FUNDAMENTALS OF NURSING MODULE 4-6

MODULE 4-6
 result oriented
Test Coverage:  designed to help you stay focused on getting the
best results in the most efficient way .
M4 – Overview of nursing process
 Nursing process PRO-ACTIVE
M5-Diagnosis
Lesson 1: Key terms related to diagnosis  emphasizes the need to not only treat problems, but
Lesson 2: How to make definitive diagnoses also
Lesson 3: Types of nursing diagnosis  maximize health by managing risk factors & by
Lesson 4: Comparison of nursing diagnosis to medical Diagnosis. encouraging healthy behaviors
M6- PLANNING
EVIDENCE-BASED
 it mandates that judgments, decisions, & actions be
MODULE 4: NURSING ASSEMENT AND PROCESS
based on the best evidence than guesswork
OVERVIEW OF NURSING PROCESS  strict documentation requirements ensure that we
have the data we need to manage care &
 a deliberate activity whereby the practice of nursing is help researchers study care practices & improve
performed in a systematic manner them
 the foundation, the essential, enduring skill that has
characterized nursing from the beginning of the INTUITIVE & LOGICAL
profession
 principles of nursing process push you to
 A SYSTEMATIC & OUTCOME ORIENTED method
acknowledge patterns & intuitive hunches, then
that nurses use to expedite diagnosis and treatment
to look for evidence that supports your intuition
of actual and potential health problems
consists of 5 INTERRELATED STEPS ;
REFLECTIVE, CREATIVE & IMPROVEMENT-
 Assessment, Diagnosis, Planning, Implementation &
Evaluation which serves as CRITICAL THINKING ORIENTED
MODEL FOR NURSING.  stresses the need for on-going evaluation, requiring
to continually reflect on both patient responses
PURPOSE OF NURSING PROCESS (outcomes) &practice (how we give care) so that
corrections can be immediately done
 ☺ to provide a systematic methodology for nursing  requires to work continually to improve nursing care,
practice: encouraging one to think creatively about how to get
 ☺ it unifies, standardizes, and directs nursing practice better results in easier, more efficient, less costly
ways.
 ☺ help the nurse continually assess & reassess the
patient’s response to illness & then plan appropriate
care in any setting for illness care or health promotion NURSING PROCESS

CHARACTERISTIC OF THE NURSING PROCESS

THAT PROMOTE CRITICAL THINGKING

PURPOSEFUL & DELIBERATE

 each step has specific principles and rules designed
to achieve a specific purpose

HUMANISTIC
 must consider unique interests, values, desires and
culture
 guides you to focus holistically on the body, mind &
spirit PRINCIPLES OF NURSING PROCESS (ACODE)
 pushes you to consider health problems in context of
how they impact on sense of well-being and ability to  A cognitive process
do desired activities  Client centered
 Outcome-directed;
 Systematic problem-solving approach
SYSTEMATIC
 Dynamic and cyclic
 five steps guide you to think systematically about  Encourages medical diagnosis.
what’s
 most important & to take deliberate steps to STEPS OF THE NURSING PROCESS
maximize efficiency
1. ASSESSMENT
STEP - BY – STEP, YET DYNAMIC  Collect & Record all information needed to
 to ensure that nothing important is missed be able to:
 Predict, detect, prevent, manage, or eliminate health
OUTCOME- FOCUSED & COST EFFECTIVE problems

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 FUNDAMENTALS OF NURSING MODULE 4-6
 Clarify expected outcomes (results?)  collecting, organizing and communicating / recording
 Develop a comprehensive plan client data

Purpose:
 to establish data base about the client’s response to
2. DIAGNOSIS health concerns or illness and the ability to manage
 Analyze assessment data, draw conclusions, health care needs
and determine:
 Actual and potential health problems and their CHARACTERISTICS OF AN ASSESSMENT THAT
cause(s) PROMOTES CRITICAL THINKING
 Presence of risk factors
 Resources, strengths, use of healthy behaviors PURPOSEFUL
 Health states that are satisfactory but could be improved  your aim is to gain all the information needed to
ensure that your patients have “individualized
3. PLANNING plans”
 Clarify expected outcomes, set priorities, and
determine interventions. The interventions FOCUSED & RELEVANT
aredesigned to:  Must be focused to gain relevant information,
 detect, prevent, and manage health problems and risk depending on purpose and context
factors
 promote optimum function, independence, and SYSTEMATIC
sense of well-being  Helps pay attention to what’s important, learn
 achieve the expected outcomes safely and efficiently. how to prioritize,be comprehensive, and avoid
omission errors.
4. IMPLEMENTATION COMPREHENSIVE & ACCURATE
 Put the plan into action by:  factual & complete
 Assessing appropriateness of (and readiness for)
interventions RECORDED IN A STANDARDIZED WAY
 Performing interventions, then reassessing to  value the importance of completing a
determine initial responses standardized tool designed to promote an
 Making immediate changes as needed assessment that’s purposeful, relevant,
 Charting to monitor progress systematic and complete.
5. EVALUATION
2 MAIN TYPES OF ASSESMENT
 Assess the patient to decide whether expected outcomes
have been met
 Data Base Assessment
 Then decide whether to discharge the patient or modify
 “start of care” assessment
the plan as appropriate, and you plan for ongoing
 Comprehensive information gathered on
continuous assessment and improvement.
initial contact with the person to assess all
aspects of health status
 Focus Assessment
NURSING PROCESS  Data gathered to determine the status of a
ASSESMENT specific condition

ASSEMENT ACTIVITIES.

