjective data, it’s essential to use quotation marks and phrases like, “The patient reports…” Building rapport is vital for obtaining accurate subjective data, particularly regarding mental, emotional, and spiritual well-being. Figure 4.5 illustrates a nurse effectively establishing rapport while gathering subjective data.
Subjective data is further categorized into primary and secondary data. Primary data comes directly from the patient, the most reliable source regarding their own experiences and feelings. Active listening is key to extracting valuable primary data and fostering a sense of well-being in the patient. Secondary data is gathered from other sources, such as family members, medical charts, or previous records. Family input is especially crucial for patients with cognitive impairments, infants, children, or those unable to communicate for themselves.
Figure 4.5 Obtaining Subjective Data in a Care Relationship
Example: Documented subjective data might read: “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”
Objective Assessment Data
Objective data includes all observable and measurable information gathered through your senses—hearing, sight, smell, and touch—during patient assessment. Objective data is verifiable and reproducible, meaning different assessors should obtain the same findings. Examples include vital signs, physical examination findings, and laboratory results. Figure 4.6 depicts a nurse conducting a physical examination.
Figure 4.6 Physical Examination
Example: An example of documented objective data is: “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”
Sources of Assessment Data
Assessment data is gathered primarily through three sources: interviews, physical examinations, and reviews of laboratory and diagnostic test results.
Interviewing Patients
Patient interviews involve asking questions, listening attentively, and observing both verbal and nonverbal communication. Reviewing the patient’s chart beforehand can streamline the interview, focusing on key areas of concern or clarification. However, always verify chart information with the patient during the interview to resolve discrepancies or incompleteness.
Start by introducing yourself, explaining your role, and stating the purpose and duration of the interview. Begin with questions about the patient’s medical diagnoses to understand their impact on function, relationships, and lifestyle. Active listening and seeking clarification are crucial. Patients may not realize certain details are important, so probing questions and careful observation are essential. Be mindful of nonverbal cues and body language, which can reveal important information. Always validate any inferences to avoid misinterpretations. For example, avoiding eye contact might be misinterpreted as depression, but could be a cultural norm. For more on effective patient communication, refer to the “Communication” chapter.
Physical Examination
A physical examination is a systematic method of collecting body data using inspection, auscultation, palpation, and percussion. Inspection is visual observation of body structures. Auscultation involves listening to organ sounds, such as heart, lung, and bowel sounds, using a stethoscope. Palpation uses touch to assess organ size, location, and tenderness. Percussion, typically performed by providers, involves tapping body parts to assess size and fluid presence. Detailed physical examination techniques are available in resources like the Open RN Nursing Skills textbook, with a head-to-toe checklist in Appendix C. Physical examination also includes vital signs measurement and analysis.
Registered Nurses (RNs) are responsible for the initial comprehensive physical examination and analysis. Follow-up data collection can be delegated to Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs), and basic measurements like vital signs and weight to trained Unlicensed Assistive Personnel (UAP), but the RN remains accountable for supervision, analysis, and documentation. All assessment data is recorded in the patient’s Electronic Medical Record (EMR).
Reviewing Laboratory and Diagnostic Test Results
Laboratory and diagnostic test results provide valuable objective data about a patient’s health status. Understanding normal and abnormal results is crucial for care planning and medication administration. Nurses must review results, notify providers of concerns, and verify prescription appropriateness based on current patient status before implementation.
Types of Nursing Assessments
Different types of nursing assessments are used depending on the clinical situation:
- Primary Survey: A rapid assessment during every patient encounter to evaluate consciousness, airway, breathing, and circulation (ABCs), and initiate emergency care if needed.
- Admission Assessment: A comprehensive assessment upon patient admission to a facility, gathering extensive data systematically.
- Ongoing Assessment: In acute care settings, a head-to-toe assessment is performed and documented at least once per shift, with changes in condition promptly reported to the provider.
- Focused Assessment: Used to reassess the status of a previously identified problem.
- Time-Lapsed Reassessment: In long-term care, used every three or more months to evaluate progress toward long-term outcomes.[4]
Putting It Together: Scenario C
Scenario C below illustrates the application of assessment concepts in a patient case.
Scenario C[5]
Ms. J., a 74-year-old woman, is admitted to the medical unit for shortness of breath, increased ankle and calf swelling, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). Medications include aspirin 81 mg daily, metoprolol 50 mg twice daily, furosemide 40 mg daily, and metformin 2,000 mg daily.
