MODULE 3

The Nursing Process

Learning Objectives:
At the end of this Module, you shall be able to;
1. Describe the phases of the nursing process accurately.
2. Identify the different major characteristics of the nursing process.
3. Differentiate the different phases and characteristics of the nursing
process comprehensively.
4. Explain how standards of care and care plans can be
individualized and used in creating a comprehensive nursing care
plan correctly.
5. Discuss the components of evaluation and re-assessment.
6. Comprehend importance of documentation in the nursing process
correctly.

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 THE NURSING PROCESS continuously notes the client’s skin color, level
of consciousness, and so on.
The nursing process is a systematic,
rational method of planning and providing Characteristics of the Nursing Process
individualized nursing care. Its purposes are to
identify a client’s health status and actual or The nursing process has distinctive
potential health care problems or needs, to characteristics that enable the nurse to respond
establish plans to meet the identified needs, and to the changing health status of the client. These
to deliver specific nursing interventions to meet characteristics include its cyclic and dynamic
those needs. The client may be an individual, a nature, client centeredness, focus on problem
family, a community, or a group. Hall originated solving and decision making, interpersonal and
the term nursing process in 1955, and Johnson collaborative style, universal applicability, and
(1959), Orlando (1961), and Wiedenbach use of critical thinking and clinical reasoning.
(1963) were among the first to use it to refer to
a series of phases describing the practice of
nursing. Since then, various nurses have
described the process of nursing and organized
the phases in different ways.

Phases of the Nursing Process

The Standards of Practice within the

most current Scope and Standards of Nursing
Practice include six phases of the nursing
process: assessment, diagnosis, outcomes
identification, planning, implementation, and
evaluation (ANA, 2010). The national licensure
examination for registered nurses (NCLEX)
uses five phases: assessment, analysis,
planning, implementing, and evaluation. This
text, and most others, uses five phases:
assessing, diagnosing (which includes
outcomes identification and analysis), planning,
implementing, and evaluating. Although nurses
may use different terms to describe the phases
(or steps) of the nursing process, the activities
of the nurse using the process are similar. For
example, implementing may be called
implementation, intervention, or intervening.
The nursing process is a systematic, rational method of planning and
providing nursing care. Its purpose is to identify a client’s health care status,
Each of the five phases is discussed in and actual or potential health problems, to establish plans to meet the
depth in this and subsequent chapters of this identified needs, and to deliver specific nursing interventions to address those
unit. The phases of the nursing process are not needs. The nursing process is cyclical; that is, its components follow a logical
separate entities but overlapping, continuing sequence, but more than one component may be involved at one time. At the
end of the first cycle, care may be terminated if goals are achieved, or the
sub processes. For example, assessing, which cycle may continue with reassessment, or the plan of care may be modified.
may be considered the first phase of the nursing
process, is also carried out during the The nursing process is interpersonal and
implementing and evaluating phases. For collaborative. It requires the nurse to
instance, while actually administering communicate directly and consistently with
medications (implementing), the nurse clients and families to meet their needs. It also
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requires that nurses collaborate, as members of outcomes of the nursing strategies and to
the health care team, in a joint effort to provide evaluate goal achievement. All phases of
quality client care.
the nursing process depend on the
accurate and complete collection of data.

The four different types of

assessments are the initial nursing
assessment, problem-focused
assessment, emergency assessment,
and time-lapsed reassessment.
Assessments vary according to their
purpose, timing, time available, and client
status. Nursing assessments focus on a
client’s responses to a health problem. A
nursing assessment should include the
client’s perceived needs, health
problems, related experience, health
practices, values, and lifestyles. To be
most useful, the data collected should be
relevant to a particular health problem.
Therefore, nurses should think critically
about what to assess.

The 2010 revision of ANA Standard 1:

Assessment adds several important aspects to
this step of the nursing process. The registered
nurse is responsible for the collection of
comprehensive data, including physical,
functional, psychosocial, emotional, cognitive,
sexual, cultural, age-related, environmental,
spiritual/transpersonal, and economic
assessments. The nursing assessment also
involves the elicitation of clients’ own
perspectives on their condition; identifying
barriers to communication; recognizing the
ASSESSMENT
impact of the nurse’s own attitudes, values, and
beliefs on the assessment process; including
Assessing is the systematic and family dynamics in assessment; and increased
continuous collection, organization, emphasis on protection of the privacy of data
validation, and documentation of data
(information). In effect, assessing is a Collecting Data
continuous process carried out during all
Data collection is the process of
phases of the nursing process. For
gathering information about a client’s health
example, in the evaluation phase, the status. Data collection must be both systematic
client is reassessed to determine the and continuous to prevent the omission of
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significant data and reflect a client’s changing relevant literature are secondary or indirect
health status. A database contains all the sources. In fact, all sources other than the client
information about a client; it includes the nursing are considered secondary sources. All data
health history, physical assessment, primary from secondary sources should be validated if
care provider’s history and physical possible.
examination, results of laboratory and
diagnostic tests, and material contributed by a. Client
other health personnel. Client data should
include past history as well as current problems. The best source of data is usually the client,
For example, a history of an allergic reaction to unless the client is too ill, young, or confused to
penicillin is a vital piece of historical data. Past communicate clearly. The nurse is often much
surgical procedures, folk healing practices, and closer to the client than other members of the
chronic diseases are also examples of historical health care team. In the acute care setting,
data. Current data relate to present nurse–client relationships will develop due to
circumstances, such as pain, nausea, sleep the close and frequent contact with the client
patterns, and religious practices. To collect data (Fawcett & Rhynas, 2012). The client can
accurately, both the client and nurse must provide subjective data that no one else can
actively participate. offer. Most often, primary data consist of
statements made by the client but also include
Types of Data those objective data that can be directly
obtained by the nurse from the client such as
Subjective data, also referred to as gender. Some clients cannot or do not wish to
symptoms or covert data, are apparent only to provide accurate data. Family members or
the person affected and can be described or significant others can be secondary sources of
verified only by that person. Itching, pain, and data if the client cannot speak for themselves, is
feelings of worry are examples of subjective a poor historian, or is a young child. If the client
data. Subjective data include the client’s is hesitant to provide data, remind the client that
sensations, feelings, values, beliefs, attitudes, the privacy of all data collected is protected and
and perception of personal health status and life can only be shared with persons who have a
situation. legitimate health-related need to know it.

Objective data, also referred to as signs b. Significant Others

or overt data, are detectable by an observer or
can be measured or tested against an accepted Family members, friends, and caregivers
standard. They can be seen, heard, felt, or who know the client well often can supplement
smelled, and they are obtained by observation or verify information provided by the client. They
or physical examination. For example, a might convey information about the client’s
discoloration of the skin or a blood pressure response to illness, the stresses the client was
reading is objective data. During the physical experiencing before the illness, family attitudes
examination, the nurse obtains objective data to on illness and health, and the client’s home
validate subjective data and to complete the environment. Support people are an especially
assessment phase of the nursing process. important source of data for a client who is very
young, unconscious, or confused. In some
Sources of Data cases—a client who is physically or emotionally
abused, for example—the person giving
Sources of data are primary or information may wish to remain anonymous.
secondary. The client is the primary source of Before eliciting data from support people, the
data. Family members or other support persons, nurse should ensure that the client, if mentally
other health professionals, records and reports, able, authorizes such input. The nurse should
laboratory and diagnostic analyses, and
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also indicate on the nursing history that the data report on a client’s ability to cope at home help
were obtained from a support person. the nurse conducting an assessment.
Laboratory records also provide pertinent health
c. Client Records information. For example, the determination of
blood glucose level allows health professionals
Client records include information to monitor the administration of oral
documented by various health care hypoglycemic medications. Any laboratory data
professionals. Client records also contain data about a client must be compared to the agency
regarding the client’s occupation, religion, and or performing laboratory’s norms for that
marital status. By reviewing such records before particular test and for the client’s age, gender,
interviewing the client, the nurse can avoid and other characteristics.
asking questions for which answers have
already been supplied. Repeated questioning Data Collection Methods
can be stressful and annoying to clients and
cause concern about the lack of communication The principal methods used to collect
among health professionals. Types of client data are observing, interviewing, and
records include medical records, records of examining. Observing occurs whenever the
therapies, and laboratory records. Medical nurse is in contact with the client or support
records (e.g., medical history, physical persons. Interviewing is used mainly while
examination, operative report, progress notes, taking the nursing health history. Examining is
and consultations done by primary care the major method used in the physical health
providers) are often a source of a client’s assessment. In reality, the nurse uses all three
present and past health and illness patterns. methods simultaneously when assessing
These records can provide nurses with clients. For example, during the client interview
information about the client’s coping behaviors, the nurse observes, listens, asks questions, and
health practices, previous illnesses, and mentally retains information to explore in the
allergies. Records of therapies provided by physical examination.
other health professionals, such as social
workers, nutritionists, dietitians, or physical a. Observation
therapists, help the nurse obtain relevant data
not expressed by the client. For example, a To observe is to gather data by using the
social agency’s report on a client’s living senses. Observing is a conscious, deliberate
conditions or a home health care agency’s skill that is developed through effort and with an
organized approach. Although nurses observe
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mainly through sight, most of the senses are There are two approaches to interviewing:
engaged during careful observations. Examples directive and nondirective. The directive
of client data observed through the senses. interview is highly structured and elicits specific
information. The nurse establishes the purpose
Observing has two aspects: (a) noticing of the interview and controls the interview, at
the data and (b) selecting, organizing, and least at the outset. The client responds to
interpreting the data. A nurse who observes that questions but may have limited opportunity to
a client’s face is flushed must relate that ask questions or discuss concerns. Nurses
observation to findings such as body frequently use directive interviews to gather and
temperature, activity, environmental to give information when time is limited (e.g., in
temperature, and blood pressure. Errors can an emergency situation). By contrast, during a
occur in selecting, organizing, and interpreting nondirective interview, or rapport building
data. For example, a nurse might not notice interview, the nurse allows the client to control
certain signs, either because they are the purpose, subject matter, and pacing.
unexpected or because they do not conform to Rapport is an understanding between two or
preconceptions about a client’s illness. Nurses more people.
often need to focus on specific data in order not
to be overwhelmed by a multitude of data. Types of Interview Questions

