principles of assignment in nursing

15.4 Nursing Standards of Delegation

Learning objectives.

By the end of this section, you will be able to:

• Identify nursing standards for delegation
• Recognize nursing principles for delegation

The act of requesting staff members to perform tasks or procedures that are outside of their normal job but within the limits of their job description is called delegation . Nurses delegate tasks and procedures to other staff members daily to cope with the constantly changing needs of patients in an active healthcare setting. Per the National Guidelines for Nursing Delegation , delegation happens when a registered nurse (RN) asks either a licensed practical nurse (LPN) /licensed vocational nurse (LVN) or assistive personnel (AP) —such as nursing assistants, certified nursing assistants, patient care technicians, or surgical technicians—to perform a task on the nurse’s behalf. RNs do not delegate to other RNs. If an RN asks another RN to perform tasks for them, it is considered a transfer of care, and the new RN becomes responsible for the patient (American Nurses Association [ANA]-National Council of State Boards of Nursing [NCSBN], 2019). While charge nurses, managers, and supervisors give assignments to other RNs, this is not considered delegating but rather assigning job tasks.

Delegation is a critical nursing skill that reflects directly on the nurse doing the delegating (NCSBN, 2016). Inappropriate delegation can cause harm to a patient and result in disciplinary action for the nurse who sets it up. Delegation is governed by nursing practice standards from the ANA, nursing practice guidelines from the ANA and the NCSBN, local and state laws regarding delegation, and individual agencies or facilities (NCSBN, 2016). All nurses must understand what they can and cannot do per the relevant guidelines and laws.

Nursing Standards for Delegation

The ANA offers basic delegation competencies in two nursing standards:

Standard 5: Implementation

• RNs can delegate based on the needs of the healthcare consumer.
• RNs can delegate “after considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations, institution, and regulatory entities while maintaining accountability for the care” (ANA, 2021, p. 82).

Standard 12: Leadership

• RNs demonstrate “authority, ownership, accountability, and responsibility for appropriate delegation of nursing care” (ANA, 2021, p. 97).

Consider those statements for a moment. They emphasize the idea of accountability: an RN who delegates a task to another staff member is responsible for that choice and answerable for its consequences.

Five Rights of Nursing Delegation

When an RN designates a job to another staff member (the delegatee ), that RN is still responsible for ensuring the job is performed appropriately (ANA-NCSBN, 2019). The five “rights” of nursing delegation specify when and how to delegate nursing duties (ANA-NCSBN, 2019): right task, right circumstance, right person, right communication, and right supervision. Each of these rights should be considered when delegating a task to another staff member.

Any activity delegated to a delegatee must be included in their job description or established through the written policies and procedures of the given setting (ANA-NCSBN, 2019). However, delegated tasks can fall outside of the delegatee’s normal duties. Agencies must ensure that written policies or procedures describe the abilities and limitations of different AP (NCSBN, 2016). Facilities must provide training for any skilled competencies (such as drawing blood or using equipment) that AP may be required to perform.

Right Circumstance

Patients must be in stable condition with expected outcomes before a nurse can delegate care responsibilities (ANA-NCSBN, 2019). If the patient’s condition changes, the RN must reassess the patient to determine whether the delegation is still appropriate. For example, it is very unusual for critical-care areas to staff large numbers of AP and LPNs/LVNs because they are limited in how much assistance they can provide to unstable patients without direct, constant supervision.

Right Person

The RN is responsible for ensuring the delegatee has completed any required education and has the necessary competencies to perform the care (ANA-NCSBN, 2019). For example, a staff member must be educated in how to use patient transfer equipment, such as ceiling lifts for moving patients between surfaces, before they can be delegated tasks involving that equipment. An RN asking an AP to transfer a patient to a stretcher would have to be sure the AP had received the necessary education and was competent to perform the transfer when making the request.

Real RN Stories

Delegating care.

Nurse: Mai C., RN Clinical setting: Inpatient psychiatric unit Years in practice: 30 Facility location: Urban psychiatric facility in Tennessee

I remember one time when I was working the night shift. We did not often have blood draws ordered on the night shift, but that night, two of them had to be completed in the early morning. I was the charge nurse and was making patient care assignments for the unit. I delegated the blood draws to one of our AP. The AP was fairly new but had been with us long enough that I thought he had completed all his competencies.

At about 2 a.m., he came to me to tell me that he could not do the blood draws because he had not been checked off on them by our lab. All staff members had to receive education and perform three successful lab draws in our outpatient lab before they could draw blood on the unit. Since he had started on night shift and never worked on days, he had not done his blood draws for check-offs.

