Nursing Process

Overview

Since the time of Florence Nightingale, the continuity of nursing care has been indispensible and, as of
the 1950’s, the care plan has been considered the ideal solution for the care of critically ill patients.1
Nursing, realizing the need to develop a working method that would make its practice more visible,
legitimate and autonomous, sought its identity by developing its own body of knowledge.2-3 The
“Nursing Process” then emerged, which was used for the first time in 1961 by Orlando.1 The Nursing
Process (NP) at that time consisted of three basic elements: the client’s behavior, the nurse’s reaction,
and the nursing actions. Care was planned based on these components and was then carried out in
phases.1 In 1985, the World Health Organization officially proposed its four-phase operationalization:
Assessment, Planning, Implementation and Evaluation.4 Thus the NP began to be used as a method to
improve the quality of nursing care, allowing nurses to systemize their actions and delegate tasks to the
nursing team clearly and efficiently, centered on the real needs of their clients. Using the nursing process
promotes flective practice and the development of critical thinking. Simultaneously, possessing critical thinking abilities is
necessary to apply the nursing process with methodological rigor and improve problem-solving in professional practice
(González & Chaves, 2009). Furthermore, the use of standardized nursing languages helps nurses understand patients’ needs with
precision and speed. It also helps accurately name the problems of the patients through nursing diagnoses and facilitate the
continuity of care between professionals by using a common language. In addition, the accurate use of nursing diagnoses
facilitates the selection of more effective nursing interventions that lead to better outcomes.

Purpose of Nursing process

The following are the purposes of the nursing process:

 To identify the client’s health status and actual or potential health care
problems or needs (through assessment).
 To establish plans to meet the identified needs.
 To deliver specific nursing interventions to meet those needs.
 To apply the best available caregiving evidence and promote human
functions and responses to health and illness (ANA, 2010).
 To protect nurses against legal problems related to nursing care when the
standards of the nursing process are followed correctly.
  To help the nurse perform in a systematically organized way their practice.
 To establish a database about the client’s health status, health concerns,
response to illness, and the ability to manage health care needs.

The Nursing Process

The common thread uniting different types of nurses who work in varied areas is the nursing
process—the essential core of practice for the registered nurse to deliver holistic, patient-
focused care.

Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first
step in delivering nursing care. Assessment includes not only physiological data, but also
psychological, sociocultural, spiritual, economic, and life-style factors as well. For example,
a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes
and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal
to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for
more pain mediation.

Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual
or potential health conditions or needs. The diagnosis reflects not only that the patient is in
pain, but that the pain has caused other problems such as anxiety, poor nutrition, and
conflict within the family, or has the potential to cause complications—for example,
respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the
basis for the nurse’s care plan.

Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short-
and long-range goals for this patient that might include moving from bed to chair at least
three times per day; maintaining adequate nutrition by eating smaller, more frequent meals;
resolving conflict through counseling, or managing pain through adequate medication.
Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses
as well as other health professionals caring for the patient have access to it.

Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient
during hospitalization and in preparation for discharge needs to be assured. Care is
documented in the patient’s record.
Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously
evaluated, and the care plan modified as needed

References:

- https://nurseslabs.com/nursing-process/

In 1958, Ida Jean Orlando began developing the nursing process still evident in

nursing care today. According to Orlando’s theory, the patient’s behavior sets the
nursing process in motion. Through the nurse’s knowledge to analyze and
diagnose the behavior to determine the patient’s needs.

Application of the fundamental principles of critical thinking, client-centered

approaches to treatment, goal-oriented tasks, evidence-based practice (EBP)
recommendations, and nursing intuition, the nursing process functions as a
systematic guide to client-centered care with five subsequent steps. These are
assessment, diagnosis, planning, implementation, and evaluation (ADPIE).

The nursing process is defined as a systematic, rational method of planning that

guides all nursing actions in delivering holistic and patient-focused care. The
nursing process is a form of scientific reasoning and requires the nurse’s critical
thinking to provide the best care possible to the client.

What is the purpose of the nursing

process? 
The following are the purposes of the nursing process:
  To identify the client’s health status and actual or potential health care
problems or needs (through assessment).
 To establish plans to meet the identified needs.
 To deliver specific nursing interventions to meet those needs.
 To apply the best available caregiving evidence and promote human
functions and responses to health and illness (ANA, 2010).
 To protect nurses against legal problems related to nursing care when the
standards of the nursing process are followed correctly.
 To help the nurse perform in a systematically organized way their practice.
 To establish a database about the client’s health status, health concerns,
response to illness, and the ability to manage health care needs.

Characteristics of the nursing process

The following are the unique characteristics of the nursing process: 

 Patient-centered. The unique approach of the nursing process requires

care respectful of and responsive to the individual patient’s needs,
preferences, and values. The nurse functions as a patient advocate by
keeping the patient’s right to practice informed decision-making and
maintaining patient-centered engagement in the health care setting.
 Interpersonal. The nursing process provides the basis for the therapeutic
process in which the nurse and patient respect each other as individuals,
both of them learning and growing due to the interaction. It involves the
interaction between the nurse and the patient with a common goal.
 Collaborative. The nursing process functions effectively in nursing and
inter-professional teams, promoting open communication, mutual respect,
and shared decision-making to achieve quality patient care.
 Dynamic and cyclical.The nursing process is a dynamic, cyclical process in
which each phase interacts with and is influenced by the other phases.
 Requires critical thinking. The use of the nursing process requires critical
thinking which is a vital skill required for nurses in identifying client
problems and implementing interventions to promote effective care
outcomes.