Observing, therefore, involves Questions are often classified as closed

distinguishing data in a meaningful manner. For or open ended, and neutral or leading. Closed
example, nurses caring for newborns learn to questions, used in the directive interview, are
ignore the usual sounds of machines in the restrictive and generally require only “yes” or
nursery but respond quickly to an infant’s cry or “no” or short factual answers that provide
movement. The experienced nurse is often able specific information. Closed questions often
to attend to an intervention (e.g., give a bed bath begin with “when,” “where,” “who,” “what,” “do
or monitor an intravenous infusion) and at the (did, does),” or “is (are, was).”
same time make important observations (e.g.,
note a change in respiratory status or skin Open-ended questions, associated with
color). The beginning student must learn to the nondirective interview, invite clients to
make observations and complete tasks discover and explore, elaborate, clarify, or
simultaneously. illustrate their thoughts or feelings. An open-
ended question specifies only the broad topic to
b. Interview be discussed, and invites answers longer than
one or two words. Such questions give clients
An interview is a planned communication or the freedom to divulge only the information that
a conversation with a purpose, for example, to they are ready to disclose.
get or give information, identify problems of
mutual concern, evaluate change, teach, A neutral question is a question the
provide support, or provide counseling or client can answer without direction or pressure
therapy. One example of the interview is the from the nurse, is open ended, and is used in
nursing health history, which is a part of the nondirective interviews. Examples are “How do
nursing admission assessment. In a focused you feel about that?” “What do you think led to
interview the nurse asks the client specific the operation?” A leading question, by contrast,
questions to collect information related to the is usually closed, used in a directive interview,
client’s problem. This allows the nurse to collect and thus directs the client’s answer. Examples
information that may have previously been are “You’re stressed about surgery tomorrow,
missed and yields more in-depth information aren’t you?” “You will take your medicine, won’t
(D’Amico & Barbarito, 2013). you?”

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 c. Examination o Obtain additional information that may
have been overlooked.
The physical examination or physical o Differentiate between cues and
assessment is a systematic data collection inferences. Cues are subjective or
method that uses observation (i.e., the senses objective data that can be directly
of sight, hearing, smell, and touch) to detect observed by the nurse; that is, what the
health problems. To conduct the examination, client says or what the nurse can see,
the nurse uses techniques of inspection, hear, feel, smell, or measure. Inferences
auscultation, palpation, and percussion are the nurse’s interpretation or
conclusions made based on the cues
The physical examination is carried out (e.g., a nurse observes the cues that an
systematically. It may be organized according to incision is red, hot, and swollen; the
the examiner’s preference, in a head-to-toe nurse makes the inference that the
approach or a body systems approach. Usually, incision is infected).
the nurse first records a general impression o Avoid jumping to conclusions and
about the client’s overall appearance and health focusing in the wrong direction to identify
status: for example, age, body size, mental and problems.
nutritional status, speech, and behavior. Then
the nurse takes such measurements as vital
signs, height, and weight. The cephalocaudal or DIAGNOSIS
head-to-toe approach begins the examination at
the head; progresses to the neck, thorax, Diagnosing is the second phase of the
abdomen, and extremities; and ends at the toes. nursing process. In this phase, nurses use
critical thinking skills to interpret assessment
Organizing of Data data and identify client strengths and problems.
Diagnosing is a pivotal step in the nursing
The nurse uses a written (or electronic) process. Activities preceding this phase are
format that organizes the assessment data directed toward formulating the nursing
systematically. This is often referred to as a diagnoses; the care planning activities following
nursing health history, nursing assessment, or this phase are based on the nursing diagnoses.
nursing database form. The format may be
modified according to the client’s physical status The purpose of NANDA International is to
such as one focused on musculoskeletal data define, refine, and promote a taxonomy of
for orthopedic clients. nursing diagnostic terminology of general use to
professional nurses. A taxonomy is a
Validating Data classification system or set of categories
arranged based on a single principle or set of
The information gathered during the principles. The members of NANDA include
assessment phase must be complete, factual, staff nurses, clinical specialists, faculty,
and accurate because the nursing diagnoses directors of nursing, deans, theorists, and
and interventions are based on this information. researchers. The group has currently approved
Validation is the act of “double-checking” or more than 200 nursing diagnosis labels for
verifying data to confirm that it is accurate and clinical use and testing.
factual. Validating data helps the nurse
complete these tasks: NANDA Nursing Diagnoses
o Ensure that assessment information is The term diagnosing refers to the
complete. reasoning process, whereas the term diagnosis
o Ensure that objective and related is a statement or conclusion regarding the
subjective data agree.
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nature of a phenomenon. The standardized Status of Nursing Diagnoses
NANDA names for the diagnoses are called
diagnostic labels; and the client’s problem The kinds of nursing diagnoses
statement, consisting of the diagnostic label according to status are actual, health promotion,
plus etiology (causal relationship between a risk, and syndrome.
problem and its related or risk factors), is called
a nursing diagnosis. The official NANDA 1. An actual diagnosis is a client problem that
definition of a nursing diagnosis is: “. . . a clinical is present at the time of the nursing
judgment concerning a human response to assessment. Examples are Ineffective
health conditions/ life processes, or a Breathing Pattern and Anxiety. An actual
vulnerability for that response, by an individual, nursing diagnosis is based on the presence
family, group, or community” (Herdman & of associated signs and symptoms.
Kamitsuru, 2014). 2. A health promotion diagnosis relates to
clients’ preparedness to implement
In 2009 the NANDA-I Think Tank behaviors to improve their health condition.
statement was developed. It states, “A nursing These diagnosis labels begin with the
diagnosis provides the basis for selection of phrase Readiness for Enhanced, as in
nursing interventions to achieve outcomes for Readiness for Enhanced Nutrition.
which the nurse has accountability” (Herdman & 3. A risk nursing diagnosis is a clinical
Kamitsuru, 2014,). This definition is consistent judgment that a problem does not exist, but
with the following: the presence of risk factors indicates that a
problem is likely to develop unless nurses
o Professional nurses (registered nurses) are intervene. For example, all people admitted
responsible for making nursing diagnoses, to a hospital have some possibility of
even though other nursing personnel may acquiring an infection; however, a client with
contribute data to the process of diagnosing diabetes or a compromised immune system
and may implement specified nursing care. is at higher risk than others. Therefore, the
o The domain of nursing diagnosis includes nurse would appropriately use the label Risk
only those health states that nurses are for Infection to describe the client’s health
educated and licensed to treat. status.
4. A syndrome diagnosis is assigned by a
nurse’s clinical judgment to describe a
cluster of nursing diagnoses that have
similar interventions (Herdman & Kamitsuru,
2014)

Components of a Nanda Nursing Diagnosis

A nursing diagnosis has three

components: (1) the problem and its definition,
(2) the etiology, and (3) the defining
characteristics. Each component serves a
specific purpose.