I found another AP who could do the blood draws that night. Then I spoke with our nurse manager to be sure that the AP had the opportunity to do his check-offs in the outpatient lab one morning before he left work. The next time I asked him to draw blood labs, he could without difficulty.

Right Communication

When RNs delegate to other employees, they must provide appropriate instructions, and the delegatee must have the opportunity to ask questions (ANA-NCSBN, 2019). Clear communication must be provided to ensure the delegatee understands the specifics of the assignment. The delegatee must also agree to perform the assignment. The delegatee cannot make any decisions regarding care changes without consulting the delegating RN (NCSBN, 2016).

Right Supervision

The RN must provide supervision to ensure the activity is performed correctly and evaluate patient outcomes. The delegatee must communicate patient information accurately to the RN. If the performance of the task is inadequate, the RN must intervene as necessary. Consider this example. An RN has asked an AP to take a patient’s vital signs. When the AP gives the information to the RN, the patient’s blood pressure is substantially higher than expected, representing a considerable alteration over previous readings. The RN then returns to the patient’s room to verify the elevated blood pressure by taking it themself.

Delegation versus Assignment

There is a difference between being delegated a task and being given a patient assignment. An assignment consists of the routine activities and procedures that are part of a staff member’s normal job and taught in either a degree or certificate program or as part of on-the-job training (ANA-NCSBN, 2019). RNs may still be responsible for supervising other staff as they complete their assignments, but not to the same degree as with delegation. For example, an LPN/LVN with a patient assignment who gives their patients medication, takes their vitals, draws their labs, and documents their responses to care is functioning within the capacity of their degree and scope of practice; they should be able to complete these tasks with limited to no supervision. In contrast, an LPN/LVN whose patient goes into respiratory arrest would reasonably expect a code team to manage the patient’s care when they arrive. With the proper supervision, however, the code team could delegate a task to the LPN/LVN, such as providing bag-mouth ventilation—that is, helping the patient breathe by squeezing a bag connected to an oxygen supply and the patient.

Principles for Delegation

The ANA and NCSBN have developed principles for delegation. These fundamental principles are strategies to protect the patient’s well-being, health, and safety, and they must be considered along with the five rights of delegation discussed previously (ANA, 2013). They include the following:

• While elements of nursing care may be delegated, the nursing process cannot.
• Decisions to delegate must be based on the nurse’s judgment and consideration of the patient’s complexity and care needs and the ability of the RN to provide appropriate supervision to the AP.
• Delegation should always be respectful of both the delegate and patient.

Link to Learning

The ANA has a booklet that explores the principles of delegation and provides a decision tree to assist nurses in knowing when delegation is appropriate.

Facilities use the nursing scope and standards of the ANA and the state’s nurse practice acts to determine the authority and practice capacity of RNs within their agencies (ANA-NCSBN, 2019; Barrow & Sharma, 2022). Under this authority, nurses are expected to complete their job duties. These duties include delegating tasks to AP and LPN/LVNs based on the needs of the patient population, the stability of training, the training of delegatees, and the nurse’s ability to provide appropriate supervision.

Accountability

Nurses are legally and ethically liable for their patient care actions, known as accountability , including decisions to delegate activities to APs and LPN/LVNs. Even when care is delegated to other personnel, the RN remains accountable for the care provided. If nurses are concerned about delegating a task, they should perform it themselves (ANA-NCSBN, 2019). Once a delegate has accepted the responsibility of a delegation, they are accountable for completing that activity correctly, timely, and per facility protocol (ANA-NCSBN, 2019).

Responsibility

All RNs are responsible for acting within their states’ nursing practice acts and performing reliable and dependable patient care tasks (Barrow & Sharma, 2022). When delegating tasks, RNs are responsible for providing high-quality communication and clearly explaining the delegated responsibility. Further, they are responsible for ensuring that delegated tasks are completed appropriately (ANA-NSCBN, 2019).

Delegatees are responsible for delegated activities they accept and should only accept activities for which they have been appropriately trained (ANA-NSCBN, 2019). They are also responsible for maintaining their competencies—reviewing and renewing educational modules or skill check-offs on an ongoing basis—for activities they may be required to perform if delegated. Figure 15.12 outlines the responsibilities of all parties involved in the delegation of nursing tasks.

