Chapter 4 Nursing Process (2024)

4.1. NURSING PROCESS INTRODUCTION

Learning Objectives

Use the nursing process to provide patient care
Identify nursing diagnoses from evidence-based sources
Describe the development of a care plan
Prioritize patient care
Describe documentation for each step of the nursing process
Differentiate between the role of the PN and RN

Have you ever wondered how a nurse can receive a quick handoff report from another nurse and immediately begin providing care for a patient they previously knew nothing about? How do they know what to do? How do they prioritize and make a plan?

Nurses do this activity every shift. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This chapter will explain how to use thenursing processas standards of professional nursing practice to provide safe, patient-centered care.

4.2. BASIC CONCEPTS

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning.Critical thinkingis a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”^[1^] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

Independence of thought:Thinking on your own
Fair-mindedness:Treating every viewpoint in an unbiased, unprejudiced way
Insight into egocentricity and sociocentricity:Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
Intellectual humility:Recognizing your intellectual limitations and abilities
Nonjudgmental:Using professional ethical standards and not basing your judgments on your own personal or moral standards
Integrity:Being honest and demonstrating strong moral principles
Perseverance:Persisting in doing something despite it being difficult
Confidence:Believing in yourself to complete a task or activity
Interest in exploring thoughts and feelings:Wanting to explore different ways of knowing
Curiosity:Asking “why” and wanting to know more

Clinical reasoningis 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^]To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience.^[3^]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoninginvolves noticing cues, making generalizations, and creating hypotheses.Cuesare data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. Ageneralizationis a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. Ahypothesisis a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1.^[4^]Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Figure 4.1

Inductive Reasoning Includes Looking for Cues

Example:A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoningis another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example:Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2).^[5^]The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Figure 4.2

Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgmentis the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”^[6^]The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP)is defined by the American Nurses Association (ANA) 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^]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.^[8^]The mnemonicADOPIEis an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process:Assessment,Diagnosis,Outcomes Identification,Planning,Implementation, andEvaluation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3^[9^]for an illustration of the nursing process.

Figure 4.3

The Nursing Process

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process^[10^]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

Assessment

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”^[11^]A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff.^[12^]

The “Assessment” component of the nursing process is further described in the “Assessment” section of this chapter.

Diagnosis

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”^[13^]A nursing diagnosis is the nurse’s clinical judgment about theclient'sresponse to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses.^[14^]

The “Diagnosis” component of the nursing process is further described in the “Diagnosis” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”^[15^]The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “Outcomes Identification” section of this chapter.

Planning

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”^[16^]Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care.^[17^]

The “Planning” component of the nursing process is further described in the “Planning” section of this chapter.

NURSING CARE PLANS

Creating nursing care plans is a part of the “Planning” step of the nursing process. Anursing care planis a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “Planning” and “Implementing” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.”^[18^]Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed.^[19^]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment.^[20^]

The “Implementation” component of the nursing process is further described in the “Implementation” section of this chapter.

Evaluation

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”^[21^]During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed.^[22^]

The “Evaluation” component of the nursing process is further described in the “Evaluation” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

Promotes quality patient care
Decreases omissions and duplications
Provides a guide for all staff involved to provide consistent and responsive care
Encourages collaborative management of a patient’s health care problems
Improves patient safety
Improves patient satisfaction
Identifies a patient’s goals and strategies to attain them
Increases the likelihood of achieving positive patient outcomes
Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition ofnursingas, “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^]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. Theart of nursingis defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”^[24^]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “Diverse Patients” chapter.

Caring and the Nursing Process

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.”^[25^]Successful use of the nursing process requires the development of a care relationship with the patient. Acare relationshipis a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development ofrapportand underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being.^[26^] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors.^[27^]See Figure 4.4^[28^]for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Figure 4.4

Touch as a Therapeutic Communication Technique

Review how to communicate with patients using therapeutic communication techniques like active listening in the “Communication” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment.^[29^]

References

1.: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221. ↵ [PubMed: 32569111]
2.: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221. ↵ [PubMed: 32569111]
3.: Powers, L., Pagel, J., & Herron, E. (2020). Nurse preceptors and new graduate success.American Nurse Journal, 15(7), 37-39.↵.
4.: “The Detective” bypaurianis licensed underCC BY 2.0↵.
5.: “In the Quiet Zone…” byC.O.D. Libraryis licensed underCC BY-NC-SA 2.0↵.
6.: NCSBN. (n.d.).NCSBN clinical judgment model.https://www.ncsbn.org/14798.htm↵.
7.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
8.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
9.: “The Nursing Process” by Kim Ernstmeyer atChippewa Valley Technical Collegeis licensed underCC BY 4.0↵.
10.: “Patient Image in LTC.JPG” byARISE projectis licensed underCC BY 4.0↵.
11.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
12.: American Nurses Association. (n.d.).The nursing process.https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/↵.
13.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
14.: American Nurses Association. (n.d.).The nursing process.https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/↵.
15.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
16.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
17.: American Nurses Association. (n.d.).The nursing process.https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/↵.
18.: American Nurses Association. (2021).Nursing: Scope and standards of practice(3rd ed.). American Nurses Association.↵.
19.: American Nurses Association. (n.d.)The nursing process.https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/↵.
20.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
21.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
22.: American Nurses Association. (n.d.).The nursing process.https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/↵.
23.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
24.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
25.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
26.: Walivaara B., Savenstedt S., Axelsson K. Caring relationships in home-based nursing care - registered nurses’ experiences. The Open Journal of Nursing. 2013;7:89–95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf ↵ [PMC free article: PMC3722540] [PubMed: 23894261]
27.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
28.: “hospice-1793998_1280.jpg” bytruthseeker08is licensed underCC0↵.
29.: Watson Caring Science Institute. (n.d.). Watson Caring Science Institute.Jean Watson, PHD, RN, AHN-BC, FAAN, (LL-AAN).https://www.watsoncaringscience.org/jean-bio/↵.