Admission vital signs:
- Blood Pressure: 162/96 mm Hg
- Heart Rate: 88 beats/min
- Oxygen Saturation: 91% on room air
- Respiratory Rate: 28 breaths/minute
- Temperature: 97.8°F orally
Weight is up 10 pounds from three weeks prior. Patient states, “I am so short of breath,” “My ankles are so swollen I have to wear slippers,” “I am so tired and weak I can’t shop,” and “Sometimes I’m afraid to get out of bed because I get dizzy.” She also expresses a desire to learn more about her health.
Physical assessment reveals bilateral basilar crackles and 2+ pitting edema in ankles and feet. Lab results show decreased serum potassium of 3.4 mEq/L.
Patient’s daughter expresses concern about her mother living alone due to fatigue.
Critical Thinking Questions
- Identify subjective data.
- Identify objective data.
- Provide an example of secondary data.
Answers are in the Answer Key at the end of the book.
References
[List of references as in the original article]
Nursing Diagnosis: The Second Step
Diagnosis, the second step in the nursing process and ANA Standard of Practice, is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, strengths, and issues are documented to facilitate outcome development and collaborative planning.[1] Accurate nursing diagnosis is a critical skill emphasized in resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition.”
Analyzing Assessment Data for Nursing Diagnosis
After assessment data collection, nurses analyze it to form generalizations and hypotheses for nursing diagnoses. This involves data analysis, information clustering, hypothesis identification, in-depth assessment (if needed), and establishing nursing diagnosis statements. Prioritized nursing diagnoses then guide the care plan.[2]
Performing Data Analysis
Nurses analyze patient assessment data using their nursing knowledge to determine if data is “expected” or “unexpected,” “normal” or “abnormal” for that patient, considering age, development, and baseline status. This analysis helps identify “clinically relevant” data to prioritize care.[3]
Example: In Scenario C from the “Assessment” section, elevated blood pressure, respiratory rate, decreased oxygen saturation, and elevated heart rate are “relevant cues.”
Clustering Information, Seeing Patterns, and Forming Hypotheses
After identifying relevant cues, nurses cluster data into patterns. Assessment frameworks like Gordon’s Functional Health Patterns aid in organizing information based on evidence-based human response patterns. (See Gordon’s Functional Health Patterns box below).[4]
Example: In Scenario C, relevant cues include elevated blood pressure and respiratory rate, lung crackles, weight gain, edema, shortness of breath, heart failure history, and diuretic use. These cluster into a pattern of fluid balance issues, under Gordon’s Nutritional-Metabolic pattern. The hypothesis is Excess Fluid Volume.
Gordon’s Functional Health Patterns[5]
Health Perception-Health Management: Patient’s view of their health and management practices.
Nutritional-Metabolic: Food and fluid intake relative to metabolic needs.
Elimination: Bowel, bladder, and skin excretory functions.
Activity-Exercise: Exercise, mobility, and daily activities.
Sleep-Rest: Sleep patterns, rest, and daily routines.
Cognitive-Perceptual: Sensory and cognitive function.
Self-perception and Self-concept: Self-esteem, body image, and mood state.
Role-Relationship: Role engagements and relationships with others.
Sexuality-Reproductive: Sexual function and reproductive health.
Coping-Stress Tolerance: Stress management and coping mechanisms.
Value-Belief: Values, beliefs (including spiritual), and guiding life principles.
Identifying Nursing Diagnoses
Following data analysis and clustering, the next step is to determine the patient’s “human responses” or 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] Nursing diagnoses are patient-specific and drive care plan development. Referencing care planning resources, like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition,” is essential to confirm diagnosis accuracy and defining characteristics before selection.
Nursing diagnoses are developed by nurses for nurses. NANDA International (NANDA-I) is a global organization that standardizes nursing terminology for human responses to health problems, based on research.[7] NANDA-I maintains a list of over 220 diagnoses, continuously updated. Appendix A lists common NANDA-I diagnoses, and comprehensive references provide the full, current list.
NANDA-I diagnoses are categorized into 13 domains (similar to Gordon’s patterns) to aid selection: Health Promotion, Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Self-Perception, Role Relationship, Sexuality, Coping/Stress Tolerance, Life Principles, Safety/Protection, Comfort, and Growth/Development.
While specific NANDA-I diagnoses are not tested on the NCLEX, cue analysis and hypothesis creation, crucial for clinical judgment, are assessed.
Nursing Diagnoses vs. Medical Diagnoses
Nursing diagnoses differ from medical diagnoses. Medical diagnoses, made by physicians or advanced practitioners, focus on diseases. Nursing diagnoses, made independently by RNs, focus on patient responses to health conditions. Patients with the same medical diagnosis may have different nursing diagnoses due to varied responses. For example, two heart failure patients might have different nursing diagnoses based on their unique responses, such as knowledge deficit or anxiety. Nursing diagnoses consider patient and family needs, strengths, and resources to create individualized, holistic care plans.