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Nursing Management: Guide to Organizing, Staffing, Scheduling, Directing and Delegating

Effective nursing management is crucial for ensuring high-quality patient care and maintaining a harmonious work environment. This involves several key concepts, including organizing, delegation, motivation, supervision, coordination, and conflict management.

Table of Contents

Organizing process, three forms of authority, organizational chart, managerial levels, patterns of organizational structure, staffing process, staffing pattern, patient classification system, shifting patterns, elements of directing, barriers in communication, common errors in delegation, steps in effective delegating, key concepts in effective delegation, conflict resolution strategies.

Organizing is a crucial management function that ensures tasks are logically identified, assigned, and grouped. It determines who is responsible for each task, establishes clear lines of reporting, and facilitates decision-making. At its core, organizing defines roles and relationships within the organization, clarifying each staff member’s functions to execute the organizational plan effectively.

The process of organizing involves the following:

• Identifying and Defining Tasks . Determine the basic tasks that need to be accomplished.
• Delegating Authority and Assigning Responsibility . Allocate authority and assign responsibilities to appropriate individuals.
• Establishing Relationships . Create a structure that separates activities, arranges them hierarchically, and fosters efficient teamwork.

Authority within an organization can be categorized into three primary forms:

Line Authority

Line authority is the direct supervisory authority that flows from a supervisor to their subordinates. It represents the clear, direct chain of command where decisions and instructions are passed down the hierarchy. For example, a nurse manager has direct supervisory authority over a team of registered nurses (RNs) on a hospital ward. The nurse manager delegates tasks, oversees patient care , and evaluates the performance of the nursing staff, ensuring that the ward operates smoothly.

Staff Authority

Staff authority is based on expertise and typically involves providing advice and support to line managers. Staff authority does not entail direct command over other employees but focuses on specialized knowledge and guidance. For example, a clinical nurse specialist (CNS) provides expert advice to the nursing staff and line managers on best practices for patient care . Although the CNS does not have direct supervisory control, they influence decisions through their specialized knowledge in areas such as wound care , pain management , or diabetes education.

Team Authority

Granted to committees or work teams involved in daily operations, team authority empowers groups of employees who share a common vision , goals, and objectives. These teams are responsible for collaborative decision-making and achieving specific outcomes. For example, in a hospital setting, the chain of command starts with the Chief Nursing Officer (CNO) at the top, followed by nurse directors, nurse managers, charge nurses, and finally the staff nurses. This hierarchy ensures that decisions and instructions are passed down systematically and that issues can be escalated appropriately.

Additional concepts related to authority include:

• Chain of Command . This is an unbroken line of reporting relationships that extends through the entire organization, defining the formal decision-making structure and ensuring clarity in the flow of authority.
• Unity of Command . This principle states that each person in the organization should take orders from and report to only one supervisor, preventing confusion and overlapping directives.
• Span of Control . This refers to the optimal number of employees that one leader-manager can effectively supervise. A well-defined span of control ensures efficient management and communication within the organization.

An organizational chart is a visual representation that illustrates the structure of an organization. It shows how different parts of the organization are linked, highlighting formal relationships, areas of responsibility, accountability, and communication channels.

Organizational Structure

The chart clearly depicts roles and expectations, as well as the arrangement of positions and working relationships within the organization.

Lines of Authority

In an organizational chart, various lines are used to represent different types of authority and relationships within the organization:

• Dotted Line. Represents staff positions or staff authority, indicating advisory roles to line managers.
• Solid Horizontal Line. Represents positions of equal status but different functions.
• Solid Vertical Line. Indicates the chain of command, showing direct authority from supervisors to subordinates (line authority).
• Centrality. Refers to the position on the chart where frequent and diverse communication occurs. Positions with smaller organizational distance, closer to the center, receive more information compared to those located more peripherally.

In an organization, managerial roles are divided into different levels, each with distinct responsibilities and scope of influence:

• Top-Level Managers . Make strategic decisions with minimal guidelines or structure. Coordinate both internal and external influences. Examples include: CEO, President, Vice President, Chief Nursing Officer
• Middle-Level Managers. Oversee day-to-day operations while also engaging in long-term planning and policy-making. Examples include: Head Nurse, Department Head, Unit Supervisor/Manager
• First-Level Managers. Focus on specific unit workflows and address immediate, day-to-day issues. Examples: charge Nurse, Team Leader, Primary Nurse, Staff Nurse

Organizational structures define how tasks, responsibilities, and authority are distributed within an organization. Different structures cater to various organizational needs and scales, each with distinct characteristics and implications for communication and management. These may include:

Tall or Centralized Structure

Tall or centralized structures are characterized by a narrow span of control, where supervisors are responsible for only a few subordinates. Due to its vertical nature, this structure involves many levels of communication. Communication can be difficult, and messages often fail to reach the top effectively. Workers tend to be boss-oriented due to close supervision.