1. The problem statement, or diagnostic label,

describes the client’s health problem or
response for which nursing therapy is given.
It describes the client’s health status clearly
and concisely in a few words. The purpose
Diagnosing—the pivotal second phase of the nursing process. of the diagnostic label is to direct the
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 formation of client goals and desired The two parts are joined by the words
outcomes. It may also suggest some nursing related to rather than due to. The phrase due to
interventions. implies that one part causes or is responsible for
the other part. By contrast, the phrase related to
o Qualifiers are words that have been added merely implies a relationship.
to some NANDA labels to give additional
meaning to the diagnostic statement, for For NANDA labels that contain the word
example: Specify, the nurse must add words to indicate
 Deficient (inadequate in amount, quality, the problem more specifically. The format is still
or degree; not sufficient; incomplete) a two-part statement. For example,
 Impaired (made worse, weakened, Noncompliance (Specify) would be
damaged, reduced, deteriorated) Noncompliance (Diabetic Diet) related to denial
 Decreased (lesser in size, amount, or of having disease.
degree)
 Ineffective (not producing the desired B. Basic 3 Part Statement
effect)
 Compromised (to make vulnerable to The basic three-part nursing diagnosis
threat). statement is called the PES format and includes
the following:
2. The etiology component of a nursing 1. Problem (P): statement of the client’s
diagnosis identifies one or more probable response (NANDA label)
causes of the health problem, gives direction 2. Etiology (E): factors contributing to or
to the required nursing therapy, and enables probable causes of the response
the nurse to individualize the client’s care. 3. Signs and symptoms (S): defining
Differentiating among possible causes in the characteristics manifested by the client.
nursing diagnosis is essential because each
may require different nursing interventions. Actual nursing diagnoses can be
documented by using the three-part statement
3. Defining characteristics are the cluster of because the signs and symptoms have been
signs and symptoms that indicate the identified. This format cannot be used for risk
presence of a particular diagnostic label. For diagnoses because the client does not have
actual nursing diagnoses, the defining signs and symptoms of the diagnosis. The PES
characteristics are the client’s signs and format is especially recommended for beginning
symptoms. For risk nursing diagnoses, no diagnosticians because the signs and
subjective and objective signs are present. symptoms validate why the diagnosis was
Thus, the factors that cause the client to be chosen and make the problem statement more
more vulnerable to the problem form the descriptive.
etiology of a risk nursing diagnosis.
The PES format can create very long
Formulating Diagnosis Statements problem statements, sometimes making the
problem and etiology unclear. To minimize long
A. Basic 2 Part Statement problem statements, the nurse can record the
signs and symptoms in the nursing notes
The basic two-part statement includes the instead of on the care plan. Another possibility,
following: recommended for students, is to list the signs
1. Problem (P): statement of the client’s and symptoms on the care plan below the
response (NANDA label) nursing diagnosis, grouping the subjective (S)
2. Etiology (E): factors contributing to or and objective (O) data. The signs and symptoms
probable causes of the responses. are easily accessible, and the problem and
etiology stand out clearly. For example:
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Noncompliance (Diabetic Diet) related to possible is inserted. Examples are Possible
unresolved anger about diagnosis as Low Self-Esteem related to loss of job and
manifested by rejection by family; Altered Thought
Processes possibly related to unfamiliar
S— “I forget to take my pills.” surroundings.
“I can’t live without sugar in my food.” 4. Using secondary to to divide the etiology into
O— Weight 98 kg (215 lb) two parts, thereby making the statement
(gain of 4.5 kg [10 lb]) more descriptive and useful. The part
Blood pressure 190/100 mmHg following secondary to is often a
pathophysiologic or disease process or a
C. One Part Statement medical diagnosis, as in Risk for Impaired
Skin Integrity related to decreased
NANDA has specified that any health peripheral circulation secondary to diabetes.
promotion diagnoses will be developed as one- 5. Adding a second part to the general
part statements beginning with the words response or NANDA label to make it more
Readiness for Enhanced followed by the precise. For example, the diagnosis
desired higher level of wellness (for example, Impaired Skin Integrity does not indicate the
Readiness for Enhanced Parenting). A location of the problem. To make this label
syndrome diagnosis is a diagnosis that is more specific, the nurse can add a descriptor
associated with a cluster of other diagnoses as follows: Impaired Skin Integrity (Left
(Alfaro-LeFevre, 2014). Currently seven Lateral Ankle) related to decreased
syndrome diagnoses are on the NANDA peripheral circulation.
International list. Risk for Disuse Syndrome, for
example, may be experienced by long-term Carpenito-Moyet (2013) has suggested that
bedridden clients. Clusters of diagnoses all collaborative (multidisciplinary) problems
associated with this syndrome include Impaired begin with the diagnostic label Potential
Physical Mobility, Risk for Impaired Tissue Complication (PC). Nurses should include in the
Integrity, Risk for Activity Intolerance, Risk for diagnostic statement both the possible
Constipation, Risk for Infection and so on. complication they are monitoring and the
disease or treatment that is present to produce
Variation of Basic Formats it. For example, if the client has a head injury
and could develop increased intracranial
1. Writing unknown etiology when the defining pressure, the nurse should write the following:
characteristics are present but the nurse
does not know the cause or contributing a. Potential Complication of Head Injury:
factors. One example is Noncompliance increased intracranial pressure When
(Medication Regimen) related to unknown monitoring for a group of complications
etiology. associated with a disease or pathology, the
2. Using the phrase complex factors when nurse states the disease and follows it with a
there are too many etiologic factors or when list of the complications:
they are too complex to state in a brief b. Potential Complication of Pregnancy-
phrase. The actual causes of chronic low Induced Hypertension: seizures, fetal
self-esteem, for instance, may be long term distress, pulmonary edema, hepatic/renal
and complex, as in the following nursing failure, premature labor, CNS hemorrhage In
diagnosis: Chronic Low Self-Esteem related some situations, an etiology might be helpful
to complex factors. in suggesting interventions. Nurses should
3. Using the word possible to describe either write the etiology when (a) it clarifies the
the problem or the etiology. When the nurse problem statement, (b) it can be concisely
believes more data are needed about the stated, and (c) it helps to suggest nursing
client’s problem or the etiology, the word actions.
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 PLANNING Types of Planning

Planning is a deliberative, systematic Planning begins with the first client

phase of the nursing process that involves contact and continues until the nurse–client
decision making and problem solving. In relationship ends, usually when the client is
planning, the nurse refers to the client’s discharged from the health care agency. All
assessment data and diagnostic statements for planning is multidisciplinary (involves all health
direction in formulating client goals and care providers interacting with the client) and
designing the nursing interventions required to includes the client and family to the fullest extent
prevent, reduce, or eliminate the client’s health possible in every step.
problem. A nursing intervention is “any
treatment, based upon clinical judgment and a. Initial Planning
knowledge, that a nurse performs to enhance
patient/client outcomes” (Bulechek, Butcher, The nurse who performs the admission
Dochterman, & Wagner, 2013, p. xv). The end assessment usually develops the initial
product of the planning phase is a client care comprehensive plan of care. This nurse has the
plan. Although planning is basically the nurse’s benefit of seeing the client’s body language and
responsibility, input from the client and support can also gather some intuitive kinds of
persons is essential if a plan is to be effective. information that are not available solely from the
Nurses do not plan for the client, but encourage written database. Planning should be initiated
the client to participate actively to the extent as soon as possible after the initial assessment.
possible. In a home setting, the client’s support
people and caregivers are the ones who b. Ongoing Planning
implement the plan of care; thus, its
effectiveness depends largely on them. All nurses who work with the client do
ongoing planning. As nurses obtain new
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information and evaluate the client’s responses specific client—needs that are not addressed by
to care, they can individualize the initial care the standardized plan. It is important for all
plan further. Ongoing planning also occurs at caregivers to work toward the same outcomes
the beginning of a shift as the nurse plans the and, if available, use approaches shown to be
care to be given that day. Using ongoing effective with a particular client. Nurses also use
assessment data, the nurse carries out daily the formal care plan for direction about what
planning for the following purposes: needs to be documented in client progress
i. To determine whether the client’s notes and as a guide for delegating and
health status has changed. assigning staff to care for clients. When nurses
ii. To set priorities for the client’s care use the client’s nursing diagnoses to develop
during the shift. goals and nursing interventions, the result is a
iii. To decide which problems to focus on holistic, individualized plan of care that will meet
during the shift. the client’s unique needs.
iv. To coordinate the nurse’s activities so
that more than one problem can be Care plans include the actions nurses
addressed at each client contact. must take to address the client’s nursing
diagnoses and produce the desired outcomes.
c. Discharge Planning The nurse begins the plan when the client is
admitted to the agency and updates it
Discharge planning, the process of throughout the client’s stay in response to
anticipating and planning for needs after changes in the client’s condition and evaluations
discharge, is a crucial part of a comprehensive of goal achievement.
health care plan and should be addressed in
each client’s care plan. Because the average
stay of clients in acute care hospitals has
become shorter, people are sometimes
discharged still needing care. Although many
clients are discharged to other agencies (e.g.,
long-term care facilities), such care is
increasingly being delivered in the home.

