2025-11-24

THE NURSING PROCESS & CARE

PLANNING

LEARNING OBJECTIVES

Describe the five phases of the nursing process

Identify the relevance of each phase of the nursing process

Practice with the Nursing Process to develop a patient care plan

THE NURSING PROCESS

• A systematic problem-solving framework that guides ALL nursing actions to create a plan
of care for the patient
• Helps nurses provide individualized, goal-directed and client-centered care
• Aids with clinical judgement and reflection
• Logical and organized
• Non-linear and dynamic

What are the 5 phases of The Nursing Process?

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THE NURSING PROCESS CONT.

• Ensures client-centered care and involvement from client/families/inter-

professional team
• Critical thinking and reconsiderations are KEY in every step
• Works with the client directly to identify needs and then work towards optimizing
outcomes - potential or actual health problems or needs can be incorporated

PHASES OF THE
NURSING
PROCESS
Assessing
Diagnosing
Planning
Implementing
Evaluating

A Delicious PIE

1. ASSESSING
(Getting the Information)

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DATA COLLECTION
Collect evidence and key information thoroughly and systematically.
• Gather information when…
• Acquiring health history
• Talking to the patient and family members
• Don’t just focus on the physical symptoms… social, psychological, emotional, spiritual/cultural,
environmental dimensions = HOLISTIC ASSESSMENT
• Observe behaviours and cues
• Ensure active listening
• Ask questions/give prompts/open & close ended questions.
• Report from health care providers
• Looking at the chart or previous medical records, tests, results, etc.
• Conducting a physical assessment/exam

DATA COLLECTION
As you gather information from different sources…
- Ask yourself questions. Does this make sense? What about ___?
- Recall previous info/experiences
- Remember best practices/policies/resources available/literature
- Validate and organize sources and information

Primary vs. Secondary vs. Tertiary Sources?

Types of Data
SUBJECTIVE DATA OBJECTIVE DATA
• Based on client’s perceptions, sensations, • Detectable or measurable
feelings, beliefs, attitudes, and understanding • An observer can see, hear, feel, smelled, or
of personal health status and life situations measure against a standard.
• Obtained by observation or physical
examination
• Described by the client
• Examples:
• Client statements e.g., “I feel sick to my
• Vomited 100 mL green-tinged fluid
stomach.” “I have bad stomach cramping”
• Abdomen firm and slightly distended
• Redness and swelling to right ankle

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After data is collected…

• Begin to recognize patterns within data
• Further organize data if needed
• If needed, go back and gather more data/ask more
questions
• Document
• Objective, subjective data, etc.
• This information can be used by other providers in their
assessments/provision of care.

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2. DIAGNOSING
(Making Meaning of
the Information)

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Analyze and Interpret Data

• Analyze and synthesize the data
• Are there common groupings of data that are pointing to an actual issue or potential
issue?

• Identifying one or more problem or potential problems

• Begin to think about establishing priority health outcomes.

• Formulate a Nursing Diagnosis.

Nursing Diagnosis vs. Medical Diagnosis?

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TYPES OF NURSING
DIAGNOSES/PROBLEM STATEMENTS
Potential diagnosis/problem
Actual diagnosis/problem statement:
statement: one in which evidence about
client problem is present at the time of
a health problem is incomplete or
the nursing assessment
unclear; need more information

Risk diagnosis/problem statement: a

Wellness diagnosis/problem
clinical judgment that a problem does
statement: describes human responses
not yet exist, but the presence of risk
to levels of wellness in an individual,
factors indicates that a problem is likely
family or community;
to develop unless the nurse intervenes

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DIAGNOSIS STATEMENT
The basic three-part statement includes the following:
• Problem: a concise term or phrase that represents a patterns of related cues
• Nursing Diagnosis Handbook (NANDA)
• Etiology: “related to” (r/t) factors contributing to or probable causes of the response.
• Allows for individualization of the care plan.
• Help guide potential interventions, therapies, and providers required.
• Use data collected
• Symptoms: “as evidenced by” symptoms that the nurse identified in the assessment
• Use data collected

Examples:
1. Disturbed Sleep Pattern related to Left lower lobe pneumonia as evidenced by cough, pain, orthopnea, fever, and
diaphoresis
2. Acute Pain (Chest) related to biological injury (pneumonia) as evidenced by patient wincing when coughing, verbalization
of 8/10 pain score
3. Risk for Interrupted Family Processes related to mother’s illness and temporary unavailability of father to provide
childcare (with “risk” diagnosis we do not see the evidence right away but know the potential is there)