Flat or Decentralized Structure

Flat or decentralized structures feature few levels and a broad span of control, making communication easy and direct. This structure shortens the administrative distance between top and lower levels, facilitates fast problem-solving and response, and encourages workers to develop their abilities and autonomy. However, it is impractical for large organizations.

Types of Organizational Structure

Organizational structures can vary significantly, each designed to meet specific operational needs and management styles. Understanding the different types helps in selecting the most appropriate structure for a given organization.

• Line Organization/Bureaucratic/Pyramidal . In a line organization, there is a clearly defined superior-subordinate relationship. Authority and power are concentrated at the top.
• Flat/Horizontal Organization . A decentralized type, flat organizations are applicable in small organizations. Nurses become more productive and directly involved in decision-making processes, leading to greater worker satisfaction.
• Functional Organization . This structure allows specialists to assist line positions within a limited and clearly defined scope of authority.
• Ad Hoc Organization . An ad hoc organization is a modification of the bureaucratic structure, often created for specific projects or purposes.
• Matrix Structure . The matrix structure focuses on both products and functions, making it the most complex type. It incorporates both vertical and horizontal chains of command and lines of communication.

Staffing is the process of assigning competent individuals to fulfill the roles designated within an organizational structure. This involves recruitment, selection, development, induction, and orientation of new staff to align with the organization’s goals, vision, mission, and philosophy.

Staffing involves a systematic approach to ensuring the organization has the right number and type of personnel to achieve its goals. The following steps outline the key stages in the staffing process:

• Preparing to Recruit . This initial step involves determining the types and number of personnel required to meet the organization’s needs.
• Attracting Staff . Formal advertisements and outreach efforts are used to attract potential candidates.
• Recruiting and Selecting Staff . This phase includes conducting interviews, induction, orientation, job orders, pre-employment testing, and signing contracts to onboard new employees.

Developing an effective staffing pattern is essential for ensuring that an organization has the right number of staff with the appropriate skills to meet its needs. There are two primary methods for creating a staffing pattern:

Determining Nursing Care Hours

This method involves calculating the number of nursing care hours required per patient. For example, if each patient needs an average of 6 hours of nursing care per day and the unit has 20 patients, the total nursing care hours needed per day would be 120 hours. This helps in determining the number of nurses required per shift to meet patient care needs effectively.

Calculating Full-Time Equivalents (FTEs)

This approach measures the work commitment of full-time employees. For instance, 1.0 FTE represents a full-time employee who works 5 days a week, 8 hours a day, totaling 40 hours a week. Conversely, 0.5 FTE corresponds to a part-time employee working 5 days every 2 weeks, totaling 20 hours a week.

Considerations in Staffing Pattern

When developing a staffing pattern, several key factors must be taken into account to ensure optimal organizational performance and compliance with regulations. The following considerations are essential:

• Benchmarking. This management tool is used to seek out the best practices within the healthcare industry to improve performance. For instance, a hospital might compare its nurse-to-patient ratio with top-performing hospitals. By measuring their staffing practices and patient outcomes against these benchmarks, the hospital can identify areas for improvement and set realistic targets for nurse staffing levels.
• Regulatory Requirements. Staffing patterns must adhere to mandated regulations, such as those outlined in relevant legislative acts. For example, the laws regarding safe staffing in certain regions mandates specific nurse-to-patient ratios that must be maintained to ensure patient safety and care quality.
• Skill Mix. The skill mix refers to the percentage or ratio of professionals to non-professionals within the staff. For example, in a hospital unit with 40 full-time equivalents (FTEs), if there are 20 registered nurses (RNs) and 20 nursing assistants, the RN mix is 50%. This ratio ensures a balanced team with the necessary expertise and support staff, allowing RNs to focus on complex patient care tasks while nursing assistants handle more routine duties.
• Staff Support. Adequate staff support must be in place for the operations of units or departments. For example, a nursing unit might need administrative staff to handle scheduling, clerical tasks, and patient records . This support allows nurses to dedicate more time to patient care rather than administrative duties.
• Historical Information. Reviewing historical data on quality and staff perceptions regarding the effectiveness of previous staffing patterns is crucial. For example, a hospital may analyze past staffing patterns during peak flu seasons to determine the optimal number of nurses required to maintain patient care standards. This historical review helps in planning and adjusting staffing levels to meet future demands more effectively.

