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Chapter 10

Nursing Process
KEY TERMS

Analysis—The examination of data and identification of Nursing Outcomes Classification (NOC) system—A
patient problems, nursing diagnoses, and/or needs; it standardized classification of patient outcomes that
is the second step of the nursing process. respond to nursing interventions.
Assessment—The ongoing, systematic collection, Nursing process—A critical thinking framework that
validation, and documentation of data; it is the first involves assessing and analyzing human responses to
step of the nursing process. plan and implement nursing care that meets patient
Critical thinking—A cognitive strategy by which one needs as evidenced by the evaluation of patient
reflects on and analyzes personal thoughts, actions, outcomes. Consists of assessment, analysis, planning,
and decisions. implementation, and evaluation.
Data—Collected information. Objective data (also known as signs)—Overt,
Delegate—Transferring the authority to act to another. measurable assessments collected via the senses.
Evaluation—The comparison of planned expected Outcome—A specific desired change in a patient’s
outcomes with a patient’s actual outcomes to condition as a result of nursing interventions.
determine whether patient needs have been met; it is Planning—The identification of goals and/or outcomes
the fifth step of the nurse process. and nursing interventions that address patient
Goal—A broad, nonspecific statement about the status problems, nursing diagnoses, or needs; it is the third
one expects a patient to achieve. step of the nursing process.
Implementation—The organization, management, and Priority—Something ranked highest in terms of
implementation of planned nursing actions that importance or urgency.
involves thinking and doing; it is the fourth step of Subjective data (also known as symptoms)—Covert
the nursing process. information, such as feelings, perceptions, thoughts,
Nonverbal data—Observable behavior transmitting a sensations, or concerns, that are shared by the
message without words. patient and can be verified only by the patient.
Nursing Interventions Classifications (NIC) system—A Verbal data—Spoken or written messages.
standardized classification of nursing interventions.

I. Introduction to the Nursing Process 3. Analysis.

4. Implementation.
The nursing process is a critical thinking framework that in- 5. Evaluation.
volves assessing and analyzing human responses to plan and B. Characteristics of the Nursing Process
implement nursing care that meets patient needs as evi- 1. Is patient-centered.
denced by evaluation of patient outcomes. Nurses use critical 2. Is interpersonal.
thinking throughout the nursing process, which involves 3. Is collaborative.
both “thinking” and “doing,” to meet complex patient needs. 4. Is dynamic and cyclical.
A. Components of the Nursing Process 5. Requires critical thinking.
1. Assessment.
2. Planning.

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214 Unit III Essential Components of Nursing Care

II. Assessment
Assessment, the first step of the nursing process, is the on-
going, systematic collection, validation, and documentation
of data. Nursing assessment should be comprehensive, ho-
listic, and accurate so that it provides all the necessary in-
formation about a patient. In addition, it should reflect the
patient’s responses to a health problem and stressors, not
disease processes. Adequate assessment depends on collect-
ing data using various methods, collecting both subjective
and objective data, verifying that data are accurate, and
communicating information about assessments to other
members of the health team.
A. Methods of Data Collection
1. Physical examination: The use of inspection, aus-
cultation, percussion, and palpation to collect data
about a patient’s physical status. (See Chapter 11,
“Physical Assessment.”)
2. Interviewing.
a. Formal approach.
(1) Used when collecting information in a pre-
scribed or official way, such as for a history
and physical.
(2) Usually involves direct rather than open-
ended questions.

MAKING THE CONNECTION

Application of Critical Thinking to the

Nursing Process: Making the Connection
Critical thinking is a cognitive strategy by which one
reflects on and analyzes personal thoughts, actions, and
decisions. It involves purposeful, goal-directed thinking
(e.g., the nursing process); requires judgment based on facts
and principles of science rather than conjecture or trial
and error (e.g., evidence-based practice); and requires nu-
merous cognitive and personal competencies. The helix
of critical thinking (Fig. 10.1) demonstrates the interwoven
relationship between cognitive competencies and per-
sonal competencies essential to thinking critically.
Throughout the thinking process, there is constant inter-
action among cognitive competencies, among personal
competencies, and between cognitive and personal com-
petencies. The more cognitive competencies and personal
competencies a person possesses, the greater the poten-
tial the person has to think critically (Fig. 10.2). Critical
thinking has an interactive relationship with the nursing
process. The nursing process is a dynamic, cyclical process
in which each phase interacts with and is influenced by
the other phases of the process. Critical thinking is an es-
sential component within, between, and among the Fig 10.1 The helix of critical thinking. (From Nugent and
phases of the nursing process. Different combinations of Vitale [2012]. Fundamentals Success, 3rd ed. Philadelphia: F. A. Davis
cognitive and personal competencies may be used during Company, with permission.)
the different phases of the nursing process (Fig. 10.3).
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Chapter 10 Nursing Process 215

b. Informal approach.
(1) Used when collecting data in a casual
and more relaxed manner, such as when
exploring a patient’s feelings while provid-
ing other nursing care.
(2) Usually involves open-ended questions.
c. See also Chapter 7, “Communication and
Documentation.”
3. Clinical record review.
a. Involves monitoring information collected
about the patient in the clinical record.
b. Gathers information about results of laboratory
examinations, diagnostic procedures, consulta-
tions by other members of the health team, and
progress notes.
B. Sources of Data
1. Primary source.
a. The patient is the only primary source of data.
! b. The patient is the most valuable source because the
data collected are most recent, unique, and specific
to the patient.

