Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: http://uep.edu.ph Email: [email protected]

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

BS NURSING

NCM 103:
FUNDAMENTALS OF NURSING PRACTICE

LESSON 3

Prepared by:

NEMIA G. FLORANO, RN, MAN, PhD

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 LESSON 3.
NURSING A SCIENCE

O VERVIEW
Introduction

Welcome to Lesson 3

This section summarizes the concept of Nursing as a

Science with the detailed discussion nursing process. It
presents the cyclical phases of assessment, diagnosis,
planning, implementation, and evaluation used as a tool
in providing quality nursing care to patients.

Let’s see what’s inside!!

Figure 1. Welcome to Fundamentals of Nursing Practice

Module Lesson 3

LEARNING OUTCOMES
1. Apply appropriate nursing concepts and actions holistically and comprehensively.

LEARNING OBJECTIVES
1. Explain what is meant by nursing process.
2. Identify the five cyclical phases of nursing process.
3. Discuss nursing assessment and its relationship to formulating nursing diagnostic statements.
4. Compare and contrast the phases in the nursing process
5. Describe the characteristics of nursing process.
6. Identify Gordon’s Typology of 11 Functional Health Patterns and its relationships.
7. Formulate an accurate diagnostic statement utilizing the components of NANDA Nursing
Diagnosis.
8. Discuss the importance of a nursing interventions classification system.
9. Develop a Nursing Care Plan indicating Long-term and Short-term goals.

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 10. Identify the types of evaluation process.
11. Describe the legal guidelines in documentation and reporting.

KEY TERMS:
Actual: describes the general judgment that the nurses have validated because of the
presence of major defining characteristics.
Assessment: is the first step of the nursing process that involves critical thinking skills
and data collection, subjective and objective cues.
Planning: A deliberate, systematic phase of the nursing process that involves decision-making
and problem-solving
Risk: describes a clinical judgment that an individual/group is more vulnerable to develop the
problem than others in the same or a similar situation.

ACTIVITY

Do this activity before reading the abstraction:

1. To understand fully this lesson, think of situations when you are confronted with problem/s
and the need to find solutions. What do you usually do? Move towards the problem or go
against it? Explore, and relate your experience as a human being. Did your ability in
resolving a problem have something to do with your attitude, knowledge and skills, or
personal values? Who influenced you to be in-charge of? Why and how? Do reflect and jot
down notes.

ANALYSIS
After doing this activity, what have you realized? I am confident that this will help you
comprehend and appreciate further the content of this lesson as you proceed to read the
abstraction.

ABSTRACTION

NURSING AS A SCIENCE

1. Problem-Solving Process

1. Problem-Solving Process
 Problem solving is the act of defining a problem; determining the cause of the problem;
identifying, prioritizing, and selecting alternatives for a solution; and implementing a
solution.

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  Problem solving is centered on your ability to identify critical issues and create or
identify solutions
o Nursing students are expected to have or develop strong problem-solving skills.
Well-developed problem-solving skills is a characteristic of a successful student.
o By thinking creatively, asking the right questions and considering multiple
options, nurses will be able to solve problems much more effectively. Those
who use problem-solving skills see problems not as obstacles but as
opportunities to improve their patients' health and well-being.

 Steps/Process: Problem-Solving Chart

NURSING AS A SCIENCE

2. Nursing Process

2. Nursing Process

 The nursing process functions as a systematic guide to client-centered care

with 5 sequential steps or steps of problem-solving in nursing process. These are
assessment, diagnosis, planning, implementation, and evaluation.

 Conceptual Models/Frameworks of Nursing

 Has been recommended by nursing leaders to:
 Guide nursing practice
 Provide building blocks for nursing practice
 Provide big picture of nurses’ responsibilities and actions
 Provide direction for the nursing process

Nursing Process: Definition

 Dynamic way of thinking of the nurse
 A framework of interrelated activities that facilitates competency in nursing care

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  Cyclical and dynamic
 Common sense approach
 Provides deliberate, systematic and organized approach to nursing practice that
accomplishes the main purpose of nursing

5 Phases of Nursing Process

1. Assessing
 collection of data
 Organize data
 Validate data
 Document data
2. Diagnosing
 analysis of data
 Identify health problems, risks and strengths
 Formulate diagnostic statements
3. Planning
 Prioritize problems/diagnosis
 Formulate/setting goals/desired outcomes
 identifying /select nursing interventions & strategies
 Write nursing orders
4. Implementing
 Reassess the client
 Determine the nurse’s need for assistance
 Taking-action
 Implement the nursing interventions
 Supervise delegated cases
 Delegate nursing activities
5. Evaluating
 Collect data related to outcome
 Compare data with outcome
 Measure progress toward goals & effectiveness of plans
 relate nursing actions to client goals/outcome
 Draw conclusions about problem status
 Continue, modify/revise or terminate the client’s care plan

Some historical notes about the Nursing Process

 1955 (Lydia Hall)
 Nursing is a process
 1959 (Dorothy Johnson)
 Assessment, decision, action
 1961 (Ida Jean Orlando)
 Client behavior
 reaction to nurse
 nursing action
 1963 (Ernestine Wiedenbach)

