Mastering Nursing Care Plans: A Comprehensive Guide to Nursing Diagnosis and Intervention

Learning Objectives

• Utilize the nursing process to deliver effective patient care.
• Identify accurate nursing diagnoses from evidence-based resources.
• Understand the development and components of a patient-centered care plan.
• Prioritize nursing care based on patient needs and clinical reasoning.
• Document each step of the nursing process effectively.
• Differentiate the roles of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) in the nursing process.

Have you ever been amazed by how nurses seamlessly take over patient care, even with limited prior knowledge? It’s not magic, but a structured approach called the nursing process. This process is a critical thinking framework that guides nurses in providing targeted, patient-centered care. Think of it as a roadmap, directing nursing actions and interventions to improve patient well-being and health outcomes. This chapter will explore the nursing process as a cornerstone of professional nursing practice, ensuring safe and effective care tailored to individual patient needs.

Core Principles of the Nursing Process

Before diving into the specifics of the nursing process, it’s crucial to grasp some fundamental concepts underpinning critical thinking and nursing practice. Let’s examine the thought processes of nurses more closely.

Critical Thinking and Clinical Reasoning in Nursing

Nurses are constantly making decisions in patient care, relying on critical thinking and clinical reasoning. Critical thinking in nursing is more than just following protocols; it’s about “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1] Critical thinking empowers nurses to proactively ensure patient safety by validating information and basing care plans on individual patient needs, current best practices, and research.

Effective critical thinkers cultivate key attitudes that promote logical thought:

• Independence of thought: Forming your own judgments and not blindly accepting information.
• Fair-mindedness: Considering all perspectives with impartiality and an open mind.
• Insight into egocentricity and sociocentricity: Recognizing personal biases and prioritizing the greater good.
• Intellectual humility: Acknowledging the limits of one’s knowledge and skills.
• Nonjudgmental approach: Applying professional ethics rather than personal biases in decision-making.
• Integrity: Maintaining honesty and strong moral principles in practice.
• Perseverance: Continuing to strive for solutions despite challenges.
• Confidence: Trusting in your abilities to perform nursing tasks effectively.
• Interest in exploring thoughts and feelings: Being open to different ways of understanding and knowing.
• Curiosity: Continuously questioning and seeking deeper understanding.

Clinical reasoning 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] Sound clinical judgment depends on generating options, evaluating evidence, and choosing the optimal course of action. Clinical reasoning skills develop with experience and a strong knowledge base. [3]

Inductive and Deductive Reasoning in Clinical Judgment

Inductive and deductive reasoning are vital critical thinking tools that inform clinical judgment within the nursing process.

Inductive reasoning moves from specific observations to broader generalizations and hypotheses. It involves noticing cues, which are deviations from expected findings that signal potential patient problems. Nurses organize these cues into patterns to form generalizations, which are judgments derived from collected data and observations. This is akin to assembling puzzle pieces until a clearer picture emerges. Based on these generalizations, nurses develop hypotheses, which are proposed explanations for a patient’s situation, aiming to uncover the “why” behind a problem to guide solution exploration.

Effective inductive reasoning starts with keen observation. Paying close attention to the patient, their environment, and interactions with family is crucial. Nurses, much like detectives as shown in Figure 4.1, must meticulously look for cues. [4] Sharpening your inductive reasoning involves actively engaging your five senses: sight, hearing, touch, smell, and taste. Strong inductive reasoning is essential for nurses, especially in fast-paced, emergency situations where recognizing patterns and acting swiftly is critical.

Figure 4.1: Inductive Reasoning: Looking for Cues

Example: A nurse assessing a surgical site observes redness, warmth, and tenderness. Recognizing these cues as a pattern indicative of infection, the nurse hypothesizes a surgical site infection. The physician is notified, and an antibiotic is prescribed. This exemplifies inductive reasoning in nursing practice.

Deductive reasoning, conversely, is “top-down thinking.” It applies general rules or standards to specific situations. Nurses utilize established standards from Nurse Practice Acts, regulations, professional guidelines (like those from the American Nurses Association), and employer policies to guide patient care decisions and problem-solving.

Example: Hospital policy dictates quiet zones at night to promote patient rest, based on research showing improved recovery with adequate rest (Figure 4.2). [5] Nurses implement this policy by clustering nighttime care activities to minimize disruptions. This is deductive reasoning, applying a general policy to all patients, regardless of their specific sleep issues.

Figure 4.2: Deductive Reasoning: Implementing Quiet Zone Policy

Clinical judgment, the outcome of critical thinking and clinical reasoning, as defined by the National Council of State Boards of Nursing (NCSBN), is “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” [6] The NCLEX exam evaluates clinical judgment and decision-making skills to ensure entry-level nurses are competent and safe.

Evidence-based practice (EBP), as defined by the American Nurses Association (ANA), is “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [7] EBP ensures nursing care is informed by the best available evidence, clinical expertise, and patient values.