4.3. ASSESSMENT

Assessmentis the first step of the nursing process (and the firstStandard of Practiceset by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.”^[1^]

Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes.Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective Assessment Data

Subjective datais information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a patient, it should be in quotation marks and start with verbiage such as,The patient reports.It is vital for the nurse to establish rapport with a patient to obtain accurate, valuable subjective data regarding the mental, emotional, and spiritual aspects of their condition.

There are two types of subjective information, primary and secondary.Primary datais information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the nurse who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known assecondary data. Family members can provide important information, especially for individuals with memory impairments, infants, children, or when patients are unable to speak for themselves.

See Figure 4.5^[2^]for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Example.An example of documented subjective data obtained from a patient assessment is,“The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data

Objective datais anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. See Figure 4.6^[3^]for an image of a nurse performing a physical examination.

Figure 4.6

Physical Examination

Example.An example of documented objective data is,“The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data

There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results.

Interviewing

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient may eliminate redundancy in the interview process and allows the nurse to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the nurse should use the interview process to verify data with the patient.

After performing patient identification, the best way to initiate a caring relationship is to introduce yourself to the patient and explain your role. Share the purpose of your interview and the approximate time it will take. When beginning an interview, it may be helpful to start with questions related to the patient’smedical diagnosesto gather information about how they have affected the patient’s functioning, relationships, and lifestyle. Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important to provide safe, quality nursing care. Sometimes nursing students can feel uncomfortable having difficult conversations or asking personal questions due to generational or other cultural differences. Don’t shy away from asking about information that is important to know for safe patient care. Most patients will be grateful that you cared enough to ask and listen.

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important. To avoid making inappropriateinferences, the nurse should validate any cues. For example, a nurse may make an inference that a patient is depressed when the patient avoids making eye contact during an interview. However, upon further questioning, the nurse may discover that the patient’s cultural background believes direct eye contact to be disrespectful and this is why they are avoiding eye contact. To read more information about communicating with patients, review the “Communication” chapter of this book.

Physical Examination

Aphysical examinationis a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a patient’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid is present. Detailed physical examination procedures of various body systems can be found in the Open RNNursing Skillstextbook with a head-to-toe checklist inAppendix C. Physical examination also includes the collection and analysis of vital signs.

Registered Nurses (RNs)complete the initial physical examination and analyze the findings as part of the nursing process. Collection of follow-up physical examination data can be delegated toLicensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs), or measurements such as vital signs and weight may be delegated to trainedUnlicensed Assistive Personnel (UAP)when appropriate to do so. However, the RN remains responsible for supervising these tasks, analyzing the findings, and ensuring they are documented .

A physical examination can be performed as a comprehensive, head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the patient’sElectronic Medical Record (EMR), an electronic version of the patient’s medical chart.

Reviewing Laboratory and Diagnostic Test Results

Reviewing laboratory and diagnostic test results provides relevant and useful information related to the needs of the patient. Understanding how normal and abnormal results affect patient care is important when implementing the nursing care plan and administering provider prescriptions. If results cause concern, it is the nurse’s responsibility to notify the provider and verify the appropriateness of prescriptions based on the patient’s current status before implementing them.

Types of Assessments

Several types of nursing assessment are used in clinical practice:

Primary Survey:Used during every patient encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.
See Also
The 5-Step approach 5 Levels of Training Evaluation Community Mobilisation: The Community Action Cycle What is Community Engagement: Examples & Models | GovOS
Admission Assessment:A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach.
Ongoing Assessment:In acute care agencies such as hospitals, a head-to-toe assessment is completed and documented at least once every shift. Any changes in patient condition are reported to the health care provider.
Focused Assessment:Focused assessments are used to reevaluate the status of a previously diagnosed problem.
Time-lapsed Reassessment:Time-lapsed reassessments are used in long-term care facilities when three or more months have elapsed since the previous assessment to evaluate progress on previously identified outcomes.^[4^]

Putting It Together

Review Scenario C in the following box to apply concepts of assessment to a patient scenario.

Scenario C^[5]

Ms. J. is a 74-year-old woman who is admitted directly to the medical unit after visiting her physician because of shortness of breath, increased swelling in her ankles and calves, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). She takes 81 mg of aspirin every day, metoprolol 50 mg twice a day, furosemide 40 mg every day, and metformin 2,000 mg every day.

Ms. J.’s vital sign values on admission were as follows:

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 degrees F orally

Her weight is up 10 pounds since the last office visit three weeks prior. The patient states, “I am so short of breath” and “My ankles are so swollen I have to wear my house slippers.” Ms. J. 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.”

The physical assessment findings of Ms. J. are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet. Laboratory results indicate a decreased serum potassium level of 3.4 mEq/L.

As the nurse completes the physical assessment, the patient’s daughter enters the room. She 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 subjective data.
2.: Identify objective data.
3.: Provide an example of secondary data.

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

References

1.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
2.: "361341143-huge.jpg”byMonkey Business Imagesis used under license fromShutterstock.com↵.
3.: “13394660711603.jpg” by CDC/ Amanda Mills is in thePublic Domain↵.
4.: Gordon, M. (2008).Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company.↵.
5.: “grandmother-1546855_960_720.jpg” byvendie4uis licensed underCC0↵.

4.4. DIAGNOSIS

Diagnosisis the second step of the nursing process (and the second Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan.^[1^]

Analyzing Assessment Data

After collection of assessment data, the registered nurse analyzes the data to form generalizations and create hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering of information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and drive the nursing care plan.^[2^]

Performing Data Analysis

After nurses collect assessment data from a patient, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that patient according to their age, development, and baseline status. From there, nurses determine what data are “clinically relevant” as they prioritize their nursing care.^[3^]

Example.In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this patient. These findings are considered “relevant cues.”

