UNIT 2 The Nursing Process
The Nursing Process is a systematic, evidence-based method used by nurses to provide individualized, patient-centered care. It serves as a framework for delivering safe, efficient, and high-quality nursing care. This process is dynamic and cyclical, consisting of five interrelated steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
The American Nurses Association (ANA) defines the nursing process as: “A critical thinking model that integrates the best evidence, clinical expertise, and patient preferences to provide individualized nursing care.”
It is a problem-solving approach that ensures continuity of care, accountability, and scientific reasoning in nursing practice.
Example: “Impaired skin integrity related to prolonged immobility as evidenced by pressure ulcers on the sacral region.”
Example: “By the end of three days, the patient will demonstrate improved pain control with a pain score of less than 3 on a scale of 10.”
Example: Administering analgesics to reduce pain, repositioning the patient to prevent bedsores, and educating the patient on deep breathing exercises.
Example: “After three days of repositioning and skincare interventions, the patient’s sacral ulcer has decreased in size by 20%.”
Critical thinking is an essential skill for nurses, allowing them to make sound clinical decisions, provide quality patient care, and respond effectively to complex healthcare situations. It involves analyzing, reasoning, problem-solving, evaluating evidence, and making informed decisions based on clinical experience and scientific knowledge.
According to the American Nurses Association (ANA): “Critical thinking in nursing is a purposeful, self-regulatory process that ensures clinical reasoning, judgment, and problem-solving for quality patient outcomes.”
Critical thinking competencies are intellectual skills that enable nurses to think analytically and solve problems effectively in clinical practice. These competencies can be categorized into three broad types:
These are the fundamental reasoning abilities applicable in all disciplines, including nursing.
The scientific method is a structured, logical approach used in research and nursing problem-solving. It includes:
Example: A nurse notices a patient experiencing shortness of breath and uses the scientific method to investigate the cause, test interventions (oxygen therapy), and evaluate patient improvement.
Problem-solving involves identifying a patient issue, evaluating possible solutions, and selecting the most effective action.
Example: A nurse observes a post-surgical patient with increasing pain despite medication and explores possible reasons (infection, medication effectiveness, positioning).
Decision-making is a deliberate process of choosing the best action from available options based on patient needs.
Steps in Decision-Making:
Example: A nurse must decide whether to administer pain medication or use non-pharmacological pain relief measures (heat therapy, repositioning) based on the patient’s condition.
These competencies apply directly to nursing practice and patient care.
Example: A nurse notices wheezing and labored breathing in a patient and infers that the patient may have an asthma attack, leading to appropriate interventions.
Example: A nurse in an emergency room prioritizes a patient with chest pain over a patient with a minor wound.
The Nursing Process (ADPIE) requires critical thinking competencies at each step.
| Step | Critical Thinking Competency Required |
|---|---|
| Assessment | Data collection, observation, interviewing, interpretation. |
| Diagnosis | Analyzing patterns, making clinical inferences. |
| Planning | Setting priorities, goal formulation, predicting outcomes. |
| Implementation | Selecting evidence-based interventions, problem-solving. |
| Evaluation | Measuring patient response, modifying care plans. |
Example: A nurse assesses a post-operative patient and, noticing low urine output, applies critical thinking to determine whether it is due to dehydration or kidney dysfunction.
| Nursing Specialty | Application of Critical Thinking |
|---|---|
| Medical-Surgical Nursing | Analyzing post-op complications, infection control. |
| Critical Care Nursing | Quick decision-making in emergencies. |
| Mental Health Nursing | Assessing patient behavior, therapeutic communication. |
| Community Health Nursing | Evaluating health promotion programs. |
| Pediatric Nursing | Recognizing developmental delays. |
Critical thinking in nursing is not just about having cognitive skills; it also involves adopting certain attitudes that support logical reasoning, sound clinical judgment, and effective decision-making. These attitudes guide how nurses approach problems, evaluate evidence, and interact with patients and colleagues.
Attitudes for critical thinking refer to dispositions or mindsets that enhance a nurse’s ability to analyze situations objectively, question assumptions, and remain open-minded while making clinical decisions.
The following attitudes are crucial in fostering critical thinking and improving nursing practice:
Critical thinking in nursing is a hierarchical process that develops over time with experience, education, and exposure to clinical scenarios. Patricia Benner’s “Novice to Expert” theory and Kataoka-Yahiro and Saylor’s Model describe how nurses progress in their critical thinking abilities.
Understanding these levels helps nurses evaluate their thinking skills and improve their clinical decision-making to provide safe and effective patient care.
According to Kataoka-Yahiro and Saylor’s Model (1994), there are three levels of critical thinking in nursing:
✅ Example:
A new graduate nurse follows the step-by-step procedure for inserting a Foley catheter but doesn’t adjust for patient discomfort or other clinical signs.
✅ Example:
A nurse is caring for a post-operative patient experiencing pain despite receiving prescribed pain medication. Instead of blindly administering another dose, the nurse assesses the patient further and considers repositioning, heat therapy, or distraction techniques before escalating medication.
✅ Example:
An ICU nurse notices subtle changes in a patient’s vital signs that indicate early signs of sepsis before lab results confirm infection. The nurse advocates for early intervention, preventing complications.
The Nursing Process is a systematic, patient-centered, and goal-oriented method used by nurses to provide high-quality, individualized care. It serves as the foundation of nursing practice, ensuring that patient needs are identified, interventions are planned and implemented, and outcomes are evaluated.
This process follows a structured five-step model known as ADPIE:
Assessment is the first and most critical step in the nursing process (ADPIE). It involves systematic data collection to understand the patient’s health status, identify actual or potential health problems, and establish a baseline for care planning.
Definition of Nursing Assessment:
“Assessment is the collection, validation, and interpretation of patient data to identify health problems and plan effective nursing care.”
Nursing assessments are categorized into different types based on the timing and purpose of data collection.
✅ Example:
A nurse conducts a comprehensive assessment of a newly admitted diabetic patient, including blood sugar levels, dietary habits, physical activity, and medication compliance.
✅ Example:
A patient reports shortness of breath. The nurse performs a focused respiratory assessment, including lung auscultation, oxygen saturation measurement, and checking for signs of cyanosis.
✅ Example:
A nurse monitors a postoperative patient’s pain levels, wound healing, and vital signs at regular intervals.
✅ Example:
A patient in the ER with a suspected heart attack undergoes an emergency assessment, including ECG, vital signs, oxygen levels, and pain evaluation.
Data is collected from various sources using different techniques.
Nurses use four fundamental techniques for a systematic physical examination.
A comprehensive health history includes the following:
✅ Example of Documentation (SOAP Format):
S: “I have been feeling extremely weak and dizzy for the past three days.”
O: BP: 90/60 mmHg, HR: 105 bpm, pale skin.
A: Risk for dehydration related to decreased fluid intake.
P: Encourage oral fluids, monitor electrolytes, administer IV fluids if needed.
Solution:
Data collection is the first and most crucial step in the assessment phase of the nursing process (ADPIE). It involves gathering, verifying, and documenting information to establish a comprehensive understanding of the patient’s health status.
Proper data collection enables nurses to:
Nursing data is classified into two main types based on how the information is obtained.
✅ Importance: Helps understand the patient’s perceptions, beliefs, and emotions about their health.
✅ Importance: Provides factual evidence that supports subjective data and aids in accurate diagnosis.
Data can come from different primary and secondary sources, depending on the availability and reliability of the information.
✅ Best for: Health history, pain assessment, emotional status.
✅ Best for: Chronic illness history, previous treatments, medication history.
✅ Best for: Planning interventions, clinical guidelines, and research.
There are various ways to collect patient data, categorized into interviewing, observation, physical examination, and diagnostic tests.
✅ Best for: Subjective data collection (patient history, lifestyle, concerns).
✅ Best for: Detecting non-verbal symptoms, mental status, and emergency conditions.
✅ Best for: Diagnosing respiratory, cardiac, and abdominal issues.
✅ Best for: Confirming infections, organ dysfunction, metabolic disorders.
✅ Solutions:
Organizing data is a crucial step in the nursing assessment process. It involves systematically arranging collected patient information to ensure accurate analysis, proper diagnosis, and effective care planning. Proper organization helps in identifying patterns, prioritizing issues, and documenting findings clearly and efficiently.
Data can be organized using different frameworks and models to provide clarity and efficiency in patient assessment.
Developed by Marjory Gordon, this model categorizes patient data into 11 functional health patterns to ensure a comprehensive assessment.
| Functional Health Pattern | Example Data |
|---|---|
| Health Perception–Health Management | Patient’s beliefs about health, past illnesses, adherence to medication. |
| Nutritional-Metabolic | Dietary habits, fluid intake, BMI, lab values (glucose, electrolytes). |
| Elimination | Bowel and bladder function, urinary incontinence, constipation. |
| Activity-Exercise | Mobility, exercise habits, fatigue, ADLs (Activities of Daily Living). |
| Sleep-Rest | Sleep quality, insomnia, use of sleep aids. |
| Cognitive-Perceptual | Memory, problem-solving ability, sensory deficits (vision, hearing). |
| Self-Perception–Self-Concept | Body image, self-esteem, emotional status. |
| Role-Relationship | Family roles, social support, occupational history. |
| Sexuality-Reproductive | Menstrual history, sexual activity, reproductive health. |
| Coping-Stress Tolerance | Stress management, coping strategies, anxiety levels. |
| Value-Belief | Cultural, spiritual, and religious beliefs influencing health decisions. |
✅ Best for: Comprehensive and holistic patient assessments.
This model organizes data based on body systems, similar to a head-to-toe assessment.
| Body System | Example Data |
|---|---|
| Neurological | Consciousness level, reflexes, motor function, sensory function. |
| Cardiovascular | Blood pressure, pulse, heart sounds, peripheral circulation. |
| Respiratory | Breath sounds, oxygen saturation, coughing, shortness of breath. |
| Gastrointestinal | Bowel sounds, appetite, nausea, vomiting, stool patterns. |
| Genitourinary | Urinary frequency, incontinence, pain during urination. |
| Musculoskeletal | Muscle strength, joint mobility, posture, gait. |
| Integumentary (Skin) | Skin color, temperature, lesions, wounds, pressure ulcers. |
| Endocrine | Blood glucose levels, thyroid function, diabetes management. |
✅ Best for: Organizing physical examination findings and diagnostic test results.
Maslow’s model prioritizes data based on the urgency of human needs, from basic survival to psychological and self-fulfillment needs.
| Maslow’s Level | Example Data |
|---|---|
| Physiological Needs | Airway, breathing, circulation (ABC), food, hydration, sleep, pain. |
| Safety Needs | Fall risk, infection control, medication safety. |
| Love/Belonging Needs | Social relationships, emotional support, mental health concerns. |
| Esteem Needs | Confidence, self-worth, independence in ADLs. |
| Self-Actualization Needs | Personal growth, goal-setting in recovery. |
✅ Best for: Prioritizing nursing diagnoses and interventions.
The SOAP method structures nursing documentation for clarity and efficiency.
| Component | Example Documentation |
|---|---|
| S (Subjective Data) | “Patient reports severe headache and nausea since this morning.” |
| O (Objective Data) | BP: 150/90 mmHg, HR: 100 bpm, Temp: 101°F. |
| A (Assessment) | Risk for dehydration due to persistent nausea and vomiting. |
| P (Plan) | Administer IV fluids, monitor hydration status, educate patient on fluid intake. |
✅ Best for: Structuring progress notes and medical records.
This method focuses on nursing interventions and their effectiveness.
| Component | Example Documentation |
|---|---|
| P (Problem) | “Patient has an elevated temperature of 102°F due to infection.” |
| I (Intervention) | “Administered prescribed antibiotics and encouraged fluid intake.” |
| E (Evaluation) | “Temperature reduced to 99°F, patient reports feeling better.” |
✅ Best for: Tracking nursing care effectiveness.
The DAR format is used for focused charting on specific patient issues.
| Component | Example Documentation |
|---|---|
| D (Data) | “Patient reports pain level of 8/10 in the lower back.” |
| A (Action) | “Administered analgesics as per prescription and repositioned patient.” |
| R (Response) | “Pain reduced to 4/10 within 30 minutes, patient comfortable.” |
✅ Best for: Documenting problem-focused nursing actions.
| Challenge | Solution |
|---|---|
| Large volumes of data | Use electronic health records (EHRs) for efficient storage and retrieval. |
| Inconsistent documentation | Train staff to use standardized formats (SOAP, PIE, DAR). |
| Difficulty in prioritization | Apply Maslow’s Hierarchy or Gordon’s Functional Patterns. |
| Communication barriers | Use structured handoff reports (e.g., SBAR – Situation, Background, Assessment, Recommendation). |
Data validation in nursing assessment ensures that the information collected is accurate, complete, and reliable before making clinical decisions. It involves double-checking, cross-referencing, and confirming data to prevent errors in diagnosis and treatment.
🔹 Why is Data Validation Important?
Data validation is the process of verifying that collected patient data is complete, accurate, and consistent before using it for diagnosis and treatment. It involves:
✅ Example:
A patient says they are not in pain (subjective data), but their facial expressions and BP of 160/100 mmHg suggest otherwise (objective data). The nurse must validate this discrepancy before concluding.
Not all data needs validation, but certain types require further confirmation, including:
✅ Example:
A nurse notices a pulse rate of 40 bpm in a healthy athlete. Since this is lower than normal, it should be validated by checking past medical history to confirm if the patient has bradycardia due to fitness.
✅ Example:
A patient reports no fever, but the nurse measures a temperature of 101°F. Further validation is needed to determine if the patient is aware of symptoms or if the reading is incorrect.
✅ Example:
A patient claims to have no difficulty breathing, but the nurse observes nasal flaring, labored breathing, and wheezing. This requires further validation.
If data is unclear, cross-check with:
✅ Example:
A patient with memory loss states they are not on any medications, but their medical records show they are on hypertension treatment. The nurse validates the information by confirming with family members.
✅ Example:
A patient with diabetes reports no symptoms of hypoglycemia, but their blood sugar is dangerously low (40 mg/dL). The nurse reassesses symptoms and prepares for intervention.
| Error Type | Example | Solution |
|---|---|---|
| Incorrect Recording | BP recorded as 180/60 mmHg instead of 120/80 mmHg. | Recheck BP and document accurately. |
| Conflicting Data | Patient reports no pain, but grimaces and holds their abdomen. | Use pain assessment scales for validation. |
| Incomplete Information | Patient doesn’t recall medications they take. | Check medical records and family reports. |
| Unrealistic Findings | Oxygen saturation at 50%, but the patient is talking normally. | Reassess with a different pulse oximeter. |
❌ Inaccurate Nursing Diagnosis – Misinterpretation can lead to incorrect care plans.
❌ Delayed or Wrong Treatment – Can cause serious complications.
❌ Patient Safety Risks – Medication errors, misdiagnosed conditions.
❌ Legal and Ethical Issues – Poor documentation can result in malpractice claims.
✅ Example of Consequence:
A nurse documents a blood glucose level of 30 mg/dL but does not validate it. The patient later becomes unconscious due to undetected hypoglycemia. This could have been prevented with proper validation.
✔ Always double-check abnormal findings.
✔ Use multiple assessment tools for accuracy.
✔ Compare subjective and objective data.
✔ Consult colleagues or senior healthcare professionals when in doubt.
✔ Ensure clear, accurate documentation.
Documentation is a vital part of the nursing process, ensuring that patient data is accurately recorded, communicated, and stored for future reference. Proper documentation improves patient safety, legal protection, continuity of care, and quality improvement.
“Nursing documentation is the process of systematically recording patient health information, nursing assessments, interventions, and outcomes in a clear, accurate, and timely manner.”
🔹 Ensures continuity of care: Helps in tracking patient progress across shifts and handovers.
🔹 Improves communication: Facilitates coordination among healthcare professionals.
🔹 Provides legal evidence: Serves as proof of care in case of legal disputes.
🔹 Supports clinical decision-making: Aids in diagnosis, treatment, and nursing interventions.
🔹 Enhances research and quality improvement: Helps in audits and policy formulation.
✅ Example: A nurse records a patient’s blood pressure trend, helping the physician adjust hypertension treatment.
✔ Accurate: Use correct details, avoid errors.
✔ Complete: Include all relevant information.
✔ Timely: Document immediately after care.
✔ Legible: Ensure readability (if handwritten).
✔ Objective: Focus on facts, not opinions.
✔ Standardized: Follow hospital protocols (e.g., SOAP, PIE).
✔ Confidential: Protect patient privacy (HIPAA compliance).
✅ Example:
Instead of: “Patient seems anxious.”
Use: “Patient stated, ‘I feel very nervous,’ HR: 110 bpm, pacing in the room.”
✅ Best for: Standardized and problem-oriented documentation.
✅ Best for: Tracking patient responses to nursing care.
✅ Best for: Problem-based charting with quick reference.
✅ Best for: Routine documentation in stable patients.
