N

URSING
PROCESS
BAUTISTA, Yhna
DUYAG, Hannah Shemaine
ENRIQUEZ, Shar
ILAW, Ma. Mikaela
REYES, Miguel
YANGA, Harriet Ann
BSN BLK 1-7

NURSING AS A SCIENCE

A. NURSING PROCESS
1. Introduction to Nursing Process
 The nursing process is defined as, “a systematic, rational method of planning
and providing individualized nursing care.” It is described as systematic for
the phases are approached in a fixed and organized manner. Each phase in the
nursing process has a process on its own, and every process within the phases
is done with scientific methods, and has a rationale behind it.

The term nursing process originated from the nurse theorist, Lydia Hall in
1955, and other nurse theorists namely, Johnson (1959), Orlando (1961) and
Wiedenbach (1963), were the first ones to make use of the term to refer to a
series of phases describing the nursing practice.

In 1973, the use of nursing process gained additional legitimacy when it was
included in the American Nurses Association (ANA).

The purpose of the nursing process is it clearly defines the client’s health
status, address their actual or potential problem, and have an establishment of
plans, deliver specific nursing interventions, provides consistency of care and
quality patient care through deliberate actions.

a. Components
The nursing process is composing of 5 phases, and each phase interrelates
with all the others.

The phases are described as interrelated for it is connected in a way to the

succeeding phases which are also dependent to the phases that precedes them.
The assessment for example being the initial phase can still be utilized in the
implementing and evaluating phases. Being closely interrelated to each other,
 if during the assessment phase, inadequate data were acquired, the succeeding
phases will be affected.

Assessment

Evaluation Diagnosis

Implement-
Planning
ation

b. Benefits

 Promotes critical thinking skills, decision-making skills

 Promotes quality of health care provision
 Prevention of any legal complications by minimizing errors or
inconsistencies
 Promotes professional growth
 Promotes accountability

The deliberate and systematic nursing process allows the structured flow of
information which benefits the nurses by the promotion of their critical thinking
skills and decision-making skills since they often encounter complicated cases,
and with that they must know how to distinguish significant information. If all
of the nursing processes are done with accuracy, the nurse should be able to
implement appropriate nursing care actions, at the same time, avoiding legal
complications as the nurse is responsible enough to do what is only needed by
the client. This kind of actions promotes professional growth among nurses, and
 it’s another advantage from following the nursing process. Finally, it promotes
accountability as well for every nurse are required to document every actions to
be given to the client, they are encouraged to do what they had planned and take
accountability for the outcomes.

c. Accountability

According to the American Nurses’ Association Code of Ethics, accountability

is, “to be answerable to oneself and others for one’s own actions”

Aside from being an important component of the nursing practice, it is also

important for the safety of the clients. We are accountable to meet the legal
requirements and standards of the nursing profession. For every actions or
behaviors that we manifest, we are accountable for it, but it is important to
know that we are not accountable for the decisions made by other nurses or
healthcare professionals.

Professional Accountability includes:

 Declining from activities wherein you’re not competent in or skilled in

 Being well-informed or seeking help/assistance
 Learning the rationale of your actions

Knowing your own limits and refraining from doing things in which
you’re not competent in will do no harm and will put you away from
further complications. If there are certain things that you’re not aware
of, it’s your responsibility to learn and be knowledgeable, more
importantly, since you’re dealing with health-related things. Seeking
assistance from other nurses/healthcare assistance when needed is also
a must, so you can prevent yourself from putting your client in danger.
And with every actions that you’ll do, there should be a reason why or
a purpose.

References:

 Berman, A. S. (2015). Kozier and Erb's Fundamentals of Nursing. (10th, Ed.)

 https://www.syndicateofhospitals.org.lb/Content/uploads/Workshops/1427_Ra
na%20Kachouh%20Nursing%20Process%20Hammoud.pdf
  http://www.cno.org/globalassets/4-
learnaboutstandardsandguidelines/prac/learn/modules/profstands/slides/accou
ntability.pdf

ASSESSMENT
Assessment is a systematic and continuous process of collecting, organizing, validating,
and documenting the client’s data to establish a database—all the information about a client—to
know the client’s response to health concerns or illness and the ability to manage health care
needs. This first phase of the nursing process is a very vital stage where you will need all
throughout the process that is why the health professional during this process has to have an
accurate and complete collection of data. This data-gathering stage will be the phase where you
will obtain information from different sources like the client’s history or physical exams, lab or
test results, client records, the client’s support system or his or her family members. Depending
upon the situation, there are different types of assessments namely: initial nursing assessment,
problem-focused assessment, emergency assessment, and time-lapsed reassessment.

Assessment includes not only physiological data, but also psychological, sociocultural,
spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a
hospitalized patient in pain includes not only the physical causes and manifestations of pain, but
the patient’s response—an inability to get out of bed, refusal to eat, and withdrawal from family
members, anger directed at hospital staff, fear, or request for more pain medication.
TYPES OF ASSESSMENT:

1. Initial Assessment
- It is the kind of assessment that is formed within specified time after admission to a
health care agency.
2. Problem-focused Assessment
- It is the kind of assessment that done in an ongoing process integrated with nursing
care.
3. Emergency Assessment
- It is the kind of assessment done during any physiological or psychological crisis of a
client.
4. Time-lapsed Assessment
- It is the kind of assessment done several months after the initial assessment of a
client.

I. Framework for Data Collection

Functional health patterns are defined as sequences of health behavior across time.
Within nursing, alternate systems of health assessment are being developed around
the organizing framework of functional health patterns (Gordon, 1987 and 1993).
According to (Kozier, 2014):

1. Health Perception – Health Management Patterns

 Aware/understands medical diagnosis
 Gives thorough history of illnesses and surgeries
 Complies with Synthroid regimen
 Relates progression of illness in detail
 Expects to have antibiotic therapy and “go home in a day or two”
2. Nutritional – Metabolic Pattern
 158 cm (5 ft, 2 in.) tall; weighs 56 kg (125 lb)
 Usual eating pattern “three meals a day”
 “No appetite” since having “cold”
 Has not eaten today; last fluids at noon
 Nauseated
 Oral temperature 39.4°C (103°F)
 Decreased skin turgor
3. Elimination Process
 Usually no problem
 Decreased urinary frequency and amount × 2 days
 Last bowel movement yesterday, formed, states was “normal”
4. Activity – Exercise Pattern
 No musculoskeletal impairment
 Difficulty sleeping because of cough
 “Can’t breathe lying down”
 States “I feel weak”
 Short of breath on exertion
 Exercises daily
5. Sleep – Rest Pattern
 Usual Sleep Pattern
 Sleep/Bedtime Pattern
 Sleep Environment. Sleep Position
 Psychophysiological influences
 Sleep-pattern disturbance symptoms
6. Cognitive – Perceptual Pattern
 No sensory deficits
 Pupils 3 mm, equal, brisk reaction
 Oriented to time, place, and person
 Responsive, but fatigued
 Responds appropriately to verbal and physical stimuli
  Recent and remote memory intact
 States “short of breath” on exertion
 Reports “pain in lungs,” especially when coughing
 Experiencing chills
 Reports nausea
7. Self-Perception – Self Concept Pattern
 Expresses “concern” and “worry” over leaving her children with their
grandparents until husband returns
 Anxiety related to missing her nursing classes, missing her medical–surgical
clinical day, and inability to study
 Well-groomed; says, “Too tired to put on makeup”
8. Role – Relationship Pattern
 Lives with husband, 13-year-old daughter, and 5-year-old son
 Husband out of town; will be back tomorrow afternoon
 Children are with their grandparents until husband returns
 States “good” relationships with friends and coworkers
 Nursing student and part-time home health aid
9. Sexuality – Reproductive Pattern
 Sex Roles and Gender identification
 Knowledge about sexuality and reproductions
 Concerns about sexual performance and satisfaction
10. Coping – Stress Tolerance Pattern
 Anxious: “I can’t breathe”
 Facial muscles tense; trembling
 Expresses concerns about work: “I’ll never get caught up”
11. Value – Belief Pattern
 Catholic
 No special practices desired except anointing of the sick
 Middle-class, professional orientation
  No wish to see chaplain or priest at present