Nursing Process Steps

The nursing process consists of five steps: assessment, diagnosis, planning,
implementation, and evaluation. The acronym ADPIE is an easy way to
remember the components of the nursing process. Nurses need to learn how to
apply the process step-by-step. However, as critical thinking develops through
experience, they learn how to move back and forth among the steps of the
nursing process.

The steps of the nursing process are not separate entities but overlapping,
continuing subprocesses. Apart from understanding nursing diagnoses and their
definitions, the nurse promotes awareness of defining characteristics and
behaviors of the diagnoses, related factors to the selected nursing diagnoses, and
the interventions suited for treating the diagnoses.

The steps of the nursing process are detailed below:

1. Assessment: “What data is
collected?”
The first phase of the nursing process is assessment. It involves collecting,
organizing, validating, and documenting the clients’ health status. This data can
be obtained in a variety of ways. Usually, when the nurse first encounters a
patient, the nurse is expected to assess to identify the patient’s health problems
as well as the physiological, psychological, and emotional state and to establish a
database about the client’s response to health concerns or illness and the ability
to manage health care needs. Critical thinking skills are essential to the
assessment, thus requiring concept-based curriculum changes.

Collecting Data
Data collection is the process of gathering information regarding a client’s health
status. The process must be systematic and continuous in collecting data to
prevent the omission of important information concerning the client.

Types of Data
Data collected about a client generally falls into objective or subjective
categories, but data can also be verbal and nonverbal. 

Objective Data or Signs

Objective data are overt, measurable, tangible data collected via the senses, such
as sight, touch, smell, or hearing, and compared to an accepted standard, such as
vital signs, intake and output, height and weight, body temperature, pulse, and
respiratory rates, blood pressure, vomiting, distended abdomen, presence of
edema, lung sounds, crying, skin color, and presence of diaphoresis.

Subjective Data or Symptoms

Subjective data involve covert information, such as feelings, perceptions,
thoughts, sensations, or concerns that are shared by the patient and can be
verified only by the patient, such as nausea, pain, numbness, pruritus, attitudes,
beliefs, values, and perceptions of the health concern and life events.

Verbal Data
Verbal data are spoken or written data such as statements made by the client or
by a secondary source. Verbal data requires the listening skills of the nurse to
assess difficulties such as slurring, tone of voice, assertiveness, anxiety, difficulty
in finding the desired word, and flight of ideas.

Nonverbal Data
Nonverbal data are observable behavior transmitting a message without words,
such as the patient’s body language, general appearance, facial expressions,
gestures, eye contact, proxemics (distance), body language, touch, posture,
clothing. Nonverbal data obtained can sometimes be more powerful than verbal
data, as the client’s body language may not be congruent with what they really
think or feel. Obtaining and analyzing nonverbal data can help reinforce other
forms of data and understand what the patient really feels.
Sources of Data
Sources of data can be primary, secondary, and tertiary. The client is the
primary source of data, while family members, support persons, records and
reports, other health professionals, laboratory and diagnostics fall under
secondary sources.

Primary Source
The client is the only primary source of data and the only one who can provide
subjective data. Anything the client says or reports to the members of the
healthcare team is considered primary.

Secondary Source
A source is considered secondary data if it is provided from someone else other
than the client but within the client’s frame of reference. Information provided by
the client’s family or significant others are considered secondary sources of data
if the client cannot speak for themselves, is lacking facts and understanding, or is
a child. Additionally, the client’s records and assessment data from other nurses
or other members of the healthcare team are considered secondary sources of
data.

Tertiary Source
Sources from outside the client’s frame of reference are considered tertiary
sources of data. Examples of tertiary data include information from textbooks,
medical and nursing journals, drug handbooks, surveys, and policy and
procedural manuals.

Methods of Data Collection

The main methods used to collect data are health interviews, physical
examination, and observation.
Health Interview
The most common approach to gathering important information is through an
interview. An interview is an intended communication or a conversation with a
purpose, for example, to obtain or provide information, identify problems of
mutual concern, evaluate change, teach, provide support, or provide counseling
or therapy. One example of the interview is the nursing health history, which is a
part of the nursing admission assessment. Patient interaction is generally the
heaviest during the assessment phase of the nursing process so rapport must be
established during this step.

Physical Examination
Aside from conducting interviews, nurses will perform physical examinations,
referencing a patient’s health history, obtaining a patient’s family history, and
general observation can also be used to gather assessment data. Establishing a
good physical assessment would, later on, provide a more accurate diagnosis,
planning, and better interventions and evaluation.

Observation
Observation is an assessment tool that depends on the use of the five senses
(sight, touch, hearing, smell, and taste) to learn information about the client. This
information relates to characteristics of the client’s appearance, functioning,
primary relationships, and environment. Although nurses observe mainly through
sight, most of the senses are engaged during careful observations such as
smelling foul odors, hearing or auscultating lung and heart sounds and feeling
the pulse rate and other palpable skin deformations.

