Nursing Care Plans E-Book: Your Guide to Nursing Diagnosis and Intervention (9th Edition Insights)

Embarking on a journey through the intricate landscape of nursing, one quickly realizes that at its heart lies the nursing process. This systematic approach isn’t just a set of steps; it’s the very compass guiding nurses in delivering patient-centered care, ensuring safety, and optimizing health outcomes. Imagine a scenario: a nurse receives a patient handover, a brief yet crucial exchange of information. How does this nurse, often meeting the patient for the first time, swiftly grasp the patient’s needs, prioritize care, and formulate a plan of action? The answer is the nursing process – a dynamic roadmap that empowers nurses to navigate complex patient situations with confidence and precision.

This chapter delves into the essence of the nursing process, illuminating its significance as a cornerstone of professional nursing practice. We will explore how it serves as a critical thinking model, enabling nurses to make informed clinical judgments and implement effective interventions. By understanding and applying the nursing process, healthcare professionals can ensure consistent, responsive, and high-quality care. Whether you are a nursing student just beginning your journey or a seasoned registered nurse seeking to refine your practice, mastering the nursing process is fundamental. This evidence-based approach not only enhances patient well-being but also underpins the very standards of professional nursing. Let’s unravel the layers of this essential framework, step by step, to elevate your nursing practice and patient care.

Basic Concepts: Critical Thinking and Clinical Reasoning in Nursing Practice

Before we delve into the specifics of the nursing process, it’s crucial to establish a firm understanding of the foundational concepts that underpin effective nursing practice: critical thinking and clinical reasoning. These cognitive skills are not merely academic terms; they are the intellectual engines that drive safe, patient-centered care.

Critical Thinking: The Cornerstone of Nursing Judgment

Critical thinking in nursing transcends simply following protocols or carrying out orders. It’s a multifaceted cognitive process that encompasses “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”¹ A nurse who embodies critical thinking is proactive, questioning assumptions, validating information, and ensuring that every action is grounded in patient needs, current best practices, and research findings. It’s about thinking beyond the immediate task and considering the broader implications for patient safety and well-being.

Becoming a critical thinker involves cultivating specific attitudes that promote rational and sound judgment. These attitudes are not innate traits but rather skills that can be developed and honed through conscious effort and reflection:

• Independence of Thought: This is the ability to think for oneself, to question norms, and to formulate your own judgments based on evidence rather than blindly accepting established practices. It’s about intellectual autonomy in your approach to patient care.
• Fair-mindedness: A fair-minded nurse approaches every situation and viewpoint with impartiality. Prejudices and biases have no place in patient care. Every perspective, whether from a patient, family member, or colleague, is considered in an unbiased and unprejudiced manner.
• Insight into Egocentricity and Sociocentricity: This involves self-awareness. Recognizing when your actions or thoughts are driven by self-interest (egocentricity) versus the greater good of the patient or community (sociocentricity) is vital. Critical thinkers strive for sociocentricity, ensuring patient needs are always paramount.
• Intellectual Humility: Acknowledging the limits of your knowledge and skills is a mark of intellectual maturity. Intellectual humility means recognizing that you don’t have all the answers, being open to learning from others, and understanding that continuous learning is part of professional growth.
• Nonjudgmental Attitude: Nurses operate within a professional ethical framework. Personal moral standards or biases must not cloud clinical judgment. Decisions should be based on professional ethics, patient rights, and evidence-based guidelines, not personal opinions.
• Integrity: Honesty and strong moral principles form the bedrock of nursing integrity. Being truthful, ethical, and consistent in your actions builds trust with patients and colleagues alike.
• Perseverance: Nursing is often challenging. Perseverance is the ability to persist in providing optimal care even when faced with difficult situations, complex patient needs, or systemic obstacles. It’s about maintaining commitment in the face of adversity.
• Confidence: Belief in your ability to provide competent care is essential. Confidence, grounded in knowledge and experience, empowers nurses to take initiative, advocate for patients, and effectively manage complex situations.
• Interest in Exploring Thoughts and Feelings: Critical thinkers are introspective. They are keen to explore different ways of knowing, understanding their own emotional responses, and recognizing how these might influence their perceptions and decisions in patient care.
• Curiosity: A curious mind is always questioning, always seeking to understand the “why” behind patient conditions and nursing interventions. Curiosity drives continuous learning and a deeper understanding of the complexities of healthcare.

Clinical Reasoning: Weaving Knowledge and Experience into Action

Clinical reasoning takes critical thinking a step further, focusing specifically on the clinical context of patient care. It 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 In essence, clinical reasoning is the process nurses use to make sound judgments and choose the best course of action for patient care. It’s a dynamic interplay of knowledge, data analysis, and decision-making.

Clinical reasoning is not a skill acquired overnight. It develops over time, nurtured by a growing knowledge base and enriched by practical experience.³ As nurses encounter diverse patient scenarios, their ability to clinically reason strengthens. It involves:

• Gathering Patient Information: This encompasses a comprehensive assessment, collecting both subjective and objective data to build a holistic picture of the patient’s condition.
• Analyzing Information: Interpreting the collected data, identifying patterns, and recognizing significant cues that point towards potential health issues or needs.
• Generating Alternatives: Considering a range of possible nursing diagnoses and interventions based on the patient’s condition and available evidence.
• Evaluating Alternatives: Weighing the pros and cons of each potential action, considering the evidence, patient preferences, and potential risks and benefits.
• Choosing the Best Course of Action: Selecting the most appropriate nursing interventions to address the identified patient needs and achieve desired outcomes.

Clinical reasoning ensures that nursing care is not just reactive but proactive and tailored to the individual patient. It moves beyond rote application of procedures and embraces a thoughtful, adaptable approach to patient care.

Inductive and Deductive Reasoning: Pathways to Clinical Judgment

Within the realm of clinical reasoning, two key types of logical thinking play crucial roles: inductive reasoning and deductive reasoning. Understanding these reasoning processes enhances a nurse’s ability to utilize clinical judgment effectively within the nursing process.

Inductive Reasoning: From Specific Cues to General Hypotheses

Inductive reasoning is often described as “bottom-up thinking.” It begins with specific observations or cues and moves towards forming broader generalizations and hypotheses. Cues are pieces of patient data that deviate from expected findings, signaling a potential problem or condition. These cues can be subtle or overt, and a keen observational skill is crucial for noticing them.

The inductive process unfolds as follows:

1. Noticing Cues: The nurse meticulously observes the patient, the environment, and interactions, paying close attention to details that might indicate a change in health status. This is akin to a detective gathering clues at a scene, as illustrated in Figure 4.1.

Figure 4.1: Inductive Reasoning Includes Looking for Cues

2. Making Generalizations: The nurse organizes these individual cues into patterns, identifying commonalities and relationships. This process of pattern recognition leads to a generalization, a judgment formed from a collection of facts, cues, and observations. It’s like piecing together fragments of a jigsaw puzzle until a discernible pattern emerges.
3. Creating Hypotheses: Based on the generalizations, the nurse formulates a hypothesis, a proposed explanation for the patient’s situation. The hypothesis attempts to answer the “why” behind the observed cues and patterns. Identifying the “why” is crucial for guiding subsequent interventions and problem-solving.

Example of Inductive Reasoning in Nursing:

Imagine a nurse assessing a post-operative patient. The nurse observes the following cues at the surgical incision site: redness, warmth to touch, and tenderness upon palpation. Recognizing these cues as a pattern indicative of inflammation and potential infection, the nurse makes a generalization: “These signs suggest a possible infection at the incision site.” Based on this generalization, the nurse formulates a hypothesis: “The surgical incision is likely infected.” This hypothesis then prompts the nurse to take further action, such as notifying the healthcare provider and anticipating orders for wound care and antibiotics.

Deductive Reasoning: From General Principles to Specific Strategies

Deductive reasoning, in contrast to inductive reasoning, is a “top-down thinking” approach. It starts with a general principle, rule, or standard and applies it to a specific situation to create a strategy or solution. Nurses frequently use deductive reasoning, drawing upon established standards and guidelines to inform their patient care decisions. These standards can originate from various sources, including:

• State Nurse Practice Acts: Legal frameworks defining the scope of nursing practice.
• Federal Regulations: Rules and guidelines set by federal agencies to ensure quality healthcare.
• American Nurses Association (ANA) Standards: Professional standards outlining expected nursing practice.
• Professional Organizations: Guidelines from specialty nursing organizations (e.g., oncology, critical care).
• Employer Policies: Institution-specific policies and procedures guiding patient care.

The deductive process involves:

1. Identifying a General Principle or Standard: The nurse accesses a relevant standard or rule applicable to the patient situation.
2. Applying the Standard to a Specific Situation: The nurse considers how this general principle applies to the unique needs of the patient.
3. Creating a Specific Strategy or Intervention: Based on the application of the standard, the nurse develops a tailored intervention strategy.

Example of Deductive Reasoning in Nursing:

Consider a hospital aiming to improve patient recovery rates. Research evidence suggests that adequate rest significantly contributes to faster recovery. Based on this general principle, the hospital administration establishes a “quiet zone” policy for nighttime hours, as depicted in Figure 4.2.

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

This policy includes interventions such as minimizing overhead paging, encouraging staff to speak softly, and dimming hallway lights. A nurse, applying deductive reasoning, implements this hospital-wide policy at the individual patient level. Regardless of whether a patient has explicitly complained about sleep disturbances, the nurse proactively organizes care to ensure uninterrupted rest periods during the night. This could involve clustering nursing tasks, minimizing nighttime awakenings for non-essential procedures, and creating a conducive sleep environment. This is deductive reasoning because the intervention (promoting quiet time) is applied broadly based on a general principle (rest promotes recovery), rather than being triggered by a specific patient complaint of sleep disturbance.

Clinical Judgment: The Synthesis of Reasoning and Experience

Clinical judgment is the culmination of critical thinking and clinical reasoning, utilizing both inductive and deductive approaches. The National Council of State Boards of Nursing (NCSBN) defines clinical judgment as “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” ⁶ It’s the tangible manifestation of a nurse’s cognitive skills, translating thought processes into effective actions.

Clinical judgment is not a static skill but rather a dynamic process refined through ongoing experience and learning. The NCLEX examination, a gateway to nursing licensure, is designed to evaluate the clinical judgment and decision-making abilities of aspiring entry-level nurses, ensuring they possess the cognitive competence to provide safe and effective care.

Evidence-Based Practice (EBP): The Foundation of Informed Clinical Judgment

Underpinning sound clinical judgment is evidence-based practice (EBP). 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.”⁷

EBP ensures that nursing practice is informed by the most current and reliable evidence, not just tradition or intuition. It’s a holistic approach that considers:

• Best Research Evidence: Findings from rigorous scientific studies and evidence-based theories.
• Clinical Expertise: The nurse’s accumulated knowledge, skills, and experience in patient care.
• Patient Values and Preferences: The unique needs, values, and cultural background of each patient.
• Available Resources: Considering the practical constraints and resources within the healthcare setting.

By integrating these components, EBP empowers nurses to make clinical judgments that are both scientifically sound and patient-centered, leading to improved health outcomes and quality of care.

The Nursing Process: A Systematic Approach to Patient-Centered Care

The nursing process stands as a robust critical thinking model, providing a systematic framework for patient-centered care. It is the practical application of critical thinking and clinical reasoning in nursing practice. Nurses employ the nursing process to make informed clinical judgments and deliver tailored care that meets individual patient needs. It is not merely a procedural checklist but a dynamic, iterative cycle that adapts to the evolving health status of the patient.

The nursing process is grounded in the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements defining the expected actions and behaviors of all registered nurses, regardless of their role, patient population, specialty, or practice setting.⁸ They serve as benchmarks for competent and ethical nursing care.