✅ Best for: Modern hospitals with integrated healthcare systems.
| Category | What to Include |
|---|---|
| Patient Information | Name, age, gender, medical record number. |
| Vital Signs | Temperature, pulse, respiration, BP, SpO₂. |
| Assessment Findings | Physical, emotional, cognitive status. |
| Nursing Diagnosis | Identified health problems. |
| Interventions | Medications, wound care, therapies provided. |
| Patient Response | Pain reduction, wound healing, symptom relief. |
| Education Provided | Health teaching, discharge instructions. |
| Communication with Team | Physician updates, handovers. |
✅ Example:
“BP 150/90 mmHg, HR 110 bpm. Patient reports headache and dizziness. Administered antihypertensive medication as per order. BP reduced to 130/80 mmHg after 30 minutes.”
🔹 Confidentiality (HIPAA Compliance):
🔹 Accuracy and Truthfulness:
🔹 Timeliness:
✅ Example:
Instead of: “Patient was given medication at some point in the morning.”
Use: “09:30 AM – Administered 500 mg acetaminophen PO as per order.”
| Error Type | Example | Solution |
|---|---|---|
| Omissions | Forgetting to document medication administration. | Chart immediately after action. |
| Inaccurate Data | Recording “normal heart sounds” without auscultating. | Verify all data before recording. |
| Vague Language | Writing “patient is better” instead of “pain reduced from 7/10 to 3/10.” | Use precise, measurable terms. |
| Illegible Writing | Poor handwriting leads to misinterpretation. | Use electronic documentation or clear handwriting. |
Nursing diagnosis is a critical step in the nursing process (ADPIE) that helps identify patient problems and guide nursing interventions. It involves analyzing assessment data to determine the patient’s actual or potential health issues.
Definition of Nursing Diagnosis (NANDA-I, 2021):
“A nursing diagnosis is a clinical judgment about the patient’s response to actual or potential health problems or life processes, providing the basis for selecting nursing interventions to achieve desired outcomes.”
🔹 Why is Nursing Diagnosis Important?
✅ Example: Instead of just noting “high blood sugar”, a nurse identifies “Risk for unstable blood glucose levels related to poor dietary habits and medication non-compliance.”
According to the North American Nursing Diagnosis Association-International (NANDA-I), nursing diagnoses are classified into four major types:
✅ Best for: Immediate nursing interventions (e.g., wound care, pain management).
✅ Best for: Preventive nursing care (e.g., hygiene, wound monitoring).
✅ Best for: Health education and lifestyle modifications.
✅ Best for: Complex health conditions requiring multidisciplinary care.
A complete nursing diagnosis statement follows the PES format:
| Component | Description | Example |
|---|---|---|
| P (Problem) | The patient’s health issue. | “Impaired mobility” |
| E (Etiology) | The cause of the problem. | “Related to stroke” |
| S (Signs/Symptoms) | Evidence supporting the diagnosis. | “As evidenced by muscle weakness in the right leg and inability to walk independently.” |
✅ Final Diagnosis: “Impaired mobility related to stroke as evidenced by muscle weakness in the right leg and inability to walk independently.”
✅ Example: A nurse observes that a postoperative patient has fever, redness, and swelling around a surgical wound → This suggests a potential infection.
✅ Example: The postoperative patient is at high risk for infection → The nurse writes “Risk for infection related to surgical incision.”
✅ Final Diagnosis: “Risk for infection related to surgical incision and compromised immunity.”
✅ Example: “Ineffective airway clearance due to excessive mucus production” takes priority over “Disturbed sleep pattern.”
| Category | Example Diagnosis (PES Format) |
|---|---|
| Respiratory | “Ineffective airway clearance related to excessive mucus as evidenced by wheezing and productive cough.” |
| Cardiac | “Decreased cardiac output related to myocardial infarction as evidenced by weak pulse and low BP.” |
| Neurological | “Risk for falls related to dizziness and impaired balance.” |
| Pain Management | “Acute pain related to surgical incision as evidenced by facial grimacing and patient’s pain rating of 8/10.” |
| Nutrition | “Imbalanced nutrition: less than body requirements related to decreased appetite as evidenced by weight loss and low serum albumin levels.” |
| Mental Health | “Disturbed sleep pattern related to anxiety as evidenced by difficulty falling asleep and reports of restlessness.” |
| Feature | Nursing Diagnosis | Medical Diagnosis |
|---|---|---|
| Focus | Patient’s response to illness | Disease condition |
| Who Makes It? | Nurse | Doctor |
| Example | “Impaired gas exchange related to pneumonia” | “Pneumonia” |
| Scope of Treatment | Nursing interventions (oxygen therapy, positioning) | Medical interventions (antibiotics, bronchodilators) |
✅ Key Point: Nurses do not diagnose diseases; they diagnose how a disease affects the patient and how to care for them.
🚫 Using a medical diagnosis instead of a nursing diagnosis.
❌ Wrong: “Diabetes Mellitus”
✅ Right: “Risk for unstable blood glucose levels related to insulin resistance.”
🚫 Writing vague or general statements.
❌ Wrong: “Patient is in pain.”
✅ Right: “Acute pain related to surgical incision as evidenced by patient’s grimacing and pain score of 7/10.”
🚫 Failing to individualize the diagnosis.
❌ Wrong: “Risk for infection.”
✅ Right: “Risk for infection related to presence of indwelling catheter and poor hygiene.”
The identification of client problems is a critical step in the nursing process (ADPIE). It involves analyzing assessment data to determine actual and potential health issues that require nursing intervention. This step is essential for formulating accurate nursing diagnoses and creating effective care plans.
“Client problem identification is the process of recognizing physical, psychological, social, and environmental factors affecting a patient’s health and well-being, leading to the development of a nursing diagnosis.”
🔹 Ensures early detection of health risks and complications.
🔹 Helps prioritize patient needs for immediate and long-term care.
🔹 Guides the selection of appropriate nursing interventions.
🔹 Enhances patient safety, comfort, and quality of life.
🔹 Supports effective communication between nurses, doctors, and healthcare teams.
✅ Example: A patient reports severe pain after surgery. The nurse identifies acute pain as a client problem, leading to interventions like pain medication, repositioning, and relaxation techniques.
The identification of client problems follows a systematic approach, starting from data collection to problem validation.
✅ Example: If a patient reports frequent urination and lab results show elevated blood glucose levels, the nurse identifies a problem related to diabetes.
✅ Example: If a patient’s oxygen saturation is 85% (normal is 95%-100%), the nurse identifies a problem with respiratory function.
| Type of Problem | Description | Example |
|---|---|---|
| Actual Problem | A present health issue requiring immediate attention. | “Impaired skin integrity due to pressure ulcers.” |
| Potential Problem (Risk) | A condition that may develop if no intervention is taken. | “Risk for infection due to surgical wound.” |
| Health Promotion Need | A need related to improving the patient’s health status. | “Readiness for enhanced nutrition to improve dietary habits.” |
✅ Example: A patient denies feeling anxious, but heart rate is 110 bpm, and they are restless. The nurse validates anxiety as a client problem.
| Priority Level | Example |
|---|---|
| High Priority (Life-threatening) | “Ineffective airway clearance due to respiratory distress.” |
| Medium Priority (Urgent but not life-threatening) | “Acute pain after surgery.” |
| Low Priority (Long-term health goals) | “Knowledge deficit about diabetes management.” |
✅ Example: A patient with difficulty breathing takes priority over a patient with mild discomfort.
Client problems can be classified into physical, psychological, social, and environmental categories.
| Category | Example |
|---|---|
| Respiratory | “Ineffective breathing pattern due to pneumonia.” |
| Cardiovascular | “Decreased cardiac output related to heart failure.” |
| Neurological | “Risk for falls due to dizziness and impaired balance.” |
| Musculoskeletal | “Impaired mobility due to arthritis.” |
| Pain Management | “Acute pain related to post-surgical incision.” |
| Integumentary (Skin) | “Risk for infection due to open wound.” |
| Category | Example |
|---|---|
| Anxiety and Stress | “Anxiety related to upcoming surgery.” |
| Depression | “Hopelessness related to chronic illness.” |
| Cognitive Impairment | “Confusion related to Alzheimer’s disease.” |
| Sleep Disturbances | “Disturbed sleep pattern due to hospital environment.” |
| Category | Example |
|---|---|
| Family and Relationship Issues | “Ineffective family coping related to patient’s chronic illness.” |
| Economic Barriers | “Ineffective health maintenance due to financial constraints.” |
| Cultural or Religious Factors | “Noncompliance with medication due to cultural beliefs.” |
| Environmental Risks | “Risk for falls due to cluttered home environment.” |
✅ Example: A homeless patient with poor hygiene and malnutrition has social and environmental problems that affect their overall health.
To systematically identify client problems, nurses use various tools and assessment methods:
| Tool | Purpose |
|---|---|
| NANDA-I Nursing Diagnosis | Provides standardized nursing diagnoses for common client problems. |
| Gordon’s Functional Health Patterns | Identifies issues in nutrition, sleep, mobility, and self-care. |
| Maslow’s Hierarchy of Needs | Helps prioritize basic physiological needs before psychosocial issues. |
| Braden Scale | Assesses risk for pressure ulcers. |
| Glasgow Coma Scale (GCS) | Evaluates level of consciousness. |
| Pain Scale (0-10) | Measures pain intensity to determine pain management needs. |
✅ Example: A patient with a Braden Scale score of 10 is at high risk for pressure ulcers, requiring urgent intervention.
🚫 Relying only on subjective data without validation.
❌ “Patient says they have no pain,” but their BP and facial expressions suggest otherwise.
✅ Validate with objective findings.
🚫 Using medical diagnoses instead of nursing problems.
❌ “Diabetes mellitus” is a medical diagnosis, not a nursing problem.
✅ Use: “Risk for unstable blood glucose levels related to poor dietary adherence.”
🚫 Failing to prioritize urgent problems.
❌ Focusing on sleep disturbances while ignoring a patient’s respiratory distress.
✅ Address life-threatening issues first.
Risk identification in nursing involves recognizing potential health problems that may develop if no preventive measures are taken. By identifying risks early, nurses can implement interventions to minimize complications and enhance patient safety.
“Client risk identification is the process of assessing a patient’s physical, psychological, social, and environmental factors to determine potential health hazards and prevent complications.”
🔹 Prevents adverse health outcomes before they occur.
🔹 Improves patient safety and reduces hospital complications.
🔹 Helps in prioritizing nursing interventions.
🔹 Enhances early detection and prevention strategies.
🔹 Supports evidence-based nursing practice.
✅ Example: A patient with immobility is at risk for pressure ulcers. Early identification leads to preventive repositioning and skin care interventions.
The identification of client risks follows a systematic approach similar to the assessment phase of the nursing process.
✅ Example: A patient with a history of smoking and high cholesterol is at risk for cardiovascular disease.
Risk factors can be classified into modifiable (can be changed) and non-modifiable (cannot be changed) categories.
| Category | Examples |
|---|---|
| Modifiable Risk Factors | Smoking, poor diet, lack of exercise, high stress levels, medication non-adherence. |
| Non-Modifiable Risk Factors | Age, genetics, family history, gender, pre-existing conditions (e.g., diabetes, hypertension). |
✅ Example: A 65-year-old diabetic is at high risk for foot ulcers, requiring early foot care education and monitoring.
Nurses use standardized scales and risk assessment tools to determine the level of risk for different health problems.
| Risk Factor | Assessment Tool | Purpose |
|---|---|---|
| Pressure Ulcers | Braden Scale | Assesses skin integrity risks. |
| Falls | Morse Fall Scale | Determines fall risk. |
| Deep Vein Thrombosis (DVT) | Wells Score | Evaluates risk for blood clots. |
| Malnutrition | Mini Nutritional Assessment | Detects risk for undernutrition. |
| Mental Health Risks | Geriatric Depression Scale | Screens for depression in elderly patients. |
✅ Example: A Braden Scale score of 12 indicates high risk for pressure ulcers, leading to early repositioning and skin monitoring interventions.
✅ Example: A pregnant woman with high BP needs further evaluation for preeclampsia risk.
Not all risks require immediate intervention. Use Maslow’s Hierarchy of Needs and nursing judgment to prioritize.
| Priority Level | Example Risk |
|---|---|
| High Priority (Life-threatening risks) | “Risk for ineffective airway clearance due to severe asthma attack.” |
| Medium Priority (Potential complications requiring close monitoring) | “Risk for infection due to post-surgical wound.” |
| Low Priority (Long-term risks, lifestyle factors) | “Risk for social isolation related to hearing impairment.” |
✅ Example: A patient at risk for aspiration due to swallowing difficulties needs immediate intervention (positioning, dietary changes).
Client risks can be categorized based on physical, psychological, social, and environmental factors.
| Category | Example Risk |
|---|---|
| Respiratory Risks | “Risk for aspiration due to difficulty swallowing.” |
| Cardiovascular Risks | “Risk for decreased cardiac output related to heart failure history.” |
| Neurological Risks | “Risk for falls related to post-stroke weakness.” |
| Musculoskeletal Risks | “Risk for impaired mobility due to arthritis.” |
| Integumentary Risks (Skin) | “Risk for pressure ulcer development in bedridden patients.” |
✅ Example: A bedridden patient with diabetes is at high risk for bedsores and infection, requiring preventive wound care.
| Category | Example Risk |
|---|---|
| Anxiety and Depression Risks | “Risk for hopelessness related to chronic illness.” |
| Cognitive Impairment Risks | “Risk for injury related to confusion and disorientation.” |
| Suicide Risks | “Risk for self-harm due to major depressive disorder.” |
✅ Example: A patient with severe depression and social withdrawal is at high risk for suicide, requiring mental health intervention.
| Category | Example Risk |
|---|---|
| Family and Relationship Risks | “Risk for caregiver role strain related to elderly patient care.” |
| Economic Risks | “Risk for non-compliance with treatment due to financial constraints.” |
| Cultural or Religious Risks | “Risk for health-seeking delay due to cultural beliefs about illness.” |
| Environmental Hazards | “Risk for injury due to cluttered home and poor lighting.” |
✅ Example: An elderly patient living alone has a high risk for falls, requiring home safety modifications.
Nurses use evidence-based tools to systematically assess risks.
| Assessment Tool | Purpose |
|---|---|
| Braden Scale | Assesses risk for pressure ulcers. |
| Morse Fall Scale | Identifies risk of falls. |
| Glasgow Coma Scale (GCS) | Evaluates consciousness level. |
| Mini Mental Status Exam (MMSE) | Assesses cognitive impairment. |
| Apgar Score (Neonates) | Determines newborn health risks. |
✅ Example: A Morse Fall Scale score of 55 indicates high risk for falls, requiring fall prevention measures.
🚫 Ignoring risk factors because no symptoms are present.
❌ A patient with diabetes may have normal skin now, but they are still at risk for foot ulcers.
✅ Provide preventive foot care education.
🚫 Failing to prioritize life-threatening risks first.
❌ Addressing a mild rash before recognizing a patient’s oxygen saturation dropping to 85%.
✅ Airway, breathing, and circulation (ABCs) come first.
🚫 Not validating risks with objective data.
❌ “Risk for infection” written without checking white blood cell count or wound status.
✅ Confirm risk factors through assessment.
Identifying client strengths is an essential aspect of holistic nursing care. While nurses focus on problems and risks, recognizing a patient’s strengths enhances recovery, promotes self-care, and boosts confidence. Strengths help support positive health behaviors and serve as resources for coping with illness or health challenges.
“Client strength identification is the process of recognizing an individual’s physical, emotional, psychological, social, and environmental abilities that contribute to health maintenance, recovery, and overall well-being.”
🔹 Encourages active patient participation in their care.
🔹 Promotes independence and self-efficacy.
🔹 Supports faster recovery and rehabilitation.
🔹 Enhances mental resilience and coping strategies.
🔹 Builds positive relationships between patients and healthcare providers.
🔹 Helps in developing personalized care plans that leverage client abilities.
✅ Example: A post-surgical patient who is motivated to walk has a strength that can be encouraged through early ambulation and physiotherapy.
Identifying strengths follows a structured approach, similar to identifying client problems and risks.
✅ Example: A stroke patient with strong family support and previous experience in managing health conditions may recover faster with home-based rehabilitation.
Client strengths can be physical, psychological, social, or spiritual.
| Category | Examples of Client Strengths |
|---|---|
| Physical Strengths | Strong immune system, ability to perform self-care, good mobility, adherence to prescribed exercises. |
| Psychological Strengths | Positive mindset, strong coping skills, ability to manage stress effectively. |
| Social Strengths | Supportive family, active participation in community, good communication skills. |
| Spiritual Strengths | Strong religious or spiritual beliefs, sense of purpose, use of meditation or prayer for healing. |
✅ Example: A patient with a history of regular exercise and good nutrition may have better wound healing and faster post-operative recovery.