II. Patient History

Eliciting a full patient history through open-ended questioning and active listening
will ultimately save time while offering critical clues to the diagnosis. In one classic
study, researchers evaluated the relative importance of the medical history, the physical
exam, and diagnostic studies. Health professionals were asked to predict their diagnosis
after taking just the history, and then again after performing the history with the physical
exam. In studies, an accurate diagnosis was predicted based solely on the medical
history. It is now estimated that between 70 to 90 percent of medical diagnoses can be
determined by the history alone; in addition to being one of the oldest diagnostic tools, a
comprehensive history is one of the most reliable.

Patient history is obtained through collecting from subjective data—verbal from

clients. This provides the opportunity to convey interest, support, and understanding to
the patient and to establish rapport. This patient history includes the client’s biographic
data, chief complaint, history of present illness, past history, family history, and the
psychosocial data.

 BIOGRAPHICAL DATA
The biographical data is obtained through interviewing the patient at the beginning
during the client’s first visit or admission. These are the list commonly used, and
sometimes critical, biographical information.

A. Full Name:
B. Address:
C. Age:
D. Sex:
E. Race:
F. Marital Status:
G. Occupation:
H. Religious Orientation:
I. Health Care Financing:

 CHIEF COMPLAINT
 This part of the patient history is recorded in the client’s own words and is in
quotation marks indicating the client’s purpose or concern why he or she came sought for
medical assistance in the hospital. The health professional may ask questions to the
patient like. “What is troubling you?” or “May we know the reason you came to the
hospital today?”. In this portion, you have to list the client’s priorities as he or she stated.

 PRESENT HEALTH HISTORY

This section describes the information relevant to the client’s reason for seeking care.
The interviewing of this phase is quite difficult especially for beginning practitioners
because this process requires both interviewing skills and clinical knowledge.

o When the symptoms started?

o How often the problem occurs

o Exact location of the distress

o Character of the complaint (e.g., intensity of pain or quality of sputum,
emesis, or discharge)
o Type of activity of client when problem occurred?

o Phenomena or symptoms associated with the chief complaint

o Factors that aggravate or alleviate the problem

o Was help or consultations sought?

o What were the medications taken?

o How has the problem interfere with your daily life?

 PAST HEALTH HISTORY

The purpose of this section is to identify all the client’s major past health problems.
Past illnesses may have an effect on the client’s current health needs and problems.
Information about the past care provided provides some indicator of client’s possible
response to current and future health issues.

o Childhood Diseases
o Immunizations

o Allergies
o Accidents and injuries

o Hospitalizations
 o Medications taken

o Operations

 FAMILY HEALTH HISTORY

The purpose of this section is to learn about the general health of the client’s blood
relatives, spouse, and children, and to identify any illnesses of a genetic, familial, or
environmental nature that may affected the client’s current or future health problems.
This also includes the health and ages of parents, siblings, children, or ages of deaths and
its cause.

 PSYCHOSOCIAL DATA
o Major stressors experienced and the client’s perception of them
o Usual coping pattern for a serious problem or a high level of stress

o Communication style: ability to verbalize appropriate emotion; nonverbal

communication—such as eye movements, gestures, use of touch, and posture;
interactions with support persons; and the congruence of nonverbal behavior
and verbal expression

III. PHYSICAL EXAMINATION

According to Berman, A., Snynder, S. & Frandsen, G., “the physical examination or
physical assessment is a systematic data collection method that uses observation (i.e., the
senses of sight, hearing, smell, and touch) to detect health problems. To conduct the
examination, the nurse uses techniques of inspection, auscultation, palpation, and percussion.
The physical examination is carried out systematically. It may be organized according to the
examiner’s preference, in a head-to-toe approach or a body systems approach. Usually, the
nurse first records a general impression about the client’s overall appearance and health
status: for example, age, body size, mental and nutritional status, speech, and behavior. Then
the nurse takes such measurements as vital signs, height, and weight. The cephalocaudal or
head-to-toe approach begins the examination at the head; progresses to the neck, thorax,
abdomen, and extremities; and ends at the toes. The nurse using a body systems approach
investigates each system individually, that is, the respiratory system, the circulatory system,
the nervous system, and so on. During the physical examination, the nurse assesses all body
parts and compares findings on each side of the body (e.g., lungs). Instead of giving a
complete examination, the nurse may focus on a specific problem area noted from the
nursing assessment, such as the inability to urinate. On occasion, the nurse may find it
necessary to resolve a client complaint or problem (e.g., shortness of breath) before
 completing the examination. Alternatively, the nurse may perform a screening examination. A
screening examination, also called a review of systems, is a brief review of essential
functioning of various body parts or systems. An example of a screening examination is the
nursing admission assessment. Data obtained from this examination are measured against
norms or standards, such as ideal height and weight standards or norms for body temperature
or blood pressure levels.”

IV. LABORATORY AND DIAGNOSTIC STUDIES

Collaboration with other clinicians in the care planning is vital. The nurse should include
modalities to help patients cope with the actual diagnostic procedure and test outcomes, as
well as accommodate patients with special needs, such as hearing or sight impairment,
ostomy care, or diabetic care. The comatose, the confused, the child, and the frail, elderly
patient also require special consideration. Nurses and other health care clinicians treat
collaborative patient problems simultaneously. During diagnostic tests, the nurse identifies
both nursing diagnoses and collaborative problems that require appropriate and independent
nursing interventions.