1. Collecting Data
2. Identifying Cues & Making Inferences
3. Validating / Verifying Data
4. Organizing / Clustering Data
5. Identifying Patterns / Testing First Impressions
6. Reporting and Recording Data

DATA GATHERING PROCEDURE

PRIMARY SOURCE
 Client / patient
ASSESMENT
SECONDARYSOURCES
 Significant others
 systematic, deliberate process
 Nursing & Medical Records
 continuous data collection
 Verbal & Written Consultations
 analyzes data about the patient, client’s human
 Diagnostic / Laboratory Studies
response, health status, strengths and concerns
 finding all the “necessary puzzle pieces” to get a
picture of your patient’s health status

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The most up-to-date information comes from your direct  Opening → sets the tone of the remainder of the
assessment of the patient. interview.
ASSEMENT ACTIVITY 1.Establish rapport → process of creating good will and trust
2. Orientation → explaining the purpose and nature of the
COLLECTING DATA interview
 Data Collection Skills
 Body → client communicates what he or she thinks, feels,
A. Observation of patient knows and perceives in response to questions from the
B. Interview of patient, family & nurse
other nurses  Closing → important in facilitating future interactions.
C. Examination of Patient
D. Medical Record Review
DATA COLLECTION SKILL
A. OBSERVATION
• noting pieces of information or cues through the use of C. EXAMINATION OF THE PATIENT (PHYSICAL
senses (sight, touch, hearing, smell and taste). ASSESSMENT)
It has to be:
➢ THOROUGH
B. INTERVIEW ➢ SYSTEMATIC
• a structured form of communication that the nurse uses to ➢ SKILLED
collect data face to face
EXAMINATION OF THE PATIENT APPROACHES:
KEYPOINT FOR INTERVIEW
> Head-to-toe Assessment/Cephalocaudal
 ability to establish rapport > Body System Approach
 ability to ask questions
EXAMINATION OF THE PATIENT
 ability to listen is essential to successful interviews
 ability to observe SKILLS USED IN PHYSICAL EXAM:
 Inspection / Visualization
INTERVIEW
 Palpation
DIRECT INTERVIEW  Percussion
 Auscultation
 Highly structured and elicit specific information by
asking closed questions that call for a specific amount D. MEDICAL RECORD/S REVIEW
of data. PURPOSES:

INDIRECT INTERVIEW  To relate the past health care history of the patient to
 The nurse allows the client to control the purpose, the present episode
subject matter and pacing  to identify what medication the patient is taking so that
the assessment can include the effectiveness of the
medication & the occurrence of any side effects
KINDS OF INTERVIEW QUESTION
COLLECTING DATA
CLOSE ENDED
Data Collection Format
 restrictive and generally require only short answers
giving specific information; often begin with when,
 Maslow’s Basic Need Frameworks
where, who, what, do, does, did.
 Henderson’s Components of Nursing Care
OPEN-ENDED  Gordon’s Functional Health Patterns
 lead or invite clients to explore their thoughts or  Nanda’s Human Response Patterns
feelings.  Nursing Theories
 Human Growth & Development.
PLANNING THE INTERVIEW AND SETTING
IDENTIFYING SUBJECTIVE & OBJECTIVE DATA
 Time → need to be scheduled when the client is
comfortable and free of pain Subjective Data
 Place → must have adequate privacy to promote  information given verbally by the patient
 communication
 Seating arrangement Objective Data
 Distance → most people feel comfortable 3 to 4 ft.  factual data that are observed by the nurse & could
apart during an interview be noted by any other skilled observer

STAGES OF AN INTERVIEW

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 FUNDAMENTALS OF NURSING MODULE 4-6
 Double check that your equipment is working
TYPES OF DATA correctly.
SUBJECTIVE DATA  Recheck own data
- symptoms or covert data  Look for factors that may alter accuracy
e.g. – itching pain, feelings of worry include  Ask someone else, preferably an expert, to collect
client’s sensations, feelings, values, beliefs, attitudes and the same data
perception of personal health status and life situations.  Compare subjective & objective data to see if what
the person is stating is congruent with what you
Problem: Fever → subjective cue: “Mainit ang observe
pakiramdam ko.”  Clarify statements and very your inferences with
the patient
OBJECTIVE DATA  Compare your impressions with those of other key
 signs or overt data members of the health care team.
•detectable by an observer or can be tested against
an accepted standard 4. ORGANIZING /CLUSTERING DATA
e.g. – discoloration of the skin RULE:
Problem: FEVER
Objective cues: skin is warm to touch Cluster your data according to your purpose
temperature is 38.9 C
 to identify nursing diagnoses and problems
 to identify signs and symptoms of possible medical
problems
 to set priorities
 clustering data one way, then clustering it another
way helps you think critically