 Identify, act, evaluate

 1967 (Knowles) 5 D’s

 Discover, delve, decide, do, discriminate

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  1967 (Wiche)

 Perception, communication, interpretation, intervention, discriminate

 1967 (Catholic U)

 Assessment, planning, intervention, evaluation

 1970 (Freeman & Heirich)

 CHN 6 steps

 1969 (Carvenalli & Little)

 Health, assessment, designation of problems, goals, nursing actions, evaluation

 1970s (Physicians/Group of Instructors)

 “physical assessment was added to the expanded role of the nurse

 1973 (NANDA)

 Establishing work relationships

 Nursing diagnosis, Planning, Evaluation, interventions

Nursing Process Comparison with Problem-solving Process:

Nursing PROCESS Scientific METHOD

CLIENT IDENTIFIED- Defining the problem

general problem areas
identified through screening

ASSESSEMENT-subjective & Collecting Data

objective

DIAGNOSIS – data analyzed, Forming hypotheses

problem identified, labeled

PLANNING – expected Protocol

outcome, strategies,
interventions

IMPLEMENTATION – Testing hypotheses

interventions provided

EVALUATION – results of the Forming conclusions

entire process analyzed

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 FLOW OF THE NURSING PROCESS: Showing series of activities-

Assessment

Nsg. Diagnosis

Planning

Intervention

Evaluation

1. ASSESSMENT

1. Assessment

ASSESSING:

 Collect data
 Organize data
 Validate data

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  Document data

PURPOSE:
To establish a database about the client’s response to health concerns or illness and the
ability to manage health care needs.

ACTIVITIES:
1. Establish a data base
-obtain nursing health history
-conduct physical assessment
-review client’s record
-review nursing literature
-consult support persons
2. Update data as needed
3. Organize data
4. Validate data
5.Communicate/document data

FOUR (4) related activities of the Assessment Process

 1. Collecting Data
 TYPES of Data
 A. Subjective: Health History
 Referred to as SYMPTOMS or COVERT
DATA
 B. Objective: Physical Examination

 Also referred to as SIGNS or OVERT DATA

 Are detectable by an observer or can be measured or tested against

an accepted standard

 Can be seen, heard, felt, or smelled and they are obtained by

observation or physical examination and diagnostic tests

 SOURCES OF DATA
 Primary Source: client
 Secondary Source: include family members or other support persons, other
professionals, records and reports, laboratory and diagnostic analyses, &
other relevant literature.

 METHODS OF DATA COLLECTION

 1. Observing
 To gather data by using the senses
 A conscious, deliberate skill that is developed through effort
and with organized approach.
 2. Interviewing

 A planned communication or conversation with a purpose

 E.g.

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  To get or give information, identify problems of mutual concern,
evaluate change, teach, provide, support, or provide counselling
or theory

 3. Examining (physical examination or physical assessment)

 A systematic data collection method that uses observation (senses of

sight, hearing, smell, and sight)

 To detect health problems

 NOTE: May be organized according to the examiners preference, in a

head-to-toe approach or a body system approach.

 A. Cephalo-caudal/head-to-toe approach

 Begins the examination with the head, progresses to the neck,

thorax, abdomen, and extremities, and ends with the toes.

 B. The BODY SYSTEM APPROACH

 Investigates each system individually, that is the respiratory

system, the circulatory, the nervous system, and so on.

 Alternatively, the nurse may perform a screening exam also

called a REVIEW OF SYSTEM, which is a brief review of the
essential functioning of various body parts or systems.

 E.g.

 Nursing admission assessment form

 4. ORGANIZING

 Gordon’s Typology of 11 Functional Health Patterns

1. health-perception/health management pattern of health.
-Describes the client’s perceived pattern of health and well-being and how health is
managed.
2. Nutritional/Metabolic pattern
-describes the client’s pattern of food and consumption relative to metabolic need and
pattern indicators of local nutrient supply.
3. Elimination Pattern
-describes the pattern of excretory function (bowel, bladder, skin)
4. Activity/Exercise Pattern
-Describes the pattern of exercise, activity, activity, leisure and recreation
5. Sleep/Rest Pattern
-Describes pattern of sleep, rest, and relaxation.

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 6. Cognitive/perceptual pattern:
-describes sensory-perceptual and cognitive patterns
7. Self-perception/self-concept pattern.
-describes the client’s self-concept pattern and perception of self. (e.g.
Self-concept/worth, comfort, body image, feeling state)
8. Role/relationship pattern.
-Describes the client’s pattern of role participation and relationships
9. Sexuality/reproductive pattern.
-Describes client’s pattern of satisfaction and dissatisfaction with sexuality pattern;
describes reproductive pattern.
10. Coping/stress tolerance pattern.
-Describes the client’s general coping pattern and the effectiveness of the pattern in terms
of stress tolerance.
11. Value/belief pattern.
-describes the patterns of values, beliefs (including spiritual), and goals that guide the client’s
choices or decisions.