Several assessment tools and models can help identify client strengths:
| Tool/Model | Purpose |
|---|---|
| Gordon’s Functional Health Patterns | Identifies strengths in self-care, nutrition, coping, and health perception. |
| Resilience Scale | Measures ability to cope with stress and challenges. |
| Patient Health Questionnaire (PHQ-9) | Identifies psychological well-being and strengths in emotional regulation. |
| Mini-Mental State Examination (MMSE) | Assesses cognitive strengths in elderly patients. |
| Spiritual Well-Being Scale | Evaluates faith-based coping mechanisms. |
✅ Example: A high score on the Resilience Scale indicates that the patient has strong coping mechanisms to handle chronic illness.
✅ Example: A patient managing their diabetes well without frequent hospital visits has strengths in self-care and medication adherence.
✅ Example: A patient with a supportive family recovering from surgery can be trained in home-based wound care to reduce hospital visits.
| Category | Example Strength |
|---|---|
| Good Physical Health | “Strong immune response, fast wound healing.” |
| Active Lifestyle | “Engages in regular physical exercise.” |
| Self-Care Ability | “Can perform ADLs (Activities of Daily Living) independently.” |
| Adherence to Treatment | “Takes medications as prescribed without reminders.” |
✅ Example: A patient who maintains a healthy diet and regular exercise has strength in preventing chronic diseases.
| Category | Example Strength |
|---|---|
| Resilience and Adaptability | “Patient remains optimistic despite chronic illness.” |
| Effective Stress Management | “Uses relaxation techniques like deep breathing and meditation.” |
| Motivation for Recovery | “Actively participates in physical therapy sessions.” |
| Self-Efficacy | “Patient confidently manages blood sugar levels and makes lifestyle adjustments.” |
✅ Example: A patient who views illness as a challenge rather than a burden has strong resilience, which aids in faster recovery.
| Category | Example Strength |
|---|---|
| Supportive Family and Friends | “Family members provide emotional and physical support.” |
| Active Social Engagement | “Involved in community health programs.” |
| Strong Communication Skills | “Expresses health concerns clearly and effectively.” |
| Financial Stability | “Can afford proper healthcare and medications.” |
✅ Example: A patient with strong family support is less likely to experience depression after a major surgery.
| Category | Example Strength |
|---|---|
| Religious or Spiritual Beliefs | “Patient finds comfort in prayer and meditation.” |
| Positive Life Perspective | “Believes in finding meaning through adversity.” |
| Sense of Purpose | “Engages in volunteer work and community service.” |
| Faith-Based Coping Strategies | “Uses spiritual guidance to deal with chronic pain.” |
✅ Example: A patient using meditation to manage pain demonstrates strong spiritual coping skills.
By leveraging client strengths, nurses can create more effective, personalized care plans.
| Client Strength | Nursing Intervention |
|---|---|
| Active participation in therapy | Encourage independence in rehabilitation activities. |
| Supportive family environment | Involve family in patient education and discharge planning. |
| Good stress management skills | Introduce additional relaxation techniques (e.g., guided imagery). |
| High motivation for learning | Provide health education on disease prevention. |
| Ability to perform self-care | Teach advanced self-care techniques for better independence. |
✅ Example: A patient willing to learn about diabetes management should be encouraged to attend education sessions on diet and exercise.
🚫 Focusing only on weaknesses and problems.
❌ Overemphasizing illness without recognizing the patient’s ability to recover.
✅ Balance problem-solving with strength-based care.
🚫 Ignoring self-reported strengths.
❌ Dismissing a patient’s confidence in managing their condition.
✅ Validate strengths through observation and history.
🚫 Underestimating social and emotional strengths.
❌ Neglecting family support in care planning.
✅ Encourage family involvement in patient recovery.
A nursing diagnosis statement is a structured way to define a patient’s health problem based on nursing assessment and clinical judgment. It provides a foundation for selecting appropriate nursing interventions and achieving patient-centered outcomes.
“A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes or a vulnerability for that response by an individual, family, or community.”
🔹 Helps identify health issues that can be managed by nurses.
🔹 Guides nursing interventions and care planning.
🔹 Enhances communication among healthcare professionals.
🔹 Supports evidence-based nursing practice.
🔹 Promotes patient-centered care by addressing physical, emotional, and social needs.
✅ Example:
Instead of stating “Patient has pneumonia” (which is a medical diagnosis), a nursing diagnosis would be:
“Ineffective airway clearance related to excessive mucus production as evidenced by wheezing, shortness of breath, and weak cough.”
A nursing diagnosis statement typically follows the PES format, which consists of:
| Part | Description | Example |
|---|---|---|
| P (Problem) | The actual or potential health issue that requires nursing care. | “Impaired skin integrity” |
| E (Etiology or Cause) | The underlying cause or contributing factor for the problem. | “Related to prolonged immobility” |
| S (Signs and Symptoms) | The observable evidence that supports the diagnosis. | “As evidenced by pressure ulcers on the sacral area, redness, and broken skin.” |
✅ Final Nursing Diagnosis Statement:
“Impaired skin integrity related to prolonged immobility as evidenced by pressure ulcers on the sacral area.”
According to NANDA International (NANDA-I), nursing diagnosis statements are classified into four types:
✅ Best for: Immediate nursing care needs like pain management, wound care, and infection control.
✅ Best for: Preventing pressure ulcers, falls, infections, and complications.
✅ Best for: Encouraging patient education, lifestyle changes, and wellness programs.
✅ Best for: Complex patient conditions requiring multidisciplinary care.
| Category | Example Nursing Diagnosis Statement |
|---|---|
| Respiratory | “Ineffective airway clearance related to excessive mucus production as evidenced by wheezing and weak cough.” |
| Cardiovascular | “Decreased cardiac output related to myocardial infarction as evidenced by weak pulse and low BP.” |
| Pain Management | “Acute pain related to surgical incision as evidenced by pain score of 8/10 and guarding behavior.” |
| Integumentary (Skin) | “Risk for impaired skin integrity related to immobility and moisture exposure.” |
| Mental Health | “Disturbed sleep pattern related to stress as evidenced by patient reports of difficulty falling asleep.” |
✅ Tip: Use NANDA-approved terminology for consistency in documentation.
✔ Use clear and specific language (avoid vague statements).
✔ Ensure data supports the diagnosis (signs and symptoms must align).
✔ Use standardized NANDA terminology for accuracy.
✔ Make the problem patient-centered (focus on how the condition affects the patient).
✅ Correct Example:
“Imbalanced nutrition: less than body requirements related to inadequate dietary intake as evidenced by weight loss and low serum albumin levels.”
❌ Do not include medical diagnoses (e.g., “Diabetes mellitus”).
❌ Avoid judgmental language (e.g., “Patient is careless about their health”).
❌ Do not write interventions as part of the diagnosis (e.g., “Patient needs insulin injections”).
🚫 Incorrect Example:
“Diabetes-related poor diet management causing high blood sugar.”
✅ Revised Example:
“Risk for unstable blood glucose levels related to inconsistent dietary intake.”
| Aspect | Nursing Diagnosis | Medical Diagnosis |
|---|---|---|
| Focus | Patient’s response to illness | Disease condition |
| Who Makes It? | Nurse | Doctor |
| Example | “Risk for aspiration related to difficulty swallowing” | “Stroke” |
| Scope of Treatment | Nursing interventions (positioning, feeding modifications) | Medical interventions (medications, surgery) |
✅ Key Point: Nurses do not diagnose diseases but focus on how diseases affect the patient’s functioning and response to treatment.
🚫 Using a medical diagnosis instead of a nursing diagnosis.
❌ “Diabetes mellitus”
✅ “Risk for unstable blood glucose levels related to impaired insulin regulation.”
🚫 Writing vague or general statements.
❌ “Patient is in pain.”
✅ “Acute pain related to surgical incision as evidenced by facial grimacing and a pain score of 8/10.”
🚫 Failing to individualize the diagnosis.
❌ “Risk for infection.”
✅ “Risk for infection related to the presence of an indwelling catheter and poor hygiene.”
A nursing diagnosis is a clinical judgment about a patient’s response to actual or potential health problems. It helps guide nursing interventions and patient care. Nursing diagnoses are different from medical diagnoses, as they focus on how the disease affects the patient’s functioning rather than the disease itself.
“A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes or a vulnerability for that response by an individual, family, or community.”
🔹 Helps in developing individualized care plans.
🔹 Promotes evidence-based nursing interventions.
🔹 Enhances communication among healthcare professionals.
🔹 Supports continuity of care across healthcare settings.
🔹 Aids in preventing complications and improving patient outcomes.
✅ Example:
Instead of writing “Pneumonia” (a medical diagnosis), a nurse writes:
“Ineffective airway clearance related to excessive mucus production as evidenced by wheezing and weak cough.”
NANDA-I (North American Nursing Diagnosis Association-International) has classified nursing diagnoses into four major types:
✅ Example:
“Impaired skin integrity related to prolonged immobility as evidenced by pressure ulcers on the sacral area, redness, and broken skin.”
✔ Best for: Addressing current patient problems like pain management, wound care, and infection control.
✅ Example:
“Risk for infection related to surgical incision and compromised immunity.”
✔ Best for: Preventing falls, pressure ulcers, infections, and complications.
✅ Example:
“Readiness for enhanced nutrition as evidenced by patient expressing interest in balanced diet options.”
✔ Best for: Encouraging self-care, health education, and wellness programs.
✅ Example:
✔ Best for: Complex conditions requiring multidisciplinary care.
| Category | Example Nursing Diagnosis Statement |
|---|---|
| Respiratory | “Ineffective airway clearance related to excessive mucus production as evidenced by wheezing and weak cough.” |
| Cardiovascular | “Decreased cardiac output related to myocardial infarction as evidenced by weak pulse and low BP.” |
| Pain Management | “Acute pain related to surgical incision as evidenced by pain score of 8/10 and guarding behavior.” |
| Integumentary (Skin) | “Risk for impaired skin integrity related to immobility and moisture exposure.” |
| Mental Health | “Disturbed sleep pattern related to stress as evidenced by patient reports of difficulty falling asleep.” |
✔ Tip: Use NANDA-approved terminology for consistency in documentation.
✔ Use clear and specific language (avoid vague statements).
✔ Ensure data supports the diagnosis (signs and symptoms must align).
✔ Use standardized NANDA terminology for accuracy.
✔ Make the problem patient-centered (focus on how the condition affects the patient).
✅ Correct Example:
“Imbalanced nutrition: less than body requirements related to inadequate dietary intake as evidenced by weight loss and low serum albumin levels.”
❌ Do not include medical diagnoses (e.g., “Diabetes mellitus”).
❌ Avoid judgmental language (e.g., “Patient is careless about their health”).
❌ Do not write interventions as part of the diagnosis (e.g., “Patient needs insulin injections”).
🚫 Incorrect Example:
“Diabetes-related poor diet management causing high blood sugar.”
✅ Revised Example:
“Risk for unstable blood glucose levels related to inconsistent dietary intake.”
| Aspect | Nursing Diagnosis | Medical Diagnosis |
|---|---|---|
| Focus | Patient’s response to illness | Disease condition |
| Who Makes It? | Nurse | Doctor |
| Example | “Risk for aspiration related to difficulty swallowing” | “Stroke” |
| Scope of Treatment | Nursing interventions (positioning, feeding modifications) | Medical interventions (medications, surgery) |
✅ Key Point: Nurses do not diagnose diseases but focus on how diseases affect the patient’s functioning and response to treatment.
🚫 Using a medical diagnosis instead of a nursing diagnosis.
❌ “Diabetes mellitus”
✅ “Risk for unstable blood glucose levels related to impaired insulin regulation.”
🚫 Writing vague or general statements.
❌ “Patient is in pain.”
✅ “Acute pain related to surgical incision as evidenced by facial grimacing and a pain score of 8/10.”
🚫 Failing to individualize the diagnosis.
❌ “Risk for infection.”
✅ “Risk for infection related to the presence of an indwelling catheter and poor hygiene.”
Formulating a nursing diagnosis is a crucial step in the nursing process (ADPIE). It involves analyzing patient data, identifying health issues, and writing a structured nursing diagnosis statement that guides patient care.
“Nursing diagnosis formulation is the process of interpreting patient data, identifying health conditions, and structuring a clear and precise statement that directs nursing interventions.”
🔹 Helps in developing individualized nursing care plans.
🔹 Guides effective and evidence-based nursing interventions.
🔹 Promotes patient safety and optimal health outcomes.
🔹 Improves communication among healthcare professionals.
🔹 Ensures legal and ethical documentation of patient care.
✅ Example:
Instead of saying “Patient has pneumonia”, a well-formulated nursing diagnosis would be:
“Ineffective airway clearance related to excessive mucus production as evidenced by wheezing and shortness of breath.”
The process of formulating a nursing diagnosis follows five systematic steps:
✅ Example:
✅ Example:
A postoperative patient with a high fever and purulent wound drainage may have the problem of infection risk.
According to NANDA-I (North American Nursing Diagnosis Association-International), nursing diagnoses are classified into four types:
| Type of Nursing Diagnosis | Description | Example |
|---|---|---|
| Actual Diagnosis | A current health problem that requires immediate care. | “Impaired skin integrity related to immobility as evidenced by pressure ulcers.” |
| Risk Diagnosis | A potential health problem that may develop. | “Risk for falls related to muscle weakness.” |
| Health Promotion Diagnosis | The patient shows readiness to improve health. | “Readiness for enhanced self-care as evidenced by the patient expressing willingness to learn.” |
| Syndrome Diagnosis | A cluster of related problems occurring together. | “Post-trauma syndrome related to abuse as evidenced by nightmares and anxiety.” |
✅ Key Tip: Use NANDA-I-approved terms for consistency and accuracy.
The PES format is the standard way of writing a nursing diagnosis:
| Component | Description | Example |
|---|---|---|
| P (Problem) | The patient’s health issue using NANDA terminology. | “Ineffective breathing pattern” |
| E (Etiology/Cause) | The contributing factors causing the problem. | “Related to bronchial constriction” |
| S (Signs/Symptoms) | The evidence supporting the diagnosis. | “As evidenced by wheezing and use of accessory muscles for breathing.” |
✅ Final Nursing Diagnosis Statement:
“Ineffective breathing pattern related to bronchial constriction as evidenced by wheezing and use of accessory muscles for breathing.”
| Priority Level | Example Nursing Diagnosis |
|---|---|
| High Priority (Life-threatening) | “Ineffective airway clearance related to excess mucus as evidenced by low oxygen saturation (85%).” |
| Medium Priority (Acute health issues) | “Acute pain related to post-surgical incision as evidenced by pain rating of 8/10.” |
| Low Priority (Long-term health goals) | “Knowledge deficit related to diabetes management as evidenced by patient asking about insulin use.” |
✅ Example:
A patient with severe respiratory distress needs immediate intervention, so “Ineffective breathing pattern” is prioritized over “Disturbed sleep pattern.”
| Category | Example Nursing Diagnosis Statement |
|---|---|
| Respiratory | “Ineffective airway clearance related to excessive mucus production as evidenced by wheezing and weak cough.” |
| Cardiovascular | “Decreased cardiac output related to myocardial infarction as evidenced by weak pulse and low BP.” |
| Pain Management | “Acute pain related to surgical incision as evidenced by patient grimacing and pain score of 8/10.” |
| Integumentary (Skin) | “Risk for impaired skin integrity related to prolonged immobility and moisture exposure.” |
| Mental Health | “Disturbed sleep pattern related to stress as evidenced by difficulty falling asleep.” |
✅ Tip: Always write clear, concise, and patient-centered diagnoses.
🚫 Using a medical diagnosis instead of a nursing diagnosis.
❌ “Pneumonia”
✅ “Ineffective airway clearance related to excessive secretions as evidenced by coughing and difficulty breathing.”
🚫 Writing vague or general statements.
❌ “Patient is in pain.”
✅ “Acute pain related to surgical incision as evidenced by a pain score of 8/10.”
🚫 Including interventions in the diagnosis statement.
❌ “Patient needs oxygen therapy to treat breathing problems.”
✅ “Impaired gas exchange related to alveolar damage as evidenced by low oxygen saturation and shortness of breath.”
🚫 Failing to individualize the diagnosis.
❌ “Risk for infection.”
✅ “Risk for infection related to surgical wound and compromised immune response.”
| Aspect | Nursing Diagnosis | Medical Diagnosis |
|---|---|---|
| Focus | Patient’s response to illness | Disease condition |
| Who Makes It? | Nurse | Doctor |
| Example | “Risk for aspiration related to difficulty swallowing” | “Stroke” |
| Scope of Treatment | Nursing interventions (positioning, feeding modifications) | Medical interventions (medications, surgery) |
✅ Key Point: Nurses do not diagnose diseases but focus on how diseases affect the patient’s functioning and response to treatment.
Formulating a nursing diagnosis is an essential step in the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation). It helps identify actual or potential health issues based on patient data, guiding the selection of appropriate nursing interventions.
“A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes or a vulnerability for that response by an individual, family, or community.”
🔹 Why is Proper Formulation Important?
To formulate a nursing diagnosis correctly, nurses should follow specific guidelines to ensure clarity, accuracy, and effectiveness.
✅ Example:
✅ Correct Example: “Impaired physical mobility related to joint stiffness as evidenced by difficulty walking and slow gait.”