Developing Care Plans

The end product of the planning phase of

the nursing process is a formal or informal plan
of care. An informal nursing care plan is a
strategy for action that exists in the nurse’s
mind. For example, the nurse may think, “Mrs.
Phan is very tired. I will need to reinforce her
teaching after she is rested.” A formal nursing Planning—the third phase of the nursing process. In this phase the nurse and
care plan is a written or computerized guide that client develop client goals/desired outcomes and nursing interventions to
organizes information about the client’s care. prevent, reduce, or alleviate the client’s health problems.
The most obvious benefit of a formal written
care plan is that it provides for continuity of care. Standard Approaches to Care Planning

A standardized care plan is a formal plan Standardized care plans are

that specifies the nursing care for groups of predeveloped guides for the nursing care of a
clients with common needs (e.g., all clients with client who has a need that arises frequently in
myocardial infarction). An individualized care the agency (e.g., a specific nursing diagnosis or
plan is tailored to meet the unique needs of a all nursing diagnoses associated with a
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particular medical condition). They are written plan information is to use a concept map. A
from the perspective of what care the client can concept map is a visual tool in which ideas or
expect. They should not be confused with data are enclosed in circles or boxes of some
standards of care. Although the two have some shape, and relationships between these are
similarities, they have important differences. indicated by connecting lines or arrows.
Standardized care plans:
THE PLANNING PROCESS
• Are kept with the client’s individualized care
plan on the nursing unit. When the client is In the process of developing client care
discharged, they become part of the permanent plans, the nurse engages in the following
medical record. activities:
• Provide detailed interventions and contain o Setting priorities
additions or deletions from the standards of care o Establishing client goals/desired outcomes
of the agency. o Selecting nursing interventions and activities
• Typically are written in the nursing process o Writing individualized nursing interventions
format: on care plans.

Problem → Goals/Desired Outcomes → a. Setting Priorities

Nursing Interventions → Evaluation
Priority setting is the process of establishing
• Frequently include checklists, blank lines, or a preferential sequence for addressing nursing
empty spaces to allow the nurse to individualize diagnoses and interventions. The nurse and
goals and nursing interventions. client begin planning by deciding which nursing
diagnosis requires attention first, which second,
Formats for Nursing Care Plans and so on. Instead of rank-ordering diagnoses,
nurses can group them as having high, medium,
Although formats differ from agency to or low priority. Life-threatening problems, such
agency, the care plan is often organized into as impaired respiratory or cardiac function, are
four sections: (1) problem/nursing diagnoses, designated as high priority. Health-threatening
(2) goals/desired outcomes, (3) nursing problems, such as acute illness and decreased
interventions, and (4) evaluation. Some coping ability, are assigned medium priority
agencies use a three-section plan in which because they may result in delayed
evaluation is done with the goals or in the development or cause destructive physical or
nurses’ notes; others have five sections that add emotional changes. A low-priority problem is
assessment data preceding the one that arises from normal developmental
problem/nursing diagnosis. needs or that requires only minimal nursing
support.
Because student care plans are a
learning activity as well as a plan of care, they b. Establishing Client Goals/ Desired
may be lengthier and detailed than care plans Outcomes
used by working nurses. To help students learn
to write care plans, educators may require that After establishing priorities, the nurse and
more of the plan be original work. They may also client set goals for each nursing diagnosis. On a
modify the plan by adding “Rationale” after the care plan, the goals/desired outcomes describe,
nursing interventions. A rationale is the in terms of observable client responses, what
evidence-based principle given as the reason the nurse hopes to achieve by implementing the
for selecting a particular nursing intervention. nursing interventions. The terms goal and
Students may also be required to cite supporting desired outcome are used interchangeably in
literature for their stated rationale. Another this text, except when discussing and using
method of organizing and representing care standardized language. Some references also
13 | P a g e
use the terms expected outcome, predicted 3. Enable the client and nurse to determine
outcome, outcome criterion, and objective. when the problem has
Some nursing literature differentiates the terms been resolved.
by defining goals as broad statements about the 4. Help motivate the client and nurse by
client’s status and desired outcomes as the providing a sense of achievement. As goals
more specific, observable criteria used to are met, both client and nurse can see that their
evaluate whether the goals have been met. For efforts have been worthwhile. This provides
example: motivation to continue following the plan,
especially when difficult lifestyle changes need
Goal (broad): Improved nutritional status. to be made.
Desired outcome (specific): Gain 5 lb. by April
25.
Short Term and Long Term Goals
When goals are stated broadly, as in this
example, the care plan must include both goals Goals may be short term or long term. A
and desired outcomes. They are sometimes short-term goal might be “Client will raise right
combined into one statement linked by the arm to shoulder height by Friday.” In the same
words “as evidenced by,”. context, a long-term goal/outcome might be
“Client will regain full use of right arm in 6
Writing the broad, general goal first may weeks.” Short-term goals are useful for clients
help students to think of the specific outcomes who (a) require health care for a short time or
that are needed, but the broad goal is just a (b) are frustrated by long-term goals that seem
starting point for planning. It is the specific, difficult to attain and who need the satisfaction
observable outcomes that must be written on of achieving a short-term goal. In an acute care
the care plan and used to evaluate client setting, much of the nurse’s time is spent on the
progress. client’s immediate needs, so most goals are
short term. However, clients in acute care
c. Purpose of Goal/ Desired Outcomes settings also need long-term goals/outcomes to
guide planning for their discharge to long-term
Although goals and outcomes are not agencies or home care, especially in a managed
necessarily the same concept, the terms are care environment. Outcomes are often set for
used by some people interchangeably. If clients who live at home and have chronic health
referenced to NOC, goals are considered to be problems and for clients in nursing homes,
met or not met, while progress toward outcomes extended care facilities, and rehabilitation
can be described along a continuum and in centers.
comparison to previous status (Moorhead et al.,
2013). Goals/desired outcomes serve the Components of Goal/Desired Outcome
following purposes: Statements

1. Provide direction for planning nursing Goal/desired outcome statements should

interventions. Ideas for interventions come have the following four components:
more easily if the desired outcomes state clearly
and specifically what the nurse hopes to 1. Subject. The subject, a noun, is the client,
achieve. any part of the client, or some attribute of the
2. Serve as criteria for evaluating client client, such as the client’s pulse or urinary
progress. Although developed in the planning output. The subject is often omitted in goals;
step of the nursing process, desired outcomes it is assumed that the subject is the client
serve as the criteria for judging the effectiveness unless indicated otherwise.
of nursing interventions and client progress in
the evaluation step
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2. Verb. The verb specifies an action the client verbs indicate what the nurse hopes to
is to perform, for example, what the client is accomplish, not what the client will do.
to do, learn, or experience. Verbs that
denote directly observable behaviors, such Correct: The client will drink 100 mL of water
as administer, show, or walk, must be used. per hour (client behavior).
Incorrect: Maintain client hydration (nursing
3. Conditions or modifiers. Conditions or action).
modifiers may be added to the verb to
explain the circumstances under which the 2. Be sure that desired outcomes are realistic
behavior is to be performed. They explain for the client’s capabilities, limitations, and
what, where, when, or how. designated time span, if it is indicated.
Limitations refers to finances, equipment,
For example: family support, social services, physical and
o Walks with the help of a cane (how). mental condition, and time. For example, the
o After attending two group diabetes outcome “Measures insulin accurately” may
classes, lists signs and symptoms of be unrealistic for a client who has poor vision
diabetes (when). due to cataracts.
o When at home, maintains weight at
existing level (where). 3. Ensure that the goals and desired outcomes
o Discusses food pyramid and are compatible with the therapies of other
recommended daily servings (what). professionals. For example, the outcome
“The client will increase the time spent out of
Conditions need not be included if the bed by 15 minutes each day” is not
criterion of performance clearly indicates compatible with a primary care provider’s
what is expected. prescribed therapy of bed rest.

4. Criterion of desired performance. The

criterion indicates the standard by which a 4. Make sure that each goal is derived from
performance is evaluated or the level at only one nursing diagnosis. For example, the
which the client will perform the specified goal “The client will increase the amount of
behavior. These criteria may specify time or nutrients ingested and show progress in the
speed, accuracy, distance, and quality. To ability to feed self” is derived from two
establish a time-achievement criterion, the nursing diagnoses:
nurse needs to ask “How long?” To establish
an accuracy criterion, the nurse asks “How Imbalanced Nutrition: Less Than Body
well?” Similarly, the nurse asks “How far?” Requirements and Feeding Self-Care Deficit.
Guidelines for Writing Goals/ Desired Outcomes Keeping the goal statement related to only one
diagnosis facilitates evaluation of care by
The following guidelines can help nurses ensuring that planned nursing interventions are
write useful goals and desired outcomes: clearly related to the diagnosis.
1. Write goals and outcomes in terms of client 5. Use observable, measurable terms for
responses, not nursing activities. Beginning outcomes. Avoid words that are vague and
each goal statement with The client will may require interpretation or judgment by the
help focus the goal on client behaviors and observer. For example, phrases such as
responses. Avoid statements that start with increase daily exercise and improve
enable, facilitate, allow, let, permit, or similar knowledge of nutrition can mean different
verbs followed by the word client. These things to different people. If used in

15 | P a g e
 outcomes, these phrases can lead to care is an intervention delegated by the nurse to
disagreements about whether the outcome another provider or performed away from but on
was met. These phrases may be suitable for behalf of the client such as interdisciplinary
a broad client goal but are not sufficiently collaboration or management of the care
clear and specific to guide the nurse when environment.
evaluating client responses.
Independent interventions are those
6. Make sure the client considers the activities that nurses are licensed to initiate on
goals/desired outcomes important and the basis of their knowledge and skills. They
values them. Some outcomes, such as those include physical care, ongoing assessment,
for problems related to self-esteem, emotional support and comfort, teaching,
parenting, and communication, involve counseling, environmental management, and
choices that are best made by the client or in making referrals to other health care
collaboration with the client. professionals.