The term Patient Classification Systems refers to measurement systems in nursing that reflect actual patient care needs for staffing purposes. These systems, also known as Acuity Systems, are used to articulate the nursing workload for specific patients or groups of patients over a defined period. While “Acuity” typically denotes the unidimensional severity of illness in a medical context, the nursing community prefers the broader term “Patient Classification” to encompass the bio-psycho-social-spiritual aspects of patient care. For this discussion, the term Patient Classification/Acuity System is used.

Patient Care Classification

Patients are classified into different categories based on their care needs:

• Self-Care or Minimal Care . These patients are capable of performing activities of daily living (ADLs) independently, such as hygiene and meals. They require minimal assistance from the nursing staff.
• Intermediate or Moderate Care . Patients in this category require some assistance from the nursing staff for special treatments or specific aspects of personal care. Examples include patients with IV fluids , catheters, or on respirators.
• Total Care . These patients are bedridden and lack the strength or mobility to perform ADLs. They require comprehensive nursing care. Examples include patients on complete bed rest (CBR), those in the immediate post-operative phase, or those with significant mobility restrictions.
• Intensive Care : Intensive care patients are critically ill and in constant danger of death or serious injury . They require continuous monitoring and specialized nursing care. Examples include comatose patients or those with life-threatening conditions who are bedridden.

By classifying patients according to their care needs, the Patient Classification System ensures that nursing resources are appropriately allocated, enhancing patient care and optimizing the nursing workload.

Scheduling is the process of creating a timetable that outlines the planned workdays and shifts for nursing personnel. Effective scheduling takes into account several key factors to ensure that staffing meets patient care needs and maintains staff well-being. Several key factors must be considered to create an optimal schedule that meets both patient needs and staff preferences. The following are some issues to consider in scheduling staff:

• Patient Type and Acuity . Different patients require varying levels of care, significantly impacting how staff is allocated. For example, intensive care unit (ICU) patients need constant monitoring and specialized care, requiring more experienced nurses compared to patients in a general ward.
• Number of Patients . The total patient count directly influences the number of staff needed. A higher patient load requires more nursing staff to ensure each patient receives adequate attention and care. For instance, during peak flu season, a hospital might need to increase its nursing staff to handle the influx of patients.
• Experience of Staff . The skill and experience levels of the staff should match the complexity of patient care required. For example, a novice nurse might handle basic patient care tasks, while a more experienced nurse might be assigned to complex cases or critical care units.
• Support Available to the Staff . The availability of support personnel, such as nursing assistants and administrative staff, affects how nursing duties are distributed. For example, having sufficient administrative support can allow nurses to focus more on patient care rather than paperwork.
• Shifting Variations . Different shift patterns are utilized to meet both patient care needs and staff preferences. These variations can help in maintaining a balanced and effective workforce.

To meet the diverse needs of patients and preferences of nursing staff, various traditional shifting patterns are utilized. Each pattern offers unique benefits and challenges, helping to ensure continuous and effective patient care.

• 3 Shift (8-hour shift) . Commonly used to provide 24-hour care, this pattern divides the day into three 8-hour shifts. For instance, one nurse might work from 7 AM to 3 PM, another from 3 PM to 11 PM, and a third from 11 PM to 7 AM.
• 12-hour Shift . This pattern involves longer shifts with fewer workdays, often preferred by nurses who enjoy having more consecutive days off. A nurse might work from 7 AM to 7 PM, providing continuity of care for patients but also requiring adequate rest between shifts to prevent burnout .
• 10-hour Shift . Less common but offers a balance between 8 and 12-hour shifts. This pattern might involve a nurse working from 7 AM to 5 PM, allowing for extended care periods without the intensity of a 12-hour shift.
• Weekend Option . Staff works primarily on weekends, which can be ideal for nurses who prefer or need weekdays off. This option helps in ensuring adequate coverage during weekends when patient admissions might fluctuate.
• Rotating Work Shift . Shifts rotate between day, evening, and night, allowing all staff to experience different times of day. This can help in maintaining a fair distribution of shifts but requires careful management to avoid disruption to staff routines and circadian rhythms.
• Self-Scheduling . Staff members create their own schedules, promoting autonomy and job satisfaction. For example, a nurse might choose to work three consecutive days followed by four days off, allowing flexibility in managing personal commitments.
• Permanent Work Shift . Staff work consistent shifts without rotation, providing stability and predictability. For instance, a nurse might always work the night shift , ensuring they can plan their personal life around a steady work schedule.
• Floaters . Staff who are “on-call” to fill in as needed. Floaters provide critical support during unexpected absences or increased patient loads, ensuring that the unit remains adequately staffed at all times.

