NURSING

PROCESS
By: Joanne Marie S. Garcia, RN, MAN
Nursing Process

• A series of planned action or operations

directed toward a particular result or goal.
• It is a systematic, rational method of
planning & providing individualized
nursing care.
• Its purpose is to identify client’s health
status, actual or potential health
problems or needs to establish plans to
meet the identified needs & to deliver
specific nursing
Interventions, to address those
needs.
• A framework for providing, professional
quality care. One impt skill is critical thinking
w/c is useful in all aspects of person’s life
and vital tool for nurse w/ regard to process.
• It is cyclical that is, its components follow a
logical sequence, but more than one
component may be involved at one time. At
the end of the 1st cycle, care may be
terminated if goals are achieved or the cycle
may continue w/ reassessment, or the plan
of care may be modified
Overview of the Nursing Process

• The term NP originated from Lydia Hall

in 1955, Johnson in 1959,Orlando in
1961, Wiedenbach in 1963.
• NP gained additional legitimacy in 1973,
when it was included in the ANA-
Standard of Nursing Practice.
• North American Nursing Diagnosis
Association(NANDA) 1974 added the
nursing diagnosis
Nursing practice prior to Nursing
Process

• Nursing care was based on medical orders

by the physician.
• Focused on specific disease condition
rather than on the person being cured for.
• Nursing rendered were often guided by
intuition rather than a scientific method.
Characteristics of the Nursing
Process

• Characterized by a unique properties that

enable it to respond to the changing health
status of the client
• Client centered. The nurse organizes the
plan of care according to clients problem
rather than the nursing goals.
• The NP is an adaptation of problem solving
& system theory.
• Decision making is involved in every phase
of the nursing process. Nurse can be highly
creative in determining when to use data to
make decisions.
• The NP is interpersonal & collaborative.
• It is universally applicable.
• Nurses must use a variety of critical-
thinking skills to carry out the NP.
Phases of nursing process
Overview of the Nursing Process

• Consists of 5 steps

–AD-PIE
ASSESSMENT
 1. ASSESSING

• A systematic & continuous collection,

organization, validation & documentation of
data.
• It is carried out during all phases of the
nursing process.
• All phases of nsg process depend on the
accurate and complete collection of data.
Purpose: to establish data base about the client’s response
to health concerns or to illness & the ability to manage
health care needs.
Activities;
Establish a data base: Obtain a nsg health hx, conduct a
physical assessment, review client record, review nsg
literature, consult support persons, consult health
professionals
Update data needed
Organize data
Validate data
Communicate/document data
Types of Assessment

• Initial assessment: Performed within

specified time after admission to health care
agency.
• Purpose: To establish a complete data base
for problem identification, reference & future
comparison.
• Example: Nursing Admission Assessment
 Problem-focused assessment

• Ongoing process integrated with the

nursing process. Focus on a particular
need or health care problem.
• Purpose: To determine the status of a
specific problem identified in an earlier
assessment.
• Example: hourly assessment of I & O in an
ICU.
 Emergency Assessment

• During any physiologic or psychologic crisis

of the client.
• Purpose: To identify life threatening
problems. To identify new or overlooked
problems.
• Example: Rapid assessment of a person’s
airway, breathing status, & circulation during
a cardiac arrest.
Assessment for suicidal tendencies
or potential for violence.
• Timed- lapsed reassessment:
• done several months after initial
assessment.
• Purpose: To compare the client’s
current status to baseline data
previously obtained.
• Example: Reassessment of a client’s
functional health patterns in a home
care or outpatient setting or in a
hospital.
Collection of Data

• A process of gathering information about a

client’s health status.
• It must be systematic & continuous to
prevent the omission of significant data &
reflect a client’s changing health status.
 Database (Baseline Data)

• Is all the information about the client. It

includes the nursing health history, physical
assessment, primary care provider’s history
& physical examination, results of
laboratory & diagnostic tests,& material
contributed by other health personnel.
• It should include the past & present health
history. Example of Nsg Health Hx (p.181)
Types of Data

• Subjective data- referred to as symptoms

or covert data, apparent only to the person
affected & can be described & verified only
by that person. Includes the client’s
sensations, feelings, values, beliefs

