what nursing assignment

The Ultimate Guide to Nursing Assignments: 7 Tips and Strategies

Nursing assignments are a critical component of every nursing student’s academic journey. They serve as opportunities to test your knowledge, apply theoretical concepts to real-world scenarios, and develop essential skills necessary for your future nursing career. However, tackling nursing assignments can often be overwhelming, particularly when you’re juggling multiple responsibilities. In this comprehensive guide, we provide valuable tips, strategies, and expert assignment help services to help you excel in your nursing assignments. Whether you’re struggling with research, structuring your assignment, or proofreading, we’re here to support you every step of the way.

Understanding the Nursing Assignments

To excel in nursing assignments , it’s crucial to start by thoroughly understanding the requirements. Take the time to carefully read the assignment prompt, paying close attention to the topic, word count, formatting guidelines, and any specific instructions provided by your instructor. Understanding these key components will ensure that you meet all the necessary criteria.

Conducting Thorough Research

Once you have a clear understanding of the assignment, it’s time to conduct thorough research. Solid research forms the foundation of any successful nursing assignment. Begin by gathering relevant and credible sources, such as nursing textbooks, scholarly articles, reputable websites , and academic databases specific to nursing. These resources will provide you with evidence-based information to support your arguments and demonstrate your understanding of the topic.

Creating a Well-Structured Outline

A well-structured outline is essential for organizing your thoughts and ensuring a logical flow in your nursing assignment. An effective outline acts as a roadmap, guiding you through the writing process and ensuring that you cover all the necessary points.

At [Your Service Name], our expert writers can assist you in creating a comprehensive outline tailored to your specific assignment. By collaborating with us, you can receive personalized guidance in organizing your ideas effectively and structuring your assignment in a logical manner. Our writers understand the nuances of nursing assignments and can help you identify the most important concepts and supporting evidence to include.

Using a Professional Tone

Maintaining a professional tone throughout your nursing assignment is crucial. As aspiring healthcare professionals, it’s essential to communicate your ideas with clarity, conciseness, and professionalism. Use clear and concise language, avoiding jargon or slang that may hinder the reader’s understanding. Present your arguments and supporting evidence in a logical and coherent manner, demonstrating your ability to think critically and apply nursing principles.

Our expert writers have extensive experience in academic writing within the field of nursing. They possess a deep understanding of the professional tone required for nursing assignments and can ensure that your assignment is written to the highest standards. By collaborating with us, you can receive guidance in maintaining a professional tone and effectively conveying your ideas.

Incorporating Practical Examples

In addition to a professional tone, incorporating practical examples into your nursing assignment can greatly enhance its quality. Practical examples bring theoretical concepts to life, illustrating their application in real-life scenarios. They demonstrate your understanding of nursing principles and showcase your ability to bridge the gap between theory and practice.

Our team consists of experienced nursing professionals who can assist you in incorporating relevant practical examples into your assignment. Drawing from their extensive knowledge and expertise, they can provide you with real-life scenarios or case studies that strengthen the impact and credibility of your work. By collaborating with us, you can elevate the quality of your assignment by demonstrating your ability to apply nursing concepts in practical settings.

Proofreading and Editing

Proofreading and editing are essential steps in the assignment writing process. They ensure that your nursing assignment is polished, error-free, and effectively communicates your ideas. After completing the initial draft, it’s crucial to take a break and return to your work with fresh eyes. During the proofreading stage, carefully review your assignment for grammar, spelling, punctuation, and sentence structure. Correct any errors and inconsistencies that may affect the clarity and professionalism of your writing.

At nursingresearchhelp.com , we have a dedicated team of proofreaders and editors who specialize in nursing assignments. They meticulously review your work, ensuring that it adheres to formatting guidelines and meets the highest standards of academic writing. Our proofreaders and editors will help you refine your assignment, ensuring that it is polished and error-free. By collaborating with us, you can rest assured that your assignment will be thoroughly reviewed and refined before submission.

Seeking Help When Needed

In addition to proofreading and editing, it’s important to seek help when needed. Nursing assignments can be challenging, and it’s perfectly normal to require assistance. Whether you’re facing difficulties in understanding the assignment prompt, need guidance in specific areas, or simply want a fresh perspective on your work, don’t hesitate to reach out for support.

Our friendly and knowledgeable support team is always available to address any questions or concerns you may have. We understand the unique challenges faced by nursing students and can provide you with the guidance and clarification you need. By seeking help when needed, you can overcome obstacles and ensure the successful completion of your nursing assignments.

Mastering nursing assignments is within your reach with the right tips, strategies, and expert assignment help services. At nursingresearchhelp.com we are committed to supporting nursing students in excelling in their academic pursuits. Our experienced writers, proofreaders, and editors can provide personalized assistance throughout the assignment writing process, ensuring that your assignments meet the highest standards of quality and professionalism.

With our help, you can confidently tackle your nursing assignments and overcome any challenges you may face. Visit our website nursingresearchhelp.com to learn more about our services and how we can support you in achieving academic excellence. Whether you need guidance in understanding the assignment, conducting thorough research, creating a well-structured outline, using a professional tone, incorporating practical examples, or ensuring a polished final product, we are here to assist you. Trust us for reliable and professional assignment help tailored to your needs.

Don’t let the challenges of nursing assignments hold you back—reach out to us for reliable and professional assignment help tailored to your needs.

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• South Dakota Nurse November 2018 issue is now available.

8 Steps for Making Effective Nurse-Patient Assignments

This article appears on page 14 of

South Dakota Nurse November 2018

Reprinted from American Nurse Today

Successful assignments require attention to the needs of both nurses and patients.

YOUR MANAGER wants you to learn how to make nurse­ patient assignments. What? Already? When did you be­came a senior nurse on your floor? But you’re up to the challenge and ready to learn the process.

Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments.

1. Find a mentor

Most nurses learn to make nurse-patient assignments from a colleague. Consider asking if you can observe your charge nurse make assignments. Ask questions to learn what factors are taken into consideration for each assignment. Nurses who make assignments are aware of their importance and are serious in their efforts to consider every piece of information when making them. By asking questions, you’ll better understand how priorities are set and the thought that’s given to each assignment. Making nurse-patient assignments is challenging, but with your mentor’s help, you’ll move from novice to competent in no time.

2. Gather your supplies (knowledge)

Before completing any nursing task, you need to gather your supplies. In this case, that means knowledge. You’ll need information about the unit, the nurses, and the patients. (See What you need to know.) Some of this information you already know, and some you’ll need to gather. But make sure you have everything you need before you begin making assignments. Missing and unknown information is dangerous and may jeopardize patient and staff safety. The unit and its environment will set the foundation for your assignments. The environment (unit physical layout, average patient length of stay [LOS]) defines your process and assignment configuration (nurse-to-patient ratios). You’re probably familiar with your unit’s layout and patient flow, but do you know the average LOS or nurse-to-patient ratios? Do you know what time of day most admissions and discharges occur or the timing of certain daily activities? And do other nursing duties need to be covered (rapid response, on call to another unit)? Review your unit’s policy and procedures manual for unit staffing and assignment guidelines. The American Nurses Association’s ANA ‘s Principles for Nurse Staffing 2nd edition also is an excellent resource.

Review the assignment sheet or whiteboard used on your unit. It has clues to the information you need. It provides the framework for the assignment-making process, including staff constraints, additional duties that must be covered, and patient factors most important on your unit. Use the electronic health record (EHR) to generate various useful pieces of patient information. You also can use the census sheet, patient acuity list, or other documents of nursing activity, such as a generic hospital patient summary or a unit-specific patient report that includes important patient factors.

Depending on your unit, the shift, and the patient population, you’ll need to consider different factors when making assignments. Ask yourself these ques­tions: What patient information is important for my unit? Does my unit generate a patient acuity or work­load factor? What are the time-consuming tasks on my unit (medications, dressing changes, psychosocial support, total care, isolation)? Which patients require higher surveillance or monitoring? Finally, always talk to the clinical nurses caring for the patients. Patient conditions change faster than they can be documented in the EHR, so rely on the clinical nurses to confirm each patient’s acuity and individual nurses’ workloads. Nurses want to be asked for input about their patients’ condition, and they’re your best resource.

Now ask yourself: How well do I know the other nurses on my unit? This knowledge is the last piece of information you need before you can make assignments. The names of the nurses assigned to the shift can be found on the unit schedule or a staffing list from a centralized staffing office. If you know the nurses and have worked with them, you’ll be able to determine who has the most and least experience, who’s been on the floor the longest, and who has specialty certifications. You’ll also want to keep in mind who the newest nurses are and who’s still on orientation.

3. Decide on the process

Now that you’ve gathered the information you need, you’re ready to develop your plan for assigning nurses. This step usually combines the unit layout with your patient flow. Nurses typically use one of three processes–area, direct, or group–to make assignments. (See Choose your process.)

4. Set priorities for the shift

The purpose of nurse-patient assignments is to provide the best and safest care to patients, but other goals will compete for consideration and priority. This is where making assignments gets difficult. You’ll need to consider continuity of care, new nurse orientation, patient requests and satisfaction, staff well-being, fairness, equal distribution of the workload, nurse development, and workload completion.

5. Make the assignments

Grab your writing instrument and pencil in that first nurse’s name. This first match should satisfy your highest priority. For example, if nurse and any other returning nurses are reassigned to the patients they had on their previous shift. If, however, you have a complex patient with a higher-than-average acuity, you just assigned your best nurse to this patient. After you’ve satisfied your highest priority, move to your next highest priority and match nurses with unassigned patients and areas.

Sounds easy, right? Frequently, though, you’ll be faced with competing priorities that aren’t easy to rate, and completing the assignments may take a few tries. You want to satisfy as many of your priorities as you can while also delivering safe, quality nursing care to patients. You’ll shuffle, move, and change assignments many times before you’re satisfied that you’ve maximized your priorities and the potential for positive outcomes. Congratulate yourself–the nurse-patient assignments are finally made.

6. Adjust the assignments

You just made the assignments, so why do you need to adjust them? The nurse-patient assignment list is a living, breathing document. It involves people who are constantly changing–their conditions improve and deteriorate, they’re admitted and discharged, and their nursing needs can change in an instant. The assignment process requires constant evaluation and reevaluation of information and priorities. And that’s why the assignments are usually written in pencil on paper or in marker on a dry-erase board. As the charge nurse, you must communicate with patients and staff throughout the shift and react to changing needs by updating assignments. Your goal is to ensure patients receive the best care possible; how that’s ac­complished can change from minute to minute.

7. Evaluate success

What’s the best way to eval­uate the success of your nurse-patient assignments? Think back to your priorities and goals. Did all the patients receive safe, quality care? Did you maintain continuity of care? Did the new nurse get the best orientation experience? Were the assignments fair? Measure success based on patient and nurse outcomes.

Check in with the nurses and patients to get their feedback. Ask how the assignment went. Did everyone get his or her work done? Were all the patients’ needs met? What could have been done better? Get specifics. Transparency is key here. Explain your rationale for each assignment (including your focus on patient safety) and keep in mind that you have more information than the nurses. You’re directing activity across the entire unit, so you see the big picture. Your colleagues will be much more understanding when you share your perspective. When you speak with patients, ask about their experiences and if all their needs were met.

8. Keep practicing

Nurse-patient assignments never lose their complexity, but you’ll get better at recognizing potential pitfalls and maximizing patient and nurse outcomes. Keep practicing and remember that good assignments contribute to nurses’ overall job satisfaction.

What you need to know

Before you make decisions about nurse-patient assignments, you need as much information as possible about your unit, nurses, and patients.

Common patient decision factors Demographics •    Age •    Cultural background •    Gender •    Language

Acuity •    Chief complaint •    Code status •    Cognitive status •    Comorbidities •    Condition •    Diagnosis •    History •    Lab work •    Procedures •    Type of surgery •    Vital signs •    Weight

Workload •    Nursing interventions •    Admissions, discharges, transfers •    Blood products •    Chemotherapy •    Drains •    Dressing changes •    End-of-life care •    I.V. therapy •    Lines •    Medications •    Phototherapy •    Treatments •    Activities of daily living •    Bowel incontinence •    Feedings •    Total care

Safety measures •    Airway •    Contact precautions •    Dermatologic precautions •    Fall precautions •    Restraints •    Surveillance

Psychosocial support •    Emotional needs •    Familial support •    Intellectual needs

Care coordination •    Consultations •    Diagnostic tests •    Orders •    Physician visit

Common nurse decision factors Demographics •    Culture/race •    Gender •    Generation/age •    Personality

Preference •    Request to be assigned/not assigned to a patient

Competence •    Certification •    Education •    Efficiency •    Experience •    Knowledge/knowledge deficit •    Licensure •    Orienting •    Skills •    Speed •    Status (float, travel)

Choose your process

Your nurse-patient assignment process may be dictated by unit layout, patient census, or nurse-to-patient ratio. Most nurses use one of three assignment processes.

Area assignment This process involves assigning nurses and patients to areas. If you work in the emergency department (ED) or postanesthesia care unit (PACU), you likely make nurse-patient assignments this way. A nurse is assigned to an area, such as triage in the ED or Beds 1 and 2 in the PACU, and then patients are assigned to each area throughout the shift.

Direct assignment The second option is to assign each nurse directly to a patient. This process works best on units with a lower patient census and nurse-to-patient ratio. For example, on a higher-acuity unit, such as an intensive care unit, the nurse is matched with one or two patients, so a direct assignment is made.

Group assignment With the third option, you assign patients to groups and then assign the nurse to a group. Bigger units have higher censuses and nurse-to-patient ratios (1:5 or 1:6). They also can have unique physical features or layouts that direct how assign­ments are made. A unit might be separated by hallways, divided into pods, or just too large for one nurse to safely provide care to patients in rooms at opposite ends of the unit. So, grouping patients together based on unit geography and other acuity/workload factors may be the safest and most effective way to make assignments.

You also can combine processes. For example, in a labor and delivery unit, you can assign one nurse to the triage area (area process) while another nurse is as­signed to one or two specific patients (direct process). Unit characteristics direct your process for making assignments. Your process will remain the same unless your unit’s geography or patient characteristics (length of stay, nurse-patient ra­tio) change.

Stephanie B. Allen is an assistant professor at Pace University in Pleasantville, New York.