2. Secondary sources.
a. These sources provide supplementary information
about the patient from some place other than the
patient, but within the patient’s frame of reference.
b. They include people other than the patient
(e.g., family members, friends, other health
team members).
c. A patient’s clinical record is also a secondary
source, as it contains a vast amount of informa-
tion about the patient’s physical, psychosocial,
and economic history as well as information
about the patient’s progress regarding physical
and emotional responses to a health problem.

DID YOU KNOW?

Although a patient’s clinical record is a secondary
source, laboratory and diagnostic procedure results
are direct objective measurements of the patient’s
status and are considered by some to be a primary
source. The clinical record is an historical view of the
patient and, for that reason, is less current than data
collected from the patient.
3. Tertiary sources.
a. These sources produce data from outside the
patient’s frame of reference.
b. Examples include information from textbooks,
surveys, medical and nursing journals, drug
books, and policy and procedure manuals.
Fig 10.2 The helix of critical thinking schematically elon-
C. Types of Data
gated. (From Nugent and Vitale [2012]. Fundamentals Success, 1. Objective data (also known as signs).
3rd ed. Philadelphia: F.A. Davis Company, with permission.)
a. Overt, measurable assessments collected via the
senses, such as sight, touch, smell, or hearing,
and compared to an accepted standard.
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216 Unit III Essential Components of Nursing Care

Fig 10.3 The interactive nature of the helix of critical thinking within the nursing process.
(From Nugent and Vitale [2012]. Fundamentals Success, 3rd ed. Philadelphia: F. A. Davis Company, with
permission.)

b. Examples include body temperature, pulse and c. Allows for the assessment of difficulties such as
respiratory rates, blood pressure, vomiting, slurring, lack of clarity, flight of ideas, difficulty
distended abdomen, presence of edema, lung finding the desired word, and inability to iden-
sounds, crying, skin color, and presence of tify an item.
diaphoresis. d. Examples include statements made by the
2. Subjective data (also known as symptoms). patient or by a secondary source.
a. Covert information, such as feelings, percep- 4. Nonverbal data.
tions, thoughts, sensations, or concerns that are a. Observable behavior transmitting a message
shared by the patient and can be verified only without words.
by the patient. b. Examples include patient’s appearance; fearful fa-
b. Examples include pruritus, nausea, pain, cial expression; body language, such as posture;
numbness, attitudes, beliefs, values, and gestures; and eye contact or lack of eye contact.
perceptions of the health problem and life D. Verifying Collected Data
circumstances. 1. Data must be double-checked (verified) after they
3. Verbal data. are collected.
a. Spoken or written data. 2. Ensures validity and accuracy.
b. Requires the nurse to listen to the pace of the 3. Ensures that the nurse does not come to a conclusion
communication pattern, tone of voice, vocabu- without adequate data to support the conclusion.
lary used, and presence of aggression, anxiety, 4. Involves collecting additional information to sup-
or assertiveness. port the initial data. For example, if a patient’s
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Chapter 10 Nursing Process 217