The Nursing Process: A Systematic Approach

The nursing process is a patient-centered, systematic critical thinking model. Nurses use it to apply clinical reasoning and judgment in patient care, guided by the American Nurses Association (ANA) Standards of Professional Nursing Practice. These standards define the expected actions and behaviors of all registered nurses across roles and settings. [8] The mnemonic ADOPIE summarizes the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

The nursing process is a dynamic, cyclical process, continuously adapting to the patient’s changing health status, as illustrated in Figure 4.3. [9]

Figure 4.3: The Nursing Process

Consider Scenario A for an example of the nursing process in action.

Patient Scenario A: Applying the Nursing Process [10]

A patient hospitalized for heart failure is prescribed Lasix 80mg IV daily. During the morning assessment, the nurse finds a blood pressure of 98/60, heart rate of 100, respirations of 18, and temperature of 98.7°F. Reviewing the patient’s chart, the nurse notes a baseline blood pressure around 110/70 and heart rate in the 80s. Recognizing these vital sign changes as cues related to fluid imbalance, the nurse hypothesizes dehydration. Further assessment reveals a 4-pound weight loss since yesterday. The patient confirms feeling light-headed and reports a dry mouth. Applying critical thinking, the nurse identifies the nursing diagnosis of Fluid Volume Deficit and sets goals for fluid rebalance. The nurse withholds the Lasix, contacts the provider to discuss the patient’s fluid status, and initiates interventions to increase oral intake and monitor hydration. By shift end, the patient’s fluid balance is evaluated as restored.

In Scenario A, the nurse demonstrates clinical judgment by not automatically administering Lasix as prescribed. The nurse assesses, identifies cues, forms a hypothesis about fluid status, plans and implements interventions, and evaluates outcomes. Importantly, patient safety is prioritized by contacting the provider before administering medication that could be harmful given the patient’s current condition.

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

Assessment

The “Assessment” Standard of Practice states: “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [11] This involves a systematic approach to gather and analyze patient data, encompassing physiological, psychological, sociocultural, spiritual, economic, and lifestyle aspects. For example, assessing a patient in pain includes not just pain level but also its impact on mobility, appetite, social interaction, and mood. [12]

The “Assessment” component is further explored in the “Assessment” section.

Diagnosis

The “Diagnosis” Standard of Practice is: “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [13] A nursing diagnosis is a nurse’s clinical judgment about a patient’s response to health conditions or needs. It forms the basis for the nursing care plan and differs from a medical diagnosis. [14]

The “Diagnosis” component is detailed in the “Diagnosis” section.

Outcomes Identification

The “Outcomes Identification” Standard is: “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [15] This involves setting measurable, achievable short- and long-term goals in collaboration with the patient, based on assessment data and nursing diagnoses.

The “Outcomes Identification” component is further described in the “Outcomes Identification” section.

Planning

The “Planning” Standard of Practice is: “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [16] Using assessment data, diagnoses, and goals, nurses select evidence-based interventions tailored to each patient. These are documented in the nursing care plan, ensuring consistent care across the healthcare team. [17]

The “Planning” component is explored in the “Planning” section.

NURSING CARE PLANS: The Blueprint for Patient Care

Nursing care plans are a crucial part of the “Planning” step. A nursing care plan is a formal document outlining individualized, planned nursing care using the nursing process. Registered Nurses (RNs) develop these plans to ensure consistent care across shifts and among healthcare staff. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or Unlicensed Assistive Personnel (UAPs) under RN supervision. Care plan development and delegation are further discussed in the “Planning” and “Implementing” sections.

Implementation

The “Implementation” Standard of Practice states: “The nurse implements the identified plan.” [18] Nursing interventions are carried out or delegated according to the care plan, ensuring consistent care. Completed interventions are documented in the patient’s electronic medical record. [19]

The “Implementation” Standard also includes “Coordination of Care” and “Health Teaching and Health Promotion” subcategories, emphasizing holistic patient care. [20]

The “Implementation” component is further detailed in the “Implementation” section.

Evaluation

The “Evaluation” Standard of Practice is: “The registered nurse evaluates progress toward attainment of goals and outcomes.” [21] Evaluation involves reassessing the patient and comparing findings to the initial assessment to gauge the effectiveness of interventions and the overall care plan. Both patient status and care plan effectiveness are continuously evaluated and adjusted as needed. [22]

The “Evaluation” component is further explored in the “Evaluation” section.

Benefits of the Nursing Process

The nursing process offers numerous advantages for nurses, patients, and the healthcare team:

• Enhances quality of patient care.
• Reduces errors and redundancies.
• Provides a consistent care framework for all staff.
• Promotes collaborative problem-solving.
• Improves patient safety and satisfaction.
• Clearly defines patient goals and strategies.
• Increases the likelihood of positive outcomes.
• Saves time and resources by providing a structured care path.

By utilizing the nursing process, nurses personalize interventions, plan outcomes, and evaluate the effectiveness of their actions in meeting patient needs. The following sections will delve deeper into each component of the nursing process. Using the nursing process and evidence-based practices is often referred to as the “science of nursing.” Let’s now consider the “art of nursing” and holistic care within this framework.