Clustering Information/Seeing Patterns/Making Hypotheses

After analyzing the data and determining relevant cues, the nurseclustersdata into patterns. Assessment frameworks such as Gordon’sFunctional Health Patternsassist nurses in clustering information according to evidence-based patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns.^[4^]Concepts related to many of these patterns will be discussed in chapters later in this book.

Example.Refer to Scenario C of the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, a medical history of heart failure, and currently prescribed a diuretic medication. These cues are clustered into a generalization/pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse makes a hypothesis that the patient has excess fluid volume present.

Gordon’s Functional Health Patterns^[5^]

Health Perception-Health Management:A patient’s perception of their health and well-being and how it is managed

Nutritional-Metabolic:Food and fluid consumption relative to metabolic need

Elimination:Excretory function, including bowel, bladder, and skin

Activity-Exercise:Exercise and daily activities

Sleep-Rest:Sleep, rest, and daily activities

Cognitive-Perceptual:Perception and cognition

Self-perception and Self-concept:Self-concept and perception of self-worth, self-competency, body image, and mood state

Role-Relationship:Role engagements and relationships

Sexuality-Reproductive:Reproduction and satisfaction or dissatisfaction with sexuality

Coping-StressTolerance:Coping and effectiveness in terms of stress tolerance

Value-Belief:Values, beliefs (including spiritual beliefs), and goals that guide choices and decisions

Identifying Nursing Diagnoses

After the nurse has analyzed and clustered the data from the patient assessment, the next step is to begin to answer the question, “What are my patient’s human responses (i.e., nursing diagnoses)?” Anursing diagnosisis 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^]Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis.

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings.^[7^]Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence. A list of commonly used NANDA-I diagnoses are listed inAppendix A. For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.

NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and 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.

Knowledge regarding specific NANDA-I nursing diagnoses is not assessed on the NCLEX. However, analyzing cues and creating hypotheses are part of the measurement model used to assess a candidate’s clinical judgment. Read more about the NCLEX and Next Generation NCLEX in the “Scope of Practice” chapter.

Nursing Diagnoses vs. Medical Diagnoses

You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on thehuman responseto health conditions and life processes and are made independently by RNs. Patients with the same medical diagnosis will oftenresponddifferently to that diagnosis and thus have different nursing diagnoses. For example, two patients have the same medical diagnosis of heart failure. However, one patient may be interested in learning more information about the condition and the medications used to treat it, whereas another patient may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each patient.

Example.A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will be related to the patient’s response to heart failure.

Additional Definitions Used in NANDA-I Nursing Diagnoses

The following definitions of patient, age, and time are used in association with NANDA-I nursing diagnoses:

Patient

The NANDA-I definition of a “patient” includes:

Individual:a single human being distinct from others (i.e., a person).
Caregiver:a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
Family:two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
Group:a number of people with shared characteristics generally referred to as an ethnic group.
Community:a group of people living in the same locale under the same governance. Examples include neighborhoods and cities.^[8^]

Age

The age of the person who is the subject of the diagnosis is defined by the following terms:^[9^]

Fetus:an unborn human more than eight weeks after conception, until birth.
Neonate:a person less than 28 days of age.
Infant:a person greater than 28 days and less than 1 year of age.
Child:a person aged 1 to 9 years
Adolescent:a person aged 10 to 19 years
Adult:a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
Older adult:a person greater than 65 years of age.

Time

The duration of the diagnosis is defined by the following terms:^[10^]

Acute:lasting less than 3 months.
Chronic:lasting greater than 3 months.
Intermittent:stopping or starting again at intervals
Continuous:uninterrupted, going on without stop.

New Terms Used in 2018-2020 NANDA-I Diagnoses

The 2018-2020 edition ofNursing Diagnosesincludes two new terms to assist in creating nursing diagnoses: at-risk populations and associated conditions.^[11^]

At-Risk Populationsare 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, stages of growth/development, or exposure to certain events/experiences.

Associated Conditionsare medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis^[12^]

Types of Nursing Diagnoses

There are four types of NANDA-I nursing diagnoses:^[13^]

Problem-Focused
Health Promotion – Wellness
Risk
Syndrome

Aproblem-focused nursing diagnosisis a “clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.”^[14^]To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present.Related factors(also called etiology) are causes that contribute to the diagnosis.Defining characteristicsare cues, signs, and symptoms that cluster into patterns.^[15^]

Ahealth promotion-wellness nursing diagnosisis “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient’s readiness to enhance specific health behaviors.^[16^]A health promotion-wellness diagnosis is used when the patient is willing to improve a lack of knowledge, coping, or other identified need.

Arisk nursing diagnosisis “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.”^[17^]A risk nursing diagnosis must be supported by risk factors that contribute to the increased vulnerability. A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. Problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a patient.^[18^]

Asyndrome diagnosisis a “clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.”^[19^]

Establishing Nursing Diagnosis Statements

When using NANDA-I nursing diagnoses, NANDA-I recommends the structure of a nursing diagnosis should be a statement that includes thenursing diagnosisandrelated factorsas exhibited bydefining characteristics. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the patient’s assessment.^[20^]

To create a nursing diagnosis statement, the registered nurse completes the following steps. After analyzing the patient’s subjective and objective data and clustering the data into patterns, the nurse generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis.Defining characteristicsis the terminology used for observable signs and symptoms related to a nursing diagnosis.^[21^]Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis. For example, objective and subjective data such as weight, height, and dietary intake can be clustered together as defining characteristics for the nursing diagnosis of nutritional status.

When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient.Related factorsis the terminology used for the underlying causes (etiology) of a patient’s problem or situation. Related factors should not be a medical diagnosis, but instead should be attributed to the underlying pathophysiology that the nurse can treat. When possible, the nursing interventions planned for each nursing diagnosis should attempt to modify or remove these related factors that are the underlying cause of the nursing diagnosis.^[22^]

Creating nursing diagnosis statements has traditionally been referred to as “using PES format.” ThePESmnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:

Problem (P)– the patientproblem (i.e., the nursing diagnosis)

Etiology (E)– related factors (i.e., theetiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”

Signs and Symptoms (S)– defining characteristics manifested by the patient (i.e., thesigns andsymptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the patient; phrased with “as manifested by” or “as evidenced by.”