• Examples: Itching, pain & feelings of worry

Objective Data
• Referred to as signs or overt data, are
detectable by an observer or can be
measured, or tested against an accepted
standard.
• They can be seen heard, felt & smelled, &
they are obtain by observation & physical
assessment.
• Examples: skin discoloration, v/s,
 Sources of Data
1. Primary source:
 Client- is the primary source, the best
source of data.
2. Secondary source:
Support People or family members,
friends, & caregivers who know the client.
Client records- include information
documented by various health care
professionals. medical records, records of
therapies
Health care professionals – nurses,
social workers, primary care providers,
physiotherapies
Literature –review of nursing literature
such as professional journals and
reference texts ( standards or norms
against w/c compare findings(ht, wt
tables, normal developmental tasks for
an age group), cultural & social health
practices, spiritual beliefs, assessment
data needed,
 Data Collection Methods
• Observing: To observe is to gather data
using the senses. Observation is a
conscious, deliberate skill that is
developed through effort & with an
organized approach.
• Particular sequence for observing
events
1. Clinical signs of client distress (e.g., pallor
or flushing, labored breathing, & behavior.
2. Threats to the client’s safety, real or
anticipated ( a lowered side rail)
3. The presence & functioning of associated
equipment ( IV equipment's, oxygen )
4. The immediate environment, including
the people in it.
Interviewing

• An interview is a planned communication or

a conversation with a purpose.( e.g. to get or
give information, identify problems of mutual
concern, evaluate change, teach, provide
support or counselling.
 Two approaches to interviewing
• Directive interview- highly structured &
• elicits specific information.
– The nurse establishes the purpose & control
the interview.
– Frequently used when time is limited to gather
& give information ( emergency situation).
• Nondirective interview- or rapport building
interview, the nurse allows the client to
control the purpose, subject matter, &
pacing . Rapport is an understanding
between 2 or more people.
 Types of interview questions:

– Closed questions- used in the directive

interview, are restrictive & generally require
only “yes” or “no” or short factual answers giving
specific information.( when, where, who, what,
do(does, did) or is (are, was)

– Open- ended questions- non-directive, invite

clients to discover, explore, elaborate, clarify or
illustrate their thoughts & feelings.
 • Useful at the beginning of interview or to change
topics or to elicit attitudes.
• Gives client to divulge only the information that they
are ready to disclose.
• Begin with: what or how
• Adv/disadvantages (p185)

– Neutral question- is a question the client can

answer without direction or pressure from the
nurse, open-ended & used in nondirective
interview. (e.g., “How do you feel about that?”,
“Why do you think you had the operation?” )
– Leading question- usually closed used in
directive interview, & thus direct the client’s
answer. (e.g., “ You’re stressed about surgery
tomorrow, aren’t you?” , “you will take your
medicine, won’t you?”)
– Gives client less opportunity to decide
whether the answer is true or not.
 Planning the Interview & Setting
• Before beginning an interview the nurse reviews
available information about the client health
problem, review the agency’s data collection.
Factors that may encourage an effective
interview
• Time . Nurses need to plan & schedule
interview with the client when the client is
physically comfortable and w/ minimal
interruptions w/ friends. At home interview is
conducted at a time selected by the client.
• Place. A well lighted, well- ventilated
room that is relatively free of noise,
movements, & distractions encourages
communication.
• Seating arrangement. Nurses should not
risks intimidating the client.(standing or
looking down to a client who is in bed or
sitting in a chair)
nurse can sit at a 45 degree angle to the
bed.
 During an initial admission interview, the client
may feel less confronted if there is an over
head table bet. the client & nurse.
• Distance. Too close or too far away the
interviewer & interviewee may feel
uncomfortable. Proxemics is the study of
use of space. Maintaining 2-3 ft distance
may be comfortable. Distance varies w/
ethnicity- Arab countries 8-12 inches, 18
inches in US, 24 inches in Britain 36
inches in Japan.
• Language. The nurse must always confirm
accurate understanding. The nurse must
convert complicated medical terminology into
common English usage and interpreters or
translators are needed if the nurse and client
do not speak the same language
 Stages of an Interview
• The opening or introduction. To establish
rapport & orient the interviewee. Can be the most
impt part of the interview bec what is said and
done at that time sets the tone for the remainder of
the interview. The nurse must be careful not to
overdo this stage: too much superficial talk can
arouse anxiety.
• The body or development. The client
communicates what he feels, thinks, knows &
perceives in response to questions from the nurse.
Use of communication technique by the nurse.
• The closing. The nurse terminates the
interview when the needed information
have been obtained. There are
techniques to close the interview with
rapport & trust for future interactions.
Examining
• The physical examination or physical
assessment is carried out systematically,
may be organized according to the
examiner’s preference, cephalo- caudal or
the body systems approach .
• To conduct the examination the nurse uses
techniques of inspection, auscultation,
palpation and percussion.
• Screening examination or review of
systems is a brief review of essential
functioning of various body parts or
systems.
ORGANIZING DATA