pulse is increased above the expected range, the quotation marks; this practice ensures that a
nurse should take the pulse again; if it is still in- patient’s meaning is not misinterpreted or
creased, the nurse should collect other vital signs inaccurately altered by words used by the nurse
to supplement the original information. to describe an event.
5. Helps to identify whether objective and subjective
data are congruent or incompatible; for example: III. Analysis
a. When a patient has an increased blood pres-
sure, pulse, and respiratory rate and is rubbing Analysis, the second step of the nursing process, requires
a shoulder, the nurse makes an inference that the nurse to use critical thinking strategies to scrutinize
the patient is experiencing pain. To validate this data. Activities associated with this step include clustering
conclusion, the nurse asks, “I noticed that you data, interpreting data, and identifying and communicat-
are rubbing your shoulder. Is it causing you ing a patient’s nursing diagnoses, problems, or needs.
discomfort?” A. Clustering Data
b. If a patient says, “I feel as though my bladder 1. Involves grouping information into related cate-
will burst,” the nurse makes the inference that gories, a beginning effort to organize and manage
the patient might be experiencing urinary information.
retention. To validate this, the nurse should 2. Data can be clustered into general categories, such
palpate the patient’s abdomen for distention. as physiological, sociocultural, psychological, and
The nurse also can ask questions that clarify spiritual. Then each category may be further
the patient’s statement. reduced into specific categories, such as nutrition,
c. If a patient says, “I feel that I am in a big, black mobility, elimination, and oxygenation.
hole,” the nurse might use the communication 3. Data can be easy or difficult to cluster depending
technique of clarification to have the patient on the amount and variety of data collected.
explain in more detail what was meant, “Tell 4. Easy to cluster information commonly involves
me more about this big, black hole that you only one body system. For example, a patient
feel you are in.” reports feeling low abdominal pressure, has not
E. Communicating Collected Data voided in 8 hours, and has abdominal distension
1. Outcomes of nursing assessments must be docu- on palpation of the suprapubic area; these clinical
mented on correct forms and in appropriate places indicators all relate to urinary elimination and
in the patient’s clinical record. Many forms are lead to the interpretation that the patient may
used to document data and are organized by topic have urinary retention.
or body systems. 5. Difficult to cluster information may at first seem
2. Communicating data ensures that pertinent and unrelated because a variety of body systems are
current information relative to the patient is involved. For example, a patient has a weak,
shared with other members of the health team. thready pulse; decreased blood pressure; rapid
respirations; pallor; and clammy skin; these
! 3. Data must be communicated in an objective and clinical indicators cross body systems, but all
factual way and not be a summary of the nurse’s
are related to hypovolemic shock.
interpretation of the data.
6. Inductive reasoning moves from the specific to the
4. Value words, such as good, bad, adequate, poor, general. For example, if you identify that a patient
and tolerated well, should be avoided. For exam- has a temperature and a wound with purulent
ple, rather than saying that a patient’s appetite is drainage, you may come to the conclusion that the
poor, the nurse should document that the patient wound is infected.
ate half of a scrambled egg and a slice of toast. This 7. Deductive reasoning moves from the general to
manner of documentation communicates objec- the specific. For example, if you know that a newly
tive, measurable information about the patient’s admitted patient has a wound infection, you might
appetite. deduce that the patient will have a temperature,
5. Value words related to a patient’s behavior, such purulent drainage, and a culture and sensitivity
as lazy, difficult, stubborn, rude, uncooperative, and laboratory result identifying the causative agent.
foolish, should be avoided. These words reflect a 8. Data must be clustered before it can be
value judgment made by the nurse that may be interpreted.
influenced by bias and personal values or beliefs. 9. Established frameworks are available to provide
Nurses must always be nonjudgmental. structure for organizing clustered data.
6. Subjective data should be documented in the a. Abraham Maslow’s hierarchy of human needs.
exact words verbalized by the patient and put in b. Marjory Gordon’s functional health patterns.
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218 Unit III Essential Components of Nursing Care

c. NANDA International (formerly the North interconnected data. For example, Impaired
American Nursing Diagnosis Association), skin integrity.
nursing diagnosis taxonomy. (2) Definition: Explains the meaning of the
10. Most health-care agencies have their own admis- diagnostic label, which differentiates it from
sion assessment forms, which commonly follow a similar nursing diagnoses. For example,
systems approach to collecting and clustering data. Altered epidermis and/or dermis.
B. Interpreting Data (3) Defining characteristics: Identifies clinical
1. Interpreting data requires identifying the signifi- indicators (signs and symptoms) that
cance of clustered data. support the diagnostic label. For example,
2. Determining significance requires a comparison of Invasion of body structures, destruction
data collected with a wide range of standards and of skin layers (dermis), disruption of skin
norms (e.g., expected vital signs and laboratory surface (epidermis).
values, growth and development patterns and (4) “Related to” factors: Situations, events, or
milestones, and cause and effect relationships). conditions that precede, cause, affect, or are
The nurse must then come to a conclusion about a in some way associated with the diagnostic
specific identified pattern. It also involves query- label. For example, Related to physical
ing evidence, exploring alternatives, and drawing immobilization. The list of related factors
initial conclusions. in the taxonomy is not all-inclusive because
3. Conclusions are drawn after the significance of it is impossible to list all possible factors.
data is determined. Conclusions are the opinions,
perceptions, judgments, and inferences that result
from the interpretation of data.
4. More data may be necessary to support the initial MAKING THE CONNECTION
conclusion. For example, a deviation from any NANDA Taxonomy and a Nursing Diagnosis
established standard or norm is evidence that A nurse is caring for a newly admitted patient who has
points to or supports a conclusion, but more data paralysis of the legs as a result of a spinal cord injury sev-
may be required to increase the validity and relia- eral years ago. The patient sits in a wheel chair most of
bility of the conclusion. A nurse should ask the the day and lies in the supine position when sleeping.
following questions: The nurse identifies that the patient has a shallow, round,
a. “Did I miss anything?” partial-thickness loss of dermis over the sacrum. The
b. “What else do I need to know?” wound bed is red with no evidence of sloughing. The
c. “Has the patient’s condition or situation nurse identifies the nursing diagnosis: Impaired skin
changed since I initially assessed the patient?” integrity (diagnostic label) related to physical immobi-
d. “Are there any inconsistent or conflicting data lization (related to factor). Because the nurse under-
that require clarification?” stands that there can be more than one “related to”
e. “Is my data cluster complete or do I need to factor, the nurse includes all the causes of the patient’s
collect additional data to better support my impaired skin and develops this nursing diagnosis:
conclusion?” Impaired skin integrity related to physical immobiliza-
C. Identifying Nursing Diagnoses tion, altered sensation, and pressure. The nurse expands
1. Introduction to nursing diagnoses. the nursing diagnosis to include “secondary to” informa-
a. Nursing diagnoses are statements of specific tion to make the etiology clearer. Often, “secondary to”
health problems that nurses are legally allowed information is a pathophysiological process or medical
to independently identify, prevent, and treat. diagnosis. The new nursing diagnosis is: Impaired skin
b. They convert an initial conclusion into a integrity related to immobility, altered sensation, and
diagnostic statement. pressure secondary to motor deficits.
c. They logically link the assessment step to the The nurse further expands the nursing diagnosis to
planning, implementation, and evaluation steps include “evidenced by” information to make the etiology
of the nursing process. even more clear. Often, “evidenced by” information is
d. NANDA International provides a taxonomy of the clinical indicators (signs and symptoms) included in
diagnostic labels and etiologies. the defining characteristics in the NANDA taxonomy. The
e. Each nursing diagnosis in the taxonomy fol- final nursing diagnosis is: Impaired skin integrity related
lows the same organization for the presentation to inactivity, altered sensation, and pressure secondary
of information. to motor deficits as evidenced by the inability to inde-
(1) Diagnostic label (title or name): A word pendently move the legs.
or phrase that is based on a pattern of
 Chapter 10 Nursing Process 219