NURSING MODELS
 1. OREM’S Self-Care Model
 Enumerates the UNIVERSAL Self-care requisites:
 Maintenance of a sufficient intake of air
 Maintenance of a sufficient intake of water
 Maintenance of a sufficient intake of food
 Provision of care associated with elimination processes and
excrement
 Maintenance of a balance between activity and rest

 OREM’S Self-Care Model

 Maintenance of balance between solitude and social interaction
 Prevention of hazards to human life, human functioning, and human well-
being.
 Promotion of human functioning and development within the social groups
in accord with human potential, known limitations, and human desire to be
normal.

 OREM’S Self-Care Model

Normalcy is used in the sense of that which is essentially human and that which is in
accord with the generic and constitutional characteristics and the talents of individuals

 2. Roy’s Adaptation Model

 Enumerates the ADAPTATION modes:
 PHYSIOLOGIC Needs
 Activity and rest
 Nutrition
 Elimination
 Fluid and electrolytes
 Oxygenation

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  Protection
 Temperature
 Regulation: Senses
 Regulation: Endocrine System
 Roy’s Adaptation Model

 Self-concept

 Physical self

 Personal self

 Role Function

 Interdependence

 3. Wellness Model

 Use to

 assist clients to identify health risks

 Explore lifestyle habits and health behaviors, beliefs, values and attitudes that
influence the levels of wellness.

 Wellness Model includes:

 Healthy history

 Physical fitness evaluation

 Nutritional assessment

 Life-stress analysis

 Lifestyle and health habits

 Health beliefs

 Sexual health

 Spiritual health

 Relationships

 Health risk appraisal

NON-NURSING MODELS
 1. Body System Model
 Focuses on abnormalities of the ff anatomic system
 Integumentary

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  Respiratory
 Cardiovascular
 Nervous
 Musculoskeletal
 Gastrointestinal
 Genitourinary
 Reproductive
 Immune
 2. MASLOW’S Hierarchy of Needs

 Clusters data pertaining to:

 Physiologic needs (survival needs)

 Safety & security needs

 Love and belongingness needs

 Self-esteem needs

 Self-actualization needs

 3. Developmental Theories

 Several physical, psychosocial, cognitive and moral developmental theories may be

used in the specific situations.

 Havighurst’s age periods and developmental tasks

 Freud’s stages of development

 Erickson’s stages of development

 Piaget’s phases of cognitive development

 Kohlberg’s stages of moral development

 5. VALIDATING DATA
 Some important terms are:
 Validation:
 The act of “double-checking” or verifying
data to confirm that it is accurate and
factual.
 Helps the nurse complete the tasks.

ASSESSMENT:

 TERMS
 CUES

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  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.
 INFERENCES

 Are the nurse’s interpretation or conclusions made based on the

cues (e.g. A nurse observes the cues that an incision is red, hot,
and swollen; the nurse makes the inference that the incisio0n is
infected).

 6. DOCUMENTING DATA

 Essential and include all data collected about the client’s health status

 Data are recorded in a factual manner and not interpreted by a nurse.

NURSING HEALTH HISTORY

 Nursing Health History

A. Biographic Data
 Name
 Address
 Age
 Sex
 Race
 Marital Status
 Occupation
 Religious Orientation
 Health care financing and usual source of medical care
 Vital Signs
 Physical Assessment

The Interview Process

 Establish rapport
 Invite the patient’s story
 Establish the agenda of the interview
 Expand and clarify the health history
 Identify the possible nursing diagnosis
 Create a shared understanding of the nursing problem
 Plan for follow-up and closing

2. Nursing Diagnosis

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2. Nursing Diagnosis

 Analyze data/synthesizing data

 Identify health problems/risks and strengths
 Formulate diagnostic statements

I. Definition: Nursing Diagnosis

1. Bircher, 1975
 An independent nursing function
 An evaluation of client’s personal responses to human experience throughout the life cycle
(Bircher, 1975)
 Developmental
 Accidental
 Crises
 Illnesses
 Hardships, or other stresses
2. Gordon, 1982
 Actual or potential health problems that nurses, by virtue of their education and experience, are
able and licensed to treat.

3. Shoemaker, 1984
 A clinical judgment about an individual which the nurse is accountable
4. Carpenito, 1988
 A statement that describes the
 human response
 Health state
 Actual/potential altered interaction pattern of an individual group
 Which the nurses can legally identify for which the nurse can order the definitive
interventions
 To maintain the health state or to reduce, eliminate, or prevent alterations
5. NANDA, 1990
 A clinical judgment about individual, family or community to actual/potential health
problems/life processes
 Provides the basis for selection of nursing interventions
 To achieve outcomes for which the nurse is accountable

PURPOSE
-To identify client strengths and health problems that can be prevented or resolved by
collaborative and independent nursing interventions
To develop a list of nursing and collaborative problems.