 EXAMPLES OF NURSE-DIRECTED TESTING

TEST NURING RESPONSSIBILITY
Blood draws for testing (arterial, venous, or Monitor blood glucose levels, cardiac
capillary) enzymes, electrolytes, drug presence (licit or
illicit), cell counts (red and white blood cells),
alcohol intake, oxygenation levels, acid-base
status, presence of bacterial pathogens,
hormone levels, tumor markers, antibodies,
etc.
Guaiac stool testing Check for fecal blood, color, consistency, and
presence of pathogenic organisms
Tuberculin skin testing Interpret results; obtain blood and/or sputum
for TB testing
HIV/AIDS testing Obtain blood or saliva and obtain informed
consent
Rectal exams Obtain stool for occult blood, positive guaiac
smears as possible sign of rectal or colon
cancer
Finger- or heelsticks Screen newborns and infants for genetic
disorders
Pap smears Perform vaginal swab for diagnosis of pre-
cancers and cancers of genital tract; check for
the presence of microorganisms
Throat swabs Swab throat for the diagnosis of
 Streptococcus infections
Urine dipsticks Determine blood glucose level, alcohol levels,
and the presence of bladder infection
Lung function testing Use spirometer for peak airflow assessment in
asthma
Breath alcohol testing Use specialized devices to detect above-
normal levels of alcohol
Audiometric examination Follow guidelines for hearing deficits
Vision testing Conduct simple to complex vision tests;
follow guidelines for retinal and macular
degeneration disorders
Pulse oximetry Apply special device to monitor arterial
oxygenation levels (during rest, walking,
exercise)
ECG Apply leads to identify normal cardiac
rhythms, arrhythmias, and myocardial
ischemia; evaluate pacemaker function
IV Draw blood and collect specimens from
invasive lines for evaluation

B. ORGANIZING INFORMATION ELEMENTS

I. DATA COLLECTION
The gathering of data about the client’s health status. It is systematic and
continuous to avoid the omission of important information.

Database- contains all the information about the client

TYPES OF DATA

1. Subjective data- also known as symptoms or covert data, are information that can
be described or verified only by that person.
2. Objective data- also known as signs or overt data, are information that can be
observed or can be measured or tested against an accepted standard.
SOURCES OF DATA

1. Primary Source- statements made by the client but also include those objective
data that can be directly obtained by the nurse from the client such as gender. The
best source of data is usually the client, unless the client is too ill, young, or
confused to communicate clearly.
2. Secondary Source- family members or other support persons, other health
professionals, records and reports, laboratory and diagnostic analyses, and
relevant literature are secondary or indirect sources.
*Information supplied by family members, significant others, or other health
professionals is considered subjective if it is not based on fact.

Client records- include all information documented by various health care

professionals.

TYPES OF CLIENT RECORDS

1. Medical Records
2. Records of Therapies
3. Laboratory Records
DATA COLLECTION METHOD

1. Observing- a conscious, deliberate skill that is developed through effort and with
an organized approach.
Has two (2) aspects:
A. noticing the data
B. selecting, organizing, and interpreting the data.

2. Interviewing- a planned communication or a conversation with a purpose.

Two approaches:

a. Directive Approach- highly structured and elicits specific information.

b. Nondirective Interview- rapport-building interview where the nurse allows the
client to control the purpose, subject matter, and pacing
TYPES OF INTERVIEW QUESTIONS

1. Close-ended Questions- used in the directive interview, are restrictive and

generally require only “yes” or “no” or short factual answers giving specific
information.
2. Open-ended question- used in nondirective interview, invite clients to discover
and explore, elaborate, clarify, or illustrate their thoughts or feelings.
3. Neutral question- a question the client can answer without direction or pressure
from the nurse, is open ended, and is used in nondirective interviews.
4. Leading question- usually closed and used in a directive interview, and thus
directs the client’s answer.
 PLANNING THE INTERVIEW AND SETTING

1. Time
2. Place
3. Seating Arrangement
4. Distance
5. Language
STAGES OF AN INTERVIEW

1. Opening- can be the most important part of the interview. The purposes of the
opening are to establish rapport and orient the interviewee.
2. Body- the client communicates what he or she thinks, feels, knows, and perceives
in response to questions from the nurse.
3. Closing- the nurse terminates the interview when the needed information has been
obtained
The following techniques are commonly used to close an interview:

1. Offer to answer questions

2. Conclude by saying “Well, that’s all I need to know for now” or “Well, those
are all the questions I have for now.”
3. Thank the client
4. Express concern
5. Plan for the next meeting
6. Provide a summary

EXAMINING

Physical Examination/Physical Assessment- a systematic data collection method that uses

observation to detect health problems.

Cephalocaudal- head-to-toe approach that begins the examination at the head; progresses
to the neck, thorax, abdomen, and extremities; and ends at the toes.

Screening Examination/Review of Systems- a brief review of essential functioning of

various body parts or systems.
 II. DATA VALIDATION
The act of “double-checking” or verifying data to confirm that it is accurate and
factual.

Helps the nurse complete these tasks:

1. Ensure that assessment information is complete.

2. Ensure that objective and related subjective data agree.
3. Obtain additional information that may have been overlooked.
4. Differentiate between cues and inferences.
Cues- subjective or objective data that can be directly observed by the nurse.
Inferences- the nurse’s interpretation or conclusions made based on the cues.

5. Avoid jumping to conclusions and focusing in the wrong direction to identify

problems.
As a rule, the nurse validates data when there are discrepancies between data
obtained in the nursing interview and the physical examinatio, or when the client’s
statements differ at different times in the assessment.

III. DATA CLUSTERING

Data clustering or grouping of cues is a process of determining the relatedness of
facts and determining whether any patterns are present, whether the data represent
isolated incidents, and whether the data are significant.

The nurse may cluster data inductively by combining data from different assessment
areas to form a pattern; or the nurse may begin with a framework.

IV. DATA DOCUMENTATION

It is the recording of the client’s data as a completion of the assessment phase. Data
should be recorded in a factual manner and not interpreted by the nurse. To increase
accuracy, the nurse records subjective data in the client’s own words, using quotation
marks.

References:

 Berman, A.S (2015) Kozier & Erb’s Fundamentals of Nursing (10th edition)
 DIAGNOSIS
Following the assessment phase, the second in the nursing process is the diagnosis. During this
phase, the critical thinking skills of the nurse would be necessary, for diagnosis is considered as a
‘pivotal’ step in the nursing process. It is because prior to diagnosis are the activities included in
the assessment phase, which will serve as an important basis for formulating the diagnosis. The
gathered data from the assessment must be accurate and comprehensive enough to make an
appropriate and error-free diagnosis, since it will be used to determine the health care needs of
the client, then the nursing planning activities will be based from it.
Brief History:

The North American Nursing Diagnosis Association (NANDA) is an organization group with
participating and contributing nurses, was initiated by Kristine Gebbie and Mary Ann Lavin in
1973. The first held national conference aimed to identify and develop nursing diagnoses, and it
was sponsored by Saint Louis University School of Nursing and Allied Health Professions,
followed by conferences in 1975 and in 1980, and every two years thereafter.

In 1977 was the First Canadian Conference in Toronto and in May 1987 in Calgary, Alberta,
Canada. The conference group accepted the name North American Nursing Diagnosis
Association, acknowledging the participation of nurses in United States and Canada, and then in
2002, it was changed to NANDA International to engage with the worldwide interests in nursing
diagnoses.

The purpose of NANDA:

To define, refine and promote taxonomy of nursing diagnostic terminology of general use to
professional nurses.

TAXONOMY: is a classification system or set of categories arranged based on a single principle

or set of principles.