Selecting Nursing Interventions & Activities Dependent interventions are activities

carried out under the orders or supervision of a
Nursing interventions and activities are licensed physician or other health care provider
the actions that a nurse performs to achieve authorized to write orders to nurses. Primary
client goals. The specific interventions chosen care providers’ orders commonly direct the
should focus on eliminating or reducing the nurse to provide medications, intravenous
etiology of the nursing diagnosis, which is the therapy, diagnostic tests, treatments, diet, and
second clause of the diagnostic statement. activity. With the client, the nurse is responsible
When it is not possible to change the etiologic for assessing the need for, explaining, and
factors, the nurse chooses interventions to treat administering the medical orders. Nursing
the signs and symptoms or the defining interventions may be written for the purpose of
characteristics in NANDA International individualizing the medical order based on the
(Herdman & Kamitsuru, 2014) terminology. client’s status.

Examples of this situation would be Pain Collaborative interventions are actions

related to surgical incision and Anxiety related the nurse carries out in collaboration with other
to unknown etiology. Interventions for risk health team members, such as physical
nursing diagnoses should focus on measures to therapists, social workers, dietitians, and
reduce the client’s risk factors, which are also primary care providers. Collaborative nursing
found in the second clause. Correct activities reflect the overlapping responsibilities
identification of the etiology during the of, and collegial relationships among, health
diagnosing phase provides the framework for personnel. For example, the primary care
choosing successful nursing interventions. provider might order physical therapy to teach
the client crutch-walking. The nurse would be
Types of Nursing Interventions responsible for informing the physical therapy
department and for coordinating the client’s care
Nursing interventions are identified and to include the physical therapy sessions.
written during the planning step of the nursing
process; however, they are actually performed In addition to the efforts of NANDA to
during the implementing step. Nursing standardize the language for describing
interventions include both direct and indirect problems that require nursing care and to create
care, as well as nurse-initiated, physician- a taxonomy of standardized client outcome
initiated, and other provider-initiated treatments. labels, nurse researchers also recognized the
Direct care is an intervention performed by the need for a standardized language to describe
nurse through interaction with the client. Indirect the interventions that nurses perform.
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 A taxonomy of nursing interventions then. This taxonomy consists of three levels:
referred to as the Nursing Interventions level 1, domains; level 2, classes; and level 3,
Classification (NIC) taxonomy, developed by the interventions.
Iowa Intervention Project, was first published in
1992 and has been updated every 4 years since

17 | P a g e
 IMPLEMENTATION them routinely to categories of clients (e.g., all
clients with pneumonia).
The nursing process is action oriented,
client centered, and outcome directed. After While implementing nursing care, the
developing a plan of care based on the nurse continues to reassess the client at every
assessing and diagnosing phases, the nurse contact, gathering data about the client’s
implements the interventions and evaluates the responses to the nursing activities and about
desired outcomes. On the basis of this any new problems that may develop. A nursing
evaluation, the plan of care is either continued, activity on the client’s care plan for the NIC
modified, or terminated. As in all phases of the intervention Airway Management might read
nursing process, clients and support persons “Auscultate breath sounds q4h.” When
are encouraged to participate as much as performing this activity, the nurse is both
possible. carrying out the intervention (implementing) and
performing an assessment. Some routine
In the nursing process, implementing is nursing activities are, themselves,
the action phase in which the nurse performs the assessments. For example, while bathing an
nursing interventions. Using Nursing older client, the nurse observes a reddened
Interventions Classification (NIC) terminology, area on the client’s sacrum. Or, when emptying
implementing consists of doing and a urinary catheter bag, the nurse measures 200
documenting the activities that are the specific mL of offensive smelling, brown urine.
nursing actions needed to carry out the
interventions. The nurse performs or delegates IMPLEMENTING SKILLS
the nursing activities for the interventions that
were developed in the planning step and then To implement the care, plan successfully,
concludes the implementing step by recording nurses need cognitive, interpersonal, and
nursing activities and the resulting client technical skills. These skills are distinct from one
responses. The fifth standard of the American another; in practice, however, nurses use them
Nurses Association (ANA) Standards of in various combinations and with different
Practice is implementation. Three of the emphasis, depending on the activity. For
implementation substandard apply to all instance, when inserting a urinary catheter, the
registered nurses: coordination of care, health nurse needs cognitive knowledge of the
teaching and health promotion, and principles and steps of the procedure,
consultation. The fourth substandard, interpersonal skills to inform and reassure the
prescriptive authority and treatment, applies client, and technical skill in draping the client
only to advanced practice nurses (ANA, 2010). and manipulating the equipment

Relationship of Implementation to the other

Phases of the Process

The first three nursing process phases—

assessing, diagnosing, and planning—provide
the basis for the nursing actions performed Implementing—the
during the implementing step. In turn, the fourth phase of the
nursing process. In
implementing phase provides the actual nursing this phase the
activities and client responses that are nurse implements
examined in the final phase, the evaluating the nursing
phase. Using data acquired during assessment, interventions and
the nurse can individualize the care given in the documents the care
provided.
implementing phase, tailoring the interventions
to fit a specific client rather than applying
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 The cognitive skills (intellectual skills) A. Reassessing the Client
include problem solving, decision making,
critical thinking, clinical reasoning, and Just before implementing an intervention,
creativity. They are crucial to safe, intelligent the nurse must reassess the client to make sure
nursing care the intervention is still needed. Even though an
order is written on the care plan, the client’s
Interpersonal skills are all of the condition may have changed. For example, a
activities, verbal and nonverbal, people use client has a nursing diagnosis of Disturbed
when interacting directly with one another. The Sleep Pattern related to anxiety and unfamiliar
effectiveness of a nursing action often depends surroundings. During rounds, the nurse
largely on the nurse’s ability to communicate discovers that the client is sleeping and
with others. The nurse uses therapeutic therefore defers the back massage that had
communication to understand the client and in been planned as a relaxation strategy. New data
turn be understood. A nurse also needs to work may indicate a need to change the priorities of
effectively with others as a member of the health care or the nursing activities. For example, a
care team. Interpersonal skills are necessary for nurse begins to teach a client who has diabetes
all nursing activities: caring, comforting, how to give himself insulin injections. Shortly
advocating, referring, counseling, and after beginning the teaching, the nurse realizes
supporting are just a few. Interpersonal skills that he is not concentrating on the lesson.
include conveying knowledge, attitudes,
feelings, interest, and appreciation of the client’s B. Determining the Nurse’s Need for
cultural values and lifestyle. Before nurses can Assistance
be highly skilled in interpersonal relations, they
must have self-awareness and sensitivity to When implementing some nursing
others. interventions, the nurse may require assistance
for one or more of the following reasons:
Technical skills are purposeful “hands-
on” skills such as manipulating equipment, o The nurse is unable to implement the
giving injections, bandaging, moving, lifting, and nursing activity safely or efficiently alone
repositioning clients. These skills are also called (e.g., ambulating an unsteady obese
tasks, procedures, or psychomotor skills. The client).
term psychomotor refers to physical actions that o Assistance would reduce stress on the
are controlled by the mind, not by reflexes. client (e.g., turning a person who
Technical skills require knowledge and, experiences acute pain when moved).
frequently, manual dexterity. The number of o The nurse lacks the knowledge or skills to
technical skills expected of a nurse has greatly implement a particular nursing activity
increased in recent years because of the (e.g., a nurse who is not familiar with a
pervasive use of technology, especially in acute particular model of traction equipment
care hospitals. needs assistance the first time it is
applied).
PROCESS OF IMPLEMENTATION
C. Implementing the Interventions
The process of implementing normally includes
the following: It is important to explain to the client what
o Reassessing the client. interventions will be done, what sensations to
o Determining the nurse’s need for expect, what the client is expected to do, and
assistance. what the expected outcome is. For many
o Implementing the nursing interventions. nursing activities it is also important to ensure
o Supervising the delegated care. the client’s privacy, for example, by closing
o Documenting nursing activities. doors, pulling curtains, or draping the client. The
19 | P a g e
number and kind of direct nursing interventions Immediate recording helps safeguard the client,
are almost unlimited. Nurses also coordinate for example, from receiving a duplicate dose of
client care. medication.