🚫 Incorrect Example: “Arthritis” (This is a medical diagnosis, not a nursing diagnosis).
A nursing diagnosis statement should be structured as follows:
| Component | Description | Example |
|---|---|---|
| P (Problem) | The actual or potential health issue. | “Impaired skin integrity” |
| E (Etiology/Cause) | The reason or contributing factor. | “Related to prolonged immobility” |
| S (Signs/Symptoms) | Observable evidence supporting the diagnosis. | “As evidenced by pressure ulcers on the sacral area.” |
✅ Final Nursing Diagnosis:
“Impaired skin integrity related to prolonged immobility as evidenced by pressure ulcers on the sacral area.”
A nursing diagnosis can be classified into four categories according to NANDA-I:
| Type | Description | Example |
|---|---|---|
| Actual Diagnosis | A current health problem requiring intervention. | “Acute pain related to surgical incision as evidenced by patient’s pain score of 8/10.” |
| Risk Diagnosis | A potential problem that may develop. | “Risk for infection related to surgical wound.” |
| Health Promotion Diagnosis | The patient’s motivation to improve health. | “Readiness for enhanced nutrition as evidenced by patient requesting diet counseling.” |
| Syndrome Diagnosis | A cluster of related diagnoses occurring together. | “Post-trauma syndrome related to past abuse as evidenced by nightmares and social withdrawal.” |
✅ Example of a Risk Nursing Diagnosis:
“Risk for aspiration related to difficulty swallowing.” (No signs/symptoms because the problem has not yet occurred).
✅ Correct Example: “Ineffective airway clearance related to excessive mucus production as evidenced by wheezing and weak cough.”
🚫 Incorrect Example: “Patient has breathing problems.” (Too vague).
✅ Correct Example: “Risk for unstable blood glucose levels related to inconsistent dietary intake.”
🚫 Incorrect Example: “Diabetes mellitus.” (Medical diagnosis).
✅ Correct Example: “Impaired physical mobility related to muscle weakness as evidenced by difficulty walking.”
🚫 Incorrect Example: “Patient refuses to walk because they are lazy.” (Judgmental and not patient-centered).
✅ Example:
Use Maslow’s Hierarchy of Needs to determine which nursing diagnosis to address first:
| Priority Level | Example Nursing Diagnosis |
|---|---|
| High Priority (Life-threatening) | “Ineffective airway clearance related to excessive secretions as evidenced by low oxygen saturation.” |
| Medium Priority (Needs prompt intervention but not life-threatening) | “Acute pain related to post-surgical incision as evidenced by a pain score of 8/10.” |
| Low Priority (Long-term health goals) | “Readiness for enhanced knowledge related to diabetes self-management.” |
✅ Key Tip: Always address breathing, circulation, and safety issues first.
✅ Example:
| Mistake | Example | Corrected Version |
|---|---|---|
| Using a medical diagnosis | “Heart failure.” | “Decreased cardiac output related to heart muscle weakness.” |
| Writing vague statements | “Patient has pain.” | “Acute pain related to surgical incision as evidenced by pain score of 7/10.” |
| Blaming the patient | “Patient does not want to cooperate.” | “Ineffective coping related to anxiety about hospitalization.” |
| Using an intervention instead of a diagnosis | “Patient needs oxygen therapy.” | “Impaired gas exchange related to alveolar damage.” |
NANDA International (NANDA-I) is a professional organization dedicated to standardizing the terminology used in nursing diagnoses. Established in 1982, NANDA-I aims to develop, refine, and promote a standardized language for nursing diagnoses, enhancing the quality of nursing care and facilitating clear communication among healthcare professionals. nanda.org
Standardized nursing diagnoses serve several critical functions:
NANDA-I’s Taxonomy II organizes nursing diagnoses into a hierarchical structure comprising 13 domains, 47 classes, and numerous specific diagnoses. This structure ensures a comprehensive approach to various aspects of patient health.en.wikipedia.org+1de.wikipedia.org+1
Here is an overview of the 13 domains and their respective classes:
Each class within these domains encompasses specific nursing diagnoses that address particular patient issues.
Below are examples of nursing diagnoses from selected domains:
For a comprehensive list of all approved nursing diagnoses, refer to the latest NANDA-I publication. nanda.org
NANDA-I periodically updates its list of nursing diagnoses to reflect advancements in nursing knowledge and practice. In the 2018–2020 edition, several new diagnoses were introduced, including:ar.israa.edu.ps
Additionally, some diagnoses were retired to maintain clinical relevance and accuracy.
Utilizing NANDA-I approved nursing diagnoses in clinical practice involves:
This structured approach ensures that nursing care is systematic, evidence-based, and tailored to each patient’s unique needs.
EXAMPLES LIST OF NANDA DIAGNOSIS ACCORDING TO PATIENTS MEDICAL DISEASE CONDITION,
NANDA International (NANDA-I) provides standardized nursing diagnoses that address patients’ responses to medical conditions. Below is a list of common medical conditions paired with corresponding NANDA-I approved nursing diagnoses:
These nursing diagnoses enable nurses to develop individualized care plans that address the specific needs and responses of patients to their medical conditions. For a comprehensive and updated list of NANDA-I approved nursing diagnoses, refer to the latest edition of “NANDA International Nursing Diagnoses: Definitions and Classification.”
In healthcare, medical diagnoses and nursing diagnoses are essential for patient care, but they serve different purposes. Medical diagnoses focus on identifying diseases, while nursing diagnoses focus on how the patient responds to health conditions and what care is needed.
“A medical diagnosis is the identification of a disease or condition made by a physician or other licensed healthcare provider, based on clinical signs, symptoms, history, laboratory findings, and diagnostic tests.”
“A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes or a vulnerability for that response by an individual, family, or community.”
✅ Example:
| Aspect | Medical Diagnosis | Nursing Diagnosis |
|---|---|---|
| Focus | Identifies a specific disease or medical condition. | Identifies the patient’s response to a health condition. |
| Who Makes It? | Physicians, Nurse Practitioners, or Specialists. | Registered Nurses (RNs) using the nursing process. |
| Scope of Treatment | Managed with medical interventions (e.g., medications, surgery). | Managed with nursing interventions (e.g., positioning, patient education, wound care). |
| Example | Diabetes mellitus | Risk for unstable blood glucose levels related to inconsistent dietary intake. |
| Standardization | Based on the ICD (International Classification of Diseases). | Based on NANDA-I (North American Nursing Diagnosis Association-International). |
| Duration | Usually remains the same throughout the patient’s condition. | Can change as the patient’s condition improves or worsens. |
✅ Example:
A patient with heart failure:
| Medical Diagnosis | Nursing Diagnosis |
|---|---|
| Stroke | Impaired physical mobility related to muscle weakness as evidenced by inability to walk independently. |
| Pneumonia | Ineffective airway clearance related to thick mucus as evidenced by persistent cough and abnormal lung sounds. |
| Hypertension | Risk for ineffective cerebral tissue perfusion related to high blood pressure. |
| Diabetes Mellitus | Risk for unstable blood glucose levels related to inconsistent dietary intake. |
| Myocardial Infarction (Heart Attack) | Decreased cardiac output related to myocardial damage as evidenced by weak pulse and fatigue. |
| Kidney Failure | Fluid volume excess related to impaired kidney function as evidenced by edema and weight gain. |
| Depression | Risk for self-harm related to feelings of hopelessness and isolation. |
✅ Key Difference:
Both medical and nursing diagnoses are essential for comprehensive patient care.
✅ How They Work Together:
🔹 Helps create individualized care plans based on the patient’s needs.
🔹 Identifies risks early to prevent complications (e.g., preventing falls in stroke patients).
🔹 Supports evidence-based nursing interventions for better patient outcomes.
🔹 Improves communication among healthcare teams for coordinated care.
🔹 Promotes holistic care by addressing physical, emotional, and psychosocial aspects.
The nursing process is a systematic approach that guides nurses in providing quality patient care. The planning phase follows the assessment and nursing diagnosis stages and focuses on setting goals, priorities, and interventions to address the patient’s health concerns.
“Planning is the process of establishing patient-centered goals, determining priorities, and selecting appropriate nursing interventions to achieve the desired health outcomes.”
🔹 Ensures individualized, patient-centered care.
🔹 Helps prioritize interventions based on urgency.
🔹 Promotes collaborative care among healthcare professionals.
🔹 Facilitates effective documentation for continuity of care.
🔹 Improves patient safety and health outcomes.
✅ Example:
A nurse develops a care plan for a post-surgical patient to prevent complications such as infection and pain.
The planning phase consists of three essential components:
| Priority Level | Example Nursing Diagnosis |
|---|---|
| High Priority (Life-threatening) | “Ineffective airway clearance related to excessive mucus production.” |
| Medium Priority (Potential complications) | “Risk for infection related to surgical wound.” |
| Low Priority (Long-term health goals) | “Readiness for enhanced knowledge about diabetes management.” |
✅ Example: If a patient is having difficulty breathing, that issue takes priority over lack of knowledge about diet.
Goals should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).
| Component | Description | Example |
|---|---|---|
| S (Specific) | Clearly defines what is to be achieved. | “The patient will maintain oxygen saturation above 95%.” |
| M (Measurable) | Can be observed and quantified. | “The patient will report pain at a level of 3/10 or lower.” |
| A (Achievable) | Realistic given the patient’s condition. | “The patient will walk 20 meters without assistance.” |
| R (Relevant) | Addresses the patient’s needs. | “The patient will practice deep breathing exercises.” |
| T (Time-bound) | Specifies a time frame. | “By the end of the shift, the patient will use an incentive spirometer every hour.” |
✅ Example:
“The patient will perform incentive spirometry exercises every hour to prevent pneumonia within 24 hours.”
Nursing interventions are actions nurses take to achieve patient goals. These interventions can be classified into three categories:
| Type of Intervention | Description | Example |
|---|---|---|
| Independent | Actions that nurses perform without a doctor’s order. | “Repositioning a bedridden patient every 2 hours to prevent pressure ulcers.” |
| Dependent | Actions that require a doctor’s order. | “Administering prescribed antibiotics for infection.” |
| Collaborative | Actions performed with other healthcare professionals. | “Working with a physiotherapist to help the patient regain mobility.” |
✅ Example:
A nurse caring for a post-surgical patient selects interventions such as pain management, wound care, and patient education on mobility.
The planning phase results in a nursing care plan, which can be:
| Type | Description | Example |
|---|---|---|
| Formal Care Plan | A structured, written document outlining patient care. | Hospital electronic medical records. |
| Informal Care Plan | A nurse’s mental plan based on patient needs. | Deciding to check a patient’s pain levels frequently. |
| Individualized Care Plan | Tailored to the unique needs of a patient. | A care plan for a stroke patient focusing on speech therapy. |
| Standardized Care Plan | Uses pre-written care plans for common conditions. | A care plan for post-operative recovery. |
✅ Example: A stroke patient’s care plan may include speech therapy, physical therapy, and nutrition interventions.
| Nursing Diagnosis | Planning (Goal & Interventions) |
|---|---|
| Impaired Skin Integrity related to prolonged immobility as evidenced by stage 2 pressure ulcer on the sacral area. | Goal: “The patient’s sacral wound will show signs of healing within one week.” Interventions: 1) Reposition the patient every 2 hours. 2) Apply prescribed wound care dressings. 3) Encourage a high-protein diet to promote healing. |
✅ Key Tip: The care plan should be continuously updated based on patient progress.
🚫 Setting vague or unrealistic goals
❌ “The patient will feel better soon.”
✅ Corrected Goal: “The patient will verbalize pain relief below a score of 3/10 within 24 hours.”
🚫 Failing to individualize the plan
❌ Using the same interventions for all patients.
✅ Correct Approach: Adjust interventions to match the patient’s specific condition and preferences.
🚫 Not involving the patient in goal setting
❌ Ignoring the patient’s input in their care plan.
✅ Correct Approach: Ask patients about their preferences, abilities, and goals.
Planning is a critical phase in the nursing process, guiding nurses in setting goals, priorities, and interventions to provide effective patient care. There are different types of planning, each serving a specific purpose in nursing practice.
“Planning is the process of establishing priorities, setting patient-centered goals, and selecting nursing interventions to promote health and improve patient outcomes.”
✅ Example:
A post-surgical patient requires planning for pain management, wound care, and mobility improvement.
Planning in nursing can be categorized into four main types:
| Type of Planning | Definition | Example |
|---|---|---|
| Initial Planning | Performed at the beginning of patient care to set the foundation for treatment. | Creating a care plan for a newly admitted patient with pneumonia. |
| Ongoing Planning | Continuous modifications to the care plan based on patient progress. | Adjusting wound care interventions based on healing progress. |
| Discharge Planning | Preparing the patient for safe transition from hospital to home or another facility. | Educating a diabetic patient about insulin self-administration before discharge. |
| Strategic Planning | Long-term planning for hospital-wide nursing policies and improvements. | Developing infection control policies in a hospital setting. |
✅ Example:
A stroke patient admitted to the hospital will have an initial plan addressing:
✅ Example:
A post-operative patient initially planned for pain management may later require wound infection prevention if signs of infection appear.
🔹 Key Aspects of Ongoing Planning:
✔ Monitor patient progress and response to interventions.
✔ Modify goals and interventions as needed.
✔ Update care plans to reflect patient condition changes.
✅ Example:
A patient recovering from heart surgery will require:
🔹 Key Components of Discharge Planning:
✔ Teaching self-care techniques (wound care, insulin injection).
✔ Coordinating with family members or caregivers.
✔ Arranging follow-up visits or referrals.
✅ Example:
A hospital implements a new policy to reduce medication errors by introducing barcode scanning for drug administration.
🔹 Key Features of Strategic Planning:
✔ Focuses on future healthcare goals and improvements.
✔ Involves leadership, management, and policy-making.
✔ Ensures evidence-based nursing practices are followed.
| Aspect | Initial Planning | Ongoing Planning | Discharge Planning | Strategic Planning |
|---|---|---|---|---|
| Timing | At patient admission | Throughout hospital stay | Before patient discharge | Long-term hospital goals |
| Focus | Immediate patient needs | Changes in patient condition | Safe transition and self-care | Nursing policies and improvement |
| Example | Planning care for a newly admitted stroke patient | Adjusting care plan based on wound healing progress | Teaching insulin self-injection before discharge | Implementing an electronic medical record system |
🔹 Ensures continuity of care from admission to discharge.
🔹 Improves patient safety by anticipating risks and preventing complications.
🔹 Enhances teamwork and collaboration among healthcare professionals.
🔹 Facilitates effective documentation of patient progress.
🔹 Supports patient education and empowerment for self-care.
✅ Example:
A diabetic patient’s planning includes:
✔ Initial Planning: Assessing blood sugar levels and dietary intake.
✔ Ongoing Planning: Adjusting insulin doses based on blood glucose trends.
✔ Discharge Planning: Teaching self-monitoring techniques and diet management.
🚫 Not individualizing the care plan.
❌ Using the same interventions for all patients.
✅ Correct Approach: Adjust interventions based on patient-specific conditions.
🚫 Failing to update care plans.
❌ Continuing the same interventions despite patient improvement or decline.
✅ Correct Approach: Modify the plan based on ongoing assessments.
🚫 Ignoring patient input.
❌ Setting goals without considering the patient’s preferences and abilities.
✅ Correct Approach: Involve the patient and family in goal-setting.
Establishing priorities is a crucial step in the planning phase of the nursing process. It helps nurses decide which patient problems require immediate attention and which can be addressed later. Prioritization ensures efficient use of resources, enhances patient safety, and improves health outcomes.
“Establishing priorities in nursing involves ranking patient needs in order of urgency to determine the most critical interventions required for optimal patient outcomes.”
✅ Example:
A patient experiencing severe respiratory distress must be treated before a patient with mild anxiety.
🔹 Ensures urgent and life-threatening conditions are managed first.
🔹 Helps in allocating resources effectively.
🔹 Reduces complications and enhances patient safety.
🔹 Improves efficiency in nursing care delivery.
🔹 Guides nurses in decision-making during emergencies.
✅ Example:
A post-surgical patient with active bleeding requires immediate intervention before a patient with moderate pain.
To prioritize patient needs, nurses must consider various principles, including Maslow’s Hierarchy of Needs, the ABCDE approach, and urgency levels.
Maslow’s theory helps prioritize patient problems based on basic human needs.
| Level of Need | Priority | Example Nursing Diagnosis |
|---|---|---|
| Physiological Needs (Basic Needs) | 🔴 Highest Priority | “Ineffective breathing pattern related to airway obstruction.” |
| Safety and Security | 🟠 Moderate Priority | “Risk for falls related to unsteady gait.” |
| Love and Belonging | 🟡 Lower Priority | “Social isolation related to hospitalization.” |
| Self-Esteem | 🟡 Lower Priority | “Chronic low self-esteem related to body image changes.” |
| Self-Actualization | 🟢 Lowest Priority | “Readiness for enhanced coping as evidenced by patient’s interest in mental health counseling.” |
✅ Example:
A patient struggling to breathe (airway obstruction) must be treated before addressing a patient’s low self-esteem due to hair loss from chemotherapy.