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Commonly used Nursing Diagnoses

• Chronic pain • Anxiety
• Acute Confusion • Risk-prone health behaviour
• Risk for infection • Risk for activity intolerance
• Impaired skin integrity • Impaired family coping
• Disturbed body image • Impaired coping
• Readiness for enhanced nutrition • Knowledge deficit
• Ineffective breathing pattern • Potential for falls
• Caregiver role strain
• Altered health maintenance
• Lack of compliance
• Decreased tissue perfusion

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In small groups, consider…

1. What is considered a priority problem/potential problem?

2. What are the factors the nurse must consider when deciding and
setting priorities?

3. Why is it essential that the nurse collaborate with the patient to

develop priorities and a plan for their care?

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3. PLANNING
(Determining Actions
to Take)

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PLANNING
• Deliberative, systematic phase of the nursing
process where a formal plan/goals are created
• Prescribes strategies and alternatives to address
nursing diagnosis and attain expected health
outcomes
• Involves decision making, problem solving and
priority planning
• Nurse refers to the client’s assessment data,
diagnostic statements, and client priorities when
designing the nursing interventions to achieve the
client’s health outcomes
• The patient/family is part of this process
• Setting goals/expectations/Interventions., etc.

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FACTORS TO CONSIDER WHEN

DEVELOPING GOALS
Client’s health values and beliefs

Client’s priorities

Resources available to the nurse and client

Urgency of the health problem

Medical treatment plan

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Remember – collaborating with the client

is essential when developing the care plan

Don’t tell the client what is best – if they

are actively part of the decisions and
planning, they will be more likely to follow
the plan

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Goals should be S.M.A.R.T.

• S-SPECIFIC
• M-MEASURABLE
• A-ATTAINABLE
• R-RELEVANT (REALISTIC)
• T-TIMELY

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GOAL SETTING & EXPECTED OUTCOMES

Short Term Goals Long Term Goals
Something you can accomplish within your Goals that work towards patient discharge.
timeframe with the patient or a relatively short May address the management of chronic health
time (ie. A 12-hour shift, within a week) conditions. Often involves a long recovery,
Examples: rehabilitation or adjustment
Impaired Physical Mobility: Inability to bear Examples:
weight on left leg related to inflammation of knee Impaired Physical Mobility: Inability to bear
joint
weight on left leg related to inflammation of knee
• The goal is improved mobility but more joint
specifically:
• The goal is improved mobility but more
• The client will demonstrate improved mobility specifically:
as evidenced by ambulating with crutches by
• The client will demonstrate improved mobility
Friday.
as evidenced by standing without assistance
by end of the month

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4. IMPLEMENTING
(Taking Action)

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IMPLEMENTATION
• The phase in which the nurse puts the nursing care plan into action
• May need to go back and assess and gather any new data.
• Assess and choose intervention to meet goals
• Who will be involved? How?
• Be as specific as possible
• Individualized to the client
• Implementing the nursing interventions
• Delegating and supervising
• Coordinating Must follow
• Delivery Scope of
• Health teaching Practice and
• Health promotion be Evidence-
• Provide therapies (meds, wound care, ambulation, oxygen etc.) Based

• Communicating the nursing action

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IMPLEMENTING
Example:
Nursing Diagnosis: Impaired tissue integrity (coccyx) related to lack of mobility
and imbalanced nutritional state
Short term Goal: The client will have decreased redness on the coccyx in 24
hours.
Nursing Actions:
• Turn the client q2h and perform skin care
• Inspect and monitor the site of impaired tissue integrity at least 3 times daily
for color changes, redness, swelling, warmth, pain, breakdown
• Maintain the head of the bed at the lowest degree of elevation possible to
reduce shear and friction

Any other nursing actions we can implement?

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Critical thinking and Clinical

Judgment are KEY; therefore…

• Review the set of all possible

nursing interventions and all
possible consequences
associated with each possible
nursing action

• Determine the effect of the

intervention on the patient.

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Working in groups…
What is the difference between independent, dependent and
collaborative nursing interventions?
Consider that you have a doctor’s order to catheterize a patient who is
experiencing urinary retention – is this independent or dependent nursing
intervention?