Validating Data
Validation is the process of verifying the data to ensure that it is accurate and
factual. One way to validate observations is through “double-checking,” and it
allows the nurse to complete the following tasks:
 1. Ensures that assessment information is double-checked, verified, and
complete.
For example, during routine assessment, the nurse obtains a reading of
210/96 mm Hg of a client with no history of hypertension. To validate the
data, the nurse should retake the blood pressure and if necessary, use
another equipment to confirm the measurement or ask someone else to
perform the assessment.
2. Ensure that objective and related subjective data are valid and
accurate.
For example, the client’s perceptions of “feeling hot” need to be compared
with the measurement of the body temperature.
3. Ensure that the nurse does not come to a conclusion without adequate
data to support the conclusion.
A nurse assumes tiny purple or bluish-black swollen areas under the
tongue of an older adult client to be abnormal until reading about physical
changes of aging.
4. Ensure that any ambiguous or vague statements are clarified.
For example, a 86-year-old female client who is not a native English
speaker says that “I am in pain on and off for 4 weeks,” would require
verification for clarity from the nurse by asking “Can you describe what
your pain is like? What do you mean by on and off?”
5. Acquire additional details that may have been overlooked.
For example, the nurse is asking a 32-year-old client if he is allergic to any
prescription or non-prescription medications. And what would happen if he
takes these medications.
6. Distinguish between cues and inferences.
Cues are subjective or objective data that can be directly observed by the
nurse; that is, what the client says or what the nurse can see, hear, feel,
smell, or measure. On the other hand, inferences are the nurse’s
interpretation or conclusions made based on the cues. For example, the
nurse observes the cues that the incision is red, hot, and swollen and
makes an inference that the incision is infected.

Documenting Data
Once all the information has been collected, data can be recorded and sorted.
Excellent record-keeping is fundamental so that all the data gathered is
documented and explained in a way that is accessible to the whole health care
team and can be referenced during evaluation. 

2. Diagnosis: “What is the problem?” 

The second step of the nursing process is the nursing diagnosis. The nurse will
analyze all the gathered information and diagnose the client’s condition and
needs. Diagnosing involves analyzing data, identifying health problems, risks, and
strengths, and formulating diagnostic statements about a patient’s potential or
actual health problem. More than one diagnosis is sometimes made for a single
patient. Formulating a nursing diagnosis by employing clinical judgment assists in
the planning and implementation of patient care.

The types, components, processes, examples, and writing nursing diagnosis are
discussed more in detail here “Nursing Diagnosis Guide: All You Need To
Know To Master Diagnosing”

3. Planning: “How to manage the

problem?”
Planning is the third step of the nursing process. It provides direction for nursing
interventions. When the nurse, any supervising medical staff, and the patient
agree on the diagnosis, the nurse will plan a course of treatment that takes into
account short and long-term goals. Each problem is committed to a clear,
measurable goal for the expected beneficial outcome. 

The planning phase is where goals and outcomes are formulated that directly
impact patient care based on evidence-based practice (EBP) guidelines. These
patient-specific goals and the attainment of such assist in ensuring a positive
outcome. Nursing care plans are essential in this phase of goal setting. Care plans
provide a course of direction for personalized care tailored to an individual’s
unique needs. Overall condition and comorbid conditions play a role in the
construction of a care plan. Care plans enhance communication, documentation,
reimbursement, and continuity of care across the healthcare continuum.
Types of Planning
Planning starts with the first client contact and resumes until the nurse-client
relationship ends, preferably when the client is discharged from the health care
facility.

Initial Planning
Initial planning is done by the nurse who conducts the admission assessment.
Usually, the same nurse would be the one to create the initial comprehensive
plan of care.

Ongoing Planning
Ongoing planning is done by all the nurses who work with the client. As a nurse
obtain new information and evaluate the client’s responses to care, they can
individualize the initial care plan further. An ongoing care plan also occurs at the
beginning of a shift. Ongoing planning allows the nurse to:

 determine if the client’s health status has changed

 set priorities for the client during the shift
 decide which problem to focus on during the shift
 coordinate with nurses to ensure that more than one problem can be
addressed at each client contact
Discharge Planning
Discharge planning is the process of anticipating and planning for needs after
discharge. To provide continuity of care, nurses need to accomplish the following:

 Start discharge planning for all clients when they are admitted to any
health care setting.
 Involve the client and the client’s family or support persons in the planning
process.
 Collaborate with other health care professionals as needed to ensure that
biopsychosocial, cultural, and spiritual needs are met.
Developing a Nursing Care Plan
A nursing care plan (NCP) is a formal process that correctly identifies existing
needs and recognizes potential needs or risks. Care plans provide communication
among nurses, their patients, and other healthcare providers to achieve health
care outcomes. Without the nursing care planning process, the quality and
consistency of patient care would be lost.

4. Implementation: “Putting the plan

into action!”
The implementation phase of the nursing process is when the nurse puts the
treatment plan into effect. It involves action or doing and the actual carrying out
of nursing interventions outlined in the plan of care. This typically begins with the
medical staff conducting any needed medical interventions. 

Interventions should be specific to each patient and focus on achievable

outcomes. Actions associated with a nursing care plan include monitoring the
patient for signs of change or improvement, directly caring for the patient or
conducting important medical tasks such as medication administration, educating
and guiding the patient about further health management, and referring or
contacting the patient for a follow-up.

A taxonomy of nursing interventions referred to as the Nursing Interventions

Classification (NIC) taxonomy, was developed by the Iowa Intervention Project,
in addition to the efforts of NANDA-I to standardize the language for describing
problems. The nurse can look up a client’s nursing diagnosis to see which nursing
interventions are recommended. 

Nursing Interventions Classification (NIC)

System
There are more than 550 nursing intervention labels that nurses can use to
provide the proper care to their patients. These interventions are categorized into
seven fields or classes of interventions according to the Nursing Interventions
Classification system.