• After data collection is completed the nurse

organizes or clusters the information in
order to identify areas of strengths &
weaknesses.
• How data are organized depends on the
assessment models used
 VALIDATING DATA

• Is the act of “double- checking” or verifying

the data to confirm that it is accurate &
factual.
– Ensure that assessment information is complete.
– Ensure that objective & related subjective data
agree.
– Obtain additional information that may have
been over-looked.
– Differentiate between cues & inferences. Cues
are subjective or objective data that can be
directly observed by the nurse. Inferences are
the nurses interpretation or conclusions made
based on the cues.

– Avoid jumping to conclusions & focusing in the

wrong direction to identify problems.
 DOCUMENTING DATA

• Accurate & complete recording of data are

essential in communicating information to
other health care team members.
• Data are recorded in a factual manner &
not interpreted by a nurse.
 2. DIAGNOSING
(NURSING DIAGNOSIS)
Identifying Nursing Diagnosis

• Common language for nurses

• A clinical judgment about an individual, family
or community response to an actual or
potential health problem or life process,
• Nursing diagnosis provide a basis for
selection of nursing interventions so that
goals and outcomes can be achieved
• NANDA list of acceptable diagnoses,
updated every 2 years.
Diagnostic Reasoning

• Apply critical thinking to problem

identification
• Requires knowledge, skill, and
experience
• Big Picture
Fundamental Principles of
Diagnostic Reasoning
• Recognize diagnoses
• Keep an open mind
• Back up diagnosis with evidence
• Intuition is a valuable tool for problem
identification
• Independent thinker
• Know your qualifications & limitations
Diagnosing
• Analyzing & synthesizing data
• Purpose:
• To identify the clients strengths &
health problems that can be prevented
or resolved.
• To develop a list of nursing &
collaborative problems
DIGNOSING

• Diagnosing -Refers to the reasoning

process.
• Diagnosis- a statement or conclusion
regarding a nature of a phenomena.
• Diagnostic labels- the standardized NANDA
names for the diagnoses.
• Nursing diagnosis- the client’s problem
statement, consisting of the diagnostic label
plus etiology.
 Nursing Diagnosis (1990
NANDA)

• A clinical judgment about individual, family

or community responses to actual &
potential health problems/ life processes.
• Provides the basis for selection of nursing
intervention to achieve outcomes for which
the nurse is accountable.
Types of Nursing Diagnosis

• Actual nursing diagnosis: A problem exists; it is

composed of the diagnostic label, related factors,
and signs and symptoms.

• Risk nursing diagnosis: A problem does not yet exist,

but special risk factors are present.