Examples of different types of nursing diagnoses are further explained below.

Problem-Focused Nursing Diagnosis

A problem-focused nursing diagnosis contains all three components of thePES format:

Problem (P)– statement of the patient response (nursing diagnosis)

Etiology (E)– related factors contributing to the nursing diagnosis

Signs and Symptoms (S)– defining characteristics manifested by that patient

SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT

Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing DiagnosisExcess Fluid Volume. The NANDA-I definition ofExcess Fluid Volumeis “surplus intake and/or retention of fluid.” The related factor (etiology) of the problem is that the patient has excessive fluid intake.^[23^]

Example

The components of aproblem-focused nursing diagnosisstatement for Ms. J. would be:

P.

Fluid Volume Excess

E.

Related to excessive fluid intake

S.: As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

A correctly written problem-focused nursing diagnosis statement for Ms. J. would look like this:

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

A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance”:^[24^]

Problem (P)– statement of the patient response (nursing diagnosis)

Signs and Symptoms (S)– the patient’s expressed desire to enhance

SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she 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 nursing diagnosisReadiness for Enhanced Health Management, which is defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.”^[25^]

Example

The components of ahealth-promotion nursing diagnosisfor Ms. J. would be:

Problem (P):Readiness for Enhanced Health Management

Symptoms (S):Expressed desire to “learn more about my health so I can take better care of myself.”

A correctly written health-promotion nursing diagnosis statement for Ms. J. would look like this:

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

A risk nursing diagnosis should be supported by evidence of the patient’s risk factors for developing that problem. Different experts recommend different phrasing. NANDA-I 2018-2020 recommends using the phrase “as evidenced by” to refer to the risk factors for developing that problem.^[26^]

A risk diagnosis consists of the following:

Problem (P)– statement of the patient response (nursing diagnosis)

As Evidenced By– Risk factors for developing the problem

SAMPLE RISK DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to vulnerability from the dizziness and weakness she is experiencing. The NANDA-I definition ofRisk for Fallsis “increased susceptibility to falling, which may cause physical harm and compromise health.”^[27^]

Example

The components of arisk diagnosisstatement for Ms. J. would be:

Problem (P)– Risk for Falls

As Evidenced By– Dizziness and decreased lower extremity strength

A correctly written risk nursing diagnosis statement for Ms. J. would look like this:

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

Syndrome Diagnosis

A syndrome is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition, but are not required.^[28^]

A syndrome statement consists of these items:

Problem (P)– the syndrome

Signs and Symptoms (S)– the defining characteristics are two or more similar nursing diagnoses

SAMPLE SYNDROME DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses that can be categorized as asyndrome. For example,Activity Intoleranceis defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.”Social Isolationis defined as “aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.” These diagnoses can be included under the the NANDA-I syndrome namedRisk for Frail Elderly Syndrome.This syndrome isdefined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.”^[29^]

Example

The components of asyndrome nursing diagnosisfor Ms. J. would be:

P.

– Risk for Frail Elderly Syndrome

S.: – The nursing diagnoses ofActivity IntoleranceandSocial Isolation

Additional related factor: Fear of falling

A correctly written syndrome diagnosis statement for Ms. J. would look like this:

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

Prioritization

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the patient. Nurses prioritize their actions while providing patient care multiple times every day.Prioritizationis the process that identifies the most significant nursing problems, as well as the most important interventions, in the nursing care plan.

It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. In critical situations, the steps of the nursing process are performed through rapid clinical judgment. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most patient situations fall somewhere between a crisis and routine care.

There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7^[30]onThe How To of Prioritization.

Figure 4.7

The How To of Prioritization

Maslow’s Hierarchy of Needsis used to categorize the most urgent patient needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8^[31]for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.

Figure 4.8

Maslow’s Hierarchy of Needs

In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the patient’s condition is an acute or chronic problem. Acute, uncompensated conditions generally require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the patient vulnerability and risk factors.

Example.Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.:Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls, andRisk for Frail Elderly Syndrome. The top priority diagnosis isFluid Volume Excessbecause it affects the physiological needs of breathing, homeostasis, and excretion. However, theRisk for Fallsdiagnosis comes in a close second because of safety implications and potential injury that could occur if the patient fell.

References

1.

American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵

4.5. OUTCOME IDENTIFICATION

Outcome Identificationis the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment.^[1^]

Anoutcomeis a “measurable behavior demonstrated by the patient responsive to nursing interventions.”^[2^]Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient.

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

Short-Term and Long-Term Goals

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.

The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals.Goalsare broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months.

A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.

Example.Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis ofFluid Volume Excess.A broad goal would be, “Ms. J. will achieve a state of fluid balance.”

Expected Outcomes

Goals are broad, general statements, but outcomes are specific and measurable.Expected outcomesare statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses.^[3^]

Patient-Centered

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic:^[4^]

Specific
Measurable
Attainable/Action oriented
Relevant/Realistic
Timeframe

See Figure 4.9^[5^]for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections.

Figure 4.9

SMART Components of Outcome Statements

Specific

Outcome statements should state precisely what is to be accomplished. See the following examples:

Not specific:“The patient will increase the amount of exercise.”
Specific:“The patient will participate in a bicycling exercise session daily for 30 minutes.”

Additionally, only one action should be included in each expected outcome. See the following examples:

“The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge”is actually two goals written as one. The outcome of ambulation should be separate from showering for precise evaluation. For instance, the patient could shower but not ambulate, which would make this outcome statement very difficult to effectively evaluate.
Suggested revision is to create two outcomes statements so each can be measured:The patient will walk 50 feet three times a day with standby assistance of one until discharge. The patient will shower every morning until discharge.