Selected references Allen SB. The nurse-patient assignment process: What clinical nurses and patients think. MEDSURG Nurs. 2018;27(2):77-82. Allen SB. The nurse-patient assignment: Purposes and decision factors. J Nurs Adm. 2015;45(12):628-35. Allen SB. Assignments matter: Results of a nurse-patient assignment survey. MEDSURG Nurs [in press]. American Nurses Association (ANA). ANA‘s Principles for Nurse Staffing. 2nd ed. Silver Spring, MD: ANA; 2012.

Nursing School Assignments and Tips to Ace All of Them

If you are about to start nursing school or considering enrolling in a nursing program, you would want to know what to expect. You will write many papers in nursing school and do many other assignments. This is true whether you pursue ADN, BSN, MSN, DNP, or PhD in Nursing.

Before we delve into the types of assignments and papers to expect in nursing school, let us begin by dispelling the myth that nursing school is hell; it is NOT. Instead, it is a beautiful and exciting journey into a noble profession. It entails a commitment to life-long continuous learning for you to grow.

Nursing school writing assignments are an excellent way for students to understand concepts taught in the classroom. You might wonder what kinds of assignments nursing students do. These assignments come in various forms and help students build critical thinking, creativity, research, clinical reasoning, and problem-solving skills that are critical in clinical settings.

This blog post looks at the diverse assignments you should expect or will cover in nursing school, including some tips to help you ace them and get better grades.

Common Nursing School Writing Assignments

Classwork forms the core of most nursing programs. You must have high-quality assignment submissions to attain better grades in nursing school. As soon as you decide to become a nursing student, you sign up for a marathon of writing different types of papers.

Whether you love or hate it, you will write papers before graduating from nursing school; that is the norm. Although not so many, you will encounter a few homework and assignments where you must submit a well-researched, formatted, and organized nursing paper.

The typical nursing school assignments include essays, research papers, term papers, and case studies. Others are article critiques/reviews, critical appraisal, evidence synthesis tables (synthesis matrix), PowerPoint Presentations, posters, discussion posts/ responses, and policy analysis papers. Other advanced papers include nursing care plans, SBAR template papers, evidence-based papers, capstone projects, theses, dissertations, proposals, etc.

These assignments are submitted either individually or as a group. Let us expound on this so you have a clear picture.

Essays for nursing classes come in various forms, including admission essays , scholarship essays, descriptive essays, persuasive essays, speech essays, expository essays, and narrative essays.

Notably, nursing essays focus on a single perspective, argument, or idea, which constantly forms the thesis of the paper.

Nursing essays focus on various topics relating to nursing practice and the broader healthcare field. You can write an essay examining a nursing theory or non-nursing theory or discuss a nursing issue .

Some essays, such as reflective nursing essays, use reflective models to reflect, analyze, and understand personal and professional encounters during clinical practice.

Each nursing essay should demonstrate your understanding of the topic, critical analysis, and organization skills. Besides, you should use evidence from peer-reviewed scholarly sources to support your arguments and ideas.

Discussion Board Posts

If you pursue a hybrid or exclusively online nursing program, you will be assigned to write weekly discussion forum posts and responses. Discussion board posts are short essay-like assignments posted in a threaded format so students can discuss nursing and healthcare topics.

You will write an original discussion post, between 200 and 300 words long, and post it on the forum. You are also expected to write a peer-response post in response to or to comment on an original post done by your peers.

Discussion boards help nursing students advance theoretical concepts, learn from one another, share ideas, and get feedback that can help them advance their knowledge in clinical reasoning and practice.

Research Papers

Nursing practice is evidence-driven, translating evidence into practice to ensure quality, accessible, and affordable healthcare. As such, nursing research takes precedence during studies and when practicing.

Nursing professors assign nursing students to write research papers on various evidence-based practice topics. The students must prove their worth by researching, analyzing, and organizing facts.

Related Writing Guides:

• How to write a nursing school research paper.
• Systematic Reviews vs Literature Review

Research papers help student nurses to review literature, conduct research, implement solutions, and draw evidence-based conclusions.

Research papers are critical in developing research and writing skills, maintaining good communication, and fostering creativity and clinical reasoning.

Potential nursing research paper topics can be quality improvement, healthcare/nursing informatics , healthcare policies, practice privileges, nursing ethics, ethical dilemmas , pathophysiology, and epidemiology .

Term Papers

In nursing school, a term paper is a type of assignment completed and submitted toward the end of the semester.

Usually, a professor can assign you a specific term paper topic, or they can let you choose a topic and consult with them for approval.

Term papers can be done individually or as a group project. A term paper has an impact on your final grade.

You should use credible scholarly sources published within the last five years for recent information.

Besides, also ensure that you plan your time well, do everything as per the instructions, and submit the nursing term paper before the deadline.

A term paper can also be a nursing process change report that is expected to address an area that needs change.

Case Studies

Nursing school case study assignments are an essential learning tool.

Most professors assign hypothetical clinical case studies or case scenarios (snippets) to test your clinical reasoning skills.

As a nursing educational tool, nursing case studies help you to develop practical, theoretical knowledge by simulating real-world experiences.

When analyzing a case study, you must use concepts and knowledge from class and class text to assess a patient, plan and implement care, and evaluate the outcomes.

Sometimes, you encounter simulated or digital clinical experience case studies such as iHuman and Shadow Health .

You should be very keen when analyzing a case study and when writing the analysis report.

Case studies help you get beyond books and use your creativity, clinical reasoning, problem-solving, and analytical skills to apply theoretical knowledge to real-world problems.

Your professor can give you a case study of a patient presenting with a given condition and expect you to take them through the care planning process, including admission and discharge, as you would in a real healthcare setting.

Other times, you can be asked to develop a hypothetical case study of a patient presenting with a chronic disease or a disorder and then use the case study guidelines, including head-to-toe assessment , diagnosis , nursing care planning , and discharge planning.

Related Guides:

• How to write a great nursing case study.
• How to complete a case conceptualization report (for psychiatric nursing students)

Nursing Care Plans and SOAP Notes

A nursing care plan can be part of a case study or a stand-alone assignment. Nursing care plans are essential in nursing education as they help students develop effective nursing care planning. Formulating a nursing care plan for a patient scenario or case helps treat them as you define the guidelines and roles of nurses in caring for the patient.

You also develop solid action plans for focused and patient-centred care by documenting the patient's needs. When they are part of an assignment, you can tabulate the nursing care plan using columns so that you explore every aspect independently.

Remember to use evidence from peer-reviewed scholarly sources when giving rationale.

The SOAP notes are a clinical tool healthcare professionals use to organize patient information to minimize confusion and assess, diagnose, and treat patients. Check our comprehensive guide on developing good SOAP Notes in nursing school .

Concept Maps

Another common nursing school assignment is concept maps. Concept mapping helps you visually organize, compartmentalize, and categorize information about nursing care planning, medical diagnosis, pathophysiology, SBAR, nursing responsibilities, etc.

A nursing concept map assignment equips you with strong critical thinking, analytical, and problem-solving skills. You also hone your clinical reasoning skills in the process.

Whether it is part of an assignment or a stand-alone, learn how to write great concept maps to score the best grades.

Concept Analysis Papers

If you are taking BSN, MSN, or DNP, you will likely be assigned to write a concept analysis paper. Make sure to distinguish this from a concept paper that is a proposal. A concept analysis paper examines the structure and function of a nursing concept.

The process entails a review of the literature and creativity in coming up with borderline, related, contrast, inverted, and illegitimate cases.

You also explore the antecedents and consequences of the concept before finalizing with empirical referents.

If you need to learn about the structure of a good concept analysis paper, check out our nursing concept analysis guide . We have listed concepts you can analyze depending on your speciality, instructions, and passion.

Capstone Projects

At an advanced stage in nursing school, students are expected to submit longer research papers; capstone project papers. A nursing capstone project is a final project that allows students to demonstrate the skills, knowledge, and concepts gained throughout the nursing program.

In nursing education, the capstone project typically covers an evidence-based practice issue or problem. You can write a nursing change paper, look into a clinical process, problem, or issue, and then develop recommendations based on a study.

Most of the MSN and DNP capstone projects focus on clinical change or quality improvement. You will be expected to develop a PICOT question and formulate a research study to examine the issue, implement a change process using evidence-based models, and make recommendations.

Nursing capstone projects are individual research projects based on nursing topics either of your professional or personal interest. You have to demonstrate competency and commitment to improve health outcomes.

Apart from capstone projects, you will also write a nursing thesis and dissertation papers, which depend on the program requirements and your professor's preferences.

Check out these specific writing guides for advanced papers:

• How to write a nursing dissertation or thesis
• Tips for choosing the best nursing dissertation topic
• How to write an excellent capstone project paper
• List of capstone project topics for nursing school
• How to formulate a PICOT question
• PICOT question examples to inspire nursing students

Group Assignments

In nursing school and practice, collaboration and teamwork are highly recommended. You will encounter collaborative group assignments such as presentations (PowerPoint slides, Prezi, or other platforms), simulation assignments, writing nursing reports, and group research projects.

Group projects allow you to research, learn, and organize ideas together so that you can understand concepts better. It is essential to avoid social loafing in a group to gain more. Besides, plan your time well and avoid excuses.

You can also be assigned to work on simulation exercises as a group of nursing students. The aim of such exercises is to build a collaborative, teamwork, and decision-making spirit among the team.

When in such groups, expect to work with your peers to assess the hypothetical patient, communicate with your peers, formulate a care plan, and manage any arising issues as you would in clinical settings. Do not take such activities for granted; they contribute significantly to your grade.

Presentations

Your professor can assign you to design a PowerPoint Slide accompanied by speaker notes and send it for grading or present it online or in class. Under presentations, you will also be requested to design flyers, posters, and other visual documents to disseminate information.

It could be about a disease, health promotion, or nursing research. You must also make PowerPoint slides when presenting a thesis, dissertation, or capstone for assessments. Remember, this is the chance to bring out your creativity.

Expect other assignments such as dosage calculations, HESI test exams, skills checkoffs, electronic medical record documentation, nursing student portfolio, online quizzes, drug write-ups, process recordings, group drug presentations, etc.

In most cases, you will be given a template to use wisely and make it as appealing as possible.

Tips to Help You Ace Nursing Assignments

A lot goes into getting the best grades in nursing school. One of the main determinants of your nursing school grades is the assignments, which you are required to do and complete within set deadlines.

Even though many nursing students perform better on clinical, that needs to reflect in written assignments. Most students fear research and writing or do not take writing assignments seriously. Regardless of the assignment, here are some practical and effective tips to help you ace your nursing school writing assignments and surprise everyone, including yourself.

1. Plan your Time

The number one challenge for nursing students that inhibits them from completing assignments is the need for more time management.

Most students are juggling studies and work to make ends meet. It worsens when you have a massive workload from more than one class and a family to look after.

The simple trick to beat this is to manage your time well. You can schedule your assignments for periods when you are free and when you can concentrate and cover more. Assignments have deadlines ranging from hours to days or a few weeks.

To succeed, keep track of your assignments and other academic activities, such as mid-term and final examinations, so that you can plan your study periods. You can use online time management tools and apps to allocate your nursing school homework time.

With proper planning, you should be reassured about the last-minute rush to complete your assignment, which is responsible for the colossal failure we are experiencing in nursing schools.

2. Follow the Course Guidelines to the T

Guidelines, prompts, and reading materials accompany each writing assignment and homework. Sometimes a professor can be generous enough also to give you access to the Rubric, which breaks down how they will assess assignments. Ensure you read everything and note what is required before working on any paper.

Pay attention to these, read, and familiarize yourself with the course guidelines. Understand the formatting requirements preferred by your school, such as Vancouver, APA, or Harvard. Most nursing schools will specify this in the course documents. Also, check the databases and journal articles you can use when writing your nursing assignments.

Preparing in advance by reading the course materials to identify the recommended study materials. You will have a deeper understanding, knowledge, and skills to handle every nursing assignment correctly.

3. Have an Active Study Buddy

A nursing study buddy can be one of your classmates whom you study with. Study buddies offer mutual support, which comes in handy when completing assignments.

Select a bright and committed person with something to offer so you are not only giving. Set the study hours and have accountability follow-ups to ensure you cover much of the syllabus and concepts in time.

A study buddy can help you understand nursing concepts, theories, models, and frameworks. They can also help you review your written papers and give valuable feedback when editing and proofreading your nursing papers.

A knowledgeable, accountable, committed study partner can help you revamp your grades by submitting high-quality assignments.

4. Join a Study Group

A study group is a tried and tested means of completing nursing assignments. Apart from building your teamwork and collaborative skills, you can brainstorm ideas, critique one another, and learn more about the class assignments. With diversity in thoughts, you can get valuable insights and inputs for personal-level work.

Besides, you are also guaranteed to ace the nursing group assignments with ease. When doing group work, try to rotate into new groups so that you can appreciate the diversity of thoughts and reasoning. You can also identify individuals from your groups, those that are active, as your study buddies.

When you have accountability partners within the group, you commit to given tasks and make necessary follow-ups. If you are a part-time student, consider having students whose free time is similar to yours to benefit everyone.

5. Get Writing Assignment Help

As with other subjects in college and university, nursing students face challenges such as time management, complexity of assignments, too many assignments, and writer's block. When you feel overwhelmed with completing your nursing class assignments, you can always pay someone to handle the class for you or at least do your coursework or assignments.

One sure way to get assistance without drawing too much attention is by trusting assignment help websites like NurseMyGrade.com with your papers. Many students do not have time to complete assignments or find them challenging. Consequently, many hire nursing assignment helpers from nursing paper writing platforms.

If you feel like hiring the right professionals, use NurseMyGrade. We offer customized writing solutions to nursing students at different academic levels. Our nursing experts can complete short and lengthy assignments. You will have a well-researched and formatted paper written in Vancouver, APA, MLA, ASA, AMA, Harvard, or any citation style you choose.

You can use the tips and insights above to master nursing school assignments. We wish you all the best as you strive towards excellence. Don't worry about the many assignments. Instead, be grateful that they will equip you with knowledge, skills, and experience to make you the best nurse.

How Many Papers to Write in Nursing School

We have so far covered the general aspects of the types of assignments to expect in nursing school. Under the assignments, you may ask yourself if you must write many papers in nursing school.

