Processes in Nursing Care
The Nursing Diagnostic Process
Planning
Implementation
Evaluation
Dr. Belal Hijji, RN, PhD
February 11, 2012
Objectives
• After this lecture, students will be able to
– Identify the steps of the nursing diagnostic process
– Discuss how to avoid common errors in nursing diagnostic
statements
– Identify and describe the steps of planning phase of the
nursing process
– Identify and discuss the steps of the implementation phase
of the nursing process
– Describe the evaluation of nursing care
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The NANDA (North American Nursing Diagnosis
Association) Diagnoses and Nursing Diagnostic Process
• The following types of nursing diagnoses identified by the
NANDA are described:
– Actual nursing diagnosis: An example, “urinary retention
related to swelling of the perineum following normal delivery”.
This diagnosis is supported by the defining characteristics of
distended bladder, voiding small amounts, and feels the urge to
void.
– Risk nursing diagnoses: An example, “an overweight client with
spinal cord injury is at risk for impaired skin integrity”. For this
diagnosis to be made, data to support client’s vulnerability is
needed. Such data may include physiological, psychosocial,
familial, and lifestyle factors that increase the client’s
vulnerability to develop the condition
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• The diagnostic process is composed of:
–
–
–
–
Data validation and clustering (described earlier)
Analysis and interpretation of data
Identification of client needs
Formulation of nursing diagnoses
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Analysis And Interpretation of Data
• Consider that a health problem, such as stomach cancer, does not
automatically indicate a certain nursing diagnosis exists. Data
analysis must be performed to formulate the client’s response.
Steps of Data Analysis
1.
2.
3.
Recognise pattern (cluster of defining characteristics).
20-lb weight loss
Poor appetite
Weakness
Previous falls
Compare with normal standards.
No weight loss
Adequate nutritional intake
No falls
Make a reasoned conclusion
Inadequate nutritional intake
Mobility and stability problems
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• Individual signs or symptoms cannot support a diagnostic
label. However, when multiple signs or symptoms are
clustered together as a group, one can think about the
relationship between and among these findings.
• For example, gray hair does not necessarily indicate that a
person is an older adult. However, clustering together gray
hair, wrinkled skin, and age spots increases the probability that
the person is an old adult.
• Defining characteristics are not within healthy norms and form
the basis for problem identification.
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Identification of Client Needs
• To individualise nursing diagnoses, a client’s needs should be
identified. This is accomplished by considering all assessment
data and focusing on the more relevant data.
• The identification phase is composed of the general health care
need, then formulating the nursing diagnosis by recognising
the specific health care need. An example is problems with
elimination and the specific problem of constipation.
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Formulation of Nursing Diagnoses
• The nursing diagnosis is stated in a two-part format: the
diagnostic label followed by a statement of a related factor.
• The related factors are etiological or contributing conditions
that have influenced the client’s response to the health
problem.
• The aetiology of the nursing diagnosis must be within the
domain of nursing practice and a condition that responds to
nursing interventions. A medical diagnosis cannot be recorded
as the aetiology of a nursing diagnosis.
• For example, acute pain related to breast cancer is incorrect.
However, acute pain related to impaired skin integrity
secondary to mastectomy incision results is nursing
interventions to reduce stress on the suture line and improving
client’s comfort.
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Avoiding Common Errors in Nursing Diagnostic
Statements
• Nursing diagnoses are easy to write! However, you need to
remember that:
– The problem portion of the statement is the client’s response to
illness.
• Avoidance of most common errors in writing nursing
diagnoses is possible through:
– Identifying the client’s response not the medical diagnosis
– Identifying the NANDA diagnostic statement rather than a
symptom which is not sufficient for problem identification. For
example, SOB, pain on inspiration, and productive cough should
be written as ineffective breathing pattern R/T increased airway
secretions.
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– Identifying a treatable aetiology rather than a clinical sign or
chronic problem
– Identifying a problem caused by the treatment or diagnostic
study rather than the treatment or study itself. For example, say
anxiety r/t lack of knowledge about cardiac catheterisation but
NOT anxiety r/t cardiac catheterisation.
– Identifying a client’s problem rather than the nursing
intervention. For example, say diarrhoea r/t food intolerance but
not offer bedpan frequently because of altered elimination
pattern
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– Identifying a client’s problem rather than the goal. For example,
say imbalanced nutrition: less than body requirements r/t
inadequate protein intake, but not client needs high protein diet
related to potential alteration in nutrition.