Currently, there are more than 200 approved nursing diagnosis labels for clinical use and testing.

NANDA NURSING DIAGNOSES

A nurse must be knowledgeable of the definitions of terms, as well as the components of nursing
diagnoses in order to utilize the concepts of nursing diagnoses effectively in formulating and
completing a nursing care plan.

DEFINITIONS:

Diagnosing refers to the reasoning process, whereas diagnosis is the statement or conclusion
regarding the nature of a phenomenon.

Diagnostic labels refer to the standardized NANDA names for the diagnoses, and the nursing
diagnosis refers to the client’s problem statement composing of the diagnostic label plus the
etiology (related factor and risk factor)

According to NANDA,
Nursing Diagnosis is “…a clinical judgment concerning a human response to health
conditions/life processes, or a vulnerability for that response, by an individual, family, group or
community”

“A nursing diagnosis provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse has accountability” This definition is consistent with the following:

o Professional nurses are responsible for making nursing diagnoses, even though other
nursing personnel may contribute date to the process of diagnosing and may implement
specified nursing care.
o The domain of nursing diagnosis includes only those health states that nurses are
educated and licensed to treat.
o A nursing diagnosis is a judgment made only after thorough, systemic data collection.
o Nursing diagnoses describe a continuum of health states: deviations from health, presence
of risk factors and areas of enhanced personal growth.

A. DIAGNOSTIC ANALYSIS

This process a nurse must go through before formulating a diagnosis requires clinical
thinking.

Analysis and interpretation of data

Steps for analyzing in the diagnostic process:
 Compare data against standards (identify significant cues)
 Cluster the cues (generate tentative hypotheses)
 Identify gaps and inconsistencies.

COMPARING DATA WITH STANDARDS

After the nurse has thoroughly gathered the client’s data, it is then followed by comparing it to a
wide range of standards or norm (laboratory values, normal vital signs, development patterns) to
identify significant and relevant cues.

Cues can be considered significant,

 If it indicates a positive or negative change in a client’s health status or pattern.

  If it deviates from norms of client population
 If it indicates a developmental delay

CLUSTERING CUES

Data clustering or grouping of client data or cues is a process wherein the presence of pattern,
relatedness and significance of data are distinguished.

The nurse may cluster data by:

 Inductive Approach: Combining of data from different assessment areas to form a

pattern
 Deductive Approach: Starting with a framework (such as Gordon’s functional
health patterns, and organize the subjective and objective data into the appropriate
categories

Involved in this process is the interpretation of the possible meaning of the cues, and
labeling of the cues with tentative diagnostic hypotheses.

IDENTIFYING GAPS AND INCONSISTENCIES IN DATA

The minimizing of gaps and inconsistencies in data are accomplished during the assessment
phase, however to ensure the accuracy and appropriacy of data, it is recommended to do a final
checking.

If there are inconsistencies, it means that there is presence of errors in assessment,

interpretations, reports, and in other sources, also incomplete or incorrect recordings and this will
result to a misleading data. Thus to prevent inconsistencies, obtained data should be clarified to
establish a valid pattern.

PROBLEM IDENTIFICATION

IDENTIFYING HEALTH PROBLEM, RISKS, AND STRENGTHS

This process includes:

 Determining the client’s problem

  Determining if the client’s problem is a nursing diagnosis, medical diagnosis, or
collaborative diagnosis
 Determining the client’s strength

The nurse identifies problems that can be treated solely with nursing intervention (nursing
diagnosis) or problems wherein a nurse could not prescribe a treatment/take independent action
(medical diagnosis), or if it’s a problem that requires both medical and nursing orders
(collaborative problem).

The establishment of strengths on the other hand can serve as the client’s assistance during the
recovery process, because it contributes to the positive thinking of the client’s self-concept and
self-image, increasing their ability to cope with their problem. Example of client strengths:
absence of allergies, smoking habits, alcoholism, etc. These kinds of strengths are obtainable
from the nursing assessment record, health examinations, and records.

References:

 Berman, A. S. (2015). Kozier and Erb's Fundamentals of Nursing. (10th, Ed.)

 https://slideplayer.com/slide/10135489/
 http://www.delmarlearning.com/companions/content/0766838366/students/ch12/
summary.asp
 https://www.slideshare.net/91varsha/analysis-and-utilization-of-relevant-data-in-
nursing-process

B. Nursing Diagnostic Analysis

I. Types of nursing diagnoses according to status:

A nursing diagnosis can be an actual diagnosis, problem-focused, a state of health
promotion, or a potential risk, wellness diagnosis, and a syndrome diagnosis.

1. An actual diagnosis is a type of diagnosis wherein the problem must be present at the
time during nursing assessment. In order to yield this diagnosis, it should be based on the
presence of associated signs and symptoms. Examples are Ineffective Breathing Pattern and
Anxiety (Kozier & Erbs, 2011).

2. A problem-focused diagnosis refers to the concerns of undesirable human response to a

health condition/life process that exists in an individual, family, group, or community (NANDA
International, 2018, p. 33). In order to make this diagnosis, there are certain elements that must
be included like: defining characteristics (signs and/or symptoms) that can be grouped to form
recognizable patterns and related factors that are somehow related to, contribute to, or led up to
the identified problem.

2. A health promotion diagnosis relates to clients’ preparedness to implement behaviors to

improve their health condition. It concerns on motivation and desire to increase well-
being and to achieve the person’s own optimum health potential (NANDA International,
2018, p. 33). These diagnoses use terms related to a patient's readiness for specific health
behaviors.

3. A risk nursing diagnosis is a diagnosis where the problem does not exist, but the
presence of risk factors indicates that a problem is likely to develop unless nurses
intervene. It examines the client’s susceptibility for developing an undesirable human
response to health conditions/life processes (NANDA International, 2018, p. 33). For
example, all people admitted to a hospital have some possibility of acquiring a
nosocomial infection; however, a client with diabetes or a weak immune system is at
higher risk than others. Therefore, the nurse would appropriately use the label Risk for
Infection to describe the client’s health status.

4. A wellness diagnosis “describes human responses to levels of wellness in an individual,

family or communities” (NANDA International, 2009, p. 420). Examples of wellness
diagnosis would be Readiness for Enhanced Spiritual Well-Being or Readiness for
Enhanced Family Coping.

5. A syndrome diagnosis is concern about a specific cluster of nursing diagnoses that occur
together in a pattern and are therefore best addressed together and through similar
interventions (NANDA International, 2018, p. 33). For example, a person that has a
chronic pain experiences recurrent or persistent pain that has lasted at least 3 months and
that significantly affects daily functionings or well-being. It has significant impact on
other human responses and thus includes other diagnoses, such as disturbed sleep pattern,
fatigue, impaired physical mobility, or social isolation.

II. Components of a NANDA Nursing Diagnosis

 Problem (Diagnostic Label) and Definition
The problem statement, or diagnostic label, defines the client’s health problem or reaction for
which a nursing treatment would be given. It describes the client’s health status clearly and
concisely. The diagnostic label directs the formation of client goals and desired outcomes and
may also suggest some nursing interventions. (Kozier & Erbs, 2011).

