NURSING PROCESS

Introduction

 The term Nursing Process was first used/ mentioned by Lydia Hall, a nursing theorist, in
1955 wherein she introduced 3 STEPs: observation, administration of care and validation.
 Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-
step process (APIE), then a 5-step (ADPIE), now a 6-step process (ADOPIE)
Assessment, Diagnosis, Outcome, Identification, Planning, Implementaton and
Evaluation.
Definition

 Is a systematic, organized method of planning, and providing quality and individualized

nursing care.
 It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse
and the client to determine the need for nursing care, to plan and implement the care and
evaluate the result.
 It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for
efficient and effective provision of nursing care.

GOAL :
 Goal-oriented – nurse make her objective based on client’s health needs.
 Remember: Goals and plan of care should be base according to clients problems/needs
NOT according to your own problem as the nurse.
 Organized/Systematic – the nursing process is composed of 6 sequential and interrelated
steps and these 6 phases follow a logical sequence.
Humanistic care

 Plan to care is developed and implemented taking into consideration the unique needs of
the individual client.
 plan of care therefore is individualized (no 2 person has the same health needs even with
same health condition/illness)
 in providing care, it involves respect of human dignity
 Efficient – plan of case is relevant/ related to the needs of the client thereby promoting
client satisfaction and progress.
 Effective – in planning care, utilized resources wisely (staff, time, money/cost)
Aside from GOSH, other characteristic of Nursing Process:

 Cyclic and Dynamic in nature – data from each phase provides the input into the next
phase so that is becomes a sequence of events (cycle) that are constantly changing
(dynamic) base on client’s health status.
 Involves skill in Decision- making – nurse makes important decisions related to client
care, she choose the best action/steps to meet a desired goal or to solve a problem. She
must make decisions whenever several choices or options are available.
 Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-
ordinary situations where decisions must be made using critical thinking.

Purpose of Nursing Process:

1. To identify a client’s health status; his Actual/Present and potential/possible health problems
or needs.
2. To establish a plan of care to meet identified needs.
3. To provide nursing interventions to meet those needs.
4. To provide an individualized, holistic, effective and efficient nursing care.

Steps/Phases of the Nursing Process:

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
ASSESSMENT – FIRST STEP IN THE NURSING PROCESS

Description

 It is systematic and continuous collection, validation and communication of client data as

compared to what is standard/norm.
 It includes the client’s perceived needs, health problems, related experiences, health
practices, values and lifestyles.
Purpose
To establish a data base (all the information about the client):

 Nursing health history

 Physical assessment
 The physician’s history & physical examination
 Results of laboratory & diagnostic tests material from other health personnel
FOUR Types of Assessment
1. Initial assessment – assessment performed within a specified time on admission
 Ex: nursing admission assessment
2. Problem-focused assessment – use to determine status of a specific problem identified in an
earlier assessment
 Ex: problem on urination-assess on fluid intake & urine output hourly
3. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of
the client to identify life threatening problems.
 Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.
4. Time-lapsed assessment – reassessment of client’s functional health pattern done several
months after initial assessment to compare the client’s current status to baseline data
previously obtained.
Activities

1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data
Assessment

 Observation of the patient + Interview of patient, family & SO + examination of the patient
+ Review of medical record
Collection of data

 gathering of information about the client

 includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect
client’s health status
 includes past health history of client (allergies, past surgeries, chronic diseases, use of
folk healing methods)
 includes current/present problems of client (pain, nausea, sleep pattern, religious
practices, meds or treatment the client is taking now)
Types of Data

1. Subjective data
 also referred to as Symptom/Covert data
 Information from the client’s point of view or are described by the person experiencing
it.
 Information supplied by family members, significant others; other health professionals
are considered subjective data.
 Example: pain, dizziness, ringing of ears/Tinnitus
2. Objective data
 also referred to as Sign/Overt data
 Those that can be detected observed or measured/tested using accepted standard or
norm.
 Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin
Methods of Data Collection