Holistic Nursing Care: Beyond the Physical

The American Nurses Association (ANA) defines nursing as: “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [23]

Nursing blends the art of nursing, defined as “unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care,” [24] with the science of evidence-based practice.

Holistic nursing addresses patients’ emotional, spiritual, psychosocial, cultural, and physical needs. It considers the patient within their family and community context when applying the nursing process. Consider this scenario illustrating holistic nursing care:

Holistic Nursing Care Scenario

A single mother brings her child to the ER with ear pain and fever. The child is diagnosed with an ear infection and prescribed an antibiotic. The mother is advised to follow up with her primary care provider. During discharge teaching, the nurse learns the mother cannot afford the prescribed antibiotic and lacks transportation to a primary care provider. The nurse consults a social worker to discuss affordable insurance and local providers reachable by bus. The nurse also contacts the physician to request a prescription for a less expensive generic antibiotic. This exemplifies holistic care, advocating for the child and family’s overall well-being.

For further insights into culturally responsive care and reducing health disparities, refer to the “Diverse Patients” chapter.

Caring as the Foundation of the Nursing Process

The American Nurses Association (ANA) emphasizes that “The act of caring is foundational to the practice of nursing.” [25] The nursing process thrives on a caring relationship built on trust, known as rapport. Rapport underpins the art of nursing, enabling nurses to assess the whole person—beliefs, values, attitudes—while respecting their vulnerability and dignity. [26] Caring interventions can be simple yet powerful: active listening, eye contact, touch, and verbal reassurance, always respecting cultural beliefs around caring behaviors. [27] Figure 4.4 demonstrates touch as a therapeutic communication of caring. [28]

Figure 4.4: Touch as Therapeutic Communication

Learn more about therapeutic communication techniques, such as active listening, in the “Communication” chapter.

Nurse theorist Dr. Jean Watson champions caring in nursing. Her theory of human caring balances the medical focus on cure with nursing’s unique role in compassionate, holistic care. Dr. Watson advocates for nurses to be authentically present with patients, creating a healing environment. [29]

Explore Dr. Watson’s caring theory further at the Watson Caring Science Institute.

With these core concepts established, let’s delve into each step of the nursing process in detail.

References

[List of references as in the original article]

4.3. ASSESSMENT: The First Step in the Nursing Process

Assessment, the first step in the nursing process and the first Standard of Practice by the American Nurses Association, is defined as: “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes ongoing, systematic data collection with compassion and respect, considering demographics, environment, social determinants of health, and physical, psychosocial, emotional, cognitive, spiritual, sociocultural, age-related, lifestyle, and economic factors. [1]

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

Subjective Assessment Data: The Patient’s Perspective

Subjective data is information from the patient and/or family, offering vital insights from their viewpoint. Documented subjective data should be in quotation marks, prefaced with “The patient reports…” Building rapport is key to obtaining accurate subjective data about mental, emotional, and spiritual well-being.

Subjective data is further classified as primary or secondary. Primary data comes directly from the patient, the best source for understanding their experiences and feelings. Secondary data is gathered from family, charts, or other sources, especially valuable for patients with cognitive impairments, infants, children, or those unable to communicate themselves.

Figure 4.5 illustrates a nurse building rapport while obtaining subjective data. [2]

Example: Documented subjective data: “The patient reports, ‘My pain is a level 2 on a 1-10 scale.'”

Objective Assessment Data: Observable and Measurable

Objective data is observable and measurable through senses: hearing, sight, smell, and touch. It’s reproducible, meaning others can verify it. Examples include vital signs, physical exam findings, and lab results. Figure 4.6 shows a nurse conducting a physical exam. [3]

Figure 4.6: Physical Examination

Example: Documented objective data: “Radial pulse 58, regular; skin warm and dry.”

Sources of Assessment Data: Interview, Examination, and Records

Assessment data comes from three primary sources: interviews, physical examinations, and review of diagnostic results.

Interviewing: Gathering Patient History

Interviews involve questioning, listening, and observing verbal and nonverbal cues. Chart review beforehand can streamline interviews, focusing on key areas or unclear information. Verify chart data with the patient during the interview.

Start by introducing yourself, explaining your role and the interview’s purpose and duration. Begin with questions about medical diagnoses to understand their impact on the patient’s life. Active listening and critical thinking can reveal valuable cues for safe, quality care. Don’t hesitate to ask personal questions relevant to care; most patients appreciate the thoroughness.

Pay attention to verbal and nonverbal responses, validating any inferences. For example, avoid assuming depression based solely on lack of eye contact; explore cultural reasons first. For more on patient communication, see the “Communication” chapter.