ORGANIZING / CLUSTERING DATA

ASSEMENT ACTIVITY

2. IDENTIFYING CUES & MAKING INFERENCES

CUES
 the subjective & objective data identified MASLOW’S HIERARCHY OF NEEDS
INFERENCE  Used to set priorities
 how one interprets or perceive a cue  Physiologic- vital signs, nutrition, sex, pain
 Safety and security-energy level, presence of risk
factors
3.VALIDATING /VERIFYING DATA  Love and belongingness- Family and relationship
Advantages  Self-esteem- honors, awards, recognitions
It helps one to avoid:
 Self-actualization- self-fulfillment, selfless service
 Making assumptions ABC (AIRWAY BREATHING CIRCULATION)
 Missing key information  Used to set priorities
 Misunderstanding situations  I.E. Bleeding-circulation, Difficulty of Breathing-
 Jumping to conclusions or focusing in the wrong Airway and Breathing
direction
 Making errors in problem identification BODY SYSTEM
 Used to identify signs and symptoms of possible
GUIDELINES IN VALIDATING/VERIFYING DATA medical problems
 I.E. Body systems- cardiovascular, respiratory,
 Data that can be measured accurately can be lymphatic systems
accepted as factual.
 Data that someone else observes (indirect data) may GORDON’S FUNCTIONAL HEALTH PROBLEMS
or may not be true.  Used to identify nursing diagnosis and problems
 Psychological, Elimination, Rest and Sleep,
Validate questionable information by using the ff. Oxygenation, Nutrition… etc.
techniques, as appropriate:
 Double check information that’s extremely
abnormal or inconsistent with patient cues

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 FUNDAMENTALS OF NURSING MODULE 4-6
5.IDENTIFYING PATTERNS / TESTING FIRST
IMPRESSIONS
 involves deciding what’s relevant & irrelevant,
making tentative decision about what the data
suggests
 focusing assessment to gain more information to
better understand the situations at hand
 remember cause & effect; find out why or how the
pattern came to be
6. REPORTING & RECORDING
Report abnormal findings as soon as possible
 Before reporting, take a moment to be sure you have
all the necessary information readilyat hand
 jot down the facts in order of importance
 give precise information, state the facts rather than
how you interpret the facts
TO SUMMARIZE……….
Nursing Assessment includes:
1. Collecting Data
2. Identifying Cues & Making Inferences
3. Validating / Verifying Data
4. Organizing / Clustering Data
5. Identifying Patterns / Testing First Impressions
6. Reporting and Recording Data
MODULE 5: DIAGNOSIS
NURSING PROCESS: DIAGNOSIS
‘’The nurse analyzes the assessment data in determining
health problems’’
DIAGNOSING
 a form of decision making that the nurse uses to
arrive at judgments and conclusions about patients’
responses to actual or potential health problems
DIAGNOSE
 To make judgment and specifically name actual and
potential health problems or risk factors present,
based on evidence from assessment data.
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NURSING DIAGNOSIS
 it refers to a problem statement that nurse makes
regarding a patient’s condition
 a clinical judgment about the patient’s response to
actual or potential health conditions or needs
 provides the basis for prescriptions (interventions) for
definitive therapy for which the nurse is accountable
 expressed concisely and includes the etiology of the
condition when known.
MODULE 5: DIAGNOSIS
LESSON 1: KEY TERMS RELATED TO
DIAGNOSIS
COMPETENCY
 having the knowledge and skills to identify problems
and risks and to perform action safely & efficiently in
various situations.
QUALIFIED
 being competent and having the authority to perform
an action of give a professional option.
NURSING DOMAIN
 actions a nurse is legally qualified to perform
MEDICAL DOMAIN
 activities and actions a physician is legally qualified to
perform depending on state regulations, APN are also
legally qualified to perform some things in the medical
domain.
ACCOUNTABLE
 being responsible and answerable for something
DEFINITIVE INTERVENTIONS
 most specific actions or treatments required to
prevent, resolve, or manage a health problem.
OUTCOME
 the result of prescribed interventions, usually referred
to as desired result of interventions, includes a
specific time frame when the outcome is expected to
be achieved.
SIGNS
 objective (observable data) known to suggest a health
problem.
SYMPTOMS
 subjective (reported) data known to suggest a health
problem.
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 FUNDAMENTALS OF NURSING MODULE 4-6
CUES
 signs and symptoms that prompt you to suspect the
presence of a health problem or desire to improve
health.
DEFINITVE DIAGNOSIS
 most specific, most correct diagnosis that clearly
identifies both the problem and the cause.
DEFINING CHARACTERISTICS
 a cluster of signs and symptoms, and related factors
usually seen with a specific nursing diagnosis.
RULE OUT
 to decide that a certain problem is NOT present.
RELATED FACTOR
 something known to be associated with specific
health problem (history of frequent falls is a related
factor to RISK FOR INJURY)
RISK FACTOR ETIOLOGY
 something known to cause, or contribute to a
diagnosis (decreased vision is a related factor for
RSK FOR INJURY)
DIAGNOSIS
Becoming a competent DIAGNOSTICIAN
 Act in your patient’s best interest, and protect yourself
from legal problems, you must understand the key
terms to DIAGNOSIS
LEGAL IMPLICATION OF THE WORD DIAGNOSIS
 The word DIAGNOSIS implies that there’s a situation
or problem requiring appropriate, qualified treatment.
 This means if you identify a problem, you must decide
whether you’re qualified to treat it or willing to accept
responsibility for treating it.
 If you’re not, you’re responsible for getting qualified
help.
PURPOSES OF NURSING DIAGNOSIS
 To provide the basis for determination of a plan of
care to achieve expected outcomes for a patient’s
health status. (ANA, 1998)
 to clarify the exact nature of the problems and risk
factors to achieve the overall expected outcomes of
care
 the conclusions you make during this phase affect
the entire plan of care.
 To identify client strengths and health problems that
can be prevented or resolved by collaborative and
independent nursing interventions
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 To develop a list of nursing and collaborative
problems
NURSING PROCESS-DIAGNOSIS
 The accuracy & relevancy of the entire plan depends
on your ability to clarify the problems and what factors
are causing or contributing to them if you make errors
in this phase, your whole plan may be USELESS,
even DANGEROUS.
MODULE 5: DIAGNOSIS
LESSON 2: HOW TO MAKE DEFINITIVE DIAGNOSIS
 Diagnostic process involves critical thinking skills of
analysis and synthesis
 In critical thinking, a person reviews data and
considers explanations before forming an opinion.
 Analysis is the separation into components, that is,
the breaking down of the whole into its parts
(deductive reasoning) Synthesis the putting together
of parts into the whole (inductive reasoning)
STEPS HOW TO MAKE DEFINITIVE DIAGNOSIS
1. Analyzing data
2. Identifying health problems, risks, and strengths
3. Formulating diagnostic statements
ANALYZING DATA
1. Compare data against standards (identify significant cues).
2. Cluster the cues (generate tentative hypotheses).
3. Identify gaps and inconsistencies
1. Compare data against standards (identify significant
cues). A cue is considered significant if it does any of the
following:
a. Points to negative or positive change in a client’s health
status or pattern.
b. Varies from norms of the client population.
c. Indicates a developmental delay.
2. Cluster the cues
 determine the relatedness of facts and
 determining whether any patterns are present,
whether the data represent isolated incidents,
whether the data are significant.
 it involves making inferences
 Interpret the possible meaning of the cues, labels the
cue clusters with tentative diagnostic hypotheses
3. Identify gaps and inconsistencies
 skillful assessments minimize gaps and
inconsistencies in data
 sources of conflicting data include measurement
error, expectations and inconsistent or unreliable
reports
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 FUNDAMENTALS OF NURSING MODULE 4-6
IDENTIFYING HEALTH PROBLEMS, RISKS, AND
STRENGTHS 9.State the diagnosis CLEARLY & CONCISELY.
High Risk for trauma related to dizziness.
Fatigue related to dizziness.
 Determining problems and risks After grouping and
clustering the data, the nurse and client together
MODULE 5: DIAGNOSIS
identify problems that support tentative actual, risk,
and possible diagnoses.
LESSON 3: TYPES OF NURSING DIAGNOSIS
 Determining strengths establish the client’s strengths,
 Actual nursing diagnosis
resources, and abilities to cope.
 Health promotion diagnosis
FORMULATING DIAGNOSTIC STATEMENTS  Risk diagnosis
 Syndrome diagnosis
Guidelines in Writing a Nursing Diagnosis ACTUAL NURSING DIAGNOSIS
1.Write the diagnosis in terms of the person’s response rather
than nursing need.  present or existing problem that may or may not
Needs suctioning because she has many secretions. necessitate immediate concern
High Risk for Aspiration related to excessive oral  a client problem that is present at the time of the
secretions. nursing assessment