Behavioral Nursing Interventions

These are interventions designed to help a patient change their behavior. With
behavioral interventions, in contrast, patient behavior is the key and the goal is to
modify it. The following measures are examples of behavioral nursing
interventions:

 Encouraging stress and relaxation techniques

 Providing support to quit smoking
 Engaging the patient in some form of physical activity, like walking, to
reduce the patient’s anxiety, anger, and hostility
Community Nursing Interventions
These are interventions that refer to the community-wide approach to health
behavior change. Instead of focusing mainly on the individual as a change agent,
community interventionists recognize a host of other factors that contribute to an
individual’s capacity to achieve optimal health, such as:

 Implementing an education program for first-time mothers

 Promoting diet and physical activities
 Initiating HIV awareness and violence-prevention programs
 Organizing a fun run to raise money for breast cancer research 
Family Nursing Interventions
These are interventions that influence a patient’s entire family.

 Implementing a family-centered approach in reducing the threat of illness

spreading when one family member is diagnosed with a communicable
disease
 Providing a nursing woman support in breastfeeding her new baby
 Educating family members about caring for the patient
Health System Nursing Interventions
These are interventions that designed to maintain a safe medical facility for all
patients and staff, such as:

 Following procedures to reduce the risk of infection for patients during

hospital stays.
 Ensuring that the patient’s environment is safe and comfortable, such as
repositioning them to avoid pressure ulcers in bed
Physiological Nursing Interventions
These are interventions related to a patient’s physical health to make sure that
any physical needs are being met and that the patient is in a healthy condition.
These nursing interventions are classified into two types: basic and complex.

 Basic. Basic interventions regarding the patient’s physical health include

hands-on procedures ranging from feeding to hygiene assistance.
 Complex. Some physiological nursing interventions are more complex,
such as the insertion of an IV line to administer fluids to a dehydrated
patient.
Safety Nursing Interventions
These are interventions that maintain a patient’s safety and prevent injuries, such
as:

 Educating a patient about how to call for assistance if they are not able to
safely move around on their own
 Providing instructions for using assistive devices such as walkers or canes,
or how to take a shower safely.

Skills Used in Implementing Nursing Care

When implementing care, nurses need cognitive, interpersonal, and technical
skills to perform the care plan successfully.
  Cognitive Skills are also known as Intellectual Skills are skills involve
learning and understanding fundamental knowledge including basic
sciences, nursing procedures, and their underlying rationale before caring
for clients. Cognitive skills also include problem-solving, decision-making,
critical thinking, clinical reasoning, and creativity.
 Interpersonal Skills are skills that involve believing, behaving, and relating
to others. The effectiveness of a nursing action usually leans mainly on the
nurse’s ability to communicate with the patient and the members of the
health care team.
 Technical Skills are purposeful “hands-on” skills such as changing a sterile
dressing, administering an injection, manipulating equipment, bandaging,
moving, lifting, and repositioning clients. All of these activities require safe
and competent performance.

Process of Implementing
The process of implementing typically includes the following:

1. Reassessing the client

Prior to implementing an intervention, the nurse must reassess the client to make
sure the intervention is still needed. Even if an order is written on the care plan,
the client’s condition may have changed.

2. Determining the nurse’s need for assistance

Other nursing tasks or activities may also be performed by non-RN members of
the healthcare team. Members of this team may include unlicensed assistive
personnel (UAP) and caregivers, as well as other licensed healthcare workers,
such as licensed practical nurses/licensed vocational nurses (LPNs/LVNs). The
nurse may need assistance when implementing some nursing intervention, such
as ambulating an unsteady obese client, repositioning a client, or when a nurse is
not familiar with a particular model of traction equipment needs assistance the
first time it is applied.

3. Implementing the nursing interventions

Nurses must not only have a substantial knowledge base of the sciences, nursing
theory, nursing practice, and legal parameters of nursing interventions but also
must have the psychomotor skills to implement procedures safely. It is necessary
for nurses to describe, explain, and clarify to the client what interventions will be
done, what sensations to anticipate, what the client is expected to do, and what
the expected outcome is. When implementing care, nurses perform activities that
may be independent, dependent, or interdependent.

Nursing Intervention Categories

Nursing interventions are grouped into three categories according to the role of
the healthcare professional involved in the patient’s care:

Independent Nursing Interventions

A registered nurse can perform independent interventions on their own without

the help or assistance from other medical personnel, such as: 

 routine nursing tasks such as checking vital signs

 educating a patient on the importance of their medication so they can
administer it as prescribed
Dependent Nursing Interventions

A nurse cannot initiate dependent interventions alone. Some actions require

guidance or supervision from a physician or other medical professional, such as:

 prescribing new medication

 inserting and removing a urinary catheter
 providing diet
 Implementing wound or bladder irrigations
Interdependent Nursing Interventions

A nurse performs as part of collaborative or interdependent interventions that

involve team members across disciplines.
  In some cases, such as post-surgery, the patient’s recovery plan may
require prescription medication from a physician, feeding assistance from a
nurse, and treatment by a physical therapist or occupational therapist.
 The physician may prescribe a specific diet to a patient. The nurse includes
diet counseling in the patient care plan. To aid the patient, even more, the
nurse enlists the help of the dietician that is available in the facility.
4. Supervising the delegated care
Delegate specific nursing interventions to other members of the nursing team as
appropriate. Consider the capabilities and limitations of the members of the
nursing team and supervise the performance of the nursing
interventions. Deciding whether delegation is indicated is another activity that
arises during the nursing process.