Physical Examination: Systematic Body Assessment

A physical examination systematically assesses the body using inspection, auscultation, palpation, and percussion. Inspection is visual observation. Auscultation uses a stethoscope to listen to organ sounds. Palpation uses touch to assess organ size, location, and tenderness. Percussion, tapping body parts to assess size and fluid presence, is typically done by providers. Open RN Nursing Skills textbook and Appendix C provide detailed physical examination procedures. Vital signs are also part of the physical exam.

Registered Nurses (RNs) perform initial physical examinations and analyze findings. Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) can collect follow-up data, and Unlicensed Assistive Personnel (UAPs) can measure vital signs and weight, but RNs remain responsible for supervision, analysis, and documentation.

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

Reviewing Laboratory and Diagnostic Test Results

Reviewing lab and diagnostic results provides crucial information for patient care. Understanding normal and abnormal results guides care planning and prescription implementation. Nurses must notify providers of concerning results and verify prescription appropriateness before administration.

Types of Nursing Assessments

Different types of assessments are used in practice:

• Primary Survey: Rapidly assesses consciousness, airway, breathing, circulation (ABCs) in every patient encounter, initiating emergency care as needed.
• Admission Assessment: Comprehensive assessment upon admission, gathering extensive data systematically.
• Ongoing Assessment: Regular head-to-toe assessments in acute care, at least once per shift, with changes reported to providers.
• Focused Assessment: Re-evaluates specific, previously identified problems.
• Time-Lapsed Reassessment: Used in long-term care, typically every three months, to evaluate progress toward outcomes. [4]

Putting It All Together: Scenario C

Scenario C applies assessment concepts to a patient case.

Scenario C [5]

Ms. J., 74, is admitted for shortness of breath, increased ankle and calf swelling, and fatigue. Her history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). Medications: aspirin 81 mg daily, metoprolol 50 mg BID, furosemide 40 mg daily, metformin 2000 mg daily.

Admission vital signs:

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

Weight is up 10 lbs in three weeks. Patient states, “I am so short of breath,” “My ankles are so swollen,” “I am so tired and weak,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She also says, “I would like to learn more about my health so I can take better care of myself.”

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

Patient’s daughter adds, “We are so worried about mom living at home alone when she is so tired!”

Critical Thinking Questions

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

Answers are in the Answer Key at the end of the book.

References

[List of references as in the original article]

4.4. DIAGNOSIS: Analyzing Data to Identify Patient Needs

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

Analyzing Assessment Data: From Cues to Diagnoses

After assessment, nurses analyze data to generalize and hypothesize nursing diagnoses. This involves data analysis, clustering, hypothesis generation, further assessment, and formulating nursing diagnosis statements. Prioritized nursing diagnoses then drive the care plan. [2]

Performing Data Analysis: Identifying Relevant Cues

Nurses analyze collected data against expected norms for the patient’s age, development, and baseline, determining “relevant cues” for prioritized care. [3]

Example: In Scenario C, the nurse identifies elevated BP, HR, RR, and decreased SpO2 as relevant cues.

Clustering Information, Seeing Patterns, and Forming Hypotheses

Relevant cues are then clustered into patterns, often using frameworks like Gordon’s Functional Health Patterns. This helps organize information based on human response patterns. See the box below for Gordon’s Functional Health Patterns. [4]

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

Gordon’s Functional Health Patterns [5]

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

Identifying Nursing Diagnoses: NANDA-I and Standardized Language

After data analysis and clustering, the question becomes: “What are my patient’s nursing diagnoses?” A nursing diagnosis is “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” [6] These diagnoses are patient-specific and guide care plan development. Nurses use resources and definitions of hypothesized diagnoses to ensure accuracy.

Nursing diagnoses are for nurses, by nurses. NANDA International (NANDA-I) develops standardized nursing terminology for human responses to health problems, based on research. [7] Over 220 NANDA-I diagnoses are currently available, continuously updated. Appendix A lists common NANDA-I diagnoses; refer to a current care plan reference for a complete list.

NANDA-I diagnoses are grouped into 13 domains, similar to Gordon’s patterns, aiding diagnosis selection based on clustered data: health promotion, nutrition, elimination, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.

While specific NANDA-I diagnoses aren’t tested on the NCLEX, cue analysis and hypothesis generation are part of clinical judgment assessment.

Nursing Diagnoses vs. Medical Diagnoses: Focus on Response vs. Disease

Nursing diagnoses differ from medical diagnoses. Medical diagnoses identify diseases by physicians or advanced practitioners. Nursing diagnoses focus on human responses to health conditions, made independently by RNs. Patients with the same medical diagnosis may have different nursing diagnoses due to varied responses. For example, two heart failure patients might have different learning needs and anxiety levels. Nursing diagnoses consider individual needs, attitudes, strengths, challenges, and resources for personalized, holistic care.

Example: Ms. J.’s medical diagnosis is heart failure. This isn’t a nursing diagnosis, but an “associated condition.” Nursing diagnoses in Scenario C will relate to her response to heart failure.