D. Supervising the Delegated Care EVALUATION

If care has been delegated to other health To evaluate is to judge or to appraise.
care personnel, the nurse responsible for the Evaluating is the fifth phase of the nursing
client’s overall care must ensure that the process. In this context, evaluating is a planned,
activities have been implemented according to ongoing, purposeful activity in which clients and
the care plan. Other caregivers may be required health care professionals determine (a) the
to communicate their activities to the nurse by client’s progress toward achievement of goals/
documenting them on the client record, outcomes and (b) the effectiveness of the
reporting verbally, or filling out a written form. nursing care plan. Evaluation is an important
The nurse validates and responds to any aspect of the nursing process because
adverse findings or client responses. This may conclusions drawn from the evaluation
involve modifying the nursing care plan. determine whether the nursing interventions
should be terminated, continued, or changed.
E. Documenting the Nursing Activities Evaluation is the sixth standard of the ANA
Standards of Practice and states that “The
After carrying out the nursing activities, the registered nurse evaluates progress towards
nurse completes the implementing phase by attainment of outcomes”
recording the interventions and client responses
in the nursing progress notes. These are a part Evaluation is continuous. Evaluation
of the agency’s permanent record for the client. done while or immediately after implementing a
Nursing care must not be recorded in advance nursing order enables the nurse to make on the-
because the nurse may determine on spot modifications in an intervention. Evaluation
reassessment of the client that the intervention performed at specified intervals (e.g., once a
should not or cannot be implemented. week for the home care client) shows the extent
of progress toward achievement of
For example, a nurse is authorized to inject goals/outcomes and enables the nurse to
10 mg of morphine sulfate subcutaneously to a correct any deficiencies and modify the care
client, but the nurse finds that the client’s plan as needed. Evaluation continues until the
respiratory rate is 8 breaths per minute. This client achieves the health goals or is discharged
finding contraindicates the administration of from nursing care. Evaluation at discharge
morphine (a respiratory depressant). The nurse includes the status of goal achievement and the
withholds the morphine and reports the client’s client’s self-care abilities with regard to follow-
respiratory rate to the nurse in charge and/or up care. Most agencies have a special
primary care provider. The nurse may record discharge record for this evaluation. Through
routine or recurring activities (e.g., mouth care) evaluating, nurses demonstrate responsibility
in the client record at the end of a shift. In the and accountability for their actions, indicate
meantime, the nurse maintains a personal interest in the results of the nursing activities,
record of these interventions on a worksheet. In and demonstrate a desire not to perpetuate
some instances, it is important to record a ineffective actions but to adopt more effective
nursing intervention immediately after it is ones.
implemented. This is particularly true of the
administration of medications and treatments Relationship of Evaluation to the other Phases
because recorded data about a client must be
up to date, accurate, and available to other Successful evaluation depends on the
nurses and health care professionals. effectiveness of the steps that precede it.
20 | P a g e
 Assessment data must be accurate and evaluative data that need to be collected and
complete so that the nurse can formulate provide a standard against which the data are
appropriate nursing diagnoses and desired judged. For example, given the following
outcomes. The desired outcomes must be expected outcomes, any nurse caring for the
stated concretely in behavioral terms if they are client would know what data to collect:
to be useful for evaluating client responses.
Finally, without the implementing phase in which o Daily fluid intake will not be less than 2,500
the plan is put into action, there would be mL.
nothing to evaluate. The evaluating and o Urinary output will balance with fluid intake.
assessing phases overlap. As previously stated, o Residual urine will be less than 100 mL.
assessment is ongoing and continuous at every
client contact. However, data are collected for The evaluation phase has five components:
different purposes at different points in the
nursing process. During the assessment phase o Collecting data related to the desired
the nurse collects data for the purpose of outcomes (NOC indicators)
making diagnoses. During the evaluation step o Comparing the data with desired outcomes
the nurse collects data for the purpose of o Relating nursing activities to outcomes
comparing it to preselected goals/outcomes and o Drawing conclusions about problem status
judging the effectiveness of the nursing care. o Continuing, modifying, or terminating the
The act of assessing is the same; the nursing care plan.
differences lie in (a) when the data are collected
and (b) how the data are used. A. Collecting Data

Using the clearly stated, precise, and

measurable desired outcomes as a guide, the
nurse collects data so that conclusions can be
drawn about whether goals have been met. It is
usually necessary to collect both objective and
subjective data. Some data may require
interpretation. Examples of objective data
requiring interpretation are the degree of tissue
turgor of a dehydrated client or the degree of
restlessness of a client with pain. Examples of
subjective data needing interpretation include
complaints of nausea or pain by the client. When
interpreting subjective data, the nurse must rely
on either (a) the client’s statements (e.g., “My
pain is worse now than it was after breakfast”)
Evaluating—the final phase of the nursing process. In this phase the or (b) objective indicators of the subjective data,
nurse determines the client’s progress toward goal achievement and the even though these indicators may require
effectiveness of the nursing care plan. The plan may be continued, further interpretation (e.g., decreased
modified, or terminated. restlessness, decreased pulse and respiratory
PROCESS OF EVALUATING RESPONSE rates, and relaxed facial muscles as indicators
of pain relief).
Before evaluation, the nurse identifies
the desired outcomes (indicators) that will be B. Comparing Data with Desired Outcomes
used to measure client goal achievement. (This
is done in the planning step.) Desired outcomes If the first two parts of the evaluating process
serve two purposes: They establish the kind of have been carried out effectively, it is relatively
simple to determine whether a desired outcome
21 | P a g e
has been met. Both the nurse and client play an (c) the client did not understand how to plan a
active role in comparing the client’s actual 1,200-calorie diet, so she did not bother with it.
responses with the desired outcomes. Did the
client drink 3,000 mL of fluid in 24 hours? Did D. Drawing Conclusions about Problem
the client walk unassisted the specified distance Status
per day? When determining whether a goal has
been achieved, the nurse can draw one of three The nurse uses the judgments about goal
possible conclusions: achievement to determine whether the care plan
was effective in resolving, reducing, or
o The goal was met; that is, the client preventing client problems. When goals have
response is the same as the desired been met, the nurse can draw one of the
outcome. following conclusions about the status of the
o The goal was partially met; that is, either client’s problem:
a short-term outcome was achieved but
the long-term goal was not, or the • The actual problem stated in the nursing
desired goal was incompletely attained. diagnosis has been resolved, or the potential
o The goal was not met. problem is being prevented and the risk factors
no longer exist. In these instances, the nurse
After determining whether or not a goal has documents that the goals have been met and
been met, the nurse writes an evaluation discontinues the care for the problem.
statement (either on the care plan or in the
nurse’s notes). An evaluation statement • The potential problem stated in the nursing
consists of two parts: a conclusion and diagnosis is being prevented, but the risk factors
supporting data. are still present. In this case, the nurse keeps
the problem on the care plan.
C. Relating Nursing Activities to Outcomes • The actual problem still exists even though
some goals are being met. For example, a
The third phase of the evaluating process is desired outcome on a client’s care plan is “Will
determining whether the nursing activities had drink 3,000 mL of fluid daily.” Even though the
any relation to the outcomes. It should never be data may show this outcome has been
assumed that a nursing activity was the cause achieved, other data (dry oral mucous
of or the only factor in meeting, partially meeting, membranes) may indicate that the nursing
or not meeting a goal. For example, a client was diagnosis Deficient Fluid Volume is applicable.
obese and needed to lose 14 kg (30 lb). When Therefore, the nursing interventions must be
the nurse and client drew up a care plan, one continued even though this one goal was met.
goal was “Lose 1.4 kg (3 lb) in 4 weeks.” A When goals have been partially met or when
nursing strategy in the care plan was “Explain goals have not been met, two conclusions may
how to plan and prepare a 1,200-calorie diet.” be drawn:
Four weeks later, the client weighed herself and • The care plan may need to be revised, since
had lost 1.8 kg (4 lb). the problem is only partially resolved. The
revisions may need to occur during the
The goal had been met—in fact, assessing, diagnosing, or planning phases, as
exceeded. It is easy to assume that the nursing well as implementing.
strategy was highly effective. However, it is OR
important to collect more data before drawing • The care plan does not need revision, because
that conclusion. On questioning the client, the the client merely needs more time to achieve the
nurse might find any of the following: (a) The previously established goal(s). To make this
client planned a 1,200-calorie diet and prepared decision, the nurse must assess why the goals
and ate the food; (b) the client planned a 1,200- are being only partially achieved, including
calorie diet but did not prepare the correct food; whether the evaluation was conducted too soon.
22 | P a g e
 E. Continuing, Modifying or Terminating the of one nurse or more broadly involve the
Nursing Care Plan evaluation of the quality of the care in an
agency, or even in a country.
After drawing conclusions about the status of
the client’s problems, the nurse modifies the Quality assurance requires evaluation of
care plan as indicated. Depending on the three components of care: structure, process,
agency, modifications may be made by drawing and outcome. Each type of evaluation requires
a line through portions of the care plan, marking different criteria and methods, and each has a
portions using a highlighting pen, or indicating different focus. Structure evaluation focuses on
revisions as appropriate for electronic charting the setting in which care is given. It answers this
systems. The nurse may also write question: What effect does the setting have on
“Discontinued” (“dc’d”), “goal met,” or “problem the quality of care? Structural standards
resolved” and the date. Whether or not goals describe desirable environmental and
were met, a number of decisions need to be organizational characteristics that influence
made about continuing, modifying, or care, such as equipment and staffing.
terminating nursing care for each problem.
Process evaluation focuses on how the
Although the checklist uses a closed-ended care was given. It answers questions such as
yes/no format, its only intent is to identify areas these: Is the care relevant to the client’s needs?
that require the nurse’s further examination. Is the care appropriate, complete, and timely?
Before making modifications, the nurse must Process standards focus on the manner in
determine the effectiveness of the plan as a which the nurse uses the nursing process.
whole. This requires a review of the entire care Some examples of process criteria are “Checks
plan and a critique of each step of the nursing client’s identification band before giving
process involved in its development. medication” and “Performs and records chest
assessment, including auscultation, once per
shift.”
F. Evaluating the Quality of Nursing Care
Outcome evaluation focuses on
In addition to evaluating goal achievement demonstrable changes in the client’s health
for individual clients, nurses are also involved in status as a result of nursing care. Outcome
evaluating and modifying the overall quality of criteria are written in terms of client responses
care given to groups of clients. This is an or health status, just as they are for evaluation
essential part of professional accountability. In within the nursing process. For example, “How
each of the processes described in the following many clients undergoing hip repairs develop
sections, nurses and all other health care pneumonia?” or “How many clients who have a
providers work together as an interprofessional colostomy experience an infection that delays
team focused on improving client care. The discharge?”
activities both use and contribute to evidence
based practice. Quality Improvement