ACTIVITIES
1. Interpret and analyze data.
-compare data against standards
-cluster or group data (generate tentative hypothesis)
-identify gaps and inconsistencies
2. Determine client’s strengths, risk, diagnosis, and problems

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 3. Formulate nursing diagnosis and collaborative problem statements.
4. Document nursing diagnosis on the care plan

II. How to make an Accurate Nursing Diagnosis

(Carpenito-Moyet, 2004)
a. Collect valid and pertinent data
b. Cluster the data
c. Differentiate Nursing Dx
d. Formulate Nursing Dx correctly
e. Select priority diagnosis

III. Types of Nursing Dx (Carpenito-Moyet, 2004)

1. Actual
 Describes a clinical judgment that the nurses has validated because of
the presence of major defining characteristics
 Example:
Ineffective Airway Clearance related to excessive and tenacious
secretions

2. Risk
 Describes a clinical judgment that an individual/group is more vulnerable to
develop the problem than others in the same or similar situation
 Example:
“Risk for Impaired Skin Integrity related to immobility secondary to fractured hip”

3. Wellness
 A clinical judgment about an individual, family, or community in transition
from a specific level of wellness to a higher level of wellness (NANDA)
 Example:
“Readiness for Enhanced Spiritual Well-being” or “Readiness for
Enhanced Family Coping”.

 Describes human responses to levels of wellness in an individual, family

or community that have a readiness for enhancement.
4. Possible
 One in which evidence about a health problem is incomplete or unclear.
 Example
 Possible social isolation to unknown etiology

5. Syndrome
 Associated with a cluster of other diagnosis
 Currently 6 syndrome diagnosis are on NANDA International list

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  Example: Risk for Disuse Syndrome associated with cluster
of diagnosis
 Impaired physical mobility
 Risk for impaired tissue integrity
 Risk for activity intolerance
 Risk for constipation
 Risk for infection
 Risk for injury cluster of diagnosis
 Impaired physical mobility
 Risk for impaired tissue integrity
 Risk for activity intolerance
 Risk for constipation
 Risk for infection
 Risk for injury
 Risk for powerlessness
 Impaired gas exchange, and so on

1. NANDA
Components of a NANDA Nursing Diagnosis:

 1. Problem (diagnostic label) and definition

 Describes the client’s health problem or response for which
nursing therapy is given
 Describes the client’s health status clearly and concisely in a
few words
 PURPOSE
 To direct the formation of client goals and desired outcomes.
It may also suggest some nursing intervention
 2. Etiology (related factors & risk factors)
 Identifies one or more probable cause of the health problem

 PURPOSE;
 Gives direction to the required nursing therapy and enables the nurse to
individualize the client’s care.
 3. Defining characteristics
 Cluster of signs and symptoms that indicate the presence of a particular
diagnostic label.
 Actual nursing diagnosis: the defining characteristics are the client’s signs and
symptoms
 Risk nursing diagnosis: no subjective & objective signs are present

Formulating Diagnostic Statements

 1. Basic One-Part Statement
 Consist of NANDA label only (some)

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  Wellness & Syndrome Diagnosis- labels are defined and tend to become
more specific, so that nursing interventions can be derived from the label
itself.
 Therefore, an etiology may not be needed
Example
 Adding an etiology to the label- Rape-Trauma Syndrome
does not make the label any more descriptive or useful
 2. Basic Two-Part Statement
 Problem (P): statement of the client’s response (NANDA Label)
 Etiology (E): factors contributing to or probable causes of responses
 The two parts are joined by the words related to rather than due to.

 The phrase due to implies that one-part causes or is responsible for the
other part.
 By contrast-
 The phrase related to merely implies a relationship.

Problem Related to Etiology

Constipation Related to Prolonged laxative use
Ineffective Related to Breast engorgement
breastfeeding

 3. Basic Three-Part Statement: PES format

 Problem (P): statement of the client’s response (NANDA Label)
 Etiology (E): factors contributing t or probable cause of the response
 Signs & Symptoms (S): defining characteristics manifested by the client

 ACTUAL Nursing Diagnosis can be documented by using the three-part statement

because the signs and symptoms have been identified.
 This format CANNOT be used for RISK diagnosis because the signs and symptoms of the
diagnosis.

Problem Related to Etiology As Manifested Signs/ Symptoms

Constipatio Related to r/t) Rejection by As manifested Hypersensitivity

n husband by (a.m.b) to criticism;
states: “I don’t
know if I can
manage by
myself’ and
rejects positive
feedback.

 Recommended for beginning diagnosticians because the signs and symptoms

validate why the diagnosis was chosen and make the problem statement more
descriptive.

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  The DISADVANTAGE
 can create very long problem statement, thereby making the
problem and etiology unclear.

RELATED FACTORS:

A. Concepts
a. Reflects a relationship between the first and the second parts of the statement.
b. Can be the contributing factors for actual diagnosis, or risk factors for risk and
possible diagnosis.
c. The more specific, the more specialized the interventions can be
d. Related factors are not new terms of medical diagnosis, medical pathology,
equipment, diagnostic studies.
e. Related factors are not written in terms of cues, inferences, goals, client needs,
nursing needs.
f. Related factors should avoid legally inadvisable/judgmental statements.
B. Types
a. Pathophysiologic
b. Treatment-related
c. Situational
d. Maturational

On-going Development of Nursing Diagnosis

 The diagnosis is no longer grouped by Gordon’s pattern but by SEVEN AXES:
1. Diagnostic concept
2. Time
3. Unit of Care
4. Age
5. Health Status
6. Descriptor
7. Topology

 In 1997, NANDA changed the name of its official journal from Nursing Diagnosis to Nursing
Diagnosis: The International Journal of Nursing Language and Classification.