1. Interview
 A planned, purposeful conversation/communication with the client to get information,
identify problems, evaluate change, to teach, or to provide support or counseling.
 it is used while taking the nursing history of a client
2. Observation
 Use to gather data by using the 5 senses and instruments.
3. Examination
 Systematic data collection to detect health problems using unit of measurements,
physical examination techniques (IPPA), interpretation of laboratory results.
 should be conducted systematically:
1. Cephalocaudal approach – head-to-toe assessment
2. Body System approach – examine all the body system
3. Review of System approach – examine only particular area affected
Source of data

1. Primary source – data directly gathered from the client using interview and physical
examination.
2. Secondary source – data gathered from client’s family members, significant others, client’s
medical records/chart, other members of health team, and related care literature/journals.
 In the Assessment Phase, obtain a Nursing Health History – a structured interview
designed to collect specific data and to obtain a detailed health record of a client.

Components of a Nursing Health History:

 Biographic data – name, address, age, sex, martial status, occupation, religion.
 Reason for visit/Chief complaint – primary reason why client seek consultation or
hospitalization.
 History of present Illness – includes: usual health status, chronological story, family
history, disability assessment.
 Past Health History – includes all previous immunizations, experiences with illness.
 Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension,
cancer, mental illness).
 Review of systems – review of all health problems by body systems

Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living,

recreation or hobbies.
 Social data – include family relationships, ethnic and educational background, economic
status, home and neighborhood conditions.
 Psychological data – information about the client’s emotional state.
 Pattern of health care – includes all health care resources: hospitals, clinics, health
centers, family doctors.
Validation of Data

 The act of “double-checking” or verifying data to confirm that it is accurate and complete.
Purposes of data validation

1. ensure that data collection is complete

2. ensure that objective and subjective data agree
3. obtain additional data that may have been overlooked
4. avoid jumping to conclusion
5. differentiate cues and inferences
Cues

 Subjective or objective data observed by the nurse; it is what the client says, or what the
nurse can see, hear, feel, smell or measure.
Inferences

 The nurse interpretation or conclusion based on the cues.

 Example:
 Red swollen wound = infected wound
 Dry skin = dehydrated
Organization of Data

Uses a written or computerized format that organizes assessment data systematically.

1. Maslow’s basic needs

2. Body System Model
3. Gordon’s Functional Health Patterns:
Gordon’s Functional Health Patterns

1. Health perception-health management pattern.

2. Nutritional- metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern
Analyze data

 Compare data against standard and identify significant cues. Standard/norm are generally
accepted measurements, model, pattern:
Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values,
normal growth and development pattern
Communicate/Record/Document Data

 nurse records al data collected about the client’s health status

 data are recorded in a factual manner not as interpreted by the nurse
 Record subjective data in client’s word; restating in other words what client says might
change its original meaning.

ASSESSMENT- OBJECTIVE & SUBJECTIVE DATA

Definition

 Assessment is the systematic and continuous collection organization validation and

documentation of data.
 The nurse gathers information to identify the health status of the patient.
 Assessments are made initially and continuously throughout patient care.
 The remaining phases of the nursing process depend on the validity and completeness of the
initial data collection.
Review of clinical record

1. Client records contain information collected by many members of the healthcare team, such
as demographics, past medical history, diagnostic test results and consultations
2. Reviewing the client’s record before beginning an assessment prevents the nurse from
repeating questions that the client has already been asked and identifies information that
needs clarification.
Interview