2. Use “RELATED TO” rather than “DUE TO” or “CAUSED BY” Actual Nursing Diagnosis = Patient problem + Causes if known
to connect the two parts of the statement.
PES APPROACH
Altered Sexuality Patterns related to change in body
image.
Altered Sexuality Patterns caused by change in body
image

3. Write the diagnosis in LEGALLY advisable terms.

High Risk for trauma related to inadequately

maintained skin traction.
High Risk for trauma related to hazards of skin
HEALTH PROMOTION DIAGNOSIS
traction.

4.Write the diagnosis WITHOUT value judgments.
Altered Parenting related to poor bonding with child.
Altered Parenting related to prolonged separation
from child.
 relates to clients’ preparedness to implement
behaviors to improve their health condition
Readiness for ……

5. Avoid reversing the parts. RISK DIAGNOSIS

Impaired social interaction related to confinement to  a clinical judgment that a problem does not exist, but
home. the presence of risk factors indicates that a problem is
Confinement to home related to impaired social likely to develop unless nurses intervene.
interaction.
PRS APPROACH
6.Avoid including signs & symptoms of illness in the first part of
the statement.
Withdrawn behavior related to inability to engage in
satisfying personal relationships.
Social isolation related to inability to engage in
satisfying personal relationships

7.Be sure that the two parts of the diagnosis do not mean the
same thing.
Stress Incontinence related to impaired muscle tone
of the urinary bladder.
Stress incontinence related to inability to control
urine. SYNDROME DIAGNOSIS

8.Express the problems and related factors in terms that can  is assigned by a nurse’s clinical judgment to describe
be changed. a cluster of nursing diagnoses that have similar
Knowledge Deficit (Prenatal Diet) interventions
Knowledge Deficit (Pregnancy)