Directing is the act of issuing orders, assignments, and instructions to achieve organizational goals and objectives. It involves guiding and supervising staff to ensure effective performance.

The following are the elements of directing:

• Communication . The exchange of ideas, thoughts, or information through verbal speech, writing, and signals.
• Delegation . Assigning responsibility and authority to subordinates.
• Motivation . Encouraging staff to achieve high performance and job satisfaction.
• Coordination :.Harmonizing efforts to ensure efficient operations.
• Evaluation . Assessing performance to provide feedback and improve outcomes.

The following are the common barriers of communication:

• Physical Barriers : Environmental factors that hinder communication, such as distance and noise.
• Social and Psychological Barriers : Judgments, emotions, and social values that obstruct communication, such as stress, trust issues, fear , and defensiveness. These include the internal climate (values, feelings, temperament, and stress levels) and external climate (weather, timing, temperature, and lack of message validation).
• Semantics : Misunderstandings arising from words, figures, symbols, penmanship, and the interpretation of messages through signs and symbols.
• Interpretations : Defects in communication skills, including verbalizing, listening, writing, reading, and using telephony

Delegation involves assigning a portion of work to someone else, along with the corresponding authority, responsibility, and accountability. According to the American Nurses Association (ANA), it is the transfer of responsibilities, but not of accountability, for the performance of a task from one person to another. Much of a manager’s work is accomplished by transferring responsibilities to subordinates.

Managers often delegate routine tasks to free themselves for more complex problems requiring higher levels of expertise. Additionally, delegation is beneficial when someone else is better prepared or has greater expertise in solving specific problems. However, some managers hesitate to delegate due to a lack of trust in others, fear of mistakes, fear of criticism, or doubt about their own ability to delegate effectively. Here are the three common errors involved in delegation:

Under Delegation

Managers may underdelegate due to the false assumption that delegation might be seen as a lack of ability to do the job correctly. For example, a charge nurse might feel that only they can correctly handle patient assessments and may avoid delegating these tasks to other nurses, leading to unnecessary workload and burnout .

Over Delegation

This occurs when subordinates become overburdened, leading to dissatisfaction and low productivity. For instance, a nurse manager who delegates too many tasks to a single nurse, such as patient care duties, administrative tasks, and training responsibilities, can cause that nurse to become overwhelmed and reduce their effectiveness and morale.

Improper Delegation

Delegating tasks to the wrong person, at the wrong time, or tasks beyond the subordinate’s capability can lead to inefficiencies and errors. For example, assigning a newly graduated nurse to handle a critical care patient without adequate supervision can lead to mistakes and compromise patient safety .

Effective delegation involves a systematic approach to ensure tasks are appropriately assigned and executed. Here are the steps to achieve effective delegation:

• Plan Ahead . Anticipate future needs and identify tasks that can be delegated. For instance, a nurse manager can plan to delegate routine check-ups during busy shifts.
• Identify Necessary Skills and Levels . Determine the skills and experience required for the tasks. For example, wound care should be delegated to a nurse with specialized training.
• Select the Most Capable Personnel . Choose individuals who are best suited for the tasks. A senior RN may be chosen to oversee the orientation of new nurses.
• Communicate Goals Clearly . Ensure that the delegate understands the objectives and expectations. For instance, clearly explain the expected outcomes of a patient discharge process.
• Empower the Delegate . Provide the necessary authority and resources for the task. Ensure that the nurse has access to all needed supplies and information.
• Set Deadlines and Monitor Progress . Establish timelines and check in regularly to ensure progress. For example, set a deadline for completing patient assessments and follow up to track progress.
• Model the Role and Provide Guidance . Demonstrate how to perform the task and offer support as needed. Show a nurse how to use new medical equipment and be available for questions.
• Evaluate Performance . Assess the delegate’s performance and provide feedback for improvement. After delegating a task, review the outcomes and discuss areas for improvement.

Effective nursing management and delegation involves several key concepts that ensure high-quality patient care and efficient team operations. Here are three essential concepts:

Motivation influences our choices and drives the direction, intensity, and persistence of our behavior. In nursing, motivation can come from personal fulfillment, professional recognition, and the desire to provide excellent patient care. For example, nurses might be motivated by positive patient outcomes or career advancement opportunities.