NANDA-I Terminology: Patient, Age, Time

NANDA-I uses specific definitions for patient, age, and time:

Patient:

• Individual: Single person.
• Caregiver: Family or helper.
• Family: Related individuals.
• Group: Ethnic group.
• Community: Neighborhood or city. [8]

Age:

• Fetus: Unborn, >8 weeks to birth.
• Neonate: <28 days old.
• Infant: >28 days to <1 year.
• Child: 1-9 years.
• Adolescent: 10-19 years.
• Adult: >19 years.
• Older adult: >65 years. [9]

Time (Duration):

• Acute: <3 months.
• Chronic: >3 months.
• Intermittent: Starts and stops.
• Continuous: Uninterrupted. [10]

New Terms: At-Risk Populations and Associated Conditions

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

At-Risk Populations: Groups sharing characteristics that increase susceptibility to a particular human response (e.g., age, history).

Associated Conditions: Medical diagnoses, injuries, treatments that support nursing diagnosis accuracy but aren’t nurse-modifiable. [12]

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

Four types of NANDA-I nursing diagnoses exist: [13]

• Problem-Focused: Undesirable response to health condition. Requires related factors and defining characteristics. [14]
• Health Promotion-Wellness: Desire to improve well-being. Expressed as readiness to enhance health behaviors. [16]
• Risk: Vulnerability to developing an undesirable response. Supported by risk factors. [17] Risk diagnoses aren’t always lower priority than problem-focused. [18]
• Syndrome: Cluster of diagnoses occurring together, best addressed together with similar interventions. [19]

Establishing Nursing Diagnosis Statements: PES Format

NANDA-I recommends using a statement structure with nursing diagnosis, related factors, and defining characteristics. Accuracy is validated by linking these components from patient assessment data. [20]

To create a statement, nurses analyze data, cluster patterns, and hypothesize diagnoses based on defining characteristics—observable signs/symptoms related to a diagnosis. [21] Care plan resources list defining characteristics and definitions for each diagnosis. Related factors are underlying causes (etiology) of the patient problem, ideally modifiable by nursing interventions. [22]

Traditionally known as “PES format,” it now aligns with:

Problem (P): Nursing diagnosis.
Etiology (E): Related factors (“related to” or “R/T”).
Signs and Symptoms (S): Defining characteristics (“as manifested by” or “as evidenced by”).

Examples of each diagnosis type are below.

Problem-Focused Nursing Diagnosis Statement

Uses the full PES format: Problem, Etiology, Signs/Symptoms.

SAMPLE PROBLEM-FOCUSED STATEMENT

For Ms. J. (Scenario C), data cluster (elevated BP/RR, crackles, edema, weight gain, shortness of breath) are defining characteristics for Excess Fluid Volume. NANDA-I defines this as “surplus intake and/or retention of fluid.” Related factor: excessive fluid intake. [23]

Example Components:

P. Fluid Volume Excess
E. Related to excessive fluid intake
S. As manifested by basilar crackles, 2+ edema, 10 lb weight gain, patient report “ankles so swollen.”

Correct 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

Includes Problem (P) and Signs/Symptoms (S), with symptoms starting “expresses desire to enhance.” [24]

SAMPLE HEALTH-PROMOTION STATEMENT

Ms. J. wants to “learn more about my health to take better care of myself,” indicating readiness for improvement. This is a defining characteristic of Readiness for Enhanced Health Management, defined as “a pattern of regulating and integrating into daily living a therapeutic regimen…which can be strengthened.” [25]

Example Components:

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

Correct Statement:

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

Risk Nursing Diagnosis Statement

Includes Problem (P) and “As Evidenced By” risk factors. [26]

SAMPLE RISK STATEMENT

Ms. J. is at Risk for Falls due to dizziness and weakness. Risk for Falls is defined as “increased susceptibility to falling, which may cause physical harm.” [27]

Example Components:

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

Correct Statement:

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

Syndrome Nursing Diagnosis Statement

Includes Problem (Syndrome) and Signs/Symptoms (defining characteristics as ≥2 nursing diagnoses). Related factors optional. [28]

SAMPLE SYNDROME STATEMENT

Ms. J.’s data clusters suggest Risk for Frail Elderly Syndrome. Activity Intolerance and Social Isolation are defining characteristics. Risk for Frail Elderly Syndrome is “dynamic state of unstable equilibrium…leads to increased susceptibility to adverse health effects, in particular disability.” [29]

Example Components:

P. Risk for Frail Elderly Syndrome
S. Activity Intolerance and Social Isolation
Related factor: Fear of falling.

Correct Statement:

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

Prioritization: Addressing Urgent Needs First

After diagnoses, prioritization is crucial, addressing life-threatening issues immediately. Prioritization identifies the most significant nursing problems and interventions.

Life-threatening crises require rapid action. The nursing process can be condensed to seconds in emergencies. In critical situations, clinical judgment is expedited. Nurses must recognize cues, apply evidence-based practices, and communicate effectively. Most situations are between crisis and routine care.