Example: In Scenario C, heart failure is a medical diagnosis. It’s an “associated condition” for nursing diagnosis, not a nursing diagnosis itself. Associated conditions are medical diagnoses, injuries, etc., that are not nurse-modifiable but support diagnosis accuracy. The nursing diagnosis in Scenario C relates to the patient’s response to heart failure.
NANDA-I Definitions: Patient, Age, and Time
NANDA-I uses specific definitions for patient, age, and time:
Patient includes Individual, Caregiver, Family, Group, and Community.[8]
Age categories include Fetus, Neonate, Infant, Child, Adolescent, Adult, and Older Adult.[9]
Time is defined as Acute (<3 months), Chronic (>3 months), Intermittent, and Continuous.[10]
New Terms in 2018-2020 NANDA-I Diagnoses
The 2018-2020 NANDA-I edition introduced “at-risk populations” and “associated conditions” to refine diagnoses.[11]
At-Risk Populations: Groups sharing characteristics that increase susceptibility to specific human responses (e.g., age, health history).
Associated Conditions: Medical diagnoses, treatments, etc., that support diagnosis accuracy but are not nurse-modifiable.[12]
Types of Nursing Diagnoses
Four NANDA-I diagnosis types exist:[13]
- Problem-Focused: Undesirable response to health condition. Requires related factors and defining characteristics.
- Health Promotion-Wellness: Desire to enhance well-being. Expressed by readiness to improve health behaviors.
- Risk: Vulnerability to developing an undesirable response. Supported by risk factors.
- Syndrome: Cluster of diagnoses best addressed together.
A problem-focused nursing diagnosis is “a clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.”[14] It must include related factors (etiology/causes) and defining characteristics (signs/symptoms).[15]
A health promotion-wellness nursing diagnosis is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential,” shown by readiness to enhance specific behaviors.[16]
A risk nursing diagnosis is “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.”[17] It’s supported by risk factors. Risk diagnoses can be as high priority as problem-focused diagnoses.[18]
A syndrome diagnosis is “a clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.”[19]
Establishing Nursing Diagnosis Statements
NANDA-I recommends a nursing diagnosis statement structure including the nursing diagnosis, related factors, and defining characteristics. Accuracy is confirmed by linking assessment findings to these components.[20]
To create a statement: analyze data, cluster patterns, hypothesize diagnoses, and check if patterns match defining characteristics of a diagnosis. Defining characteristics are observable signs and symptoms.[21] Resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition” list these for each diagnosis.
Also identify related factors, the underlying causes (etiology), not medical diagnoses but treatable pathophysiology.[22] Interventions should aim to modify these factors.
Nursing diagnosis statements were traditionally in “PES format.” PES is no longer NANDA-I terminology, but components are similar:
Problem (P): Nursing diagnosis.
Etiology (E): Related factors, “related to” (R/T).
Signs and Symptoms (S): Defining characteristics, “as manifested by” or “as evidenced by.”
Examples of diagnosis types are below.
Problem-Focused Nursing Diagnosis
Includes all PES components:
Problem (P): Nursing diagnosis statement.
Etiology (E): Related factors.
Signs and Symptoms (S): Defining characteristics.
SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT
For Ms. J. (Scenario C), data clusters (elevated BP, RR, crackles, edema, etc.) are defining characteristics for Excess Fluid Volume. NANDA-I defines it as “surplus intake and/or retention of fluid.” The related factor is excessive fluid intake.[23]
Example Statement:
P. Fluid Volume Excess
E. Related to excessive fluid intake
S. As manifested by bilateral basilar crackles, 2+ pitting edema, 10-pound weight gain, and patient report, “My ankles are so swollen.”
Correctly written: 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
Includes Problem (P) and Symptoms (S). Symptoms start with “expresses desire to enhance”:[24]
Problem (P): Nursing diagnosis statement.
Symptoms (S): Patient’s expressed desire to enhance.
SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT
Ms. J. (Scenario C) shows readiness to improve health by saying she wants to “learn more about my health so I can take better care of myself.” This is a defining characteristic of Readiness for Enhanced Health Management, defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.”[25]
Example Statement:
Problem (P): Readiness for Enhanced Health Management
Symptoms (S): Expressed desire to “learn more about my health so I can take better care of myself.”
Correctly written: 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
Supported by risk factors, phrased as “as evidenced by”:[26]
Problem (P): Nursing diagnosis statement.
As Evidenced By: Risk factors.
