The Nursing Process

Diagnosing and Planning

Mary Joan Therese Valera – Kourdache, RN, MPH

Purpose:

 Lydia Hall was one the first nurses to

use the term with the purpose of
“describing the accepted method of
delivering nursing care”
 Provide a framework within which the
individualized needs of the patient,
family, and community can be met
Definition:

 An organized, systematic method of

giving care that focuses on identifying
and treating unique responses of
individuals or groups to actual or
potential alterations in health
Reasons for planning care
 The patient has a right to expect the
nursing care to be complete and of
high quality
 Care planning and its documentation
provide opportunities of professional
communication
 Provides legal protection for the nurse
Characteristics:
 Open and Flexible
 Cyclic and dynamic
 Client Centered
 Individualized to meet the client’s needs
 Interpersonal and Collaborative
 Planned
 Goal-directed
 Permits creativity
 Emphasizes Feedback
 Universally accepted
 ANA’s Standards of Clinical Nursing
Standard I. The nurse collects client health data
Assessment :
Standard II. The nurse analyzes the assessment data
Diagnosis : determining diagnosis
Standard III. The nurse identifies expected outcomes
Outcome individualized to the client.
Identification :
Standard IV. The nurse develops a plan of care prescribes
Planning : interventions to attain expected outcomes.
Standard V. The nurse implements the interventions
Implementation : identified in the plan of care
Standard VI. The nurse evaluates the client’s progress
Evaluation : toward attainment of outcomes.
From American Nurses Association:
Standards of Clinical nursing practice,
Washington, DC, 1991
 ASSESSING DIAGNOSING
 Collect data
 Analyze data
Assessing  Organize data
 Identify health problems, risks and
 Validate data
strengths
Document data
 Formulate diagnostic statements
Diagnosing PLANNING
 Prioritize problem/Nursing Diagnoses
Formulate goals/ desired outcomes

Planning Select nursing interventions

Write nursing orders
IMPLEMENTING
 Reassess the client
Implementing  Determine the nurse’s need for assistance
Implement the nursing orders
Document nursing actions
EVALUATING
Evaluating Collect data related to outcomes
Draw conclusions about problem status
Continue, modify or terminate client’s care
The Nursing Process
 ASSESSMENT
– Making an assessment
– Select the area to be assessed
– Gather the data
– Sort and categorize the data

 DIAGNOSIS
– Writing a summary
statement/formulate a nursing
diagnosis (NANDA has developed
a set of standardized nursing
diagnoses)
 PLANNING
Designing a nursing care plan
A. Formulating desired outcomes with client-based
nursing diagnosis
– stating desired behavioral outcome
– stating the timetable for behavioral change
– use in the evaluation phase
B. Nursing interventions to help achieve desired
outcomes
– Health promotion
– Health maintenance
– Health restoration
– Health rehabilitation
Nursing Diagnosis: NANDA

Gives nurses a common language

Promotes identification of appropriate
goals
Provides acuity information
Can create a standard nursing practice
Provides a quality improvement base
Pattern Description

 Nurses assist clients who have limited

knowledge and understanding of:
1. Their current health status
2. How to achieve a good health status
3. How to maintain a good health status
Planning
 Involves developing a nursing
care plan
 Consist of three important
activities
- Setting priorities/prioritization of NDxs
or nursing problems
- Writing client – oriented goals
- Planning nursing actions
Priority setting
 Involves determination of the sequence
of addressing client problems
 Maximize efforts and resources toward
resolution of client’s most important
problems based on:
- Maslow’s hierarchy of needs
- Effect of lower needs on satisfaction of higher needs
- Fulfillment of patient’s preferences
- Potential for future problems
- Medical problems and treatment
Components of Nursing Diagnosis
Statement
 Label: should be descriptive of the diagnosis
definition and defining characteristics(Gordon, 1990)
 Definition: clear and precise meaning of the
diagnosis according to the North American Nursing
Diagnosis Association
 Defining characteristics: the clinical cues
(subjective & objective signs/symptoms) that point to
the nursing diagnosis
Components of Nursing Diagnosis
Statement
 Related factors: etiologic or contributory factor
that have influenced the health status change
Four categories:
1. Pathophysiologic – biologic or psychological
2. Treatment-related – medications, limitations due
to a diagnostic procedure, surgery, treatments
3. Situational – environmental (home, community),
personal (roles, life experiences)
4. Maturational – (age-related influences, i.e. elder,
newborn, adolescent)
Writing Nursing Goals
 The desired outcomes of nursing care
or actions/interventions
 A change in health status
 2 types:
- Long term = takes an extended period of time
- Short term = can be met in a relatively short
period of time
Writing Nursing Goals
 A goal consists of:
1. Subject – describes the patient or any
part of the patient

2. Verb – action that the subject is

expected to perform
Writing Nursing Goals
 A goal consists of:
3. Criteria of satisfactory performance –
indicate the level at which the patient
performs the specific behavior together
with date or time of achievement of
expected behavior
4. Condition – indicate the circumstances
under which the behavior will be
performed
Objectives
 Requires inclusion of specific,
behaviorally stated and measurable
outcomes
 Changes in cognitive (knowledge),
psychomotor (skill), affective (attitude)
 Stated Specific
Measurable
Achievable
Realistic
Time-bound/time-related
 Planning Nursing Actions
 The selection of appropriate
interventions/actions by the nurse in
order to achieve a certain objective
 Nursing actions are activities done by
the nurse in order to assist patients
achieve the goals of the NCP.
 Nursing orders communicate specific
instructions for nursing care
Types of Nursing Diagnoses