Measurable

Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained. Refer to Figure 4.10^[6^]for examples of verbs that are measurable and not measurable in outcome statements.

Figure 4.10

Measurable Outcomes

See the following examples:

Not measurable:“The patient will drink adequate fluid amounts every shift.”
Measurable:“The patient will drink 24 ounces of fluids during every day shift (0600-1400).”

Action-Oriented and Attainable

Outcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb. Refer to Figure 4.11^[7^]for examples of action verbs.

Figure 4.11

Action Verbs

See the following examples:

Not action-oriented:“The patient will get increased physical activity.”
Action-oriented:“The patient will list three types of aerobic activity that he would enjoy completing every week.”

Realistic and Relevant

Realistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient.

See the following examples:

Not realistic:“The patient will jog one mile every day when starting the exercise program.”
Realistic:“The patient will walk ½ mile three times a week for two weeks.”

Time Limited

Outcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised.

See the following examples:

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

Putting It Together

In Scenario C in Box 4.3, Ms. J.’s priority nursing diagnosis statement wasFluid Volume Excessrelated 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.”An example of an expected outcome meeting SMART criteria for Ms. J. is,“The patient will have clear bilateral lung sounds within the next 24 hours.”

References

1.: American Nurses Association. (2021).Nursing:Scope and standards of practice(4th ed.). American Nurses Association.↵.
2.: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).Nursing diagnoses: Definitions and classification, 2018-2020.Thieme Publishers New York.↵.
3.: Johnson, M., Moorhead, S., Bulechek, G., Butcher, H., Maas, M., & Swanson, E. (2012).NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care.Elsevier.↵.
4.: Campbell, J. (2020). SMART criteria.Salem Press Encyclopedia.↵.
5.: “SMART-goals.png” byDungdm93is licensed underCC BY-SA 4.0↵.
6.: “Measurable Outcomes” by Valerie Palarski forChippewa Valley Technical Collegeis licensed underCC BY 4.0↵.
7.: “Action Verbs” by Valerie Palarski forChippewa Valley Technical Collegeis licensed underCC BY 4.0↵.

4.6. PLANNING

Planningis the fourth step of the nursing process (and the fourth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team. Elements of the plan are prioritized. The plan is modified according to the ongoing assessment of the health care consumer’s response and other indicators. The plan is documented using standardized language or terminology.^[1^]

After expected outcomes are identified, the nurse begins planning nursing interventions to implement.Nursing interventionsare evidence-based actions that the nurse performs to achieve patient outcomes. Just as a provider makes medical diagnoses and writes prescriptions to improve the patient’s medical condition, a nurse formulates nursing diagnoses and plans nursing interventions to resolve patient problems. Nursing interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible.^[2^]Nursing interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

Planning Nursing Interventions

You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan?” There are several sources that nurses and nursing students can use to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Nurses can also refer to other care planning books our sources such as the Nursing Interventions Classification (NIC) system. Based on research and input from the nursing profession, NIC categorizes and describes nursing interventions that are constantly evaluated and updated. Interventions included in NIC are considered evidence-based nursing practices. The nurse is responsible for using clinical judgment to make decisions about which interventions are best suited to meet an individualized patient’s needs.^[3^]

Direct and Indirect Care

Nursing interventions are considered direct care or indirect care.Direct carerefers to interventions that are carried out by having personal contact with patients. Examples of direct care interventions are wound care, repositioning, and ambulation.Indirect careinterventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.

Classification of Nursing Interventions

There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12^[4^]for an image of a nurse collaborating with the health care team when planning interventions.)

Figure 4.12

Collaborative Nursing Interventions

Independent Nursing Interventions

Any intervention that the nurse can independently provide without obtaining a prescription is considered anindependent nursing intervention. An example of an independent nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

Example.Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed withFluid Volume Excess. An example of an evidence-based independent nursing intervention is,“The nurse will reposition the patient with dependent edema frequently, as appropriate.”^[5^]The nurse would individualize this evidence-based intervention to the patient and agency policy by stating,“The nurse will reposition the patient every 2 hours.”

Dependent Nursing Interventions

Dependent nursing interventionsrequire a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider.^[6^]Aprimary health care provideris a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

Example.Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed withFluid Volume Excess. An example of a dependent nursing intervention is,“The nurse will administer scheduled diuretics as prescribed.”

Collaborative Nursing Interventions

Collaborative nursing interventionsare actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint.^[7^]

Example.Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed withFluid Volume Excess. An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels. The respiratory therapist plans oxygen therapy and obtains a prescription from the provider. The nurse would document “The nurse will manage oxygen therapy in collaboration with the respiratory therapist” in the care plan.

Individualization of Interventions

It is vital for the planned interventions to be individualized to the patient to be successful. For example, adding prune juice to the breakfast meal of a patient with constipation will only work if the patient likes to drink the prune juice. If the patient does not like prune juice, then this intervention should not be included in the care plan. Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective interventions. The number of interventions included in a nursing care plan is not a hard and fast rule, but enough quality, individualized interventions should be planned to meet the identified outcomes for that patient.

Creating Nursing Care Plans

Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans are legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. CMS guidelines state, “Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best and patient representatives can be present, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision-making. A resident has the right to select or refuse specific treatment options before the care plan is instituted.”^[8^]The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care.^[9^]

Many facilities have established standardized nursing care plans with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient. See Figure 4.13^[10^]for an image of a standardized care plan.

Figure 4.13

Standardized Care Plan

Nursing care plans created in nursing school can also be in various formats such as concept maps or tables. Some are fun and creative, while others are more formal.Appendix Bcontains a template that can be used for creating nursing care plans.