The American Nurses Association and the National Council of State Boards of
Nursing (2006) define delegation as “the process for a nurse to direct another
person to perform nursing tasks and activities.” It generally concerns the
appointment of the performance of activities or tasks associated with patient care
to unlicensed assistive personnel while retaining accountability for the outcome.

Nevertheless, registered nurses cannot delegate responsibilities related to

making nursing judgments. Examples of nursing activities that cannot be
delegated to unlicensed assistive personnel include assessment and evaluation of
the impact of interventions on care provided to the patient.

5. Documenting nursing activities

Record what has been done as well as the patient’s responses to nursing
interventions precisely and concisely.

5. Evaluation: “Did the plan work?”

Evaluating is the fifth step of the nursing process. This final phase of the nursing
process is vital to a positive patient outcome. Once all nursing intervention
actions have taken place, the team now learns what works and what doesn’t by
evaluating what was done beforehand. Whenever a healthcare provider
intervenes or implements care, they must reassess or evaluate to ensure the
desired outcome has been met. The possible patient outcomes are generally
explained under three terms: the patient’s condition improved, the patient’s
condition stabilized, and the patient’s condition worsened.

Steps in Evaluation
Nursing evaluation includes (1) collecting data, (2) comparing collected data with
desired outcomes, (3) analyzing client’s response relating to nursing activities, (4)
identifying factors that contributed to the success or failure of the care plan, (5)
continuing, modifying, or terminating the nursing care plan, and (6) planning for
future nursing care.

1. Collecting Data
The nurse recollects data so that conclusions can be drawn about whether goals
have been fulfilled. It is usually vital to collect both objective and subjective data.
Data must be documented concisely and accurately to facilitate the next part of
the evaluating process.

2. Comparing Data with Desired Outcomes

The documented goals and objectives of the nursing care plan become the
standards or criteria by which to measure the client’s progress whether the
desired outcome has been met, partially met, or not met.

 The goal was met, when the client response is the same as the desired
outcome.
 The goal was partially met, when either a short-term outcome was
achieved but the long-term goal was not, or the desired goal was
incompletely attained.
 The goal was not met.
3. Analyzing Client’s Response Relating to Nursing
Activities
It is also very important to determine whether the nursing activities had any
relation to the outcomes whether it was successfully accomplished or not.

4. Identifying Factors Contributing to Success or

Failure
It is required to collect more data to confirm if the plan was successful or a
failure. Different factors may contribute to the achievement of goals. For example,
the client’s family may or may not be supportive, or the client may be
uncooperative to perform such activities. 

5. Continuing, Modifying, or Terminating the Nursing

Care Plan
The nursing process is dynamic and cyclical. If goals were not sufficed, the
nursing process begins again from the first step. Reassessment and modification
may continually be needed to keep them current and relevant depending upon
general patient condition. The plan of care may be adjusted based on new
assessment data. Problems may arise or change accordingly. As clients complete
their goals, new goals are set. If goals remain unmet, nurses must evaluate the
reasons these goals are not being achieved and recommend revisions to the
nursing care plan.

6. Discharge Planning
Discharge planning is the process of transitioning a patient from one level of care
to the next. Discharge plans are individualized instructions provided as the client
is prepared for continued care outside the healthcare facility or for independent
living at home. The main purpose of a discharge plan is to improve the client’s
quality of life by ensuring continuity of care together with the client’s family or
other healthcare workers providing continuing care.

The following are the key elements of IDEAL discharge planning according
to the Agency for Healthcare Research and Quality:
  Include the patient and family as full partners in the discharge planning
process.
 Discuss with the patient and family five key areas to prevent problems at
home:
 Describe what life at home will be like
 Review medications
 Highlight warning signs and problems
 Explain test results
 Schedule follow-up appointments
 Educate the patient and family in plain language about the patient’s
condition, the discharge process, and next steps throughout the hospital
stay.
 Assess how well doctors and nurses explain the diagnosis, condition, and
next steps in the patient’s care to the patient and family and use teach
back.
 Listen to and honor the patient’s and family’s goals, preferences,
observations, and concerns. 
A discharge plan includes specific components of client teaching with
documentation such as:

 Equipment needed at home. Coordinate home-based care and special

equipment needed.
 Dietary needs or special diet. Discuss what the patient can or cannot eat
at home.
 Medications to be taken at home. List the patient’s medications and
discuss the purpose of each medicine, how much to take, how to take it,
and potential side effects.
 Resources such as contact numbers and addresses of important
people. Write down the name and contact information of someone to call
if there is a problem.
 Emergency response: Danger signs. Identify and educate patients and
families about warning signs or potential problems.
 Home care activities. Educate patient on what activities to do or avoid at
home.
 Summary. Discuss with the patient and family about the patient’s
condition, the discharge process, and follow-up checkups.
Assessment
This is the first stage of the nursing process. It involves the collection of information
from the patient and their family/carers concerning their condition and perceived
problems. Hamilton and Price (2013) state that this is the cornerstone in establishing
the needs of the patient and if done well, the nursing process will be a success.
Information can be collected in a number of ways and the support worker will take an
active part in this. Good communication, both verbal and non-verbal, together with
observational skills are key.
Information gathered can be either subjective or objective, and primary or secondary
(Kozier et al, 2008). Subjective is information that the patient tells you, how they are
feeling, levels and sensation of pain. This is open to interpretation, however you
must always accept what the patient is telling you. Objective information is that which
can be measured such as blood pressure or weight. Primary information is that
which is gained from the patient themselves whereas secondary data is information
from other sources, such as family members.
Even before the nurse or support worker has seen the patient there will often be
existing notes to read or a handover to receive. This initial information will help to
guide the first stages and should give the nurse a starting point on how to approach
the patient. Identifying any communication needs and recognising if any special
adjustments need to be made. Of course in certain situations this is not always
possible, where a patient is admitted urgently to the accident and emergency
department and care must commence immediately, an initial short term assessment
will be made (Hamilton and Price, 2013).
The next part of the assessment takes place even before any words are spoken. As
you approach the patient you will be observing them and looking for any outward
signs, both positive and negative. This can be done very quickly on first seeing the
patient. Do they look in pain, do they appear to be pale or clammy? Are they
conscious and sitting up, or appear unconscious?
An assessment of the patient’s airway, breathing and circulation needs to be
performed immediately. Once these three areas have been assessed as being
stable, then the more formal assessment can take place. Observations are taken to
gain a baseline and again to identify anything abnormal which may need urgent
intervention. Pulse, respirations, blood pressure, oxygen saturations, capillary refill
time and anything else which is relevant to the patients presenting problems. These
are all recorded to be repeated and compared.
General information is gathered together with a thorough health history (Kozier et al,
2008). This includes exactly how the patient is presenting at this moment in time.
What symptoms are they describing to you? Other important questions are asked
such as is the patient allergic to anything. Models of nursing care will be used as a
tool to guide this process. These will already be established within the working
environment and form a basis for the documentation used.
The focus of the assessment is the patient and how they are experiencing their
illness and ill health. Once all the information has been collected it can be
documented and sorted (Melin-Johansson et al, 2017). Excellent record keeping is
key, so that all the information gathered is recorded and presented in a way that is
accessible to the whole multidisciplinary team.
Nursing Diagnosis
This is an extra stage to the original four and is more wide spread and common in
North America. Here the information gained from the assessment is used to identify
actual and potential problems, as well as strengths (Yildirim and Ozkahraman,
2011). Strengths might be self-caring abilities or independence in certain areas. Or
prior knowledge or experience of the illness. Actual problems are those that come
directly out of the assessment, for example pain from a fracture. Potential problems
are those that could arise from out of the problem, for example the risk of developing
a pressure sore if confined to bed (Hogston, 2011). However Peate (2013) has a
word of warning that the person making the diagnosis must have gained the
sufficient expertise and experience to do so, otherwise this could be potentially
dangerous.
PlanningThe planning stage is where interventions are identified to reduce, resolve or
prevent
the patient’s problems while supporting the patient’s strengths in an organised goal
directed way (Kozier et al, 2008). Care needs to be prioritised on the needs of the
patient and the seriousness of the problems identified. Hogston (2011) identifies two
steps in the planning stage, setting goals and identifying actions. Goals need to be
set, both short term and long term. SMART goals should be identified which are
Specific, Measurable, Achievable, Realistic and Timely (Hamilton and Price, 2013).
These are all done in collaboration with the patient.
In action planning the actual care that is going to be implemented needs to be clearly
stated. Hogston (2011) advises using the REEPIG criteria to ensure that care is of
the highest standards. Firstly, that the care planned is Realistic given available
resources. Secondly, that the care planned is Explicitly stated. Be clear in exactly
what needs to be done so there is no room for misinterpretation of instructions.
Thirdly, Evidence based. That there is research that supports what is being
proposed. Fourthly, that the care being planned is Prioritised. The most urgent
problems being dealt with first. Fifth, is to Involve both the patient and other
members of the multidisciplinary team who are going to be involved in implementing
the care. And lastly, Goal centred, that the care planned will meet and achieve the
goal set.
Implementation
This is where the care is delivered and more than likely it will be the support worker
who will be delivering the majority of the basic and increasingly, more advanced
care. Especially when the patient is in their own home or a community setting.
Implementation of the care occurs throughout the twenty four hour period. As each
new member of the caring team comes on duty they need to re-assess if the care
being delivered is still appropriate. Has anything new developed to change the plan
of care. How is the patient responding to the care delivered? On-going assessment
of the patient is vital and again this is where good record keeping is important
(Alfaro-LeFevre, 2010).
Evaluation
The most important part of the nursing process after the assessment is done is
evaluating has the care achieved the desired result. This should not just occur at the
end of a course of treatment or care, but should occur constantly as care is being
implimented. Evaluation at the end of a course of treatment involves reassessment
of all the plan of care to determine if the expected outcomes have been achieved
(Yildirim and Ozkahraman, 2011). Hogston (2011:16) also states that evaluation is
an “opportunity to review the entire process and determine whether the assessment
was accurate and complete, the diagnosis correct, the goals realistic and achievable,
and the prescribed actions appropriate.” With evaluation the whole process starts
again.
The Nursing Process Deliberative nursing process is a term that Orlando uses
for process where there is ongoing validation of nurse’s actions together
with the patient. Basically that process consists of four steps that are:
patient action, nurse reaction, nurse-patient validation and nurse action.
(Schmieding, 2006, 439) Automatic nursing process term describes a process
where the nurse’s response to the need of help is done according only to the
perceptions of the nurse, leaving the role of the patient quite passive in his
own care. Automatic nursing process actions are not necessarily wrong or
inappropriate but a nurse using the deliberative nursing process in co-
operation with a patient is more likely to reach positive outcomes, since the
nurse is checking with the patient if the nurse’s own views and feelings are
correct ones when it comes to patient’s behavior, and whether the nurse’s
actions where suitable and relieving in that certain situation. But while
using the automatic nursing process such outcomes are not as likely. (Peterson
& Bredow, 2009, 241-244) One way to describe the nursing process is usually
four to six steps linear model. Although steps of the nursing process are
going to be viewed separately they are not independent in relation to one
another, instead they are extremely interactive, and sometimes overlapping
since connections between different steps is needed to answer the patient’s
needs. (Chabeli, 2007, 77-78) The relationship between different steps shortly
explained: “The assessment data have to be comprehensive, complete, accurate,
valid and reliable…The diagnostic statements should be correct for the goals
and nursing orders to flow logically for an individual, unique plan for the
identified health problems. The goals and nursing orders serve to guide the
nurse’s actions during the implementation phase and also serve later as