SAMPLE RISK DIAGNOSIS STATEMENT
Ms. J. (Scenario C) is at Risk for Falls due to dizziness and weakness. NANDA-I defines Risk for Falls as “increased susceptibility to falling, which may cause physical harm and compromise health.”[27]
Example Statement:
Problem (P): Risk for Falls
As Evidenced By: Dizziness and decreased lower extremity strength.
Correctly written: Risk for Falls as evidenced by dizziness and decreased lower extremity strength.
Syndrome Diagnosis
Cluster of diagnoses addressed together. Needs Problem (P) and Symptoms (S), where Symptoms are two or more similar nursing diagnoses. Related factors are optional.[28]
Problem (P): Syndrome name.
Symptoms (S): Defining characteristics are nursing diagnoses.
SAMPLE SYNDROME DIAGNOSIS STATEMENT
For Ms. J. (Scenario C), Activity Intolerance (“insufficient energy for daily activities”) and Social Isolation (“aloneness imposed by others”) fit Risk for Frail Elderly Syndrome, defined as “unstable equilibrium affecting older adults experiencing deterioration in health domains and increased susceptibility to adverse effects, particularly disability.”[29]
Example Statement:
Problem (P): Risk for Frail Elderly Syndrome
Symptoms (S): Activity Intolerance and Social Isolation.
Related factor: Fear of falling.
Correctly written: Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling.
Prioritization of Nursing Diagnoses
After diagnosis identification, prioritization is essential, based on patient needs. Prioritization identifies the most significant nursing problems and interventions. Life-threatening concerns are top priority, addressed immediately using rapid clinical judgment. Most situations fall between crisis and routine care.
Concepts for prioritization include Maslow’s Hierarchy of Needs, ABCs (Airway, Breathing, Circulation), and acute vs. chronic conditions. Figure 4.7 illustrates prioritization.
Figure 4.7 The How To of Prioritization
Maslow’s Hierarchy of Needs ranks needs by urgency, with physiological and safety needs at the base (Figure 4.8). ABCs are also crucial, though safety may sometimes precede airway (e.g., in a fire, safety first, then ABCs).
Figure 4.8 Maslow’s Hierarchy of Needs
Acute, uncompensated conditions usually take priority over chronic conditions. Actual problems generally precede potential problems, but risk diagnoses can be prioritized based on patient vulnerability and risk factors.
Example: For Ms. J. (Scenario C), Fluid Volume Excess, Readiness for Enhanced Health Promotion, Risk for Falls, and Risk for Frail Elderly Syndrome were identified. Fluid Volume Excess is highest priority due to physiological needs (breathing, homeostasis). Risk for Falls is a close second due to safety concerns.
References
[List of references as in the original article]
Outcome Identification: Setting Patient Goals
Outcome Identification, the third step in the nursing process and ANA Standard of Practice, is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the patient, interprofessional team, and family to set outcomes that reflect the patient’s culture, values, and ethical considerations. Outcomes are documented as measurable goals with specific timeframes.[1] This step is vital for directing care and evaluating effectiveness, often guided by resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition.”
An outcome is a “measurable behavior demonstrated by the patient responsive to nursing interventions.”[2] Outcomes should be established before planning interventions. Post-implementation, nurses evaluate if outcomes were met within the set timeframe.
Outcome identification involves setting short- and long-term goals and creating specific, measurable outcome statements for each nursing diagnosis.
Short-Term and Long-Term Goals
Nursing care must be patient-centered and individualized. Goals and outcomes should be tailored to each patient’s unique needs, values, and cultural beliefs. Patient and family involvement in goal-setting is crucial, promoting awareness, realistic expectations, and motivation.
The nursing care plan is a roadmap guiding care toward common patient goals. Goals are broad statements outlining the overall aim of care, either short-term or long-term. Timeframes vary by setting; critical care short-term goals might be hours, while outpatient goals might be months.
A nursing goal is the desired direction of patient progress, often the opposite of the identified problem.
Example: For Ms. J.’s Fluid Volume Excess diagnosis (Scenario C), a broad goal could be: “Ms. J. will achieve a state of fluid balance.”
Expected Outcomes: SMART Criteria
Goals are broad; expected outcomes are specific and measurable actions the patient will achieve within a timeframe due to nursing interventions. Nurses can develop outcomes independently or use classification systems like the Nursing Outcomes Classification (NOC), which lists over 330 standardized nursing outcomes aligned with NANDA-I diagnoses.[3]
Patient-Centered Outcomes
Outcome statements are always patient-centered, developed collaboratively, and tailored to individual needs, values, and culture. They start with “The patient will…” and aim to resolve the defining characteristics of the nursing diagnosis. Outcomes must be achievable and patient-agreed.