References

1.: American Nurses Association. (2021).Nursing:Scope and standards of practice(4th ed.). American Nurses Association.↵.
2.: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.↵.
3.: Butcher, H. K., Bulechek, G. M., Dochterman, J. M., & Wagner, C. M. (2018).Nursing interventions classifications (NIC)(7th ed.). Elsevier.↵.
4.: "400845937-huge.jpg" byFlamingo Imagesis used under license fromShutterstock.com↵.
5.: Butcher, H. K., Bulechek, G. M., Dochterman, J. M., & Wagner, C. M. (2018).Nursing interventions classifications (NIC)(7th ed.). Elsevier.↵.
6.: NCSBN. (n.d.).2019 NCLEX-RN test plan.https://www.ncsbn.org/2019_RN_TestPlan-English.htm↵.
7.: Vera, M. (2020).Nursing care plan (NCP): Ultimate guide and database.https://nurseslabs.com/nursing-care-plans/#:~:text=Collaborative%20interventions%20are%20actions%20that,to%20gain%20their%20professional%20viewpoint.↵.
8.: Centers for Medicare and Medicaid Services. (2017).State operations manual: Appendix PP - Guidance to surveyors for long term care facilities.https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf↵.
9.: The Joint Commission (n.d.).Standards and guides pertinent to nursing practice.https://www.jointcommission.org/resources/for-nurses/nursing-resources/↵.
10.: "Figure 3-3. An example of a nursing care plan in an Australian residential aged care home..png" byNurseRecordis licensed underCC BY-SA 4.0↵.

4.7. IMPLEMENTATION OF INTERVENTIONS

Implementationis the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circ*mstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy.^[1^]

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “Diagnosis” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states,“The nurse will ambulate the patient 100 feet three times daily.”However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient.^[2^]

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titledTo Err Is Human: Building a Safer Health System. The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors.To Err Is Humanbroke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system.^[3^]In 2007 the IOM published a follow-up report titledPreventing Medication Errorsand reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety.^[4^]

Read additional information about specific actions that nurses can take to prevent medication errors; go to the “Preventing Medication Errors” section of the “Legal/Ethical”chapter of the Open RNNursing Pharmacologytextbook.

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care.^[5^]

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is 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 participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps.Quality improvementis 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^]

Delegation of Interventions

While implementing interventions, RNs may elect to delegate nursing tasks.Delegationis defined by the American Nurses Association as, “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.”^[8^]RNs are accountable for determining the appropriateness of the delegated task according to condition of the patient and the circ*mstance; the communication provided to an appropriately trained LPN or UAP; the level of supervision provided; and the evaluation and documentation of the task completed. The RN must also be aware of the state Nurse Practice Act, federal regulations, and agency policy before delegating. The RN cannot delegate responsibilities requiring clinical judgment.^[9^]See the following box for information regarding legal requirements associated with delegation according to the Wisconsin Nurse Practice Act.

Delegation According to the Wisconsin Nurse Practice Act

During the supervision and direction of delegated acts a Registered Nurse shall do all of the following:

a.: Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.
b.: Provide direction and assistance to those supervised.
c.: Observe and monitor the activities of those supervised.
d.: Evaluate the effectiveness of acts performed under supervision.^[10^]

The standard of practice for Licensed Practical Nurses in Wisconsin states, “In the performance of acts in basic patient situations, the LPN. shall, under the general supervision of an RN or the direction of a provider:

a.

Accept only patient care assignments which the LPN is competent to perform.

b.

Provide basic nursing care. Basic nursing care is defined as 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.

c.

Record nursing care given and report to the appropriate person changes in the condition of a patient.

d.

Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

e.

Perform the following other acts when applicable:

1.: Assist with the collection of data.
2.: Assist with the development and revision of a nursing care plan.
3.: Reinforce the teaching provided by an RN provider and provide basic health care instruction.
4.: Participate with other health team members in meeting basic patient needs.”^[11^]

Read additional details about the scope of practice of registered nurses (RNs) and licensed practical nurses (LPNs) in Wisconsin’s Nurse Practice Act inChapter N 6 Standards of Practice.

Read more about the American Nurses Association’sPrinciples of Delegation.

Table 4.7 outlines general guidelines for delegating nursing tasks in the state of Wisconsin according to the role of the health care team member.

Table 4.7

General Guidelines for Delegating Nursing Tasks

Documentation of Interventions

As interventions are performed, they must be documented in the patient’s record in a timely manner. As previously discussed in the “Ethical and Legal Issues” subsection of the “Basic Concepts” section, lack of documentation is considered a failure to communicate and a basis for legal action. A basic rule of thumb is if an intervention is not documented, it is considered not done in a court of law. It is also important to document administration of medication and other interventions in a timely manner to prevent errors that can occur due to delayed documentation time.

Coordination of Care and Health Teaching/Health Promotion

ANA’s Standard of Professional Practice for Implementation also includes the standards5ACoordination of Careand5BHealth Teaching and Health Promotion.^[12^]Coordination of Careincludes competencies such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team.Health Teaching and Health Promotionis defined as, “Employing strategies to teach and promote health and wellness.”^[13^]Patient education is an important component of nursing care and should be included during every patient encounter. For example, patient education may include teaching about side effects while administering medications or teaching patients how to self-manage their conditions at home.

Putting It Together

Refer to Scenario C in the “Assessment” section of this chapter. The nurse implemented the nursing care plan documented in Appendix C. Interventions related to breathing were prioritized. Administration of the diuretic medication was completed first, and lung sounds were monitored frequently for the remainder of the shift. Weighing the patient before breakfast was delegated to the CNA. The patient was educated about her medications and methods to use to reduce peripheral edema at home. All interventions were documented in the electronic medical record (EMR).