1. The subtitle emphasizes that nursing diagnosis is part of a larger, developing system of
standardized nursing language.

 This system includes classification of:

1. Nursing Interventions (NIC) and

2. Nursing Outcomes (NOC) that are being developed by other research groups and
linked to the NANDA diagnostic labels

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2. The SEVEN AXES: Taxonomy II
Axes Dimension of the Values Examples
Human Responses

1 Diagnostic Concept N=99 Anxiety, falls, nutrition,

walking, etc.

2 Unit of Care N=4 Acute, chronic,

intermittent, continuous

3 Time N=4 Individual, family,

group, community

4 Age N=12 Infant, adolescent,

young, old adult, etc.

5 Health Status N-3 Wellness, sick, actual

6 Descriptor N=26 Anticipatory, deficient,

imbalanced, perceived,
etc.

7 Topology N=17 body parts/region Cerebral, gustatory,

renal, visual, etc.

3. THE PLANNING
PROCESS
3. Planning

 Definition
 A deliberate, systematic phase of the nursing process that involves
 Decision-making
 Problem-solving
 In planning, the nurse refers to the

 Client’s assessment data, and

 Diagnostic statements for direction in formulating client goals and designing the nursing
interventions required to

 Prevent

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  Reduce or eliminate the client’s health problems

 Planning involves making:

 Long-term goals
 Short-term goals
 Priority setting
 Formulation of objectives

PLANNING
 Prioritize problem/diagnosis
 Formulate goal/desired outcomes
 Select nursing interventions
 Write nursing interventions

PLANNING

 -Determining how to prevent, reduce, or resolve the identified client problems, how to
support client strengths; and how to implement nursing interventions in an organized,
individualized and goal-directed manner.

PURPOSE
To develop an individualized care plan that specifies client goals/desired outcomes, and
related nursing interventions.

ACTIVITIES
1. Set priorities and goals/outcomes in collaboration with client
2. Write goals/desired outcomes.
3. Select nursing strategies/interventions.
4. Consult other health professionals
5. Set priorities and goals/outcomes in collaboration with client
6. Write goals/desired outcomes.
7. Select nursing strategies/interventions.
8. Consult other health professionals

TYPES OF PLANNING

1. Types: Initial, On-going, Discharge

1. Initial Planning
a. Usually developed by the admitting nurse who performs the assessment
b. Planning should be initiated as soon as possible after the initial assessment, especially
because of the trend toward shorter hospital stays.

2. On-going Planning

a. Is done by all nurses who work with the client

b. Also occurs at the beginning of the shift as the nurse plans the care to be given that
day.

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3. Discharge Planning

a. The process of anticipating and planning for needs after discharge

b. Started upon admission of the patient

Developing a Nursing Care Plan

NURSING CARE PLAN: A written guide for nursing intervention which aims to assist the
patient to meet health needs and coordinate the care provided by the nursing staff. Its purpose is
to develop a plan of action that will reduce or eliminate patient’s problems and promote health.

 1. Informal Care Plan

 A strategy for action that exists in the nurse’s mind
 E.g.
 The nurse may think, “Mrs Cruz is very
tired. I will need to reinforce her teaching
after her rest.”
 2. Formal Care Plan

 A written or computerized guide that organizes information about the client’s

care

 3. Standardized Care Plan

 a formal plan that specifies the nursing care for groups of clients with common
needs

 E.g. All client’s with myocardial infarction

 4. Individualized Care Plan

 Tailored to meet the unique needs of a specific client needs that are not addressed
by the standardized plan

Standardized Approaches to Care Planning

 A. Standards of Care
 Describe nursing actions for clients with similar medical conditions rather
than individuals, they also describe achievable, rather than ideal nursing
care.
 Define the interventions for which nurses are held accountable that do not
contain medical interventions.
 Are usually agency records and not part of the client’s care plan, they may
be referred to in the plan.
 E.g.
 A nurse might write “see unit standards of care for cardiac catheterization.

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  B. Standardized Care Plans
 Are reprinted guides for the nursing care of the client who has a need that
arises frequently in the agency.
 E.g.
 A specific nursing diagnosis associated with
a particular medical condition
 Re-written from the perspective of what care the clients can expect.
 Should not be confused with standards of care.
 Both have some similarities and have important differences.

 C. Protocols
 Are reprinted to indicate the actions commonly required for a particular
group of clients
 E.g.
 An agency may have a protocol for
admitting a client to the ICU, for
administering magnesium sulfate to a client
with pre-eclampsia, or for caring for a client
receiving continuous epidural anesthesia
-May include both physicians & nursing interventions.

 D. Policies & Procedures

 Developed to govern the handling of frequently occurring situations
 E.g.
 A hospital may have a policy specifying the
number of visitors a client may have
 E. Standing Order

 A written document about policies, rules, regulations, or orders regarding client

care

 Give nurses the authority to carry out specific actions under certain
circumstances; often when a physician is not immediately available.