 The purpose of an interview is to gather and provide information, identify problems of

concerns, and provide teaching and support.
 The goals of an interview are to develop a rapport with the client and to collect data
 An interview has 3 major stages:
 Opening: purpose is to establish rapport by creating goodwill and trust; this is
often achieved through a self – introduction, nonverbal gestures (a handshake),
and small talk about the weather, local sports team, or recent current event; the
purpose of the interview is also explained to the client at this time.
 Body: during this phase, the client responds to open and closed-ended questions
asked by the nurse.
 Closing: either the client or the nurse may terminate the interview, it is
important fro the nurse to try to maintain the rapport and trust that was
developed thus far during the interview process.
 Types of questions
 Closed questions used in directive interview
 Re short factual answers; e.g. “Do you have pain?”
 Answers usually reveal limited amounts of information
 Useful with clients who are highly stressed and/or have difficulty communicating
 Open-ended questions used in nondirective interview
 Encourage clients to express and clarify their thoughts and feelings; e.g. “How
have you been sleeping lately?’
 Specify the broad area to be discussed and invite longer answers
 Useful at the start of an interview or to change the subject
 Leading questions
 Direct the client’s answer; e.g. “You don’t have any questions about your
medications, do you?”
 Suggests what answer is expected
 Can result in client giving inaccurate data to please the nurse
 Can limit client choice of topic for discussion
Nursing History

1. Collection of information about the effect of the client’s il ness on daily functioning and
ability to cope with the stressor (the human response)
2. Subjective data
 May be cal ed “covert data”
 Not measurable or observable
 Obtained from client (primary source), significant others, or health professionals
(secondary sources).
  For example, the client states, “I have a headache”
3. Objective data
 May be cal ed “overt data”
 Can be detected by someone other than the client
 Includes measurable and observable client behavior
 For example, a blood pressure reading of 190/110 mmHg.
Physical assessment

1. Systematic collection of information about the body systems through the use of observation,
inspection, auscultation, palpation and percussion
2. A body system format for physical assessment is found below:
 General assessement
 Integumentary system
 Head, ears, eyes, nose, throat
 Breast and axillae
 Thorax and lungs
 Cardiovascular system
 Nervous system
 Abdomen and gastrointestinal system
 Anus and rectum
 Genitourinary system
 Reproductive system
 Musculoskeletal system
Psychosocial assessment

1. Helpful framework for organizing data

2. A suggested format for psychosocial assessment is found below:
 Vocation/education/financial
 Home and Family
 Social, leisure, spiritual and cultural
 Sexual
 Activities of daily living
 Health Habits
 Psychological
3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be
helpful for guiding data collection
Purposes of assessment

1. To establish Database: all the information about a client: it includes:

o The nursing health history
o Physical examination
o The physician’s history
o Results of laboratory and diagnostic tests
2. Assessment is part of each activity the nurse does for and with the patient. The purposes is
 To validate a diagnosis
 To provide basis for effective nursing care.
 It helps in effective decision making
 Basis for accurate diagnosis
It promote holistic nursing care
 To provide effective and innovative nursing care (1. To collecting data for nursing
research 2. To evaluation of nursing care)
Consultation

1. The nurse collects data from multiple sources: primary (client) and secondary (family
members, support persons, healthcare professionals and records)
2. Consultation with individuals who can contribute to the client’s database is helpful in
achieving the most complete and accurate information about a client
3. Supplemental information from secondary sources (any source other then the client) can
help verify information, provide information for a client who cannot do so, and convey
information about the client’s status prior to admission
Review of literature

1. A professional nurse engages in continued education to maintain knowledge of current

information related to health care
2. Reviewing professional journals and textbooks can help provide additional data to support
or help analyze the client database

DIAGNOSIS – SECOND STEP IN THE NURSING PROCESS

Definition

 Is the 2nd step of the nursing process.

 the process of reasoning or the clinical act of identifying problems
Purpose

 To identify health care needs and prepare a Nursing Diagnosis.

