Assessment Diagnosis Planning Intervention Rationale Evaluation

Step 1: Data Collection or Assessment Step 2: Data Analysis and Step 3: Formulating Your Nursing Step 4: Setting Priorities A nursing rationale is a stated purpose Step 5: Establishing Client Goals and
Organization Diagnoses for carrying out a nursing intervention. Desired Outcomes
The first step in writing a nursing care Setting priorities deals with establishing Nursing interventions are actions that
plan is to create a client database using a preferential sequence for addressing nurses perform to help patients achieve
Now that you have information about NANDA nursing diagnoses are a After assigning priorities for your
assessment techniques and data nursing diagnoses and interventions. In specified health goals. A nursing
the client’s health, analyze, cluster, and uniform way of identifying, focusing on, nursing diagnosis, the nurse and the
collection methods (physical this step, the nurse and the client begin rationale is written next to each nursing
organize the data to formulate your and dealing with specific client needs client set goals for each determined
assessment, health history, interview, planning which nursing diagnosis intervention in the nursing care plan.
nursing diagnosis, priorities, and and responses to actual and high-risk priority. Goals or desired outcomes
medical records review, diagnostic desired outcomes. problems. Actual or potential health requires attention first. Diagnoses can describe what the nurse hopes to
studies). A client database includes all problems that can be prevented or be ranked and grouped as having a high, achieve by implementing the nursing
the health information gathered. In this resolved by independent nursing medium, or low priority. interventions derived from the client’s
step, the nurse can identify the related intervention are termed nursing Life-threatening problems should be nursing diagnoses. Goals provide
or risk factors and defining diagnoses. We’ve detailed the steps on given high priority. direction for planning interventions,
characteristics that can be used to how to formulate your nursing serve as criteria for evaluating client
formulate a nursing diagnosis. Some diagnoses in this guide: Nursing A nursing diagnosis encompasses progress, enable the client and nurse to
agencies or nursing schools have Diagnosis (NDx): Complete Guide and Maslow’s Hierarchy of Needs and helps determine which problems have been
specific assessment formats you can use. List to prioritize and plan care based on resolved, and help motivate the client
patient-centered outcomes. In 1943, and nurse by providing a sense of
Subjective data is gathered from the Goals should be SMART: Abraham Maslow developed a hierarchy achievement.
patient telling you something that you based on basic fundamental needs
cannot use your five senses to measure. innate to all individuals. Basic
Specific. It should be clear, significant,
Problem-Focused Nursing Diagnosis physiological needs/goals must be met
and sensible for a goal to be effective.
(galing sa pt yung information at hindi before higher needs/goals can be
Measurable or Meaningful. Making sure
nasusukat ng nurse using 5 senses) A problem-focused diagnosis (also achieved, such as self-esteem and
a goal is measurable makes it easier to
known as actual diagnosis) is a client self-actualization. Physiological and
monitor progress and know when it
problem present at the time of the safety needs provide the basis for
If a patient tells you they have had reaches the desired result.
nursing assessment. These diagnoses implementing nursing care and nursing
diarrhea for the past two days, that is Attainable or Action-Oriented. Goals
are based on the presence of associated interventions. Thus, they are at the base
subjective, you cannot know that should be flexible but remain possible.
signs and symptoms. Actual nursing of Maslow’s pyramid, laying the
information any other way besides being Realistic or Results-Oriented. This is
diagnosis should not be viewed as more foundation for physical and emotional
told that is what happened. important to look forward to effective
important than risk diagnoses. There health.
and successful outcomes by keeping in
are many instances where a risk mind the available resources at hand.
Ask yourself, did the patient tell me this
diagnosis can be the diagnosis with the Timely or Time-Oriented. Every goal
information or can I measure or observe Evaluating is a planned, ongoing,
highest priority for a patient. needs a designated time parameter, a
this information by myself? purposeful activity in which the client’s
deadline to focus on, and something to progress towards achieving goals or
Problem-focused nursing diagnoses work toward. desired outcomes and the effectiveness
● Is this something I can observe have three components: (1) nursing of the nursing care plan (NCP).
using my five senses? diagnosis, (2) related factors, and (3) Hogston (2011) suggests using Evaluation is an essential aspect of
● Has the patient told me this defining characteristics. Examples of the REEPIG standards to ensure that the nursing process because
information and can I verify it? actual nursing diagnoses are: care is of the highest standards. By this conclusions drawn from this step
means, nursing care plans should be: determine whether the nursing
1. Ineffective Breathing intervention should be terminated,
Pattern related to pain as Realistic. Given available resources. continued, or changed.
