NURSING PROCESS

-NURSING DIAGNOSIS
-NURSING CARE PLANNING

FATOBA B.A.
 Nursing Process:
A process is a series of steps or acts that lead to accomplishment of some goal or purpose. Nursing
process: is a systemic method for providing care to clients. The purpose is to provide individualized,
holistic, effective client care efficiently. Although the steps of nursing process build on each other, each
step overlaps with the previous and subsequent steps.
Purposes of nursing process
1. Providing professional, quality nursing care.
2. Directs nursing activities for health promotion, health protection, and 10 disease prevention and is
used by nurses in every practice setting and specialty.
3. Provides the basis for critical thinking in nursing.

Phases of the nursing process:

1. Assessment (of patient's needs).
2. Diagnosis (of human response needs that nurses can deal with).
3. Planning (of patient's care).
4. Implementation (of care).
5. Evaluation (of the implemented care).

Steps (Phases) of nursing process:

1. Assessment:
Is the first step in the nursing process and includes systemic collection, verification, organization,
interpretation (analysis), and documentation of data. The completeness and correctness of the
information obtained during assessment are directly related to the accuracy of the steps that follow.
Assessment involves several steps:
a. Data collection from a variety of sources.
b. Data validation.
c. Organizing the data.
d. Data interpretation (Data analysis).
e. Making initial inferences or impressions.
f. Recording or reporting data.

Purpose of assessment:
1. Organize a database regarding a client physical, psychological, and emotional health.
2. Identified of health promoting behaviors and actual or potential health problems.
3. The nurse can ascertain of the clients about:
a. Functional abilities,
b. Absence or the presence of dysfunction,
c. Normal activities of daily living, and
d. Lifestyle pattern.
4. Identifying the client strengths gives the nurse information about the abilities, behavior, and skills the
client can use during the treatment and recovery process.
5. Provides an opportunity to form a therapeutic interpersonal relationship with clients.
6. The client can discuss health care concerns and goals with the nurse.

Type of assessment:
The information needed for assessment is usually determined by health care setting and needs of the
clients. Three types of assessment include:
1. Comprehensive assessment:
a. Provide baseline of client data including a complete health history and current needs assessment.
b. Usually completed upon admission to health care agency.
c. Changes in the client’s health status can be measured against this database.
 d. Includes of clients physical and psychological health, perception of health, presence of health
risk factors, and coping patterns.
2. Focused assessment:
a. Is limited to potential health care risks, a particular need, or health care concern.
b. There are not as a detailed as comprehensive assessment.
c. Often used when short stays are anticipated (e.g., outpatient surgery and emergency
departments).
d. Used in specialty areas such as mental health settings and delivery.
e. Used in screening for specific problems or risk factors.
3. Ongoing assessment:
a. Follow up or monitoring of specific problems.
b. Broadens the database and allow the nurse to confirm the validity of data 13 obtained during
the initial assessment.
c. Systematic monitoring allows the nurse to determine the client’s response to nursing
interventions and to identify any other problems.

Sources of Data collection by assessment methods:

A. Primary sources: the client should be considered the primary source of data. As much information
as possible should be gathered from the client, using both interview techniques and physical
examination skills.
B. Secondary sources: data source from other than the client is considered secondary sources (family
members, other health care providers, and medical records).

Types of Data collection by assessment methods:

A. Subjective data (also called symptoms):
are data from the client’s point of view (provided verbally by the patient) and include feelings,
perceptions, and concerns. Interview is the primarily method of collecting subjective information. Steps
of collecting subjective data:
1. Begin with the patient’s main concern (chief complain).
2. Reason of seeking health care. The question, “What happened that made you decide to come to the
hospital (clinic, office)?”
3. Use the letters of the “WHAT’S UP?” questioning format to remember questions to ask the patient,
4. Obtain a patient history by asking the patient and family questions about patient’s past and present
health problems, including specific questions about each body system, family health problems, and risk
factors for health problems. The patient’s medical record may also be consulted for background history
information.
Examples of subjective information:
a. I have had pains in my legs for three days ago.
b. I have had headache, nausea, vomiting, dizziness for three hours ago.
c. I have had anxiety from surgery.
WHAT’S UP? Guide to Symptom Assessment
W—Where is it?
H—How does it feel? Describe the quality.
A—Aggravating and alleviating factors. What makes it worse? What makes it better?
T—Timing. When did it start? How long does it last?
S—Severity. How bad is it? This can often be rated on a scale of 0 to 10.
U—Useful other data. What other symptoms are present that might be related?
P—Patient’s perception of the problem. The patient often has an idea about what the problem is, or
the cause, but may not believe that his or her thoughts are worth sharing unless specifically asked.
Data that are collected must be organized to be useful to the health care professional collecting the data
as well as others involved with the client’s care. Data should be organized through:
a. Data clustering (admission assessment format): is the process to putting the data together to
identify areas of the client problems and strengths.
b. Assessment model: is a framework providing a systematic way to organize data such as:
1. Hierarchy of needs: proposes that an individual basic needs (physiological) must be meet before
higher level can be meet.
2. Body system model: organizes data according to tissue and organ function in the various body
systems.
3. Functional health pattern: cluster information about client habitual pattern and any change to
determine if the client’s current response is functional or dysfunctional.
4. Theory of self-care: based on the client ability to meet self-care needs and identifying existing self-
care deficits.

Interpreting the data: when data are placed in clusters the nurse can:
a. Distinguish between relevant and irrelevant data.
b. Determine whether and where there are gaps in the data.
c. Identify patterns of cause and effect.

Documenting the data:

Assessment data must be recorded and reported. The nurse must make a judgment about which data are
to be reported immediately and which data need only to be recorded at that time. Data that reflect a
significant deviation from the normal (for example, rapid heart rate with irregular rhythm, severe
difficulty in breathing, or high levels of anxiety) would need to be reported as well as recorded.
Examples of data that need only to be recorded at the time include a report that prescribed medication
has relieved a headache and a determination that an abdominal dressing is dry and intact.
NOTE: Assessment does not end with the initial interview and physical examination. Assessment is
dynamic and continues with each nurse-client interaction.

2. Nursing Diagnosis phase:

A nursing diagnosis is a fundamental part of the nursing process. It’s an essential tool for nurses and
subsequently for the entire healthcare field. Involves further analysis and synthesis of the data that
have been collected. It is a concrete and evidence-based way for nurses to communicate
their professional judgments to patients, fellow nursing professionals, members of other medical areas,
and the public. According to the North American Nursing Diagnosis Association (NANDA) a nursing
diagnosis: Is a clinical judgment about individual, family, or community responses to actual or
potential health problems / life processes. The nursing diagnoses provide the basis for client care
delivered through the remaining steps. The nursing diagnosis is developed based on information
gathered in the assessment phase. Further, once a nursing diagnosis is elaborated, the nurse can move
ahead and create a care plan, which can be used to measure outcomes of a patient’s care at a later
phase.Clients receive both medical and nursing diagnoses.

What Are the Differences Between a Nursing Diagnosis and Other Types of Diagnosis?
Nursing diagnosis is not the only diagnosis one might come across in the process of care. That’s why it’s
important to know the difference between different types of diagnosis. The three main ones to consider
are nursing diagnosis, medical diagnosis, and collaborative diagnosis.

A nursing diagnosis refers to the process and, subsequently, the label nurses use to assign meaning to
patient data collected in the Assessment phase. The data is labeled with NANDA-I approved nursing
diagnosis. For instance, while assessing a patient, the nurse may notice that the patient coughs prior to
swallowing any food, displays inadequate laryngeal elevation, and repeatedly reports “something stuck”
in their throat. The nurse can conclude a nursing diagnosis based on these symptoms: impaired
swallowing.
Examples of nursing diagnosis: risk for impaired liver function; urinary retention; disturbed sleep
pattern; decreased cardiac output.