The ABCDE method helps prioritize critical conditions that threaten life.
| Category | Priority Level | Example |
|---|---|---|
| A – Airway | 🔴 Highest Priority | “Obstructed airway due to anaphylaxis.” |
| B – Breathing | 🔴 High Priority | “Respiratory distress due to asthma.” |
| C – Circulation | 🟠 Moderate Priority | “Shock due to blood loss from surgery.” |
| D – Disability (Neurological) | 🟡 Lower Priority | “Confusion due to dehydration.” |
| E – Exposure (Temperature, Skin Integrity, etc.) | 🟢 Lowest Priority | “Mild fever due to viral infection.” |
✅ Example:
A patient with severe wheezing (Breathing issue) must be treated before a patient with a mild skin rash (Exposure issue).
This system categorizes nursing priorities into three levels.
| Priority Level | Definition | Example |
|---|---|---|
| High Priority | Life-threatening situations | “Ineffective airway clearance due to choking.” |
| Medium Priority | Problems that could become serious if left untreated | “Risk for infection in a diabetic foot ulcer.” |
| Low Priority | Minor health concerns or long-term goals | “Readiness for enhanced nutrition for weight management.” |
✅ Example:
A patient with chest pain (High priority) requires immediate attention compared to a patient requesting diet counseling (Low priority).
The nursing process helps establish priorities systematically.
✅ Example:
A patient reporting difficulty breathing with SpO₂ of 85% must be assessed immediately.
✅ Example:
✅ Example:
“The patient will maintain an oxygen saturation level of 95% or above within 30 minutes after receiving nebulization.”
✅ Example:
For impaired gas exchange, the nurse will:
✔ Administer oxygen (dependent intervention).
✔ Monitor SpO₂ levels every 30 minutes (independent intervention).
✔ Collaborate with the respiratory therapist for nebulization therapy.
✅ Example:
A stable post-operative patient may suddenly develop difficulty breathing, shifting priorities from pain management to airway management.
| Scenario | High Priority | Medium Priority | Low Priority |
|---|---|---|---|
| Post-Surgical Care | Uncontrolled bleeding | Post-op nausea | Dressing change |
| Cardiac Care | Chest pain (possible MI) | Elevated blood pressure | Dietary counseling |
| Respiratory Care | Respiratory distress | Mild cough | Patient education on smoking cessation |
✅ Example:
In a cardiac unit, a patient with chest pain (High priority) must be treated before a patient with mildly elevated blood pressure (Medium priority).
🚫 Focusing on low-priority issues first
❌ Addressing patient education before stabilizing vital signs.
✅ Correct Approach: Treat critical conditions first.
🚫 Not reassessing priorities
❌ Using the same plan even when the patient’s condition changes.
✅ Correct Approach: Reassess frequently and adjust interventions accordingly.
🚫 Ignoring patient preferences
❌ Setting goals without involving the patient in decision-making.
✅ Correct Approach: Include the patient’s preferences and lifestyle in the plan.
In the planning phase of the nursing process, goals and expected outcomes are established based on the patient’s nursing diagnosis. These guide nursing interventions and provide a benchmark to measure patient progress.
✅ Example:
Goal: Improve patient’s respiratory function.
Expected Outcome: The patient’s oxygen saturation will remain above 95% within 2 hours of oxygen therapy.
🔹 Provides direction for nursing care.
🔹 Helps in evaluating the effectiveness of interventions.
🔹 Ensures continuity of care among healthcare providers.
🔹 Improves patient engagement and motivation.
🔹 Serves as a basis for documentation and legal records.
✅ Example:
A diabetic patient must learn self-care techniques to manage blood sugar levels. Goals and outcomes ensure measurable improvements in self-management.
Goals in nursing are classified into short-term and long-term goals.
| Type | Definition | Example |
|---|---|---|
| Short-Term Goals | Achieved in a few hours or days | “The patient will report a pain level of 3/10 within 4 hours after medication.” |
| Long-Term Goals | Achieved over weeks, months, or beyond discharge | “The patient will maintain an independent walking ability within 6 weeks post-surgery.” |
✅ Example:
For a stroke patient:
✔ Short-Term Goal: The patient will complete swallowing exercises safely within 48 hours.
✔ Long-Term Goal: The patient will regain independent feeding ability within 4 weeks.
To ensure goals are effective and meaningful, nurses should follow these guidelines:
A well-formulated goal or expected outcome should have the following components:
| Component | Description | Example |
|---|---|---|
| Subject (Who?) | The patient or a specific group | “The patient…” |
| Behavior (What?) | The expected action or response | “…will maintain a blood pressure of less than 140/90 mmHg…” |
| Criteria (How Well?) | The standard of performance or success measure | “…as evidenced by BP readings measured twice daily…” |
| Time Frame (When?) | The deadline for achieving the goal | “…within 1 week of initiating antihypertensive therapy.” |
✅ Final Example of a Complete Goal Statement:
“The patient will maintain a blood pressure of less than 140/90 mmHg as evidenced by BP readings measured twice daily within one week of initiating antihypertensive therapy.”
Nursing goals should follow the SMART format:
| SMART Component | Definition | Example |
|---|---|---|
| S – Specific | Clearly defines what is to be achieved | “The patient will drink 2000 mL of water per day…” |
| M – Measurable | Can be quantified or observed | “…as evidenced by a urine output of at least 30 mL/hr.” |
| A – Achievable | Within the patient’s ability | “…given the patient’s stable kidney function.” |
| R – Relevant | Addresses the patient’s health needs | “…to prevent dehydration and electrolyte imbalance.” |
| T – Time-bound | Specifies a deadline | “…within 24 hours of hospital admission.” |
✅ Example of a SMART Goal Statement:
“The patient will drink 2000 mL of water per day as evidenced by a urine output of at least 30 mL/hr within 24 hours of hospital admission.”
| Nursing Diagnosis | Goal | Expected Outcome |
|---|---|---|
| Ineffective Airway Clearance related to mucus obstruction | “The patient will maintain clear airways.” | “The patient will have a respiratory rate of 12-20 breaths per minute within 8 hours.” |
| Risk for Falls related to muscle weakness | “The patient will prevent falls during hospitalization.” | “The patient will ambulate with assistance and report no falls within 24 hours.” |
| Acute Pain related to surgical incision | “The patient will experience pain relief.” | “The patient will report a pain score of 3/10 or lower within 6 hours after pain medication.” |
✅ Key Tip: The goal is broad, while the expected outcome is specific and measurable.
🚫 Setting unrealistic goals
❌ “The patient will regain full mobility within 24 hours after a stroke.”
✅ Correct Approach: “The patient will move from bed to chair with assistance within 48 hours.”
🚫 Failing to make goals measurable
❌ “The patient will feel less anxious.”
✅ Correct Approach: “The patient will verbalize a reduction in anxiety symptoms (heart rate below 90 bpm) within 2 hours of relaxation therapy.”
🚫 Ignoring the patient’s involvement
❌ Setting goals without consulting the patient.
✅ Correct Approach: Discuss goals with the patient and ensure they align with their expectations and willingness to participate.
Nursing interventions are the actions taken by nurses to help patients achieve their health goals. These interventions are based on nursing diagnoses, patient needs, and clinical judgment.
“Nursing interventions are actions taken by a nurse to improve, maintain, or restore a patient’s health status and to prevent complications.”
✅ Example:
A nurse administers oxygen to a patient with impaired gas exchange to maintain adequate oxygen levels.
🔹 Helps in achieving patient goals and expected outcomes.
🔹 Promotes patient safety and comfort.
🔹 Prevents complications and disease progression.
🔹 Supports evidence-based practice in nursing care.
🔹 Enhances patient recovery and quality of life.
✅ Example:
A bedridden patient is turned every 2 hours to prevent pressure ulcers.
Nursing interventions are classified into three main categories:
| Type of Intervention | Definition | Example |
|---|---|---|
| Independent Nursing Interventions | Actions that nurses can perform without a physician’s order. | Repositioning a patient to prevent pressure ulcers. |
| Dependent Nursing Interventions | Actions that require a doctor’s prescription or order. | Administering prescribed medications. |
| Collaborative Nursing Interventions | Actions performed in collaboration with other healthcare professionals. | Working with a physiotherapist for rehabilitation exercises. |
✅ Example:
A nurse educating a diabetic patient on insulin administration is an independent intervention, while administering insulin as prescribed is a dependent intervention.
✅ Examples:
✔ Repositioning a patient every 2 hours to prevent bedsores.
✔ Teaching deep breathing exercises to prevent pneumonia.
✔ Providing emotional support to a patient with anxiety.
✅ Examples:
✔ Administering IV fluids or medications as prescribed.
✔ Inserting a Foley catheter under physician’s instructions.
✔ Performing a dressing change for a wound based on a doctor’s order.
✅ Examples:
✔ Working with a physical therapist to develop a mobility plan for a stroke patient.
✔ Consulting a dietitian for a patient’s diabetic meal plan.
✔ Assisting a respiratory therapist in oxygen therapy management.
Apart from the three main types, nursing interventions can also be categorized based on their function or purpose:
| Category | Definition | Example |
|---|---|---|
| Direct Care Interventions | Performed directly with the patient. | Turning a patient to prevent bedsores. |
| Indirect Care Interventions | Actions performed away from the patient to support care. | Consulting with a dietitian about the patient’s nutrition plan. |
| Preventive Interventions | Aimed at preventing illness or complications. | Administering vaccines to prevent infections. |
| Supportive Interventions | Helps patients cope with stress and mental health issues. | Providing emotional support for a grieving patient. |
| Technical Interventions | Involves technical skills and procedures. | Inserting a nasogastric (NG) tube. |
✅ Example:
A nurse providing emotional support to a cancer patient is a supportive intervention, while administering chemotherapy medication is a technical intervention.
| Condition | Independent Interventions | Dependent Interventions | Collaborative Interventions |
|---|---|---|---|
| Hypertension | Teaching relaxation techniques | Administering antihypertensive drugs | Consulting a dietitian for a low-sodium diet |
| Diabetes Mellitus | Educating on insulin self-administration | Administering insulin as prescribed | Working with a nutritionist for meal planning |
| Respiratory Distress | Teaching deep breathing exercises | Administering oxygen therapy | Collaborating with a respiratory therapist |
| Pain Management | Repositioning the patient for comfort | Giving prescribed pain medication | Consulting a physiotherapist for rehabilitation |
✅ Example:
For a patient with hypertension, the nurse can:
✔ Educate on stress management (Independent).
✔ Give prescribed antihypertensive drugs (Dependent).
✔ Work with a dietitian for diet modifications (Collaborative).
To ensure effective patient care, nurses should follow these guidelines when choosing interventions:
🚫 Failing to Individualize Care
❌ Using the same interventions for all patients without assessing individual needs.
✅ Correct Approach: Tailor interventions to each patient’s condition.
🚫 Ignoring Patient Preferences
❌ Forcing interventions without considering patient beliefs and choices.
✅ Correct Approach: Involve the patient in decision-making.
🚫 Not Documenting Interventions Properly
❌ Failing to record nursing actions and patient responses.
✅ Correct Approach: Always document interventions accurately for legal and professional accountability.
Selecting appropriate nursing interventions is a crucial part of the nursing process, ensuring effective and individualized patient care. Protocols and standing orders provide structured guidelines to help nurses implement evidence-based interventions safely and efficiently.
“Nursing interventions are specific actions taken by a nurse to promote patient health, prevent complications, and achieve patient-centered goals.”
✅ Example:
A nurse follows a standing order to administer oxygen to a patient with low oxygen saturation without waiting for a physician’s order.
🔹 Ensures safe and standardized care.
🔹 Helps nurses act quickly in emergencies.
🔹 Supports evidence-based practice.
🔹 Reduces treatment delays and improves patient outcomes.
🔹 Allows nurses to work independently within their scope of practice.
✅ Example:
In a hospital, a nurse uses a protocol for fall prevention, ensuring all at-risk patients have side rails up and a fall alert bracelet.
| Term | Definition | Example |
|---|---|---|
| Protocols | Step-by-step clinical guidelines developed for managing specific conditions, ensuring consistency in care. | A hospital sepsis protocol guides nurses in early recognition, fluid resuscitation, and monitoring. |
| Standing Orders | Pre-approved medical instructions that allow nurses to perform specific interventions without obtaining a new physician order each time. | A standing order for chest pain may instruct nurses to administer aspirin and start an ECG before contacting a doctor. |
✅ Key Difference:
A nursing protocol is a structured plan that outlines the step-by-step management of specific health conditions. It ensures consistency and adherence to best practices.
✔ Developed based on evidence-based guidelines.
✔ Ensures uniformity in patient care.
✔ Used for common conditions or procedures.
✔ May vary between hospitals, clinics, and long-term care facilities.
| Protocol Type | Example |
|---|---|
| Fall Prevention Protocol | Ensures bed alarms, non-slip socks, and fall risk assessments for high-risk patients. |
| Pain Management Protocol | Guides assessment and administration of pain medications based on pain scores. |
| Sepsis Management Protocol | Directs early recognition, lab tests, and fluid resuscitation for sepsis. |
| Post-Operative Care Protocol | Outlines pain control, mobility exercises, and infection prevention. |
✅ Example:
A hypoglycemia protocol in a hospital instructs nurses to:
✔ Check blood glucose levels immediately.
✔ Administer oral glucose or IV dextrose based on severity.
✔ Monitor the patient’s vital signs and response.
Standing orders are pre-approved medical instructions that allow nurses to initiate specific treatments without a direct physician’s order.
✔ Developed by physicians and approved by hospital administration.
✔ Provides quick decision-making power for nurses.
✔ Common in emergency departments, ICUs, and outpatient clinics.
✔ Helps in early intervention and improved patient safety.
| Standing Order Type | Example |
|---|---|
| Emergency Chest Pain | Administer aspirin, nitroglycerin, and oxygen before physician arrival. |
| Hypoglycemia Management | If blood glucose <70 mg/dL, administer 15g glucose orally or IV dextrose. |
| Hypertension Management | If BP >180/110 mmHg, give PRN antihypertensive medication. |
| Anaphylaxis Treatment | Give epinephrine IM, antihistamines, and corticosteroids immediately. |
✅ Example:
A standing order in a dialysis unit may allow nurses to administer heparin to prevent clotting without contacting a doctor each time.
✅ Example:
A nurse assessing a patient with fever, low BP, and rapid breathing initiates a sepsis protocol for early treatment.
✅ Example:
A nurse follows the fall prevention protocol by:
✔ Placing bed rails up.
✔ Giving non-slip socks.
✔ Using a bed alarm for a confused patient.
✅ Example:
If a patient with chest pain still has pain after aspirin and nitroglycerin, the nurse calls the physician for further instructions.
| Benefit | Protocols | Standing Orders |
|---|---|---|
| Enhances Patient Safety | Ensures evidence-based practices. | Allows rapid intervention in emergencies. |
| Reduces Delays in Treatment | Standardized guidelines prevent confusion. | Nurses can act immediately without waiting for a doctor. |
| Promotes Consistency | All nurses follow the same procedures. | Ensures uniformity in emergency responses. |
| Improves Healthcare Efficiency | Reduces treatment variability. | Helps manage high-risk conditions efficiently. |
✅ Example:
A hospital stroke protocol ensures rapid CT scans and clot-dissolving medications are given immediately to reduce brain damage.
🚫 Not verifying patient eligibility
❌ Using a diabetes management protocol for a non-diabetic patient.
✅ Correct Approach: Always confirm patient conditions before implementing protocols.
🚫 Failure to document interventions
❌ Administering medications without recording the action.
✅ Correct Approach: Always document the intervention, time, and patient response.
🚫 Overlooking contraindications
❌ Giving antihypertensive medication when the patient’s BP is already low.
✅ Correct Approach: Assess contraindications before following standing orders.
The Nursing Intervention Classification (NIC) is a standardized system used to classify nursing interventions. It helps organize and describe nursing care in a clear, measurable way. NIC was developed by the University of Iowa’s College of Nursing to support evidence-based practice, nursing education, and research.
“The Nursing Intervention Classification (NIC) is a comprehensive, research-based, standardized classification of interventions that nurses perform to enhance patient outcomes.”
✅ Example:
If a patient has a nursing diagnosis of “Impaired Gas Exchange”, the nurse can select the NIC intervention “Oxygen Therapy (3320)” to improve oxygen levels.
NIC provides a universal language for nurses to document and communicate patient care effectively.
✔ Standardizes nursing interventions across healthcare settings.
✔ Enhances communication among nurses and healthcare teams.
✔ Facilitates research and evidence-based practice.
✔ Supports electronic health records (EHRs) for accurate documentation.
✔ Improves patient outcomes by guiding appropriate interventions.
✅ Example:
A nurse caring for a diabetic patient can use the NIC “Blood Glucose Monitoring (2300)” intervention to ensure proper blood sugar control.