A helpful mnemonic to remember the ANA Standards and the components of the nursing process is ADOPIE. Each letter represents a distinct phase:

• Assessment: Gathering comprehensive patient data.
• Diagnosis: Identifying nursing diagnoses based on assessment data.
• Outcomes Identification: Setting patient-centered goals and expected outcomes.
• Planning: Developing a nursing care plan with evidence-based interventions.
• Implementation: Putting the care plan into action.
• Evaluation: Assessing the effectiveness of interventions and progress towards outcomes.

Figure 4.3 visually depicts the cyclical and continuous nature of the nursing process. It’s not a linear progression but an ongoing loop, constantly adapting to the patient’s changing condition.

Figure 4.3: The Nursing Process

To illustrate the practical application of the nursing process, let’s consider Patient Scenario A.

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: blood pressure 98/60, heart rate 100, respirations 18, temperature 98.7°F. Reviewing the patient’s medical record, the nurse observes a baseline blood pressure around 110/70 and heart rate in the 80s. Recognizing the current vital signs as deviations from baseline and potential cues of fluid imbalance, the nurse hypothesizes dehydration. Further assessment reveals a 4-pound weight decrease since the previous day. The patient reports a “cotton mouth” and lightheadedness, validating the dehydration hypothesis. Applying clinical judgment, the nurse formulates the nursing diagnosis “Fluid Volume Deficit” and sets outcomes focused on restoring fluid balance. Critically, the nurse withholds the scheduled Lasix, contacts the healthcare provider to discuss the patient’s fluid status, and implements interventions to promote oral fluid intake and closely monitor hydration. By shift’s end, fluid balance is evaluated as restored.

In this scenario, the nurse demonstrates the essence of the nursing process. Instead of simply “following orders” and administering the Lasix, the nurse uses clinical judgment, assesses the patient, recognizes critical cues, formulates a hypothesis, plans and implements tailored interventions, and evaluates the outcome. This proactive approach, prioritizing patient safety by questioning a medication order based on assessment findings, exemplifies the power of the nursing process in action.

Each component of the nursing process, aligned with the ANA’s Standards of Professional Nursing Practice, will be explored in detail in the subsequent sections.

Holistic Nursing Care: Integrating Art and Science

The American Nurses Association (ANA) has recently updated its definition of nursing, emphasizing its holistic nature: “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

This definition highlights the crucial integration of both the art of nursing and the science of nursing. The science of nursing is rooted in the evidence-based nursing process, utilizing research and best practices to guide interventions and achieve optimal patient outcomes. It is the systematic, logical, and knowledge-driven aspect of nursing care.

However, nursing is not solely a scientific endeavor. The art of nursing is equally vital. It is defined as “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”²⁴ The art of nursing encompasses the caring, empathetic, and humanistic dimensions of practice. It involves building therapeutic relationships, understanding patient experiences, and providing individualized care that acknowledges the patient as a whole person, not just a collection of symptoms or diagnoses.

Holistic nursing care embodies this integration of art and science. It means caring for the patient’s entire being – encompassing their emotional, spiritual, psychosocial, cultural, and physical needs. Nurses practicing holistically consider the patient within the context of their family and community, recognizing that health and well-being are influenced by a multitude of interconnected factors.

Holistic Nursing Care Scenario:

Consider a single mother bringing 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 care provider in two weeks. During discharge teaching, the nurse uncovers significant barriers to care: the mother cannot afford the prescribed antibiotic and lacks transportation to reach a primary care provider accessible by bus. Demonstrating holistic care, the nurse connects the mother with a social worker to explore affordable health insurance options and local providers accessible by public transport. Furthermore, the nurse advocates with the prescribing physician to obtain a prescription for a less costly generic antibiotic. This scenario exemplifies holistic nursing by addressing not only the child’s immediate medical need but also the broader social and economic factors impacting the family’s health and access to care.

Caring and the Nursing Process: Building Therapeutic Relationships

The American Nurses Association (ANA) emphasizes that “The act of caring is foundational to the practice of nursing.”²⁵ Effective utilization of the nursing process is intrinsically linked to the development of a care relationship with the patient. A care relationship is a mutual and reciprocal connection built on trust, often termed rapport. Rapport is the cornerstone of the art of nursing, fostering an environment of openness, empathy, and understanding.

Establishing a caring relationship involves assessing the whole person – their beliefs, values, attitudes, and acknowledging their vulnerability and inherent dignity.²⁶ It’s about seeing beyond the medical condition and connecting with the patient as an individual human being. Caring interventions can be expressed through simple yet powerful gestures:

• Active Listening: Paying full attention to the patient, both verbally and nonverbally, demonstrating genuine interest in their concerns.
• Eye Contact: Maintaining appropriate eye contact to convey engagement, respect, and sincerity.
• Touch: Using therapeutic touch, when culturally appropriate, to offer comfort, reassurance, and connection, as illustrated in Figure 4.4.
• Verbal Reassurance: Providing words of comfort, encouragement, and support to alleviate anxiety and build confidence.
• Cultural Sensitivity: Respecting and being attuned to the patient’s cultural beliefs and values, ensuring caring behaviors are culturally appropriate and meaningful.

Figure 4.4: Touch as a Therapeutic Communication Technique

Dr. Jean Watson’s Theory of Human Caring:

Dr. Jean Watson, a renowned nurse theorist, has profoundly influenced the nursing profession with her extensive work on the art and science of caring. Her Theory of Human Caring sought to rebalance the cure-focused orientation of medicine, emphasizing nursing’s unique disciplinary, scientific, and professional standing centered around caring. Watson’s philosophy encourages nurses to be authentically present with their patients, creating a healing environment that nurtures both the body and spirit.²⁹ Her work underscores that caring is not just a soft skill but a fundamental aspect of effective nursing practice, integral to the nursing process.

With these foundational concepts of critical thinking, clinical reasoning, holistic care, and the art of caring in mind, we now proceed to explore each component of the nursing process in greater depth, beginning with the first critical step: Assessment.

Assessment: The First Pillar of the Nursing Process

Assessment, the foundational first step of the nursing process and the inaugural Standard of Practice as defined by the American Nurses Association (ANA), is far more than just gathering data. It is a systematic, ongoing, and compassionate process of collecting “pertinent data and information relative to the health care consumer’s health or the situation.”¹ This encompasses a comprehensive understanding of the patient, including their demographics, environmental and occupational exposures, social determinants of health, health disparities, and a holistic evaluation of their physical, functional, psychosocial, emotional, cognitive, spiritual, sexual, sociocultural, age-related, environmental, and lifestyle/economic factors.

Nurses engage in assessment to uncover vital clues, formulate generalizations, and ultimately, diagnose human responses to health conditions and life processes. Patient data collected during assessment is broadly categorized as either subjective or objective, and it’s derived from a multitude of sources to paint a complete patient picture.

Subjective Assessment Data: The Patient’s Perspective

Subjective data is information gleaned directly from the patient and/or their family members. It offers invaluable insights into their personal experiences, perceptions, and feelings. Documenting subjective data accurately is paramount; it should be enclosed in quotation marks and prefaced with phrases like, “The patient reports…” Establishing rapport with the patient is crucial to elicit honest and insightful subjective data, particularly concerning their mental, emotional, and spiritual well-being.

Subjective data is further categorized into primary and secondary sources. Primary data originates directly from the patient. Patients are the foremost experts on their own bodies and feelings. Active listening by the nurse not only yields valuable information but also fosters a sense of validation and well-being for the patient. Secondary data, conversely, is gathered from sources other than the patient, such as family members, medical charts, or previous healthcare records. Family members are particularly vital sources of information for patients who are cognitively impaired, infants, children, or those unable to communicate for themselves.

Figure 4.5 illustrates the essence of obtaining subjective data – a nurse engaging in conversation with a patient, establishing rapport, and actively listening to their experiences.

Figure 4.5: Obtaining Subjective Data in a Care Relationship

Example of Subjective Data Documentation:

“The patient reports, ‘My pain is a level 2 on a 1-10 scale.’” This statement captures the patient’s self-reported pain level, a crucial piece of subjective information.

Objective Assessment Data: Verifiable and Measurable Information

Objective data is tangible, observable, and measurable information that the nurse gathers through their senses – sight, hearing, smell, and touch – during patient assessment. A hallmark of objective data is its reproducibility; meaning, another healthcare professional should be able to obtain the same data using the same assessment techniques. Examples of objective data include vital signs (blood pressure, heart rate, temperature, respiratory rate, oxygen saturation), physical examination findings (e.g., skin color, presence of edema, lung sounds), and laboratory and diagnostic test results (e.g., blood glucose levels, electrolyte values, imaging reports). Figure 4.6 depicts a nurse performing a physical examination, a key method for collecting objective data.

Figure 4.6: Physical Examination

Example of Objective Data Documentation:

“The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.” This documentation clearly states observable and measurable objective findings.

Sources of Assessment Data: A Multifaceted Approach

Nurses draw upon three primary sources to gather comprehensive assessment data: interviews, physical examinations, and reviews of laboratory and diagnostic test results.

Interviewing: Engaging in Therapeutic Communication

Interviewing is a cornerstone of the assessment process. It involves a dynamic exchange between the nurse and the patient, encompassing asking purposeful questions, actively listening to verbal responses, and keenly observing nonverbal communication. Prior to initiating the interview, reviewing the patient’s medical chart can be beneficial. This proactive step helps avoid redundancy, allows the nurse to focus on areas requiring clarification, and demonstrates preparedness and respect for the patient’s time. However, it’s crucial to verify chart information with the patient directly, as records may be incomplete or unclear.

Establishing a caring nurse-patient relationship begins with introductions. Clearly introduce yourself, explain your role in their care, and outline the purpose and approximate duration of the interview. Initiating the interview with questions related to the patient’s medical diagnoses can be a helpful starting point. This approach allows the nurse to understand how these diagnoses impact the patient’s daily functioning, relationships, and overall lifestyle. Active listening is paramount. Seek clarification when information is unclear, and encourage the patient to elaborate on their responses. Patients may unintentionally omit crucial details, not realizing their significance to their care. Critical thinking and attentive listening can unearth valuable cues that are essential for safe and effective nursing care.

Navigating sensitive topics or personal questions can sometimes feel challenging, especially for nursing students who may be navigating generational or cultural differences. However, it’s vital to overcome discomfort and ask questions that are essential for patient safety and well-being. Most patients appreciate a nurse who demonstrates genuine care and concern through thoughtful inquiry and attentive listening.

Pay close attention not only to what the patient says but also how they say it, and what they don’t say. Nonverbal cues, such as body language and facial expressions, can be as revealing as verbal responses. A keen sense of observation is indispensable. However, avoid making hasty inferences. Always validate cues through further questioning and exploration. For example, a patient who avoids eye contact might initially be inferred as being depressed. However, further exploration might reveal cultural beliefs where direct eye contact is considered disrespectful. Validation ensures accurate interpretation of cues and avoids misjudgments.

Physical Examination: A Systematic Body Scan

A physical examination is a structured, systematic method of collecting objective data about the patient’s body. It employs four primary techniques: inspection, auscultation, palpation, and percussion.

• Inspection: This involves careful visual observation of the patient’s anatomical structures, noting any abnormalities in appearance, color, symmetry, or movement.
• Auscultation: Listening to sounds produced by the body’s organs, particularly heart, lung, and bowel sounds, using a stethoscope to amplify these sounds. Auscultation helps assess organ function and identify any abnormal sounds (e.g., wheezes, crackles, absent bowel sounds).
• Palpation: Using touch to assess organs and body parts for size, location, texture, temperature, moisture, tenderness, and masses. Palpation provides tactile information that complements visual and auditory findings.
• Percussion: An advanced technique, typically performed by physicians or advanced practice nurses, involving tapping on body surfaces with fingers to assess underlying structures. Percussion helps determine organ size, density, and the presence of fluid or air in body cavities.