 To diagnose in nursing
 It means to analyze assessment information and derive meaning from this analysis.
Nursing Diagnosis

 Is a statement of a client’s potential or actual health problem resulting from analysis of

data.
 Is a statement of client’s potential or actual alterations/changes in his health status.
 A statement that describes a client’s actual or potential health problems that a nurse can
identify and for which she can order nursing interventions to maintain the health status, to
reduce, eliminate or prevent alterations/changes.
 Is the problem statement that the nurse makes regarding a client’s condition which she
uses to communicate professionally.
 It uses the critical-thinking skills analysis and synthesis in order to identify client
strengths & health problems that can be resolves/prevented by collaborative and
independent nursing interventions.
o Analysis – separation into components or the breaking down of the whole into its
parts.
 o Synthesis – the putting together of parts into whole
Three Activities in Diagnosing:

1. Data Analysis
2. Problem Identification
3. Formulation of Nursing Diagnosis
Characteristics of Nursing Diagnosis

1. It states a clear and concise health problem.

2. It is derived from existing evidences about the client.
3. It is potentially amenable to nursing therapy.
4. It is the basis for planning and carrying out nursing care.
Components of A nursing diagnosis (PES or PE)

1. Problem statement/diagnostic label/definition = P

2. Etiology/related factors/causes = E
3. Defining characteristics/signs and symptoms = S
*Therefore may be written as 2-Part or a 3-Part statement.
Types of Nursing Diagnosis

1. Actual Nursing Diagnosis – a client problem that is present at the time of the nursing
assessment. It is based on the presence of signs and symptoms.
a. Examples:
 Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea.
 Disturbed Sleep Pattern r/t cough, fever and pain.
 Constipation r/t long term use of laxative.
 Ineffective airway clearance r/t to viscous secretions
 Noncompliance (Medication) r/t unknown etiology
 Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
 Acute Pain (Chest) r/t cough 2nrdary to pneumonia
 Activity Intolerance r/t general weakness.
 Anxiety r/t difficulty of breathing & concerns over work
2. Potential Nursing diagnosis – one in which evidence about a health problem is incomplete
or unclear therefore requires more data to support or reject it; or the causative factors are
unknown but a problem is only considered possible to occur.
a. Examples:
 Possible nutritional deficit
 Possible low self-esteem r/t loss job
 Possible altered thought processes r/t unfamiliar surroundings
3. Risk Nursing diagnosis – is a clinical judgment that a problem does not exist, therefore no
S/S are present, but the presence of RISK FACTORS is indicates that a problem is only is
likely to develop unless nurse intervene or do something about it. No subjective or objective
cues are present therefore the factors that cause the client to be more vulnerable to the
problem are the etiology of a risk nursing diagnosis.
a. Examples:
 Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in
diabetes.
 Risk for interrupted family processes r/t mother’s il ness & unavailability to
provide child care.
 Risk for Constipation r/t inactivity and insufficient fluid intake
 Risk for infection r/t compromised immune system.
 Risk for injury r/t decreased vision after cataract surgery.
Formula in writing nursing diagnosis (PES or PE)

1. Actual nursing diagnosis = Patient problem + Etiology – replace the (+) symbol with the
words “RELATED TO” abbreviated as r/t. = Problem + Etiology + S/S
2. Risk Nursing diagnosis = Problem + Risk Factors
3. Possible nursing diagnosis = Problem + Etiology
Qualifiers – words added to the diagnostic label/problem statement to gain additional meaning.
 “deficient” – inadequate in amount, quality, degree, insufficient, incomplete
 “impaired” – made worse, weakened, damaged, reduced, deteriorated
 “decreased” – lesser in size, amount, degree
 “ineffective” – not producing the desired effect
Activities during diagnosis:
1. Compare data against standards
2. Cluster or group data
3. Data analysis after comparing with standards
4. Identify gaps and inconsistencies in data
5. Determine the client’s health problems, health risks, strengths
6. Formulate Nursing Diagnosis – prioritize nursing diagnosis based on what problem
endangers the client’s life
Situation: Functional Health Pattern – Activity/Exercise

 Anna, 35 years of laundry woman seeks consultation at the Philippine General Hospital due
to fever 2 days prior to admission PTA. She verbalizes: “Bigla na lang ako giniginaw,
masakit ang ulo at mainit ang pakiramdam pagkatapos kong maglaba sa kabilang kanto. “(“I
suddenly felt cold, headache and warm after I done laundry”). She has 3 children she walks
off to school everyday before she goes to work
Vital Signs