References

1.: American Nurses Association. (2021).Nursing:Scope and standards of practice(4th ed.). American Nurses Association.↵.
2.: Robert Wood Johnson Foundation. (2011, April 28).Nurses are key to improving patient safety.https://www.rwjf.org/en/library/articles-and-news/2011/04/nurses-are-key-to-improving-patient-safety.html↵.
3.: Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000).To err is human: Building a safer health system. National Academies Press.https://pubmed.ncbi.nlm.nih.gov/25077248/↵. [PubMed: 25077248]
4.: Institute of Medicine. (2007).Preventing medication errors. National Academies Press. 10.17226/11623.↵. [CrossRef]
5.: Robert Wood Johnson Foundation. (2011, April 28).Nurses are key to improving patient safety.https://www.rwjf.org/en/library/articles-and-news/2011/04/nurses-are-key-to-improving-patient-safety.html↵.
6.: QSEN Institute. (n.d.).Project overview: The evolution of the quality and safety education for nurses (QSEN) initiative.http://qsen.org/about-qsen/project-overview/↵.
7.: Batalden P. B., Davidoff F. What is "quality improvement" and how can it transform healthcare?. BMJ Quality & Safety. 2007;16(1):2–3. ↵ [PMC free article: PMC2464920] [PubMed: 17301192] [CrossRef]
8.: American Nurses Association. (2013).ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). American Nurses Association.https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf↵.
9.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
10.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
11.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
12.: American Nurses Association. (2021).Nursing: Scope and standards of practice (4thed.). American Nurses Association.↵.
13.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.

4.8. EVALUATION

Evaluationis the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is definedas, “The registered nurse evaluates progress toward attainment of goals and outcomes.”^[1^]Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed.^[2^]

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

Did anything unanticipated occur?
Has the patient’s condition changed?
Were the expected outcomes and their time frames realistic?
Are the nursing diagnoses accurate for this patient at this time?
Are the planned interventions appropriately focused on supporting outcome attainment?
What barriers were experienced as interventions were implemented?
Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
Are different interventions required?

Putting It Together

Refer to Scenario C in the “Assessment” section of this chapter and Appendix C. The nurse evaluates the patient’s progress toward achieving the expected outcomes.

For the nursing diagnosisFluid Volume Excess, the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:

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.

Evaluation of the patient condition on Day 1 included the following 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 data, the nurse evaluated the expected outcomes as “Partially Met” and revised the care plan with two new interventions:

1.: Request prescription for TED hose from provider.
2.: Elevate patient’s legs when sitting in chair.

For the second nursing diagnosis,Risk for Falls, the nurse evaluated the outcome criteria as “Met” based on the evaluation, “The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred.”

The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record.

References

1.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
2.: American Nurses Association. (n.d.)The nursing process.https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/↵.

4.9. SUMMARY OF THE NURSING PROCESS

You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.

Video Review of Creating a Sample Care Plan^[1^]

References

1.: RegisteredNurseRN. (2015, June11).Nursing care plantutorial| How to complete a care plan in nursing school. [Video]. YouTube. All rights reserved. Video used with permission.https//youtu.be/07Z4ywfmLg8↵.

4.10. LEARNING ACTIVITIES

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 inAppendix Bas a guide.

The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests. The tests are scheduled for the morning.

After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The patient also remarked, “I’m so uptight I will never be able to sleep tonight.” The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states, “My mouth is so dry.” The nurse observes his vital signs to be: T 98, P 104, R 30, BP 180/96. The nurse notes that his skin feels sweaty (diaphoretic) and cool to the touch.

Critical Thinking Activity:

1.: Group (cluster) the subjective and objective data.
2.: Create a problem-focused nursing diagnosis (hypothesis).
3.: Develop a broad goal and then identify an expected outcome in “SMART” format.
4.: Outline three interventions for the nursing diagnosis to meet the goal. Cite an evidence-based source.
5.: Imagine that you implemented the interventions that you identified. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met.

IV GLOSSARY

Advocacy

The act or process of pleading for, supporting, or recommending a cause or course of action.^[1^]

Art of nursing

Unconditionally acceptance of the humanity of others, respecting their need for 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, stages of growth/development, or exposure to certain events/experiences.^[3^]

Associated conditions

Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions 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 described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family.^[6^]

Client

Individual, family, or group, which includes significant others and populations.^[7^]

Clinical judgment

The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.^[8^]

Clinical reasoning

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.^[9^]

Clustering data

Grouping data into similar domains or patterns.

Collaborative nursing interventions

Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP).

Coordination of care

While implementing interventions during the nursing process, includes components such as organizing the components of the plan with input from the health care consumer, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team.^[10^]

Critical thinking

Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.^[11^]

Cue

Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

Deductive reasoning

“Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

Defining characteristics

Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled.^[12^]

Delegation

The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome.^[13^]

Dependent nursing interventions

Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant.

Direct care

Interventions that are carried out by having personal contact with a patient.

Electronic Medical Record (EMR)

An electronic version of the patient’s medical record.

Evidence-Based Practice (EBP)

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.^[14^]

Expected outcomes

Statements of measurable action for the patient within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame.

Functional health patterns

An evidence-based assessment framework for identifying patient problems and risks during the assessment phase of the nursing process.

Generalization

A judgment formed from a set of facts, cues, and observations.

Goals

Broad statements of purpose that describe the aim of nursing care.

Health teaching and health promotion

Employing strategies to teach and promote health and wellness.^[15^]

Independent nursing interventions

Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else.

Indirect care

Interventions performed by the nurse in a setting other than directly with the patient. An example of indirect care is creating a nursing care plan.

Inductive reasoning

A type of reasoning that involves forming generalizations based on specific incidents.

Inference

Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations.

Licensed Practical Nurses or Licensed Vocational Nurses (LPNs/LVNs)

Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act.

Medical diagnosis

A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual.

Nursing

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.^[16^]

Nursing care plan

Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission.

Nursing process

A systematic approach to patient-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.”

Objective data

Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data.

Outcome

A measurable behavior demonstrated by the patient that is responsive to nursing interventions.^[17^]

PES Statement

The format of a nursing diagnosis statement that includes:

Problem (P) – statement of the patient problem (i.e., the nursing diagnosis)

Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis

Signs and Symptoms (S) – defining characteristics manifested by the patient of that nursing diagnosis

Prescription

Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider.^[18^]

Primary data

Information collected from the patient.