• Wellness nursing diagnosis: Indicates client’s desire

to attain higher level of wellness in some area of
function.
Writing a Nursing Diagnosis

• Actual Problems: Problem (NANDA

label) & Etiology & Supporting Signs
and Symptoms
• Impaired Communication related to
language barrier as evidenced by
inability to speak English
Writing a Nursing Diagnosis

• Potential or Risk Problems: Problem

(NANDA label) & etiology or problem &
risk factors with related to statement
linking problem to risk factors.
• Risk for Impaired skin integrity related
to obesity, excessive diaphoresis, and
immobility.
Writing A Nursing Diagnosis

• Use accepted qualifying terms (Altered,

Decreased, Increased, Impaired)
• Don’t use Medical Diagnosis (Altered
Nutritional Status related to Cancer)
• Don’t state 2 separate problems in one
diagnosis
• Refer to NANDA list in a nursing text
books
Nursing Diagnosis

• Actual or Potential problems identified

• Actual: actual evidence of
signs/symptoms of diagnosis exist.
(Fluid Volume Deficit)
• Potential/Risk for Diagnosis: client’s
data base contains risk factors of
diagnosis, but no true evidence (Risk
for altered skin integrity)
Types of Nursing Diagnoses

1. An actual diagnosis- a client problem that

is present at the time of the nursing
assessment. E.g., Ineffective Breathing
Pattern, Anxiety, Impaired Skin Integrity.
2. A risk nursing diagnosis- a clinical
judgment that a problem does not exist,
but the presence of risk factors indicates
that a problem is likely to develop unless
nurses intervene.
• E.g., High Risk for infection, Risk for
Injury, Risk for impaired Skin Integrity.

3. A wellness diagnosis- “ Describes

human responses to levels of wellness in
an individual, family, or community that
have a readiness for enhancement”. E.g.,
Readiness for Enhanced Spiritual Well-
Being, Readiness for Enhanced family
Coping.
4. A possible nursing diagnosis- is one in
which evidence about a health problem is
incomplete or unclear, or the causative
factors are unknown. E.g., Possible social
Isolation R/T unknown etiology, Possible
Self Esteem Disturbance R/T recent
retirement.
5. A syndrome diagnosis- associated with a
cluster of other diagnoses. Currently there
are 6 on NANDA international list,
• E.g., Risk for Disuse Syndrome ( for long
term bedridden patient). Clusters of
diagnoses associated with this syndrome
include; Impaired Physical Mobility, Risk for
Impaired Tissue Integrity, Risk for Activity
Intolerance, Risk for constipation, Risk for
Infection, Risk for Injury, Risk for
Powerlessness, etc.
 Components of a NANDA
Nursing Diagnosis

• Problem (diagnostic Label) & Definition-

describes the client’s health problem or
response for which nursing therapy is given.
• Its purpose is to direct the formation of
client goals & desired outcomes, may also
suggest some nursing interventions.
• Each diagnostic label approved by NANDA
carries a definition & clarifies its meaning.
• E.g., Activity Intolerance: Insufficient physiological
or psychological energy to endure or complete
required or desired daily activities.
• Etiology (Related Factors & Risk Factors)-
identifies one or more probable causes of health
problems, given direction to the required nursing
therapy, & enables the nurse to individualize the
client’s care.
• E.g., Activity Intolerance R/T bed rest or
immobility, generalized weakness, imbalance bet.
Oxygen supply/demand, sedentary lifestyle
• Defining Characteristics- are the cluster of
the sign & symptoms that indicate the
presence of a particular diagnostic label.
• E.g., verbal report of fatigue or weakness,
abnormal heart rate or blood pressure,
response to activity, ECG changes reflecting
arrhythmias or ischemia, exertional
discomfort or dyspnea. (Activity Intolerance)
Difference between ND & Medical
Diagnosis & Collaborative problems

• Medical diagnosis- is made by a physician

& refers to a condition that only a physician
can treat.
• A disease process- specific pathophysiologic
responses that are fairly uniform from one
client to another.
Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Identifies conditions the Identifies situations the
MD is licensed & nurse is licensed &
qualified to treat qualified to treat
Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Identifies conditions the Identifies situations the
MD is licensed & nurse is licensed &
qualified to treat qualified to treat