While the answer depends on your professor, institutional curriculum requirements, and nursing level, you will undoubtedly write a couple of academic papers before graduating from nursing school. You will write research papers, essays, proposals, white papers, policy analysis papers, capstone project papers, case studies, scholarship essays, personal statements, quality improvement reports, etc.

Suppose you are pursuing a Licensed Practical Nurse (LPN) program. In that case, you will likely write between 13 and 15 papers during the LPN program, including short and long essays, reflective journals, essays, patient-based case studies, and others as your professor pleases.

If you are in a 2-year ADN program, expect to complete about 20 to 30 papers, including care plans, SBAR reports, essays, case studies analyses, research papers, reports, and other assignments.

For a 4-year Bachelor of Science in Nursing (BSN) program, you will write between 35 and 50 papers. If you are taking the online class program options, like the WGU BSN program, you might write more papers because they form the basis for your assessment.

BSN-level papers are demanding because you must strictly adhere to the formatting styles and be critical and organized in your presentation.

If you are taking a Master of Science in Nursing (MSN) program, an advanced-level study for registered nurses (RNs), you will do about 20-50 papers, given that it offers the foundation for nursing research. Again, at an advanced level, the MSN writing assignments are complex.

You need to plan well, research widely, and analyze facts thoroughly before drawing conclusions. During this level, expect to write papers such as MSN essays, discussion posts and responses, specialized case studies, research papers, clinical reports, advanced SOAP notes, nursing care plans, policy papers, position papers (white papers), dissertations, theses, capstone papers, project papers, and change project papers.

You are expected to show exquisite research skills for the Doctor of Nursing Practice (DNP) program, considered the highest level or terminal degree in nursing practice. At this level, you have specialized, advanced your knowledge, and have adequate experience.

Mostly, DNP papers are a little longer. You will write between 20-30 papers; depending on your nursing school curriculum and supervisor's preference, it could be less or more.

If you opt for the research route, you will write many research papers, technical papers, policy analysis papers, white papers, reflection papers, nursing dissertations, PICOT-based change project papers (DNP change project papers), and other assignments.

Finally, for the Doctor of Philosophy (PhD) in nursing programs, you should expect to write between 10 and 15 papers covering research-oriented topics.

Attaining this degree makes you the epitome of success in the field. You can advance into a nursing researcher, educator, leader, or manager.

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There are many assignments and papers to complete in nursing school, including written assignments, quizzes, exams (oral and written), reflective journals, journal entries, e-Portfolio, integrative reviews, teaching plans, presentations, etc. Whether taking an LPN program or advancing your career by pursuing a Ph.D. in Nursing, you will do many nursing school assignments.

Do not take assignments as a punishment. Instead, consider them as tools to equip and shape you into a desirable nurse practitioner.

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Common Assignments: Writing in Nursing

Although there may be some differences in writing expectations between disciplines, all writers of scholarly work are required to follow basic writing standards such as writing clear, concise, and grammatically correct sentences; using proper punctuation; demonstrating critical thought; and, in all Walden programs, using APA style. When writing in nursing, however, students must also be familiar with the goals of the discipline and discipline-specific writing expectations.

Nurses are primarily concerned about providing quality care to patients and their families, and this demands both technical knowledge and the appropriate expression of ideas (“Writing in nursing,” n.d). As a result, nursing students are expected to learn how to present information succinctly, and even though they may often use technical medical terminology (“Writing in nursing,” n.d.), their work should be accessible to anyone who may read it. Among many goals, writers within this discipline are required to:

• Document knowledge/research
• Demonstrate critical thinking
• Express creative ideas
• Explore nursing literature
• Demonstrate understanding of learning activities. (Wagner, n.d., para. 2)

Given this broad set of objectives, nursing students would benefit from learning how to write diverse literature, including scholarly reports, reviews, articles, and so on. They should aim to write work that can be used in both the research and clinical aspects of the discipline. Walden instructors often ask nursing students to write position and reflective papers, critique articles, gather and analyze data, respond to case studies, and work collaboratively on a project. Although there may be differences between the writing expectations within the classroom and those in the workplace, the standards noted below, though more common in scholarly writing, require skills that are transferrable to the work setting.

Because one cannot say everything there is to say about a particular subject, writers present their work from a particular perspective. For instance, one might choose to examine the shortage of nurses from a public policy perspective. One’s particular contribution, position, argument, or viewpoint is commonly referred to as the thesis and, according to Gerring et al. (2004), a good thesis is one that is “new, true, and significant” (p. 2). To strengthen a thesis, one might consider presenting an argument that goes against what is currently accepted within the field while carefully addressing counterarguments and adequately explaining why the issue under consideration matters (Gerring et al., 2004). The thesis is particularly important because readers want to know whether the writer has something new or worthwhile to say about the topic. Thus, as you review the literature, before writing, it is important to find gaps and creative linkages between viewpoints with the goal of contributing innovative ideas to an ongoing discussion. For a contribution to be worthwhile you must read the literature carefully and without bias; doing this will enable you to identify some of the subtle differences in the viewpoints presented by different authors and help you to better identify the gaps in the literature. Because the thesis is essentially the heart of your discussion, it is important that it is argued objectively and persuasively.

With the goal of providing high quality care, the healthcare industry places a premium on rigorous research as the foundation for evidence-based practices. Thus, students are expected to keep up with the most current research in their field and support the assertions they make in their work with evidence from the literature. Nursing students also must learn how to evaluate evidence in nursing literature and identify the studies that answer specific clinical questions (Oermann & Hays, 2011). Writers are also expected to critically analyze and evaluate studies and assess whether findings can be used in clinical practice (Beyea & Slattery, 2006). (Some useful and credible sources include journal articles, other peer-reviewed sources, and authoritative sources that might be found on the web. If you need help finding credible sources contact a librarian.)

Like other APA style papers, research papers in nursing should follow the following format: title, abstract, introduction, literature review, method, results, discussion, references, and appendices (see APA 7, Sections 2.16-2.25). Note that the presentation follows a certain logic: In the introduction one presents the issue under consideration; in the literature review, one presents what is already known about the topic (thus providing a context for the discussion), identifies gaps, and presents one’s approach; in the methods section, one would then identify the method used to gather data; and in the results and discussion sections, one then presents and explains the results in an objective manner, noting the limitations of the study (Dartmouth Writing Program, 2005). Note that not all papers need to be written in this manner; for guidance on the formatting of a basic course paper, see the appropriate template on our website.

In their research, nursing researchers use quantitative, qualitative, or mixed methods. In quantitative studies, researchers rely primarily on quantifiable data; in qualitative studies, they use data from interviews or other types of narrative analyses; and in mixed methods studies, they use both qualitative and quantitative approaches. A researcher should be able to pose a researchable question and identify an appropriate research method. Whatever method the researcher chooses, the research must be carried out in an objective and scientific manner, free from bias. Keep in mind that your method will have an impact on the credibility of your work, so it is important that your methods are rigorous. Walden offers a series of research methods courses to help students become familiar with the various research methods.

Instructors expect students to master the content of the discipline and use discipline- appropriate language in their writing. In practice, nurses may be required to become familiar with standardized nursing language as it has been found to lead to the following:

• better communication among nurses and other health care providers,
• increased visibility of nursing interventions,
• improved patient care,
• enhanced data collection to evaluate nursing care outcomes,
• greater adherence to standards of care, and
• facilitated assessment of nursing competency. (Rutherford, 2008)

Like successful writers in other disciplines and in preparation for diverse roles within their fields, in their writing nursing students should demonstrate that they (a) have cultivated the thinking skills that are useful in their discipline, (b) are able to communicate professionally, and (c) can incorporate the language of the field in their work appropriately (Colorado State University, 2011).

If you have content-specific questions, be sure to ask your instructor. The Writing Center is available to help you present your ideas as effectively as possible.

Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation . http://www.hcmarketplace.com/supplemental/3737_browse.pdf

Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm

Dartmouth Writing Program. (2005). Writing in the social sciences . http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing , 13 (1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html

Wagner, D. (n.d.). Why writing matters in nursing . https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/

Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html

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3.3 Assignment

Nursing team members working in inpatient or long-term care settings receive client assignments at the start of their shift. Assignment refers to routine care, activities, and procedures that are within the legal scope of practice of registered nurses (RN), licensed practical/vocational nurses (LPN/VN), or unlicensed assistive personnel (UAP). [1] Scope of practice for RNs and LPNs is described in each state’s Nurse Practice Act. Care tasks for UAP vary by state; regulations are typically listed on sites for the state’s Board of Nursing, Department of Health, Department of Aging, Department of Health Professions, Department of Commerce, or Office of Long-Term Care. [2]

See Table 3.3a for common tasks performed by members of the nursing team based on their scope of practice. These tasks are within the traditional role and training the team member has acquired through a basic educational program. They are also within the expectations of the health care agency during a shift of work. Agency policy can be more restrictive than federal or state regulations, but it cannot be less restrictive.

Client assignments are typically made by the charge nurse (or nurse supervisor) from the previous shift. A charge nurse is an RN who provides leadership on a client-care unit within a health care facility during their shift. Charge nurses perform many of the tasks that general nurses do, but also have some supervisory duties such as making assignments, delegating tasks, preparing schedules, monitoring admissions and discharges, and serving as a staff member resource. [3]

Table 3.3a. Nursing Team Members’ Scope of Practice and Common Tasks [4]

An example of a client assignment is when an RN assigns an LPN/VN to care for a client with stable heart failure. The LPN/VN collects assessment data, monitors intake/output throughout the shift, and administers routine oral medication. The LPN/VN documents this information and reports information back to the RN. This is considered the LPN/VN’s “assignment” because the skills are taught within an LPN educational program and are consistent with the state’s Nurse Practice Act for LPN/VN scope of practice. They are also included in the unit’s job description for an LPN/VN. The RN may also assign some care for this client to UAP. These tasks may include assistance with personal hygiene, toileting, and ambulation. The UAP documents these tasks as they are completed and reports information back to the RN or LPN/VN. These tasks are considered the UAP’s assignment because they are taught within a nursing aide’s educational program, are consistent with the UAP’s scope of practice for that state, and are included in the job description for the nursing aide’s role in this unit. The RN continues to be accountable for the care provided to this client despite the assignments made to other nursing team members.

Special consideration is required for UAP with additional training. With increased staffing needs, skills such as administering medications, inserting Foley catheters, or performing injections are included in specialized training programs for UAP. Due to the impact these skills can have on the outcome and safety of the client, the National Council of State Board of Nursing (NCSBN) recommends these activities be considered delegated tasks by the RN or nurse leader. By delegating these advanced skills when appropriate, the nurse validates competency, provides supervision, and maintains accountability for client outcomes. Read more about delegation in the “ Delegation ” section of this chapter.

When making assignments to other nursing team members, it is essential for the RN to keep in mind specific tasks that cannot be delegated to other nursing team members based on federal and/or state regulations. These tasks include, but are not limited to, those tasks described in Table 3.3b.

Table 3.3b. Examples of Tasks Outside the Scope of Practice of Nursing Assistive Personnel

As always, refer to each state’s Nurse Practice Act and other state regulations for specific details about nursing team members’ scope of practice when providing care in that state.

Find and review Nurse Practice Acts by state at https://www.ncsbn.org/policy/npa.page .

Read more about the Wisconsin’s Nurse Practice Act and the standards and scope of practice for RNs and LPNs at Wisconsin’s Legislative Code Chapter N6.

Read more about scope of practice, skills, and practices of nurse aides in Wisconsin at DHS 129.07 Standards for Nurse Aide Training Programs.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf ↵
• McMullen, T. L., Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R. (2015). Certified nurse aide scope of practice: State-by-state differences in allowable delegated activities. Journal of the American Medical Directors Association, 16 (1), 20–24. https://doi.org/10.1016/j.jamda.2014.07.003 ↵
• RegisteredNursing.org. (2021, April 13). What is a charge nurse? https://www.registerednursing.org/specialty/charge-nurse/ ↵
• RegisteredNursing.org. (2021, January 27). Assignment, delegation and supervision: NCLEX-RN. https://www.registerednursing.org/nclex/assignment-delegation-supervision/ ↵
• State of Wisconsin Department of Health Services. (2018). Medication administration by unlicensed assistive personnel (UAP): Guidelines for registered nurses delegating medication administration to unlicensed assistive personnel. https://www.dhs.wisconsin.gov/publications/p01908.pdf ↵

Routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/VN, or routine functions of the assistive personnel.

Making adjustments to medication dosage per an established protocol to obtain a desired therapeutic outcome.

Nursing Management and Professional Concepts 2e Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Nursing Care Plans (NCP) Ultimate Guide and List

Writing the  best   nursing care plan  requires a step-by-step approach to complete the parts needed for a care plan correctly. This tutorial will walk you through developing a care plan. This guide has the ultimate database and list of nursing care plans (NCP) and nursing diagnosis samples  for our student nurses and professional nurses to use—all for free! Care plan components, examples, objectives, and purposes are included with a detailed guide on writing an excellent nursing care plan or a template for your unit. 

Table of Contents

Standardized care plans, individualized care plans, purposes of a nursing care plan, three-column format, four-column format, student care plans, step 1: data collection or assessment, step 2: data analysis and organization, step 3: formulating your nursing diagnoses, step 4: setting priorities, short-term and long-term goals, components of goals and desired outcomes, types of nursing interventions, step 7: providing rationale, step 8: evaluation, step 9: putting it on paper, basic nursing and general care plans, surgery and perioperative care plans, cardiac care plans, endocrine and metabolic care plans, gastrointestinal, hematologic and lymphatic, infectious diseases, integumentary, maternal and newborn care plans, mental health and psychiatric, musculoskeletal, neurological, pediatric nursing care plans, reproductive, respiratory, recommended resources, references and sources, what is a nursing care plan.

A  nursing care plan (NCP)  is a formal process that correctly identifies existing needs and recognizes a client’s potential needs or risks. Care plans provide a way of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.

Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice .

Types of Nursing Care Plans

Care plans can be informal or formal: An informal nursing care plan is a strategy of action that exists in the nurse ‘s mind. A  formal nursing care plan is a written or computerized guide that organizes the client’s care information.