Prioritization tools include Maslow’s Hierarchy of Needs, ABCs (Airway, Breathing, Circulation), and acute vs. chronic conditions. Figure 4.7 is an infographic on prioritization. [30]

Figure 4.7: The How To of Prioritization

Maslow’s Hierarchy of Needs categorizes needs by urgency, with physiological and safety needs at the base (Figure 4.8). [31] While ABCs are critical, safety often precedes them. For example, in a car crash, safety (removing from danger) precedes airway management.

Figure 4.8: Maslow’s Hierarchy of Needs

Acute, uncompensated conditions generally take priority over chronic ones. Actual problems are prioritized over potential risks, though high-risk situations may take precedence.

Example: For Ms. J., Fluid Volume Excess is the highest priority due to physiological impact. Risk for Falls is a close second due to safety concerns.

References

[List of references as in the original article]

4.5. OUTCOME IDENTIFICATION: Setting Measurable Goals

Outcome Identification, the third step and ANA Standard, is defined as: “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” This involves collaboration with the patient and team, considering culture, values, and ethics, documenting measurable goals with timeframes. [1]

An outcome is a “measurable behavior demonstrated by the patient responsive to nursing interventions.” [2] Outcomes are set before planning interventions. After implementation, nurses evaluate outcome achievement.

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

Short-Term and Long-Term Goals: Patient-Centered Direction

Nursing care must be individualized and patient-centered. Goals and outcomes should be tailored to each patient’s needs, values, and culture, involving patients and families in goal-setting to ensure relevance and motivation.

Nursing care plans are roadmaps, aligning the healthcare team towards common goals. Goals are broad statements of purpose, either short- or long-term, depending on the care setting. Timeframes vary; in critical care, short-term goals might be within 8 hours, long-term within 24. In outpatient settings, short-term might be a month, long-term six months.

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

Example: For Ms. J.’s Fluid Volume Excess, a goal would be: “Ms. J. will achieve fluid balance.”

Expected Outcomes: Specific and Measurable

Goals are broad; expected outcomes are specific, measurable actions within a timeframe, responsive to interventions. Nurses can create outcomes or use classification systems like Nursing Outcomes Classification (NOC), which lists over 330 standardized outcomes aligned with NANDA-I diagnoses. [3]

Patient-Centered and SMART

Outcome statements are always patient-centered, developed collaboratively, and individualized. They begin with “The patient will…” and aim to resolve defining characteristics. Outcomes must be achievable and patient-agreed.

Outcome statements follow the SMART mnemonic: [4]

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

Figure 4.9 illustrates SMART components. [5]

Figure 4.9: SMART Components of Outcome Statements

Specific: Clear and Precise

Outcomes must clearly state what should be achieved.

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

Each outcome should address only one action.

• Poor example: “The patient will walk 50 feet TID and shower daily until discharge.” (Two outcomes combined.)
• Revised (separate outcomes): “The patient will walk 50 feet three times a day with standby assistance of one until discharge.” and “The patient will shower every morning until discharge.”

Measurable: Quantifiable Progress

Measurable outcomes use numerical parameters or concrete methods for assessment, relying on objective data. Avoid vague terms like “acceptable” or “normal.” Figure 4.10 lists measurable and non-measurable verbs. [6]

Figure 4.10: Measurable Outcomes

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

Action-Oriented and Attainable: Patient Action

Outcomes should clearly state patient actions, using action verbs. Figure 4.11 shows action verbs. [7]

Figure 4.11: Action Verbs

• Not action-oriented: “The patient will have increased activity.”
• Action-oriented: “The patient will list three aerobic activities they enjoy and will do weekly.”

Realistic and Relevant: Patient Capabilities

Realistic outcomes consider the patient’s condition, values, culture, beliefs, socioeconomic status, and health literacy. Re-evaluate and revise outcomes for attainability as needed. Unmet outcomes often result from unrealistic timeframes or goals.

• Not realistic: “Patient will jog 1 mile daily from program start.”
• Realistic: “Patient will walk ½ mile three times a week for two weeks.”

Time Limited: Specific Timeframe

Outcomes must include a timeframe for evaluation, varying from shift-by-shift to weekly or monthly, depending on the intervention and patient condition. Evaluation assesses outcomes by the specified timeframe, revising the care plan if unmet.

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

Putting It Together: Scenario C Outcome

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

References

[List of references as in the original article]

4.6. PLANNING: Charting the Course of Care

Planning, the fourth step and ANA Standard, is defined as: “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” This includes individualized, holistic, evidence-based plans, created with patient and team input, prioritized and documented using standardized language, and adapted based on ongoing patient assessment. [1]

After outcome identification, nurses plan nursing interventions—evidence-based actions to achieve patient outcomes. Like physician prescriptions address medical conditions, nursing interventions address nursing diagnoses, aiming to resolve related factors. [2] Care plans document interventions, goals, and outcomes for consistent care.