criteria for evaluating patient progress”. (Chabeli, 2007, 83) 4.1.1
Assessment Assessment is a process where the nurse collects information in
various ways, for example, by interviewing, observing and taking different
measurements. Assessment step helps then discovering the needs of a patient
which can then be addressed with proper nursing interventions. Interpretation
and evaluation of the data collected is important before drawing any
conclusions. Nurse needs to have enough evidence before stating an argument.
Here nurse’s skill to compare different factors and finding out those
factors’ value for patient, leading to finding out patient’s actual or
greatest 6 problem, demands critical thinking skills. If there is enough
trust-worthy evidence nurse needs to be open-minded to adjust path of inquiry
rather that following certain routines. (Chabeli, 2007, 77-80) According to
Baid (2006) physical assessment is important tool for nurses to use for
collecting knowledge since it can help nurses to recognize any abnormalities.
It begins with collecting the health history of the patient. Nurse can
interview both the patient and the persons that can have important
information, such as, people close to the patient, for example, the parents, a
living partner, or people otherwise connected to the patient, for example, an
ambulance driver. Information can be collected also from the patient’s
previous health records. (Baid, 2006, 710) After coming in a contact with the
patient, the nurse starts observing the patient and his/her behavior. Also
vital signs should be taken. Information collected helps the nurse to
determine how throughout the following assessment should be, meaning is the
patient’s main problem linked only to one, or couple of the body systems, for
example, renal and/or musculoskeletal system, or is general approach, covering
all the body systems needed. Methods used in complete physical assessment
include inspection, palpation, percussion, and auscultation. (Baid, 2006 710,
712) Chabeli (2007, 79) discusses that it is crucial that nurses notice
special areas that are important, for example, by identifying certain
behaviors, learning from even smallest cues, and predicting what will happen
in the future. For example, Coombs, Curtis & Crookes (2011, 368) discuss in
their article that psychiatric nurses should pay attention to, besides
physical health, also to important factors like knowledge about person’s
social situation, behavior, mental status and situational context as important
factors while making an assessment. 4.1.2 Nursing Diagnosis and Classification
Nursing diagnosis is the part of the nursing process were nurse draws
conclusions from the assessment data collected before, compares different
hypothesis and forms diagnostic statements that describe the patient’s needs.
Forming a correct nursing diagnosis demands critical thinking skills,
scientific knowledge, social skills and multi-sided knowledge about the
patient and his situation. (Gouveia Dias Bittencourt & da Graça Oliveira
Crossetti, 2012) Important is to realize that only diagnostic title is not
enough, Müller-Staub, Lavin, Needham & van Actenberg (2006) claim. Having
diagnostic title alone cannot express the patient’s problems, since only
diagnoses that 7 are specific in their etiology are the base for choosing
correct interventions. (Müller-Staub et al., 2006, 529) The nursing process
can be documented in a structured way with help of structured classifications,
for example, with help of FinCC. (Liljamo et al., 2012, 10) Paans, Nieweg, van
der Schans and Sermeus (2011) remind that nursing diagnosis itself is not
limited to classifications but the conclusions in the diagnostic process made
by the nurses need to be documented in a way that is understandable for the
colleagues and other healthcare team members alike. With that duty
classifications are helpful. (Paans et al., 2011, 2401) NANDA (North American
Nursing Diagnosis Association) is perhaps the most famous one of the
standardized nursing classifications. First NANDA version was established in
USA in the early 80s and nowadays term NANDA-I (Nanda International) is used
to reflect expelling movement of nursing diagnosis and NANDA classification
itself in countries worldwide. (NANDA, 2013) FinCC is a classification for
documenting nursing care. It has been available for all health care
professionals since year 2008. FinCC has common structure at component level
with Clinical Care Classification (CCC) but additional to only translating the
classification, FinCC has gone through several pilot studies and user
feedbacks which have been retrieved to form a classification that suites needs
of patients in the Finnish culture, still keeping chance for an international
comparison. (Liljamo et al. 2012, 9) In this thesis the respondent is going to
refer to CCC for a closer look of a classification due to CCC’s & FinCC’s
relationship. CCC was previously named as Home Health Care Classification
(HHCC). In the United States of America CCC was one of the first
classifications to be noticed by American Nurses Association (ANA) as a
supporting tool for clinical nursing. (McCormick, 2007) CCC structure consists
of care components, nursing diagnoses, expected outcomes, nursing
interventions, action types, and actual outcomes. Care components are factors
describing different kinds of issues under several health patterns. Nursing
diagnoses are diagnostic statements representing patient problems. Expected
outcomes represent future goals of the care given with three concept choices:
improve, stabilize or deteriorate. Nursing interventions are single actions
that a nurse is responsible for, and that are planned to take care of
different patient problems that need nursing care. Action types describe and
specify nursing interventions. Actual outcomes are the evaluations of the
effects of given care, with same concepts in present tense that were mentioned
with expected outcomes: improved, stabilized or deteriorated. CCC follows
nursing process and can be linked to its six steps: care components are linked
to the assessment step, nursing diagnoses represent the diagnosis part,
expected outcomes 8 represent the outcome identification, nursing
interventions are tool for the planning, at the implementation step CCC
represents 4 different kinds of action types and the evaluation step is
described by actual outcome. (Saba, 2007, 152-155) 4.1.3 Planning Leach (2008)
describe planning as a “phase of client care, which immediately follows
client assessment and diagnosis, but precedes treatment and evaluation, is a
projected course of action aimed at strategically addressing a client’s
presenting problem”. (Leach, 2008, 1729) Planning is important for nursing
process, since it is the part where the goals of care (expected outcomes) are
formed. Goals should be formulated with an idea that they are fully realistic
while considering resources, health care team’s skills and most of all,
patient’s capability and willingness to achieve those goals. (Leach, 2008,
1732) The nursing process offers systematic framework that helps care
planning. (Leach, 2008, 1731) Planning is also ongoing during the whole
process. Every time when nurse collects new information and sees how patient
responds to care given planning continues. Correctness of steps already
implemented is crucial for conducting correct plans. Of course this is
presumption also in the whole nursing process. (Chabeli, 2007, 83) 4.1.4
Intervention “A nursing intervention is defined as a single nursing action…
designed to achieve an outcome to a nursing diagnosis, or to a medical action,
for which the nurse is accountable.” (Saba, 2007) While a nurse chooses an
intervention certain questions needs to be answered: does the intervention
help the patient to reach the goals and what is the knowledge base for the
intervention? In other words: evidence-based practice, experience or just a
tradition and routine? The nurse who does the interventions needs also to
evaluate the effects of the method chosen for the intervention. (Chabeli,
2007, 83-84) Suhonen, Välimäki, and Leino-Kilpi (2006) discovered in their
literature review concerning effects of personalized interventions that there
seems to be a more positive correlation to patient outcomes if nurses make
interventions suitable for their patients than if they do routine
interventions. 9 (Suhonen et al. 2006, 856) This demand for individualized
care continues the statement for taking patient actively in the consideration
in the whole nursing process. Chabeli (2007, 84) also points out that whether
or not a nurse has good communication with the patient is connected to the
successfulness of the interventions. 4.1.5 Evaluation Evaluation in the
nursing process can be described as an ongoing process within the nursing
process. In the whole nursing process during the assessment a nurse evaluates
whether or not enough information has been collected to form nursing
diagnosis, the nursing diagnoses are evaluated for their correctness, and then
goals and interventions are evaluated for their chance to be realistic and
reachable. If they are not, plan should be developed or changed. While doing
interventions, evaluation is needed to consider if those interventions lead to
achieving goals. Evaluation is important since in the absence of evaluation it
is almost impossible to know if the care actually helps to meet the needs of
the patient. Although intervention would not help patient, the knowledge from
evaluating the intervention helps the nurses to develop care. (Chabeli, 2007,
85-86) If all the steps of the nursing process are not systematically
implemented it is a risk for the care continuity. (Baena de Moraes Lopes,
Higa, José dos Reis, De Oliveira & Mafra Christóforo 2010, 121) Also according
to Finnish law (§12, 2000/653) healthcare professionals must document any
information needed for organizing, planning, implementing and following
patient’s care.