For detailed guidance on physical examination procedures across various body systems, refer to comprehensive resources like the Open RN Nursing Skills textbook, which includes a head-to-toe checklist in Appendix C. Physical examination also includes the routine collection and analysis of vital signs – temperature, pulse, respiration, blood pressure, and pain (often considered the fifth vital sign).

Registered Nurses (RNs) are responsible for conducting the initial comprehensive physical examination and analyzing the findings as part of the nursing process. However, aspects of follow-up physical examinations can be delegated to Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs). Routine measurements like vital signs and weight can be appropriately delegated to trained Unlicensed Assistive Personnel (UAP). Crucially, the RN retains ultimate responsibility for supervising delegated tasks, ensuring accurate data collection, analyzing findings, and documenting all assessments in the patient’s Electronic Medical Record (EMR), the digital repository of the patient’s health information.

Physical examinations can be comprehensive, a head-to-toe assessment performed during initial encounters or admissions, or focused, targeting specific body systems or problems based on the patient’s presenting condition or concerns. All assessment data, whether comprehensive or focused, is meticulously documented in the patient’s EMR, ensuring a complete and accessible record of their health status.

Reviewing Laboratory and Diagnostic Test Results: Objective Clinical Evidence

Reviewing laboratory and diagnostic test results is an indispensable source of objective assessment data. These results provide quantifiable and often definitive information about the patient’s physiological status, organ function, and presence of disease. Understanding normal and abnormal ranges for various tests, and their implications for patient care, is crucial for nurses. This knowledge directly informs care planning, intervention implementation, and medication administration.

When reviewing test results, nurses must be vigilant for any values that fall outside the normal range or deviate significantly from the patient’s baseline. If results raise concerns or are unexpected, it is the nurse’s professional responsibility to promptly notify the healthcare provider. Furthermore, before implementing any provider prescriptions, particularly medications or treatments guided by test results, the nurse must critically evaluate the appropriateness of the prescription in light of the patient’s current clinical status and the most recent test findings. This crucial step of verification safeguards patient safety and prevents potential errors.

Types of Nursing Assessments: Tailoring the Approach

Nursing assessments are not monolithic; they are tailored to the specific clinical context and patient needs. Several distinct types of assessments are employed in practice:

• Primary Survey: This is a rapid, focused assessment performed during every patient encounter, regardless of setting or presenting complaint. Its primary purpose is to immediately evaluate the patient’s level of consciousness, airway, breathing, and circulation (often remembered as the “ABCs”). The primary survey is designed to identify and address any immediate life-threatening conditions. If critical issues are detected, emergency care is initiated immediately, and the assessment becomes more detailed once stability is achieved.
• Admission Assessment: A comprehensive assessment conducted when a patient is admitted to a healthcare facility (hospital, long-term care, etc.). It is broad in scope, gathering a large volume of data across all body systems and functional health patterns using an organized and systematic approach. The admission assessment establishes a baseline patient profile and identifies initial nursing diagnoses and care needs.
• Ongoing Assessment: In acute care settings like hospitals, ongoing assessments are frequent and vital. A head-to-toe assessment is typically performed and documented at least once per nursing shift, often more frequently depending on patient acuity. Ongoing assessments monitor the patient’s condition, detect any changes from baseline, and evaluate the effectiveness of interventions. Any significant changes in patient status are promptly reported to the healthcare provider.
• Focused Assessment: This assessment type is targeted and in-depth, focusing on a specific body system or problem that has already been identified. It is used to re-evaluate the status of a pre-existing condition, investigate new symptoms, or monitor the response to specific treatments. For example, a focused respiratory assessment would be performed on a patient with pneumonia to monitor lung sounds, respiratory rate, and oxygen saturation.
• Time-Lapsed Reassessment: This type of assessment is particularly relevant in long-term care settings. It is a comprehensive reassessment performed at established intervals (typically every three or more months) after the initial admission assessment. The time-lapsed reassessment evaluates the patient’s progress towards previously identified goals, updates the care plan based on changes in health status, and ensures ongoing appropriateness of care for patients in long-term care settings.⁴

Putting It All Together: Scenario C – Applying Assessment Principles

Let’s apply the concepts of assessment to a real-world patient scenario.

Scenario C ⁵

Ms. J., a 74-year-old woman, is admitted to the medical unit from her physician’s office due to increasing shortness of breath, worsening 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). Her medications are aspirin 81 mg daily, metoprolol 50 mg twice daily, furosemide 40 mg daily, and metformin 2000 mg daily.

Upon admission, Ms. J.’s vital signs are:

• 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

Her weight is up 10 pounds since her office visit three weeks prior. Ms. J. states, “I am so short of breath,” and “My ankles are so swollen I have to wear my house slippers.” She also shares, “I am so tired and weak that I can’t get out of the house to shop for groceries,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She confides, “I would like to learn more about my health so I can take better care of myself.”

Physical assessment reveals bilateral basilar crackles in her lungs and bilateral 2+ pitting edema in her ankles and feet. Laboratory results show a decreased serum potassium level of 3.4 mEq/L.

While the nurse is completing the assessment, Ms. J.’s daughter enters the room and confides, “We are so worried about Mom living at home by herself when she is so tired all the time!”

Critical Thinking Questions:

1. Identify the subjective data in Scenario C.
2. Identify the objective data in Scenario C.
3. Provide an example of secondary data in Scenario C.

(Answers to critical thinking questions are available in the Answer Key at the end of the book.)

By meticulously collecting and categorizing both subjective and objective data, and considering primary and secondary sources, nurses like the one in Scenario C lay the groundwork for the next crucial step in the nursing process: Diagnosis.

Diagnosis: Analyzing Data to Identify Patient Needs

Diagnosis, the second step in the nursing process and the second Standard of Practice outlined by the American Nurses Association (ANA), moves beyond data collection to data interpretation. It’s defined as “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.”¹ This involves a rigorous cognitive process where 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.” The diagnoses, problems, strengths, and issues identified are then documented in a manner that facilitates the development of expected outcomes and a collaborative care plan.

In essence, the diagnosis phase is where the nurse transforms raw assessment data into meaningful insights about the patient’s health status and needs. It’s the bridge between “what is” (the assessment data) and “what needs to be addressed” (the nursing diagnoses).

Analyzing Assessment Data: From Cues to Hypotheses

The process of moving from assessment data to nursing diagnoses involves several key steps: data analysis, clustering information, identifying hypotheses, performing in-depth assessment (if needed), and formulating nursing diagnosis statements. These steps are iterative and build upon each other, leading to prioritized nursing diagnoses that drive the patient’s care plan.²

Performing Data Analysis: Distinguishing Relevant Cues

After meticulously collecting assessment data, nurses engage in data analysis. This involves applying their nursing knowledge to interpret the data and determine if it’s “expected” or “unexpected,” “normal” or “abnormal” for that specific patient. This determination is not based on abstract norms but rather on the patient’s age, developmental stage, baseline health status, and individual circumstances. From this analysis, nurses discern clinically relevant cues – data points that signal a potential health issue or need and warrant further attention and nursing action.³

Example: Consider Scenario C from the Assessment section. Analyzing Ms. J.’s vital signs, the nurse recognizes that her blood pressure, heart rate, and respiratory rate are elevated above expected ranges, while her oxygen saturation is decreased. These vital sign abnormalities, in the context of her presenting symptoms and medical history, are identified as “relevant cues” signaling potential cardiopulmonary compromise.

Clustering Information: Identifying Patterns in Patient Data

Once relevant cues are identified, the next step is clustering information. This involves grouping related cues together to discern patterns and potential problem areas. Assessment frameworks, such as Gordon’s Functional Health Patterns, provide a structured approach to organizing and clustering information. Gordon’s framework, outlined in the box below, categorizes data into eleven functional health patterns, representing holistic dimensions of human functioning.⁴ Using such a framework ensures a systematic and comprehensive approach to data clustering, preventing oversight of important patterns. Many of these functional health patterns will be explored in greater detail in subsequent chapters.

Gordon’s Functional Health Patterns ⁵

• Health Perception-Health Management: Patient’s perceived health status and health management practices.
• Nutritional-Metabolic: Food and fluid intake in relation to metabolic needs.
• Elimination: Bowel, bladder, and skin excretory functions.
• Activity-Exercise: Exercise patterns, activity levels, and mobility.
• Sleep-Rest: Sleep patterns, rest quality, and relaxation practices.
• Cognitive-Perceptual: Sensory functions (sight, hearing, taste, touch, smell, pain) and cognitive abilities (thought processes, memory, decision-making).
• Self-perception and Self-concept: Self-esteem, body image, and emotional state.
• Role-Relationship: Social roles, relationships, and social support systems.
• Sexuality-Reproductive: Sexual function, reproductive health, and satisfaction with sexuality.
• Coping-Stress Tolerance: Stress response, coping mechanisms, and stress management resources.
• Value-Belief: Values, beliefs (including spiritual beliefs), and goals guiding life choices and decisions.

Example: Returning to Scenario C, the nurse clusters Ms. J.’s relevant cues: elevated blood pressure, elevated respiratory rate, lung crackles, weight gain, worsening edema, shortness of breath, history of heart failure, and current diuretic medication prescription. These clustered cues point towards a pattern related to fluid balance, which aligns with Gordon’s Nutritional-Metabolic Functional Health Pattern. This pattern recognition leads the nurse to the next step: hypothesis generation.

Identifying Nursing Diagnoses: Formulating Hypotheses

With clustered data and identified patterns, the nurse begins to formulate hypotheses about potential nursing diagnoses. The central question becomes: “What are my patient’s human responses (i.e., nursing diagnoses) to their health condition?” A nursing diagnosis is defined as “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”⁶ Crucially, nursing diagnoses are patient-centered, individualized, and drive the development of the nursing care plan.

To ensure accuracy, nurses should consult a reliable care planning resource. These resources provide definitions, defining characteristics, related factors, and risk factors for a wide range of NANDA-I (North American Nursing Diagnosis Association International) nursing diagnoses. Reviewing these resources allows the nurse to validate their hypotheses, determine if additional in-depth assessment is needed to confirm the diagnosis, and select the most precise and appropriate nursing diagnosis statement.

NANDA International (NANDA-I) is the globally recognized professional nursing organization responsible for developing and standardizing nursing terminology, including nursing diagnoses. NANDA-I diagnoses represent actual or potential human responses to health problems and life processes, grounded in research and continuously updated.⁷ Currently, over 220 NANDA-I nursing diagnoses are recognized, categorized into 13 domains that align with Gordon’s Functional Health Patterns, facilitating diagnosis selection based on clustered data patterns. These domains include 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. Appendix A provides a list of commonly used NANDA-I diagnoses, and comprehensive care planning references offer the complete, current NANDA-I list.

Important Note: While familiarity with the process of selecting nursing diagnoses is essential, memorization of specific NANDA-I diagnoses is not tested on the NCLEX exam. However, the underlying skills of analyzing cues and generating diagnostic hypotheses are core components of clinical judgment assessment on the NCLEX.

Nursing Diagnoses vs. Medical Diagnoses: Distinguishing Nursing’s Focus

A critical distinction to understand is the difference between nursing diagnoses and medical diagnoses. Medical diagnoses are made by physicians, physician assistants, or advanced practice nurses and focus on diseases or pathological conditions. For example, “pneumonia,” “heart failure,” and “diabetes mellitus” are medical diagnoses.

Nursing diagnoses, in contrast, are made independently by registered nurses and focus on the patient’s human response to health conditions and life processes. They describe the patient’s reaction to their medical condition, illness, or life situation. Importantly, patients with the same medical diagnosis can have vastly different nursing diagnoses because their individual responses and needs will vary.