What type of independent interventions might the nurse consider

including in the care plan of a patient with an indwelling urinary
catheter?
(Hint: Think of things you are learning about in Nursing Skills 1).

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5. EVALUATING
(Evaluate Outcomes
and your Thinking)

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THE PROCESS OF EVALUATION

Through critical thinking and reflective practice, nurses evaluate the
effectiveness of the nursing care plan by considering the following:
• Was the patient's problem accurately identified?
• Were the goals realistic, measurable, and achieved within an
appropriate timeframe?
• Were the selected nursing interventions appropriate and effective in
addressing the patient’s needs and desired health outcomes?

Through assessment the nurse will be able to answer these questions

• Pain reassessment, vital signs reassessment, reassessing new lab

values, conversations with client/family., etc.
Based on the patient’s outcomes, we will decide whether to continue,
modify, or terminate the current nursing care plan.
Document and report findings and if needed, new care plan.

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THE PROCESS OF EVALUATION

• During the evaluation process, it’s important to

assess for any new or potential health concerns that
may have emerged, so we can address them
promptly and update the care plan accordingly.
• The process of evaluation is connected to every
other aspect of the nursing care plan/nursing process
- Evaluation is a continuous process

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In Review…

Assessment: Planning: Interventions and Goal Implementation:

Writing
• Getting and verifying • Taking action, Doing,
the information (signs, • What actions should we take to
symptoms, story, etc.) solve/improve/prevent the • Delegating,
problem? • & always….. Documenting!
• What does the patient want
Diagnosis: Thinking about the to happen/to see happen?
previous data… decide Evaluation:
• What goals can make it happen?
• What is the problem/issue? • Did it work?
• What is the priority problem? • Has the problem/potential
problem changed? Improvement?
Decline?
• If not, start again….

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Working in groups…

How can nurses effectively collaborate with others during the creation and
execution of a care plan?
Consider the following partnerships and discuss specific strategies for
each:
• Families
• Health Care Providers
• Community Services

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Sometimes the nursing process...is carried out

as a mental process and other times… a formal
written plan
Dependent on:
• The complexity of the patient/number and severity of
issues
• Institutional Policy
• Setting
• Nurse experience and practice with the Nursing
Process

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Question 1
You see Mrs. Chekov, a 70-year-old, walking around the
parking garage looking confused. What is the nurse’s initial
action?

A. 1. Ask Mrs. Chekov if she is ok and what he is looking

for.
B. 2. Ask Mrs. Chekov if she would like a turkey sandwich
C. 3. Take Mrs. Chekov to the cafeteria
D. 4. Ask Mrs. Chekov if she is more comfortable now.

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Question 2
Which of the following behaviours is most representative
of the nursing diagnosis phase of the nursing process?

A. [Link] major problems or needs

B. [Link] data in the client’s family history
C. [Link] short-term and long-term goals
D. [Link] an antibiotic

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Question 3
Which of the following behaviours would indicate that the
nurse was using the planning phase of the nursing
process to correctly?
A. Think about potential helpful interventions
B. Reassess the patient after a nursing intervention
C. Collect and organize key data
D. Create SMART goals in collaboration with the patient

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Activity #1
You will be assigned a simple case study in your group. As a group fill in the
template from the case study information.
 Complete the assessment areas (identify subjective and objective
findings)
 Determine 1 relevant Nursing Diagnosis
 Write 1 short term and 1 long term goal
 Determine appropriate nursing interventions
 Identify how you would engage the patient in all parts of the nursing
process.

You will present components of the nursing process on completion of the

activity.

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Activity #2
Working in groups, discuss how the nursing process would be applied to the following scenarios:

a. You are back to work from your 4 days off and you are assigned to get Mrs. H, an 85-year-old
resident in Shady Pines Nursing Home ready to attend breakfast in the dining area. You are told
that Mrs. H is a 1-person transfer to her wheelchair.
b. When providing morning care for Mr. S, you notice a reddened area on his coccyx.
c. As the RPN, you are administering medications to your client. You are to provide J.C. with a
medication for pain every morning at 10am as ordered by the physician. J.C. is an active resident
in the extended care community where you work and never complains about anything.
d. The PSW you are working with provides a report for Ms. W. The PSW states Ms. W’s temperature is
38 C, P-98, R-22 and BP 122/80. The PSW also states she thought there may have been a foul
odour to Ms. W’s urine this morning when she was assisting Ms. W to the washroom.

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