DID YOU KNOW? (2) A high-priority problem poses the greatest

Although nursing diagnoses provide a framework for threat and should be addressed first (e.g., an
identifying a patient’s nursing problems using a stan- impaired airway).
dardized nomenclature or language, some profes- (3) A medium-priority problem follows a high-
sionals believe that they have become too complex priority problem. It may be related to harmful
and abstract to be useful in everyday practice. As a physiological responses that are not an imme-
result, some areas of practice are moving away from diate threat to life (e.g., impaired mobility).
using nursing diagnoses. (4) A low-priority problem should pose the
least threats and be ranked last. It may
D. Communicating Patient Nursing Diagnoses, require minimal support (e.g., nausea).
Problems, or Needs c. Patient’s priorities.
1. Nurses communicate patient nursing diagnoses, (1) Ranks patient needs based on what is most
problems, or needs in a written plan of care. important to the patient.
2. The plan of care may be kept in a variety of places (2) Although a patient’s preference should
(e.g., patient’s clinical record, the medication ad- always be taken into consideration, basic
ministration record, and Kardex). life-threatening needs require urgent inter-
ventions and override less important needs.
IV. Planning d. Future impact of the patient’s condition.
(1) Although a problem might not be life-
Planning, the third step of the nursing process, provides threatening and is not recognized by the
direction for nursing interventions. It is concerned with patient as important, the nurse may deter-
identifying priorities, establishing goals and expected out- mine that it can cause future negative
comes, and selecting nursing interventions that will help consequences if not addressed.
the patient achieve those goals and expected outcomes. (2) For example: A nurse identifies that a pa-
Planning begins when a patient is admitted and is ongoing tient newly diagnosed with type 1 diabetes
to meet the changing or emerging needs of the patient. has dirty feet and is wearing sandals instead
Effective planning includes collaboration with all appro- of shoes that enclose the feet. The nurse
priate health team members to facilitate continuity of care knows that people with diabetes are at risk
in a patient-centered, individualized, and coordinated for foot problems secondary to impaired
manner. Planning culminates in a document about circulation to the lower extremities. There-
the proposed plan of care that is communicated to all fore, the patient has a potential for skin
members of the health team. breakdown, which can lead to infection and
A. Identifying Priorities even amputation. The nurse ranks this issue
1. A nurse must place a patient’s nursing diagnoses, as a priority and plans interventions to
problems, and needs in order of importance when educate the patient about foot care.
confronted with a variety of patient issues. B. Identifying Goals and Expected Outcomes
2. A nurse must have a strong foundation of scientific 1. Basic concepts.
theory, knowledge of the commonalities and differ- a. A goal is a broad, nonspecific statement about
ences in response to nursing interventions, and the status one expects a patient to achieve.
theories to determine the priority of a patient’s b. A goal generally is derived from the “diagnostic
needs. label” component of a nursing diagnosis. For
3. Certain theoretical bases promote the prioritiza- example, if a patient has the nursing diagnosis
tion of care. Ineffective airway clearance related to excessive
a. Maslow’s hierarchy of needs. respiratory secretions, the goal might be: “The
(1) Needs are placed in order from the most patient will maintain a patent airway.”
basic needs to the highest level needs. c. An outcome identifies a specific change in a
(2) Physiological is the first level need, followed patient’s condition as a result of nursing inter-
by safety and security, love and belonging, ventions. It is commonly influenced by the
self-esteem, and self-actualization (see “related to” component of a nursing diagnosis.
Fig. 1.3, page 7). Also, it provides criteria to be used in the evalua-
b. Urgency of the health problem. tion phase of the nursing process. For example,
(1) Ranks problems based on the degree of the outcome statement using the previously state
threat to the patient’s life. The nurse can use goal (“The patient will maintain a patent airway”)
the ABCs of assessment (Airway, Breathing, might be: “The patient will expectorate respira-
Circulation) when determining priorities. tory secretions while hospitalized” (Box 10.1).
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220 Unit III Essential Components of Nursing Care