Example: Two patients may both have the medical diagnosis of “stroke.” However, one patient might experience the nursing diagnosis of “Impaired Physical Mobility related to muscle weakness as evidenced by inability to ambulate independently,” while another patient, with a less severe stroke, might have the nursing diagnosis of “Readiness for Enhanced Self-Care as evidenced by expressed desire to regain independence in activities of daily living.” The nursing diagnoses are tailored to each patient’s unique response to their stroke and guide individualized care planning.

Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and available resources. This holistic perspective ensures that the nursing care plan is customized to provide individualized care that addresses the patient’s unique human experience of health and illness.

Example: In Scenario C, Ms. J.’s medical diagnosis is “heart failure.” However, “heart failure” itself cannot be used as a nursing diagnosis. Instead, it is considered an associated condition – a medical diagnosis, injury, procedure, medical device, or pharmacological agent that is not independently modifiable by the nurse but provides important context for understanding the nursing diagnosis. The nursing diagnoses for Ms. J. will focus on her responses to heart failure, such as fluid retention, activity intolerance, and knowledge deficit.

Key Definitions in NANDA-I Nursing Diagnoses: Patient, Age, Time

NANDA-I employs specific definitions for terms used in nursing diagnoses to ensure clarity and consistency:

Patient: NANDA-I’s definition of “patient” is broad, encompassing:⁸

• Individual: A single human being.
• Caregiver: A family member or helper providing regular care.
• Family: Two or more people with sustained relationships, reciprocal obligations, and shared meanings.
• Group: A collection of people sharing characteristics (e.g., ethnic group).
• Community: People living in a shared locale under common governance (e.g., neighborhood, city).

Age: NANDA-I defines age categories to ensure age-appropriate diagnosis:⁹

• Fetus: Unborn human > 8 weeks gestation to birth.
• Neonate: Person < 28 days old.
• Infant: Person > 28 days and < 1 year old.
• Child: Person aged 1-9 years.
• Adolescent: Person aged 10-19 years.
• Adult: Person > 19 years old (unless national law defines adulthood earlier).
• Older adult: Person > 65 years old.

Time: NANDA-I specifies timeframes for diagnoses:¹⁰

• Acute: Lasting < 3 months.
• Chronic: Lasting > 3 months.
• Intermittent: Stopping and starting at intervals.
• Continuous: Uninterrupted, ongoing.

New Terms in 2018-2020 NANDA-I Diagnoses: At-Risk Populations and Associated Conditions

The 2018-2020 NANDA-I edition introduced two new terms to refine nursing diagnoses: at-risk populations and associated conditions.¹¹

At-Risk Populations are groups sharing characteristics that increase their susceptibility to specific human responses. These characteristics can include demographics (age, ethnicity), health/family history, developmental stage, or exposure to specific events/experiences.

Associated Conditions, as previously discussed, are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently managed by nurses but provide crucial context and support diagnostic accuracy.¹²

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

NANDA-I categorizes nursing diagnoses into four primary types:¹³

• Problem-Focused Nursing Diagnosis: Describes an undesirable human response to a health condition or life process that is currently present. For a problem-focused diagnosis to be valid, related factors (etiology or causes) and defining characteristics (signs and symptoms) must be evident in the patient’s assessment data.^{14, 15}
• Health Promotion-Wellness Nursing Diagnosis: Describes a patient’s motivation and desire to enhance well-being and actualize human health potential. These diagnoses are used when a patient expresses readiness to improve specific health behaviors or conditions.¹⁶
• Risk Nursing Diagnosis: Describes a patient’s vulnerability to developing an undesirable human response to health conditions or life processes. A risk diagnosis is supported by risk factors – factors that increase the patient’s susceptibility to the problem. Crucially, with a risk diagnosis, the problem has not yet occurred. Risk diagnoses are not inherently less important than problem-focused diagnoses; in some cases, addressing a risk diagnosis proactively can be a higher priority to prevent a potentially serious problem.^{17, 18}
• Syndrome Diagnosis: Represents a cluster of nursing diagnoses that frequently occur together and are best addressed collectively through similar interventions.¹⁹

Establishing Nursing Diagnosis Statements: The PES Format and Beyond

When formulating NANDA-I nursing diagnoses, the recommended structure is a statement that includes the nursing diagnosis label, related factors, and defining characteristics. The accuracy of a nursing diagnosis is validated by a clear link between these three components, all derived from the patient’s assessment data.²⁰

The nurse’s process for creating a nursing diagnosis statement involves: analyzing subjective and objective data, clustering data into patterns, and generating diagnostic hypotheses based on how these patterns align with the defining characteristics of specific nursing diagnoses. Defining characteristics are observable signs and symptoms associated with a particular nursing diagnosis.²¹ Care planning resources list defining characteristics for each diagnosis, guiding the nurse in selecting the most accurate fit.

In addition to defining characteristics, a nursing diagnosis statement includes related factors, the underlying causes or contributing factors (etiology) of the patient’s problem. Related factors should ideally be factors that nurses can address through interventions, focusing on the pathophysiology or situation contributing to the nursing diagnosis. It’s important to note that related factors should not be medical diagnoses themselves. Effective nursing interventions are often directed at modifying or removing these related factors, thereby resolving the nursing diagnosis.²²

The traditional method for constructing nursing diagnosis statements is often referred to as the PES format. While NANDA-I no longer explicitly uses the term “PES,” the underlying components remain essential:

• Problem (P): The patient problem, stated as the NANDA-I nursing diagnosis label.
• Etiology (E): Related factors contributing to the problem, phrased as “related to” (R/T).
• Signs and Symptoms (S): Defining characteristics manifested by the patient, the subjective and objective data supporting the diagnosis, phrased as “as manifested by” or “as evidenced by.”

Let’s examine examples of each type of nursing diagnosis statement using the PES format.

Problem-Focused Nursing Diagnosis Statement: Addressing Existing Problems

A problem-focused nursing diagnosis statement includes all three PES components: Problem, Etiology, and Signs and Symptoms.

Sample Problem-Focused Nursing Diagnosis Statement:

Referring to Scenario C, Ms. J.’s data cluster (elevated BP, respiratory rate, crackles, edema, weight gain, shortness of breath) aligns with the defining characteristics of the NANDA-I diagnosis Excess Fluid Volume. NANDA-I defines Excess Fluid Volume as “surplus intake and/or retention of fluid.”²³ Let’s assume, for this example, that the related factor (etiology) is determined to be excessive fluid intake.

PES Components for Ms. J. (Problem-Focused Diagnosis):

• P (Problem): Fluid Volume Excess
• E (Etiology): Related to excessive fluid intake
• S (Signs and Symptoms): As manifested by bilateral basilar crackles, 2+ pitting edema of ankles/feet, 10-pound weight gain, and patient report: “My ankles are so swollen.”

Resulting Problem-Focused Nursing Diagnosis Statement:

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

Health-Promotion Nursing Diagnosis Statement: Enhancing Wellness

A health-promotion nursing diagnosis statement includes the Problem (P) and Signs and Symptoms (S), with the defining characteristics component starting with “expresses desire to enhance.” ²⁴

Sample Health-Promotion Nursing Diagnosis Statement:

In Scenario C, Ms. J. expresses a desire to improve her health: “I would like to learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I diagnosis 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

Components for Ms. J. (Health-Promotion Diagnosis):

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

Resulting Health-Promotion Nursing Diagnosis Statement:

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

Risk Nursing Diagnosis Statement: Addressing Potential Problems

A risk nursing diagnosis statement includes the Problem (P) and Risk Factors (As Evidenced By). NANDA-I recommends using “as evidenced by” to link the risk factors to the potential problem.²⁶

Sample Risk Nursing Diagnosis Statement:

Ms. J. in Scenario C reports dizziness and weakness, increasing her risk of falls. The NANDA-I diagnosis Risk for Falls is defined as “increased susceptibility to falling, which may cause physical harm and compromise health.”²⁷

Components for Ms. J. (Risk Diagnosis):

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

Resulting Risk Nursing Diagnosis Statement:

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

Syndrome Nursing Diagnosis Statement: Addressing Clusters of Diagnoses

A syndrome diagnosis statement includes the Problem (P) – the syndrome label – and Signs and Symptoms (S) – the defining characteristics, which are two or more related nursing diagnoses. Related factors can be included for clarity but are not mandatory.²⁸

Sample Syndrome Nursing Diagnosis Statement:

In Scenario C, Ms. J.’s data suggests multiple interconnected nursing diagnoses. For example, “Activity Intolerance” (insufficient energy for daily activities) and “Social Isolation” (aloneness perceived as negative) might be present due to her fatigue and mobility limitations. These diagnoses can be clustered under the NANDA-I syndrome Risk for Frail Elderly Syndrome, defined as “a dynamic state of unstable equilibrium affecting an older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leading to increased susceptibility to adverse health effects, in particular disability.”²⁹

Components for Ms. J. (Syndrome Diagnosis):

• P (Problem): Risk for Frail Elderly Syndrome
• S (Signs and Symptoms): Nursing diagnoses of Activity Intolerance and Social Isolation.
• Related Factor (Optional): Fear of falling (adding clarity to the syndrome)

Resulting Syndrome Nursing Diagnosis Statement:

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

Prioritization: Ordering Nursing Diagnoses by Importance

After identifying multiple nursing diagnoses, the crucial final step in the diagnosis phase is prioritization. Nurses constantly prioritize their actions throughout their shift, and prioritizing nursing diagnoses is essential for guiding care planning and ensuring the most critical patient needs are addressed first. Prioritization is the process of ranking nursing problems and interventions based on their significance to the patient’s immediate and long-term well-being.

Life-threatening concerns and crises always take precedence. In critical situations, the entire nursing process may be condensed into seconds, demanding rapid clinical judgment. However, most patient situations fall between crisis management and routine care, requiring thoughtful prioritization.

Several frameworks guide prioritization, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing, Circulation), and consideration of acute vs. chronic conditions. Figure 4.7 provides a helpful infographic summarizing prioritization principles.

Figure 4.7: The How To of Prioritization

Maslow’s Hierarchy of Needs is a pyramid-shaped model categorizing human needs in order of priority. The base levels, representing the most urgent needs, are physiological needs (air, water, food, shelter, sleep, etc.) intertwined with safety needs. Higher levels include love/belonging, esteem, and self-actualization. In healthcare, physiological and safety needs typically take priority. Figure 4.8 illustrates Maslow’s Hierarchy.

Figure 4.8: Maslow’s Hierarchy of Needs

The “ABCs” (Airway, Breathing, Circulation) framework is a fundamental principle in emergency care and prioritization. Ensuring a patent airway, adequate breathing, and effective circulation are paramount for sustaining life. However, prioritization is context-dependent. Consider a scenario: encountering a fiery car crash with an unresponsive passenger. While airway is critical, safety (removing the passenger from the burning vehicle) takes immediate priority according to Maslow’s Hierarchy. Only after ensuring safety and calling for help are ABCs directly addressed through CPR until emergency services arrive.

In addition to Maslow’s and ABCs, nurses consider the acuity of patient conditions. Acute, uncompensated conditions (sudden onset, unstable) generally require higher priority than chronic, stable conditions. Furthermore, actual problems typically take precedence over potential (risk) problems. However, risk diagnoses can sometimes be prioritized if the patient is highly vulnerable and the potential risk is significant.

Example: For Ms. J. in Scenario C, we identified four nursing diagnoses: Fluid Volume Excess, Readiness for Enhanced Health Promotion, Risk for Falls, and Risk for Frail Elderly Syndrome. The highest priority diagnosis is Fluid Volume Excess. This is because it directly impacts physiological needs – breathing, homeostasis, and excretion – placing it at the base of Maslow’s Hierarchy and potentially affecting ABCs. Risk for Falls is a close second priority due to safety implications and the potential for injury, which also falls within the physiological/safety level of Maslow’s. While health promotion and frailty risk are important, they are lower priority in the immediate context of Ms. J.’s acute fluid imbalance and safety risk.