On the other hand, a medical diagnosis is made by a doctor or advanced health care practitioner. This
type of diagnosis focuses on the patient’s disease, medical condition, or pathologic state – determining
which falls into the expertise of advanced medical practitioners. While the nursing diagnosis can be
subject to change, the medical diagnosis generally doesn’t change. It remains imprinted on the patient’s
medical history forever.

Examples of medical diagnosis: atrial fibrillation; hepatitis; chronic kidney disease; hypertension.

Collaborative diagnoses are the ones that require both nursing and medical interventions. For the most
part, these imply teamwork: RNs keep an eye on the health problems while the medical professionals
prescribe drugs and more diagnostic tests.

Examples of collaborative diagnosis: respiratory insufficiency.

Comparison of Medical Diagnoses and Nursing Diagnoses

Medical Diagnosis Nursing Diagnosis
Focuses on illness, injury, or disease process. Focuses on clients’ responses to actual or
potential health problems or life processes.
Remains constant until a cure is achieved or Changes as the client’s response and/or the
client dies. health problem changes.
Recognizes conditions the physician is licensed Recognizes situations that the nurse is licensed
and qualified to treat. and qualified to intervene.
Example: (Lung cancer, Congestive heart failure, Example: (Nausea, Acute pain, Anxiety,
Brain tumor, Exploratory surgery, Impaired physical mobility, Ineffective breathing
Appendectomy, Bronchial asthma). pattern, Risk for imbalanced fluid volume).

Catergories of Nursing Diagnoses:

1. Actual nursing diagnosis (Problem Focused): also known as actual diagnoses, are patient issues or
problems that are present and observable during the assessment phase. They are based on the presence
of certain signs or symptoms (Indicates that a problem exists). comprises three components.
-Composed of (diagnostic label, related factors, and signs and symptoms).
-Example (Impaired Skin Integrity related to prolonged pressure on bony prominence as
manifested by stage II pressure ulcer over coccyx, 3 cm in diameter).

2. Risk nursing diagnosis (Potential problems): refers to clinical judgments concerning a patient’s
vulnerability to developing undesirable health conditions unless the nurse intervenes. Essentially, a risk
diagnosis says that a problem does not yet exist, but there are risk factors that could potentially lead to a
problem emerging. Thus, nurses will offer care to avoid it. There are two component nurses must
account for with this type of diagnosis:
- the diagnostic label preceded by the phrase “risk for” with the specific risk factors listed.
-An example of a risk diagnosis is: (Risk for Impaired Skin Integrity related to inability to turn self
from side to side in bed).
*A Possible (Potential) nursing diagnosis indicates a situation in which a problem could arise unless
preventive action is taken.
- A possible diagnosis is composed of the diagnostic label and related factors.
-An example of a possible diagnosis is: (Possible Self-Esteem Disturbance related to recent
retirement and relocation). The nurse may not yet have enough data to confirm this diagnosis or a
more specific one. However, this diagnosis will alert other nurses to collect data that will either confirm
this or another diagnosis, verify a risk diagnosis, or rule out the existence of a problem.
3. Wellness nursing diagnosis (Health Promotion): are the clinical judgments about the motivation
and desire to increase well-being and reach one’s health potential. These judgments express a patient’s
readiness to improve specific health behaviors. Health promotion diagnosis can exist at an individual,
family, group, or community level.
a. Indicates the client’s expression of a desire to attain a higher level of wellness in some area of
function.
b. Composed of the diagnostic label preceded by the phrase “potential for enhanced.”
c. For example a client who is neither overweight nor underweight tells the nurse that she knows she
could improve her diet in some ways. She expresses a desire to know more about how to improve her
diet. The nurse would make a wellness diagnosis of Potential for Enhanced Nutrition.

4.Collaborative problems (Syndromes): are the least present diagnosis in the NANDA-I taxonomy.
They concern the clinical judgments that relate to a cluster of nursing diagnoses that occur together and
are dealt with through similar interventions.
Are defined as physiologic complications monitored by nurses to assess changes in client status.
Usually, collaborative problems involve alterations in organ and/or system function or structure (e.g.,
myocardial infarction, duodenal ulcer). Collaborative problems begin with the label potential
complication followed by the situation. for example, respiratory are the specific collaborative problems
of potential complication: hypoxemia.