Diagnostic labels need to be specific; when the word Specify follows a NANDA label, the nurse
states the area in which the problem occurs, for example, Deficient Knowledge (Medications) or
Deficient Knowledge (Dietary Adjustments).

Qualifiers are words that have been added to some NANDA labels to give additional meaning to
the diagnostic statement; for example:
■ Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete)
■ Impaired (made worse, weakened, damaged, reduced, deteriorated)
■ Decreased (lesser in size, amount, or degree)
■ Ineffective (not producing the desired effect)
■ Compromised (to make vulnerable to threat).

 Etiology (Related Factors and Risk Factors)

The etiology identifies the related factors (causes or the contributing factors) and the risk factor
which is the determinant (increase risk). It gives direction to the required nursing intervention,
and enables the nurse to individualize the client’s care. A review of client history often helps to
identify related factors. Whenever possible, nursing interventions should be aimed at these
etiological factors in order to remove the underlying cause of the nursing diagnosis. (NANDA
International, 2018, p.38).

 Defining Characteristics
Defining characteristics are the observable cluster of signs and symptoms that indicate the
presence of a particular diagnostic label. For actual nursing diagnoses, the defining
characteristics are the client’s signs and symptoms. For risk nursing diagnoses, no subjective and
objective signs are present. Thus, the factors that cause the client to be more vulnerable to the
problem form the etiology of a risk nursing diagnosis.

III. Formulating Diagnostic Statements (Kozier & Erbs, 2011).

Most nursing diagnoses are written as two-part or three-part statements, but there are variations
of these.

Basic Two-Part Statements

1. Problem (P): statement of the client’s response
(NANDA label)
2. Etiology (E): factors contributing to or probable
causes of the responses.
The two parts are linked by the term related to (RT)

Basic Three-Part Statements (Kozier & Erbs, 2011).

The basic three-part nursing diagnosis statement is called the
PES format and includes the following:
1. Problem (P): statement of the client’s response
(NANDA label)
2. Etiology (E): factors contributing to or probable causes of
the response
3. Signs and symptoms (S): defining characteristics manifested
by the client.
Actual nursing diagnoses can be documented by using the three-part statement because the signs
and symptoms have been identified. This format cannot be used for risk diagnoses because the
client does not have signs and symptoms of the diagnosis. The PES format is especially
recommended for beginning diagnosticians because the signs and symptoms validate why the
diagnosis was chosen and make the problem statement more descriptive.

One-Part Statements (Kozier & Erbs, 2011).

Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses,
consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more
specific, so that nursing interventions can be derived from the label itself. Therefore, an etiology
may not be needed.

NANDA has specified that any new wellness diagnoses will be developed as one-part statements
beginning with the words Readiness for Enhanced followed by the desired higher level of
wellness (for example, Readiness for Enhanced Parenting). Currently the NANDA list includes
several wellness diagnoses. Some of these are Spiritual Well-Being, Childbearing Process, and
Comfort.

IV. Avoiding Errors in Diagnostic Reasoning

It is important for nurses to make nursing diagnoses with a high level of accuracy.

 Accurate and complete collection of data

 Use of an organizational framework for clustering data cues
 Thorough analysis and validation of data
 Correct writing of the nursing diagnosis

V. Differentiating Nursing Diagnoses from Medical Diagnoses (Kozier & Erbs, 2011).

Nursing Diagnoses Medical Diagnoses Collaborative

 Clinical judgment by a
professional nurse that
identifies the client’s
actual, risk, wellness,
or syndrome responses
to a health state or
problem.
 Describes the client’s
response, physical,
Problem/Diagnosis
 Clinical judgment by  Manages by a nurse
physician that identifies or using both
determines specific independent and
disease or condition. physician-prescribed
 Refers to a condition only interventions
a physician can treat.  Independent nursing
 It refers to disease interventions for a
processes in which collaborative problem
specific pathophysiologic focus mainly on
 sociocultural, responses are fairly monitoring the client’s
psychological, and uniform from one client to condition and
spiritual responses to another. preventing
an illness. development of the
 More individualized to potential complication
a specific client  Definitive treatment
 Emphasizes human of the condition
responses to which the requires both medical
nurse can and nursing
independently take interventions.
action.

Nursing diagnosis relates to independent functions in which the areas of health care that are
unique to nursing and separate and distinct from medical management. With regard to medical
diagnoses, nurses are obligated to carry out physician-prescribed therapies and treatments, that
is, dependent functions.

References:
 Berman, A., & Kozier, B. (2011). Kozier & Erbs fundamentals of nursing, ninth
edition. Upper Saddle River, NJ: Prentice Hall.

 Herdman, T. H., & Kamitsuru, S. (2018). Nursing diagnoses: Definitions and

classification, 2018-2020, eleventh edition. New York: Thieme.

 https://www.slideshare.net/ArulValan/nursing-diagnosis-15266748
 PLANNING
The third (3rd) phase of nursing process after identifying the nursing diagnoses and
strengths of the client. It involves decision-making, problem solving, and focuses on the
goals and outcomes of the nursing. In planning, the nurse refer to the client’s assessment
data and diagnostic statements for direction in formulating client goals and designing the
nursing interventions required to prevent, reduce, or eliminate the client’s health
problems.

There are three types of Planning. (1) Initial Planning, the nurse who performs the
admission assessment usually develops the initial comprehensive plan of care; (2)
Ongoing Planning, is done by all nurses who work with the client. As the nurse obtain
new information and evaluate the client’s response to care, they can individualize the
initial care plan further; and (3) Discharge Planning, the process of anticipating and
planning for needs after discharge, is a crucial part of comprehensive health care and
should be addressed in each client’s care plan.

A. Setting Priorities
 Priority setting is the process of establishing a preference sequence for addressing
nursing diagnoses and interventions. The nurse and client begin planning by
deciding which nursing diagnoses requires attention first, which second, and so
on. Instead of rank-ordering diagnoses, nurses can group them as having high,
medium, or low priority. In other words, as you care for a client or a group of
clients, there are certain aspects of care that you need to deal with before others.

Priorities can change as the client’s responses, problems, and therapies change.
The nurse must consider a variety of factors when assigning priorities, including
the following:
 1. Client’s health values and beliefs
2. Client’s priorities
3. Resources available to nurse and client:
4. Urgency of the health problem
5. Medical Treatment

I. Establishing Goals
 Once the nursing diagnosis identified, always ask, what is the best approach to
address and resolve the problem? Knowing the client has the certain
diagnosis, what do you plan to achieve? Moreover, the goals and expected
outcomes are the specific statements of client’s behavior or physiological
responses that you set to achieve in nursing diagnosis or collaborative
problem resolution. It will provide a clear focus for the type of intervention
necessary to care for you client.