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COMPONENTS OF A NANDA NURSING DIAGNOSIS
North American Nursing Diagnosis Association
A nursing diagnosis has three components:
(1) the problem and its definition,
(2) the etiology,
(3) the defining characteristics Each component serves a
specific purpose
NAME THE PROBLEMS BY USING THE LABELS THAT
MOST CLOSELY MATCH ASSESMENT CUES
Diagnosis is based on recognizing when patient cues match
the signs and symptoms or defining characteristics of a specific
diagnosis.
WHEN YOU SUSPECT A SPECIFIC PROBLEM, LOOK FOR
OTHER SIGNS, SYMPTOMS, AND RISK FACTORS
COMMONLY ASSOCIATED WITH THE PROBLEM.

PROBLEM (DIAGNOSTIC LABEL) AND DEFINITION “More than one cue, more likely it’s TRUE. More than one
source, more likely of course.’’
 The standardized NANDA names for the diagnoses
WHEN YOU MAKE DIAGNOSIS, BACK IT UP WITH
are called diagnostic labels the client’s problem
EVIDENCES.
statement, consisting of the diagnostic label plus
etiology (causal relationship) between a problem and
 Cues are like “key puzzle pieces”, if you don’t have
its related or risk factors is called a nursing diagnosis.
them, you can’t complete the puzzle and label the
problem.
Qualifiers are words that have been added to some
NANDA labels to give additional meaning to the diagnostic
INCLUDE PROBLEMS FROM PATIENT’S PERSPECTIVE
statement,

DEFICIENT  Patients know themselves best, and must be included

in the diagnostic process.
 Inadequate in amount, quality, or degree; not
sufficient.  Things that the patient sees as problems should be
given a high priority.
IMPAIRED
 Made worse, weakened, damaged, reduced, PATIENTS OFTEN PRESENT COMPLAINING OF TWO OR MORE
deteriorated RELATED PROBLEMS

DECREASED  Often one problem creates another.

 Lesser in size, amount, or degree.
MODULE 5: DIAGNOSIS
LESSON 4: COMPARISON OF NURSING DIAGNOSIS
FUNDAMENTAL PRINCIPLES AND RULES OF VS MEDICAL DIAGNOSIS
DIAGNOSTIC REASONING
MEDICAL DIAGNOSIS
KNOW YOUR QUALIFICATION AND LIMITATION
→ made by a physician refers to a pathophysiologic response
that are fairly uniform from one client to another. ▪
 People have the right to be assessed by a qualified
health care professional.
 Although you may feel that you have the knowledge
NURSING DIAGNOSIS
to do an assessment and diagnose the problems, you
must determine (for your patient and your own legal
protection) whether you have the authority to do so → describes the clients’ physical, sociocultural, psychologic
and spiritual responses to an illness or potential health
KEEP AN OPEN MIND problems; vary among individuals.

 Prevents you from seeing problems from a narrow

perspective, a common critical thinking error. A NURSING DIAGNOSIS

IS
MAKING A DIAGNOSES INVOLVES COMPARING YOUR ▪ A statement of a patient problem
PATIENT’S CUES (Sign and symptoms) WITH ‘’TEXTBOOK ▪ Actual or potential
PICTURE’’ OF DIAGNOSES YOU SUSPECT ▪ Within the scope of nursing practice
▪ Directive of nursing intervention
 You make a definitive diagnosis, when your patient’s
data closely match the “textbook picture” of the IS NOT
diagnosis you suspect. A medical diagnosis
▪ A nursing actions
▪ A physician orders
▪ A therapeutic treatment

MAIN FOCUS
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 FUNDAMENTALS OF NURSING MODULE 4-6
identifies pathologic basis identifies response to illness
NURSING DIAGNOSIS for illness
Focuses on the physical Focuses on the physical,
 The impact of disease, trauma or life changes upon condition of the client psychosocial & spiritual
patient and families (human responses) needs of the client
 Problems with functioning independently (ADL) Addresses actual existing Addresses actual & potential
 Quality of life issues (pain, ability to do desired problems problems
activities) Not validated with the client Validated with the client, if
possible
MEDICAL DIAGNOSIS Uses standardized goals & Uses INDIVIDUALIZED
treatments goals & interventions
 Disease, trauma and pathophysiology May not be resolvable usually resolvable
 Quality of life tissues (pain, ability to do desired
activities, but to a lesser extent than nursing – they MEDICAL DIAGNOSIS
often refer this problem to other disciplines.
 Allows opportunity to ramble and get off track.  Myocardial infarction
 Chronic ulcerative colitis
 Chronic ulcerative colitis
PRIMARY MANAGER OF THE PROBLEM  Cancer of the breast
 Cerebral vascular accident
NURSING DIAGNOSIS
NURSING DIAGNOSIS
 Nurse (may use other resources such as physical
therapy or physician expertise, but the nurse accepts  Fear r/t possible recurrence of uncertain outcome
primary responsibility for monitoring status and  Diarrhea r/t dis. Process
allocating resources.  Alteration in nutrition: less than body requirements r/t
 Definitive Diagnosis altered GI absorptions
 Authority to diagnose is within the nursing domain  Risk for (Potential) body image disturbance if
mastectomy is required
 Self-care deficit: dressing & grooming r/t right sided
MEDICAL DIAGNOSIS flaccidity