Components of a Nursing Diagnosis?

When writing a nursing diagnosis, certain components should be included. The components may differ
depending on the diagnosis type. Below, you’ll find an overview of all the features of a nursing
diagnosis:

Diagnosis label – It is a name that reflects the diagnostic focus and the nursing judgements.

Examples: ineffective health self-management; acute pain; impaired skin integrity.

Definition – This component delivers a clear, exact diagnosis description, making it easier to
differentiate from similar diagnoses.

Example: for an imbalanced nutrition nursing diagnosis, the definition is: “intake of nutrients
insufficient to meet metabolic needs.”

Defining characteristics – These refer to the observable details that pinpoint the existence of a problem
focused, health promotion diagnosis or syndrome. It includes things that the nurse can see and things
that can be heard, touched or smelled, or information coming from the patient or the family.

Example: for an impaired gas exchange nursing diagnosis, some of the defining characteristics might be:
abnormal arterial blood gasses; abnormal skin color (e.g., pale, dusky, cyanosis); and headache upon
awakening.

Risk factors – Risk factors can fall into one of several categories: environmental, physiological,
psychological, genetic, or chemical elements that increase a patient’s vulnerability to an unhealthy
event. Bear in mind that risk factors are only applicable to risk diagnosis.

Example: a risk for infection diagnosis may have one (or more) of these risk factors: chronic illness, like
diabetes; inadequate vaccination; invasive procedure; malnutrition.

Related factors: These are the factors that in some way present a connection to the nursing diagnosis.
They may have been existent before the diagnosis; they may be associated with it; they may contribute
or abet a particular diagnosis. Related factors only occur in the case of problem focused nursing
diagnosis and syndromes. Rarely, health promotion diagnosis may have related factors.
For an ineffective peripheral tissue perfusion diagnosis, hypertension is one of the potentially related
factors. Others are diabetes mellitus, smoking, or a sedentary lifestyle.

How to Write a Nursing Diagnostic?

First, you need to carefully analyze all the data and identify the patient’s health problems, health risks,
and strengths. Once you have all the information, you can formulate the diagnosis statement. NANDA
International strongly recommends that diagnosis follow a specific template. This allows for accurate,
precise, and valid diagnoses that nurses and other healthcare team members can easily understand and
follow.

Each type of nursing diagnosis needs to contain certain information. Below, you will find the outline of
how to write nursing diagnoses, including examples.

Problem focused diagnosis:

-Impaired bed mobility related to musculoskeletal impairment as evidenced byimpaired ability to

reposition self in bed.
-Constipation related to inadequate toileting habits as evidenced by change in bowel pattern.

Risk Diagnosis:

-Risk for decreased cardiac output as evidenced by alteration in heart rhythm.

-Risk for adult pressure injury as evidenced by Inadequate adherence to incontinence treatment
regimen.

Health Promotion Diagnosis:

-Sedentary lifestyle as evidenced by insufficient motivation for physical activity.

-Ineffective family health self-managementas evidenced by difficulty with the prescribed regimen.

Syndrome Diagnosis:

Below, you will find examples of each type of diagnosis from NANDA-I definitive guide to nursing
diagnoses, Nursing Diagnosis: Definitions and Classifications, 2021-2023.
Problem Focused Diagnosis Risk Diagnosis

• Decisional conflict • Risk for chronic functional

• Ineffective airway clearance constipation
• Impaired oral mucous membrane • Risk for acute confusion
integrity • Risk for autonomic dysreflexia
• Hyperthermia • Risk for adult falls
• Dysfunctional ventilatory weaning • Risk for peripheral neurovascular
response dysfunction

Health Promotion Diagnosis

• Readiness for enhanced spiritual well-

being
• Readiness for enhanced coping
Syndrome Diagnosis
• Readiness for enhanced self-care
• Readiness for enhanced parenting
• Readiness for enhanced exercise
engagement

More Nursing Diagnosis to Help You Elaborate Your Care Plans:

As we have mentioned before, with 267 inputs, the NANDA-I nursing diagnosis list is comprehensive
and an excellent tool for nurses used worldwide. Several nursing diagnosis examples throughout this
guide, all collected from the NANDA-I 2021-2023 complete handbook. Below will provide you with
additional nursing diagnosis examples that you can use to formulate and implement future nursing care
plans.