By systematically analyzing assessment data, clustering cues, formulating nursing diagnoses, and prioritizing these diagnoses based on established frameworks, nurses effectively transition from assessment to the next phase of the nursing process: Outcome Identification.

Outcome Identification: Setting Patient-Centered Goals

Outcome Identification, the third step in the nursing process and the third ANA Standard of Practice, focuses on defining the desired patient results of nursing care. It is defined as “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”¹ This involves a collaborative process where the RN works with the patient, interprofessional team, and family (when appropriate) to establish expected outcomes that are culturally sensitive, value-congruent, and ethically sound. These outcomes are then documented as measurable goals with specific timeframes for achievement.

An outcome in nursing terms is a “measurable behavior demonstrated by the patient responsive to nursing interventions.”² Outcomes are not just abstract aspirations; they are concrete, observable changes in patient status that result from nursing care. Importantly, outcomes are established before planning nursing interventions. Once interventions are implemented, the nurse will then evaluate whether these outcomes were achieved within the specified timeframe.

Outcome identification involves two key components: setting short-term and long-term goals and crafting specific expected outcome statements for each identified nursing diagnosis.

Short-Term and Long-Term Goals: Charting the Course of Recovery

Effective nursing care is always individualized and patient-centered. No two patients are identical, and consequently, no two nursing care plans should be carbon copies. Goals and outcomes must be meticulously tailored to each patient’s unique needs, values, cultural beliefs, and preferences. Whenever feasible, patients and their families should be actively involved in the goal-setting process. This collaborative approach fosters patient autonomy, enhances awareness of identified needs, promotes realistic goal setting, and increases patient motivation and adherence to the treatment plan. Shared goals also ensure that the care plan aligns with the patient’s life priorities and aspirations.

The nursing care plan serves as a comprehensive roadmap, guiding all members of the healthcare team towards shared patient goals. Goals are broad statements of purpose that articulate the overall desired direction of care. They are not specific measurable targets but rather overarching aims. Goals can be categorized as short-term or long-term, with the timeframe for each being context-dependent, varying based on the care setting.

For example, in a critical care unit, a short-term goal might be designed to be achieved within an 8-hour nursing shift, focusing on immediate stabilization, while a long-term goal might extend to 24 hours, aiming for sustained improvement. Conversely, in an outpatient setting, a short-term goal might be set for achievement within one month, focusing on initial steps towards health improvement, and a long-term goal might be set for six months, targeting more substantial and sustained health outcomes.

A well-formulated nursing goal directly addresses the identified nursing diagnosis. It often represents the opposite of the problem described in the diagnosis, indicating the desired resolution or improvement.

Example: In Scenario C, Ms. J.’s priority nursing diagnosis was Fluid Volume Excess. A broad, overarching goal for this diagnosis would be: “Ms. J. will achieve a state of fluid balance.” This goal is broad and direction-setting, but lacks the specificity needed to guide daily nursing actions and evaluate progress. This is where expected outcomes come into play.

Expected Outcomes: SMART Targets for Measurable Progress

While goals are broad directional statements, expected outcomes are specific, measurable, and time-bound statements of patient behavior or status that are achievable as a result of nursing interventions. They translate broad goals into concrete, actionable targets. Nurses can independently develop expected outcomes, or they can utilize standardized outcome classification systems for guidance and consistency.

Just as NANDA-I provides standardized nursing diagnoses, the Nursing Outcomes Classification (NOC) system offers a standardized language for nursing-sensitive patient outcomes. NOC is a comprehensive list of over 330 nursing outcomes, each with a definition, indicators (specific patient states or behaviors related to the outcome), and measurement scales. NOC outcomes are designed to align with established NANDA-I diagnoses, providing a standardized framework for outcome identification and measurement.³

Patient-Centered Outcomes:

Outcome statements must always be patient-centered, reflecting what the patient will achieve, not what the nurse will do. They should be developed in collaboration with the patient (when possible), reflecting their individual needs, values, and cultural beliefs. Outcome statements typically begin with the phrase “The patient will…” and are directly linked to resolving the defining characteristics of the corresponding nursing diagnosis. Furthermore, the outcome must be realistically achievable and something the patient is willing to actively participate in attaining.

Effective outcome statements adhere to the “SMART” criteria, a mnemonic ensuring outcomes are well-defined and measurable:⁴

• Specific: Clearly defined, focused on a particular patient behavior or status.
• Measurable: Quantifiable, using objective data to assess achievement.
• Attainable/Action-oriented: Realistic for the patient, involving an action verb.
• Relevant/Realistic: Aligned with patient’s goals, values, and circumstances.
• Time-bound: Specifying a timeframe for outcome achievement and evaluation.

Figure 4.9 visually summarizes the SMART components of outcome statements.

Figure 4.9: SMART Components of Outcome Statements

Let’s examine each SMART component in detail:

Specificity: Clear and Unambiguous

Outcome statements must be specific, clearly stating exactly what is to be accomplished. Vague outcomes are difficult to measure and evaluate effectively.

Example of Specificity:

• Non-specific: “The patient will increase exercise.” (What kind of exercise? How much increase?)
• Specific: “The patient will participate in a bicycling exercise session daily for 30 minutes.” (Clearly defines type, duration, and frequency of exercise).

Furthermore, each outcome statement should focus on one action or behavior. Combining multiple actions into a single outcome can make evaluation complex and ambiguous.

Example of Single Action per Outcome:

• Combined, unclear outcome: “The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge.” (This combines ambulation and showering, making it difficult to evaluate if one part is achieved but not the other).
• Revised, separate outcomes (measurable and clear):
  • “The patient will walk 50 feet three times a day with standby assistance of one until discharge.” (Focuses solely on ambulation).
  • “The patient will shower every morning until discharge.” (Focuses solely on showering).

Measurability: Quantifiable and Observable

Measurable outcomes utilize numeric parameters or other concrete methods to judge whether the outcome has been achieved. Objective data is essential for measuring outcomes reliably. Avoid vague terms like “adequate,” “normal,” or “acceptable,” as these are subjective and difficult to evaluate consistently. Figure 4.10 provides examples of measurable and non-measurable verbs for outcome statements.

Figure 4.10: Measurable Outcomes

Example of Measurability:

• Non-measurable: “The patient will drink adequate fluids each shift.” (What is “adequate”? How will it be measured?)
• Measurable: “The patient will drink 24 ounces of fluids during every day shift (0600-1400).” (Specifies quantity and timeframe, easily measured).

Attainability and Action-Orientation: Realistic and Patient-Driven

Outcome statements should be action-oriented, clearly stating an action to be performed by the patient or significant others. This requires using an action verb. Figure 4.11 provides examples of effective action verbs for outcome statements.

Figure 4.11: Action Verbs

Furthermore, outcomes must be attainable or achievable for the patient, considering their current physical and mental status, abilities, and resources.

Example of Action-Orientation and Attainability:

• Non-action-oriented: “The patient will get increased physical activity.” (Vague, doesn’t specify patient action).
• Action-oriented and Attainable: “The patient will list three types of aerobic activity that he would enjoy completing every week.” (Patient actively lists activities, achievable and patient-centered).

Relevance and Realism: Patient-Centered and Practical

Realistic outcomes are tailored to the patient’s overall condition, considering their physical and mental health, cultural and spiritual values, beliefs, socioeconomic status, and available support systems. Outcomes must be relevant to the patient’s overall goals of care and life situation. Factors like disease processes, pain, mobility limitations, health literacy, and resource availability must be considered when setting realistic outcomes. Outcomes should be continuously reevaluated and revised as needed to ensure they remain attainable and relevant. If an outcome is not met within the timeframe, it’s often because the initial outcome was unrealistic or the timeframe was too ambitious.

Example of Relevance and Realism:

• Non-realistic: “The patient will jog one mile every day when starting the exercise program.” (Unrealistic for someone starting an exercise program, potentially discouraging).
• Realistic: “The patient will walk ½ mile three times a week for two weeks.” (Gradual, achievable starting point).

Time-Bound: Specifying a Timeframe for Evaluation

Outcome statements must include a timeframe for evaluation. This timeframe depends on the nature of the intervention, the patient’s condition, and the expected rate of progress. Some outcomes require frequent evaluation (e.g., every shift), while others may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, outcomes are assessed against the specified timeframe. If an outcome is not met by the deadline, the nursing care plan should be revised.

Example of Time-Bound Outcomes:

• Non-time-bound: “The patient will stop smoking cigarettes.” (No timeframe for achieving this complex behavior change).
• Time-bound: “The patient will complete the smoking cessation plan by December 12, 2023.” (Provides a specific deadline for evaluation of progress).

Putting It Together: SMART Outcome for Scenario C

In Scenario C, Ms. J.’s priority nursing diagnosis statement was Fluid Volume Excess related to excess 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.”

A SMART expected outcome for this diagnosis could be: “The patient will have clear bilateral lung sounds within the next 24 hours.”

Let’s analyze this outcome against the SMART criteria:

• S (Specific): Focuses on lung sounds, a clear indicator of fluid status.
• M (Measurable): “Clear bilateral lung sounds” is objectively assessed through auscultation.
• A (Attainable/Action-oriented): Achieving clear lung sounds within 24 hours is a realistic short-term goal for managing fluid volume excess.
• R (Relevant/Realistic): Directly addresses the defining characteristic of lung crackles associated with fluid volume excess.
• T (Time-bound): Specifies “within the next 24 hours” for evaluation.

By crafting SMART expected outcome statements for each nursing diagnosis, nurses set clear, measurable targets that guide care planning, intervention implementation, and evaluation of patient progress. This leads us to the next step in the nursing process: Planning.

Planning: Charting the Course with Nursing Interventions

Planning, the fourth step of the nursing process and the fourth ANA Standard of Practice, is where the blueprint for patient care is created. It is defined as “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”¹ This involves the RN developing an individualized, holistic, and evidence-based plan in partnership with the patient, family, significant others, and the interprofessional team. The plan prioritizes elements of care, is continuously modified based on ongoing patient assessment, and is documented using standardized language.

After establishing expected outcomes in the previous step, the nurse now focuses on planning nursing interventions. Nursing interventions are evidence-based actions that nurses implement to help patients achieve their desired outcomes. Just as physicians make medical diagnoses and prescribe medical treatments, nurses formulate nursing diagnoses and plan nursing interventions to address patient problems within their scope of practice. Whenever possible, nursing interventions should target the related factors (etiology) of the nursing diagnoses, aiming to eliminate or reduce the underlying causes of the patient’s problems.² The carefully planned nursing interventions, along with the established goals and expected outcomes, are meticulously documented in the nursing care plan. This care plan serves as a central communication tool, ensuring continuity of care across nursing shifts, between nurses, and among all members of the interprofessional healthcare team.

Planning Nursing Interventions: Evidence-Based Actions

A common question for nurses, particularly those new to practice, is: “How do I know what evidence-based nursing interventions to include in the care plan?” Fortunately, nurses have access to numerous resources to guide intervention selection. Many healthcare agencies integrate care planning tools and references directly into the electronic health record (EHR), streamlining documentation and promoting evidence-based practice. Nurses can also consult external care planning books and resources, such as the Nursing Interventions Classification (NIC) system.

The NIC system is a standardized classification of nursing interventions, developed and continuously updated based on research and input from the nursing profession. NIC categorizes and describes a wide range of nursing interventions, each considered an evidence-based nursing practice. NIC provides a standardized language for interventions, promoting consistency and clarity in care planning and documentation. While NIC offers a valuable resource, it’s crucial to remember that the nurse retains professional responsibility for using clinical judgment to select the interventions that are most appropriate and effective for each individual patient’s unique needs and circumstances.³ No standardized system can replace the nurse’s critical thinking and patient-specific assessment.