Box 10.1 Nursing Outcomes Classification (NOC) Additional examples of time frames include
System by discharge, within 24 hours, at all times,
and will maintain (the word maintain
The Nursing Outcomes Classification (NOC) system is a stan- implies continuously).
dardized classification of patient outcomes that respond to e. Be realistic.
nursing interventions. Each NOC outcome has a label, indicators, (1) The performance criteria identified must
and measurement scale. The advantages of the NOC system are
that it uses language common to all health-care professionals, it be reasonable and feasible in light of the
is specific, and it identifies indicators with a measurement scale patient’s emotional and physical status.
to allow nurses to evaluate patient progress toward an outcome. (2) Goals are realistic when the outcomes can
Example of NOC outcomes with indicators for Impaired skin be achieved in the indicated time frames.
integrity: (3) Example of a realistic outcome for a patient
• Tissue integrity: Skin and mucous membranes will be intact
as evidenced by the following indicators: Skin intactness/ who had abdominal surgery is: “The patient
skin lesions/tissue perfusion/skin temperature. will exhibit bowel sounds within 3 days after
• Rate each indicator of tissue integrity: skin and mucous surgery.”
membranes: 1 = severely compromised, 2 = substantially com- (4) Example of an unrealistic outcome for a
promised, 3 = moderately compromised, 4 = mildly compro- patient with hemiplegia due to a brain
mised, 5 = not compromised.
attack is: “The patient will perform active
range-of-motion exercises independently
within 1 week.”
d. Patients and nurses together should set goals C. Identifying Nursing Interventions
and outcomes to ensure that these goals and 1. Selecting appropriate interventions depends
outcomes are realistic, achievable, and in align- on the accuracy and thoroughness of the data
ment with what the patient and nurse want to collected.
achieve. 2. Nursing interventions generally address the
2. Criteria for goals and outcomes. “related to” part (etiology) of the patient’s problem
a. Be patient centered. or nursing diagnosis. For example, if a person is at
(1) The patient is the center of the health team; risk for impaired skin integrity related to urinary
therefore, the patient should be the subject incontinence and immobility, the nursing inter-
of all goals and outcomes. ventions selected should keep the patient clean
(2) For example, “The patient will transfer from and dry and relieve pressure.
the bed to a chair safely within 1 week.” 3. Nursing interventions should include nursing as-
Some agencies believe that the words the sessments, nursing care to avoid complications,
patient are understood and therefore do not administration of ordered treatments and pre-
include them when stating a goal. scribed medications, and health promotion and
b. Contain an action verb. illness prevention activities, as appropriate.
(1) The goal or outcome should identify the 4. Selected actions should have the greatest probabil-
action that the patient will learn, do, or ity of achieving the desired goal/outcome with the
verbalize or the physical status the patient least risk to the patient. The nurse must consider:
will attain. a. Cause: Planned action.
(2) For example: “The patient will transfer from b. Effect: Patient’s response.
the bed to chair safely within 1 week.” c. Risk: Potential for the patient to have a negative
c. Include performance criteria. consequence as a result of the planned action.
(1) Actions must be specific and measurable. d. Probability: Degree to which the patient may
For example, “The patient will transfer from have a positive consequence as a result of the
the bed to chair safely within 1 week.” planned action.
(2) Conditions may be included to describe the e. Value of the consequences: Significance of
kind of assistance or resources needed by results of the planned action to the patient.
the patient. For example, “The patient will 5. Selected interventions should be based on evi-
transfer from the bed to chair safely with a dence-based practice—that is, interventions that
one-person assist within 1 week.” have been proven to be effective based on rigorous
d. Include a time frame. scientific evidence and clinical effectiveness stud-
(1) The goal must be achievable within a set ies rather than tradition, intuition, or anecdotal
time frame. information. Nursing practice based on evidence
(2) For example, “The patient will transfer improves the quality of patient care and justifies
from the bed to chair safely within 1 week.” nursing interventions (Box 10.2).
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Chapter 10 Nursing Process 221

