Nursing Process
Part Two
Status of the Nursing
Diagnosis
• It refers to the actuality or the potentiality of the
problem/syndrome
• Actual Dx: the problem that exists at the time of
assessment
• Risk Dx: Problem does not exist but there are risk
factors to suggest a problem will develop unless the
nurse intervene
• Health promotion Dx: related to the clients’ readiness
to practice behaviors to improve their health. They
begin with readiness for enhanced nutrition
• Syndrom Dx: describe a collection of NDx that have
similar interventions
Components of the
NANDA Nursing Diagnosis
•A typical nursing diagnosis statement
has two or three parts/statements.
•In two parts nursing diagnosis, the first
component is a problem statement or
diagnostic label (as listed in NANDA),
while second component is the etiology.
•Both of two parts are linked by the term
related to (RT).
•The three-part nursing diagnosis
statement consists of the Problem+
Etiology + Sign & Symptoms (defining
characteristics) joined to the first two
component by connecting phrase “as
evidence by” (AEB).
Actual nursing diagnosis
• An actual nursing diagnosis represents condition that is currently present.
• An actual nursing diagnosis statement is usually represented by a three-
part statement written in the following order:
• The nursing diagnosis label from the NANDA list .
• The etiology.
• The specific cues/signs and symptoms from the patient's assessment.
• Connecting phrases are used to join the three parts of the statement:
• "Related to" (R/T) : links the first and second parts.
• "Manifested by" (M/B): joins the second and third parts.
• e.g., constipation related to (R/T) decreased fluid intake manifested by
abdominal distention
At Risk nursing diagnosis
•At risk for nursing diagnosis are written as two-part statement.
• The two parts are:
(1) The nursing diagnosis label from the NANDA list
(2) The risk factors.
The two parts are connected by
the words "related to"
e.g., Risk for impaired skin
integrity related to prolonged
immobility .
Notice: There is no third part
("manifested by') in this statement.
If there were signs or symptoms,
an actual problem would exist.
Taxonomy of NDx
NANDA NDx
Nursing Planning and Outcome
identification
Planning is a third phase of nursing process in
which
client centered goals are established and
strategies are designed to achieve the goals.
During the planning process of developing client
care plans, the nurse engages in the following
activities:
1. Setting priorities.
2. Establishing goals/desired patient
outcomes.
3. Selecting nursing interventions.
4. Writing nursing orders (nursing
interventions).
Priority Setting
■ Is the process of establishing a proper (preferential) sequence for addressing
nursing diagnoses and interventions.
■ The nurse and client begin planning by deciding the priority of which
diagnoses will receive the most attention first according to their severity and
potential for causing more serious harm.
■ Life-threatening problems such as loss of respiratory or cardiac function are
designated as high priority.
Establishing Client Goals/Desired Outcomes
■ After establishing priorities, the nurse and client set Goals/Desired Outcomes for each
nursing diagnosis.
■ It describes what the nurse hopes to achieve by implementing the nursing interventions.
■ Guidelines for writing goals/desired outcomes:
■ Write goals and outcomes in terms of client responses, not nurse activities.
■ Use observable, measurable terms for outcomes.
■ Make sure that each goal is derived from only one NDx
■ Be sure that desired outcomes are realistic for the patient
Establishing Client • Nursing diagnosis • Goal/outcome statement
Goals/Desired Outcomes • Impaired skin integrity • Patient will have intact
Patient-centered goals/ skin within 3 weeks.
• Related to prolonged
desired outcome • Note that intact skin is a
statements indicate a • Immobility manifested by "2" reversal of impaired skin.
Diameter ulcer on coccyx.
reversal of the problem
identified by the NANDA
nursing diagnosis label,
as shown in the
following example:
Selecting Nursing Interventions and Activities
• Nursing interventions and activities are the actions that a nurse performs to
achieve client goals:
• Independent interventions:
• Activities initiated by the nurse on the basis of her knowledge and skills.