Effective outcome statements follow the SMART criteria:[4]
- Specific
- Measurable
- Attainable/Action oriented
- Relevant/Realistic
- Timeframe
Figure 4.9 illustrates the SMART components.
Figure 4.9 SMART Components of Outcome Statements
Specific Outcomes
Outcomes should clearly state what is to be accomplished.
- Not specific: “The patient will increase exercise.”
- Specific: “The patient will bicycle for 30 minutes daily.”
Each outcome should include only one action for clear evaluation.
- Poor example (two goals combined): “The patient will walk 50 feet three times a day with standby assistance and will shower in the morning until discharge.”
- Revised (separate outcomes): “The patient will walk 50 feet three times a day with standby assistance until discharge.” and “The patient will shower every morning until discharge.”
Measurable Outcomes
Measurable outcomes use numeric parameters or concrete methods for evaluation, relying on objective data. Avoid vague terms like “acceptable” or “normal.” Figure 4.10 shows measurable vs. non-measurable verbs.
Figure 4.10 Measurable Outcomes
- Not measurable: “The patient will drink adequate fluids daily.”
- Measurable: “The patient will drink 24 ounces of fluids during each day shift (0600-1400).”
Action-Oriented and Attainable Outcomes
Outcomes should specify actions the patient or others will take, using action verbs (Figure 4.11).
Figure 4.11 Action Verbs
- Not action-oriented: “The patient will have increased physical activity.”
- Action-oriented: “The patient will list three types of aerobic activity they would enjoy weekly.”
Realistic and Relevant Outcomes
Realistic outcomes consider the patient’s physical and mental state, culture, values, beliefs, socioeconomic status, health literacy, and available resources. Outcomes should be achievable and revised if necessary. Unattained outcomes often result from unrealistic timeframes or patient capabilities.
- Not realistic: “The patient will jog one mile daily from the start of the exercise program.”
- Realistic: “The patient will walk ½ mile three times a week for two weeks.”
Time-Limited Outcomes
Outcomes must include a timeframe for evaluation, varying from shift-based to weekly or monthly, depending on the intervention and patient condition. Evaluation at the specified time determines outcome achievement and the need for care plan revision.
- Not time-limited: “The patient will stop smoking.”
- Time-limited: “The patient will complete the smoking cessation plan by December 12, 2021.”
Putting It Together: Scenario C Outcome Example
For Ms. J.’s Fluid Volume Excess diagnosis (Scenario C), a SMART outcome example is: “The patient will have clear bilateral lung sounds within the next 24 hours.”
References
[List of references as in the original article]
Planning Nursing Interventions: The Fourth Step
Planning, the fourth step of the nursing process and ANA Standard of Practice, is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN creates a holistic, evidence-based plan in partnership with the patient, family, and interprofessional team, prioritizing plan elements and modifying it based on ongoing patient assessment. The plan is documented using standardized language.[1] Effective planning, often referencing resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition,” is critical for guiding patient care.
After setting expected outcomes, nurses plan nursing interventions, evidence-based actions to achieve these outcomes. Like medical prescriptions, nursing interventions address patient problems—nursing diagnoses—aiming to resolve or reduce their related factors (etiology).[2] Interventions, goals, and outcomes are documented in the nursing care plan for care continuity.
Selecting Nursing Interventions
How do nurses choose evidence-based interventions? Several resources are available, including agency care planning tools within the EMR and external references like the Nursing Interventions Classification (NIC) system. NIC, based on research and nursing input, categorizes and updates evidence-based interventions. While NIC provides a valuable resource, nurses must use clinical judgment to select the most appropriate interventions for individual patient needs.[3]
Direct and Indirect Nursing Care
Nursing interventions are categorized as direct or indirect care. Direct care involves personal patient contact, such as wound care, repositioning, and ambulation. Indirect care is provided away from the patient, like care conferences, documentation, and inter-professional communication.
Classification of Nursing Interventions
Three types of nursing interventions exist: independent, dependent, and collaborative (Figure 4.12).
Figure 4.12 Collaborative Nursing Interventions
Independent Nursing Interventions
Independent nursing interventions are actions nurses can initiate without prescriptions. Examples include monitoring intake/output for fluid balance risk or using therapeutic communication for coping with a new diagnosis.
Example: For Ms. J.’s Fluid Volume Excess (Scenario C), an independent intervention is: “The nurse will reposition the patient with dependent edema frequently, as appropriate.”[5] Individualized to: “The nurse will reposition the patient every 2 hours.”