Box 10.2 Nursing Interventions Classification (NIC) 3. A plan of care may require modification after the
System evaluation step of the nursing process when it is
identified that the patient did not achieve an
The Nursing Interventions Classifications (NIC) system is a stan- expected outcome or because the patient’s status
dardized classification of nursing interventions. It includes both improved.
physiological and psychosocial interventions that can be per-
formed across all nursing disciplines. It consists of intervention
labels. Each intervention label has a definition and a list of V. Implementation
related nursing actions. The advantages of the NIC system are
it uses language common to all health-care professionals, it is Implementation, the fourth step of the nursing process, is
specific, and it is based on evidence-based practice. the actual performance of nursing actions. It is the execu-
Example of NIC interventions for pressure ulcer care: tion of the plan of care and involves thinking and doing.
• Pressure ulcer care: Monitor color, temperature, edema,
moisture, and appearance of surrounding skin; note charac- Therefore, nurses must not only have a strong knowledge
teristics of any drainage. 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. Nurses must implement only nursing actions
D. Communicating the Plan of Care that are described in their state’s nurse practice act and
1. Plans of care promote communication and coordi- conform to professional nursing standards of care.
nation among health team members, improving A. Legal Parameters of Nursing Interventions
the continuity of patient care. 1. A nurse must know the legal parameters of
2. Information that should be included on a nursing interventions, which include:
comprehensive plan of care includes: a. Dependent nursing interventions.
a. Patient nursing diagnoses, problems, or needs (1) Require an order or prescription from a
and related independent and dependent health-care professional with prescriptive
nursing interventions. privileges (e.g., physicians, podiatrists,
b. Activities of daily living (ADLs) and basic dentists, physician’s assistants, nurse
needs. practitioners).
c. Medical orders and prescriptions and the (2) Nurses must ensure that ordered interven-
nursing interventions required to implement tions and prescribed medications are appro-
them. priate to meet the needs of a patient. If a
d. Requirements to prepare the patient for nurse implements an inappropriate order or
discharge, such as teaching, equipment, prescription, the nurse can be held legally
and services. accountable as a contributor to the initial
3. Various types of care plans are used. error made by the primary health-care
a. Computer-generated care plans can be stan- provider. Nurses must question inappropri-
dardized or individualized. The nurse chooses a ate orders or prescriptions and not follow
nursing diagnosis or health problem, and the them blindly.
computer presents potential goals/outcomes (3) Examples of dependent nursing interven-
and nursing interventions. The nurse can then tions include:
select interventions that are appropriate for the (a) Administering medications or
patient. The computer then generates a written intravenous solutions.
printout of the plan of care. (b) Implementing activity orders.
b. Multidisciplinary care plans (collaborative care (c) Inserting or removing a urinary
plans, critical pathways) sequence care that is to retention catheter.
be delivered each day during a patient’s length (d) Providing a diet.
of stay. Each day has a column and vertical (e) Implementing wound or bladder
boxes that address specific care that is to be irrigations.
delivered by each health-care discipline. b. Independent nursing interventions.
E. Modifying the Plan of Care (1) Registered nurses (RNs) can legally order
1. Plans of care are dynamic and require modifica- and implement independent nursing
tion to keep them current and relevant. interventions without supervision or
2. The original plan of care may require changes direction from a person with a prescrip-
because the original plan was inadequate or tive license.
inappropriate or because additional assessments (2) Each state’s nurse practice act defines the
provide new information. scope of nursing practice within the state.
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222 Unit III Essential Components of Nursing Care

(3) Examples of independent nursing interven- 2. Teaching.