Direct and Indirect Care Interventions: Patient-Focused Actions

Nursing interventions are broadly classified as either direct care or indirect care. Direct care interventions involve direct interaction and personal contact with patients. These are actions performed “at the bedside” or in direct proximity to the patient. Examples of direct care interventions include:

• Wound care (dressing changes, wound assessment)
• Repositioning patients to prevent pressure ulcers
• Assisting with ambulation and mobility
• Medication administration
• Patient education and counseling
• Emotional support and therapeutic communication

Indirect care interventions, in contrast, are actions performed away from the patient but still on their behalf, contributing to their overall care. Examples of indirect care interventions include:

• Attending interprofessional care conferences to discuss patient progress and care planning
• Documenting patient care in the medical record
• Communicating with other healthcare providers about patient status and needs
• Collaborating with ancillary services (e.g., social work, case management)
• Ensuring a safe and therapeutic patient environment
• Reviewing and updating the nursing care plan

Both direct and indirect care interventions are essential components of comprehensive nursing care, working in synergy to promote patient well-being and achieve desired outcomes.

Classification of Nursing Interventions: Independent, Dependent, and Collaborative

Nursing interventions can also be categorized based on the level of autonomy and collaboration involved in their planning and implementation: independent, dependent, and collaborative interventions. Figure 4.12 illustrates a nurse engaging in collaborative planning with the healthcare team.

Figure 4.12: Collaborative Nursing Interventions

Independent Nursing Interventions: Nurse-Initiated Actions

Independent nursing interventions are actions that a registered nurse is authorized to initiate based on their professional knowledge and skills, without requiring a prescription or specific direction from a physician or other healthcare provider. These interventions stem from the nurse’s assessment, clinical judgment, and understanding of evidence-based practices. They are within the RN’s scope of practice and are crucial for addressing patient needs autonomously.

Examples of independent nursing interventions include:

• Monitoring vital signs and physiological parameters: Assessing trends, detecting changes, and responding appropriately.
• Implementing comfort measures: Providing pain relief through positioning, massage, or relaxation techniques.
• Educating patients on health topics: Teaching about medications, disease management, self-care strategies, and preventive measures.
• Providing emotional support and counseling: Using therapeutic communication to address anxiety, fear, grief, or other emotional distress.
• Implementing fall prevention strategies: Ensuring a safe environment, using assistive devices, and educating patients on fall risks.
• Repositioning patients: Preventing pressure ulcers and promoting comfort.
• Encouraging deep breathing and coughing exercises: Promoting respiratory function.

Example of Independent Nursing Intervention (Scenario C):

In Scenario C, Ms. J. was diagnosed with Fluid Volume Excess. An evidence-based independent nursing intervention for this diagnosis is: “The nurse will reposition the patient with dependent edema frequently, as appropriate.”⁵ To individualize this intervention for Ms. J. and align with agency policy, the nurse might specify: “The nurse will reposition the patient every 2 hours.” This intervention is independent because it is initiated by the nurse based on their assessment and knowledge, without requiring a physician’s order.

Dependent Nursing Interventions: Prescription-Driven Actions

Dependent nursing interventions are actions that require a prescription from a physician, advanced practice nurse (APN), or physician assistant (PA) before they can be implemented. These prescriptions are orders for specific treatments, medications, or procedures that fall outside the RN’s independent scope of practice. A prescription is defined as an “orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider.”⁶ A primary health care provider is a licensed and authorized member of the healthcare team (physician, APN, PA) who can legally formulate prescriptions on behalf of patients.

Examples of dependent nursing interventions include:

• Administering medications: This always requires a prescription, specifying the medication name, dose, route, frequency, and timing.
• Administering intravenous fluids: Prescription required for type and rate of infusion.
• Ordering laboratory tests or diagnostic imaging: Prescription needed to initiate these tests.
• Implementing specific medical treatments: Wound care protocols, respiratory therapies, or other treatments directed by a provider.
• Dietary orders: Specific therapeutic diets often require a provider’s order.

Example of Dependent Nursing Intervention (Scenario C):

Again, in Scenario C with Ms. J.’s Fluid Volume Excess, a dependent nursing intervention would be: “The nurse will administer scheduled diuretics as prescribed.” The administration of furosemide (Lasix), a diuretic medication, is a dependent intervention because it requires a physician’s prescription specifying the medication, dose (40 mg), route (oral or IV), and frequency (daily). The nurse incorporates this dependent intervention into Ms. J.’s overall care plan by linking it to the nursing diagnosis of Fluid Volume Excess.

Collaborative Nursing Interventions: Team-Based Actions

Collaborative nursing interventions are actions that the nurse carries out in collaboration with other members of the healthcare team. These interventions involve consulting with, coordinating care with, or working jointly with other professionals, such as physicians, social workers, respiratory therapists, physical therapists, occupational therapists, dietitians, and pharmacists. Collaborative interventions leverage the expertise of multiple disciplines to provide holistic and integrated patient care. These interventions are developed in consultation with other healthcare professionals, incorporating their unique professional perspectives and skills.⁷

Examples of collaborative nursing interventions include:

• Consulting with a respiratory therapist: For patients with respiratory compromise to optimize oxygen therapy, airway management, and breathing treatments.
• Referring to physical therapy: For patients with mobility impairments to develop exercise programs, gait training, and assistive device recommendations.
• Consulting with occupational therapy: For patients needing assistance with activities of daily living (ADLs), adaptive equipment, and home safety modifications.
• Referring to social work or case management: For patients with psychosocial needs, discharge planning needs, resource identification, and financial assistance.
• Collaborating with a dietitian: For patients requiring specialized dietary modifications, nutritional support, or education.
• Participating in interdisciplinary team meetings: To discuss patient progress, coordinate care, and plan discharge.

Example of Collaborative Nursing Intervention (Scenario C):

In Scenario C, if Ms. J.’s oxygen saturation levels were to deteriorate despite initial interventions for Fluid Volume Excess, a collaborative nursing intervention would be: “The nurse will manage oxygen therapy in collaboration with the respiratory therapist.” This intervention involves consulting with the respiratory therapist to assess Ms. J.’s respiratory status, determine the need for supplemental oxygen, and establish the appropriate oxygen delivery method and flow rate. The respiratory therapist may obtain a physician’s prescription for oxygen therapy, and the nurse would then implement and monitor the oxygen therapy in collaboration with the respiratory therapist, adjusting care based on their joint assessment and expertise.

Individualization of Interventions: Tailoring Care to the Patient

A crucial principle in planning nursing interventions is individualization. For interventions to be effective, they must be tailored to the specific patient, taking into account their preferences, values, lifestyle, cultural background, and individual circumstances. What works for one patient may not work for another, even with the same nursing diagnosis.

Example of Individualization:

Consider a nursing intervention for a patient with constipation: “Increase dietary fiber intake.” A common and evidence-based approach is to recommend prune juice. However, if a patient dislikes prune juice, this intervention is unlikely to be successful. A truly individualized approach would involve exploring other high-fiber food options that the patient does enjoy, such as fruits, vegetables, whole grains, or fiber supplements, ensuring the intervention is palatable and acceptable to the patient.

Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective and individualized interventions. The number of interventions included in a nursing care plan is not rigidly fixed, but sufficient quality, individualized interventions should be planned to realistically address the identified outcomes for that specific patient and nursing diagnosis.

Creating Nursing Care Plans: Documenting the Plan of Action

Nursing care plans are the documented product of the planning phase. They are created by registered nurses (RNs) and serve as a formal record of the patient’s nursing diagnoses, goals, expected outcomes, and planned interventions. Documentation of individualized nursing care plans is not merely best practice; it is a legal requirement in many healthcare settings.

The Centers for Medicare and Medicaid Services (CMS) mandate individualized care plans in long-term care facilities, emphasizing patient participation in care planning decisions. Similarly, The Joint Commission, a leading healthcare accreditation organization, requires hospitals to document individualized care plans, recognizing them as essential for coordinating communication and ensuring safe and effective care.^{8, 9}

Many healthcare facilities utilize standardized nursing care plans within their EHR systems. These standardized plans provide pre-populated lists of potential nursing diagnoses, goals, outcomes, and interventions for common patient conditions. However, it is crucial to understand that standardized care plans are templates and must be customized and individualized for each patient. The nurse must review and adapt the standardized content to reflect the patient’s specific assessment data, nursing diagnoses, and unique needs. Some facilities may also require nurses to develop care plans independently, without relying on standardized templates.

Regardless of the format, the key principle is that nursing care plans must be individualized to meet the specific and unique needs of each patient. Figure 4.13 shows an example of a standardized care plan.

Figure 4.13: Standardized Care Plan

Nursing care plans created in nursing school can take various forms, including concept maps, tables, or narrative formats. Appendix B provides a sample template that can be used for creating nursing care plans in an educational setting.

By meticulously planning nursing interventions that are evidence-based, individualized, and documented in a comprehensive care plan, nurses prepare for the next crucial phase of the nursing process: Implementation.

Implementation of Interventions: Putting the Care Plan into Action

Implementation, the fifth step in the nursing process and the fifth ANA Standard of Practice, is the action phase. It is defined as “The registered nurse implements the identified plan.”¹ This involves putting the carefully developed nursing care plan into action, translating planned interventions into concrete nursing care activities. During implementation, RNs may also delegate certain interventions to other qualified healthcare personnel, such as Licensed Practical Nurses (LPNs) or Unlicensed Assistive Personnel (UAP), while retaining accountability for the overall outcome of care. Delegation decisions are guided by factors such as patient condition, task complexity, and the skills and competencies of the delegatee, as well as legal and agency policies.

Effective implementation requires the RN to continuously utilize critical thinking and clinical judgment. The initial care plan is not static; it must be viewed as a dynamic guide that requires ongoing reassessment of the patient. Continual monitoring is essential to detect any changes in the patient’s condition that may necessitate modifications to the original care plan. This dynamic nature of the nursing process, with its emphasis on ongoing reassessment and adaptation, is paramount for ensuring patient safety and optimal care delivery.

Key aspects of the implementation phase include: prioritizing intervention implementation, ensuring patient safety during interventions, delegating interventions appropriately, and documenting interventions accurately and promptly.

Prioritizing Implementation: Addressing Urgent Needs First

Prioritizing the implementation of interventions follows similar principles to prioritizing nursing diagnoses, as discussed earlier. Maslow’s Hierarchy of Needs and the ABCs (Airway, Breathing, Circulation) remain essential frameworks for determining the urgency of interventions. Interventions addressing physiological needs and life-threatening conditions take precedence. Whenever clinically appropriate and safe, least invasive interventions are generally preferred initially, minimizing patient discomfort and risk of complications.

Beyond immediate urgency, prioritizing implementation also involves considering the potential impact of delayed interventions on future patient outcomes. Timing is critical. For example, if a patient is scheduled for surgery later in the day, implementing the NPO (nothing by mouth) prescription takes high priority, even if other interventions are also important. Delaying the NPO order could lead to surgery cancellation or complications. Understanding the patient’s overall purpose of care, their current clinical situation, and the expected outcomes of interventions are all crucial factors in accurate prioritization.

Patient Safety During Implementation: Preventing Errors and Harm

Patient safety must be paramount during the implementation of all nursing interventions. Nurses are the frontline providers, directly delivering care and closely monitoring patients. This position places them at the forefront of error prevention. At times, a patient’s condition may change unexpectedly, rendering a previously planned nursing intervention or a provider’s prescription potentially unsafe or inappropriate to implement.