NIC is structured into seven domains and 30 classes, which group related interventions based on patient needs.
| Domain | Classes (Categories of Interventions) | Example Interventions |
|---|---|---|
| 1. Physiological: Basic | Activity and Exercise Management, Elimination Management, Immobility Management, Nutrition Support, Physical Comfort Promotion | Positioning (0840), Pain Management (1400), Nutrition Monitoring (1020) |
| 2. Physiological: Complex | Electrolyte and Acid-Base Management, Drug Management, Neurologic and Cardiovascular Management | Oxygen Therapy (3320), IV Therapy (4200) |
| 3. Behavioral | Behavior Therapy, Cognitive Therapy, Communication Enhancement, Coping Assistance | Anxiety Reduction (5820), Emotional Support (5270) |
| 4. Safety | Risk Management, Infection Control, Tissue Perfusion Management | Fall Prevention (6490), Pressure Ulcer Prevention (3540) |
| 5. Family | Caregiving Facilitation, Family Support, Childbearing Care | Family Integrity Promotion (7160) |
| 6. Health System | Information Management, Health Policy, Health System Mediation | Shift Report (7920), Infection Surveillance (6650) |
| 7. Community | Community Health Promotion, Disaster Preparedness | Disaster Preparedness (7970), Smoking Cessation Assistance (4490) |
✅ Example:
A nurse working in an ICU may use the NIC “Mechanical Ventilation Management (3300)” intervention to optimize patient breathing support.
NIC interventions are categorized based on how nurses deliver care.
| Type of Intervention | Definition | Example |
|---|---|---|
| Independent Nursing Interventions | Actions nurses perform without a doctor’s order. | Repositioning a patient to prevent bedsores (NIC: “Positioning (0840)”). |
| Dependent Nursing Interventions | Actions that require a physician’s order. | Administering IV medications (NIC: “IV Therapy (4200)”). |
| Collaborative Nursing Interventions | Actions performed in coordination with other healthcare professionals. | Working with a dietitian to develop a diabetic meal plan (NIC: “Nutrition Counseling (5240)”). |
✅ Example:
A nurse helping a patient with mobility issues may select the NIC “Ambulation Therapy (0200)” to improve walking ability.
| Condition | Nursing Diagnosis | NIC Intervention |
|---|---|---|
| Hypertension | Risk for ineffective cerebral tissue perfusion | Blood Pressure Monitoring (4315) |
| Diabetes Mellitus | Risk for unstable blood glucose levels | Blood Glucose Monitoring (2300) |
| Post-Surgical Care | Acute pain related to surgical incision | Pain Management (1400) |
| Pneumonia | Ineffective airway clearance | Airway Suctioning (3160) |
| Stroke Recovery | Impaired physical mobility | Range of Motion Exercises (0205) |
✅ Example:
For a patient with pressure ulcers, the nurse may select “Wound Care (3660)” from NIC to promote healing.
✅ Example:
A nurse caring for a patient with anxiety may select the NIC “Anxiety Reduction (5820)”, which includes relaxation techniques, breathing exercises, and emotional support.
Proper documentation ensures effective communication and continuity of care.
| Documentation Requirement | Example |
|---|---|
| Intervention Name | “Oxygen Therapy (3320)” |
| Date & Time | “March 10, 2025, 10:00 AM” |
| Action Taken | “Administered 2L oxygen via nasal cannula.” |
| Patient Response | “Oxygen saturation improved to 96% after 30 minutes.” |
✅ Example:
A nurse documents: “Repositioned patient every 2 hours as per NIC ‘Positioning (0840)’. No new pressure ulcers observed.”
🚫 Lack of Awareness
❌ Some nurses are unfamiliar with NIC interventions.
✅ Solution: Provide training and education on NIC.
🚫 Inconsistent Documentation
❌ Failure to record nursing interventions in medical records.
✅ Solution: Use electronic health records (EHRs) for accurate documentation.
🚫 Limited Resources
❌ Some interventions require specialized equipment or staff.
✅ Solution: Prioritize essential interventions based on available resources.
The Nursing Outcome Classification (NOC) is a standardized system that defines measurable patient outcomes in response to nursing interventions. Developed by the University of Iowa’s College of Nursing, NOC helps nurses evaluate the effectiveness of their interventions and improves patient care documentation.
“The Nursing Outcome Classification (NOC) is a standardized set of patient outcomes that reflect the impact of nursing interventions on patient health.”
✅ Example:
A nurse implementing the “Pain Management (NIC: 1400)” intervention can measure its success using the NOC “Pain Level (NOC: 2102)”, which evaluates the patient’s pain intensity on a scale.
🔹 Provides a measurable way to assess patient progress.
🔹 Enhances nursing documentation and communication.
🔹 Supports evidence-based practice.
🔹 Helps in quality improvement and research.
🔹 Facilitates continuity of care across healthcare settings.
✅ Example:
If a nurse implements a NIC intervention for respiratory distress, they can use the NOC “Respiratory Status (0415)” to evaluate improvements in oxygen levels and breathing patterns.
The NOC system organizes outcomes into seven domains and 32 classes, grouping similar outcomes together.
| Domain | Classes (Categories of Outcomes) | Example Outcomes (NOC Codes) |
|---|---|---|
| 1. Functional Health | Mobility, Activity Tolerance, Self-Care | Walking (0211), Self-Care Status (0300) |
| 2. Physiologic Health | Cardiac, Respiratory, Neurologic, Endocrine | Respiratory Status (0415), Pain Level (2102) |
| 3. Psychosocial Health | Coping, Communication, Mental Well-being | Anxiety Reduction (1211), Social Interaction Skills (1502) |
| 4. Health Knowledge & Behavior | Health Promotion, Medication Adherence | Medication Management (1823), Health Literacy (1802) |
| 5. Perceived Health | Satisfaction, Quality of Life | Quality of Life (2008), Satisfaction with Care (2501) |
| 6. Family Health | Caregiver Well-being, Family Coping | Caregiver Stress (2203), Family Coping (2205) |
| 7. Community Health | Public Health, Access to Care | Community Health Status (2702), Health Promotion (2708) |
✅ Example:
A patient recovering from a heart attack may have the outcome “Cardiac Pump Effectiveness (NOC: 0403)”, which assesses heart function and blood circulation.
Outcomes in NOC are classified based on how they reflect patient progress.
| Type of Outcome | Definition | Example |
|---|---|---|
| Short-Term Outcomes | Changes within hours or days. | “Pain Level (2102)” improves within 4 hours after pain medication. |
| Intermediate Outcomes | Achieved within a few weeks. | “Mobility Level (0212)” increases after 2 weeks of physiotherapy. |
| Long-Term Outcomes | Achieved after months or more. | “Quality of Life (2008)” improves 3 months after surgery. |
✅ Example:
For a patient with diabetes, the NOC outcome “Blood Glucose Level (0410)” can be measured short-term after insulin administration and long-term with lifestyle changes.
| Condition | Nursing Diagnosis | NIC Intervention | NOC Outcome |
|---|---|---|---|
| Hypertension | Risk for ineffective cerebral tissue perfusion | Blood Pressure Monitoring (4315) | Blood Pressure Control (0405) |
| Diabetes Mellitus | Risk for unstable blood glucose levels | Blood Glucose Monitoring (2300) | Blood Glucose Level (0410) |
| Post-Surgical Care | Acute pain related to surgical incision | Pain Management (1400) | Pain Level (2102) |
| Pneumonia | Ineffective airway clearance | Airway Suctioning (3160) | Respiratory Status (0415) |
| Stroke Recovery | Impaired physical mobility | Range of Motion Exercises (0205) | Mobility Level (0212) |
✅ Example:
A nurse caring for a patient with pneumonia may use the NIC intervention “Oxygen Therapy (3320)” and assess its success using the NOC “Oxygenation Status (0402)”.
✅ Example:
A nurse treating a post-surgical patient’s pain may document that the NOC outcome “Pain Level (2102)” improved from 3 (moderate pain) to 5 (no pain) after medication.
Proper documentation ensures continuity of care and accurate evaluation of nursing interventions.
| Documentation Requirement | Example |
|---|---|
| Outcome Name & Code | “Pain Level (2102)” |
| Baseline Score | “Initial pain level: 2 (Severe pain)” |
| Intervention Applied | “Administered oral analgesic and repositioned patient.” |
| Final Score | “Pain level improved to 4 (Mild pain) after 30 minutes.” |
✅ Example:
A nurse records:
“Pain Level (NOC: 2102) improved from 2 to 4 after pain medication and ice pack application.”
🚫 Lack of Awareness
❌ Some nurses do not use standardized outcomes.
✅ Solution: Provide training on NOC documentation.
🚫 Inconsistent Outcome Measurement
❌ Nurses may not use measurement scales correctly.
✅ Solution: Ensure proper training on using NOC scales.
🚫 Limited Integration with Electronic Records
❌ Some hospitals lack electronic health records (EHR) compatibility.
✅ Solution: Implement standardized documentation in EHR systems.
A nursing care plan (NCP) is a structured document that outlines a patient’s nursing diagnoses, goals, interventions, and expected outcomes. It serves as a roadmap for patient care, ensuring that nursing actions are evidence-based, individualized, and goal-directed.
“A nursing care plan is a written outline of the nursing process that includes assessment, diagnosis, planning, implementation, and evaluation to provide individualized patient care.”
✅ Example:
For a patient with pneumonia, a care plan includes:
✔ Nursing Diagnosis: Ineffective airway clearance
✔ Goal: Patient will maintain clear airways within 48 hours.
✔ Interventions: Positioning, oxygen therapy, deep breathing exercises.
✔ Expected Outcome: Patient’s oxygen saturation will be ≥95%.
🔹 Ensures continuity of care across different nurses and shifts.
🔹 Provides a structured, organized approach to patient care.
🔹 Enhances communication between healthcare professionals.
🔹 Supports evidence-based practice and improves patient outcomes.
🔹 Serves as a legal document in case of disputes or audits.
✅ Example:
A post-surgical nursing care plan ensures effective pain management, wound care, and mobility support.
A well-written nursing care plan consists of five essential components, following the ADPIE (Assessment, Diagnosis, Planning, Implementation, and Evaluation) framework.
| Component | Description | Example |
|---|---|---|
| 1. Assessment | Collect subjective and objective data to identify patient problems. | “Patient reports shortness of breath; SpO₂ = 89%.” |
| 2. Nursing Diagnosis | Identify the problem based on assessment data using NANDA-I approved diagnoses. | “Ineffective airway clearance related to mucus production as evidenced by dyspnea and wheezing.” |
| 3. Goals/Outcomes | Define SMART goals that describe expected patient improvements. | “Patient’s SpO₂ will improve to ≥95% within 24 hours.” |
| 4. Nursing Interventions | List specific nursing actions to achieve goals. | “Administer oxygen therapy, encourage deep breathing exercises.” |
| 5. Evaluation | Assess patient response to interventions and adjust care as needed. | “After 24 hours, SpO₂ improved to 96%; goal met.” |
✅ Example:
For a postoperative patient, the care plan might include:
✔ Assessment: Pain score of 8/10
✔ Diagnosis: Acute pain related to surgical incision
✔ Goal: Pain score will be ≤3/10 within 6 hours
✔ Intervention: Administer prescribed analgesic, apply ice pack, encourage relaxation techniques
✔ Evaluation: Pain score reduced to 3/10 after interventions.
To ensure clarity and effectiveness, follow these guidelines when writing a nursing care plan.
🚫 Incorrect: “Pneumonia” (Medical diagnosis).
✅ Correct: “Ineffective airway clearance related to mucus production as evidenced by dyspnea and wheezing.”
Each nursing diagnosis statement should include three components:
| Component | Definition | Example |
|---|---|---|
| P – Problem | The nursing diagnosis (NANDA-I). | Impaired skin integrity |
| E – Etiology (Cause) | The related factors or causes. | Related to prolonged immobility |
| S – Signs/Symptoms | The evidence supporting the diagnosis. | As evidenced by a stage 2 pressure ulcer on the sacrum. |
✅ Example of a Nursing Diagnosis Statement:
“Impaired skin integrity related to prolonged immobility as evidenced by a stage 2 pressure ulcer on the sacrum.”
Each goal or expected outcome should follow the SMART format:
| SMART Component | Definition | Example |
|---|---|---|
| S – Specific | Clearly define the desired change. | “The patient will maintain oxygen saturation ≥95%.” |
| M – Measurable | Include quantifiable criteria. | “Pain score will be ≤3/10 within 6 hours.” |
| A – Achievable | Ensure realistic expectations. | “Patient will ambulate with assistance within 48 hours.” |
| R – Relevant | Address the patient’s actual needs. | “Patient will verbalize effective pain relief techniques.” |
| T – Time-bound | Specify a timeframe for achievement. | “Within 24 hours of intervention.” |
✅ Example of a Goal Statement:
“The patient will report a pain level of ≤3/10 within 6 hours after receiving prescribed analgesics.”
Each intervention should be:
✔ Based on evidence-based guidelines.
✔ Specific and actionable.
✔ Documented properly in the care plan.
| Type of Intervention | Example |
|---|---|
| Independent (Nurse-initiated) | Repositioning a bedridden patient every 2 hours. |
| Dependent (Physician-ordered) | Administering IV antibiotics as prescribed. |
| Collaborative (Multidisciplinary) | Working with a physiotherapist for stroke rehabilitation. |
✅ Example of Nursing Interventions for a Stroke Patient:
✔ Encourage range-of-motion exercises to prevent contractures.
✔ Assist with feeding using adaptive utensils for independent eating.
✔ Provide speech therapy consultation for swallowing difficulties.
✅ Example:
✔ Goal: “Patient will report pain ≤3/10 within 6 hours.”
✔ Evaluation: “After intervention, pain score was 4/10. Adjusted analgesic dosage per protocol.”
| Component | Details |
|---|---|
| Assessment | “Patient reports difficulty breathing, wheezing, and SpO₂ = 89%.” |
| Nursing Diagnosis | “Ineffective airway clearance related to mucus production as evidenced by dyspnea and wheezing.” |
| Goal/Outcome | “Patient’s oxygen saturation will improve to ≥95% within 24 hours of oxygen therapy.” |
| Nursing Interventions | 1) Administer oxygen therapy as prescribed. 2) Encourage deep breathing exercises every 2 hours. 3) Monitor lung sounds and oxygen saturation every 4 hours. |
| Evaluation | “After 24 hours, SpO₂ improved to 96%. Goal met.” |
✅ Key Takeaway:
The care plan must be specific, measurable, and adaptable based on the patient’s response.
The implementation phase is the fourth step in the nursing process (after Assessment, Diagnosis, and Planning). This stage involves carrying out the planned nursing interventions to achieve the desired patient outcomes. It is a dynamic, action-oriented phase where nurses apply clinical judgment and skills to improve patient health.
“Implementation is the process of executing the planned nursing interventions to achieve patient-centered goals and expected outcomes.”
✅ Example:
For a patient with pneumonia, implementation includes:
✔ Administering oxygen therapy as prescribed.
✔ Encouraging deep breathing exercises.
✔ Monitoring respiratory status and oxygen levels.
🔹 Ensures nursing interventions are carried out effectively.
🔹 Helps in achieving patient goals and expected outcomes.
🔹 Provides individualized patient care.
🔹 Facilitates collaboration between nurses, physicians, and other healthcare professionals.
🔹 Promotes evidence-based practice and improves patient safety.
✅ Example:
A post-operative patient requires interventions such as pain management, wound care, and early ambulation to prevent complications.
The implementation phase includes the following key elements:
| Element | Description |
|---|---|
| 1. Reassessing the Patient | Before carrying out interventions, the nurse must reassess the patient’s condition. |
| 2. Determining the Need for Assistance | If a task requires help, the nurse seeks assistance from other healthcare professionals. |
| 3. Implementing Nursing Interventions | The nurse executes the planned interventions based on the care plan. |
| 4. Supervising Delegated Care | If care tasks are delegated to nursing assistants, the nurse ensures proper execution. |
| 5. Documenting Nursing Interventions | The nurse records actions taken and patient responses in the medical record. |
✅ Example:
A nurse reassesses a patient with high fever and finds the temperature has increased. The nurse adjusts the intervention by administering prescribed antipyretics and increasing fluid intake.
The nursing interventions implemented during this phase fall into three categories:
✅ Examples:
✔ Repositioning a patient every 2 hours to prevent pressure ulcers.
✔ Providing emotional support to a patient experiencing anxiety.
✔ Teaching a diabetic patient how to check blood glucose levels.
✅ Examples:
✔ Administering IV medications as prescribed.
✔ Starting oxygen therapy for a patient with low oxygen levels.
✔ Applying a wound dressing as per the physician’s orders.
✅ Examples:
✔ Working with a physical therapist to develop a mobility plan for a stroke patient.
✔ Consulting a dietitian to create a nutritional plan for a malnourished patient.
✔ Collaborating with a pharmacist to monitor medication side effects.