Actual
a clinical judgment of a client’s
response to a health problem present
at the time of assessment

Example: “Ineffective Airway Clearance

related to excessive and tenacious
secretions”
Types of Nursing Diagnoses
Wellness
Indicates a healthy response of a client
from specific level of wellness to a
higher level of wellness

Example: “Readiness for enhanced

family coping”
Types of Nursing Diagnoses
Risk
a clinical judgment that a client is more
vulnerable to develop the problem than
others in the same or a similar situation

Example: “Risk for Infection r/t immuno-

compromised status”
Types of Nursing Diagnoses
Syndrome
Comprises a cluster of problems that is
predicted to present because of a
certain situation or event

Examples:
“Rape Trauma Syndrome”
“Relocation Stress Syndrome”
Types of Nursing Diagnoses
Possible
Evidence about the health problem is
unclear or causative factors are
unknown; requires more data

Example: “Possible Social Isolation r/t

unknown etiology”
Types of Nursing Diagnoses
Collaborative
a potential problem where the definitive
treatment of the health problem requires
both medical & nursing interventions;
nursing interventions for these problems
are mainly monitoring client condition &
preventing complications

Example: “Potential Complications:

Hemorrhage r/t anti-coagulant therapy”
 Nursing Diagnosis:
Is there a problem in a specific area?

Yes No

Collect more focused data If no problem, is the person at risk

(or high risk) for developing a problem?
Is a problem present?

Yes No
No
Yes Does the person desire to
improve his/ her health?
Possible Nursing Diagnosis
Wellness Nursing Diagnosis

Actual Nursing Diagnosis

Risk Nursing Diagnosis

(Carpenito- Moyet, 2003)

 Guidelines for Making a Nursing
Diagnosis
 Should be prioritized in terms of the
client’s needs.
 Write the Diagnosis in terms of the
person’s unique human response rather
than nursing need
 Use “related to” rather than “due to” or
“caused by” to connect the two parts of the
statement
 Write the Diagnosis in legally advisable
terms
 Write the Diagnosis without value
judgments
 Guidelines for Making a Nursing
Diagnosis
 Avoid reversing the parts
 Avoid including signs and symptoms of the
illness in the first part of the statement
 Be sure that the two parts of the diagnosis
do not mean the same thing
 Express the problems and related factors
in terms that can be changed.
 State the diagnosis clearly and concisely
 Exercise: Classify the following data
into the following:
 Dyspnea
 NDx Nursing Diagnosis
 Weight loss
 MD Medical Dx  Hematuria
 S Sign  Hypertension
 Sx Symptom  Self-care deficit
 Rx Treatment  Constipation
 Acute Myocardial Infarction
 Noncompliance
 Violent behavior
 Diarrhea
 Anxiety
 Major Depression
 Hemoptysis
 Hyperthermia
 Acute Pain
Exercise: Which ND are correctly
written?
 Self-care deficit: Grooming related to
weakness
 Powerlessness related to hospitalization
 Anger related to diagnosis of cancer
 Sleep deprivation r/t disturbed sleeping
pattern
 Frustrations with self related to anxiety
 Alteration in thought processes related to
impaired thinking
 Readiness for Enhanced Spiritual Well-being
Guidelines for Formulating Nursing
Objectives
 Goals: end goal  reversal of the nursing
problem
 Objectives:
– outcomes to achieve the goal
– SMART
 Objectives should be related to human
responses; should be client-centered
 Objectives should be determined by the
nurse and the client.
Guidelines for Writing Nursing
Interventions
 Should include precise action verbs and
list specific activities to achieve the desired
outcomes

 Should define, who, what , where, when

how and how often identified activities will
take place
Guidelines for Writing Nursing
Interventions

 Should be consistent with the plan of care

 Should be based on scientific principles

 Should be individualized to the client

 Should include modifications of standard

therapy
A
A vague uneasy feeling, the
n source of which is often
x nonspecific or unknown to
the individual
i  Related Factors
– Unconscious conflicts about essential
e values and goals
– Threat to self-concept
– Threat of death
t – Threat or change in health status
 Defining Characteristics
y – Subjective: increased tension,
apprehension
Examples of Nursing Diagnoses
Wellness Nursing Diagnoses
 Health Seeking Behaviors: (specify)
 Altered Dentition r/t (changeable etiology)
 Readiness for Enhanced Family Coping
 Fear r/t (known etiology)
 Imbalanced Nutrition r/t
 Impaired skin and tissue integrity r/t
 Sleep Deprivation r/t
Activity Intolerance
 The state in which an individual has
insufficient physiological or
psychological energy to endure or
complete required or desired daily
activities

Related Factors
 Generalized weakness
 Sedentary lifestyle
Defining Characteristics
 Verbal report of fatigue
 Exertional discomfort or dyspnea
Ineffective Airway Clearance
 The state in which an individual is unable to
clear secretions or obstruction from the
respiratory tract to maintain airway patency
 Related Factors
– Decreased energy and fatigue
– Tracheobronchial infection or secretions Trauma
 Characteristics
– Abnormal breathe sounds
– Tachypnea
– Cyanosis
– Dyspnea
– Fever
Remember there are no mistakes,
only lessons.

Be open to possibilities. Trust your

choices, and you’ll see that
everything is possible."