 Physician or Advanced Practice Nurse MODULE 6: PLANNING

 Definitive Diagnosis LESSON 1: TYPES OF PLANNING
 Nursing is required to seek physician or APN
diagnosis. PLANNING

NURSING RESPONSIBILITIES - Planning is a category of nursing behavior in which

client centered goals and expected outcomes are
NURSING DIAGNOSIS established and nursing intervention are selected to
achieve the goals and outcomes of care
1. Identification of risk factors, anticipating potential
complications. TYPES OF PLANNING
2. Monitoring to detect and report early signs and
symptoms or potential complications or change in - Planning begins with the first client contact and continues
status. until the nurse–client relationship ends, usually when the client
3. Initiating actions within the nursing domain to prevent is discharged from the health care agency. All planning is
or minimize the problems and their potential multidisciplinary (involves all health care providers interacting
complications. with the client) and includes the client and family to the fullest
4. Implementing medical orders (physician or APN is extent possible in every step.
primary manager of the problem.
INITIAL PLANNING
- The nurse who performs the admission assessment
MEDICAL DIAGNOSIS
usually develops the initial comprehensive plan of
care. This nurse has the benefit of seeing the client’s
1. Identification of signs, symptoms and risk factors
body language and can also gather some intuitive
2. Early detection of actual or potential problem.
kinds of information that are not available solely from
3. Initiation of a comprehensive plan to prevent, correct,
the written database. Planning should be initiated as
or control the problems (nurse is the primary manager
soon as possible after the initial assessment.
of the problems)
ONGOING PLANNING
- All nurses who work with the client do ongoing
planning. As nurses obtain new information and
evaluate the client’s responses to care, they can
MEDICAL DIAGNOSIS NURSING DIAGNOSIS individualize the initial care plan further. Ongoing

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planning also occurs at the beginning of a shift as the
nurse plans the care to be given that day. Using
ongoing assessment data, the nurse carries out daily
planning for the following purposes:
1. To determine whether the client’s health status has
changed
2. To set priorities for the client’s care during the shift
3. To decide which problems to focus on during the
shift
4. To coordinate the nurse’s activities so that more
than one problem can be addressed at each client
contact.
DISCHARGE PLANNING
- Discharge planning, the process of anticipating and
planning for needs after discharge, is a crucial part of
a comprehensive health care plan and should be
addressed in each client’s care plan. Because
the average stay of clients in acute care hospitals has
become shorter,people are sometimes discharged still
needing care. Although many clients are discharged
to other agencies (e.g., long-term care facilities), such
care is increasingly being delivered in the home.
Effective discharge planning begins at first client
contact and involves comprehensive and ongoing
assessment to obtain information about the client’s
ongoing needs. 
 
THE PLANNING PROCESS
In the process of developing client care plans, the nurse
engages in the following activities:
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and activities
• Writing individualized nursing interventions on care plans.
1.Setting Priorities
- Priority setting is the process of establishing a
preferential sequence for addressing nursing
diagnoses and interventions. The nurse and client
begin planning by deciding which nursing diagnosis
requires attention first, which second, and so on.
Instead of rank-ordering diagnoses, nurses can group
them as having high, medium, or low priority. Life-
threatening problems, such as impaired respiratory or
cardiac function, are designated as high priority.
Health-threatening problems, such as acute illness
and decreased coping ability, are assigned medium
priority because they may result in delayed
development or cause destructive physical or
emotional changes. A low-priority problem is one that
arises from normal developmental needs or that
requires only minimal nursing support A low-priority
problem is one that arises from normal developmental
needs or that requires only minimal nursing support.
- Nurses frequently use Maslow’s hierarchy of needs
when setting priorities. In Maslow’s hierarchy,
physiological needs such as air, food, and water are
basic to life and receive higher priority than the need
for security or activity. Growth needs, such as self-
esteem, are not perceived as “basic” in this
framework. It is not necessary to resolve all high-
priority diagnoses before addressing others. The
LOREY MANALO
nurse may partially address a high-priority diagnosis
and then deal with a diagnosis of lesser priority.
Furthermore, because the client may have several
problems, the nurse often deals with more than one
diagnosis at a time. 
Priorities 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: Values concerning health
may be more important to the nurse than to the client. 
2. Client’s priorities: Involving the client in prioritizing and care
planning enhances cooperation. Sometimes, however, the
client’s perception of what is important conflicts with the
nurse’s knowledge of potential problems or complications. 
3. Resources available to the nurse and client. If finances,
equipment, or personnel are scarce in a health care agency,
then a problem may be given a lower priority than usual. 
4. Urgency of the health problem. Regardless of the framework
used, life-threatening situations require that the nurse assign
them a high priority. 
5. Medical treatment plan. The priorities for treating health
problems must be congruent with treatment by other health
professionals. 
2.Establishing Client Goals/ Desired Outcomes
- After establishing priorities, the nurse and client set
goals for each nursing diagnosis. On a care plan,
the goals/ desired outcomes describe, in terms of
observable client responses, what the nurse hopes to
achieve by implementing the nursing interventions. 
ESTABLISHING GOALS AND EXPECTED OUTCOMES
GOALS:
Is and educated guess
Addresses directly the problem started in nursing diagnosis
EXPECTED OUTCOMES:
Is a measurable client behavior that indicated whether the
person has achieved the expected benefit of nursing care.
Example for goal and expected outcome
Goal: Mr. X will ambulance independently in 3 days
Expected outcome:
Mr. X will turn in bed independently in 24 hours
Mr. X will get up to chair 3 times daily for next 2 days
Mr. X will walk with assistance to hallway in 48 hours
3.Selection of intervention
 Characteristic of nursing diagnosis
 Goals and expected outcome
 Feasibility of the intervention
 Acceptability of the patient
 Own competency
 Evidence base for the intervention.
4.Selecting nursing intervention strategy
10
 FUNDAMENTALS OF NURSING MODULE 4-6