Advantages of Nursing process

The nurse care planning process is an important aid in the treatment of patients. In turn it creates a systematic care

plan approach which with the inclusion of other health care professionals allows the patients the best route to full

fitness. When used effectively, the nurse planning process offers many advantages to the health care environment:

 It's patient-centred, helping to ensure that your patient's health problems and his response to them are the

primary focus of care.

  It enables you to individualise care for each individual patient.

 It promotes the patient's participation in their care, encourages independence and concordance and gives the

patient a greater sense of control - important factors in a positive health outcome. (See Putting the 'P' in

planning.)
 It improves communication by providing you and other nurses with a summary of the patient's recognised

problems or needs so you all work towards the same goals.

 It promotes accountability for nursing activities, which in turn promotes quality assurance and quality health

care provision.
 It promotes critical thinking, decision-making and problem-solving for the benefits of health care provision.

 It's outcome-focused and encourages the evaluation of results.

 It minimises errors and omissions in care planning.

Basis for the nursing care planning process The nurse care planning process is based on the scientific method of

problem-solving, which involves:

 stating the problem you observed

 forming a hypothesis about the solution to the problem ('if... then' statements)

 developing a method to test the hypothesis

 collecting the test data

 analysing the data

 drawing conclusions about the hypothesis.

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The nursing process helps the nurse and the nursing in many ways
Helps to create a health data base of a patient
 
Helps to identify actual or potential health problems of a patient
 
Helps to establish priorities of nursing actions for providing proper services
to the patients.
 
 Helps to define specific nursing actions for providing proper services to the
patients

Helps to develop planned organized and individualised nursing care.

 
Helps to encourage for innovative nursing care.
 
Helps to provide for alternative nursing actions.
 
Helps to develop nursing autonomy and to foster nursing accountability
 
Helps to increase the effectiveness of nursing care.

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