 Temperature (T) =39.2°C Respiratory Rate (RR) = 35 P = 96; with flush skin and warm to
touch, teary eyed and with dry lips and mucous membrane.
Nursing Diagnosis

 Hyperthermia [related to (r/t)] environmental condition AMB T = 39°C, flush skin, warm to
touch, teary eyed and dry lip and mucous membrane.
Situation: Functional Health Pattern = Nutritional/Metabolic

1. States, “No appetite since having cough”

2. Has not eaten today; last fluids at noon today
3. Has lost 8 lbs in past 2 weeks
4. Nauseated x 2 days
Nursing Diagnosis

 Imbalanced Nutrition: Less than body Requirements r/t decreased appetite and nausea
2ndary to disease process/cough
Situation: Functional Health Pattern = Activity/Exercise

1. Difficulty sleeping because of cough

2. States, “Can’t breath lying down”
3. Report pain on chest when coughing
Nursing Diagnosis

 Disturbed Sleep Pattern r/t a disease process, orthopnea and pain. Acute Pain (chest) r/t
pathologic condition 2ndary to pneumonia
Situation: Functional Health Pattern = Coping/Stress

1. Anxious
2. State, “I can’t breath”
3. Facial muscles tense, trembling
4. Expresses concern and worry over leaving daughter with neighbors
5. Husband out of town, will be back next week.
Nursing Diagnosis

 Anxiety r/t difficulty of breathing and concerns over parenting roles.

PLANNING
Definition

 Involves determining before and the strategies or course of actions to be taken before
implementation of nursing care. To be effective, the client and his family should be involve
in planning.
Purpose

 To determine the goals of care and the course of actions to be undertaken during the
implementation phase.
 To promote continuity of care.
 To focus charting requirements.
 To allow for delegation of specific activities.
1. Establish/Set priorities

 Priority – is something that takes precedence in position, and considered the most important
among several items. It is a decision making process that ranks the order of nursing
diagnosis in terms of importance to the client.
Guideline for setting priorities:
1. Life-threatening situations should be given highest priority.
2. Use the principle of ABC’s (airway, breathing, circulation)
3. Use Maslow’s hierarchy of needs.
 4. Consider something that is very important to the client.
5. Actual problems take precedence over potential concerns.
6. Clients with unstable condition should be given priority over those with stable conditions.
Ex: attend to client with fever before attending to client who is scheduled for physical
therapy in the afternoon.
7. Consider the amount of time, materials, equipment required to care for clients. Ex: attend to
client who requires dressing change for postop wound before attending to client who
requires health teachings & is ready to be discharged late in the afternoon.
8. Attend to client before equipment. Ex: assess the client before checking IV fluids, urinary
catheter, and drainage tube.
2. Plan nursing interventions/nursing orders to direct activities to be carried out in the
implementation phase.
Nursing interventions
 Any treatment, based upon clinical judgment and knowledge, that a nurse performs to
enhance client outcomes.
 They are used to monitor health status; prevent, resolve or control a problem; assist with
activities of daily living; or promote optimum health and independence.
 They maybe independent, dependent and independent/collaborative activities that nurses
carry out to provide client care.

o Independent Nursing Intervention – those activities that the nurse is licensed to
initiate as a result of the nurse’s own knowledge and skil s.
o Dependent Nursing Intervention – those activities carried out on the order of a
physician, under a physician’s supervision, or according to specific routines.
o Interdependent/Collaborative – those activities the nurse carries out in
collaboration or in relation with other members of the health care team.
3. Write a Nursing Care Plan

Nursing Care Plan (NCP)

 A written summary of the care that a client is to receive.
 It is the “blueprint” of the nursing process.
 It is nursing centered in that the nurse remains in the scope of nursing practice domain in
treating human responses to actual or potential health problems.
 It is s step-by-step process as evidence by:
o Sufficient data are collected to substantiate nursing diagnosis.
o At least one goal must be stated for each nursing diagnosis.
o Outcome criteria must be identified for each goal.
o Nursing interventions must be specifically designed to meet the identified goal.
o Each intervention should be supported by a scientific rationale, which is the
justification or reason for carrying out the intervention.
o Evaluation must address whether each goal was completely met, partially met or
completely unmet.
 IMPLEMENTATION
Definition

 Is putting the nursing care plan into action.