The nursing implementation process follows a systematic approach to ensure effective care.
| Step | Description |
|---|---|
| Step 1: Reassess the Patient | Before performing any intervention, reassess the patient’s condition. |
| Step 2: Validate the Care Plan | Ensure that interventions are still appropriate based on current patient needs. |
| Step 3: Organize Resources and Equipment | Gather all necessary supplies and arrange the environment. |
| Step 4: Implement the Interventions | Carry out nursing actions according to the care plan. |
| Step 5: Monitor the Patient’s Response | Evaluate how the patient reacts to the intervention. |
| Step 6: Document the Care Provided | Record the intervention, patient response, and any modifications. |
✅ Example:
For a patient receiving oxygen therapy, the nurse:
✔ Step 1: Reassesses oxygen levels (SpO₂).
✔ Step 2: Confirms the oxygen order is correct.
✔ Step 3: Ensures oxygen mask and tubing are ready.
✔ Step 4: Administers the oxygen therapy.
✔ Step 5: Monitors respiratory rate and improvement.
✔ Step 6: Documents SpO₂ changes and patient response.
| Condition | Independent Interventions | Dependent Interventions | Collaborative Interventions |
|---|---|---|---|
| Hypertension | Teach relaxation techniques | Administer prescribed antihypertensives | Work with a dietitian for a low-sodium diet |
| Diabetes Mellitus | Educate on insulin self-administration | Administer prescribed insulin | Collaborate with a nutritionist for meal planning |
| Pneumonia | Encourage deep breathing exercises | Start IV antibiotics as prescribed | Work with a respiratory therapist for chest physiotherapy |
| Pain Management | Apply cold compress, reposition for comfort | Administer prescribed pain medications | Work with a physiotherapist for pain-relief exercises |
✅ Example:
For a patient with post-operative pain, interventions include:
✔ Repositioning for comfort (Independent).
✔ Administering IV analgesics (Dependent).
✔ Coordinating with a physiotherapist for mobilization (Collaborative).
Proper documentation ensures legal, ethical, and professional accountability.
✔ Time and date of intervention.
✔ Specific nursing actions taken.
✔ Patient response to interventions.
✔ Any modifications to the care plan.
✅ Example:
“March 10, 2025, 10:00 AM: Administered oxygen therapy at 2L/min via nasal cannula. Patient’s SpO₂ improved from 89% to 96% after 30 minutes. No signs of respiratory distress observed.”
🚫 Not reassessing the patient before intervention
❌ Incorrect Approach: Performing interventions without checking if they are still needed.
✅ Correct Approach: Always reassess the patient’s condition before proceeding.
🚫 Lack of patient involvement
❌ Incorrect Approach: Providing care without explaining procedures to the patient.
✅ Correct Approach: Educate and involve the patient in decision-making.
🚫 Incomplete documentation
❌ Incorrect Approach: Failing to record patient response to interventions.
✅ Correct Approach: Document all nursing actions and patient outcomes.
The implementation phase is the fourth step of the nursing process (after Assessment, Diagnosis, and Planning). During this stage, nurses carry out the planned interventions to help the patient achieve the desired health outcomes.
“Implementation is the execution of planned nursing interventions to achieve patient-centered goals and expected outcomes.”
✅ Example:
For a patient with pneumonia, implementation includes:
✔ Administering oxygen therapy.
✔ Encouraging deep breathing exercises.
✔ Monitoring respiratory status and oxygen saturation levels.
The implementation process consists of five essential steps to ensure safe and effective nursing care.
| Step | Description | Example |
|---|---|---|
| 1. Reassessing the Patient | Evaluate the patient’s current condition to ensure the selected interventions are still appropriate. | Before administering insulin, check the patient’s blood glucose level. |
| 2. Reviewing and Modifying the Care Plan | Adjust interventions if the patient’s condition has changed or if outcomes are not being met. | If pain persists despite medication, adjust the intervention by changing the dosage or adding non-pharmacological pain relief. |
| 3. Organizing Resources and Delegating Tasks | Gather necessary equipment, supplies, and staff support before implementation. | Before inserting an IV line, ensure sterile gloves, IV fluids, and catheter are available. |
| 4. Implementing the Nursing Interventions | Perform planned independent, dependent, and collaborative interventions. | Repositioning a bedridden patient every 2 hours to prevent pressure ulcers. |
| 5. Documenting the Care Provided | Record interventions performed and the patient’s response in medical records. | “Administered 500mL IV fluids; BP improved from 88/60 to 110/75 mmHg after 30 minutes.” |
✅ Example:
For a post-operative patient, the implementation steps include:
✔ Reassessing pain levels before giving medication.
✔ Modifying the care plan if pain persists despite intervention.
✔ Ensuring the patient has ice packs and analgesics available.
✔ Administering prescribed analgesics and repositioning the patient.
✔ Documenting pain reduction from 8/10 to 3/10 after intervention.
During implementation, nurses perform three types of interventions:
| Type | Definition | Example |
|---|---|---|
| Independent Nursing Interventions | Actions nurses perform without a doctor’s order based on clinical judgment. | Repositioning a patient to prevent bedsores. |
| Dependent Nursing Interventions | Actions that require a physician’s order. | Administering IV medications as prescribed. |
| Collaborative Nursing Interventions | Actions performed in collaboration with other healthcare professionals. | Working with a dietitian to create a diabetic meal plan. |
✅ Example:
For a patient with hypertension, the nurse will:
✔ Educate on lifestyle modifications (Independent).
✔ Administer prescribed antihypertensive drugs (Dependent).
✔ Collaborate with a nutritionist for dietary planning (Collaborative).
To ensure safe and effective patient care, follow these guidelines during the implementation phase.
✅ Example:
For a patient recovering from a stroke, interventions include:
✔ Encouraging the patient to perform self-care tasks (to regain independence).
✔ Collaborating with a physiotherapist for mobility training.
✔ Using assistive devices like a walker or handrails.
Proper documentation is essential for legal, ethical, and professional reasons.
✔ Date and time of intervention.
✔ Specific nursing actions performed.
✔ Patient response to intervention.
✔ Any modifications made to the care plan.
✅ Example of Documentation:
“March 15, 2025, 10:00 AM: Administered 2L oxygen via nasal cannula. Patient’s SpO₂ improved from 89% to 96% after 20 minutes. No signs of respiratory distress observed.”
🚫 Skipping Patient Reassessment
❌ Performing interventions without checking if the patient’s condition has changed.
✅ Correct Approach: Always reassess before intervention.
🚫 Lack of Patient Involvement
❌ Not explaining procedures to the patient before implementation.
✅ Correct Approach: Educate and gain patient consent whenever possible.
🚫 Poor Documentation
❌ Failing to record nursing actions and patient response.
✅ Correct Approach: Document all interventions immediately.
🚫 Not Prioritizing Urgent Needs
❌ Addressing minor issues before life-threatening conditions.
✅ Correct Approach: Use Maslow’s Hierarchy of Needs and the ABCDE approach to set priorities.
| Component | Details |
|---|---|
| Assessment | “Patient complains of difficulty breathing and wheezing; SpO₂ = 89%.” |
| Nursing Diagnosis | “Ineffective airway clearance related to mucus production as evidenced by dyspnea and abnormal lung sounds.” |
| Goal/Outcome | “Patient’s oxygen saturation will improve to ≥95% within 24 hours of oxygen therapy.” |
| Nursing Interventions | 1) Administer oxygen therapy at 2L/min via nasal cannula. 2) Encourage deep breathing exercises every 2 hours. 3) Monitor lung sounds and oxygen saturation every 4 hours. |
| Implementation Actions | – Administered oxygen therapy at 2L/min. – Encouraged incentive spirometry exercises. – Reassessed respiratory rate and lung sounds every 4 hours. |
| Evaluation | “After 24 hours, SpO₂ improved to 96%. Goal met.” |
✅ Key Takeaway:
The care plan should be adaptable based on the patient’s response and changing condition.
Nursing care is provided in two main forms: Direct care and Indirect care. These two types ensure comprehensive and holistic patient care, addressing both immediate patient needs and supportive functions that facilitate high-quality healthcare.
“Nursing care involves the application of clinical knowledge, skills, and judgment to improve patient health, prevent illness, and promote well-being.”
✅ Example:
✔ Direct Care: Administering medications to a patient with fever.
✔ Indirect Care: Sterilizing medical instruments to prevent infection.
✔ Helps nurses prioritize tasks effectively.
✔ Ensures holistic, patient-centered care.
✔ Improves time management and delegation of nursing duties.
✔ Enhances patient safety and healthcare efficiency.
✔ Facilitates teamwork among healthcare professionals.
✅ Example:
A nurse assisting a patient with mobility exercises provides direct care, while a nurse coordinating a discharge plan is engaged in indirect care.
Nursing care is broadly divided into two categories:
| Type of Care | Definition | Example |
|---|---|---|
| 1. Direct Nursing Care | Care provided face-to-face with the patient to improve their health condition. | Administering IV medications, performing wound dressing, assisting with feeding. |
| 2. Indirect Nursing Care | Activities performed away from the patient, but essential for their care. | Documenting patient progress, coordinating with the healthcare team, maintaining infection control procedures. |
“Direct care refers to hands-on, face-to-face interactions where the nurse performs procedures, treatments, and assessments directly on the patient.”
✔ Requires physical presence and direct interaction.
✔ Involves therapeutic communication and patient education.
✔ Can be preventive, curative, or rehabilitative.
✔ Provides immediate feedback on the patient’s response.
| Category | Examples |
|---|---|
| Physical Care | Taking vital signs, assisting with personal hygiene, inserting a catheter. |
| Procedural Care | Administering injections, starting IV therapy, dressing wounds. |
| Emotional Support | Providing reassurance, counseling, and crisis intervention. |
| Patient Education | Teaching about disease management, medication use, and self-care practices. |
✅ Example:
A nurse changing a post-operative wound dressing is performing direct care.
“Indirect care includes activities performed away from the patient that contribute to patient care, support healthcare delivery, and improve outcomes.”
✔ Involves behind-the-scenes activities.
✔ Supports continuity of care and healthcare safety.
✔ Improves healthcare efficiency and teamwork.
✔ Includes administrative and coordination tasks.
| Category | Examples |
|---|---|
| Documentation & Reporting | Updating medical records, writing care plans, recording interventions. |
| Coordination & Communication | Collaborating with doctors, dietitians, physiotherapists, and social workers. |
| Equipment & Environment Maintenance | Ensuring medical equipment is functional, maintaining aseptic conditions. |
| Policy & Safety Management | Following infection control protocols, ensuring patient safety guidelines. |
✅ Example:
A nurse preparing a discharge summary for a patient going home is performing indirect care.
| Aspect | Direct Nursing Care | Indirect Nursing Care |
|---|---|---|
| Interaction with Patient | Face-to-face, hands-on | Not in direct contact with the patient |
| Purpose | Immediate patient care and treatment | Supporting and coordinating healthcare services |
| Examples | Administering medications, wound care, assisting in mobility | Charting, ordering supplies, discussing patient care in team meetings |
| Impact on Patient | Directly influences health improvement | Supports safe, efficient, and continuous care |
✅ Example:
A nurse assisting a patient with a nebulizer is direct care, while a nurse updating patient care notes in a medical record is indirect care.
✔ Ensures comprehensive, high-quality care.
✔ Prevents burnout by delegating indirect tasks effectively.
✔ Improves patient safety and healthcare system efficiency.
✔ Enhances interdisciplinary collaboration.
✅ Example:
A nurse balancing direct care (administering IV fluids) with indirect care (coordinating patient discharge) ensures effective care delivery.
Proper documentation is essential for both direct and indirect care.
✔ Record all direct patient interactions, including assessments and interventions.
✔ Log indirect care activities, such as communication with healthcare providers.
✔ Use standardized formats and hospital protocols.
✅ Example:
“March 10, 2025, 10:00 AM: Administered 500mL IV fluids as per physician’s order. BP improved from 88/60 to 110/75 mmHg. Patient tolerated the procedure well.”
🚫 Focusing only on Direct Care
❌ Providing treatments but not documenting them properly.
✅ Correct Approach: Always record interventions and patient response.
🚫 Overlooking Indirect Care Activities
❌ Ignoring infection control protocols or failing to restock essential supplies.
✅ Correct Approach: Prioritize both hands-on care and supportive activities.
🚫 Poor Time Management Between Direct and Indirect Care
❌ Spending too much time on documentation while delaying urgent patient care.
✅ Correct Approach: Balance patient interaction with essential paperwork.
| Component | Details |
|---|---|
| Patient Condition | 65-year-old female with pneumonia and difficulty breathing. |
| Direct Nursing Care | ✔ Administer oxygen therapy ✔ Perform chest physiotherapy ✔ Encourage deep breathing exercises |
| Indirect Nursing Care | ✔ Document patient’s progress ✔ Coordinate with a respiratory therapist ✔ Ensure availability of oxygen supplies |
| Outcome | Patient’s SpO₂ improved from 89% to 96% after interventions. |
✅ Key Takeaway:
A combination of direct and indirect care ensures effective treatment and healthcare coordination.
Evaluation is the final step in the nursing process (following Assessment, Diagnosis, Planning, and Implementation). This phase helps nurses determine whether the patient goals and expected outcomes have been achieved and whether the nursing interventions were effective.
“Evaluation is the process of assessing the effectiveness of nursing interventions by comparing actual patient outcomes with expected goals.”
✅ Example:
For a patient with hypertension, if the goal was to maintain a blood pressure below 140/90 mmHg, the nurse evaluates if the BP readings have improved after interventions.
✔ Ensures that nursing care is effective and patient-centered.
✔ Helps in decision-making regarding continuing, modifying, or terminating interventions.
✔ Supports evidence-based practice by measuring patient progress.
✔ Improves patient safety and quality of care.
✔ Facilitates clear documentation and communication within the healthcare team.
✅ Example:
If a patient was receiving pain management interventions, evaluation will determine if the pain score decreased from 8/10 to the goal of ≤3/10.
The evaluation phase follows a structured process to ensure systematic assessment of patient progress.
| Step | Description | Example |
|---|---|---|
| 1. Reassess the Patient | Compare the patient’s current condition with baseline data. | Rechecking blood glucose levels after insulin administration. |
| 2. Compare Actual Outcomes with Expected Goals | Determine if the SMART goals set during planning were achieved. | If the goal was SpO₂ ≥95%, check if oxygen therapy was effective. |
| 3. Identify Factors Affecting Outcomes | Analyze whether internal (patient-related) or external (treatment-related) factors influenced progress. | If pain persists despite analgesics, consider tolerance or ineffective dose. |
| 4. Modify the Care Plan if Needed | Adjust interventions or set new goals if initial plans were ineffective. | If BP remains high, adjust medications and add lifestyle modifications. |
| 5. Document Findings and Communicate with the Healthcare Team | Record evaluation results and share with the healthcare team for coordinated care. | “Patient’s temperature reduced from 102°F to 98.6°F after antipyretic therapy.” |
✅ Example:
A nurse assessing a post-surgical patient’s mobility progress evaluates whether the goal “Patient will walk 10 steps independently within 2 days” was achieved.
Evaluation can be classified into different types based on timing, focus, and method of assessment.
| Type | Definition | Example |
|---|---|---|
| Ongoing Evaluation | Continuous assessment of the patient’s response during care. | Monitoring pain levels every 2 hours after administering analgesics. |
| Intermittent Evaluation | Performed at specific time intervals during care. | Checking BP readings every morning in hypertensive patients. |
| Terminal Evaluation | Conducted at the time of discharge or after treatment completion. | Assessing functional mobility in a stroke patient before discharge. |
✅ Example:
A nurse monitoring oxygen saturation every 4 hours during pneumonia treatment is performing ongoing evaluation.
| Type | Definition | Example |
|---|---|---|
| Formative Evaluation | Evaluates nursing care in real-time to improve interventions. | Checking pain relief after giving morphine. |
| Summative Evaluation | Conducted after interventions to assess overall effectiveness. | Evaluating weight loss in a patient following a 6-week diet plan. |
✅ Example:
After implementing a low-sodium diet for 1 month, a nurse evaluates blood pressure changes (summative evaluation).
| Type | Definition | Example |
|---|---|---|
| Objective Evaluation | Uses measurable data (vital signs, lab values) to assess outcomes. | Checking blood glucose levels before and after insulin therapy. |
| Subjective Evaluation | Based on patient-reported symptoms and feelings. | Asking a patient, “On a scale of 0-10, how is your pain now?” |
✅ Example:
A nurse measuring SpO₂ levels after oxygen therapy is conducting objective evaluation, while asking the patient if breathing feels easier is subjective evaluation.
Once interventions are carried out, the nurse compares expected and actual patient outcomes.
| Expected Outcome | Actual Outcome | Result |
|---|---|---|
| BP will be ≤140/90 mmHg | BP is 136/85 mmHg | Goal met ✅ |
| Patient will rate pain ≤3/10 | Patient reports 5/10 pain | Goal partially met 🔄 |
| Patient will ambulate 50 meters | Patient walked only 20 meters | Goal not met ❌ |
✅ Example:
If a goal was “Patient will have a respiratory rate of 12-20 breaths per minute”, and the actual outcome was 22 breaths per minute, the goal was not fully met, and adjustments are needed.
If a goal is unmet or partially met, the care plan must be adjusted.
✔ Patient condition changed unexpectedly.