Formal care plans are further subdivided into standardized care plans and individualized care plans:  Standardized care plans specify the nursing care for groups of clients with everyday needs.  Individualized care plans are tailored to meet a specific client’s unique needs or needs that are not addressed by the standardized care plan.

Standardized care plans are pre-developed guides by the nursing staff and health care agencies to ensure that patients with a particular condition receive consistent care. These care plans are used to ensure that minimally acceptable criteria are met and to promote the efficient use of the nurse’s time by removing the need to develop common activities that are done repeatedly for many of the clients on a nursing unit.

Standardized care plans are not tailored to a patient’s specific needs and goals and can provide a starting point for developing an individualized care plan .

Care plans listed in this guide are standard care plans which can serve as a framework or direction to develop an individualized care plan.

An individualized care plan care plan involves tailoring a standardized care plan to meet the specific needs and goals of the individual client and use approaches shown to be effective for a particular client. This approach allows more personalized and holistic care better suited to the client’s unique needs, strengths, and goals.

Additionally, individualized care plans can improve patient satisfaction . When patients feel that their care is tailored to their specific needs, they are more likely to feel heard and valued, leading to increased satisfaction with their care. This is particularly important in today’s healthcare environment , where patient satisfaction is increasingly used as a quality measure.

Tips on how to individualize a nursing care plan:

• Perform a comprehensive assessment of the patient’s health, history, health status, and desired goals.
• Involve the patient in the care planning process by asking them about their health goals and preferences. By involving the client, nurses can ensure that the care plan is aligned with the patient’s goals and preferences which can improve patient engagement and compliance with the care plan.
• Perform an ongoing assessment and evaluation as the patient’s health and goals can change. Adjust the care plan accordingly.

The following are the goals and objectives of writing a nursing care plan:

• Promote evidence-based nursing care and render pleasant and familiar conditions in hospitals or health centers.
• Support holistic care , which involves the whole person, including physical, psychological, social, and spiritual, with the management and prevention of the disease.
• Establish programs such as care pathways and care bundles. Care pathways involve a team effort to reach a consensus regarding standards of care and expected outcomes. In contrast, care bundles are related to best practices concerning care for a specific disease.
• Identify and distinguish goals and expected outcomes.
• Review communication and documentation of the care plan.
• Measure nursing care.

The following are the purposes and importance of writing a nursing care plan:

• Defines nurse’s role. Care plans help identify nurses’ unique and independent role in attending to clients’ overall health and well-being without relying entirely on a physician’s orders or interventions.
• Provides direction for individualized care of the client.  It serves as a roadmap for the care that will be provided to the patient and allows the nurse to think critically in developing interventions directly tailored to the individual.
• Continuity of care. Nurses from different shifts or departments can use the data to render the same quality and type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
• Coordinate care. Ensures that all members of the healthcare team are aware of the patient’s care needs and the actions that need to be taken to meet those needs preventing gaps in care.
• Documentation . It should accurately outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is no evidence the care was provided.
• Serves as a guide for assigning a specific staff to a specific client.  There are instances when a client’s care needs to be assigned to staff with particular and precise skills.
• Monitor progress. To help track the patient’s progress and make necessary adjustments to the care plan as the patient’s health status and goals change.
• Serves as a guide for reimbursement.  The insurance companies use the medical record to determine what they will pay concerning the hospital care received by the client.
• Defines client’s goals. It benefits nurses and clients by involving them in their treatment and care.

A nursing care plan (NCP) usually includes nursing diagnoses , client problems, expected outcomes, nursing interventions , and rationales . These components are elaborated on below:

• Client health assessment , medical results, and diagnostic reports are the first steps to developing a care plan. In particular, client assessment relates to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. Information in this area can be subjective and objective.
• Nursing diagnosis . A nursing diagnosis is a statement that describes the patient’s health issue or concern. It is based on the information gathered about the patient’s health status during the assessment.
• Expected client outcomes. These are specific goals that will be achieved through nursing interventions . These may be long and short-term.
• Nursing interventions . These are specific actions that will be taken to address the nursing diagnosis and achieve expected outcomes . They should be based on best practices and evidence-based guidelines.
• Rationales. These are evidence-based explanations for the nursing interventions specified.
• Evaluation . These includes plans for monitoring and evaluating a patient’s progress and making necessary adjustments to the care plan as the patient’s health status and goals change.

Care Plan Formats

Nursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some agencies use a three-column plan where goals and evaluation are in the same column. Other agencies have a five-column plan that includes a column for assessment cues.

The three-column plan has a column for nursing diagnosis, outcomes and evaluation, and interventions.

This format includes columns for nursing diagnosis, goals and outcomes, interventions, and evaluation.

Below is a document containing sample templates for the different nursing care plan formats. Please feel free to edit, modify, and share the template.

Download: Printable Nursing Care Plan Templates and Formats

Student care plans are more lengthy and detailed than care plans used by working nurses because they serve as a learning activity for the student nurse.

Care plans by student nurses are usually required to be handwritten and have an additional column for “Rationale” or “Scientific Explanation” after the nursing interventions column. Rationales are scientific principles that explain the reasons for selecting a particular nursing intervention.

Writing a Nursing Care Plan

How do you write a nursing care plan (NCP)? Just follow the steps below to develop a care plan for your client.

The first step in writing a nursing care plan is to create a client database using assessment techniques and data collection methods ( physical assessment , health history , interview, medical records review, and diagnostic studies). A client database includes all the health information gathered . In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing schools have specific assessment formats you can use.

Critical thinking is key in patient assessment, integrating knowledge across sciences and professional guidelines to inform evaluations. This process, crucial for complex clinical decision-making , aims to identify patients’ healthcare needs effectively, leveraging a supportive environment and reliable information

Now that you have information about the client’s health, analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities, and desired outcomes.

Nursing diagnoses are a uniform way of identifying, focusing on and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses.

We’ve detailed the steps on how to formulate your nursing diagnoses in this guide:  Nursing Diagnosis (NDx): Complete Guide and List .

Setting priorities involves establishing a preferential sequence for addressing nursing diagnoses and interventions. In this step, the nurse and the client begin planning which of the identified problems requires attention first. Diagnoses can be ranked and grouped as having a high, medium, or low priority. Life-threatening problems should be given high priority.

A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved, such as self-esteem and self-actualization. Physiological and safety needs are the basis for implementing nursing care and interventions. Thus, they are at the base of Maslow’s pyramid, laying the foundation for physical and emotional health.

Maslow’s Hierarchy of Needs

• Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure ) (ABCs), sleep , sex, shelter, and exercise.
• Safety and Security: Injury prevention ( side rails , call lights, hand hygiene , isolation , suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety ( therapeutic relationship ), patient education (modifiable risk factors for stroke , heart disease).
• Love and Belonging: Foster supportive relationships, methods to avoid social isolation ( bullying ), employ active listening techniques, therapeutic communication , and sexual intimacy.
• Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance or body habitus.
• Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one’s maximum potential.

The client’s health values and beliefs, priorities, resources available, and urgency are factors the nurse must consider when assigning priorities. Involve the client in the process to enhance cooperation.

Step 5: Establishing Client Goals and Desired Outcomes

After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each determined priority. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.

One overall goal is determined for each nursing diagnosis. The terms “ goal outcomes “ and “expected outcome s” are often used interchangeably.

According to Hamilton and Price (2013), goals should be SMART . SMART stands for specific, measurable, attainable, realistic, and time-oriented goals.

• Specific. It should be clear, significant, and sensible for a goal to be effective.
• Measurable or Meaningful. Making sure a goal is measurable makes it easier to monitor progress and know when it reaches the desired result.
• Attainable or Action-Oriented. Goals should be flexible but remain possible.
• Realistic or Results-Oriented. This is important to look forward to effective and successful outcomes by keeping in mind the available resources at hand.
• Timely or Time-Oriented. Every goal needs a designated time parameter, a deadline to focus on, and something to work toward.

Hogston (2011) suggests using the REEPIG standards to ensure that care is of the highest standards. By this means, nursing care plans should be:

• Realistic. Given available resources. 
• Explicitly stated. Be clear about precisely what must be done, so there is no room for misinterpretation of instructions.
• Evidence-based. That there is research that supports what is being proposed. 
• Prioritized. The most urgent problems are being dealt with first. 
• Involve. Involve both the patient and other members of the multidisciplinary team who are going to be involved in implementing the care.
• Goal-centered. That the care planned will meet and achieve the goal set.

Goals and expected outcomes must be measurable and client-centered.  Goals are constructed by focusing on problem prevention, resolution, and rehabilitation. Goals can be short-term or long-term . Most goals are short-term in an acute care setting since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or live at home, in nursing homes, or in extended-care facilities.

• Short-term goal . A statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days.
• Long-term goal . Indicates an objective to be completed over a longer period, usually weeks or months.
• Discharge planning . Involves naming long-term goals, therefore promoting continued restorative care and problem resolution through home health, physical therapy, or various other referral sources.

Goals or desired outcome statements usually have four components: a subject, a verb, conditions or modifiers, and a criterion of desired performance.

• Subject. The subject is the client, any part of the client, or some attribute of the client (i.e., pulse, temperature, urinary output). That subject is often omitted in writing goals because it is assumed that the subject is the client unless indicated otherwise (family, significant other ).
• Verb. The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience.
• Conditions or modifiers. These are the “what, when, where, or how” that are added to the verb to explain the circumstances under which the behavior is to be performed.
• Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These are optional.

When writing goals and desired outcomes, the nurse should follow these tips:

• Write goals and outcomes in terms of client responses and not as activities of the nurse. Begin each goal with “Client will […]” help focus the goal on client behavior and responses.
• Avoid writing goals on what the nurse hopes to accomplish, and focus on what the client will do.
• Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.
• Desired outcomes should be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.
• Ensure that goals are compatible with the therapies of other professionals.
• Ensure that each goal is derived from only one nursing diagnosis. Keeping it this way facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis set.
• Lastly, make sure that the client considers the goals important and values them to ensure cooperation.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the priority nursing problem or diagnosis. As for risk nursing problems, interventions should focus on reducing the client’s risk factors. In this step, nursing interventions are identified and written during the planning step of the nursing process ; however, they are actually performed during the implementation step.

Nursing interventions can be independent, dependent, or collaborative:

• Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgement and skills. Includes: ongoing assessment, emotional support, providing comfort , teaching, physical care, and making referrals to other health care professionals.
• Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy , diagnostic tests, treatments, diet, and activity or rest. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions.
• Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists. These actions are developed in consultation with other health care professionals to gain their professional viewpoint.

Nursing interventions should be:

• Safe and appropriate for the client’s age, health, and condition.
• Achievable with the resources and time available.
• Inline with the client’s values, culture, and beliefs.
• Inline with other therapies.
• Based on nursing knowledge and experience or knowledge from relevant sciences.

When writing nursing interventions, follow these tips:

• Write the date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.
• Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “ Educate parents on how to take temperature and notify of any changes,” or “ Assess urine for color, amount, odor, and turbidity.”
• Use only abbreviations accepted by the institution.

Rationales, also known as scientific explanations, explain why the nursing intervention was chosen for the NCP.

Rationales do not appear in regular care plans. They are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention.

Evaluation is a planned, ongoing, purposeful activity in which the client’s progress towards achieving goals or desired outcomes is assessed, and the effectiveness of the nursing care plan (NCP). Evaluation is an essential aspect of the nursing process because the conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed.

The client’s care plan is documented according to hospital policy and becomes part of the client’s permanent medical record, which may be reviewed by the oncoming nurse. Different nursing programs have different care plan formats. Most are designed so that the student systematically proceeds through the interrelated steps of the nursing process , and many use a five-column format.

Nursing Care Plan List

This section lists the sample nursing care plans (NCP) and nursing diagnoses for various diseases and health conditions. They are segmented into categories:

Miscellaneous nursing care plans examples that don’t fit other categories:

Care plans that involve surgical intervention .

Nursing care plans about the different diseases of the cardiovascular system :

Nursing care plans (NCP) related to the endocrine system and metabolism:

Care plans (NCP) covering the disorders of the gastrointestinal and digestive system :

Care plans related to the hematologic and lymphatic system:

NCPs for communicable and infectious diseases:

All about disorders and conditions affecting the integumentary system:

Nursing care plans about the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:

Care plans for mental health and psychiatric nursing:

Care plans related to the musculoskeletal system:

Nursing care plans (NCP) for related to nervous system disorders:

Care plans relating to eye disorders:

Nursing care plans (NCP) for pediatric conditions and diseases:

Care plans related to the reproductive and sexual function disorders:

Care plans for respiratory system disorders:

Care plans related to the kidney and urinary system disorders:

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Recommended reading materials and sources for this NCP guide: 

• Björvell, C., Thorell-Ekstrand, I., & Wredling, R. (2000). Development of an audit instrument for nursing care plans in the patient record.   BMJ Quality & Safety ,  9 (1), 6-13. [ Link ]
• DeLaune, S. C., & Ladner, P. K. (2011).  Fundamentals of nursing: Standards and practice . Cengage learning .
• Freitas, F. A., & Leonard, L. J. (2011). Maslow’s hierarchy of needs and student academic success .  Teaching and learning in Nursing ,  6 (1), 9-13.
• Hamilton, P., & Price, T. (2007). The nursing process, holistic.  Foundations of Nursing Practice E-Book: Fundamentals of Holistic Care , 349.
• Lee, T. T. (2004). Evaluation of computerized nursing care plan: instrument development .  Journal of Professional Nursing ,  20 (4), 230-238.
• Lee, T. T. (2006). Nurses’ perceptions of their documentation experiences in a computerized nursing care planning system .  Journal of Clinical Nursing ,  15 (11), 1376-1382.
• Rn , B. O. C., Rn, H. M., Rn, D. T., & Rn, F. E. (2000). Documenting and communicating patient care : Are nursing care plans redundant?.  International Journal of Nursing Practice ,  6 (5), 276-280.
• Stonehouse, D. (2017). Understanding the nursing process .  British Journal of Healthcare Assistants ,  11 (8), 388-391.
• Yildirim, B., & Ozkahraman, S. (2011). Critical thinking in nursing process and education .  International journal of humanities and social science ,  1 (13), 257-262.

69 thoughts on “Nursing Care Plans (NCP) Ultimate Guide and List”

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Hi Paul, on your browser go to File > Print > Save as PDF. Hope that helps and thanks for visiting Nurseslabs!