Formats for Nursing Care Plans

 Although formats differ from agency to agency, the care plan is often organized into four
(4) categories
 A. Nursing Diagnosis
 B. Goals/Desired Outcomes
 C. Nursing Orders
 D. Evaluation
 Some agencies use a three-column in which evaluation is done in the goal column or in
nurse’s notes, others have a five column plan that adds a column for assessment data
preceding the nursing diagnosis column

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Planning Process
 Nurse engages in the following activities:
 1. Setting Priorities
 The process of establishing preferential sequence for
addressing nursing diagnosis and interventions
 Nurses frequently use Maslow’s Hierarchy of Needs when
setting priorities
 2. Establishing Client Goals (desired outcomes)

 Describe, in terms of observable client responses, what the nurse hopes to

achieve by implementing the nursing interventions

 The term goal/desired outcome/ expected outcome/predicted outcome/outcome

criterion, and objective are used interchangeably

 Some nursing literatures differentiates the terms by defining goals as broad

statements about the clients’ status and desired outcomes as the more specific,
observable criteria used to evaluate whether the goals have been met.

 E.g.

 Goal (broad): improved nutritional status

 Desired Outcome (specific) Gain 5lb by June 25

 The Nursing Outcomes Classification (NOC)

 Outcomes belong to one of seven domains

 An NOC outcome is similar to a goal in traditional language

 Broadly stated and conceptual

 It is “a measurable patient or family caregiver state, behavior, or perception that

is conceptualized as a variable and is largely influenced by and sensitive to
nursing interventions.

 To be measured, an outcome must be made more specific by identifying the

specific indicators that apply to a client.

 INDICATOR is concrete, “observable patient state, behavior, or self-reported

perception or evaluation” and is similar to desired outcomes in traditional
language.

 Indicators are also stated in neutral terms, but each outcome includes a five-point
scale (a measure) that is used to rate the client’s status on each indicator.

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LONG-TERM and SHORT-TERM GOALS
TYPES:

1. Long-term goal
 Often used for clients who live at home and have chronic health problems
and for client’s in nursing homes, extended care facilities, and rehabilitation
center.
 Are outcomes that take an extended period of time to accomplish and
require nursing actions dealing directly with that goal.
 Example:
 Prevention of skin breakdown while on bedrest
 The nurse, then, plans nursing interventions that deal with this goal
and might include:
 Massage
 Frequent change of position
 Use of air mattress

2. Short-Term Goal

 Those that can be met in a relatively short period of time (a few

days or even a few hours.

 Useful for clients who require health care for a short time

 For clients who are frustrated by long-term goals that seem difficult
to attain and who need the satisfaction of achieving a short-term
goal

 Examples:

 Oral intake will be 1800 ml in 24 by 6/28

 Patient will demonstrate correct procedures for wrapping

ace bandage by 6/28

 Remember:

 A series of short-term goals maybe used to reach a long-

term goal

 Example:

 Long-term Goal: Patient will lose 25 lbs by 6/28

 Progressive Short-term Goals:

 Patient will weigh 148 lbs by 6/28

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  Patient will weight 146 lbs by 7/7

 Patient will weigh 144 lbs by 7/28

Guidelines for Writing Goals/Desired Outcomes

 1. write goals and outcomes in terms of client responses, not nurse activities
 2. beginning each goal statement with the client will, may help focus the goal on client
behaviors and responses
 Correct: client will drink 100cc of water per hour (client behavior)
 Incorrect: maintain client hydration (nursing action)
 3. be sure that desired outcomes are realistic for the client’s capabilities, limitations, and
designed time span, if it is indicated
 4. ensure that the goals and the desired outcomes are compatible with the therapies of other
professionals
 5. make sure that each goal is derived from only one nursing diagnosis.
 6. use observable, measurable, terms for outcomes.
 7. make sure the client considers the goals/desired outcomes important and values them

3. Selecting Nursing Interventions and Activities

 Nursing interventions and activities are actions that a nurse performs to
achieve client goals

D. INTERVENTION

D. Intervention

IMPLEMENTING
-Carrying out the planned nursing interventions

TYPES:

 Collaborative
 Independent Nursing Interventions

PURPOSE
To assist the client to meet desired goals/outcomes; promote wellness; prevent illness &
disease; restore health; and facilitate coping with related functioning.

ACTIVITIES
1. Reassess the client to update the data base.
2. Determine need for nursing assistance
3. Perform planned nursing interventions.
4. Communicate what nursing actions were implemented

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 -document care and client responses to care
-give verbal reports as necessary

1. Nursing Intervention Classification (NIC)

Need and Significance of Nursing Interventions Classification (NIC):

a. To standardize nomenclature of nursing treatment.
b. To expand nursing knowledge about links between diagnosis, treatments and
outcomes
c. To develop information systems for nursing and health care.
d. To teach decision-making.
e. To determine nursing costs.
f. To allocate nursing resources.
g. To communicate nursing to non-nurse.
h. To link nursing knowledge with classification systems of others.