tions include: a. Nurses provide teaching in relation to the cog-
(a) Assessing a patient. nitive, psychomotor, and affective domains.
(b) Diagnosing a patient’s nursing needs. b. Examples include conducting a class about the
(c) Planning, implementing, and evaluating signs and symptoms of hyperglycemia (cogni-
nursing care. tive domain), teaching a patient how to self-
(d) Assisting with ADLs. administer insulin (psychomotor domain), and
(e) Teaching any subject associated with facilitating a group session of adolescents dis-
health promotion and illness prevention. cussing and role-playing how to say no when
(f) Counseling. pressured to engage in alcohol or drug use
(g) Advocating for a patient. (affective domain).
(h) Encouraging a patient to verbalize fears c. See Chapter 9, “Teaching and Learning,” for
and feelings. more information about the various learning
(i) Encouraging coughing and deep domains and the nurse’s role in teaching and
breathing. learning.
(j) Referring a patient to community 3. Responding to life-threatening events.
resources. a. Nurses use clinical judgment to identify and
c. Interdependent nursing interventions. respond to life-threatening changes in a
(1) Nurses work in collaboration with primary patient’s condition.
health-care providers to implement depend- b. The related interventions generally are
ent nursing interventions that have set associated with meeting a patient’s basic
parameters. physiological needs.
(2) Some settings, such as intensive care units c. Examples include performing abdominal
and birthing units, have standing orders or thrusts for a patient who is choking, imple-
protocols that delineate the parameters menting cardiopulmonary resuscitation for a
within which the nurse can implement a patient who has no palpable pulse and is not
dependent nursing intervention. breathing, and discontinuing a blood transfu-
(3) Examples of interdependent nursing inter- sion when a patient has clinical indicators of a
ventions include: transfusion reaction.
(a) An order says, “Out of bed as tolerated.” 4. Implementing health promotion and illness
The nurse determines whether the prevention activities.
patient is tolerating an activity and a. Nurses provide interventions that assist
therefore the amount of activity in people to maintain health and avoid health
which to engage the patient. problems.
(b) A prescription for a pain medication b. They aim to help people who are at an increased
states, “Acetaminophen (Tylenol) risk for illness because of their developmental
650 mg every 6 hours for mild lower level, such as neonates, young children, and
back pain prn.” The nurse assesses the older adults. They aim to help people who are at
level of the patient’s pain and then an increased risk for negative consequences of
decides whether to administer the their behaviors, such as people who smoke,
prescribed dose. drink alcohol excessively, abuse drugs, have
B. Types of Nursing Interventions multiple sexual partners, or overeat. They also
1. Assisting with ADLs. aim to help people limit exacerbations of ill-
a. Nurses assist patients with activities that people nesses and subsequent health problems as a
perform daily to promote comfort, health, and result of an initial illness.
well-being. c. Examples include administering a vaccine,
b. Problems interfering with these actions can be teaching a class about healthy nutrition, pro-
acute or chronic, temporary or permanent, and moting smoking cessation or weight reduction,
require teaching or assistance to restore func- using standard precautions, and turning and
tion. positioning an immobile patient.
c. Examples include helping a debilitated patient 5. Performing technical skills.
eat, ambulating a patient after surgery, provid- a. Nurses must competently perform technical
ing range-of-motion exercises, turning and psychomotor skills associated with a procedure.
positioning a bed-bound patient, and adminis- b. The nurse should know the steps, principles,
tering an enema. rationales, and expected outcomes relative to
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Chapter 10 Nursing Process 223

nursing procedures to implement them in the (4) Evaluating the patient’s responses to the
appropriate situation safely. interventions implemented.
c. Examples include administering medications 8. Reporting and documenting nursing interventions
via various routes, suctioning a patient’s respi- and patient responses.
ratory tract, changing a wound dressing, and a. Nurses communicate information verbally and
irrigating a colostomy. in writing to other members of the health team
6. Employing psychosociocultural interventions. to provide continuity of patient care. Written
a. Nurses use therapeutic interviewing techniques documentation also establishes a permanent
to encourage patients to ventilate feelings and legal record of the care provided and the
concerns. Once the nurse identifies a patient’s patient’s response.
emotional needs, the nurse continues to sup- b. Examples include documenting vital signs on a
port the patient emotionally while exploring patient’s graphic record, indicating the charac-
potential coping strategies. In addition, the teristics of a patient’s skin integrity on a pres-
nurse uses interpersonal interventions when sure ulcer flow sheet, providing a verbal report
working as an advocate for the patient, coordi- regarding the status of patients to a nurse arriv-
nating health-care activities, and collaborating ing for the next shift, and documenting the
with others on the patient’s behalf. administration of medications and patient
b. Examples include using nondirective interview- responses to medications.
ing techniques, gently addressing a patient’s
behavior, collaborating with a patient to identify
! c. If interventions are not documented, they are
considered not done.
a goal, and explaining to family members that
their loved one’s angry behavior is associated
with the anger stage of grieving in response to VI. Evaluation
the diagnosis of cancer.
7. Delegating, supervising, and evaluating delegated Evaluation, the fifth step of the nurse process, involves
nursing interventions. issues related to structure, process, and patient outcomes.
a. Nurses may delegate nursing care to: The nurse first reassess the patient to identify patient
(1) Unlicensed assistive nursing personnel. responses to interventions (actual outcomes) and then
(a) Uncomplicated, basic interventions. compares the actual outcomes with expected outcomes to
(b) Examples: Bathing a bed-bound patient, determine goal achievement. It is a continuous process
ambulating a stable postoperative patient, that requires the plan of care to be modified as often as
obtaining vital signs from patients who necessary either during or after care.
are stable. A. Components of Evaluation of the Delivery of Nurs-
(2) Licensed practical nurse (LPN). ing Care
(a) Routine nursing care for patients 1. Structure.
who are stable and whose care is a. Associated with the setting and effect of organi-
uncomplicated. zational features on the quality or excellence of
(b) Examples: Administering medications, nursing care.
changing a sterile dressing, instilling b. Based on such things as policy and proce-
an enema. dures, economic resources, available equip-
(3) Registered nurse (RN). ment, and the number, credentials, and
(a) Complex nursing interventions. experiential background of members of the
(b) Examples: Performing a physical assess- nursing team.
ment, teaching a patient how to self- c. Example of a structure goal against which the
administer insulin, formulating a delivery of nursing care can be assessed: Use a
patient’s plan of care. controller pump for administration of intra-
b. The nurse delegating care is responsible for: venous medication.
(1) Assuming responsibility for the care that is 2. Process.
delegated and its consequences. a. Associated with evaluation of clinical perform-
(2) Ensuring that the person implementing the ance of nursing team members.
care is legally permitted to provide the dele- b. Example of a process goal against which the
gated care, is knowledgeable, and is able to care delivered by a nurse can be assessed:
deliver the care safely. Provide for patient privacy by pulling the
(3) Ensuring that the care is implemented curtain and draping the patient when assessing
according to standards of care. a patient’s wound.
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224 Unit III Essential Components of Nursing Care