One of example is, in the case of Ms. ABC who has a diagnosis of acute pain
related to pressure on spinal nerves, a goal of care includes “Client achieves
improved pain control before surgery”. In order for the nurse to monitor Ms.
ABC progress, it is necessary to use expected outcomes or measurable criteria
to evaluate goal achievement. Measureable outcomes for the goal of pain
relief include “Client’s self-report of pain will be 3 or less on the scale of 0 to
10,” and “Client will be able to turn without reportedly discomfort”. The
outcomes will gauge the nurse success in selecting interventions for Ms.
ABC’s pain relief. After administering an analgesic repositioning the client a
few minutes later, the nurse will return to Ms. ABC’s room and in 30 minutes
and ask the client to rate her pain and to report on her comfort level. If the
client rates her pain at a 3 or less and similarly reports minimal discomfort
when turning, her goal will have been met. Until so, the nurse will continue
her plan until the client Ms. ABC goes to surgery.

II. Identifying expected desired outcomes

 For every nursing diagnosis, the nurse must write the desired outcome/s that
when achieved, directly demonstrates resolution of the problem. When
developing goals or desired outcomes, ask the following question:
 1. What is the client’s problem?
2. What is the opposite, healthy response?
3. How will the client look or behave if the healthy response is achieved?
(What will I be able to see, hear, measure, palpate, smell, or otherwise
observe with my senses)
4. What must the client do and how well must the client do it to
demonstrate problem resolution or to demonstrate the capability of
resolving the problem?

B. Planning appropriate nursing intervention

 Nursing intervention are identify and written during the planning step of
nursing process; however, they are actually perform during the implementing
phase. Nursing intervention includes two caring process: (1) Direct care, an
intervention performed through interaction with the client; and (2) Indirect
care, an intervention performed away from but on behalf of the client such
interdisciplinary collaboration or management of the care of the environment.
In addition, there are three categories of nursing intervention: (1) nurse-
initiated, (2) physician-initiated and (3) collaborative interventions. The
nurses must base his/her selection of interventions on the client needs. Some
clients requires all three categories, whereas other clients need only nurse- and
physician-initiated interventions.

I. Independent nursing intervention (Nurse-initiated intervention)

 Are those activities that nurses are licensed to initiate based on their
knowledge and skills. These do not require direction or an order from another
health care professional. As a nurse, you act independently on a client’s
behalf. In addition, it is an autonomous actions based on scientific rationale.
Example are instructing client in side effects of medications or directing a
client to splint an incision during coughing.

II. Dependent nursing intervention (Physician-initiated intervention)

 Are activities carried out under the physician’s orders or supervision, or
according to specified routines. As the nurse, you intervene by carrying out
the independent provider’s written and/or verbally orders. Examples are
administering a medication, implementing an invasive procedure, changing a
dressing and preparing a client for diagnostic tests.
 III. Collaborative nursing intervention (Interdependent nursing intervention)
 Are actions the nurse carries out in collaboration with other health team
members, such a physical therapists, social workers, dietitians and physicians.
Typically, as a nurse when you plan care for a client, you will review the
necessary interventions and determine if the collaboration of other health care
disciplines is necessary. A client care conference with an interdisciplinary
health care team results in selection of interdependent nursing intervention.

C. Selection of nursing intervention

 Nursing interventions are the actions that a nurse perform to achieve client
goal. As a nurse, you need to learn to not select interventions randomly. When
choosing interventions, you consider the six important factors: (1)
characteristic of the nursing diagnosis, (2) goals and expected outcomes, (3)
evidence base (research or proven practice guidelines) for the intervention, (4)
feasibility of the intervention, (5) acceptability to the client, and (6) your own
competency. As the nurse select interventions, he/she must review their
client’s needs, priorities, and previous experiences to select intervention that
have the best potential for achieving the expected or desired outcomes.

Choosing Nursing Interventions

1. Characteristic of the Nursing Diagnosis 4. Feasibility
- Interventions should alter the etiological (related - A specific intervention has the potential
to) factor or signs of symptoms associated with for interacting with other interventions;
the diagnostic label; - Be knowledgeable about the total plan of
- When an etiological factor cannot change, direct care
the interventions toward treating the signs and - Consider cost
symptoms; - Consider time
- For potential or high-risk diagnoses, direct
interventions at altering or eliminating risk
factors for the diagnosis.
2. Expected Outcomes
- Because nurses state outcomes in terms used to
evaluate the effect of an intervention, this
language assists in selecting the intervention;
- Nursing Intervention Classification (INC) is
designed to show the link to Nursing Outcomes
Classification (NOC).
3. Research Base
- Research evidence in support of a nursing
intervention will indicate the effectiveness of
using the intervention with certain types of
clients;
- When research is not available, use scientific
principles or consult a clinical expert about your
client population. (eg. Infectious control)
5. Acceptability to the Client
- A treatment plan needs to be acceptable to
the client and family and match the client’s
goals, health care values and culture;
- Promote informed choice; help a client
know how to participate in and anticipate
the effect of interventions.
6. Capability of the Nurse
- Be prepared to carry out the intervention
- Know the scientific rationale for the
intervention
- Have the necessary psychosocial and
psychomotor skills to complete the
intervention.
- Be able to function within the specific
setting and effectively and efficiently use
health care resources.

D. Developing nursing care plan

 In any health care setting, a nurse is responsible for providing a written plan
of care for all client. Generally, a written nursing care plan includes nursing
diagnoses, goals and/or expected outcomes and specific nursing intervention
so that any nurse is able to quickly identify a client’s clinical needs and
situations. Moreover, the end product of planning has two phase: (1) Informal
nursing care plan, a strategy for action that exists the nurse’s mind (2)
Formal nursing care plan, a written or computerized guide that organizes
information about the client’s care. Under the formal nursing care plan there
are two other care plan mentioned, they are (1) Standardized care plan, a
formal plan that specifies the nursing care for a group of clients with common
needs; and (2) Individualized care plan, is tailored to meet the unique needs
of specific client needs that are not addressed by the standardized plan.

During planning phase, the nurse must (1) decide which of the client’s
problems need individualized plans and which problems can be addressed by
standardized plans and routine care; and (2) write individualized desired
outcomes and nursing interventions for client problems that require nursing
attention beyond preplanned, routine care. Technically, the complete plan of
care for a client is made up of several different documents, they are:

1. Described the routine care needed to meet the basic need;

 2. Address the client’s nursing diagnoses and collaborative problems;
and
3. Specify nursing responsibilities in carrying out the medical plan of
care.

References:

 Berman, A.S (2015) Kozier & Erb’s Fundamentals of Nursing (8th Edition)
 Potter, Perry Fundamentals of Nursing (7th Edition)
 IMPLEMENTING
In performing the nursing process, implementing is the action phase in which the nurse performs
his or her nursing interventions. With the use of Nursing Interventions Classification’s meaning,
the process implementing consists of doing and documenting the activities that are the specific
nursing actions needed to carry out the interventions. During this stage, the nurse performs and
prepares thoroughly the nursing activities for the interventions that were developed in the
planning step and then concludes the implementing step by recording nursing activities and the
resulting client responses. It is also throughout this course of action the nurse organize the
coordination of care, health teaching and health promotion, and consultation.
A. Relationship of Implementing to Other Nursing Process Phases

The process of nursing and its phases are interrelated to one another. The first three
nursing process phases namely, assessing, diagnosing, and planning provide the basis for the
nursing actions performed during the implementing step. In return, the implementing phase then
provides the actual nursing activities and client responses that are examined in the final phase,
which is the evaluating phase. Using the data acquired during assessment, the nurse can create
their own plan of care. They can now modify and alter the interventions to fit a specific client
rather than applying them consistently to group of clients. While implementing nursing care, the
nurse continues to reassess the client at every contact, gathering data about the client’s responses
to the nursing activities and about any new problems that may develop.