Dependent Nursing Interventions
Dependent nursing interventions require a prescription from an authorized primary health care provider.[6] A primary health care provider is a licensed professional (physician, advanced practice nurse, physician’s assistant) authorized to prescribe. Medication administration is a dependent intervention. Nurses integrate these into the care plan, linking each intervention to the relevant nursing diagnosis.
Example: For Ms. J.’s Fluid Volume Excess, a dependent intervention is: “The nurse will administer scheduled diuretics as prescribed.”
Collaborative Nursing Interventions
Collaborative nursing interventions are carried out with other healthcare team members like physicians, social workers, and therapists. These are developed in consultation with these professionals, incorporating their expertise.[7]
Example: For Ms. J.’s Fluid Volume Excess, a collaborative intervention is consulting respiratory therapy for declining oxygen saturation. The therapist plans oxygen therapy and obtains a provider prescription, with the nurse documenting: “The nurse will manage oxygen therapy in collaboration with the respiratory therapist.”
Individualization of Interventions
Individualized interventions are crucial for effectiveness. For instance, prune juice for constipation only works if the patient likes it. Patient and interprofessional team collaboration is key for selecting effective, personalized interventions. The number of interventions isn’t fixed, but enough quality, individualized actions should be planned to meet patient outcomes.
Creating Nursing Care Plans
Nursing care plans are created by RNs and are legally required in long-term care (CMS) and hospitals (The Joint Commission). CMS guidelines mandate resident participation in care planning, including treatment decisions and refusals.[8] The Joint Commission views care planning as a framework for communication, ensuring safe and effective care.[9]
Many facilities use standardized care plans with customizable intervention lists (Figure 4.13). Others require independent care plan development. Regardless of format, plans must be individualized. Appendix B provides a template for nursing care plan creation.
Figure 4.13 Standardized Care Plan Example
References
[List of references as in the original article]
Implementation of Nursing Interventions: Putting the Plan into Action
Implementation, the fifth step in the nursing process and ANA Standard of Practice, is defined as, “The registered nurse implements the identified plan.” The RN may delegate interventions, considering patient condition, task complexity, communication, supervision needs, and relevant regulations and policies.[1] Effective implementation, often informed by resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition,” requires critical thinking and ongoing patient assessment.
Implementation involves continual patient reassessment to detect changes requiring care plan adjustments, emphasizing the dynamic nature of the nursing process and the priority of patient safety. This phase includes prioritizing interventions, ensuring patient safety during implementation, delegating appropriately, and documenting all actions.
Prioritizing Intervention Implementation
Prioritization of interventions mirrors diagnosis prioritization, using Maslow’s Hierarchy and ABCs. Least invasive methods are generally preferred initially. (See “Diagnosis” section for prioritization methods.)
The impact of timely task completion is also key. For example, pre-operative NPO orders are prioritized over pre-op education if the patient is scheduled for surgery soon, as food intake could delay the procedure. Understanding care goals, patient situation, and expected outcomes is vital for accurate prioritization.
Patient Safety During Implementation
Patient safety is paramount during intervention implementation. Changes in patient condition may render planned interventions unsafe. For example, a planned ambulation intervention is contraindicated if the patient reports dizziness and has low blood pressure. Such decisions, with supporting assessment data, must be documented and communicated to the healthcare team.
Implementation extends beyond following orders and care plans; it’s about actively ensuring patient safety. Nurses are frontline providers, positioned to prevent errors before they reach the patient.[2]
The 2000 Institute of Medicine (IOM) report, To Err Is Human, highlighted the significant issue of preventable medical errors, estimating up to 98,000 deaths annually in US hospitals. This report initiated a national focus on improving patient safety through system-level changes.[3] A 2007 follow-up, Preventing Medication Errors, reported over 1.5 million annual injuries from medication errors in hospitals, emphasizing system-level improvements for medication safety.[4]
For more on medication error prevention, see the “Preventing Medication Errors” section in the Open RN Nursing Pharmacology textbook.
Errors involving nurses endanger patient safety across a broad spectrum, from “wrong site, wrong patient, wrong procedure” errors to medication mistakes, infection prevention failures, and falls. Causes range from nurse fatigue due to long shifts to flawed systems lacking safety checks and interruptions during critical tasks.[5]
The Quality and Safety Education for Nurses (QSEN) project, started in 2005, aims to prepare nurses to continuously improve healthcare quality and safety. QSEN’s vision is to “inspire health care professionals to put quality and safety as core values.”[6] Nurses and students are expected to participate in quality improvement (QI) initiatives, identifying areas for change and implementing improvements. Quality improvement is “the combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).”[7]
Delegation of Nursing Interventions
During implementation, RNs may delegate tasks. Delegation, according to the ANA, is “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.”[8] RNs are responsible for appropriate delegation based on patient condition, task complexity, communication, supervision, and regulatory guidelines. RNs cannot delegate tasks requiring clinical judgment.[9]
See the box for Wisconsin Nurse Practice Act delegation guidelines.