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Hello, please check out our guide on how to write nursing diagnoses here: https://nurseslabs.com/nursing-diagnosis/

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For everything you need to know about managing acute pain, including a detailed nursing care plan (NCP), definitely check out our acute pain nursing care plan guide . It’s packed with insights on assessment, interventions, and patient education to effectively manage and alleviate acute pain.

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Chapter 4 Nursing Process

4.1. nursing process introduction, learning objectives.

• Use the nursing process to provide patient care
• Identify nursing diagnoses from evidence-based sources
• Describe the development of a care plan
• Prioritize patient care
• Describe documentation for each step of the nursing process
• Differentiate between the role of the PN and RN

Have you ever wondered how a nurse can receive a quick handoff report from another nurse and immediately begin providing care for a patient they previously knew nothing about? How do they know what to do? How do they prioritize and make a plan?

Nurses do this activity every shift. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This chapter will explain how to use the  nursing process  as standards of professional nursing practice to provide safe, patient-centered care.

4.2. BASIC CONCEPTS

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [ 1 ] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness:  Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity:  Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility:  Recognizing your intellectual limitations and abilities
• Nonjudgmental:  Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity:  Being honest and demonstrating strong moral principles
• Perseverance:  Persisting in doing something despite it being difficult
• Confidence:  Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings:  Wanting to explore different ways of knowing
• Curiosity:  Asking “why” and wanting to know more

Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [ 2 ]  To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [ 3 ]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning  involves noticing cues, making generalizations, and creating hypotheses.  Cues  are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A  generalization  is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A  hypothesis  is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1 . [ 4 ]  Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Inductive Reasoning Includes Looking for Cues

Example:  A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning  is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example:  Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2 ). [ 5 ]  The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment  is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”  [ 6 ]  The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP)  is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [ 7 ]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [ 8 ]  The mnemonic  ADOPIE  is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process:  A ssessment,  D iagnosis,  O utcomes Identification,  P lanning,  I mplementation, and  E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [ 9 ]  for an illustration of the nursing process.

The Nursing Process

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process [ 10 ]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [ 11 ]  A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [ 12 ]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [ 13 ]  A nursing diagnosis is the nurse’s clinical judgment about the  client's  response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [ 14 ]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [ 15 ]  The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [ 16 ]  Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [ 17 ]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

NURSING CARE PLANS

Creating nursing care plans is a part of the “Planning” step of the nursing process. A  nursing care plan  is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [ 18 ]  Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [ 19 ]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [ 20 ]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 21 ]  During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [ 22 ]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of  nursing  as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [ 23 ]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The  art of nursing  is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [ 24 ]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “ Diverse Patients ” chapter.

Caring and the nursing process.

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [ 25 ]  Successful use of the nursing process requires the development of a care relationship with the patient. A  care relationship  is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of  rapport  and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [ 26 ] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [ 27 ]  See Figure 4.4 [ 28 ]  for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Touch as a Therapeutic Communication Technique

Review how to communicate with patients using therapeutic communication techniques like active listening in the “ Communication ” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [ 29 ]

Read more about Dr. Watson’s theory of caring at the  Watson Caring Science Institute .

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

4.3. ASSESSMENT

Assessment  is the first step of the nursing process (and the first  Standard of Practice  set by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.” [ 1 ]

Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective Assessment Data

Subjective data  is information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a patient, it should be in quotation marks and start with verbiage such as,  The patient reports.  It is vital for the nurse to establish rapport with a patient to obtain accurate, valuable subjective data regarding the mental, emotional, and spiritual aspects of their condition.

There are two types of subjective information, primary and secondary.  Primary data  is information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the nurse who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known as  secondary data . Family members can provide important information, especially for individuals with memory impairments, infants, children, or when patients are unable to speak for themselves.

See Figure 4.5 [ 2 ]  for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Example.  An example of documented subjective data obtained from a patient assessment is,  “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data

Objective data  is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. See Figure 4.6 [ 3 ]  for an image of a nurse performing a physical examination.

Physical Examination

Example.  An example of documented objective data is,  “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data

There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results.

Interviewing

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient may eliminate redundancy in the interview process and allows the nurse to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the nurse should use the interview process to verify data with the patient.

After performing patient identification, the best way to initiate a caring relationship is to introduce yourself to the patient and explain your role. Share the purpose of your interview and the approximate time it will take. When beginning an interview, it may be helpful to start with questions related to the patient’s  medical diagnoses  to gather information about how they have affected the patient’s functioning, relationships, and lifestyle. Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important to provide safe, quality nursing care. Sometimes nursing students can feel uncomfortable having difficult conversations or asking personal questions due to generational or other cultural differences. Don’t shy away from asking about information that is important to know for safe patient care. Most patients will be grateful that you cared enough to ask and listen.

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important. To avoid making inappropriate  inferences , the nurse should validate any cues. For example, a nurse may make an inference that a patient is depressed when the patient avoids making eye contact during an interview. However, upon further questioning, the nurse may discover that the patient’s cultural background believes direct eye contact to be disrespectful and this is why they are avoiding eye contact. To read more information about communicating with patients, review the “ Communication ” chapter of this book.

A  physical examination  is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a patient’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid is present. Detailed physical examination procedures of various body systems can be found in the Open RN  Nursing Skills  textbook with a head-to-toe checklist in  Appendix C . Physical examination also includes the collection and analysis of vital signs.

Registered Nurses (RNs)  complete the initial physical examination and analyze the findings as part of the nursing process. Collection of follow-up physical examination data can be delegated to  Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) , or measurements such as vital signs and weight may be delegated to trained  Unlicensed Assistive Personnel (UAP)  when appropriate to do so. However, the RN remains responsible for supervising these tasks, analyzing the findings, and ensuring they are documented .

A physical examination can be performed as a comprehensive, head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the patient’s  Electronic Medical Record (EMR) , an electronic version of the patient’s medical chart.

Reviewing Laboratory and Diagnostic Test Results

Reviewing laboratory and diagnostic test results provides relevant and useful information related to the needs of the patient. Understanding how normal and abnormal results affect patient care is important when implementing the nursing care plan and administering provider prescriptions. If results cause concern, it is the nurse’s responsibility to notify the provider and verify the appropriateness of prescriptions based on the patient’s current status before implementing them.

Types of Assessments

Several types of nursing assessment are used in clinical practice:

• Primary Survey:  Used during every patient encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.
• Admission Assessment:  A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach.
• Ongoing Assessment:  In acute care agencies such as hospitals, a head-to-toe assessment is completed and documented at least once every shift. Any changes in patient condition are reported to the health care provider.
• Focused Assessment:  Focused assessments are used to reevaluate the status of a previously diagnosed problem.
• Time-lapsed Reassessment:  Time-lapsed reassessments are used in long-term care facilities when three or more months have elapsed since the previous assessment to evaluate progress on previously identified outcomes. [ 4 ]

Putting It Together

Review Scenario C in the following box to apply concepts of assessment to a patient scenario.

Scenario C [5]

Ms. J. is a 74-year-old woman who is admitted directly to the medical unit after visiting her physician because of shortness of breath, increased swelling in her ankles and calves, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). She takes 81 mg of aspirin every day, metoprolol 50 mg twice a day, furosemide 40 mg every day, and metformin 2,000 mg every day.

Ms. J.’s vital sign values on admission were as follows:

• Blood Pressure: 162/96 mm Hg
• Heart Rate: 88 beats/min
• Oxygen Saturation: 91% on room air
• Respiratory Rate: 28 breaths/minute
• Temperature: 97.8 degrees F orally

Her weight is up 10 pounds since the last office visit three weeks prior. The patient states, “I am so short of breath” and “My ankles are so swollen I have to wear my house slippers.” Ms. J. also shares, “I am so tired and weak that I can’t get out of the house to shop for groceries,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She confides, “I would like to learn more about my health so I can take better care of myself.”

The physical assessment findings of Ms. J. are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet. Laboratory results indicate a decreased serum potassium level of 3.4 mEq/L.

As the nurse completes the physical assessment, the patient’s daughter enters the room. She confides, “We are so worried about mom living at home by herself when she is so tired all the time!”

Critical Thinking Questions

Identify subjective data.

Identify objective data.

Provide an example of secondary data.

Answers are located in the Answer Key at the end of the book.

4.4. DIAGNOSIS

Diagnosis  is the second step of the nursing process (and the second Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan. [ 1 ]

Analyzing Assessment Data

After collection of assessment data, the registered nurse analyzes the data to form generalizations and create hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering of information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and drive the nursing care plan. [ 2 ]

Performing Data Analysis

After nurses collect assessment data from a patient, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that patient according to their age, development, and baseline status. From there, nurses determine what data are “clinically relevant” as they prioritize their nursing care. [ 3 ]

Example.  In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this patient. These findings are considered “relevant cues.”

Clustering Information/Seeing Patterns/Making Hypotheses

After analyzing the data and determining relevant cues, the nurse  clusters  data into patterns. Assessment frameworks such as Gordon’s  Functional Health Patterns  assist nurses in clustering information according to evidence-based patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns. [ 4 ]  Concepts related to many of these patterns will be discussed in chapters later in this book.

Example.  Refer to Scenario C of the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, a medical history of heart failure, and currently prescribed a diuretic medication. These cues are clustered into a generalization/pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse makes a hypothesis that the patient has excess fluid volume present.

Gordon’s Functional Health Patterns [ 5 ]

Health Perception-Health Management:  A patient’s perception of their health and well-being and how it is managed

Nutritional-Metabolic:  Food and fluid consumption relative to metabolic need

Elimination:  Excretory function, including bowel, bladder, and skin

Activity-Exercise:  Exercise and daily activities

Sleep-Rest:  Sleep, rest, and daily activities

Cognitive-Perceptual:  Perception and cognition

Self-perception and Self-concept:  Self-concept and perception of self-worth, self-competency, body image, and mood state

Role-Relationship:  Role engagements and relationships

Sexuality-Reproductive:  Reproduction and satisfaction or dissatisfaction with sexuality

Coping-Stress Tolerance:  Coping and effectiveness in terms of stress tolerance

Value-Belief:  Values, beliefs (including spiritual beliefs), and goals that guide choices and decisions

Identifying Nursing Diagnoses

After the nurse has analyzed and clustered the data from the patient assessment, the next step is to begin to answer the question, “What are my patient’s human responses (i.e., nursing diagnoses)?” A  nursing diagnosis  is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” [ 6 ]  Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis.

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings. [ 7 ]  Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence. A list of commonly used NANDA-I diagnoses are listed in  Appendix A . For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.

NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and include health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.

Knowledge regarding specific NANDA-I nursing diagnoses is not assessed on the NCLEX. However, analyzing cues and creating hypotheses are part of the measurement model used to assess a candidate’s clinical judgment. Read more about the NCLEX and Next Generation NCLEX in the “ Scope of Practice ” chapter.

Nursing diagnoses vs. medical diagnoses.

You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on the  human response  to health conditions and life processes and are made independently by RNs. Patients with the same medical diagnosis will often  respond  differently to that diagnosis and thus have different nursing diagnoses. For example, two patients have the same medical diagnosis of heart failure. However, one patient may be interested in learning more information about the condition and the medications used to treat it, whereas another patient may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each patient.

Example.  A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will be related to the patient’s response to heart failure.

Additional Definitions Used in NANDA-I Nursing Diagnoses

The following definitions of patient, age, and time are used in association with NANDA-I nursing diagnoses:

The NANDA-I definition of a “patient” includes:

• Individual:  a single human being distinct from others (i.e., a person).
• Caregiver:  a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
• Family:  two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
• Group:  a number of people with shared characteristics generally referred to as an ethnic group.
• Community:  a group of people living in the same locale under the same governance. Examples include neighborhoods and cities. [ 8 ]

The age of the person who is the subject of the diagnosis is defined by the following terms: [ 9 ]

• Fetus:  an unborn human more than eight weeks after conception, until birth.
• Neonate:  a person less than 28 days of age.
• Infant:  a person greater than 28 days and less than 1 year of age.
• Child:  a person aged 1 to 9 years
• Adolescent:  a person aged 10 to 19 years
• Adult:  a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
• Older adult:  a person greater than 65 years of age.

The duration of the diagnosis is defined by the following terms: [ 10 ]

• Acute:  lasting less than 3 months.
• Chronic:  lasting greater than 3 months.
• Intermittent:  stopping or starting again at intervals
• Continuous:  uninterrupted, going on without stop.

New Terms Used in 2018-2020 NANDA-I Diagnoses

The 2018-2020 edition of  Nursing Diagnoses  includes two new terms to assist in creating nursing diagnoses: at-risk populations and associated conditions. [ 11 ]

At-Risk Populations  are groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.

Associated Conditions  are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis [ 12 ]

Types of Nursing Diagnoses

There are four types of NANDA-I nursing diagnoses: [ 13 ]

• Problem-Focused
• Health Promotion – Wellness

A  problem-focused nursing diagnosis  is a “clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.” [ 14 ]  To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present.  Related factors  (also called etiology) are causes that contribute to the diagnosis.  Defining characteristics  are cues, signs, and symptoms that cluster into patterns. [ 15 ]

A  health promotion-wellness nursing diagnosis  is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient’s readiness to enhance specific health behaviors. [ 16 ] A health promotion-wellness diagnosis is used when the patient is willing to improve a lack of knowledge, coping, or other identified need.

A  risk nursing diagnosis  is “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.” [ 17 ]  A risk nursing diagnosis must be supported by risk factors that contribute to the increased vulnerability. A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. Problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a patient. [ 18 ]

A  syndrome diagnosis  is a “clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.” [ 19 ]

Establishing Nursing Diagnosis Statements

When using NANDA-I nursing diagnoses, NANDA-I recommends the structure of a nursing diagnosis should be a statement that includes the  nursing diagnosis  and  related factors  as exhibited by  defining characteristics . The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the patient’s assessment. [ 20 ]

To create a nursing diagnosis statement, the registered nurse completes the following steps. After analyzing the patient’s subjective and objective data and clustering the data into patterns, the nurse generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis.  Defining characteristics  is the terminology used for observable signs and symptoms related to a nursing diagnosis. [ 21 ]  Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis. For example, objective and subjective data such as weight, height, and dietary intake can be clustered together as defining characteristics for the nursing diagnosis of nutritional status.