2. Types: Independent, Dependent, Interdependent

Types of Nursing Interventions:

 A. Independent Interventions
 Also called “Nurse-Initiated Treatments
 Are activities that nurses are licensed to initiate on the basis of their
knowledge and skills.
 Include:
 Physical care
 on-going statement
 Emotional support and comfort
 Teaching, counselling
 Environmental management
 Making referrals to other health care
professionals
 B. Interdependent
 C. Dependent

3. Health Education

NURSING INTERVENTIONS CLASSIFICATION NIC TAXONOMY

1. Physiological: Basic (Care that supports physical functioning)

2. Physiological: Complex (Care that supports homeostatic regulation)
3. Behavioral: (Care that supports psychosocial functioning and facilities lifestyle changes)
4. Safety: (Care that supports protection against harm)
5. Family: (Care that supports the family units)
6. Health System: (Care that supports effective use of health care delivery system)

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FACTORS TO CONSIDER WHEN CHOOSING AN INTERVENTION

1. Desired patient outcomes

a. Patient outcomes should be specified before an intervention is chosen. They serve as
criteria against which to judge the success of a nursing intervention.
b. Outcomes describes behavior s, responses, feelings of the patient in response to the
care given
2. Characteristics of the nursing diagnosis
a. The intervention is directed toward altering the etiological factors associated with the
nursing diagnosis.
b. If the intervention is successful in altering the etiology, the patient’s status can be
expected to improve.
c. It is not always possible to change the etiological factors, and when this is the case, it
is necessary to treat the signs and symptoms (Bulecheck and McCloskey, 1992).
d. For potential or high risk nursing diagnosis, the intervention is aimed at altering or
eliminating the risk factors for diagnosis.
3. Research base for the intervention.
a. Research will indicate the effectiveness of using the intervention with certain
b. Some interventions have been widely tested for specific populations but many are
still at the concept development level.
c. If there is no research base to assist the nurse in choosing the interventions, use
scientific principles or consult experts ( e.g. infection transmission).
4. Feasibility of doing the intervention.
a. Feasibility concerns include how the particular intervention interacts with other
interventions, but those nurse and those other health care providers.
b. It is important that the nurse is involved in the total plan of care for the patient.
c. Critical feasibility concerns with the cost of the intervention and the time for the
implementation
5. Acceptability to the patient.
a. An intervention must be acceptable to the patient.
b. For each intervention, to facilitate an informed choice, the patient should be given all
the information about she/he is expected to participate. The patient’s values, beliefs
and culture must all be considered when choosing an intervention.
6. Capability of the nurse.
a. The nurse must be able to carry out that particular intervention.
b. There are three (3) areas in which the nurse must be competent. The nurse must:
i. Have the knowledge of the scientific rationale for the intervention.
ii. Possess the necessary psychomotor and interpersonal skills
iii. Be able to function within the particular setting to effectively use health care
resources (Bulechek and McCloskey)
c. No one nurse has the capability of doing all the interventions in the classification.
Many nurses perform within their specialty, there may be a need to refer or
collaborate with others.

NOTE:

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  As nurses we have to remember three major principles when caring for our
patients: comfort. safety, and privacy.
 Let us always remember to stay focused as we care for our patients and let us
use our MANUS, CAPUS and CORE and emphasize caring values

5. EVALUATION

E. Evaluation

 EVALUATING -measuring the degree to which goals/outcomes have been achieved and
identifying factors that positively or negatively influence goal achievement .

It can be:

 Formative
 Summative

PURPOSE
To determine whether to continue, modify or terminate the plan of care

ACTIVITIES
1. Collaborate with client and collect data related to desired outcomes.
2. Judge whether goals/outcomes have been achieved.
3. Relate nursing actions to client outcomes
4. Make decisions about problem status.
5. Review and modify the care plan as indicated or terminate nursing care
6. Document achievement of outcomes and modification of the care plan.

EVALUATION Types: Planned, On-going, Purposeful

1. On-going:
a. done while doing the intervention or immediately after the nursing intervention
b. do on-the-spot modification
2. Intermittent
a. Specified
b. Shows progress toward goal achieved
c. Correct the deficiencies and modify as needed
3. Terminal
a. Condition at the time of discharge

EVALUATION PROCESS:
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 1. Identify expected outcomes to measure goal achievement.
2. Collect data related to the expected outcomes.
3. Judge whether goals have been achieved.
4. Relating nursing actions to client outcomes.
5. Drawing conclusions related to problem status.
6. Reviewing and modifying the nursing care plan.