1. Choose a method of assigning priorities and use it

consistently.
 example: some nurses use the ABC method
 make sure that the patient has NO
THREATS to his
 A  AIRWAY
 B  BREATHING
 C  CIRCULATION

2. Maslow’s Hierarchy of Needs

Priority 1 Physiologic Needs – problems with

breathing, circulation, nutrition, hydration, elimination,
temperature regulation, physical comfort

PLANNING Priority 2  Safety and Security -- environmental hazards,

- “The nurse develops a plan of care that fear
prescribes interventions to attain expected
outcomes” Priority 3  Love & Belonging -- isolation, loss of loved one

Priority 4  Self Esteem -- inability to perform normal

activities

Priority 5  Personal Goals -- Threat to the ability to achieve

personal goals.

3. Problems usually present in a cluster – study the

relationships among the problems to determine major
priorities.
- Assign high priority to problems that contribute to
other problems.

example: if someone has chest pain and difficulty of

breathing, pain management is a high priority because pain
causes increased stress and oxygen demand.

GUIDELINES FOR SETTING PRIORITIES

4 MAIN PURPOSES OF THE PLAN FOR CARE
1. Maslow’s hierarchy of basic needs can guide the selection
of high-priority problems.
1. Promotes communication among caregivers to
2. Focus on the problems the patient feels are most important
promote continuity of care.
if this priority does not interfere with medical treatment
2. Directs care and documentation.
3.Consider the patient’s culture, values and beliefs when
3. Creates a record that can later be used for evaluation,
setting priorities.
research & legal reasons.
4.Consider the effect of potential problems when setting
4. Provides documentation of health care needs for
priorities
insurance reimbursement purposes.
5.Consider costs, resources available, personnel and time
needed to plan & treat each of the patient’s identified problems
ACTIVITIES OF PLANNING PHASE 6.Consider state laws, hospital policy statements, and outcome
criteria established for the particular setting.
 Attending to urgent priorities
 Clarifying expected outcomes
CLARIFYING OR ESTABLISHING
 Deciding which problems must be prescribed
 Determining Individualized Nursing interventions OUTCOME(RESULT)
 Making sure the plan is adequately recorded
Patient Outcome
SETTING PRIORITIES  the desired result of nursing care;
 that which one hopes to achieve with the patient and
which is designed to prevent, remedy or lessen the
- it serves the purpose of ordering the delivery of
problem identified in the nursing diagnosis
nursing care so that the more important or life-
threatening problems are treated before less critical
problems are treated