Supervision

Supervision entails guiding and directing work, motivating staff, and encouraging participation in activities that meet organizational goals while fostering personal development. Effective supervision in nursing includes regular check-ins, feedback, and professional growth opportunities. For instance, nurse managers might hold weekly meetings to discuss challenges, celebrate successes, and provide training on new protocols.

Coordination

Coordination involves arranging activities to create harmony and facilitate success. In nursing, effective coordination ensures team members work together efficiently to provide optimal patient care. This includes coordinating schedules, assigning tasks based on expertise, and ensuring clear communication.

Conflict Management

Conflict arises from internal and external discord due to differences in ideas, values, or feelings between two or more people. It often stems from economic and professional value differences and can significantly impact workplace harmony and productivity. Conflict can either be competitive or disruptive:

• Competitive Conflict. This occurs when two or more groups vie for the same goal, but only one can attain it. Management typically sets these goals, leading to a competitive environment where each group strives to outperform the others.
• Disruptive Conflict. This type of conflict happens in environments filled with anger, fear, and stress. There are no mutually acceptable rules, and each party’s goal is to eliminate the opponent. This destructive form of conflict can severely hinder cooperation and productivity.

Effective conflict management involves employing various strategies to address and resolve conflicts constructively in the nursing field. Here are some common approaches:

• Use of Dominance and Suppression . This win-lose strategy involves one party imposing their will on the other, often leading to anger and resentment. For example, a head nurse might unilaterally decide on a new scheduling system without consulting the staff, leading to dissatisfaction and resistance.
• Smoothing Behavior. This strategy involves persuading the opponent diplomatically to maintain harmony and avoid confrontation. For example, a nurse manager might smooth over a conflict between two nurses by diplomatically discussing their concerns and finding a temporary compromise to ease tensions.
• Avoidance Behavior. Both parties are aware of the conflict but choose not to acknowledge or resolve it. For example, two nurses who have a personal disagreement might avoid discussing it, which can lead to unresolved issues affecting teamwork and patient care.
• Majority Rule. This approach relies on a unanimous decision-making process. For instance, when deciding on a new policy, the nursing team might vote on the options, with the majority’s decision being implemented.
• Compromising. This consensus strategy involves each side agreeing to solutions that partially satisfy both parties, aiming for a middle ground. For example, a nurse manager might compromise on shift preferences to balance the needs of the staff and the unit.
• Interactive Problem-Solving. A constructive process where the parties involved recognize the conflict, assist each other, and openly work together to solve the problems. For example, a nursing team might hold a meeting to discuss and collaboratively find solutions to recurring staffing issues.
• Win-Win Strategy. This strategy focuses on goals and attempts to meet the needs of both parties, fostering cooperation and mutual satisfaction. For example, a head nurse and a staff nurse might work together to develop a new patient care protocol that improves efficiency and meets both management and frontline needs.
• Lose-Lose Strategy. In this approach, neither side wins, often leading to a situation where both parties are dissatisfied. For example, if a nurse manager enforces a policy change that neither the administration nor the nursing staff fully support, it may result in widespread dissatisfaction.
• Confrontation. Considered the most effective means of resolving conflict, confrontation involves addressing the issue openly with knowledge and reason, seeking a solution through direct communication. For example, a nurse manager might directly address a conflict between two staff members by facilitating a mediated discussion to resolve their differences.
• Negotiation. This “give and take” process involves both sides making concessions to reach an agreement that satisfies both parties to some extent. For instance, during a staff meeting, nurses and management might negotiate shift schedules to balance personal preferences and unit needs.

Effective nursing management integrates crucial concepts to create a well-functioning healthcare environment . By organizing tasks and defining roles, clarity and efficiency are ensured. Delegation allows managers to focus on complex issues while empowering staff. Motivation, supervision, and coordination are vital for maintaining high performance and smooth operations. Conflict management strategies, including competitive and disruptive conflict resolution, ensure disputes are handled constructively, fostering a positive work atmosphere. By applying these principles, nursing managers can create a supportive and efficient workplace, leading to improved patient outcomes and higher staff satisfaction.