B. Implementing Skills
Necessary skills are required when providing an excellent execution of the intervention or
implementation. In order to implement the care plan successfully, the nurses should be able to
possess cognitive, interpersonal and technical skills. Nevertheless, they can use them in a range
of different combinations depending on the weight of the activity.

 Cognitive skills can also be called the intellectual skills. It includes problem solving,
decision making, critical thinking, and creativity. These skills are exceptionally crucial in
giving an intelligent nursing care.

 Interpersonal skills are all of the activities, verbal and nonverbal, people use when
interacting directly with one another.The effectiveness of a nursing action often depends
largely on the nurse’s ability to communicate with others. The nurse uses therapeutic
communication to understand the client and in turn be understood. Nurse also needs to
work effectively with others as a member of the health care team.

These skills are necessary for all nursing activities such as caring, comforting,
advocating, referring, counseling, and supporting. It also consists of conveying
knowledge, attitudes, feelings, interest, and appreciation of the client’s cultural values
and lifestyle. Before a nurse can be highly skilled in interpersonal skills, he or she must
have self-awareness and is sensitive to others.

 Technical skills are hands-on skills such as manipulating equipment, giving injections,
bandaging, and moving, lifting, and repositioning clients. These skills are also called
tasks, procedures, or psychomotor skills which refer to the physical actions that are
controlled by the mind, not by reflexes.

It requires knowledge and manual dexterity. Due to the presence of technology, number
of technical skills are expected of a nurse has greatly increased in recent years.
C. Process of Implementing

The process of implementing normally includes the following:

■ Reassessing the client
■ Determining the nurse’s need for assistance
■ Implementing the nursing interventions
■ Supervising the delegated care
■ Documenting nursing activities.
Reassessing the Client

 Before implementing an intervention, the nurse must reassess the client to make sure the
intervention is still needed.
 Even though an order is written on the care plan, the client’s condition may have changed.
 New data may indicate a need to change the priorities of care or the nursing activities.

Determining the Nurse’s Need for Assistance

When implementing some nursing interventions, the nurse may require assistance and it may
include the following:
■ Nurse is unable to implement the nursing activity safely or efficiently alone
■ Assistance would reduce stress on the client
■ Nurse lacks the knowledge or skills to implement a particular nursing activity
Implementing the Nursing Interventions

It is important to explain to the patients what nursing interventions will be done to him or
her. You may need to tell them what sensations, they are expected to do and most essential is the
expected outcome based on the intervention. Nurses should also be able to ensure the client’s
privacy. It also involves scheduling the patient’s contacts to other hospital departments and it
serves a connection among the other members of the health care team.

When implementing interventions, nurses should follow these guidelines:

 Base nursing interventions on scientific knowledge, nursing research, and professional

standards of care when these exist.
 Clearly understand the interventions to be implemented and question any that are not
understood. The nurse is responsible for intelligent implementation of medical and
nursing plans of care.
 Adapt activities to the individual client.
 Implement safe care.
  Provide teaching, support, and comfort.
 Be holistic
 Respect the dignity of the client and enhance the client’s self esteem.
 Encourage clients to participate actively in implementing the nursing interventions.

Supervising Delegated Care

If the care has been assigned to other health care professionals, then nurse is responsible
for the client’s overall care. They also must ensure that the activities have been implemented
according to the nursing care plan. Several other healthcare providers may be required to
communicate their activities to the nurse by documenting them one by one. The nurse validates
and responds to any undesirable findings.

Documenting Nursing Activities

After carrying out the nursing activities, the nurse then completes the implementing
phase by recording the interventions and client responses in the nursing progress notes. These
will become a part of the agency’s permanent record for the client. The nursing care must not be
recorded in advance because the nurse may determine on reassessment of the client that the
intervention should not or cannot be implemented.

The nurse may record routine or recurring activities in the client record at the end of a
shift. In the meantime, the nurse maintains a personal record of these interventions on a
worksheet. In some instances, it is important to record a nursing intervention immediately after it
is implemented. This is particularly true of the administration of medications and treatments
because recorded data about a client must be up to date, accurate, and available to other nurses
and health care professionals. Immediate recording helps safeguard the client.

Nursing activities are communicated verbally as well as in writing. When a client’s health
is changing rapidly, the charge nurse and/or the primary care provider may want to be kept up to
date with verbal reports. Nurses also report client status at a change of shift and on a client’s
discharge to another unit or health agency in person, via a voice recording, or in writing.
 EVALUATING
Evaluating is the fifth phase of the nursing process. It is a planned, ongoing, purposeful
activity in which clients and health care professionals determine (a) the client’s progress toward
achievement of goals/outcomes and (b) the effectiveness of the nursing care plan.

Evaluation is an important aspect of the nursing process because conclusions drawn from
the evaluation determine whether the nursing interventions should be terminated, continued, or
changed. The evaluation is continuous and should not stop there. It is done while or immediately
after implementing a nursing order enables the nurse to make modifications in an intervention.
Evaluation performed at specified intervals shows the extent of progress toward achievement of
goals and enables the nurse to correct any deficiencies and modify the care plan as needed.

Evaluation continues until the client achieves the health goals or is discharged from
nursing care. Evaluation at discharge includes the status of goal achievement and the client’s
self-care abilities with regard to follow-up care. Through evaluating, nurses demonstrate
responsibility and accountability for their actions, indicate interest in the results of the nursing
activities, and demonstrate a desire not to perpetuate ineffective actions but to adopt more
effective ones.

Similarly, the effectiveness of interventions and achievement identified outcomes is

continuously evaluated as the client status is assessed. Evaluation should ultimately occur at each
step in the nursing process, as well as once the plan of care has been implemented.
1 .Evaluation of goal achievement

Before evaluation, the nurse identifies the desired outcomes that will be used to measure
client goal achievement. Desired outcomes serve two purposes: They establish the kind of
evaluative data that need to be collected and provide a standard against which the data are
judged.

 Collecting data related to the desired outcomes

 Comparing the data with desired outcomes
 Relating nursing activities to outcomes
 Drawing conclusions about problem status
 Continuing, modifying, or terminating the nursing care plan.

Collecting Data
Using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse collects
data so that conclusions can be drawn about whether goals have been met. It is usually necessary
to collect both objective and subjective data.

When interpreting subjective data, the nurse must rely on either

(a) the client’s statements
(b) objective indicators

Data must be recorded concisely and accurately to facilitate the next part of the evaluating
process.

Comparing Data with Desired Outcomes

Both the nurse and client play an active role in comparing the client’s actual responses with the
desired outcomes.