Quality Assurance Serious national efforts are currently

under way to evaluate and improve the quality
A quality assurance (QA) program is an of health care based on internal assessment by
ongoing, systematic process designed to health care providers and increasing awareness
evaluate and promote excellence in the health by the public that medical errors are not
care provided to clients. Quality assurance uncommon and can be lethal. In 2000 the
frequently refers to evaluation of the level of Committee on Quality of Health Care in America
care provided in a health care agency, but it may of the Institute of Medicine (IOM) issued a
be limited to the evaluation of the performance landmark report, To Err Is Human:
23 | P a g e
Building a Safer Health System (Kohn, Ethical & Legal Considerations
Corrigan, & Donaldson, 2000). The emphases
of the report are increasing knowledge related The American Nurses Association Code
to medical errors and establishing systems for of Ethics (2001) states that “. . . the nurse has a
enhancing safe care. The IOM followed with duty to maintain confidentiality of all patient
another report in 2001, Crossing the Quality information” (p. 12). The client’s record is also
Chasm: A New Health System for the 21st protected legally as a private record of the
Century, which delineated that care should be client’s care. Access to the record is restricted
safe, effective, client centered, timely, efficient, to health professionals involved in giving care to
and equitable. The entire reports are available the client. The institution or agency is the rightful
at the National Academies Press website. Since owner of the client’s record. This does not,
the reports were issued, improved attention to however, exclude the client’s rights to the same
these issues has come from a variety of records. Changes in the laws regarding client
sources. privacy became effective on April 14, 2003. The
new HIPAA regulations maintain the privacy and
DOCUMENTATION confidentiality of protected health information
(PHI). HIPAA refers to the Health Insurance
Effective communication among health Portability and Accountability Act of 1996. PHI is
professionals is vital to the quality of client care. identifiable health information that is transmitted
Generally, health personnel communicate or maintained in any form or medium, including
through discussion, reports, and records. A verbal discussions, electronic communications
discussion is an informal oral consideration of a with or about clients, and written
subject by two or more health care personnel to communications (Hebda & Czar, 2013).
identify a problem or establish strategies to
resolve a problem. A report is oral, written, or Ensuring Confidentiality of Computer Records
computer-based communication intended to
convey information to others. For instance, Because of the increased use of EHRs
nurses always report on clients at the end of a health care agencies have developed policies
hospital work shift. A record, also called a chart and procedures to ensure the privacy and
or client record, is a formal, legal document that confidentiality of client information stored in
provides evidence of a client’s care and can be computers. In addition, the Security Rule of
written or computer based. Although health care HIPAA became mandatory in 2005. This rule
organizations use different systems and forms governs the security of electronic PHI. The
for documentation, all client records have similar following are some suggestions for ensuring the
information. The process of making an entry on confidentiality and security of computerized
a client record is called recording, charting, or records:
documenting. Each health care organization
has policies about recording and reporting client 1. A personal password is required to enter and
data, and each nurse is accountable for sign off computer files. Do not share this
practicing according to these standards. password with anyone, including other health
team members.
Agencies also indicate which nursing 2. After logging on, never leave a computer
assessments and interventions can be recorded terminal unattended.
by RNs and which can be charted by unlicensed 3. Do not leave client information displayed on
personnel. In addition, The Joint Commission the monitor where others may see it.
requires client record documentation to be 4. Shred all unneeded computer-generated
timely, complete, accurate, confidential, and worksheets.
specific to the client. Health care reform has 5. Know the facility’s policy and procedure for
been pivotal in the process of increasing the use correcting an entry error.
of the electronic health record (EHR).
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6. Follow agency procedures for documenting a charting-by-exception system (discussed
sensitive material, such as a diagnosis of AIDS. later) may use narrative charting when
7. Information technology (IT) personnel must describing abnormal findings. When using
install a firewall to protect the server from narrative charting, it is important to organize the
unauthorized access. information in a clear, coherent manner. Using
the nursing process as a framework is one way
Documentation Systems to do this.

A number of documentation systems are B. Problem Oriented Medical Record

in current use: the source oriented record; the
problem-oriented medical record; the problems, Problem Oriented record (POR), established
interventions, evaluation (PIE) model; focus by Lawrence Weed in the 1960s, the data are
charting; charting by exception (CBE); arranged according to the problems the client
computerized documentation; and case has rather than the source of the information.
management. These documentation systems Members of the health care team contribute to
can be implemented using the traditional paper the problem list, plan of care, and progress
forms or with EHRs. notes. Plans for each active or potential problem
are drawn up, and progress notes are recorded
A. Source Oriented Record for each problem.

The traditional client record is a source- The advantage of POMR is that (a) it
oriented record. Each person or department encourages collaboration and (b) the problem
makes notations in a separate section or list in the front of the chart alerts caregivers to
sections of the client’s chart. For example, the the client’s needs and makes it easier to track
admissions department has an admission the status of each problem.
sheet; the primary care provider has a
physician’s order form, a physician’s history Its disadvantages are that (a) caregivers
sheet, and progress notes; nurses use the differ in their ability to use the required charting
nurses’ notes; and other departments or format, (b) it takes constant vigilance to maintain
personnel have their own records. In this type of an up-to-date problem list, and (c) it is
record, information about a particular problem is somewhat inefficient because assessments and
distributed throughout the record. For example, interventions that apply to more than one
if a client had left hemiplegia (paralysis of the left problem must be repeated.
side of the body), data about this problem might
be found in the physician’s history sheet, on the The POMR has four basic components:
physician’s order form, in the nurses’ notes, in o Database
the physical therapist’s record, and in the social o Problem list
service record. o Plan of care
o Progress notes.
Narrative charting is a traditional part of
the source-oriented record. It consists of written In addition, flow sheets and discharge
notes that include routine care, normal findings, notes are added to the record as needed.
and client problems. There is no right or wrong
order to the information, although chronologic a. Database
order is frequently used. Today, few institutions
use only narrative charting. Narrative recording The database consists of all information
is being replaced by other systems, such as known about the client when the client first
charting by exception and focus charting. Many enters the health care agency. It includes the
agencies combine narrative charting with nursing assessment, the primary care provider’s
another system. For example, an agency using history, social and family data, and the results of
25 | P a g e
the physical examination and baseline O—Objective data consist of information that is
diagnostic tests. Data are constantly updated as measured or observed by use of the senses
the client’s health status changes. (e.g., vital signs, laboratory and x-ray results).

b. Problem List A—Assessment is the interpretation or

conclusions drawn about the subjective and
The problem list is derived from the objective data. During the initial assessment,
database. It is usually kept at the front of the the problem list is created from the database, so
chart and serves as an index to the numbered the “A” entry should be a statement of the
entries in the progress notes. Problems are problem. In all subsequent SOAP notes for that
listed in the order in which they are identified, problem, the “A” should describe the client’s
and the list is continually updated as new condition and level of progress rather than
problems are identified and others resolved. All merely restating the diagnosis or problem.
caregiver’s may contribute to the problem list,
which includes the client’s physiological, P—The plan is the plan of care designed to
psychological, social, cultural, spiritual, resolve the stated problem. The initial plan is
developmental, and environmental needs. written by the person who enters the problem
into the record. All subsequent plans, including
c. Plan of Care revisions, are entered into the progress notes.
Over the years, the SOAP format has been
The initial list of orders or plan of care is modified. The acronyms SOAPIE and SOAPIER
made with reference to the active problems. refer to formats that add interventions,
Care plans are generated by the individual who evaluation, and revision:
lists the problems. Primary care providers write
physician’s orders or medical care plans; nurses I—Interventions refer to the specific
write nursing orders or nursing care plans. The interventions that have actually been performed
written plan in the record is listed under each by the caregiver.
problem in the progress notes and is not isolated
as a separate list of orders. E—Evaluation includes client responses to
nursing interventions and medical treatments.
d. Progress Notes This is primarily reassessment data.