POSSIBLE CONCLUSIONS: RE-OUTCOME

1. GOAL was MET – resolved

2. GOAL was PARTIALLY MET – retain the problem, analyze, continue
3. GOAL was UNMET – What should the nurse do now?
a. Evaluate the whole process
b. Change the nursing approach
c. Re-assess the nursing diagnosis

DOCUMENTATION &
REPORTING

F. Documentation of Plan of Care

Documentation

 Written communication that permanently documents information relevant to client’s

health care management
 It is a continuing account of the client’s health needs.
 Legally, if nursing care is not documented it is presumed care was not provided.
 Using my version “What is NOT WRITTEN IS NOT DONE”

CHARACTERISTICS of DOCUMENTATION: (these are also considered as COMMON

ERRORS if NOT followed)

 Accuracy
o chart facts and exact observations
o do not chart opinions
 Conciseness
o Provide precise, essential information.
o Avoid unnecessary words and irrelevant detail.
o Do not chart the word “client” or “patient” it is understood the chart belongs to
the patient.
 Thoroughness

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 o Although concise, must contain complete information (e,g, IVF- name, infusing
or not,; rate (drops per minute), site (vein), location (Left or Right hand),
condition of the insertion site)
 Currentness
o Write activities when it occurs, decisions are made based on current condition
o Use accepted time system
 Organization
o Chronological or logical format, group together
 Legibility
o Clear. concise
 Confidentiality
o Privacy
 Always USE the CARE PLAN AS A BASIS OF CHARTING (ensures coordinated
care).

PROGRESS NOTES FORMAT:

 SOAPIE (subject- objective- assessment- plan- interventions- evaluation)

 PIE (problem- intervention- evaluation)
 Flow sheets – shows important clinical trend

CHECK YOUR STOCK KNOWLEDGE:

 IF YOU MAKE CHARTING ERRORS, YOU SHOULD:

o Use correction fluid to completely cover the error, then sign and date it.
o Erase the error completely, then initial and date it.
o Draw a single line through the error, write ‘mistaken entry” above and beside it, and
initial and date it.
o Use ink to completely cross out the error, then sign and date it.

o REMEMBER:
 Please AVOID COMMITTING ERRORS in documentation because the
patient chart is a legal document.

 Recording
 LEGAL GUIDELINES for RECORDING:
 Do not erase, apply correction fluid or scratch out an error made while recording.
 Charting becomes eligible, it may appear as though nurse was attempting
to hide into or deface the record.
 Do not write retaliatory or critical comments about the client or care of other
health care professionals.
 Can be used as evidence for non-professional behavior or poor quality of
care.
 Chart only objective descriptions of client’s behavior and care
administered.
 Correct all errors promptly

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  Errors in recording can lead to errors in treatment
 Avoid rushing to complete charting, be sure info is accurate.
 Record only facts
 Record must be accurate and reliable
 Entry is factual, do not speculate or guess
 Do not leave blank spaces
 Another person can add incorrect info to the space.
 Draw a line horizontally through the space and sign your name at
its end
 All record entries should be eligible and written in ink
 Eligible entries can be misinterpreted, causing errors and lawsuits, ink
cannot be erased.
 If you question an order, record that a clarification was sought
 If nurse performs an order known to be incorrect, the nurse is just as
liable
 Do not record “physician made an error,” instead chart that Dr.
Roxas was called to clarify order.
 Chart only for yourself
 Accountability is that of the nurse entering info
 Never chart for someone else.
 AVOID using generalized empty phrases such as “status unchanged” or “had a
good day”
 If too generalized info may be deleted
 Use complete, concise descriptions of care
 Begin each entry with the date and time and end with your signature and title.
 Ensures correct sequence of events is recorded
 Do not wait until the end of shift to record important changes
that occurred several hours earlier. Be sure to sign.

NURSES NOTES REQUIREMENTS FOR REIMBURSEMENT

 Identification of medical purpose to the message

 Statement of skilled cared rendered
 Identification of the instruction of the skilled activity to client and primary care giver with a
return demo establishing learner’s comprehension.
 Concise and factual info
 Elimination of all subjective statements
 Avoidance of words that suggest a chronic condition: on-going, repeatedly, continues,
monitor, stable.

POST-TEST
Mastery:
Part I. Essay Test
Directions: Explain each question, before you begin writing, read the statement
carefully and plan what you will say. Your essay should be as well organized and as
carefully written as you can make it. Challenge yourself. Use your own words. Do not
google your answer. Remember, this is a post-test. (10 points each question)

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 1. What do you mean by the definition of Nursing Process as a dynamic way of
thinking of the nurse.
______________________________________________________________

2. Discuss why nursing process is considered a tool by nurses in providing

quality patient care?
______________________________________________________________
______________________________________________________________

3. Explore and discuss why is evaluation is important in nursing practice?

______________________________________________________________
______________________________________________________________

FEEDBACK
How was the lesson? Were you able to understand the lesson, answer the
activities /post-test and met the learning objectives? If you were able to do it without
difficulty, congratulations! You’re now ready with the next lesson.

SUMMARY
Lesson 3 presents a detailed summary of the Nursing Process, with the discussion of the
different steps of assessment, nursing diagnosis, planning, implementation and evaluation, including
documentation and reporting.

REFERENCES:
1. Kozier and Erb, Fundamentals of Nursing: Process, Concepts, and Practice. 10 th
edition. Upper Saddle River, N. J.: Pearson Prentice Hall, 2016.
2. Potter, P.A. & Perry, A. G. Fundamentals of Nursing. 9th edition. St. Louis:
Elsevier/Mosby, 2017.

Recommended Follow-Up/Readings:
To reinforce your understanding of the material, you are encouraged to review/read the
following:
1. Nursing Process in the references listed above.

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