Nursing process and
nursing diagnosis
Nursing process
An organizing framework for professional
nursing practice
Step I – nursing assessment
Step II – making nursing diagnosis
Step III – planning
Step IV – implementation care
Step V – evaluation the nursing care has been
given
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Step I: Assessment
Perfoming a thorough holistic nursing
assessment of client
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Taking a medical history
Perfoming a physical assessment
Noting diagnostic test results
Step I: Assessment
To elicit as many symptoms as possible, the nurse
should use open-ended rather than yes/no
questions.
Examples:
“Describe what you are feeling”
“How long have you been feeling this way?”
“When did the symptoms start?”
“Describe the symptoms”
This type of questions will encourage the client to
give more information about his or her situation.
Listen carefully for cues and record relevant
information.
Step II: Nursing Diagnosis
A nursing diagnosis is a clinical judgment
about individual, family, or community
responses to actual or potential health
problems or life processes. Nursing
diagnosis provide the basis for selection of
nursing intervention to achieve outcomes
for which the nurse is accountable
(NANDA, 2003)
Step II: Nursing Diagnosis
A working of nursing diagnosis may have two or
three parts.
The three-part system consists of the nursing
diagnosis, the “related to” statement, and the
defining characteristics.
PES system:
P (problem) - The nursing diagnosis, the label; a concise
term or phrase that represent a pattern of related cues
E (etiology) – “Related to” phrase or etiology; related
cause or contributor to the problem
S (symptoms) –Defining characteristics phrase; symptoms
that the nurse identifted in the assessment
Step II: Nursing Diagnosis
Case study:
A 73-year-old man has been admitted to the
unit with a diagnosis of chronic obstructive
pulmonary disease (COPD). He states that he
has “difficulty breathing when walking short
distances”. He also states that his “heart feels
like it is racing” at the same time. He states
that he is “tired all the time”, and while
talking to you he is comtinually wringing his
hands and looking out the window.
Step II: Nursing Diagnosis
Part 1 (Problem)
Interpretation of information:
 “difficulty breathing when walking short
distances”= dyspnea
 “heart feels like it is racing”= dysrythmia
 “tired all the time”= fatigue
In Section II we can find the nursing
diagnosis Activity intolerance listed with
these symptoms.
Step II: Nursing Diagnosis
To validate that the diagnosis Activity
intolerance is appropriate for the client,
we have to read NANDA definition of the
nursing diagnosis.
When reading, ask Does this definition
describe the symptoms demonstrated by the
client? If the appropriate nursing diagnosis
has been selected, the definition should
describe the condition that has been
observed.
Activity intolerance
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NANDA Definition
Insufficient physiological or psychological energy to
endure or complete required or desired daily activities.
Defining Characteristics
Verbal report of fatique or weakness; abnormal heart
rate or blood pressure response to activity; exertional
discomfort or dyspnea; electrocardiografic changes
reflecting dysrhytmias or ischemia
Related factors (r/t)
Bed rest or immobility; generalized weakness,;
sedentary lifestyle; imbalance between oxygen supply
and demand
Part 2 (Etiology)
“Reated to” Phrase
This phrase states what may be causing or contributing to
the nursing diagnosis, commonly referred to as the
etiology.
Ideally the etiologe, or cause, of the nursing diagnosis is
something that can be treated by a nurse. When this is the
case, the diagnosis is identified as an independent nursing
diagnosis. If medical Intervention is also necessary, it
might be identified as a collabarative diagnosis.
For each suggested nursing diagnosis, the nurse should
refer to the statements listed under the heading “Related
Factors”
Part 3 (Symptoms)
Defining Characteristic phrase
It consist of the signs and symptoms that
have been gathered during the assessment
phase. Signs and symptoms are labeled as
defining characteristics in Section III.
The use of identifying defining characteristics
is similar to the process the physician uses
when making a medical diagnosis.
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Writing a Nursing Diagnosis Statement
P - Activity intolerance
E – “Related to” imbalance between oxygen
supply and demand
S – Verbal reports of fatique, exertional dyspnea
(“difficulty breathing when walking”), and
dysrythmia (“racing heart ”)
Step III: Planning (outcomes and
interventions)
Consists of writing measurable client outcomes and nursing
intervention to accomplish the outcomes. Before this can be done,
if the client has more than one diagnosis, the priority of the
nursing diagnoses must be determined.
Step III: Planning (outcomes and
interventions)
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Outcomes are conceptualized as variable client
states influenced by nursing intervention. Thus
client outcomes represent patient states that vary
and can be measured and compared with a baseline
over time.
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Development of appropriate oucomes can de done
one or two ways: using Nursing Outcomes
Classification (NOC) or writing an outcomes
statement.
Step III: Planning (outcomes and
interventions)
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NOC outcome is defined as follows: An individual,
family, or community state; behavior; or perception
that is measured along a continium in response to
one or more nursing interventions.
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Each outcome has a group of indicators that are
used to determine patient status in relation to
outcome (Moorhed, 2003)
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Because the NOC outcomes are very specific, they
enhance the nursing process by helping to nurse to
record changes after interventions have been
perfomed.
Step III: Planning (outcomes and
interventions)
Activity intolerance
 NOC outcomes
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Activity Tolerance
Endurance
Energy Conservation
Self-Care: Instrumental Activities of Daily
Living
Step III: Planning (outcomes and
interventions)
Endurance as evidenced by the following indicators:
Perfomance of usual routine /Activity /Rested
appearence/Blood oxygen level within normal limits
/Expresses feelings about loss /Verbalizes acceptance of
loss /Describes meaning of the loss or death/Report
decreased preoccupation with loss/Express positive
expectations about the future (Rate each indicator of
Endurance: 1=extremely compromised, 2=substantially
compromised, 3=moderately compromised, 4=mildly
compromised, 5=not compromised)
Step III: Planning (outcomes and
interventions)
Interventions are like road maps directing the best
ways to provide nursing care.
 The National Guidelines Clearinghouse (NGC) is
a comprehensive database of evidence-based
clinical practice guidelines and related documents
www.guideline.gov
 Evidance-Based Nursing
www.evidancebasednursing.com
 www.globalevidence.com
Step III: Planning (outcomes and
interventions)
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Section III suplies choices of interventions for
each nursing diagnosis. The interventions are
identified as independent ( autonomous actions
that are initiated by the nurse in response to a
nursing diagnosis) or collaborative (actions that
the nurse perfoms in collaborations with other
health care professionals and that may require a
physician’s order and may be in response to both
nursing snd medical diagnosis).
Step IV: Implementation
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It is actual initiation of the nursing care plan.
During this phase the client is assessed to
determine whether the interventions are effecive.
An important part of this phase is documentation.
Documentation is also necessary for legal
reasons because in a legal dispute anything that
has not been charted is considered not to have
been done.
Step V: Evaluation
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It is actually an integrl part of each phase
and something that is done continually. At
the last phase the clients’ outcomes are
evaluated to determine whether they were
met.