– Avoiding legally inadvisable statements. You can say chronic
pain r/t improper use of medication, but not recurrent angina
related to insufficient medication.
– Identifying only one problem in the diagnostic statement.
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Planning
• In this phase, client-centred goals and interventions to achieve
them are designed.
• Planning requires decision-making and problem-solving skills
to design nursing care.
• In this phase, the nurse should:
– establish priorities
– determine goals and expected outcomes
– formulate a plan of nursing care
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Establishing Priorities
• Means mutually ranking nursing diagnoses in order of
importance based on the client’s safety, desires, and needs.
• Priorities are classified as:
– High: If untreated, harm could result, or progress to achieve
outcomes will be deterred. They can be both psychological and
physiological.
– Intermediate: Non-emergent, non-life-threatening needs
– Low: May not be directly related to a specific illness or
prognosis but may affect the client’s future well-being.
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Priority Setting
Nursing Diagnosis
High Priority
Rationale
Ineffective coping r/t anxiety about
unknown medical diagnosis
Prompt intervention will help client
prepare for and cope with a
diagnostic test, treatment, or Dx.
Due to the risk of postop. surgery
pulmonary complications,
preventive pt. education will begin
early.
Ineffective airway clearance after
r/ t abdominal incision pain
Intermediate Priority
Imbalanced nutrition: less than body
requirements r/ t chronic diarrhea
This nursing diagnosis does not
affect the client’s immediate physiological or emotional status.
Low Priority
Deficient knowledge regarding
smoking cessation programmes
This diagnosis reflects client’s
long-term needs.
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Goals and Expected Outcomes
• Refer to specific statements of client behaviour or responses a
nurse aims to achieve as a result of nursing care.
• Are formulated after establishing priorities.
• A goal is specific and measureable behaviour or response that
reflects the client’s highest possible level of wellness and
independence in function.
• An expected outcome is the measureable, specific, step-bystep objective that leads to attainment of the goal and the
resolution of the aetiology for the nursing diagnosis.
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Formulating a Plan of Nursing Care
• This means selecting appropriate nursing interventions.
• This selection is a decision-making process; interventions
should successfully meet the established goals and expected
outcomes.
• Interventions selection requires the nurse to have knowledge
of the scientific rationale for the intervention, to possess
psychomotor and interpersonal skills, and to be able to
function within a particular setting and use available resources.
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Nursing Care Plan
• Is composed of nursing diagnostic statement, goals, expected
outcomes, and specific nursing activities and interventions.
• Coordinates nursing care, promotes continuity of care, and
lists outcome criteria to be used in the evaluation of nursing
care.
• Decreases the risk of incomplete, incorrect, or inaccurate care.
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Implementation
• Refers to the initiation and completion of nursing actions
necessary for achieving the goals and expected outcomes of
nursing care.
• Implementation includes interventions for performing,
assisting, or directing the performance of ADL; counselling
and teaching; providing direct care; delegating, supervising,
and evaluating the work of other nurses; and recording and
exchanging information relevant to client care.
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Implementation Skills
• Cognitive skills: involve application of nursing knowledge.
• Interpersonal skills: these are essential for nursing practice.
They are built on trusting relationship and clear
communication.
• Psychomotor skills: require the integration of cognitive and
motor activities, such as learning to give an injection. In this
regard, the nurse must understand anatomy and pharmacology
(cognitive) and the mechanics of preparing and giving an
injection (motor).
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Types of Nursing Interventions
Category of
intervention
ADL
Counselling
Teaching
Nursing diagnoses
Impaired physical mobility
Confusion, acute & chronic
Fatigue
Self-care deficit
Anxiety
Coping
Fear
Grieving
Ineffective health maintenance
Health seeking behaviours
Noncompliance
Specific examples
Assistance with feeding,
hygiene, ambulation, and
elimination
Short-term and long-term
crises intervention, referral
to other professionals
Specific education programmes for disease management and behaviour
change
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Evaluation
• Is concerned with two aspects of nursing care:
– Evaluate the client’s response to nursing care. Questions to
consider are: “Was the intervention effective in improving the
client’s level of health or functional status?”, “Did the client
benefit?”.
– Evaluate if the client’s expectations of care were met. Questions
to ask include: “Did you receive the type of pain management
you expected?”, “Did you get enough information to help you
manage your asthma at home?”.
• Could be positive when the desired results are met, indicating
that the nursing intervention effectively met the client’s goal of
improved comfort.
• Could be negative indicating that the intervention was not
effective was not effective in minimising or resolving the
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actual problem or avoiding a potential problem.