They include physical care, emotional support and comfort, teaching,
counseling….,
• Dependent interventions;
• Are activities carried out under the physician’s orders or supervision, or
according to specified routines.
• Collaborative interventions:
• Are actions the nurse carries out in collaboration with other health team
members, such as physical therapist, social workers, and physicians.
Writing Nursing • Goal/outcome Statement • Nursing Dx
Order(intervention) • Patient will have intact skin • Impaired skin integrity
within 3 weeks.
• Related to prolonged
• Note that intact skin is
a reversal of impaired skin. • Immobility manifested by
"2" Diameter ulcer on
coccyx.
Patient-centered goals/desired outcome statements indicate
a reversal of the problem identified by the NANDA nursing diagnosis
label, as shown in the example
.
Selecting Nursing Interventions and Activities
• Nursing interventions and activities are the actions that a nurse performs to achieve
client goals:
• Independent interventions:
• Activities initiated by the nurse on the basis of her knowledge and skills. They include
physical care, emotional support and comfort, teaching, counseling….,
• Dependent interventions;
• Are activities carried out under the physician’s orders or supervision, or according to
specified routines.
• Collaborative interventions:
• Are actions the nurse carries out in collaboration with other health team members, such
as physical therapist, social workers, and physicians.
Writing Nursing Order(intervention)
• After choosing the appropriate nursing interventions, the nurse writes them on the care plan
as nursing orders.
• Nursing orders are instructions for the specific individualized activities the nurse performs to
help the client meet established health care goals.
• Writing nursing orders should include the followings:
• 1- Date.
• 2- Content area.
• 3- Action verb.
• 4- Time element.
• 5- Signature of nurse prescribing the orders.
Implementation
• During the implementation phase ; the established plan is put into action to promote outcome
achievement .
• The implementation phase includes:
• Reassessing the Client.
• Prioritization.
• Implementing the Nursing Interventions.
• Documenting Nursing Activities.
• Documentation is a vital component of the implementation phase.
•"if it was not Documented, it was not done."
Evaluation
THE LAST PHASE OF THE EVALUATION IS A THIS STEP DETERMINE THE DECISION EITHER TO
NURSING PROCESS DECISION MADE ABOUT THE SUCCESS/ CONTINUE, MODIFY OR
WHICH INCLUDE THE THE EXTENT TO WHICH EFFECTIVENESS OF THE REPEAT THE PROCESS
JUDGMENT OF THE THE ESTABLISHED WHOLE NURSING DEPENDS ON
EFFECTIVENESS OF OUTCOMES HAVE BEEN PROCESS. EVALUATION.
NURSING CARE TO ACHIEVED.
MEET CLIENT GOALS
BASED ON THE CLIENT’S
BEHAVIORAL
RESPONSES.
Evaluation steps
1-The nurse reviews the patient-centered goals/desired patient outcomes
that were established in the planning phase .
2-The nurse reassesses the patient to gather data indicating the patient's
actual response to the nursing interventions.
3-The nurse compares the actual outcome with the desired outcome and
makes a critical judgment about whether the patient -centered goal/
desired patient outcome were achieved.
Purposes of Evaluation
• Determine client’s behavioral response
• Compare the client’s response with outcome criteria
• Assess the extent to which client’s goals
• Identify the errors in the plan of care monitor the quality of nursing care
Drawing Conclusions about Problem Status
• The nurse uses the judgments about goal achievement to determine whether the care plan was effective
in resolving, reducing, or preventing client problems.
• When goals have been met, the nurse can draw one of the following conclusions about the client’s
problem:
• The actual problem has been resolved; or potential problem is being prevented and the risk factors no
longer exist.
• So; the nurse documents that the goals have been met and discontinues the care for the problem.
• The potential problem is being prevented, but the risk factors are still present.
• In this case, the nurse keeps the problem on the care plan.
• After drawing conclusions about the status of the client’s problems, the nurse modifies the care plan as
indicated.