Focuses on illness, Focuses on the clients

injury or disease responses to actual or
processes potential health / life
problems
Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Remains constant Changes as the clients
until a cure is response and/or the health
effected problem changes
Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Remains constant Changes as the clients
until a cure is response and/or the health
effected problem changes

i.e. Breast cancer i.e. Knowledge deficit

Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
Diangosis

Nursing diagnosis Medical diagnosis

Breathing patterns, Chronic obstructive

ineffective pulmonary disease
Activity intolerance Cerebrovascular accident

Pain Appendectomy

Body image disturbance Amputation

Body temperature, risk for Strep throat

altered
• Collaborative Problems- a type of
potential problem that nurses manage using
both independent & physician prescribed
interventions .
• Definite treatment of the condition requires
both medical & nursing interventions.
• E.g., Potential complication of pneumonia:
atelectasis, respiratory failure, pleural
effussion, pericarditis, & meningitis.
The Diagnostic Process

• Analyzing Data-involves the ff steps:

1. Compare data against standards. A standard
or norm is a generally accepted measure, rule
model or pattern.
2. Clustering cues. A process of determining the
relatedness of facts & determining whether any
pattern are present. It involves making
inferences about the data.
 3. Identifying gaps & inconsistencies in data.
Data analysis should include final check to
ensure that data are complete & correct.
• Identifying Health Problems, Risks,&
Strengths- primarily a decision-making
process.
1. Determining problems & Risks
2. Determining Strengths
• Formulating Diagnostic Statements
1. Basic two part statements.
– E.g., Ineffective Airway Clearance R/T
Copious/ secretions.
– Anxiety R/T up coming surgery
– Impaired Gas Exchange R/T decreased lung
expansion
2. Basic Three-Part Statements.
– PES format
– E.g., Ineffective Airway R/T copious
secretions as manifested by dyspnea,
adventitious breath sounds (crackles,
wheezes)
3. One- Part Statements
– Wellness diagnoses & syndrome nursing
diagnoses
– E.g., Readiness for Enhanced Parenting
– Rape Trauma Syndrome
3. PLANNING
Planning & Outcome identification

–Types of
planning
• Initial
• Ongoing
• Discharge
Planning & Outcome identification

• Outcome
identification =
Goals
– Short term
• Hrs - days (<
week)
– Long term
• Wks. – mons.
Planning & Outcome identification

• Interventions
– Independent interventions
• No MD order needed
– Interdependent interventions
• With interdisciplinary team member
– Dependent interventions
• MD order required
 Planning

• Determining how to prevent, reduce, or

resolve the identified priority client problems;
how to support client strengths; how to
implement nursing interventions in an
organized, individualized & goal- directed
manner.
• Purpose: To develop an individualized care
plan that specifies client goals/ desired
outcomes, & related nursing interventions.
 PLANNING
• A deliberate, systematic phase that involves
decision making & problem solving.
• The nurse refers to the client’s assessment
data & diagnostic statements for direction in
formulating client’s goal & designing the
nursing interventions required to prevent,
reduce or eliminate the client’s health
problem.
• Nurses do not plan for the client but
encourage the client to participate actively.
 Types of Planning
• Initial planning- usually done by the nurse
who did the admission assessment. Initiated
as soon as possible after initial assessment.
• Ongoing planning- done by all nurses who
work with the client. As nurses obtain new
information & evaluate the client’s responses
to care, they can individualize the initial care
plan further.
• Reasons for daily planning (purposes)
– To determine whether the client’s health status
has changed.
– To set priorities for the client’s care during the
shift.
– To decide which problems to focus on during the
shift.
– To coordinate the nurse’s activity so that more
than one problem can be addressed at each
client contact .
• Discharge Planning- the process of
anticipating & planning for needs after
discharge. Is a crucial part of comprehensive
health care & should be addressed in each
client’s care plan.
• Effective discharge planning begins at first
client contact & involves comprehensive &
ongoing needs
Short Term vs. Long Term Goals

• Short term goal can be achieved in a

reasonable amount of time ( few hours to few
days)
• Long term goals may take weeks/months to
be achieved
• Client will ambulate down the hall within 2
days.
• Client will walk the length of the hallway
independently by the end of 2 weeks
 Nursing Care Plans