Delegation According to the Wisconsin Nurse Practice Act
RNs in Wisconsin must:
a. Delegate tasks based on supervisee’s preparation and abilities.
b. Provide direction and assistance.
c. Observe and monitor supervisee’s activities.
d. Evaluate the effectiveness of supervised acts.[10]
LPNs in Wisconsin, under RN supervision, must:
a. Accept assignments they are competent to perform.
b. Provide basic nursing care (predictable patient responses to defined procedures).
c. Record care and report patient condition changes.
d. Consult providers if delegated acts may harm patients.
e. Perform additional acts including data collection assistance, care plan assistance, reinforcing teaching, and basic needs assistance.[11]
For more details, see Wisconsin’s Nurse Practice Act, Chapter N 6 Standards of Practice, and ANA’s Principles of Delegation.
Table 4.7 outlines general delegation guidelines in Wisconsin.
Table 4.7 General Delegation Guidelines in Wisconsin
Documentation of Implemented Interventions
Timely documentation of interventions is crucial. Lack of documentation is a legal liability. Undocumented interventions are legally considered undone. Prompt documentation of medication administration and other interventions prevents errors from delayed recording.
Coordination of Care and Health Teaching/Health Promotion
ANA’s Implementation Standard includes Coordination of Care (Standard 5A) and Health Teaching and Health Promotion (Standard 5B).[12] Coordination of Care involves organizing care components, engaging patients in self-care, and advocating for holistic care. Health Teaching and Health Promotion involves “Employing strategies to teach and promote health and wellness.”[13] Patient education is integral to nursing, including medication teaching and self-management strategies.
Putting It Together: Scenario C Implementation
In Scenario C, interventions related to breathing were prioritized. Diuretics were administered first, with frequent lung sound monitoring. CNA delegation included pre-breakfast weight measurement. Patient education covered medications and edema reduction at home. All interventions were documented in the EMR.
References
[List of references as in the original article]
Evaluation: Assessing Outcome Achievement
Evaluation, the sixth and final step of the nursing process and ANA Standard of Practice, is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”[1] This step, often detailed in resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition,” involves continuously assessing patient status and care plan effectiveness, adjusting the plan as needed.[2]
Evaluation focuses on intervention effectiveness by reviewing expected outcomes against set timeframes. Nurses critically analyze reassessment data to determine if outcomes are met, partially met, or unmet. Unmet or partially met outcomes require care plan revision. Reassessment should occur continuously – at every patient interaction, during interprofessional discussions, and when reviewing new test results. Care plans should be updated as new priorities emerge. Evaluation results are documented in the patient’s medical record.
Ideally, interventions lead to positive patient responses and outcome achievement. However, when interventions are ineffective, the care plan must be revised. Key questions for revision include:
- Were there unanticipated events?
- Has the patient’s condition changed?
- Were outcomes and timeframes realistic?
- Are diagnoses still accurate?
- Are interventions focused on outcome attainment?
- What implementation barriers existed?
- Does new data suggest revised diagnoses, outcomes, interventions, or implementation strategies?
- Are different interventions needed?
Putting It Together: Scenario C Evaluation
Referencing Scenario C and Appendix C care plan, the nurse evaluates progress toward expected outcomes.
For Fluid Volume Excess, the nurse assesses four outcomes:
- Decreased dyspnea within 8 hours.
- Clear lung sounds within 24 hours.
- Decreased edema within 24 hours.
- Weight return to baseline by discharge.
Day 1 evaluation data: “Patient reports less shortness of breath, lung crackles resolved. Weight down 1 kg, but 2+ edema persists.” Outcomes are “Partially Met.” Care plan revised with new interventions:
- Request TED hose prescription.
- Elevate legs when sitting.
For Risk for Falls, outcome: “Met,” based on evaluation: “Patient verbalizes understanding and calls for assistance. No falls occurred.”
Ongoing reassessment and care plan revisions continue throughout hospitalization, with all evaluations documented in the medical record.
References
[List of references as in the original article]
Summary of the Nursing Process: A Cyclical Approach to Patient Care
You have now explored each step of the nursing process, aligned with ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are integral to assessment, care planning, and intervention implementation. Continuous reassessment and care plan revision are essential for outcome achievement. Throughout the process, the patient remains central to care. Individualized, patient-centered care, evaluated for outcome success, is the hallmark of safe, professional nursing practice. Resources like “Nursing Care Plan Nursing Diagnosis and Intervention 6th Edition” provide ongoing support for mastering this vital process.