When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient.  Related factors  is the terminology used for the underlying causes (etiology) of a patient’s problem or situation. Related factors should not be a medical diagnosis, but instead should be attributed to the underlying pathophysiology that the nurse can treat. When possible, the nursing interventions planned for each nursing diagnosis should attempt to modify or remove these related factors that are the underlying cause of the nursing diagnosis. [ 22 ]

Creating nursing diagnosis statements has traditionally been referred to as “using PES format.” The  PES  mnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:

Problem (P)  – the patient  p roblem (i.e., the nursing diagnosis)

Etiology (E)  – related factors (i.e., the  e tiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”

Signs and Symptoms (S)  – defining characteristics manifested by the patient (i.e., the  s igns and  s ymptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the patient; phrased with “as manifested by” or “as evidenced by.”

Examples of different types of nursing diagnoses are further explained below.

Problem-Focused Nursing Diagnosis

A problem-focused nursing diagnosis contains all three components of the  PES format :

Problem (P)  – statement of the patient response (nursing diagnosis)

Etiology (E)  – related factors contributing to the nursing diagnosis

Signs and Symptoms (S)  – defining characteristics manifested by that patient

SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT

Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing Diagnosis  Excess Fluid Volume . The NANDA-I definition of  Excess Fluid Volume  is “surplus intake and/or retention of fluid.” The related factor (etiology) of the problem is that the patient has excessive fluid intake. [ 23 ]

The components of a  problem-focused nursing diagnosis  statement for Ms. J. would be:

Fluid Volume Excess

Related to excessive fluid intake

As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 10 pounds, and the patient reports, “ My ankles are so swollen .”

A correctly written problem-focused nursing diagnosis statement for Ms. J. would look like this:

Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis

A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance”: [ 24 ]

Signs and Symptoms (S)  – the patient’s expressed desire to enhance

SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she would like to “learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I nursing diagnosis  Readiness for Enhanced Health Management , which is defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.” [ 25 ]

The components of a  health-promotion nursing diagnosis  for Ms. J. would be:

Problem (P):  Readiness for Enhanced Health Management

Symptoms (S):  Expressed desire to “learn more about my health so I can take better care of myself.”

A correctly written health-promotion nursing diagnosis statement for Ms. J. would look like this:

Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis

A risk nursing diagnosis should be supported by evidence of the patient’s risk factors for developing that problem. Different experts recommend different phrasing. NANDA-I 2018-2020 recommends using the phrase “as evidenced by” to refer to the risk factors for developing that problem. [ 26 ]

A risk diagnosis consists of the following:

As Evidenced By  – Risk factors for developing the problem

SAMPLE RISK DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to vulnerability from the dizziness and weakness she is experiencing. The NANDA-I definition of  Risk for Falls  is “increased susceptibility to falling, which may cause physical harm and compromise health.” [ 27 ]

The components of a  risk diagnosis  statement for Ms. J. would be:

Problem (P)  – Risk for Falls

As Evidenced By  – Dizziness and decreased lower extremity strength

A correctly written risk nursing diagnosis statement for Ms. J. would look like this:

Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis

A syndrome is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition, but are not required. [ 28 ]

A syndrome statement consists of these items:

Problem (P)  – the syndrome

Signs and Symptoms (S)  – the defining characteristics are two or more similar nursing diagnoses

SAMPLE SYNDROME DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses that can be categorized as a  syndrome . For example,  Activity Intolerance  is defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.”  Social Isolation  is defined as “aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.” These diagnoses can be included under the the NANDA-I syndrome named  Risk for Frail Elderly Syndrome.  This syndrome is defined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.” [ 29 ]

The components of a  syndrome nursing diagnosis  for Ms. J. would be:

– Risk for Frail Elderly Syndrome

– The nursing diagnoses of  Activity Intolerance  and  Social Isolation

Additional related factor: Fear of falling

A correctly written syndrome diagnosis statement for Ms. J. would look like this:

Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling

Prioritization

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the patient. Nurses prioritize their actions while providing patient care multiple times every day.  Prioritization  is the process that identifies the most significant nursing problems, as well as the most important interventions, in the nursing care plan.

It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. In critical situations, the steps of the nursing process are performed through rapid clinical judgment. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most patient situations fall somewhere between a crisis and routine care.

There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7 [30]  on  The How To of Prioritization .

The How To of Prioritization

Maslow’s Hierarchy of Needs  is used to categorize the most urgent patient needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8 [31]  for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.

Maslow’s Hierarchy of Needs

In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the patient’s condition is an acute or chronic problem. Acute, uncompensated conditions generally require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the patient vulnerability and risk factors.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.:  Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls , and  Risk for Frail Elderly Syndrome . The top priority diagnosis is  Fluid Volume Excess  because it affects the physiological needs of breathing, homeostasis, and excretion. However, the  Risk for Falls  diagnosis comes in a close second because of safety implications and potential injury that could occur if the patient fell.

American Nurses Association. (2021).  Nursing: Scope and standards of practice  (4th ed.). American Nurses Association.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020 . Thieme Publishers New York.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020.  Thieme Publishers New York.  ↵

Gordon, M. (2008).  Assess notes: Nursing assessment and diagnostic reasoning.  F.A. Davis Company.  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms /  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

NANDA International. (n.d.).  Glossary of terms.   https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

“The How To of Prioritization” by Valerie Palarski for  Chippewa Valley Technical College  is licensed under  CC BY 4.0   ↵

“ Maslow's hierarchy of needs.svg ” by  J. Finkelstein  is licensed under  CC BY-SA 3.0   ↵

4.5. OUTCOME IDENTIFICATION

Outcome Identification  is the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment. [ 1 ]

An  outcome  is a “measurable behavior demonstrated by the patient responsive to nursing interventions.” [ 2 ]  Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient.

Outcome identification includes setting short- and long-term goals and then creating specific expected outcome statements for each nursing diagnosis.

Short-Term and Long-Term Goals

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.

The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals.  Goals  are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months.

A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis of  Fluid Volume Excess.  A broad goal would be, “ Ms. J. will achieve a state of fluid balance. ”

Expected Outcomes

Goals are broad, general statements, but outcomes are specific and measurable.  Expected outcomes  are statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses. [ 3 ]

Patient-Centered

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic: [ 4 ]

• M easurable
• A ttainable/Action oriented
• R elevant/Realistic

See Figure 4.9 [ 5 ]  for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections.

SMART Components of Outcome Statements

Outcome statements should state precisely what is to be accomplished. See the following examples:

• Not specific:  “The patient will increase the amount of exercise.”
• Specific:  “The patient will participate in a bicycling exercise session daily for 30 minutes.”

Additionally, only one action should be included in each expected outcome. See the following examples:

• “The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge”  is actually two goals written as one. The outcome of ambulation should be separate from showering for precise evaluation. For instance, the patient could shower but not ambulate, which would make this outcome statement very difficult to effectively evaluate.
• Suggested revision is to create two outcomes statements so each can be measured: The patient will walk 50 feet three times a day with standby assistance of one until discharge. The patient will shower every morning until discharge.

Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained. Refer to Figure 4.10 [ 6 ]  for examples of verbs that are measurable and not measurable in outcome statements.

Figure 4.10

Measurable Outcomes

See the following examples:

• Not measurable:  “The patient will drink adequate fluid amounts every shift.”
• Measurable:  “The patient will drink 24 ounces of fluids during every day shift (0600-1400).”

Action-Oriented and Attainable

Outcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb. Refer to Figure 4.11 [ 7 ]  for examples of action verbs.

Figure 4.11

Action Verbs

• Not action-oriented:  “The patient will get increased physical activity.”
• Action-oriented:  “The patient will list three types of aerobic activity that he would enjoy completing every week.”

Realistic and Relevant

Realistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient.

• Not realistic:  “The patient will jog one mile every day when starting the exercise program.”
• Realistic:  “The patient will walk ½ mile three times a week for two weeks.”

Time Limited

Outcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised.

• Not time limited: “The patient will stop smoking cigarettes.”
• Time limited:  “The patient will complete the smoking cessation plan by December 12, 2021.”

In Scenario C in Box 4.3, Ms. J.’s priority nursing diagnosis statement was  Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”  An example of an expected outcome meeting SMART criteria for Ms. J. is,  “The patient will have clear bilateral lung sounds within the next 24 hours.”

4.6. PLANNING

Planning  is the fourth step of the nursing process (and the fourth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team. Elements of the plan are prioritized. The plan is modified according to the ongoing assessment of the health care consumer’s response and other indicators. The plan is documented using standardized language or terminology. [ 1 ]

After expected outcomes are identified, the nurse begins planning nursing interventions to implement.  Nursing interventions  are evidence-based actions that the nurse performs to achieve patient outcomes. Just as a provider makes medical diagnoses and writes prescriptions to improve the patient’s medical condition, a nurse formulates nursing diagnoses and plans nursing interventions to resolve patient problems. Nursing interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible. [ 2 ]  Nursing interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

Planning Nursing Interventions

You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan?” There are several sources that nurses and nursing students can use to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Nurses can also refer to other care planning books our sources such as the Nursing Interventions Classification (NIC) system. Based on research and input from the nursing profession, NIC categorizes and describes nursing interventions that are constantly evaluated and updated. Interventions included in NIC are considered evidence-based nursing practices. The nurse is responsible for using clinical judgment to make decisions about which interventions are best suited to meet an individualized patient’s needs. [ 3 ]

Direct and Indirect Care

Nursing interventions are considered direct care or indirect care.  Direct care  refers to interventions that are carried out by having personal contact with patients. Examples of direct care interventions are wound care, repositioning, and ambulation.  Indirect care  interventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.

Classification of Nursing Interventions

There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12 [ 4 ]  for an image of a nurse collaborating with the health care team when planning interventions.)

Figure 4.12

Collaborative nursing interventions, independent nursing interventions.

Any intervention that the nurse can independently provide without obtaining a prescription is considered an  independent nursing intervention . An example of an independent nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of an evidence-based independent nursing intervention is,  “The nurse will reposition the patient with dependent edema frequently, as appropriate.” [ 5 ]  The nurse would individualize this evidence-based intervention to the patient and agency policy by stating,  “The nurse will reposition the patient every 2 hours.”

Dependent Nursing Interventions

Dependent nursing interventions  require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 6 ]  A  primary health care provider  is a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a dependent nursing intervention is,  “The nurse will administer scheduled diuretics as prescribed.”

Collaborative nursing interventions  are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint. [ 7 ]

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels. The respiratory therapist plans oxygen therapy and obtains a prescription from the provider. The nurse would document “ The nurse will manage oxygen therapy in collaboration with the respiratory therapist ” in the care plan.

Individualization of Interventions

It is vital for the planned interventions to be individualized to the patient to be successful. For example, adding prune juice to the breakfast meal of a patient with constipation will only work if the patient likes to drink the prune juice. If the patient does not like prune juice, then this intervention should not be included in the care plan. Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective interventions. The number of interventions included in a nursing care plan is not a hard and fast rule, but enough quality, individualized interventions should be planned to meet the identified outcomes for that patient.

Creating Nursing Care Plans

Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans are legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. CMS guidelines state, “Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best and patient representatives can be present, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision-making. A resident has the right to select or refuse specific treatment options before the care plan is instituted.” [ 8 ]  The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care. [ 9 ]

Many facilities have established standardized nursing care plans with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient. See Figure 4.13 [ 10 ]  for an image of a standardized care plan.

Figure 4.13

Standardized Care Plan

Nursing care plans created in nursing school can also be in various formats such as concept maps or tables. Some are fun and creative, while others are more formal.  Appendix B  contains a template that can be used for creating nursing care plans.

4.7. IMPLEMENTATION OF INTERVENTIONS

Implementation  is the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circumstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy. [ 1 ]

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “ Diagnosis ” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states,  “The nurse will ambulate the patient 100 feet three times daily.”  However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient. [ 2 ]

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titled  To Err Is Human: Building a Safer Health System . The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors.  To Err Is Human  broke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system. [ 3 ]  In 2007 the IOM published a follow-up report titled  Preventing Medication Errors  and reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety. [ 4 ]

Read additional information about specific actions that nurses can take to prevent medication errors; go to the “Preventing Medication Errors” section of the “ Legal/Ethical”  chapter of the Open RN  Nursing Pharmacology  textbook.

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care. [ 5 ]

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.” [ 6 ]  Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps.  Quality improvement  is defined as, “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 7 ]

Delegation of Interventions

While implementing interventions, RNs may elect to delegate nursing tasks.  Delegation  is defined by the American Nurses Association as, “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.” [ 8 ]  RNs are accountable for determining the appropriateness of the delegated task according to condition of the patient and the circumstance; the communication provided to an appropriately trained LPN or UAP; the level of supervision provided; and the evaluation and documentation of the task completed. The RN must also be aware of the state Nurse Practice Act, federal regulations, and agency policy before delegating. The RN cannot delegate responsibilities requiring clinical judgment. [ 9 ]  See the following box for information regarding legal requirements associated with delegation according to the Wisconsin Nurse Practice Act.

Delegation According to the Wisconsin Nurse Practice Act

During the supervision and direction of delegated acts a Registered Nurse shall do all of the following:

Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.

Provide direction and assistance to those supervised.

Observe and monitor the activities of those supervised.

Evaluate the effectiveness of acts performed under supervision. [ 10 ]

The standard of practice for Licensed Practical Nurses in Wisconsin states, “In the performance of acts in basic patient situations, the LPN. shall, under the general supervision of an RN or the direction of a provider:

Accept only patient care assignments which the LPN is competent to perform.

Provide basic nursing care. Basic nursing care is defined as care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.

Record nursing care given and report to the appropriate person changes in the condition of a patient.

Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

Perform the following other acts when applicable:

Assist with the collection of data.

Assist with the development and revision of a nursing care plan.

Reinforce the teaching provided by an RN provider and provide basic health care instruction.

Participate with other health team members in meeting basic patient needs.” [ 11 ]

Read additional details about the scope of practice of registered nurses (RNs) and licensed practical nurses (LPNs) in Wisconsin’s Nurse Practice Act in  Chapter N 6 Standards of Practice .

Read more about the American Nurses Association’s  Principles of Delegation.