• Decreased activity tolerance

• Risk for surgical site infection
• Deficient knowledge
• Decreased cardiac output
• Deficient fluid volume
• Ineffective coping
• Acute pain
• Ineffective thermoregulation
• Ineffective breathing pattern
• Risk for electrolyte imbalance
• Bathing/dressing/feeding self-care deficit
• Risk for ineffective childbearing process
• Risk for injury
• Fatigue
• Impaired physical mobility
• Ineffective airway clearance
• Readiness for enhanced communication
• Impaired comfort
• Obesity
• Risk for metabolic syndrome
• Disturbed body image
• Deficient community health
• Neonatal hypothermia
• Risk for bleeding
• Risk for vascular trauma
3.Outcome Identification and Planning phase: A nursing care plan present in two forms: informal and
formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish
during their shift. Informal care plan is not included in the patient chat. A formal care plans written or
computerized guide that organizes patient care. It further subdivided into standardized and
individualized care plan.
Includes the formulation of guidelines that establish the proposed course of nursing action in the
resolution of nursing diagnoses and the development of the client’s plan of care. After selecting a
diagnosis, the nurse will create Specific, Measurable, Achievable, Relevant and Tim-bound (SMART)
short and long terms goals according to the patients needs. The goals must also be desired by the patient.

The planning of nursing care occurs in three phases:

a. Initial planning: Developed by the nurse who performs the admission assessment and gathers the
comprehensive admission assessment data.
b. Ongoing planning: Updating of the client’s plan of care.
c. Discharge planning: Critical anticipation and planning for the client’s needs after discharge.

The planning phase involves several tasks:

a. Establishing priorities of nursing diagnoses.
b. Setting goals and developing expected outcomes (outcome identification).
c. Planning nursing interventions (with collaboration and consultation as needed).
d. Record the entire nursing care plan in the client record.
There are several frameworks used to prioritize nursing diagnoses; however, those diagnoses involving
life-threatening situations are given the highest priority.
A goal: is an aim, intent, or end. Goals are broad statements that describe the intended or desired change
in the client’s behavior. Expected outcomes are specific objectives related to the goals and are used to
evaluate the nursing interventions. They must be measurable, have a time limit, and be realistic. A
nursing intervention is the activity that the nurse will perform for and with the client to enable
accomplishment of the goals.
4. Implementation phase:
Involves the execution of the nursing care plan derived during planning phase. It consists of performing
nursing activities that have been planned to meet the goals set with the client. The implementation phase
of the nursing process requires cognitive (intellectual), psychomotor (technical), and interpersonal skills.
The nurse must continue to assess the client’s condition before, during, and after the nursing
intervention.
Nursing implementation activities include:
a. Ongoing assessment.
b. Establishment of priorities.
c. Allocation of resources.
d. Initiation of nursing interventions.
e. Documentation of interventions and client response.

5. Evaluation phase:
Involves determining whether the goals have been met, partially met, or not met.
1. If the goal has been met, the nurse must then decide whether nursing activities will stop or continue
for status to be maintained.
2. If the goal has been partially met or not been met, the nurse must reassess the situation and change the
plan of care accordingly. New problems may be identified at this stage, and thus the process will start all
over again.

There are several possible reasons that goals are not met or are only partially met, including:
a. The initial assessment data were incomplete.
b. The goals and expected outcomes were not realistic.
c. The time frame was too optimistic.
d. The goals and/or the nursing interventions planned were not appropriate for the client.