✔ Interventions were ineffective or needed reinforcement.
✔ New complications developed requiring a different approach.
✅ Example:
If a diabetic patient’s blood sugar remains high despite medication, the nurse may:
✔ Reassess dietary intake and insulin effectiveness.
✔ Modify the care plan to include increased physical activity.
✔ Educate the patient on insulin timing adjustments.
Proper documentation is critical for tracking patient progress and ensuring continuity of care.
✔ Date and time of evaluation.
✔ Patient condition before and after interventions.
✔ Comparison of expected and actual outcomes.
✔ Modifications made to the care plan.
✔ Next steps or follow-up actions.
✅ Example of Documentation:
“March 15, 2025, 10:00 AM: Goal was for the patient’s pain level to reduce to ≤3/10. After administering ibuprofen 400mg, the patient reports a pain score of 2/10. Goal met. No further pain medication required.”
🚫 Failing to Compare Actual vs. Expected Outcomes
❌ Not assessing whether interventions had the desired effect.
✅ Correct Approach: Always compare results with planned goals.
🚫 Incomplete Documentation
❌ Not recording whether a goal was met or not.
✅ Correct Approach: Clearly document patient response to interventions.
🚫 Not Revising Care Plan When Needed
❌ Continuing ineffective interventions without making adjustments.
✅ Correct Approach: Modify the care plan if outcomes are not achieved.
| Component | Details |
|---|---|
| Assessment | “Patient reports severe pain (8/10) after surgery.” |
| Nursing Diagnosis | “Acute pain related to surgical incision as evidenced by facial grimacing and verbal reports.” |
| Goal/Expected Outcome | “Patient will report a pain level ≤3/10 within 6 hours of intervention.” |
| Interventions | ✔ Administer prescribed pain medications. ✔ Use cold compress therapy. ✔ Encourage relaxation techniques. |
| Evaluation | “Pain level reduced from 8/10 to 2/10 after 4 hours. Goal met.” |
✅ Key Takeaway:
If a goal is not met, interventions must be adjusted and reassessed.
The evaluation phase is the final step in the nursing process, following Assessment, Diagnosis, Planning, and Implementation. It determines whether the nursing interventions were successful in achieving the expected patient outcomes and guides future care decisions.
“Evaluation is the systematic process of assessing the effectiveness of nursing interventions by comparing actual patient outcomes with the expected goals.”
✅ Example:
For a patient with pneumonia, evaluation assesses whether oxygen therapy improved oxygen saturation from 88% to the target of ≥95%.
✔ Ensures patient-centered care by assessing progress.
✔ Determines effectiveness of interventions and identifies needed changes.
✔ Prevents complications by addressing unmet goals.
✔ Improves nursing decision-making through evidence-based practice.
✔ Provides legal and professional documentation of patient care.
✅ Example:
If a hypertension patient’s BP remains high despite medication, evaluation helps in modifying the care plan (e.g., adjusting dosage or adding lifestyle modifications).
The evaluation process consists of a structured approach to assess nursing interventions and patient progress.
| Step | Description | Example |
|---|---|---|
| 1. Reassess the Patient | Compare the patient’s current status with baseline assessment. | Checking blood glucose levels after insulin administration. |
| 2. Compare Actual Outcomes with Expected Goals | Determine if the SMART goals set during planning were met. | If the goal was pain reduction to ≤3/10, check the current pain score. |
| 3. Identify Factors Affecting Outcomes | Analyze whether internal (patient-related) or external (treatment-related) factors influenced results. | If a wound is not healing, consider infection or poor nutrition. |
| 4. Modify the Care Plan if Needed | Adjust interventions if the expected outcome is not achieved or partially met. | If BP remains high, adjust medications or add a low-sodium diet. |
| 5. Document Findings and Communicate with the Healthcare Team | Record evaluation results and share with nurses, doctors, and therapists. | “Patient’s SpO₂ improved from 88% to 96% after oxygen therapy.” |
✅ Example:
A nurse monitoring a post-operative patient’s pain evaluates whether the goal “Pain score ≤3/10 within 6 hours” was achieved.
Evaluation can be classified into different types based on timing, focus, and method of assessment.
| Type | Definition | Example |
|---|---|---|
| Ongoing Evaluation | Continuous assessment of the patient’s response during care. | Monitoring pain levels every 2 hours after giving analgesics. |
| Intermittent Evaluation | Conducted at specific intervals during care. | Checking BP readings daily in hypertensive patients. |
| Terminal Evaluation | Performed at discharge or after treatment completion. | Assessing functional mobility in a stroke patient before discharge. |
✅ Example:
A nurse monitoring oxygen levels every 4 hours during pneumonia treatment is performing ongoing evaluation.
| Type | Definition | Example |
|---|---|---|
| Formative Evaluation | Real-time assessment to improve interventions. | Checking pain relief after giving morphine. |
| Summative Evaluation | Conducted after interventions to assess overall effectiveness. | Evaluating weight loss in a patient following a 6-week diet plan. |
✅ Example:
After implementing a low-sodium diet for 1 month, a nurse evaluates BP changes (summative evaluation).
| Type | Definition | Example |
|---|---|---|
| Objective Evaluation | Uses measurable data (vital signs, lab values). | Checking blood glucose before and after insulin. |
| Subjective Evaluation | Based on patient-reported symptoms. | Asking “On a scale of 0-10, how is your pain now?” |
✅ Example:
A nurse measuring SpO₂ levels after oxygen therapy is conducting objective evaluation, while asking the patient if breathing feels easier is subjective evaluation.
Once interventions are carried out, the nurse compares expected and actual patient outcomes.
| Expected Outcome | Actual Outcome | Result |
|---|---|---|
| BP will be ≤140/90 mmHg | BP is 136/85 mmHg | Goal met ✅ |
| Patient will rate pain ≤3/10 | Patient reports 5/10 pain | Goal partially met 🔄 |
| Patient will ambulate 50 meters | Patient walked only 20 meters | Goal not met ❌ |
✅ Example:
If a goal was “Patient will have a respiratory rate of 12-20 breaths per minute”, and the actual outcome was 22 breaths per minute, the goal was not fully met, and adjustments are needed.
If a goal is unmet or partially met, the care plan must be adjusted.
✔ Patient condition changed unexpectedly.
✔ Interventions were ineffective or needed reinforcement.
✔ New complications developed requiring a different approach.
✅ Example:
If a diabetic patient’s blood sugar remains high despite medication, the nurse may:
✔ Reassess dietary intake and insulin effectiveness.
✔ Modify the care plan to include increased physical activity.
✔ Educate the patient on insulin timing adjustments.
Proper documentation is critical for tracking patient progress and ensuring continuity of care.
✔ Date and time of evaluation.
✔ Patient condition before and after interventions.
✔ Comparison of expected and actual outcomes.
✔ Modifications made to the care plan.
✔ Next steps or follow-up actions.
✅ Example of Documentation:
“March 15, 2025, 10:00 AM: Goal was for the patient’s pain level to reduce to ≤3/10. After administering ibuprofen 400mg, the patient reports a pain score of 2/10. Goal met. No further pain medication required.”
🚫 Failing to Compare Actual vs. Expected Outcomes
❌ Not assessing whether interventions had the desired effect.
✅ Correct Approach: Always compare results with planned goals.
🚫 Incomplete Documentation
❌ Not recording whether a goal was met or not.
✅ Correct Approach: Clearly document patient response to interventions.
🚫 Not Revising Care Plan When Needed
❌ Continuing ineffective interventions without making adjustments.
✅ Correct Approach: Modify the care plan if outcomes are not achieved.
Documentation and reporting are critical components of the nursing process that ensure accurate communication, legal protection, and continuity of care. Proper documentation helps track patient progress, support clinical decisions, and provide evidence for legal and research purposes.
“Documentation is the process of recording all nursing actions, observations, and patient responses in a legal, structured, and standardized manner.”
✅ Example:
A nurse documents that a patient’s temperature reduced from 102°F to 98.6°F after administering an antipyretic.
“Reporting is the process of verbally or electronically sharing patient-related information with other healthcare professionals for continuity of care.”
✅ Example:
A nurse in the ICU reports a change in a patient’s vital signs to the incoming shift nurse.
✔ Ensures continuity of care by providing a clear record of treatment.
✔ Promotes patient safety by tracking medical history and interventions.
✔ Supports legal protection by serving as evidence in medical lawsuits.
✔ Improves communication among nurses, doctors, and healthcare teams.
✔ Facilitates research and quality improvement in healthcare.
✔ Enhances accountability by tracking actions performed by healthcare professionals.
✅ Example:
If a patient develops an allergic reaction after receiving a medication, documentation ensures the allergy is flagged for future care.
To maintain high-quality records, documentation should follow the FACTUAL format:
| Principle | Description |
|---|---|
| F – Factual | Use objective data (e.g., “BP 140/90 mmHg,” NOT “Patient looks unwell”). |
| A – Accurate | Avoid errors and record precise times, medications, and interventions. |
| C – Complete | Include all essential details, such as patient response and follow-up actions. |
| T – Timely | Document immediately after an intervention to avoid forgetting details. |
| U – Unbiased | Avoid personal opinions (e.g., “Patient was rude,” instead document “Patient expressed frustration”). |
| A – Avoid assumptions | Do not assume symptoms, document only what you observe. |
| L – Legible & Legal | Ensure readable handwriting or use electronic records correctly. |
✅ Example of Proper Documentation:
“March 10, 2025, 10:00 AM: Administered 500mg acetaminophen orally for fever of 101°F. After 30 minutes, patient’s temperature reduced to 98.6°F. No signs of distress observed.”
✅ Example:
A nurse documents wound care in a nursing progress note, while a physician records medication orders in a physician’s chart.
✅ Example of SOAP Note:
✔ Subjective: “Patient reports severe headache for 2 days.”
✔ Objective: BP: 150/95 mmHg, HR: 90 bpm.
✔ Assessment: Hypertension with possible migraine.
✔ Plan: Administer antihypertensive and pain reliever, monitor BP.
✅ Example:
✔ Normal: “Lung sounds clear bilaterally.” (Not documented)
✔ Abnormal: “Lung sounds diminished in right lower lobe.” (Documented)
✅ Example:
“Patient admitted with complaints of chest pain. Administered nitroglycerin 0.4mg SL at 9:30 AM. Patient reports pain reduction from 8/10 to 2/10 after 10 minutes. No further complaints noted.”
✅ Example:
✔ A nurse updates an EHR with vital signs, medication administration, and nursing interventions.
✅ Example:
“Patient admitted with pneumonia. Received IV antibiotics at 6 PM. Oxygen saturation stable at 96%. Monitor for fever overnight.”
✅ Example:
“Patient fell while attempting to walk to the bathroom unassisted. No visible injuries. Physician notified, and fall risk measures reinforced.”
✅ Example of SBAR Report:
✔ Situation: “Patient’s BP dropped to 80/50 mmHg after medication.”
✔ Background: “Patient has a history of hypotension and received antihypertensives.”
✔ Assessment: “Patient is dizzy and confused.”
✔ Recommendation: “Should we stop the medication and give IV fluids?”
✅ Example:
“Patient transferred to ICU due to worsening respiratory distress. On oxygen therapy 4L/min. BP 110/70, HR 88 bpm, SpO₂ 92%.”
✅ Example:
“Patient discharged in stable condition. Prescribed amoxicillin 500mg BID for 7 days. Advised to follow up in 2 weeks.”
🚫 Using Subjective or Judgmental Language
❌ “Patient is non-compliant and lazy.”
✅ Correct Approach: “Patient refused medication and verbalized concerns about side effects.”
🚫 Failure to Document in Real-Time
❌ Documenting interventions hours later, leading to missing details.
✅ Correct Approach: Record all actions immediately after performing them.
🚫 Illegible or Incomplete Entries
❌ “Pt. had meds. Feeling better.”
✅ Correct Approach: “Patient received acetaminophen 500mg PO at 9 AM for headache. Reports pain decreased from 6/10 to 2/10.”
🚫 Failing to Correct Errors Properly
❌ Erasing or using correction fluid.
✅ Correct Approach: Draw a single line through the error, write “error,” and sign your initials.
ADDITIONAL DETAILS.
Pain assessment is a critical component of nursing care that helps determine the severity, location, and impact of pain on a patient’s well-being. Proper assessment ensures that appropriate interventions are provided to relieve pain and improve quality of life.
“Pain assessment is the systematic process of evaluating a patient’s pain level, type, and response to treatment using subjective and objective measures.”
✅ Example:
A nurse asks a post-surgical patient to rate their pain on a scale of 0-10 to guide pain management.
✔ Ensures effective pain management and improves patient comfort.
✔ Prevents complications like chronic pain or anxiety.
✔ Guides treatment decisions (medications, physical therapy, alternative therapies).
✔ Supports legal documentation and ethical care.
✔ Enhances communication between patients, nurses, and healthcare teams.
✅ Example:
A patient with arthritis reports severe pain (9/10), prompting the nurse to administer pain medication and reassess later.
Pain is classified into different types based on origin, duration, and mechanism.
| Type | Definition | Example |
|---|---|---|
| Acute Pain | Sudden onset, short duration, usually due to injury or surgery. | Post-surgical pain, fractures, burns. |
| Chronic Pain | Lasts for more than 3-6 months, often due to a long-term condition. | Arthritis, cancer pain, back pain. |
| Type | Definition | Example |
|---|---|---|
| Nociceptive Pain | Pain due to tissue damage or inflammation. | Sprains, burns, surgery. |
| Neuropathic Pain | Pain due to nerve damage or dysfunction. | Diabetic neuropathy, sciatica. |
| Psychogenic Pain | Pain influenced by psychological factors without physical injury. | Depression-related pain, phantom limb pain. |
✅ Example:
A patient with nerve injury experiences burning and tingling sensations (neuropathic pain), requiring different treatment than nociceptive pain from a cut.
Pain scales are tools used to quantify pain intensity and help nurses tailor pain management strategies.
✅ Example:
A patient reports pain as 7/10, indicating severe pain requiring immediate intervention.
✅ Example:
A child points to the “crying face” (8/10), prompting the nurse to administer pain relief.
✅ Example:
A post-operative patient marks pain at 6/10, guiding pain management decisions.
| Category | 0 Points | 1 Point | 2 Points |
|---|---|---|---|
| Face | No expression | Occasional grimace | Constant frown, clenched jaw |
| Legs | Normal | Uneasy, restless | Kicking, rigid |
| Activity | Normal movement | Squirming, tense | Arched back, jerking |
| Cry | No cry | Whimpers | Loud crying, screaming |
| Consolability | Content, relaxed | Comforted by touch | Difficult to console |
✅ Example:
A crying infant with clenched fists scores 8/10, indicating severe pain needing immediate relief.
✅ Example:
A dementia patient grimacing, moaning, and restless scores 6/10, requiring pain management.
A detailed pain assessment helps identify characteristics of pain.
| Assessment Factor | Questions to Ask | Example Response |
|---|---|---|
| P – Provocation/Palliation | “What makes the pain better or worse?” | “Pain worsens with movement, but improves with rest.” |
| Q – Quality | “Describe the pain (sharp, dull, burning)?” | “It feels like a stabbing pain.” |
| R – Region/Radiation | “Where is the pain? Does it spread?” | “Pain is in my lower back and shoots down my legs.” |
| S – Severity | “How bad is the pain on a scale of 0-10?” | “It is 7/10 right now.” |
| T – Timing | “When did the pain start? Is it constant?” | “It started after my surgery and is constant.” |
✅ Example:
A post-operative patient reports sharp pain (7/10) that worsens with movement, guiding pain relief measures.
Proper documentation ensures effective pain management and continuity of care.
✔ Time of assessment (Before and after interventions).
✔ Pain score using appropriate scale.
✔ Location and characteristics of pain.
✔ Pain-relief measures taken.
✔ Patient’s response to interventions.
✅ Example of Documentation:
“March 15, 2025, 10:00 AM: Patient reports sharp pain in the right knee, rated 8/10 on NRS. Administered acetaminophen 500mg PO. Pain reassessed after 30 minutes, now 3/10. Patient comfortable.”
Based on the pain assessment, nurses select appropriate interventions.
| Pain Level | Intervention |
|---|---|
| Mild (1-3/10) | Repositioning, relaxation, cold compress. |
| Moderate (4-6/10) | Oral pain medications (acetaminophen, ibuprofen). |
| Severe (7-10/10) | IV pain medications (morphine, opioids), urgent medical intervention. |
✅ Example:
A patient with severe cancer pain (9/10) requires opioid analgesics and palliative care measures.
🚫 Not using the right pain scale
❌ Using a numerical scale for infants or dementia patients.
✅ Correct Approach: Use FLACC for infants, PAINAD for dementia.
🚫 Not reassessing after pain relief measures
❌ Failing to check if pain improved after medication.
✅ Correct Approach: Reassess pain after 30-60 minutes.
🚫 Ignoring non-verbal signs of pain
❌ Assuming a silent patient is pain-free.
✅ Correct Approach: Observe grimacing, restlessness, and guarding behavior.