• The end product of the planning phase is a

formal or informal plan of care.
• Informal nursing care plan- is a strategy
for action that exists in the nurse’s mind.
E.g., “Mrs. Phan is tired. I will need to
reinforce her teaching after she is rested.
• Formal nursing care plan- is a written or
computerized guide that organizes
information about the client’s care.
• Formal written care plan provides for
continuity of care.
• Standardized care plan is a formal plan
that specifies the nursing care for groups of
clients with common needs. (e.g., all clients
with myocardial infarction)
• Individualized care plan is tailored to meet
the unique needs of a specific client need
that are not addressed by the standardized
plan.
 Nursing Care Plan format

• Problem Goals/Desired Outcomes

Nursing Intervention Evaluation
• Assessment Nursing Diagnosis
Planning Nursing Intervention
Evaluation
• PES Planning Nursing Intervention
Rationale Evaluation
Guidelines for writing Nursing Care
Plans

1. Date & sign the plan

2. Use category headings: Nursing
Diagnoses, goals/desired outcomes,
Nursing Intervention , & Evaluation.
3. Use standardized/ approved medical or
English symbols & key words rather than
complete sentences to communicate your
ideas unless the agency policy dictates it
otherwise.
4. Be specific about expected timing of an
intervention.
5. Refer to procedure books or other sources of
information rather than including all steps on a
written plan.
6. Tailor the plan to the unique characteristics of
the client by ensuring that the client’s choices,
such as preferences about the times of care &
the method used, are included.
7. Ensure that the nursing plan incorporates
preventive & health maintenance aspects as well
as restorative ones. (e.g., ROM)
8. Ensure that the plan contains interventions
for ongoing assessment of the client (e.g.,
“inspect incision q8h”)
9. Include collaborative & coordination
activities in the plan (e.g., nutritionist,
physical therapist)
10. Include plans for the client’s discharge &
home care needs.
The Planning Process

• Setting Priorities.
– Priority setting- is the process of establishing a
preferential sequence for addressing nursing
diagnoses & interventions.
– Nurse & client decide which nursing diagnosis
requires attention first, which second & so on.
– Can be grouped as having high, medium or low
priority.
– The nurse examines the nursing diagnoses &
ranks them in order of physiological or
psychological importance.
– Life threatening problems, such as loss of
respiratory or cardiac function, are designated
as high priority.
– Health threatening problems, such as acute
illness & decreased coping ability , are
assigned as medium priority.
– Low priority problem usually arises from
from normal developmental needs or that
requires minimal nursing support.
– Moderate & low priorities often involve the
prevention of anticipated potential or risk
diagnosis.
– Establishing priorities does not mean that one
problem must be or must be totally resolved
before addressing others.
• Nurses frequently use Maslow’s hierarchy of
needs when setting priorities.
• Rank the following:
– Ineffective airway clearance
– Sleep pattern disturbance
– Altered comfort

– Anxiety r/t hospitalization

– Ineffective coping
– Decreased cardiac output r/t ineffective heart
contractions
• Establishing Client Goals/Desired
Outcomes
– Describe, in terms of observable client
responses, what the nurse hopes to achieve by
implementing the nursing interventions.
– Goal is a broad statement, about a client’s
status.
– Expected outcomes are more specific,
observable criteria used to evaluate whether
goals have been met. Can be identified based
on the goals.
• E.g., Goal: Improved Nutritional Status
• Expected Outcome: Client will gain 5lb by
April 25.
• Goal: Effective airway Clearance
• Expected Outcome: The client will:
– Have lungs clear to auscultations during entire
postoperative period.
– No cyanosis by 12 hours post op.
– Demonstrate good cough effort within 24 hours.
• Purpose of desired goals/outcome
– Provide directions for planning nursing
interventions.
– Serve as criteria for evaluating clients.
– Enable the client & nurse to determine when
the problem Has been resolved.
– Hep motivate the client & the nurse by
providing a sense of achievement.
• Long-term & short term goals
– Short-term goals are useful for clients who
require health care for a short time & for those
who are frustrated by long- term goals that
seem difficult to attain & who need the
satisfaction of achieving a short term goal.
e.g., Client will raise right arm to shoulder
height by Friday.
– Long term goals are often used for clients who
live at home & have chronic health illness.
 Guidelines for writing
Goals/Desired Outcome
• Write goals & outcomes in terms of client
responses not nurse activities. E.g., Client
will drink 100 ml of water per hour.
Maintain client hydration ( incorrect)
• Be sure that desired outcomes are realistic
for the client.
• Ensure that the goals & desired outcomes
are compatible with the therapies of other
professionals.
• Make sure that each goal is derived from
only one nursing diagnosis. E.g., “The
client will increase the amount of nutrients
ingested & show progress in the ability to
feed self”.
• Use observable, measurable terms for
outcomes. E.g., increase exercise,
improved knowledge of nutrition.
(incorrect)
• Make sure the client considers the
goals/desired outcomes important &
values them.
• Selecting Nursing Interventions & Activities are
actions & activities that a nurse performs to
achieve client goals.
• The specific interventions chosen should
focus on eliminating or reducing the etiology
of the nursing diagnosing.
• The nurse chooses interventions to treat the
signs & symptoms or the defining
characteristics.
• Interventions for risk nursing diagnoses
should focus on the measures to reduce the
risk factors.
 Types of Nursing Interventions