3. Patient outcome. the patient to achieve the expected outcome. In

a. Associated with measurable changes in a other words, a positive evaluation is indicated
patient’s status as a result of care implemented when an actual outcome meets the expected
by a nurse. outcome.
b. Example of an expected patient outcome b. If they are not the same, then the nurse can
against which an actual patient outcome can be infer that the nursing care was not effective in
assessed: The patient’s skin will remain clean, assisting the patient to achieve the expected
dry, and intact. outcome. In other words, a negative evaluation
B. Types of Evaluation Activities is indicated when an actual outcome does not
1. Routine evaluations. meet the expected outcome.
a. Occur at preset regular time frames. c. Once it is determined that the expected out-
b. For example, obtaining patients’ vital signs come was not achieved, the nurse must analyze
every shift; documenting intake and output factors that may have affected the actual
every shift and every 24 hours. outcomes of care.
2. Ongoing evaluations. 3. Analyze factors that may have influenced
a. Occur during and immediately after adminis- nonachievement of expected goals/outcomes.
tering nursing care or after interacting with a a. Each step of the nursing process must be exam-
patient. ined to determine what contributed to the fail-
b. For example, assessing a patient’s response to ure to achieve expected goals/outcomes.
irrigation of a colostomy; determining whether For example, the nurse must ask important
a patient understands the content in a teaching questions such as:
session. (1) Was the data cluster thorough and
3. Intermittent evaluations. accurate?
a. Occur in specific situations. (2) Was the nursing diagnosis, problem, or
b. For example, obtaining daily weights to moni- need identified correctly?
tor a patient receiving a diuretic; assessing the (3) Was the goal realistic and attainable?
degree of pain relief after a patient receives an (4) Were the expected outcomes specific and
analgesic. measurable?
4. Terminal evaluations. (5) Did the planned interventions address all
a. Occur in preparation for a patient’s discharge; the etiological factors of the problem?
health-care agencies generally have a compre- (6) Were the nursing interventions consistently
hensive discharge form that provides structure implemented as planned?
and consistency within an agency. b. The specific reason for not achieving a goal/
b. For example, evaluating a patient’s physical and expected outcome should be identified. A
emotional status; determining progress toward variety of reasons may have influenced the non-
goal/outcome achievement; and formulating a achievement of a goal/expected outcome. For
plan of care to be implemented in the community example, the patient might not have shared
setting, including topics such as medications, important information, the staff might not have
treatments, diet, and scheduled follow-up care. completed all tasks as planned, the patient
C. Nursing Interventions to Ensure Thorough Evalua- might not have been motivated to participate
tion of Patient Responses to Nursing Care adequately in the planned care, the patient’s
1. Reassess the patient to identify actual outcomes condition may have changed.
(patient responses). D. Modifying the Plan of Care
a. The nurse must reassess the patient to collect 1. Plans of care are dynamic and require modifica-
data, organize the data, and determine the tion to keep them current and relevant.
significance of the data. 2. The plan of care must be modified as soon as a
b. Actual outcomes are then compared to the nurse identifies that a plan of care is ineffective.
expected outcomes identified in the written 3. The plan will have to be modified when an
plan of care to determine whether the patient expected goal/outcome is met. Goals and expected
successfully achieved the goals/outcomes. outcomes advance to address evolving needs as the
2. Compare an actual outcome with an expected patient moves toward health on the health-illness
outcome to determine goal achievement. continuum.
a. If they are the same, then the nurse can infer 4. Once a new plan of care is implemented, the step
that the nursing care was effective in assisting of evaluation beings again.