BASIC PRINCIPLES: ATTENDING TO URGENT OUTCOME IDENTIFICATION

PRIORITIES
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 FUNDAMENTALS OF NURSING MODULE 4-6
“The nurse identifies expected outcomes individualized  PERFORMANCE CRITERIA: How well is the
to the patient” person to perform the actions?
 TARGET TIME: By when is the person expected
 the nurse develops outcomes for the patient to to be able to perform the actions?
achieve showing an optimum or improved level of
functioning in the problem areas identified in the PATIENT BEHAVIOR
nursing diagnoses - An observable activity the patient will demonstrate at
some time in the future showing improvement in the
A SHIFT FROM GOALS & OBJECTIVES TO problem area
OUTCOMES
Examples:
GOALS & OBJECTIVES - (The patient) will void
 refers to the INTENT - Decrease in (the patient’s) BP
 What you intend to do - (The patient) will ambulate
- (The patient) will report
OUTCOMES - (The patient) will drink
 refers to RESULTS
CONDITIONS
 what you expect the patient to be able to do
- specific aids that will help the patient perform a
behavior at the level specified in the criteria portion of
Expected Outcomes  describes what will be observed in
the outcome statement
the patient after care is done to show the benefits of nursing NOTE: “not all outcomes will have conditions”
care.
3 MAIN PURPOSES
CONDITIONS
1. They are the “measuring sticks” specific aides which will facilitate the patient performing a
for the plan of care.
behavior at the level in the criteria and within the specified
2. They direct interventions. time frame
3. They are motivating factors
 With the help of a walker
 With the use of a wheelchair
PRINCIPLE OF PATIENT- CENTERED OUTCOMES  With the help of the family
 With the use of medication
1. Outcome describe the specific benefits you  Using oral analgesics q3-4 hrs
expect to see in the patient after care has been  Using IM Demerol q3-4 hrs
given.
PERFORMANCE CRITERIA
SHORT TERM OUTCOME – describe early expected benefits - a stated level or standard for the patient behavior
of nursing interventions stated in the outcome
- it specifies a realistic improvement in functioning in
LONG TERM OUTCOME – describe the benefits expected to the problem area by a stated time and will be used to
be seen at a certain point in time after the plan has been determine whether the outcome was satisfactorily
implemented achieved
- It clarifies and individualizes the outcome based on
2. Outcome may relate to problems or interventions. the patient’s ability and a realistic expectation for the
level of functioning in the future
PROBLEM OUTCOMES -- state what you expect to observe in
the patient when the problems are resolved or controlled TIME FRAME
INTERVENTION OUTCOMES -- state the benefit you expect - a time or date to clarify how long it would realistically
to observe in the patient after an intervention is performed take for the patient to reach the level of functioning
stated in the criteria part of the outcome
3. To create explicit (very specific outcomes, include
the following components. a. INTERMEDIATE OUTCOMES
> subject it identifies behavior a patient can achieve fairly quickly
> verb e.g.: in an 8-hr shift, daily basis
> condition
> performance criteria b. LONG TERM OR FINAL OUTCOMES
> target time - it gives direction for the nursing care over time
- it tries to identify the maximum level of functioning
COMPONENTS OF OUTCOME STATEMENTS possible for a patient with a particular nursing diagnosis
e.g.: breastfeeding 10 to 15mins/ breast every 2 to 5 hrs,
 SUBJECT: Who is the person expected to within 2 wks of delivery
achieve the outcome (e.g. Patient or parent)
 VERB: What actions must the person take to  TIME FRAME
achieve the outcome? - a designated time or date when the patient should
 CONDITION: Under what circumstances is the be able to achieve the behavior
person to perform the actions?  Within the next hour

LOREY MANALO 12
 FUNDAMENTALS OF NURSING MODULE 4-6
 By discharge
 At the end of this shift
 By Dec. 25
 In 2 months

c.DISCHARGE OUTCOMES

-it appears at the end of the critical pathways used with the
hospitalized patients
-it identifies the behavior the patient is
expected to achieve to be safely discharged from the institution

e.g.: Return of the swallow-gag reflex vital signs in the normal

range for this patient

d.HEALTH PROMOTION / WELLNESS OUTCOMES

4. Use measurable verbs (verbs that describe things you

can see, feel, smell or hear).

COMPONENTS OF GOALS/DESIRED OUTCOMES

5. Consider affective, cognitive and psychomotor

outcomes.

 Affective domain -- changes in attitude, feelings, or

GUIDELINES FOR WRITING OUTCOME
values STATEMENTS OR OBJECTIVES
 Cognitive domain – dealing with acquired knowledge
or intellectual skills 1. For an actual nursing diagnosis, the outcome is a
patient behavior that demonstrates reduction or
 Psychomotor domain – dealing with developing motor
alleviation of the problem.
skills
2. For at risk nursing diagnosis, the outcome is a
patient behavior that demonstrates maintenance of
EXAMPLES OF VERBS REPRESENTING THE 3 DOMAINS
the current status of health or functioning.
3. The outcome is realistic for the patient’s capabilities in
COGNITIVE AFFECTIVE PSYCHOMOTOR
the time span you designate in your outcome
Teach Express Demonstrate
4. The outcome is realistic for the nurse’s level of skill,
Discuss share Practice experience and time/ workload.
Identify Listen Perform 5. The outcome is congruent with and supportive of
Describe Communicate Walk other therapies.
List Relate Administer 6. Whenever possible, the outcome is important and
Explore Give valued by the patient, family, the nurse and the
physician.
At a basic level, determining outcomes requires you to 7. The outcome is an observable or measurable patient
simple “reverse the problem”, or state what you behavior
expect to observe in the patient after you perform an 8. Write outcomes in terms of patient behavior, not
intervention. nursing actions.
9. Keep the outcome short.
DERIVING DESIRED OUTCOME NURSING 10. Make the outcome specific.
DIAGNOSES

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 FUNDAMENTALS OF NURSING MODULE 4-6
11. Derive each outcome from only one nursing
diagnosis.
12. Designate a specific time for the achievement of each
outcome.

DECIDING WHICH PROBLEM MUST BE RECORDED

- is influenced by your understanding of:

 the whole picture of all the problems present

 the person’s overall health status and expected
discharge outcomes
 the expected length of contact with the patient.
Focus on what MUST be achieved before what’s
NICE to do.
 the patient’s perception of priorities
 whether there are standard plans that apply, are there
critical pathways? Guidelines? Protocols?

- Always check policies and procedures for

recording the plan, as they are designed to help
your patients and protect you from legal liability.

3 BASIC STEPS TO DETERMINING WHICH

PROBLEMS MUST BE RECORDED

1. Create a problem list.

2. Decide which problem must be managed in order to
achieve the overall outcomes of care.
3. Determine what documentation will guide how each
problem will be managed.

- It’s your responsibility to make sure that any

problems, diagnoses, risk factors that are likely to
impede progress toward outcome achievement
are addressed somewhere on the patient record.

LOREY MANALO 14