Purpose

 To carry out planned nursing interventions to help the client attain goals and achieve
optimal level of health.
Activities

1. Reassessing – to ensure prompt attention to emerging problems.

2. Set priorities – to determine the order in which nursing interventions are carried out.
3. Perform nursing interventions – these may be independent. Dependent or collaborative
measures.
4. Record actions – to complete nursing interventions, relevant documentation should be done.
Remember: Something that is NOT written is considered as NOT done at all.
Requirements of Implementation

1. Knowledge – include intellectual skills like problem-solving, decision-making and teaching.

2. Technical skills – to carry out treatment and procedures.
3. Communication skills – use of verbal and non-verbal communication to carry out planned
nursing interventions.
4. Therapeutic use of self – is being willing and being able to care.

EVALUATION
Introduction

 Evaluation, the final step of the nursing process, is crucial to determine whether, after
application of the nursing process, the client’s condition or wel -being improves. The nurse
applies all that is known about a client and the client’s condition, as wel as experience with
previous clients, to evaluate whether nursing care was effective. The nurse conducts
evaluation measures to determine if expected outcomes are met, not the nursing
interventions.
 The expected outcomes are the standards against which the nurse judges if goals have been
met and thus if care is successful.Providing health care in a timely, competent, and cost-
effective manner is complex and challenging. The evaluation process will determine the
effectiveness of care, make necessary modifications, and to continuously ensure favorable
client outcomes.
Definition

 Is assessment the client’s response to nursing interventions and then comparing that
response to predetermined standards or outcome criteria.
Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals;
in this phase nurse compare the client behavioral responses with predetermined client goals and
outcome criteria. –CRAVEN 1996

Sample Case Study

Nursing Diagnosis : Impaired skin integrity related to physical mobility

Expected Outcomes : The patient will be able to get recovery of pressure sore.
Planning:
 Pressure sore dressing
 Rationale: Cleansing the area will prevent further infection
 Back care
 Rationale: It will promote blood circulation
 Change the position frequently
 Rationale: It will put little pressure on the sore site
 Encourage the patient to ambulate
 Rationale: It will put little pressure on the sore site
 Take protein rich diet
 Rationale: Protein helps in repair of tissues
Evaluation : Wound healing was observed (tissues were red, healthy)

Purposes

1. Determine client’s behavioral response to nursing interventions.

2. Compare the client’s response with predetermined outcome criteria.
3. Appraise the extent to which client’s goals were attained.
4. Assess the collaboration of client and health care team members.
5. Identify the errors in the plan of care.
6. Monitor the quality of nursing care.
Components of Evaluation

1. Collecting the data related to the desired outcomes

2. Comparing the data with outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusion about problem status
5. Continuing, modifying, or terminating the nursing care plan
Collecting the data

 The nurse collects the data so that conclusion can be drawn about whether goals have been
met. It is usually necessary to collect both subjective & objective data. Data must be
recorded concisely and accurately to facilitate the next part of the evaluating process.
Comparing the data with outcomes

 If the first part of the evaluation process has been carried out effectively , it is relatively
simple to determine whether a desired outcome has been met. Both the nurse and client play
an active role in comparing the client’s actual responses with the desired outcomes.
Relating nursing activities to outcomes

 The third aspect of the evaluating process is determined whether the nursing activities had
any relation to the outcome.
Drawing conclusion about problem status

 The nurse uses the judgement 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 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 is being prevented, but the risk factors 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. In this case the
nursing interventions must be continued.
Continuing , modifying , or terminating the nursing care plan

After drawing conclusion about the status of the client’s problems , the nurse modifies the
care plan as indicated. Whether or not goals were met, a number of decision need to be made
about continuing, modifying or terminating nursing care for each problem.

