Nursing Process and Plan of Care Guidelines
ASSESSMENT:
NURSING DIAGNOSIS (NANDA)
DATA
Subjective data
Problem: (3 part statement)
(symptoms specific to the
patient problem and
etiology)
* Interview
* Patient statements -
Nursing Diagnosis / problem
Objective data
(signs specific to the
patient problem and
etiology)
* Physical exam
* Health record
* Observation of
behavior
* Other sources
This data provides the
defining characteristics
for actual nursing
diagnoses
ANALYSIS:
Clustering data using
Gordon’s Functional
Assessment
Step 1: Organize the data
Step 2: Compare
individual data with
standards and norms
Step 3: Cluster significant
cues, looking for patterns
and relationships
Step 4: Look at patterns –
which is best represented
by the data
Step 5: Identify data gaps
and inconsistencies
Step 6: Are there
explanations for the cues?
Step 7: Identify
problems/wellness Dx.
r / t (related to)
Etiology / related factors (probable
cause)
AMB (as manifested by) or AEB / (as
evidenced by) defining characteristics
(signs/symptoms)
Example:
activity intolerance r/t compromised
oxygen transport 2o (secondary to)
COPD AMB ↓ Hgb, shortness of
breath on exertion, verbal report of
weakness
NOTE: these manifestations must
appear in your data collection.
Risk For / Potential: (2 part statement)
Risk for Nursing Diagnosis / problem
r/t
risk factors (that could lead to the
problem developing)
e.g. Risk for activity intolerance r/t
increased metabolic demands 2o to
surgery
----------------------------------------------Definitions……..
Nursing Diagnosis/Problem:
Patient / Human Response to
illness / medical treatment /
life processes
Related factors/ Etiology factors that lead
to the nursing diagnosis - within scope
of nursing practice to treat
AMB (as manifested by) or AEB / as
evidenced by: Defining characteristics:
Major signs and symptoms – seen in the
data collection that contributes to the
problem
PLAN:
PLAN / IMPLEMENTATION:
EXPECTED OUTCOMES
INTERVENTIONS
The expected outcomes are the
measurable indicators that tell us if the
problem outlined in the nursing
diagnosis is resolved.
Expected outcomes guide the selection
of nursing interventions
GOAL: (summary statement of what is to
be accomplished when all expected
outcomes are met)
EXPECTED OUTCOMES: (the expected
measurable results)
The patient will:
. Show resolution or improvement of the
problem / reduce risk factors
a.___________ by when
b.___________ by when
(focus on problem and etiology / related
factors - measurable criteria) with time
frame
Example:
Goal: The patient will progress activity
to pre-surgical level by POD 5
Expected Outcomes:
Patient will
- report feeling less weak during
activity by POD 4
-Hgb will return to normal limits by
POD 3
-Patient will walk to the end of the hall
with no SOB by POD4.
Guidelines:
* Patient centered
* Observable
* Measurable
* Time-Limited
* Realistic
* Mutual
Nursing Interventions to
assist the patient to achieve
the stated expected
outcome(s)
Components of nursing
intervention:
 Date you write action
 Verb: action to be performed
 Subject: who is to do it
 Descriptive phase: how, when
where,
 Specific time when, how long,
or how much, how often
(frequency):
Example:
1. assess BP, P, R pre and 3
minutes post activity.
2. dangle pt at side of bed day
of surgery x 15 minutes
3. Patient to be out of bed x 3
POD 1.
4. Walk to washroom with
assistance of 1 nurse on day
of surgery.
5.Increase distance walked by
10meters with each walk.
6. monitor Hgb daily.
7. Administer iron
supplements as ordered.
8. Encourage iron rich foods
when eating and for snacks.
RATIONALE
The “why” for the
Interventions
Base on scientific
Knowledge – must be
referenced
Reflect how the
intervention will
solve the problem/
nursing diagnosis /
achieve the expected
outcome
Example:
1. Response to
activity can be
evaluated by
comparing
preactivity BP, P, R
with post activity
results. Strenuous
activity may increase
the pulse by 50
beats. This rate is
still satisfactory as
long as it returns to
resting pulse within
3 minutes. (Hibbard,
2003 as cited in
Carpenito 2011).
EFFECTIVENESS
OF
INTERVENTIONS
How each
intervention
worked for the
patient
1.
Example:
1. Pulse > 6 beats
preactvity pulse,
respirations
remained
elevated post
activity. Reduce
distance walked
to 5 meters.
EVALUATION:
OF EXPECTED OUTCOMES
As of date/time:
1. a. Expected outcome(s)
status
* Met
* Partially met
* Not met
Description of actual
patient action, statement or
change of behavior of the
patient
Revision of care plan /
follow-up actions / changes:
* Reassessment
* Nursing diagnosis
* Expected outcomes
* Interventions
* Communication and
documentation
Re-evaluation of expected
outcome(s) with time frame
Guidelines:
* Consistent with medical
treatment plan
* Safe
* Individualized
* Promote patient
involvement - self-care
* Holistic
* Nurse accountable for action
* Collaboration with health
care team and significant
others
Revised 2013