Example of Patient Safety Consideration:

A nursing care plan for a patient with mobility issues includes the intervention: “The nurse will ambulate the patient 100 feet three times daily.” However, during the morning assessment, the patient reports feeling unusually dizzy, and their blood pressure is significantly lower than baseline at 90/60. Applying critical thinking and clinical judgment, the nurse recognizes that implementing the planned ambulation intervention in this current condition could be unsafe, increasing the risk of falls and injury. Therefore, the nurse decides to withhold the ambulation intervention at this time. This decision, along with the supporting assessment findings (dizziness, low blood pressure), must be thoroughly documented in the patient’s chart and effectively communicated during shift handoff report to ensure continuity of safe care. Promptly notifying the healthcare provider of the patient’s change in condition is also essential.

Effective implementation of nursing interventions extends far beyond simply carrying out provider prescriptions and completing tasks listed on the care plan. It fundamentally centers on patient safety. Nurses, as vigilant and skilled professionals, are uniquely positioned to identify potential errors before they reach the patient, acting as a critical safety net within the healthcare system.

The Institute of Medicine (IOM) Reports on Patient Safety:

In 2000, the Institute of Medicine (IOM) released a groundbreaking report, “To Err Is Human: Building a Safer Health System.” This report brought to light the alarming reality of preventable medical errors, estimating that as many as 98,000 deaths occur annually in U.S. hospitals due to such errors. “To Err Is Human” broke the silence surrounding medical errors, initiating a national dialogue and setting a national agenda focused on reducing errors and enhancing patient safety through systemic improvements in healthcare delivery.³

In 2007, the IOM followed up with another crucial report, “Preventing Medication Errors.” This report highlighted that medication errors are a significant source of patient harm, with over 1.5 million Americans injured annually in hospitals due to medication-related mistakes. The report emphasized specific actions that healthcare systems could implement to improve medication safety and reduce these preventable errors.⁴

Common Nursing-Related Errors Endangering Patient Safety:

Errors involving nurses that compromise patient safety span a wide spectrum, including:⁵

• “Wrong site, wrong patient, wrong procedure” errors: Mistakes in patient identification or procedure execution.
• Medication errors: Incorrect dose, wrong medication, wrong route, wrong time, omission errors.
• Failures to follow infection prevention protocols: Leading to central line bloodstream infections, surgical site infections, and other healthcare-associated infections.
• Errors leading to patient falls: Inadequate fall risk assessment, lack of supervision, unsafe environment.

Contributing factors to these errors can include:

• Nurse fatigue: Long shifts, inadequate staffing levels, leading to decreased vigilance and increased error rates.
• Flawed systems: Complex procedures, lack of safety checks, poor communication pathways.
• Interruptions and distractions: During medication administration or other critical tasks, increasing the risk of errors.

Quality and Safety Education for Nurses (QSEN):

The Quality and Safety Education for Nurses (QSEN) project was launched in 2005 to address the critical need for preparing future nurses to continuously improve the quality and safety of healthcare systems. The QSEN initiative aims to “inspire health care professionals to put quality and safety as core values to guide their work.”⁶ Nurses and nursing students are expected to actively participate in quality improvement (QI) initiatives within their practice settings. Quality improvement is defined as “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 This involves identifying areas where improvements are needed, contributing to the design and implementation of QI initiatives, and actively participating in efforts to enhance patient safety and quality of care.

Delegation of Interventions: Utilizing the Healthcare Team

During the implementation phase, RNs often delegate nursing tasks to other members of the healthcare team, such as LPNs or UAPs. Delegation, as defined by the American Nurses Association, 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 It’s not simply assigning tasks; it’s entrusting specific care activities to qualified individuals while maintaining RN responsibility for the patient’s overall nursing care.

The RN remains accountable for the appropriateness of delegation, ensuring that:⁹

• Patient condition and circumstance: The delegated task is suitable for the patient’s current health status and needs.
• Task complexity: The task is within the skill set and competence of the LPN or UAP.
• Communication: Clear and comprehensive instructions are provided to the delegatee.
• Supervision: Appropriate level of supervision is provided, based on the delegatee’s experience and task complexity.
• Evaluation and documentation: The RN ensures the delegated task is completed correctly and documented appropriately.
• Legal and agency policies: Delegation adheres to the state Nurse Practice Act, federal regulations, and agency-specific policies.

Crucially, RNs cannot delegate responsibilities that require professional nursing judgment. Tasks requiring assessment, diagnosis, planning, evaluation, or complex decision-making must be performed by the RN. Delegation is about entrusting tasks, not responsibility for the nursing process itself.

Delegation Guidelines and Legal Considerations:

Delegation practices are governed by state Nurse Practice Acts, which define the scope of practice for RNs, LPNs, and UAPs. These acts outline legal parameters for delegation, ensuring patient safety and appropriate utilization of healthcare personnel. Agency policies further refine delegation practices within specific healthcare settings. It is imperative that RNs are thoroughly familiar with their state’s Nurse Practice Act and their agency’s delegation policies to ensure legal and ethical practice.

Table 4.7 provides general guidelines for delegating nursing tasks in the state of Wisconsin, illustrating how delegation responsibilities are differentiated based on the role of the healthcare team member (RN, LPN, CNA/UAP). Specific delegation guidelines vary by state and agency; this table is illustrative and not universally applicable.

Table 4.7: General Guidelines for Delegating Nursing Tasks

Documentation of Interventions: A Legal and Ethical Imperative

As nursing interventions are implemented, timely and accurate documentation in the patient’s medical record is absolutely essential. As previously discussed in the “Ethical and Legal Issues” section, failure to document is considered a failure to communicate and can have serious legal and ethical implications. In a court of law, the adage “if it wasn’t documented, it wasn’t done” holds significant weight. Lack of documentation can be construed as negligence and can form the basis for legal action.

Beyond legal ramifications, timely documentation is crucial for patient safety and continuity of care. Delayed documentation increases the risk of errors, omissions, and miscommunication among healthcare team members. Prompt documentation of medication administration, treatments, assessments, and patient responses ensures an accurate and up-to-date record of care, facilitating informed decision-making and coordinated care delivery.

Coordination of Care and Health Teaching/Health Promotion: Holistic Implementation

The ANA’s Standard of Professional Practice for Implementation extends beyond task execution to encompass broader aspects of holistic nursing care. Standard 5A focuses on Coordination of Care, and Standard 5B emphasizes Health Teaching and Health Promotion.¹²

Coordination of Care during implementation involves:

• Organizing the components of the care plan: Ensuring a logical and efficient sequence of interventions.
• Engaging the patient in self-care: Empowering patients to actively participate in their care and achieve goals.
• Advocating for dignified and holistic care: Ensuring the interprofessional team delivers patient-centered, respectful, and comprehensive care.

Health Teaching and Health Promotion, as defined by ANA Standard 5B, involves “Employing strategies to teach and promote health and wellness.”¹³ Patient education is not a separate, isolated activity but an integral component of nursing care that should be incorporated into every patient encounter. This can range from brief “teachable moments” during medication administration (e.g., explaining side effects) to structured teaching sessions on self-management techniques for chronic conditions. Health promotion activities aim to empower patients to adopt healthier lifestyles and prevent future health problems.

Putting It Together: Scenario C – Implementation in Action

Referring back to Scenario C with Ms. J., the nurse implementing the care plan (partially documented in Appendix C) would prioritize interventions based on urgency and patient needs. Interventions related to breathing (addressing Fluid Volume Excess and potential respiratory compromise) would be prioritized. Medication administration (diuretic) would be completed promptly as prescribed. Frequent monitoring of lung sounds would be implemented to evaluate the effectiveness of diuretic therapy. Delegation would be utilized appropriately – for example, delegating patient weight measurement to a CNA/UAP before breakfast. Patient education would be integrated throughout the encounter, teaching Ms. J. about her medications, fluid management strategies, and methods to reduce peripheral edema at home. Documentation of all implemented interventions, assessments, and patient responses would be diligently recorded in the electronic medical record (EMR) in a timely manner.

By thoughtfully prioritizing, safely implementing, delegating appropriately, and documenting meticulously, nurses bring the nursing care plan to life, moving patients closer to their desired outcomes and ensuring safe, effective care. This sets the stage for the final, critical step in the nursing process: Evaluation.

Evaluation: Measuring Progress and Refining the Care Plan

Evaluation, the sixth and final step of the nursing process and the sixth ANA Standard of Practice, is the critical phase of assessing the effectiveness of the nursing care plan and the patient’s progress towards achieving desired outcomes. It is defined as “The registered nurse evaluates progress toward attainment of goals and outcomes.”¹ Evaluation is not a one-time event but an ongoing, dynamic process. Both the patient’s current health status and the effectiveness of the nursing care plan must be continuously evaluated, and the care plan must be revised as needed based on the evaluation findings.² Evaluation is the feedback loop that ensures the nursing process remains responsive to the patient’s evolving needs.

The primary focus of evaluation is to determine the effectiveness of the implemented nursing interventions in achieving the expected outcomes established in the outcome identification phase. This involves systematically reviewing each expected outcome and assessing whether it has been met, partially met, or not met within the specified timeframe. During evaluation, nurses employ critical thinking to analyze reassessment data, comparing the patient’s current status against the initial assessment baseline and the desired outcomes.

Evaluation is not a static, end-of-shift activity. Reassessment should be an ongoing process, occurring every time the nurse interacts with the patient, discusses the care plan with other members of the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans are living documents that must be updated dynamically as patient needs change, higher priority goals emerge, or interventions prove ineffective. The findings of each evaluation must be meticulously documented in the patient’s medical record, providing a clear record of progress, revisions, and ongoing care needs.

Guiding Questions for Care Plan Revision:

If expected outcomes are not fully met or are only partially met within the established timeframe, the nursing care plan requires revision. Critical reflection and analysis are essential to understand why outcomes were not fully achieved and to identify areas for improvement. The following questions can guide this revision process:

• Did anything unanticipated occur? Were there unexpected events, complications, or changes in the patient’s condition that impacted outcome achievement?
• Has the patient’s condition changed? Has the patient’s health status improved, worsened, or remained the same since the care plan was initiated? Do reassessment data indicate new or emerging needs?
• Were the expected outcomes and their timeframes realistic? Were the initial outcomes too ambitious, too vague, or not achievable within the specified timeframe given the patient’s condition and resources? Do outcomes need to be revised to be more realistic and attainable?
• Are the nursing diagnoses accurate for this patient at this time? Do reassessment data suggest that the original nursing diagnoses are still the most appropriate and accurate? Are there new or revised diagnoses that need to be considered based on the patient’s evolving needs?
• Are the planned interventions appropriately focused on supporting outcome attainment? Were the selected interventions evidence-based and directly targeted at addressing the related factors and defining characteristics of the nursing diagnoses? Were the interventions implemented consistently and effectively?
• What barriers were experienced as interventions were implemented? Were there patient-related barriers (e.g., adherence issues, lack of motivation, physical limitations), system-related barriers (e.g., resource limitations, staffing issues), or other obstacles that hindered intervention effectiveness?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies? Based on the comprehensive evaluation, which aspects of the care plan need to be adjusted, refined, or completely changed to better address the patient’s needs and promote outcome achievement?
• Are different interventions required? Are alternative or additional interventions needed to more effectively address the nursing diagnoses and facilitate progress toward desired outcomes? Should the plan incorporate new or different evidence-based strategies?

By thoughtfully considering these questions and analyzing evaluation data, nurses can systematically revise and refine the nursing care plan, ensuring it remains a dynamic and effective tool for guiding patient-centered care.

Putting It Together: Scenario C – Evaluation in Practice

Let’s revisit Scenario C and Ms. J.’s care plan (partially in Appendix C) to illustrate the evaluation process. The nurse systematically evaluates Ms. J.’s progress towards achieving the expected outcomes established for the nursing diagnosis Fluid Volume Excess.

For the nursing diagnosis Fluid Volume Excess, the following four expected outcomes were established:

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

Following implementation of the care plan interventions for Day 1, the nurse conducts a thorough evaluation of Ms. J.’s condition, gathering reassessment data: “The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves.”