• Independent interventions are activities that

nurses are licensed to initiate on the basis
of their knowledge & skills.
• Dependent interventions are activities
carried out under the physician’s orders or
supervision, or according to specified
routine. The nurse is responsible for
assessing the needs for explaining, &
administering the medical orders. E.g.,
“progressive ambulation as tolerated”
• Collaborative interventions are actions the
nurse carries out in collaboration with other
health team members. Nursing activities
reflect the overlapping responsibilities of &
collegial relationships between health
personnel. E.g., physician’ s order “Physical
Therapy to teach client crutch walking”.
 Considering the Consequences of
each Intervention

• Determining the consequences of each

nursing intervention requires nursing
knowledge experience.
• Usually several possible interventions can
be identified for each nursing goal. It is
important to choose those that most likely to
achieve the desired client outcomes.
 Criteria for choosing the Nursing
Interventions

• Safe & appropriate for the individual’s age,

health, & condition.
• Achievable with the resources available.
• Congruent with the client values, beliefs,
culture.
• Congruent with other therapies (e.g., if the
client is not permitted food, the strategy of an
evening snack must be deferred until health
permits).
• Based on nursing knowledge & experience
or knowledge from the relevant sciences.
(i.e., based on a rationale).
• Within established standards of care as
determined by laws, professional
associations, & policies of the institutions.
• Writing Individualized Nursing
Interventions
• Nursing Interventions on the care plan are
dated when they are written & reviewed
regularly at intervals that depend on the
individual’s needs.
• The format of written intervention is similar to
that of outcomes: verb, conditions &
modifiers, plus time element.
• The time element answers when, how long,
or often the nursing action is to occur.
• E.g., “Explain the actions of insulin” is more
precise rather than “Teach about insulin”.
• “Apply spiral bandage firmly to left lower
leg”. rather than “Apply spiral bandage to
left leg”.
• “Administer analgesic 30 minutes prior to
physical therapy”.
 Relationship of Nursing Interventions to
Problem Status

• Depending on type of client problem, the

nurse writes interventions for observation,
prevention & treatment, & health promotion.
• Observations include assessment made to
determine whether a complication is
developing, as well as nursing client’s
responses to nursing & other therapies.
• Prevention interventions prescribe the care
needed to avoid complications or reduce
risk factors. Applicable for potential nursing
diagnoses & collaborative problems.
• Treatments include teaching, referrals,
physical care & other care needed for an
actual nursing diagnosis.
• Health promotions interventions are
appropriate when the client has no health
problems or when a nurse makes a
wellness nursing diagnosis.
• Delegating Implementation
• While choosing & writing nursing
interventions, the nurse must also
determine who should actually perform the
activity.
• The ability to delegate client care & assigns
tasks is a vital skill for registered nurses
because many health care institutions use
assistive health care personnel.
IMPLEMENTING
 Implementing

• Carrying out or delegating, & documenting

the planned nursing actions or
interventions.
• Purpose: To assist Client to meet desired
goals/outcomes; promotes wellness;
prevent illness & disease; restore health; &
facilitate coping with altered functioning.
 Implementing