When determining whether a goal has been achieved, the nurse can draw one of three possible
conclusions:

1. The goal was met; that is, the client response is the same as the desired outcome.
2. The goal was partially met; that is, either a short-term outcome was achieved but the long-term
goal was not, or the desired goal was incompletely attained.
3. The goal was not met.

2. Formulating the Quality of nursing care

After determining whether or not a goal has been met, the nurse writes an evaluation statement
 An evaluation statement consists of two parts: a conclusion and supporting data. The
conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The
supporting data are the list of client responses that support the conclusion.

Relating Nursing Activities to Outcomes

The third phase of the evaluating process is determining whether the nursing activities had any
relation to the outcomes. It should never be assumed that a nursing activity was the cause of or
the only factor in meeting, partially meeting, or not meeting a goal.

Drawing Conclusions About Problem Status

The nurse uses the judgments about goal achievement to determine whether the care plan was
effective in resolving, reducing, or preventing client problems. When goals have been met, the
nurse can draw one of the following conclusions about the status of the client’s problem:

■ The actual problem stated in the nursing diagnosis has been resolved, or the potential problem
is being prevented and the risk factors no longer exist. In these instances, the nurse documents
that the goals have been met and discontinues the care for the problem.

■ The potential problem stated in the nursing diagnosis is being prevented, but the risk factors
are still present. In this case, the nurse keeps the problem on the care plan.

■ The actual problem still exists even though some goals are being met.

■ The care plan may need to be revised, since the problem is only partially resolved. The
revisions may need to occur during the assessing, diagnosing, or planning phases, as well as
implementing. OR

■ The care plan does not need revision, because the client merely needs more time to achieve the
previously established goal. To make this decision, the nurse must assess why the goals are being
only partially achieved, including whether the evaluation was conducted too soon.

3. Care Plan Revision

Continuing, Modifying, or Terminating the Nursing Care Plan

After drawing conclusions about the status of the client’s problems, the nurse modifies
the care plan as indicated. Depending on the agency, modifications may be made by drawing a
line through portions of the care plan, marking portions using a highlighting pen, or indicating
revisions as appropriate for electronic charting systems. Whether or not goals were met, a
number of decisions need to be made about continuing, modifying, or terminating nursing care
for each problem.
 Before making modifications, the nurse must determine the effectiveness of the plan as a
whole. This requires a review of the entire care plan and a critique of each step of the nursing
process involved in its development.

ASSESSING

An incomplete or incorrect database influences all subsequent steps of the nursing

process and care plan. If data are incomplete, the nurse needs to reassess the client and record the
new data. In some instances, new data may indicate the need for new nursing diagnoses, new
goals/outcomes, and new nursing interventions.

DIAGNOSING

If the database was incomplete, new diagnostic statements may be required. If the
database was complete, the nurse needs to analyze whether the problems were identified
correctly and whether the nursing diagnoses were relevant to that database. After making
judgments about problem status, the nurse revises or adds new diagnoses as needed to reflect the
most recent client data.

PLANNING: DESIRED OUTCOMES

If a nursing diagnosis was inaccurate, obviously the goal/outcome statement will need
revision. If the nursing diagnosis was appropriate, the nurse then checks if the goals were
realistic and attainable. Unrealistic goals require correction. The nurse should also determine
whether priorities have changed and whether the client still agrees with the priorities. Goals and
outcomes must also be written for any new nursing diagnoses.

PLANNING: NURSING INTERVENTIONS

The nurse investigates whether the nursing interventions were related to goal
achievement and whether the best nursing interventions were selected. Even when diagnoses and
goals/outcomes were appropriate, the nursing interventions selected may not have been the best
ones to achieve the goal. New nursing interventions may reflect changes in the amount of
nursing care the client needs, scheduling changes, or rearrangement of nursing activities to group
similar activities or to permit longer rest or activity periods for the client.

IMPLEMENTING

Even if all sections of the care plan appear to be reasonable, the manner in which the plan
was implemented may have interfered with goal achievement. Before selecting new
interventions, the nurse should check whether they were carried out. Other personnel may not
have carried them out, either because the interventions were unclear or because they were
unreasonable in terms of external constraints such as money, staff, time, and equipment. After
making the necessary modifications to the care plan, the nurse implements the modified plan and
begins the nursing process cycle again.
4. Evaluating the Quality of Nursing Care

In addition to evaluating goal achievement for individual clients, nurses are also involved
in evaluating and modifying the overall quality of care given to groups of clients. This is an
essential part of professional accountability of the nurse. Nurses and all other health care
providers work together as an interdisciplinary team focused on improving client care. The
activities both use and contribute to evidence-based practice.

a. Quality Assurance

A quality assurance program is an ongoing, systematic process designed to evaluate

and promote excellence in the health care provided to clients. Quality assurance frequently refers
to evaluation of the level of care provided in a health care agency, but it may be limited to the
evaluation of the performance of one nurse or more broadly involve the evaluation of the quality
of the care in an agency, or even in a country.

Quality assurance requires evaluation of three components of care: structure, process, and
outcome.

Structure evaluation It focuses on the setting in which care is given. It answers this question:
What effect does the setting have on the quality of care? Structural standards describe desirable
environmental and organizational characteristics that influence care, such as equipment and
staffing.

Process evaluation focuses on how the care was given. It answers questions such as these: Is the
care relevant to the client’s needs? Is the care appropriate, complete, and timely? Process
standards focus on the manner in which the nurse uses the nursing process.

Outcome evaluation focuses on demonstrable changes in the client’s health status as a result of
nursing care. Outcome criteria are written in terms of client responses or health status, just as
they are for evaluation within the nursing process.

b. Quality Improvement
Serious national efforts are currently under way to evaluate and improve the quality of
health care based on internal assessment by health care providers and increasing awareness by
the public that medical errors are not uncommon and can be lethal.

Center for Quality Improvement and Patient Safety

1. Conducts and supports user-driven research on client safety and health care quality
measurement, reporting, and improvement.

2. Develops and disseminates reports and information on health care quality measurement,
reporting, and improvement.
 3. Collaborates with stakeholders across the health care system to implement evidence-
based practices, accelerating amplifying improvements in quality and safety for clients.

4. Assesses our own practices to ensure continuous learning and improvement for the
Center and its members.”

A sentinel event is an unexpected occurrence involving death or serious physical or

psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or
function. The phrase “or the risk thereof” includes any process variation for which a recurrence
would carry a significant chance of a serious adverse outcome.

Root cause analysis is a process for identifying the factors that bring about deviations in
practices that lead to the event. It focuses primarily on systems and processes, not individual
performance. It begins with examination of the single event but with the purpose of determining
which organizational improvements needed to decrease the likelihood of such events occurring
again

c. Nursing Audit

An audit refers to the examination or review of records. A retrospective audit is the

evaluation of a client’s record after discharge from an agency. Retrospective means “relating to
past events.” A concurrent audit is the evaluation of a client’s health care while the client is still
receiving care from the agency. These evaluations use interviewing, direct observation of nursing
care, and review of clinical records to determine whether specific evaluative criteria have been
met.

References:
 Berman, A.S (2015) Kozier & Erb’s Fundamentals of Nursing (9th Edition)
 Nanda (11th Edition)