Video Review: Creating a Sample Care Plan[1]
References
[List of references as in the original article]
Learning Activities: Applying the Nursing Process
Learning Activities
(Answers in the Answer Key at the end of the book. Interactive activity answers provided within elements.)
Instructions: Create a nursing care plan for the following scenario using the template in Appendix B.
Mark S., 57-year-old male, admitted for “severe” abdominal pain unresponsive to ED management. Physician informs Mark of diagnostic tests scheduled for the morning.
After the news, Mark paces constantly, repeatedly asking about test duration. He states, “I’m so uptight I will never be able to sleep tonight.” Nurse observes avoided eye contact, fidgeting, darting eyes, tense posture, strained expression, and reports “My mouth is so dry.” Vital signs: T 98°F, P 104, R 30, BP 180/96. Skin is diaphoretic and cool.
Critical Thinking Activity:
- Cluster subjective and objective data.
- Create a problem-focused nursing diagnosis.
- Develop a broad goal and a SMART expected outcome.
- Outline three evidence-based interventions (cite sources).
- Evaluate outcome achievement: Met – Partially Met – Not Met.
Glossary of Nursing Process Terms
IV GLOSSARY
Advocacy: Pleading for or supporting a cause or action.[1]
Art of nursing: Compassionate, comforting care, respecting patient dignity and worth.[2]
At-risk populations: Groups susceptible to specific human responses due to shared characteristics.[3]
Associated conditions: Medical diagnoses, treatments, etc., supporting diagnosis accuracy.[4]
Basic nursing care: Predictable care following defined procedures.[5]
Caring relationship: Holistic assessment balancing patient vulnerability and dignity.[6]
Client: Individual, family, group, or community.[7]
Clinical judgment: Outcome of critical thinking, using knowledge for safe care delivery.[8]
Clinical reasoning: Cognitive process to analyze patient data and weigh actions.[9]
Clustering data: Grouping data into patterns.
Collaborative nursing interventions: Interventions requiring interprofessional cooperation.
Coordination of care: Organizing care plan components with patient input.[10]
Critical thinking: Reasoning about clinical issues like teamwork and workflow.[11]
Cue: Data hinting at a potential problem.
Deductive reasoning: “Top-down” thinking from general to specific.
Defining characteristics: Observable cues manifesting a nursing diagnosis.[12]
Delegation: Assigning tasks to UAP or LPNs while retaining accountability.[13]
Dependent nursing interventions: Interventions requiring a provider prescription.
Direct care: Interventions with personal patient contact.
Electronic Medical Record (EMR): Digital patient medical chart.
Evidence-Based Practice (EBP): Integrating best evidence, expertise, and patient values.[14]
Expected outcomes: Measurable patient actions in response to interventions (SMART).
Functional health patterns: Assessment framework for identifying patient problems.
Generalization: Judgment from facts, cues, and observations.
Goals: Broad statements of nursing care purpose.
Health teaching and health promotion: Strategies to educate and promote wellness.[15]
Independent nursing interventions: Nurse-initiated interventions without prescriptions.
Indirect care: Interventions performed away from the patient (e.g., care planning).
Inductive reasoning: Reasoning from specific incidents to generalizations.
Inference: Interpretations based on cues and personal experiences.
Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs): Licensed nurses with specific training, scope of practice varies.
Medical diagnosis: Disease or illness diagnosed by a provider.
Nursing: Art and science of caring, focusing on health, healing, and alleviation of suffering.[16]
Nursing care plan: Documentation of planned nursing care.
Nursing process: Systematic approach: Assessment, Diagnosis, Outcomes, Planning, Implementation, Evaluation (ADOPIE).
Objective data: Observable, measurable, reproducible data.
Outcome: Measurable patient behavior responsive to interventions.[17]
PES Statement: Nursing diagnosis statement format: Problem, Etiology, Signs/Symptoms.
Prescription: Provider orders for treatments or interventions.[18]
Primary data: Information from the patient.
Primary health care provider: Authorized prescriber (physician, NP, PA).[19]
Prioritization: Deciding action order for optimal outcomes and safety.
Quality improvement: Efforts to enhance patient outcomes, system performance, and professional development.[20]
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 care.
Scientific method: Knowledge discovery through problem recognition, data collection, and hypothesis testing.
Secondary data: Information from sources other than the patient.
Subjective data: Patient/family reports, nurse inferences.
Unlicensed Assistive Personnel (UAP): Trained unlicensed personnel supporting nursing care.[21]
References
[List of references as in the original article]