evidenced by pursed-lip
breathing, reports of pain
 during inhalation, use of Explicitly stated. Be clear in precisely Nursing interventions are activities or
accessory muscles to breathe what must be done so there is no room actions that a nurse performs to achieve
2. Anxiety related to stress as for misinterpretation of instructions. client goals. Interventions chosen
evidenced by increased tension, Evidence-based. That there is research should focus on eliminating or reducing
apprehension, and expression of that supports what is being proposed. the etiology of the nursing diagnosis. As
concern regarding Prioritized. The most urgent problems for risk nursing diagnosis, interventions
upcoming surgery are dealt with first. should focus on reducing the client’s
3. Acute Pain related to decreased Involve. Involve both the patient and risk factors. In this step, nursing
myocardial flow as evidenced by other members of the multidisciplinary interventions are identified and written
grimacing, expression of pain, team who are going to be involved in during the planning step of the nursing
guarding behavior. implementing the care. process; however, they are actually
4. Impaired Skin Integrity related Goal centered. That the care planned performed during the implementation
to pressure over bony will meet and achieve the goal set. step.
prominence as evidenced by
pain, bleeding, redness, wound Short Term and Long-Term Goals Types of Nursing Interventions
drainage.
Goals and expected outcomes must Nursing interventions can be
Risk Nursing Diagnosis be measurable and client-centered. Goal independent, dependent, or
Sample 1 s are constructed by focusing on collaborative:
The second type of nursing diagnosis is problem prevention, resolution, and
called risk nursing diagnosis. These are rehabilitation. Goals can
Situation:
clinical judgments that a problem does be short-term or long-term. Most goals
not exist, but the presence of risk are short-term in an acute care setting
Your patient is holding their stomach factors indicates that a problem is likely since much of the nurse’s time is spent
and moaning. They say, “I can’t take this to develop unless nurses intervene. on the client’s immediate needs.
pain anymore! It feels like someone is There are no etiological factors (related Long-term goals are often used for
cutting my belly with a jagged hot factors) for risk diagnoses. The clients who have chronic health
knife!” The patient’s face is red and individual (or group) is more susceptible problems or live at home, nursing
sweaty, their heart rate is 115 bpm, and to developing the problem than others homes, or in extended-care facilities.
their respirations are shallow. The in the same or a similar situation
patient’s abdomen is hard, round, because of risk factors. For example, Short-term goal. A statement ● Independent nursing
distended and when you percuss over an elderly client with diabetes and distinguishing a shift in behavior that interventions are activities that
each quadrant you hear dull short tones. vertigo who has difficulty walking can be completed immediately, usually nurses are licensed to initiate
The patient then informs you they feel refuses to ask for assistance during within a few hours or days. based on their sound judgment
dizzy. You perform an EKG and the ambulation may be appropriately Long-term goal. Indicates an objective and skills. Includes: ongoing
results are normal sinus rhythm (NSR). diagnosed with Risk for Injury. to be completed over a longer period, assessment, emotional support,
The patient starts to cry and plead for
usually over weeks or months. providing comfort, teaching,
you to help them. You reassure them
Components of a risk nursing diagnosis Discharge planning. Involves naming physical care, and making
that they are in the right place and you
include (1) risk diagnostic label, and (2) long-term goals, therefore promoting referrals to other health care
are so happy to be taking care of them.
risk factors. Examples of risk nursing continued restorative care and problem professionals.
They dry their tears and thank you.
diagnosis are: resolution through home health, ● Dependent nursing
physical therapy, or various other interventions are activities
Let’s break this down: referral sources. carried out under the
● Risk for Falls as evidenced
by muscle weakness physician’s orders or
● Objective: ● Risk for Injury as evidenced supervision. Includes orders to
○ Their face is red and by altered mobility direct the nurse to provide
sweaty medications, intravenous
○ Heart rate 115 bpm therapy, diagnostic tests,
 ○ Shallow respirations ● Risk for Infection as evidenced Components of Goals and Desired treatments, diet, and activity or
○ Abdomen hard, round, by immunosuppression Outcomes rest. Assessment and providing
distended explanation while administering
○ Percussed dull noises Health Promotion Diagnosis Goals or desired outcome statements medical orders are also part of
○ Patient holding usually have four components: a subject, the dependent nursing
abdomen and moaning Health promotion diagnosis (also a verb, conditions or modifiers, and a interventions.