A progress note in the POMR is a chart entry R—Revision reflects care plan modifications
made by all health professionals involved in a suggested by the evaluation. Changes may be
client’s care; they all use the same type of sheet made in desired outcomes, interventions, or
for notes. Progress notes are numbered to target dates.
correspond to the problems on the problem list
and may be lettered for the type of data. For e. PIE
example, the SOAP format is frequently used.
SOAP is an acronym for subjective data, The PIE documentation model groups
objective data, assessment, and planning. information into three categories. PIE is an
acronym for problems, interventions, and
S—Subjective data consist of information evaluation of nursing care. This system consists
obtained from what the client says. It describes of a client care assessment flow sheet and
the client’s perceptions of and experience with progress notes. The flow sheet uses specific
the problem. When possible, the nurse quotes assessment criteria in a particular format, such
the client’s words; otherwise, they are as human needs or functional health patterns.
summarized. Subjective data are included only The time parameters for a flow sheet can vary
when it is important and relevant to the problem. from minutes to months. In a hospital intensive
care unit, for example, a client’s blood pressure
26 | P a g e
may be monitored by the minute, whereas in an
ambulatory clinic a client’s blood glucose level
may be recorded once a month. After the
assessment, the nurse establishes and records
specific problems on the progress notes, often
using NANDA diagnoses to word the problem. If
there is no approved nursing diagnosis for a
problem, the nurse develops a problem
statement using NANDA International’s three-
part format: client’s response, contributing or
probable causes of the response, and g. Computerized Documentation
characteristics manifested by the client.
Electronic health records (EHRs) are used to
f. FOCUS Charting manage the huge volume of information
required in contemporary health care. That is,
Focus charting is intended to make the client the EHR can integrate all pertinent client
and client concerns and strengths the focus of information into one record. Nurses use
care. Three columns for recording are usually computers to store the client’s database, add
used: date and time, focus, and progress notes. new data, create and revise care plans, and
The focus may be a condition, a nursing document client progress. Some institutions
diagnosis, a behavior, a sign or symptom, an have a computer terminal at each client’s
acute change in the client’s condition, or a client bedside, or nurses carry a small handheld
strength. The progress notes are organized into terminal, enabling the nurse to document care
(D) data, (A) action, and (R) response, referred immediately after it is given. Multiple flow sheets
to as DAR. The data category reflects the are not needed in computerized record systems
assessment phase of the nursing process and because information can be easily retrieved in a
consists of observations of client status and variety of formats.
behaviors, including data from flow sheets (e.g.,
vital signs, pupil reactivity). The nurse records For example, the nurse can obtain results
both subjective and objective data in this of a client’s blood test, a schedule of all clients
section. The action category reflects planning on the unit who are to have surgery during the
and implementation and includes immediate day, a suggested list of interventions for a
and future nursing actions. It may also include nursing diagnosis, a graphic chart of a client’s
any changes to the plan of care. The response vital signs, or a printout of all progress notes for
category reflects the evaluation phase of the a client. Many systems can generate a work list
nursing process and describes the client’s for the shift, with a list of all treatments,
response to any nursing and medical care. procedures, and medications needed by the
client. Computers make care planning and
The focus charting system provides a holistic documentation relatively easy. To record
perspective of the client and the client’s needs. nursing actions and client responses, the nurse
It also provides a nursing process framework for either chooses from standardized lists of terms
the progress notes (DAR). The three or types narrative information into the computer.
components do not need to be recorded in order
and each note does not need to have all three KARDEXES
categories. Flow sheets and checklists are
frequently used on the client’s chart to record The Kardex is a widely used, concise
routine nursing tasks and assessment data. method of organizing and recording data about
a client, making information quickly accessible
to all health professionals. The system consists
of a series of cards kept in a portable index file
27 | P a g e
or on computer generated forms. The card for a  Planning involves the nurse, the client, support people, and
particular client can be quickly accessed to other caregivers.
reveal specific data.  Shorter acute care hospitalization stays necessitate careful
discharge planning.
The Kardex may or may not become a  Standardized care plans should be adapted and used with
part of the client’s permanent record. In some individualized plans to meet individual client needs.
organizations it is a temporary worksheet written  The nursing care plan provides direction for individualized
care of the client.
in pencil for ease in recording frequent changes
 The planning process includes setting diagnostic priorities,
in details of a client’s care. establishing client goals/desired outcomes, selecting
nursing interventions and activities, and writing
individualized nursing interventions on the care plan.
IN A NUTSHELL  Nursing diagnoses are assigned high, medium, and low
priorities in consultation with the client, if health permits.
 Client goals/desired outcomes are used to plan nursing
 The nursing process is a systematic, rational method of interventions that will achieve anticipated changes in the
planning and providing individualized nursing care for client.
individuals, families, communities, and groups.  A taxonomy of nursing outcome statements, the Nursing
 The goals of the nursing process are to identify a client’s Outcomes Classification (NOC), has been developed to
health status and actual or potential health care needs, to describe measurable states, behaviors, or perceptions that
establish plans to meet the identified needs, and to deliver respond to nursing interventions. Each outcome has a
and evaluate specific nursing interventions to meet those definition, a measuring scale, and an indicator.
needs.  Client records are legal documents that provide evidence of
 The nursing process is organized into five interrelated, a client’s care.
interdependent phases: assessing, diagnosing, planning,  The nurse has a legal and ethical duty to maintain
implementing, and evaluating. confidentiality of the client’s record; this includes special
 The nursing process can be used in all health care settings. measures to protect client information stored in computers.
It is cyclic and dynamic, client centered, focuses on problem  Client records are kept for a number of purposes, including
solving and decision making, interpersonal and communication, planning client care, auditing health
collaborative, universally applicable, and requires critical agencies, research, education, reimbursement, legal
thinking and clinical reasoning. documentation, and health care analysis.
 The purpose of the NANDA International organization is to  Examples of documentation systems include source
define, refine, and promote a taxonomy of nursing oriented, problem oriented, PIE, focus charting, charting by
diagnostic terminology. exception, computerized documentation, and case
 A diagnosis is a statement or conclusion regarding the management.
nature of a phenomenon.  In source-oriented clinical records, each health care
 Professional standards of care hold that registered nurses professional group provides its own record. Recording is
are responsible for making nursing diagnoses, even though oriented around the source of the information.
others may contribute data or implement care.  In problem-oriented clinical records, recording is organized
 A nursing diagnosis is a clinical judgment about the client’s around client problems.
responses to actual and potential health problems or life  Computers make care planning and documentation
processes. relatively easy. The use of computer terminals at the
 A nursing diagnosis provides the basis for selecting bedside allows immediate documentation of nursing
independent nursing interventions to achieve outcomes for actions.
which the nurse is accountable.  The case management model emphasizes quality, cost-
 Nursing diagnoses have a status of actual, health effective care delivered within an established length of stay.
promotion, risk, and wellness.  The Kardex is used to organize client data, making
 A nursing diagnosis has three components: the problem information quick to access for health professionals.
(and its definition), the etiology, and the defining  Nursing progress notes provide information about the
characteristics. Each component serves a specific purpose. progress the client is making toward desired outcomes. The
 Planning is the process of designing nursing activities format for the progress note depends on the documentation
required to prevent, reduce, or eliminate a client’s health system at the facility.
problems.

28 | P a g e
 Practice Exercise: Critical Thinking Alert!
SUPPLEMENTATION
Create 1 Nursing Care Plan base from the
situation stipulated. Follow designated format
administered by your instructor.

Situation: Mr. A, a 75-year-old male is currently

admitted on BRENT Hospital and Colleges Inc.,
with the following complaints;
a. Severe back pain for almost 1 week with
pain scale of 7/10, (+) facial grimace, (+)
guarding behavior.
b. Incontinence for almost 1 week, (+)
bloated abdomen, (+) abdominal
discomfort.
c. Noted, abrasions on the both lower
extremities.
Need to understand more on nursing process? You may visit
d. Has difficulty of swallowing.
https//:[Link]/watch=Ug4fDIJNQhwAs
an additional reference.
As a nurse on duty, how can you help the
patient? Create a care plan.

Need to understand more on nursing process? You may visit

[Link]
an additional reference.

Self- Reflection

As a future nurse, how important for us to

follow the steps of the nursing process? What
will be the effect on the patient? Explain briefly
based on your understanding.

29 | P a g e Note: Please answer this on a separate sheet of paper and email it to the official emails of your NCM 103 Instructor. For further
clarifications regarding the above topics, you contact them via your Facebook group messenger or on their official emails.