Based on this evaluation data, the nurse assesses the status of each expected outcome:

1. Outcome 1 (Decreased dyspnea): Met. Ms. J. reported subjective improvement in shortness of breath.
2. Outcome 2 (Clear lung sounds): Met. Objective assessment revealed absence of crackles in lower lung bases.
3. Outcome 3 (Decreased edema): Partially Met. Some weight loss occurred (1 kg), indicating fluid reduction, but 2+ edema persisted, indicating the outcome was not fully achieved.
4. Outcome 4 (Weight return to baseline): Not Met. Weight had decreased but not yet returned to baseline by Day 1.

Based on this evaluation, the nurse determines that the outcomes for Fluid Volume Excess are “Partially Met.” The care plan requires revision to more aggressively address the persistent edema. The nurse revises the care plan, adding two new interventions:

1. Request prescription for TED hose from provider. (Dependent intervention to promote venous return and reduce edema).
2. Elevate patient’s legs when sitting in chair. (Independent intervention to promote gravity-assisted fluid mobilization).

For the second nursing diagnosis, Risk for Falls, the expected outcome was: “The patient will verbalize understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred.”

The nurse evaluates this outcome based on ongoing observation and patient interaction: “The patient verbalizes understanding of fall precautions and is consistently using the call light to request assistance when getting out of bed. No falls have occurred during hospitalization.” Based on this, the nurse evaluates this outcome as “Met.”

The nurse continues to reassess Ms. J.’s progress throughout her hospitalization, evaluating outcomes according to the care plan and making further revisions as needed. The evaluation findings, including outcome status (Met, Partially Met, Not Met) and care plan revisions, are meticulously documented in Ms. J.’s medical record, ensuring a complete and accurate record of her care journey.

By consistently engaging in evaluation, analyzing patient progress, and dynamically revising the care plan, nurses ensure that the nursing process remains a responsive and effective framework for achieving optimal patient outcomes and delivering high-quality, patient-centered care.

Summary of the Nursing Process: A Cycle of Continuous Improvement

You have now journeyed through each step of the nursing process – Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation – understanding its alignment with the ANA Standards of Professional Nursing Practice. Throughout this process, critical thinking, clinical reasoning, and clinical judgment have been emphasized as essential cognitive tools for nurses. From initial patient assessment to ongoing evaluation and care plan revision, these cognitive skills are the intellectual engines driving effective nursing practice.

The nursing process is not a rigid, linear sequence but a dynamic, cyclical, and iterative process. Frequent reassessment and care plan revision are not signs of failure but rather hallmarks of a responsive and patient-centered approach. This continuous cycle of assessment, planning, implementation, and evaluation ensures that the care plan remains relevant, effective, and tailored to the patient’s evolving needs and health status.

Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care is not just a philosophy; it’s the ethical and professional imperative of nursing practice. The ultimate goal of the nursing process is to evaluate whether nursing care has been successful in achieving desired patient outcomes. This focus on outcomes and patient-centeredness is what defines safe, effective, and professional nursing practice.

Video Review: Creating a Sample Care Plan ¹

Nursing Care Plan Tutorial Video

To further solidify your understanding of the nursing process and its application, consider reviewing video tutorials and engaging in practice scenarios. Mastering the nursing process is not just about memorizing steps; it’s about internalizing a way of thinking, a systematic approach to problem-solving, and a commitment to delivering the highest quality, patient-centered care.

Learning Activities: Applying the Nursing Process

Learning Activities

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

Instructions: Apply what you’ve learned in this chapter by creating a nursing care plan using the following scenario. Use the template in Appendix B as a guide.

Patient Scenario: Mark S.

The client, Mark S., is a 57-year-old male admitted to the hospital with “severe” abdominal pain, unmanaged in the Emergency Department. Diagnostic tests are scheduled for the morning, as informed by his physician.

Upon receiving this news, Mark begins pacing the floor, exhibiting constant movement and repeatedly asking the nurse, “How long will the tests take?” He remarks, “I’m so uptight I will never be able to sleep tonight.” The nurse observes Mark avoids eye contact, fidgets with the call light, and his eyes dart around the room. He appears tense with a strained facial expression, stating, “My mouth is so dry.” Vital signs are: T 98°F, P 104 bpm, R 30 breaths/min, BP 180/96 mmHg. His skin is diaphoretic and cool to the touch.

Critical Thinking Activity:

1. Data Clustering: Group (cluster) the subjective and objective data from the scenario.
2. Nursing Diagnosis: Create a problem-focused nursing diagnosis (hypothesis) based on the clustered data.
3. Goal and Outcome: Develop a broad goal and then identify a SMART expected outcome for the nursing diagnosis.
4. Interventions: Outline three evidence-based nursing interventions to address the nursing diagnosis and meet the goal. Cite an evidence-based source for each intervention.
5. Evaluation: Imagine implementing your interventions. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met. Justify your evaluation.

Interactive Learning Activity 1

Interactive Learning Activity 2

Interactive Learning Activity 3

IV. Glossary of Key Terms in the Nursing Process

Advocacy: The act or process of pleading for, supporting, or recommending a cause or course of action, particularly on behalf of patients.¹

Art of nursing: The component of nursing that involves unconditionally accepting the humanity of others, respecting their dignity and worth, while providing compassionate, comforting care.²

At-risk populations: Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, or exposure to certain events/experiences.³

Associated conditions: Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis.⁴

Basic nursing care: Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.⁵

Caring relationship: A relationship characterized by mutual trust and understanding, where the whole person is assessed while balancing vulnerability and dignity.⁶

Client: Individual, family, or group, which includes significant others and populations receiving nursing care.⁷

Clinical judgment: The observed outcome of critical thinking and decision-making in nursing practice. It is an iterative process using nursing knowledge to assess situations, prioritize concerns, and generate evidence-based solutions for safe patient care.⁸

Clinical reasoning: A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate its significance, and weigh alternative actions in patient care.⁹

Clustering data: The process of grouping related assessment data into similar domains or patterns to identify trends and potential nursing diagnoses.

Collaborative nursing interventions: Nursing interventions that require cooperation and coordination among health care professionals and unlicensed assistive personnel (UAP) to implement effectively.

Coordination of care: A component of the implementation phase that includes organizing the care plan, engaging the patient in self-care, and advocating for holistic, patient-centered care delivery by the interprofessional team.¹⁰

Critical thinking: Reasoning about clinical issues, encompassing teamwork, collaboration, and workflow optimization to ensure safe and effective patient care.¹¹

Cue: Subjective or objective data that provides a hint or indication of a potential patient problem, health process, or disorder.

Deductive reasoning: “Top-down thinking” that moves from general principles or standards to specific conclusions or strategies in patient care.

Defining characteristics: Observable cues, inferences, signs, and symptoms that cluster together as manifestations of a problem-focused, health-promotion diagnosis, or syndrome.¹²

Delegation: The assignment of patient care activities or tasks to unlicensed assistive personnel (UAP) or licensed practical nurses (LPNs) while the registered nurse retains accountability for the outcome.¹³

Dependent nursing interventions: Interventions that require a prescription or order from a physician, advanced practice nurse, or physician’s assistant before they can be implemented by the nurse.

Direct care: Nursing interventions that involve personal contact and interaction with patients to provide hands-on care and support.

Electronic Medical Record (EMR): A digital version of a patient’s medical chart, containing comprehensive patient information, assessment data, care plans, and treatment records.

Evidence-Based Practice (EBP): A lifelong problem-solving approach that integrates the best research evidence, clinical expertise, patient values and preferences, and available resources to guide patient care decisions.¹⁴

Expected outcomes: Specific, measurable, attainable, relevant, and time-bound (SMART) statements of patient behavior or status that are expected to result from nursing interventions within a defined timeframe.

Functional health patterns: An evidence-based assessment framework, developed by Marjory Gordon, used to organize patient data and identify potential nursing diagnoses based on eleven functional health areas.

Generalization: A judgment or conclusion formed from a set of facts, cues, and observations, often used in inductive reasoning to identify patterns in patient data.

Goals: Broad statements of purpose that describe the overall aim or desired direction of nursing care for a patient, often derived from the nursing diagnosis.

Health teaching and health promotion: Nursing interventions that employ strategies to educate patients and promote health, wellness, self-management, and preventive behaviors.¹⁵

Independent nursing interventions: Nursing interventions that a registered nurse is authorized to initiate autonomously based on their professional knowledge and skills, without requiring a prescription or direction from a provider.

Indirect care: Nursing interventions performed by the nurse away from the patient but on their behalf, such as care planning, documentation, interprofessional collaboration, and ensuring a safe patient environment.

Inductive reasoning: “Bottom-up thinking” that involves forming generalizations and hypotheses based on specific observations, cues, and patient data patterns.

Inference: An interpretation or conclusion made by the nurse based on cues, subjective data, personal experiences, or generalizations, requiring validation to ensure accuracy.

Licensed Practical Nurses or Licensed Vocational Nurses (LPNs/LVNs): Nurses who have completed specific vocational training and passed a licensing exam, providing basic nursing care under the supervision of a registered nurse or physician.

Medical diagnosis: A disease, illness, or pathological condition diagnosed by a physician or advanced health care provider, focusing on the identification of a specific medical problem.

Nursing: A healthcare profession that integrates the art and science of caring, focusing 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 involves the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations.¹⁶

Nursing care plan: A documented plan of care that outlines the individualized nursing care to be provided to a patient, including nursing diagnoses, goals, expected outcomes, and planned interventions.

Nursing process: A systematic, cyclical, patient-centered approach to nursing care, consisting of six steps: Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation (ADOPIE).

Objective data: Measurable and observable patient data that the nurse can gather through senses (sight, hearing, touch, smell) or through reproducible methods such as vital signs and laboratory results.

Outcome: A measurable behavior, change in condition, or patient status that is responsive to nursing interventions and demonstrates progress towards a nursing goal.¹⁷

PES Statement: A format used to write nursing diagnosis statements, including three components: Problem (P), Etiology (E), and Signs and Symptoms (S).

Prescription: Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider for a patient’s medical management.¹⁸

Primary data: Subjective information gathered directly from the patient during the nursing assessment interview.

Primary health care provider: A licensed healthcare professional (physician, advanced practice nurse, physician assistant) authorized to formulate prescriptions and direct medical care for patients.¹⁹

Prioritization: The skillful process of determining the order in which nursing actions should be completed, based on patient needs, urgency, and potential impact on outcomes and safety.

Quality improvement: The combined and unceasing efforts of healthcare professionals, patients, families, researchers, payers, planners, and educators to make changes that lead to better patient outcomes, system performance, and professional development.²⁰

Rapport: Developing a relationship of mutual trust, understanding, and empathy between the nurse and patient, essential for effective therapeutic communication and patient-centered care.

Registered Nurse (RN): A nurse who has completed a designated nursing education program, passed the NCLEX-RN licensing exam, and is licensed by a state Board of Nursing to practice professional nursing.

Related factors: The underlying causes, contributing factors, or etiology of a nursing diagnosis, representing the factors that the nurse aims to address through interventions.

Right to self-determination: The ethical and legal principle that patients have the right to make informed decisions about their own healthcare, including the right to accept or refuse treatment.

Scientific method: Principles and procedures used in the systematic pursuit of knowledge, involving problem identification, data collection, hypothesis formulation, and testing, mirroring the steps of the nursing process.

Secondary data: Information gathered from sources other than the patient, such as family members, medical records, previous healthcare providers, or diagnostic test results.

Subjective data: Information reported by the patient or family, reflecting their perceptions, feelings, experiences, and symptoms, and including the patient’s health history and narrative.

Unlicensed Assistive Personnel (UAP): Individuals who are not licensed healthcare professionals but are trained to provide supportive care services under the supervision of a licensed nurse.²¹

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