○ NSR EKG criterion of desired performance. ● Collaborative interventions are
known as wellness diagnosis) is a
○ Tearful actions that the nurse carries
clinical judgment about motivation and
● Subjective: out in collaboration with other
○ Burning sharp pain desire to increase well-being. Health health team members, such as
○ Dizziness promotion diagnosis is concerned with physicians, social workers,
the individual, family, or community dietitians, and therapists. These
transition from a specific level of actions are developed in
The description of the patients’ pain, as consultation with other health
wellness to a higher level of wellness.
well as the feeling of being dizzy, is care professionals to gain their
Components of a health promotion
subjective data that you are not able to professional viewpoint.
diagnosis generally include only the
confirm. The patient is only able to tell ● Subject. The subject is the
diagnostic label or a one-part statement. Nursing interventions should be:
you this is how they feel. client, any part of the client, or
Examples of health promotion some attribute of the client (i.e.,
diagnosis: pulse, temperature, urinary ● Safe and appropriate for the
Remember that each patient will feel output). That subject is often client’s age, health, and
their pain differently. ● Readiness for Enhanced omitted in writing goals condition.
However, it is not just pain that is Spiritual Well Being because it is assumed that the ● Achievable with the resources
subjective. Some other examples of ● Readiness for Enhanced Family subject is the client unless and time available.
subjective data include the following: Coping indicated otherwise (family, ● In line with the client’s values,
● Readiness for Enhanced significant other). culture, and beliefs.
Reports of past health issues, such as
Parenting ● Verbs. The verb specifies an ● In line with other therapies.
diarrhea or coughing
● action the client is to perform, ● Based on nursing knowledge
● Dizziness Components of a Nursing Diagnosis for example, what the client is and experience or knowledge
to do, learn, or experience. from relevant sciences.
● Tiredness
A nursing diagnosis typically has three ● Conditions or modifiers. These
● Nausea components: (1) the problem and its are the “what, when, where, or When writing nursing interventions,
definition, (2) the etiology, and (3) the how” that are added to the verb follow these tips:
● Itching
defining characteristics or risk factors to explain the circumstances
● Shortness of breath (for risk diagnosis). under which the behavior is to 1. Write the date and sign the
be performed. plan. The date the plan is
● Chills
● Criterion of desired written is essential for
Pro Tip: performance. The criterion evaluation, review, and future
indicates the standard by which planning. The nurse’s signature
You should note that although pain is
a performance is evaluated or demonstrates accountability.
referred to as subjective information,
the level at which the client will 2. Nursing interventions should be
you may be able to make some
perform the specified behavior. specific and clearly stated,
observations even if your patient cannot
These are optional. beginning with an action verb
rate his pain.
indicating what the nurse is
Objective signs that could point to pain expected to do. Action verb
include grimacing, frowning, clutching starts the intervention and must
a body part, increased respirations, be precise. Qualifiers of how,
and grinding the teeth. when, where, time, frequency,
Sample 2 When writing goals and desired and amount provide the content
outcomes, the nurse should follow these of the planned activity. For
tips: example: “Educate parents on
Mr. Smith is a thirty-year-old, white how to take temperature and
male presenting to the outpatient clinic 1. Write goals and outcomes in notify of any changes,” or
with complaints of nausea and vomiting terms of client responses and “Assess urine for color, amount,
for two days. He reports the last time he not as activities of the nurse. odor, and turbidity.”
vomited was about an hour before Begin each goal with “Client 3. Use only abbreviations accepted
arriving at the clinic. Mr. Smith states will […]” help focus the goal on by the institution.
he feels weak and shaky. He is sweating client behavior and responses.
but complains of being cold. BP 142/84, 2. Avoid writing goals on what the
P 72, R 18, T 100.5; Denies pain; no nurse hopes to accomplish,
changes in medications since last clinic and focus on what the client
visit. will do.
3. Use observable, measurable
terms for outcomes. Avoid using
What is the Subjective Data: The vague words that require
examples of subjective data in nursing interpretation or judgment of
PES Format the observer.
in this scenario are the patient’s
complaints of nausea, vomiting, feeling 4. Desired outcomes should be
Another way of writing nursing realistic for the client’s
shaky and cold, and denying pain.
diagnostic statements is by using resources, capabilities,
the PES format, which stands for limitations, and on the
Problem (diagnostic label), Etiology designated time span of care.
What is the Objective Data: In this
(related factors), and Signs/Symptoms 5. Ensure that goals are
scenario, the objective nursing data are
(defining characteristics). Diagnostic compatible with the therapies
Mr. Smith’s age, vital signs, and being
statements can be one-part, two-part, or of other professionals.
sweaty.
three-part using the PES format. 6. Ensure that each goal is derived
from only one nursing
diagnosis. Keeping it this way
facilitates evaluation of care by
ensuring that planned nursing
interventions are clearly related
to the diagnosis set.
7. Lastly, make sure that the client
considers the goals important
and values them to ensure
cooperation.