Planning Nursing Interventions: Evidence-Based Actions

“How do I choose evidence-based interventions?” Nurses use resources like care planning tools in electronic health records, care planning books, and the Nursing Interventions Classification (NIC) system. NIC categorizes and updates evidence-based interventions. Nurses use clinical judgment to select the best interventions for each patient. [3]

Direct and Indirect Care: Patient Contact and Support

Interventions are direct or indirect. Direct care involves patient contact (e.g., wound care, ambulation). Indirect care supports patient care away from the bedside (e.g., care conferences, documentation).

Classification of Nursing Interventions: Independent, Dependent, Collaborative

Three types of interventions exist: independent, dependent, and collaborative (Figure 4.12). [4]

Figure 4.12: Collaborative Nursing Interventions

Independent Nursing Interventions: Nurse-Initiated Actions

Independent nursing interventions are nurse-initiated, requiring no prescription. Examples: monitoring intake/output for fluid balance risk, therapeutic communication for coping with a new diagnosis.

Example: For Ms. J.’s Fluid Volume Excess, an independent intervention is: “Reposition patient with edema frequently, every 2 hours.” [5]

Dependent Nursing Interventions: Prescription-Required Actions

Dependent nursing interventions require a prescription from a primary health care provider—physician, advanced practice nurse, or physician assistant. [6] Medication administration is a dependent intervention. Nurses integrate these into the care plan, linking them to nursing diagnoses.

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

Collaborative Nursing Interventions: Team-Based Actions

Collaborative nursing interventions are carried out with other team members—physicians, social workers, therapists. [7] They are developed in consultation and incorporate diverse perspectives.

Example: For Ms. J.’s Fluid Volume Excess, a collaborative intervention is: “Manage oxygen therapy in collaboration with respiratory therapist.”

Individualization of Interventions: Patient-Specific Care

Interventions must be individualized for effectiveness. For example, prune juice for constipation only works if the patient likes it. Patient and team collaboration is key. The number of interventions isn’t fixed but should be sufficient to meet outcomes.

Creating Nursing Care Plans: Legal and Standard Practice

RNs create nursing care plans, legally required in long-term care (CMS) and hospitals (The Joint Commission). CMS guidelines mandate patient participation in care planning. [8] The Joint Commission views care planning as a communication framework for safe, effective care. [9]

Many facilities use standardized care plans with customizable intervention lists. Others require independent plan development. All plans should be individualized. Figure 4.13 shows a standardized care plan example. [10]

Figure 4.13: Standardized Care Plan

Nursing school care plans vary in format (concept maps, tables). Appendix B provides a care plan template.

References

[List of references as in the original article]

4.7. IMPLEMENTATION OF INTERVENTIONS: Putting the Plan into Action

Implementation, the fifth step and ANA Standard, is defined as: “The registered nurse implements the identified plan.” This includes delegation, considering patient condition, task complexity, communication, supervision, Nurse Practice Acts, regulations, and agency policies. [1]

Implementation requires critical thinking and ongoing patient reassessment to adapt the plan as needed. This dynamic nature ensures safe care.

Implementation involves prioritizing interventions, ensuring patient safety, delegating appropriately, and documenting actions.

Prioritizing Implementation: ABCs and Urgency

Prioritization mirrors diagnosis prioritization, using Maslow’s Hierarchy and ABCs. Less invasive actions are preferred. Consider the impact of timing; for example, NPO status is prioritized pre-surgery. Understanding patient purpose, situation, and outcomes is essential for prioritization.

Patient Safety: Preventing Errors

Patient safety is paramount during implementation. Changes in patient condition may contraindicate planned interventions. For example, if a patient becomes dizzy, planned ambulation should be withheld. This decision and supporting assessment must be documented and communicated.

Implementation goes beyond tasks; it’s about preventing errors. Nurses are frontline safety providers. [2]

The 2000 IOM report, To Err Is Human, highlighted preventable medical errors causing up to 98,000 US hospital deaths annually. [3] The 2007 Preventing Medication Errors report noted 1.5 million annual injuries in hospitals, with daily medication errors per patient, emphasizing system improvements. [4]

For medication error prevention strategies, see the “Preventing Medication Errors” section in the Open RN Nursing Pharmacology textbook.

Nurses’ errors endangering safety include wrong-site/patient/procedure errors, medication mistakes, infection control lapses, and falls. Causes include fatigue from long shifts, flawed systems, and interruptions. [5]

The Quality and Safety Education for Nurses (QSEN) project (2005) aims to improve healthcare quality and safety, promoting quality improvement (QI)—”unceasing efforts…to make changes that will lead to better patient outcomes, better system performance, and better professional development.” [6, 7] Nurses participate in QI by identifying gaps and implementing solutions.

Delegation of Interventions: Appropriate Task Assignment

RNs may delegate tasks to LPNs or UAPs, retaining accountability. Delegation is “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.” [8] RNs assess task appropriateness, communicate clearly, supervise, and evaluate delegated tasks, adhering to Nurse Practice Acts, regulations, and policies. Clinical judgment cannot be delegated. [9] See the box below for Wisconsin delegation guidelines.