Table 4.7 outlines general guidelines for delegating nursing tasks in the state of Wisconsin according to the role of the health care team member.

General Guidelines for Delegating Nursing Tasks

Documentation of Interventions

As interventions are performed, they must be documented in the patient’s record in a timely manner. As previously discussed in the “Ethical and Legal Issues” subsection of the “ Basic Concepts ” section, lack of documentation is considered a failure to communicate and a basis for legal action. A basic rule of thumb is if an intervention is not documented, it is considered not done in a court of law. It is also important to document administration of medication and other interventions in a timely manner to prevent errors that can occur due to delayed documentation time.

Coordination of Care and Health Teaching/Health Promotion

ANA’s Standard of Professional Practice for Implementation also includes the standards  5A   Coordination of Care  and  5B   Health Teaching and Health Promotion . [ 12 ]   Coordination of Care  includes competencies such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team.  Health Teaching and Health Promotion  is defined as, “Employing strategies to teach and promote health and wellness.” [ 13 ]  Patient education is an important component of nursing care and should be included during every patient encounter. For example, patient education may include teaching about side effects while administering medications or teaching patients how to self-manage their conditions at home.

Refer to Scenario C in the “Assessment” section of this chapter. The nurse implemented the nursing care plan documented in Appendix C. Interventions related to breathing were prioritized. Administration of the diuretic medication was completed first, and lung sounds were monitored frequently for the remainder of the shift. Weighing the patient before breakfast was delegated to the CNA. The patient was educated about her medications and methods to use to reduce peripheral edema at home. All interventions were documented in the electronic medical record (EMR).

4.8. EVALUATION

Evaluation  is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 1 ]  Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed. [ 2 ]

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

• Did anything unanticipated occur?
• Has the patient’s condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this patient at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

Refer to Scenario C in the “Assessment” section of this chapter and Appendix C . The nurse evaluates the patient’s progress toward achieving the expected outcomes.

For the nursing diagnosis  Fluid Volume Excess , the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:

The patient will report decreased dyspnea within the next 8 hours.

The patient will have clear lung sounds within the next 24 hours.

The patient will have decreased edema within the next 24 hours.

The patient’s weight will return to baseline by discharge.

Evaluation of the patient condition on Day 1 included the following data: “ The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves .” Based on this data, the nurse evaluated the expected outcomes as “ Partially Met ” and revised the care plan with two new interventions:

Request prescription for TED hose from provider.

Elevate patient’s legs when sitting in chair.

For the second nursing diagnosis,  Risk for Falls , the nurse evaluated the outcome criteria as “ Met ” based on the evaluation, “ The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred. ”

The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record.

4.9. SUMMARY OF THE NURSING PROCESS

You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.

Video Review of Creating a Sample Care Plan [ 1 ]

4.10. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Instructions: Apply what you’ve learned in this chapter by creating a nursing care plan using the following scenario. Use the template in   Appendix B   as a guide.

The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests. The tests are scheduled for the morning.

After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The patient also remarked, “I’m so uptight I will never be able to sleep tonight.” The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states, “My mouth is so dry.” The nurse observes his vital signs to be: T 98, P 104, R 30, BP 180/96. The nurse notes that his skin feels sweaty (diaphoretic) and cool to the touch.

Critical Thinking Activity:

Group (cluster) the subjective and objective data.

Create a problem-focused nursing diagnosis (hypothesis).

Develop a broad goal and then identify an expected outcome in “SMART” format.

Outline three interventions for the nursing diagnosis to meet the goal. Cite an evidence-based source.

Imagine that you implemented the interventions that you identified. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met.

• IV GLOSSARY

The act or process of pleading for, supporting, or recommending a cause or course of action. [ 1 ]

Unconditionally acceptance of the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care. [ 2 ]

Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences. [ 3 ]

Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. [ 4 ]

Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable. [ 5 ]

A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family. [ 6 ]

Individual, family, or group, which includes significant others and populations. [ 7 ]

The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care. [ 8 ]

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.  [ 9 ]

Grouping data into similar domains or patterns.

Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP).

While implementing interventions during the nursing process, includes components such as organizing the components of the plan with input from the health care consumer, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team. [ 10 ]

Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow. [ 11 ]

Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

“Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled. [ 12 ]

The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. [ 13 ]

Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant.

Interventions that are carried out by having personal contact with a patient.

An electronic version of the patient’s medical record.

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values. [ 14 ]

Statements of measurable action for the patient within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame.

An evidence-based assessment framework for identifying patient problems and risks during the assessment phase of the nursing process.

A judgment formed from a set of facts, cues, and observations.

Broad statements of purpose that describe the aim of nursing care.

Employing strategies to teach and promote health and wellness. [ 15 ]

Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else.

Interventions performed by the nurse in a setting other than directly with the patient. An example of indirect care is creating a nursing care plan.

A type of reasoning that involves forming generalizations based on specific incidents.

Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations.

Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act.

A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual.

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity. [ 16 ]

Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission.

A systematic approach to patient-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.”

Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data.

A measurable behavior demonstrated by the patient that is responsive to nursing interventions. [ 17 ]

The format of a nursing diagnosis statement that includes:

Problem (P) – statement of the patient problem (i.e., the nursing diagnosis)

Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis

Signs and Symptoms (S) – defining characteristics manifested by the patient of that nursing diagnosis

Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 18 ]

Information collected from the patient.

Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client. [ 19 ]

The skillful process of deciding which actions to complete first, second, or third for optimal patient outcomes and to improve patient safety.

The “combined and unceasing efforts of everyone — health care professionals, patients and their families, researchers, payers, planners, and educators — to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 20 ]

Developing a relationship of mutual trust and understanding.

A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing.

The underlying cause (etiology) of a nursing diagnosis when creating a PES statement.

Patients have the right to determine what will be done with and to their own person.

Principles and procedures in the discovery of knowledge involving the recognition and formulation of a problem, the collection of data, and the formulation and testing of a hypothesis.

Information collected from sources other than the patient.

Data that the patient or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as  “The patient appears anxious.”

Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. [ 21 ]

Obtaining Subjective Data in a Care Relationship

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 4 Nursing Process.
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• LEARNING ACTIVITIES

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Completing a Health Assessment in Nursing

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• What is a Comprehensive Health Assessment?
• Beginning an Assessment

Conducting the Physical Exam

Are you ready to earn your online nursing degree.

It’s a common occurrence in any health facility: nurses walk into a room and make a head-to-toe assessment of the patient. This is a critical part of creating a healthcare plan, but what does a nursing health assessment actually entail?

Keep reading to learn more about health assessments in nursing and why they matter.

What is a Comprehensive Health Assessment in Nursing?

Nurses conduct health assessments in clinics, physician offices, hospitals, and emergency rooms. How a nurse performs an assessment depends on the case, namely the person’s age and condition.

All nursing health assessments include paperwork and physical exams. Nurses systematically work on the patient from head to toe, beginning with the least invasive procedure.

Health assessments in nursing begin the moment a nurse walks into the room. Nurses note nonsocial cues. They use their sight and smell to look for symptoms. From there, nurses take a patient’s vital signs — temperature, heart rate, and blood pressure.

Advanced practical nurses (APRNs) may conduct an annual physical exam, while registered nurses (RNs) complete problem-focused exams for patients admitted into hospitals or urgent care departments.

Nursing health assessments help health professionals diagnose diseases and illnesses. Assessments also inform preventative care plans. Through nursing health assessments, nurses can provide guidance and gain patient trust.

Beginning a Nursing Health Assessment

Nursing programs teach students how to conduct nursing health assessments, but nurses often fine tune their skills on the job. Each nurse develops their own style to build patient relationships.

1 Build Patient Rapport

Patients often face social, emotional, and/or cultural barriers in accessing healthcare. Nurses have the power to calm patients — especially from historically excluded communities — who feel anxious or worried about their health.

A nurse’s mannerisms and the questions a nurse asks can build trust. For instance, when nurses start an assessment, they can develop a relationship through an introduction and by explaining what they are about to do. At this point, nurses can also assess a patient’s preference for the physical exam and make an effort to address any fears.

2 Family and Past Health History

On an initial patient visit, nurses ask about family and past medical histories. This information can help shape nursing care plans. During this process, nurses learn of any chronic illnesses, past surgeries, medications taken, sexual activity, and social habits such as smoking or drug use.

During this process, nurses can put patients at ease and build rapport by showing empathy and allowing patients to answer in their own time.

3 General Status and Vital Signs

After a nurse records a patient’s health history, they move to the physical exam. The first part of the physical exam entails the general status check-up. Nurses take vital signs, checking a patient’s heart rate, blood pressure, temperature, and respiratory rate.

Nurses can assess a patient at first sight by taking into account the patient’s posture, emotional state, speech, and hygiene. After nurses take a patient’s vital signs, the physical exam begins. Nurses examine the patient methodically from head to toe, beginning with the head, ears, eyes, nose, and throat (HEENT).

Palpating the head and scalp to check the shape, size, and symmetry can provide information about underlying issues or trauma such as concussions. Nurses also examine facial expressions for drooping or asymmetry, which can help in the diagnosis of a stroke or other conditions that cause facial paralysis. The head assessment also includes:

• Moving hair in sections to look for injuries
• Observing the scalp to look for lice, dandruff, or lesions
• Inspecting the head for masses or tenderness
• Checking that facial movements are symmetrical by asking patients to move their eyebrows or smile

Inspecting the ears using an otoscope can provide insight on hearing loss, vertigo, or tinnitus. Nurses can also identify any cancers or lesions on the outer ear. Ear assessments may also involve:

• Using an otoscope to look for discharge or skin discoloration
• Hitting a tuning fork to test for hearing loss
• Investigating cerumen (earwax) impaction as a cause of hearing loss
• Asking patients about any medications they take
• Checking the inner ear for perforations or swelling in the membrane

Testing the eyes can provide information about a patients’ brain function. A pupil examination can offer signs about head injury. Nurse uses an ophthalmoscope to inspect the external eye functionality. They also:

• Visually inspect the eyes for excessive discharge, redness, or growths
• Record eyesight aids patient uses, including contacts or eyeglasses
• Check the pupils for PERRLA — Pupils: Equal, Round, Reactive to Light, and Accommodation (transitioning focus between close and far objects)

A nose assessment begins by inspecting the exterior for discoloration, symmetry, swelling, malformations, or lesions. For instance, a nurse may note if they find a lesion or dark spot. Using a penlight or the light from an otoscope, nurses examine the nasal cavities for discoloration, discharge, and symmetry. They may continue assessing the nose by:

• Using their thumb to palpate one sinus at a time to identify pain or tenderness
• Closing one nostril at a time to check for normal airflow
• Checking to make sure that the nose is the same color as the patient’s face

A throat inspection can lead to early detection of oral cancer and potentially save someone’s life. Assessments can also help nurses detect strep throat or dysphagia.

Nurses inspect the throat for abnormalities. Throat examinations involve checking the teeth and gums, tongue, uvula, and tonsils, inner lining of the lips and cheeks, and the soft and hard palates. Nurses also:

• Use a tongue depressor to inspect the cheeks for abnormalities such as lesions
• Examine the top and underside of the tongue for discoloration
• Visually inspect the lips for lesions
• Check the coloration of the lips and gums
• Note fouls smells or a fruity scent that could be a sign of ketoacidosis

Nurses inspect the neck to check for jugular venous distention, range of motion, and to see if patients can easily shrug with resistance. A neck examination begins with nurses looking at the location of the trachea to make sure it’s center, and then includes:

• Palpating the sides of the neck to check for swollen lymph nodes
• Checking the neck for tenderness and lumps
• Inspecting thyroid size and shape
• Examining the back of the neck for signs of spinal column injuries
• Looking at the neck for lesions and lumps

Respiratory

Nurses need to know the basics of the respiratory system to recognize signs of respiratory deterioration. Checking the lungs for tenderness and masses, and listening to the lung sounds can provide clues about underlying health issues. Respiratory assessments also include:

• Making visual assessments of a patient’s respiratory rate
• Asking patients if they experience shortness of breath or have a cough
• Placing their hand to the patient’s back to evaluate symmetrical chest rise.
• Using the stethoscope to listen for full inspiration and expiration
• Inspecting the size, shape, and symmetry of the chest

It takes a stethoscope and keen observation skills to perform a cardiac assessment, which provides crucial data about cardiovascular system function. Nurses use palpation and visual cues to look for the quality of cardiac blood flow. The exam often includes:

• Using a stethoscope to auscultate the five points of the heart: Erb’s point and the aortic, pulmonic, tricuspid, and mitral valves
• Palpating the chest wall, looking for vibratory sensations
• Listening for normal heart rates and rhythms

From a supine position, nurses can begin an abdomen examination. This includes auscultation, percussion, and palpation. Nurses may perform abdomen assessments on patients with percutaneous endoscopic gastrostomy feeding tubes or with ostomy pouches. Otherwise routine abdomen assessments include:

• Asking questions about any pain in bowel and urination movements
• Inspecting the abdomen to look at contours and pulsations
• Looking for masses or wounds
• Using the stethoscope to listen to bowel sounds at all four quadrants
• Listening to vascular sounds using the stethoscope’s bell

Pulse assessments tell nurses about a patient’s health status. Nurses look for pulses in different areas of the body — the neck, arms, legs, and feet — depending on the case. During CPR, nurses may check the carotid artery for a pulse to determine if the brain and head are receiving blood flow. Where a nurse looks for a pulse also depends on the patient’s age. Nurses can:

• Check the temporal artery for a pulse
• Find the apical pulse point
• Assess the blood pressure by checking the brachial artery
• Palpate the radial, femoral, posterior tibial, and dorsalis pedi pulse points

Extremities

An essential part of the head-to-toe includes examining the extremities: the arms, hands, legs, and feet. Nurses look for lesions, redness, swelling, injuries, and — in the case of hospitalized patients — they may check the entrypoint of an intravenous line.