Primary health care provider

Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client.^[19^]

Prioritization

The skillful process of deciding which actions to complete first, second, or third for optimal patient outcomes and to improve patient safety.

Quality improvement

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).”^[20^]

Rapport

Developing a relationship of mutual trust and understanding.

Registered Nurse (RN)

A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing.

Related factors

The underlying cause (etiology) of a nursing diagnosis when creating a PES statement.

Right to self-determination

Patients have the right to determine what will be done with and to their own person.

Scientific method

Principles and procedures in the discovery of knowledge involving the recognition and formulation of a problem, the collection of data, and the formulation and testing of a hypothesis.

Secondary data

Information collected from sources other than the patient.

Subjective data

Data that the patient or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as“The patient appears anxious.”

Unlicensed Assistive Personnel (UAP)

Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated.^[21^]

References

1.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
2.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
3.: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.↵.
4.: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).Nursing diagnoses: Definitions and classification, 2018-2020.Thieme Publishers New York.↵.
5.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
6.: Walivaara B., Savenstedt S., Axelsson K. Caring relationships in home-based nursing care - registered nurses’ experiences. The Open Journal of Nursing. 2013;7:89–95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf ↵ [PMC free article: PMC3722540] [PubMed: 23894261]
7.: NCSBN. (n.d.). 2019NCLEX-RN test plan.https://www.ncsbn.org/2019_RN_TestPlan-English.htm↵.
8.: NCSBN. (n.d.).NCSBN clinical judgment model.https://www.ncsbn.org/14798.htm↵.
9.: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221. ↵ [PubMed: 32569111]
10.: American Nurses Association. (2021).Nursing: Scope and standards of practice(3rd ed.). American Nurses Association.↵.
11.: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221. ↵ [PubMed: 32569111]
12.: NANDA International. (n.d.).Glossary of terms.https://nanda.org/nanda-i-resources/glossary-of-terms/↵.
13.: American Nurses Association. (2013).ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). American Nurses Association.https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf↵.
14.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
15.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
16.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
17.: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).Nursing diagnoses: Definitions and classification, 2018-2020.Thieme Publishers New York.↵.
18.: NCSBN. (n.d.).2019 NCLEX-RN test plan.https://www.ncsbn.org/2019_RN_TestPlan-English.htm↵.
19.: NCSBN. (n.d.).2019 NCLEX-RN test plan.https://www.ncsbn.org/2019_RN_TestPlan-English.htm↵.
20.: Batalden P. B., Davidoff F. What is "quality improvement" and how can it transform healthcare?. BMJ Quality & Safety. 2007;16(1):2–3. ↵ [PMC free article: PMC2464920] [PubMed: 17301192] [CrossRef]
21.: NCSBN. (n.d.).2019 NCLEX-RN test plan.https://www.ncsbn.org/2019_RN_TestPlan-English.htm↵.

Figure 4.5

Obtaining Subjective Data in a Care Relationship

Chapter 4 Nursing Process (2024)

4.1. NURSING PROCESS INTRODUCTION

Learning Objectives

4.2. BASIC CONCEPTS

Critical Thinking and Clinical Reasoning

Inductive and Deductive Reasoning and Clinical Judgment

Nursing Process

Patient Scenario A: Using the Nursing Process[10]

Assessment

Diagnosis

Outcomes Identification

Planning

NURSING CARE PLANS

Implementation

Evaluation

Benefits of Using the Nursing Process

Holistic Nursing Care

Holistic Nursing Care Scenario

Review how to provide culturally responsive care and reduce health disparities in the “Diverse Patients” chapter.

Caring and the Nursing Process

Review how to communicate with patients using therapeutic communication techniques like active listening in the “Communication” chapter.

Read more about Dr. Watson’s theory of caring at theWatson Caring Science Institute.

References

4.3. ASSESSMENT

Subjective Assessment Data

See Figure 4.5[2]for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Objective Assessment Data

Sources of Assessment Data

Interviewing

Physical Examination

Reviewing Laboratory and Diagnostic Test Results

Types of Assessments

Putting It Together

Scenario C[5]

References

4.4. DIAGNOSIS

Analyzing Assessment Data

Performing Data Analysis

Clustering Information/Seeing Patterns/Making Hypotheses

Gordon’s Functional Health Patterns[5]

Identifying Nursing Diagnoses

Nursing Diagnoses vs. Medical Diagnoses

Additional Definitions Used in NANDA-I Nursing Diagnoses

New Terms Used in 2018-2020 NANDA-I Diagnoses

Types of Nursing Diagnoses

Establishing Nursing Diagnosis Statements

Problem-Focused Nursing Diagnosis

SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT

Health-Promotion Nursing Diagnosis

SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT

Risk Nursing Diagnosis

SAMPLE RISK DIAGNOSIS STATEMENT

Syndrome Diagnosis

SAMPLE SYNDROME DIAGNOSIS STATEMENT

Prioritization

References

4.5. OUTCOME IDENTIFICATION

Short-Term and Long-Term Goals

Expected Outcomes

Patient-Centered

Specific

Measurable

Action-Oriented and Attainable

Realistic and Relevant

Time Limited

Putting It Together

References

4.6. PLANNING

Planning Nursing Interventions

Direct and Indirect Care

Classification of Nursing Interventions

Independent Nursing Interventions

Dependent Nursing Interventions

Collaborative Nursing Interventions

Individualization of Interventions

Creating Nursing Care Plans

References

4.7. IMPLEMENTATION OF INTERVENTIONS

Prioritizing Implementation of Interventions

Patient Safety

Patient Scenario A: Using the Nursing Process^[10^]

See Figure 4.5^[2^]for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Scenario C^[5]

Gordon’s Functional Health Patterns^[5^]

Video Review of Creating a Sample Care Plan^[1^]