Delegation in Wisconsin Nurse Practice Act

RNs in Wisconsin must:

a. Delegate tasks matching supervisee’s abilities.
b. Provide direction and assistance.
c. Monitor activities.
d. Evaluate effectiveness. [10]

Wisconsin LPNs, under RN supervision, must:

a. Accept only competent assignments.
b. Provide basic nursing care (predictable responses, defined procedures).
c. Record care and report changes.
d. Consult providers if delegated acts might harm patients.
e. Perform acts like data collection assistance, care plan assistance, reinforcing teaching, and basic needs assistance. [11]

See Wisconsin Nurse Practice Act Chapter N 6 Standards of Practice and ANA Principles of Delegation for more details.

Table 4.7 outlines Wisconsin delegation guidelines by role.

Table 4.7: Wisconsin Delegation Guidelines

Documentation of Interventions: Timely and Accurate Records

Interventions must be documented promptly in the patient record. Lack of documentation is a legal liability. Undocumented interventions are legally considered undone. Timely documentation prevents errors and ensures accurate records.

Coordination of Care and Health Teaching/Promotion: Holistic Implementation

ANA Implementation Standards include Coordination of Care and Health Teaching and Health Promotion. [12] Coordination of Care involves plan organization, patient self-care engagement, and advocating for holistic care. Health Teaching and Health Promotion involves teaching and promoting wellness. [13] Patient education is integral to nursing care, including medication teaching and self-management strategies.

Putting It Together: Scenario C Implementation

In Scenario C, interventions from Appendix C were implemented, prioritizing breathing-related actions. Diuretics were administered first, lung sounds monitored, weight delegated to CNA. Patient education on medications and edema reduction was provided. All interventions were documented in the EMR.

References

[List of references as in the original article]

4.8. EVALUATION: Assessing Outcome Achievement

Evaluation, the sixth and final step and ANA Standard, is: “The registered nurse evaluates progress toward attainment of goals and outcomes.” [1] Continuous evaluation of patient status and care plan effectiveness is crucial, adapting the plan as needed. [2]

Evaluation assesses intervention effectiveness by reviewing expected outcomes and their timeframes. Nurses analyze reassessment data to determine if outcomes are met, partially met, or unmet. Unmet or partially met outcomes require care plan revision. Reassessment occurs continuously – with each patient interaction, team discussion, or review of new data. Care plans are updated as priorities shift. Evaluation results must be documented.

Ideally, interventions lead to positive patient responses and outcome achievement. If not, the care plan must be revised using these guiding questions:

• Unanticipated events?
• Patient condition changes?
• Outcomes and timeframes realistic?
• Diagnoses still accurate?
• Interventions outcome-focused?
• Implementation barriers?
• Need to revise diagnoses, outcomes, interventions, or implementation?
• Different interventions needed?

Putting It Together: Scenario C Evaluation

For Scenario C and Appendix C, the nurse evaluates Ms. J.’s progress toward outcomes.

For Fluid Volume Excess, outcomes were evaluated:

1. Decreased dyspnea in 8 hours.
2. Clear lung sounds in 24 hours.
3. Decreased edema in 24 hours.
4. Weight at baseline by discharge.

Day 1 evaluation: “Patient reports less dyspnea, lungs clear in bases. Weight down 1 kg, but 2+ edema persists.” Outcomes: “Partially Met.” Care plan revised with interventions:

1. TED hose prescription.
2. Leg elevation when sitting.

For Risk for Falls, outcome “Met“: “Patient understands and calls for assistance. No falls.”

Ongoing reassessment and care plan revisions continue throughout hospitalization. Evaluation is documented in the EMR.

References

[List of references as in the original article]

4.9. SUMMARY OF THE NURSING PROCESS: A Cycle of Care

You’ve now explored each step of the nursing process according to ANA standards. Critical thinking, clinical reasoning, and judgment are essential throughout assessment, planning, and implementation. Continuous reassessment and plan revision are vital for outcome achievement. The patient remains central throughout, with individualized, patient-centered care and outcome evaluation being key to safe, professional nursing practice.

Video Review: Sample Care Plan Creation [1]

References

[List of references as in the original article]

4.10. LEARNING ACTIVITIES: Applying the Nursing Process

Learning Activities

(Answers in the Answer Key. Interactive element answers are immediate.)

Instructions: Create a nursing care plan for Mark S. using Appendix B as a guide.

Mark S., 57, admitted for “severe” abdominal pain, needs diagnostic tests tomorrow.

News of tests causes pacing, repeated questions (“How long will tests take?”), statement “I’m so uptight I will never sleep tonight.” Avoids eye contact, fidgets, darting eyes, tense, strained expression, “My mouth is so dry.” Vital signs: T 98, P 104, R 30, BP 180/96. Skin diaphoretic, cool.

Critical Thinking Activity:

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

[Interactive H5P elements as in the original article]

IV GLOSSARY

[Glossary terms as in the original article]

References

[Glossary references as in the original article]