• The action phase in which the nurse performs the

nursing interventions.
• Consists of doing & documenting the activities that
are the specific nursing actions needed to carry out
the interventions.
• The nurse performs or delegates the nursing
activities for the interventions that were develop in
the planning step & then concludes the
implementing step by recording nursing activities &
the resulting client responses.
 Relationship of Implementing to
other Nursing Process Phases
• The first three nursing process phases-
assessing, diagnosing, & planning- provide
the basis for nursing actions performed
during the implementing step.
• While implementing nursing care the nurse
continues to reassess the client at every
contact, gathering data about the client’s
responses & about any new problem that
may develop.
Implementing Skills

• Cognitive skills (intellectual skills) include problem

solving, decision making, critical thinking, &
creativity.
• Interpersonal skills. The effectiveness of nursing
actions often depends largely on the nurse’s ability
to communicate with others.
• Technical skills are purposeful “hands on” skills
such as manipulating equipment, giving injections,
bandaging etc. skills are also called tasks,
procedures, or psychomotor skills.
 Process of Implementing

• Reassessing the client

• Determining the Nurse’s need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
Categories of Nursing Interventions

• Independent: Actions initiated by nurse that do not

require direction or an order from another health care
professional

• Interdependent: Actions implemented in collaborative

manner by nurse in conjunction with other health
care professionals

• Dependent: Actions that require an order from a

physician or other health care professional.
Types of Nursing Interventions

• Specific order - written by physician or nurse

especially for an individual client.

• Standing order - A standardized intervention written,

approved and signed by a physician that is kept on
file to be used in predictable situations or in
circumstances requiring immediate attention.

• Protocol - A series of standing orders or procedures.

Types of Nursing Interventions

• Specific order: written by physician or nurse

especially for an individual client
• Standing order: A standardized intervention
written, approved and signed by a physician
that is kept on file to be used in predictable
situations or in circumstances requiring
immediate attention.
• Protocol: A series of standing orders or
procedures
EVALUATING
 Evaluating

• Measuring the degree to which the

goals/outcomes have been achieved &
identifying factors that positively or
negatively influence goal achievement.
• Purpose: To document whether to continue,
modify or terminate the plan of care.
 Evaluating
• Is a planned, ongoing, purposeful activity in
which clients & health care professionals
determine:
– The client’s progress toward achievement of
goals/outcomes
– The effectiveness of the nursing care plan
• It is an important aspect of the nursing
process because conclusion is drawn from
the evaluation, determine whether the
nursing intervention could be terminated,
continued, or changed.
Relationship of Evaluating to other
Nursing Process Phases

• Successful evaluation depends on the

effectiveness of the steps that precede it.
• The evaluating & assessing phases overlap.
Assessment is ingoing & continuous at every
client contact.
Process of Evaluating Client
Responses

• Collecting Data. Using the clearly stated,

precise & measurable desired outcomes as
a guide, the nurse collects data so that
conclusions can be drawn about whether
goals have been met. It is necessary to
collect both objective & subjective data.
• Comparing Data with Outcomes. Both the
nurse & client play an active role in
comparing the client’s actual responses with
the desired outcomes.
• Three possible conclusions:
– The goal was met; that is the client response is
the same a the desired outcome.
– The goal was partially met; that is, either a short
term goal was achieved, but the long term goal
was not, or the desired outcome was partially
attained.
– The goal was not met.
After determining whether a goal has been met,
the nurse writes an evaluative statement, which
consists of two parts; the conclusion &
supporting data.
• Relating Nursing Activities To Outcomes .
– IT should never be assumed that a nursing
activity was the cause of or only factor in
meeting, partially meeting or not meeting the
goal.
• Drawing Conclusions about Problem
Status. When goals have been met, the
nurse can draw one of the following
conclusions;
– The actual problem has been resolved
– The potential problem is being prevented
• Continuing, modifying, & terminating the
Nursing Care Plan.
 Nursing Care Plan

Assessment Nursing Planning

Diagnosis
The Nursing Process
is Critical Thinking

 Critical thinking, problem-solving, and

decision-making are important in the
use of the nursing process.

 These skills can be learned!

NURSING CARE PLAN EXAMPLE