Before making individual modification, the nurse must first determine why the plan as a whole
was not completely effective. This require a review of the entire plan.

Factors Affecting Goal Attainment

1. Family Members
2. Health Team Members
 3. Nurse
Evaluation Skill Required for Nurses

1. Nurse must know the hospital policies, procedure and protocols of interventions and
recording.
2. Nurse must have up to date knowledge and information of many subject.
3. Nurse must have intellectual and technical skill to monitor the effectiveness of nursing
interventions.
4. Nurse must have knowledge and skill of collecting subjective data and objective data.

OUTCOME IDENTIFICATION

Definition
 Refers to formulating and documenting measurable, realistic and client-focused goals that
will provide the basis for evaluating nursing diagnosis.
Purposes

1. To provide individualized care

2. To promote client participation
3. To plan care that is realistic and measurable
4. To allow involvement of support people
Activities during Outcome Identification

1. Establish client’s goals and outcome criteria

Client Goal
 Is an educated guess made as a broad statement about what the client’s state or condition
will be AFTER the nursing intervention is carried out.
 Are written to indicate a desired state. They contain action word/verb and a qualifier that
indicate the level of performance that needs to be achieved.
 Example of verbs used in client goals:

 Calculate
 Classify
 Communicate
 Compare
 Define
 Demonstrate
 Describe
 Construct
 Contrast
 Distinguish
 Draw
 Explain
 Express
  Identify
 List
 Name
 Maintain
 Perform
 Particular
 Practice
 Recall
 Recite
 Record
 State
 Use
 Verbalize
 Ambulates
 *a Qualifier is a description of the parameter or criteria for achieving the goal.
Example:

Ambulates safely with one-person assistance.

Identifies actual & risk environmental hazards.
Demonstrates signs of sufficient rest before Surgery.
Goals may be short term or long term

 Short Term Goal (STG) – can be met in a short period (within days or less than a week)
 Long Term Goal (LTG) – requires more time (several weeks or months)
 Outcome Criteria – are specific, measurable, realistic statements goal attainment. They
are written in a manner that they answer the questions: who, what actions, under what
circumstance, how well and when.
 Therefore the characteristic of well-stared outcome criteria are:
o S = smart
 M = measurement
 A = attainable
 R = realistic
 T = time-framed
Example of Goals and Outcome Criteria

1. Goal – The client will report a decreased anxiety level regarding Surgery.Possible Outcome
Criteria:
 The client discusses fears & concern regarding surgical procedure after client teaching.
 After client teaching, the client verbalizes decreased anxiety.
 The client identifies a support system and strategies to use to reduce stress and anxiety
related to the surgical experience.
2. Goal – The client will demonstrate safety habits when performing activities of daily living.
Possible Outcome Criteria:
 Immediately after instruction by the nurse, the client uses call light system for assistance
when needs to use the bathroom.
 The client demonstrates safety practices when dressing and doing personal hygiene.
 The client uses over-the-bed lights, non-skid slippers when transferring to chair or getting
out of bed.
 The client identifies modification for home safety (removal of throw pillows, installation of
hand rails in hal way, better lighting of hal way and stairway), 12 hours after nurse’s
instruction about home safety.
3. Goal – The client will mobilize lung secretions.
Possible Outcome Criteria:
 After teaching session, the client demonstrates proper coughing techniques.
 The client drinks at least 6 glasses of water per day while in the hospital.
 The caregiver or significant other demonstrates proper technique of chest physiotherapy
including percussion, vibration and postural drainage before discharge.

PREPARED BY

DR.ANJALATCHI M.SC(N) MBA(HA)MD(AM)

ELMCH,ERA UNIVERSITY