A proper assessment can help doctors diagnose gout, diabetes, or deep vein thrombosis. Nurses during an assessment may:

• Palpate the radial artery and joints — the elbows, wrists, and hands — to check skin temperature
• Ask the patient to move and flex their arms and legs against resistance
• Check the color of the legs and toes
• Test extremities for a range of motion
• Inspect the strength and musculature of extremities

Neurological

An examination of coordination, balance, and sensory response can provide information about neurological trauma and prevent long-term damage. In the emergency room and hospital neuro units, patients receive neurological assessments. Nurses also perform neuro exams in other departments. The exams include:

• Using the Romberg test to assess balance
• Checking the gait, including posture
• Examining olfactory and optic nerves
• Checking a patient’s level of consciousness by using the Glasgow Coma Scale
• Assessing orientation and memory by asking a patient routine questions

Frequently Asked Questions About Health Assessments

What is a complete health assessment.

A complete nursing health assessment requires a health professional to examine a patient in a systematic fashion, from head to toe. Nurses rely on self-reported symptoms, visual observation, reported health histories, and a physical medical examination to make a health assessment. This data then informs the nursing care plan.

When are health assessments performed in nursing?

A nursing health assessment helps nurses and other health professionals in a variety of settings to understand a patient’s mental and physical health. In the emergency room, a patient may receive a neurological assessment to test their level of consciousness.

Patients also receive health assessments during their annual physical checkups. At outpatient clinics or long-term care facilities, nurses use health assessments to identify trauma or injury, or to treat disease and illnesses.

Why are nursing health assessments important?

A proper nursing health assessment can lead to early intervention, which saves lives. Nurses also use health assessments to start conversations about social or cultural barriers that patients face in assessing healthcare.

A verbal and physical nursing health assessment helps nurses to gather information about a person’s symptoms, pain, and mobility level. A problem-focused assessment can also direct analysis to specific areas: cardiac, extremities, respiratory, or throat.

What are the four techniques used in physical nursing assessments?

Nurses have a set of skills and tools that they rely on to conduct a nursing health assessment. Health assessments include observation and inspection, palpation, percussion, and auscultation. Nurses perform these techniques sequentially, except during abdominal assessments.

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IntelyCare for Healthcare Facilities > Resources > Nurse Management > How to Manage an Assignment Despite Objection: 5 Tips for Facilities

How to Manage an Assignment Despite Objection: 5 Tips for Facilities

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Nurses are legally accountable for the quality of care they provide to patients. Under that responsibility, they must ensure that they’re competent to provide the treatment necessary for each individual assigned to their care. While most supervisors attempt to allocate patients according to each nurse’s ability, there are instances where a nurse may believe that their assignment places themselves or their patients at risk.

In these situations, it is the nurse’s duty to complete an Assignment Despite Objection (ADO) form . You may be wondering — What does ADO paperwork look like, and what are the steps required to ensure the forms are completed appropriately?

In this article, we introduce the purpose of ADO forms, review an example scenario that highlights the ADO paperwork submission process, and list five tips for facilities looking to appropriately manage ADO situations to ensure staff protection and patient safety.

What Does Assignment Despite Objection Mean?

The term “Assignment Despite Objection” is used to describe a situation in which a nurse has been made responsible for an unmanageable patient load. Despite making it clear to unit leadership that the staff member feels unsafe, unqualified, or unsupported in managing the care of that particular assignment, they have been mandated to assume care for that assignment. A nurse may complete an ADO for a number of reasons, including:

• Being assigned to care for a number of patients that falls outside of any legal nurse-to-patient ratio .
• Feeling inexperienced or untrained in a particular area or specialty.
• Experiencing a shortage of support staff that would make the assignment manageable.
• Lacking sufficient safety equipment or machinery to provide care effectively.
• Being forced to work overtime or miss meal breaks.

ADO paperwork helps provide legal protection for nurses who believe they may be put in an unsafe patient care situation. “Whistleblowing” the potential for patient harm doesn’t completely remove liability from the nurse, but it does raise concerns for facility leadership and can put them on notice of elevated patient care risks. State nursing boards and nursing unions encourage staff to complete ADO paperwork to protect themselves and their patients.

What Does ADO Paperwork Look Like?

Each state nursing board or nursing union utilizes its own version of an ADO form , which covers employees working in that state. While they all vary in terms of layout or design, each form contains similar elements, including:

• The nurse’s name, license number, and place of employment.
• The supervisor’s name and date/time of notification.
• The reason for the nurse’s objection.
• The unit’s census details, including the number of patients and staff members.
• A space to outline any actual or potential patient harm that may have been caused.

Assignment Despite Objection: Example Scenario

The ADO process can seem confusing out of clinical context. The table below lists the steps involved when a nursing professional files an ADO, along with a scenario to help highlight the process in a realistic clinical situation.

Managing an ADO: 5 Tips for Facilities

As you review how the Assignment Despite Objection form submission process works, you’re probably looking for tips on how to effectively manage these situations in your unit or facility. Below, we review five key strategies for managing an ADO safely and effectively.

1. Ensure All Patient Assignments Meet Mandated State Staffing Ratios

A key step to keeping clinical operations running smoothly is to prevent ADO situations from arising in the first place. Adhering to your state’s legally mandated staffing ratios is the first step to ensuring compliance and safety .

2. Provide Staff Training on ADO Protocol

Many nurses might not be familiar with the ADO process. They may not know how to speak up if they find themselves in a situation where they aren’t able to practice safely or competently. One way to prevent this from happening is to include Assignment Despite Objection education as part of your employee onboarding training .

Be sure to show staff where to find the forms, explain how to complete them, and relay who to submit them to when necessary. This not only helps your staff feel empowered and supported, but also ensures that your patients receive the best possible care.

3. Encourage Team Cohesion

As the term “objection” implies, ADO submissions can become contentious if management and nursing staff perceive each other to be on separate teams. It’s important that both sides abandon the “them versus us” mentality and understand that the entire unit is focused on preserving staff and patient safety.

Team bonding activities can help to unite facility leadership and bedside staff and ensure that no side feels like they’re fighting against the other. Collaborative team meetings can also help clinical leaders and staff work side-by-side to discuss mutual issues and problem solve together.

4. Incorporate Per Diem and Float Pool Nurses to Cover Schedule Gaps

One of the most common reasons an ADO arises is due to short staffing . By utilizing flexible staffing solutions, you can ensure that all patient assignments can be safely distributed, even during high census.

Per diem nurses, who work only one or two shifts a week, could be added into the staffing matrix on busy shifts or during predictable nursing shortages like maternity leaves or staff vacations. Float pool nurses, alternatively, could be requested on short notice to assist with unpredictable staff shortages like sick calls.

5. Review Submitted ADO Paperwork to Plan Long-Term Solutions

The submission of an ADO form only means that the situation has been documented. It doesn’t mean that the situation was handled safely or that outcomes were improved.

Therefore, it’s essential that facility management reviews those forms and performs a root-cause analysis to prevent future improper patient assignments. Typically, this is done in unit leadership meetings or in a facility-wide shared governance committee .

Discover More Ways to Promote Patient Safety in Your Facility

Safely managing an Assignment Despite Objection situation prevents future patient harm and ensures your staff members practice safely and effectively. Follow along in our expertly-written newsletter for additional tips and strategies on encouraging employee engagement and optimizing care quality.

Legal Disclaimer: This article contains general legal information, but it is not intended to constitute professional legal advice for any particular situation and should not be relied on as professional legal advice. Any references to the law may not be current, as laws regularly change through updates in legislation, regulation, and case law at the federal and state level. Nothing in this article should be interpreted as creating an attorney-client relationship. If you have legal questions, you should seek the advice of an attorney licensed to practice in your jurisdiction.

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A Pod Design for Nursing Assignments

Donahue, Lisa DrNP, RN

Lisa Donahue is the director of inpatient quality and innovation at the University of Pittsburgh Medical Center Shadyside in Pennsylvania.

Contact author: [email protected] .

Eliminating unnecessary steps and increasing patient satisfaction by reconfiguring care assignments.

Our participation in the Transforming Care at the Bedside (TCAB) initiative at the University of Pittsburgh Medical Center (UPMC) Shadyside began in 2003. At the time I was unit director of 3 Main, a 38-bed cardiothoracic and vascular surgery unit. On the day shift, a nurse cares for four or five patients; on the night shift, it can be as many as six or seven. Patient acuity is high on this unit, and patient care assignments are determined by acuity and care requirements.

The unit is laid out on two 200-foot parallel hallways, with rooms totaling 20 beds along one hallway and 18 beds along the other. Patient rooms are only on the outer sides of the hallways. In the middle, between the two hallways, there is a central nursing station, a utility room, and a patient kitchen. Three pathways connect the long hallways.

Nurses often had patients on both hallways and sometimes in all four corners of the unit. This caused them to waste steps and their energy. Dissatisfaction with this situation was high among both the staff and the patients, who had to wait longer than they liked for nurses. We decided to address the problem through TCAB because it affected all four TCAB focus areas (patient-centered care, teamwork and vitality, value-added processes, and safe and reliable care).

THE PROBLEM

Our history as an established TCAB unit that encouraged openness enabled our nurses to bring up their concerns and issues at staff meetings and elsewhere, and several staff members told us that the assignment method we were using was challenging and unproductive. The primary issue was that the distance between their patients' rooms required them to do a great deal of walking. This issue was important not just in terms of its effect on overall productivity, but also because of the extra physical demands it placed on the nurses. On our unit, 29% of the RN staff were near or beyond the average age of nurses in the United States, 46.8 years. 1 The potential this presented for increased injury and reduced ability to meet some of the physical demands of their work 2 prompted us to reassess the way the RNs performed their work.

In my quest for evidence and ideas about how to restructure our assignments, I found minimal literature on care assignments among nurses. The most comprehensive article dated back to 1973 and suggested that it was important to keep assigned patients in close proximity. 3

CREATING PODS

Along with the hospital's improvement specialists, the nurse on the unit who was on the hospital's TCAB committee and I decided to divide the unit into four "pods" with two nurses assigned to each pod during each shift. We thought this would decrease the number of unnecessary steps and improve nurses' ability to monitor and be accessible to their patients. Within each pod, patients would be equally divided between the nurses by their acuity, which would be reassessed at every shift change. However, when we presented the idea, the staff was resistant and raised concerns about the potential unfairness of assignments.

We then went back to TCAB basics and collected data to support the need for making the change and to address the staff's concerns. We planned to develop tests of change based on the information we gathered. First, we created a spaghetti diagram to show the path a nurse traveled during a four-hour period. Spaghetti diagrams are used in manufacturing to expose inefficient layouts. 4 We created our baseline spaghetti diagram by directly observing a nurse who was chosen because she was organized, thorough, and able to complete her work in a timely fashion. The spaghetti diagram of her steps before we implemented the pod design revealed an erratic pattern. According to a pedometer, the nurse walked 1,075 steps in four hours and 3,928 steps in eight hours.

We then assessed the patient complaints and scores collected on our Press Ganey patient satisfaction surveys. We paid particular attention to patients' assessments of nurses' promptness in responding to their calls, attention to their personal needs, and overall care. We felt that the metrics supported performing a test of change of the pod design.

We created four pods that covered 100 feet each, two for each hallway. Each pod had eight rooms—with 10 beds each in pods A and B and nine beds each in pods C and D—whose occupants were divided between two RNs. We were careful to distribute acutely ill patients, confused patients, those in isolation, and empty rooms as equally as possible among the pods. The charge nurse quickly reassessed patient care assignments at the end of each shift to ensure fairness in the assignments for the following shift's nurses. Midshift changes were made only in the event of an emergency.

We began using the pod design in April 2007. The entire unit participated in the test of change for 30 days, which we thought would give staff enough time to adjust to and be able to articulate pros and cons about the new arrangement.

We saw a consistent and sustained improvement in patient satisfaction scores in the months immediately after we implemented the pod design (see Figure 1 ). Patient complaints, which are reported, processed, and tabulated by the hospital's patient relations department, dwindled to a single complaint in June and in July, less than the usual two or three complaints and one or two grievances per month. (A complaint is a verbally communicated patient or family concern or issue that can be resolved quickly by the staff, whereas a grievance is a written or verbal complaint that was not resolved at the time it occurred.) The spaghetti diagram, created with the same nurse and technique as before, showed an improved, less erratic work flow. The number of steps the nurse had to take decreased significantly, to 877 steps in four hours and 2,291 steps in eight hours.

Using personal digital assistants (PDAs) and a work sampling study, we documented a consistent increase in the amount of time spent in direct patient care (see Figure 2 ). Time devoted to value-added care—patient-centered actions that directly benefit the patient—also increased. Work sampling involves applying statistical sampling techniques to work activities and is typically used to estimate the proportion of a worker's time that is devoted to different tasks. 5 The PDAs were set to vibrate randomly approximately 22 times over a 12-hour period. The nurse then selected her or his location and the most accurate description of the activity being performed.

We have been using the pod design for patient care assignments for more than two years. At times, we have adapted the staffing patterns somewhat by slightly overlapping a nurse's patients in adjacent pods. We also sometimes change the pod division, depending on the number of RNs working in a shift.

OVERALL ASSESSMENT

The pod design for patient care assignments has improved patient satisfaction by increasing the visibility and accessibility of nurses and has enhanced nurses' ability to provide safe and reliable care. This care assignment design has also improved staff vitality by reducing the number of unnecessary steps nurses take during a shift.

The pod design has been spread to and adapted by other nursing units at UPMC Shadyside that have the same physical layout. We supplied our design plan and outcome metrics to the spread units and presented them at our hospital's weekly TCAB meeting and the UPMC health system's TCAB forum. Unit directors who presented the idea to their staffs reported that they also initially encountered resistance to the idea, but the TCAB philosophy of adapting changes enabled these units to make the design more suitable for their use.

This TCAB experience proved to me that the cautions I had read in the literature about resistance to change are not exaggerated. Although the unit's staff had identified that there was a problem with the old way of making assignments, they didn't want to try something new. We found that nothing can break down resistance to change like good metrics. The measurements we gathered opened the eyes of many doubters on our staff, who then supported changing to the pod design. Tests of change are the TCAB way of life, and the staff has largely become accustomed to them. Although they still create some discomfort simply because they involve change—though it may be as small as relocating a printer—the negativity that accompanied our first test of change has abated.

I also learned that the sustainability of a change often hinges on the ability to adapt as necessary. For example, our nurses work a mixture of eight- and 12-hour shifts, which makes adjusting patient assignments necessary. In the end, the adaptations made the pod concept stronger.

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The Nursing Process

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Assessment An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

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

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

Implementation Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

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