12 thoughts on “Nursing Management: Guide to Organizing, Staffing, Scheduling, Directing and Delegating”

nice article :)

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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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7 Main Ethical Principles in Nursing + Why They’re Important

Are you a nurse with a genuine desire to give the best care possible to patients and their families and to become a strong member of your nursing team? Maybe you are a nursing student eager to learn as much as possible to help you succeed in nursing. If so, the most important lesson you can learn is how to establish ethical nursing practices. There are several ways to demonstrate strong ethics, and knowing the main ethical principles of nursing is a great place to start. Perhaps you are wondering, "What are the 7 main ethical principles in nursing, and why they are important?” In this article, you will learn about ethical nursing principles and how they apply to you. As you continue reading, you will find an in-depth look at the 7 main ethical principles in nursing, why they’re important, and examples of how they are applied in the four main areas of nursing.

What Exactly is an Ethical Principle in Nursing?

What is the source of ethical principles in nursing, 7 reasons why ethical principles are so important in nursing, how many ethical principles are there in nursing.

1. Accountability 2. Justice 3. Nonmaleficence 4. Autonomy 5. Beneficence 6. Fidelity 7. Veracity

Are There any Conflicting Ethical Principles in Nursing?

What are the 7 main ethical principles in nursing and why they are important.

5 Most Common Challenges You Will Face While Applying the 7 Ethical Principles in Nursing and How to Overcome Them

Challenge #1: knowing where to draw the line between autonomy and beneficence, what is it:, how to overcome:, challenge #2: deciding whether to withhold information or be honest about a patient’s status or prognosis, challenge #3: supporting autonomy related to informed consent, challenge #4: keeping promises when your circumstances change, challenge #5: determining if nonmaleficence overrules a patient’s right to privacy, my final thoughts.

8 steps for making effective nurse-patient assignments

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

Takeaways:  

• Making nurse-patient assignments is challenging but rewarding. 
• Nurse-patient assignments are created based on knowledge and understanding of nursing unit environment, nurse qualities, and patient characteristics. 
• Clinical nurses are vital resources for critical changes in patient status. 
• Nurse-patient assignments should be frequently reassessed and changed as needed to ensure continuous, safe, quality nursing care.

By Stephanie B. Allen, PhD, RN, NE-BC

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What is the Nursing Code of Ethics?

• 4 Ethical Principles in Nursing

Nursing Code of Ethics Interpretive Statements

Making ethical decisions as a nurse, history of the nursing code of ethics, how nurses use the nursing code of ethics.

According to the American Nurses Association (ANA) , the nursing code of ethics is a guide for “carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.”

Ethics, in general, are the moral principles that dictate how a person will conduct themselves. Ethical values are essential for ALL healthcare workers, but ethical principles in nursing are particularly important given their role as caregivers.

There are 4 main principles of the nursing code of ethics:

• Beneficence
• Non-maleficence

These principles are ideally what every nurse should be aware of in their daily nursing practice. While ethical principles are sometimes confusing and often taught briefly during undergraduate nursing -- they should be constants in nursing practice in order to provide the best, safest, and most humane care to all patients.

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4 Ethical Principles in Nursing 

1. autonomy .

Autonomy in nursing is recognizing each individual patient’s right to self-determination and decision-making. As patient advocates, it is imperative that nurses ensure that patients receive all medical information, education, and options in order to choose the option that is best for them. This includes all potential risks, benefits, and complications to make well-informed decisions. 

Once the patient has all the relevant information, the medical and nursing team can make a plan of care in compliance with the medical wishes of the patient. 

It is important that nurses support the patient in their medical wishes and ensure that the medical team is remembering those wishes. Sometimes, nurses will need to continue to advocate for a patient despite the wishes being verbalized because the medical team might not agree with those wishes.

Many factors may influence a patient's acceptance or refusal of medical treatment, such as culture, age, gender, sexual orientation, general health, and social support system.

2. Beneficence

Beneficence in nursing is acting for the good and welfare of others and including such attributes as kindness and charity. The American Nurses Association defines this as “actions guided by compassion.”

Justice is that there should be an element of fairness in all medical and nursing decisions and care. Nurses must care for all patients with the same level of fairness despite the individual's financial abilities, race, religion, gender, and/or sexual orientation. 

An example of this is when working at a free flu clinic or diabetes screening clinic. These are open to all individuals in the community regardless of the previously mentioned factors.

4. Nonmaleficence 

Nonmaleficence is to do no harm. This is the most well-known of the main principles of nursing ethics. More specifically, it is selecting interventions and care that will cause the least amount of harm to achieve a beneficial outcome

The principle of nonmaleficence ensures the safety of the patient and community in all care delivery. Nurses are also responsible for reporting treatment options that are causing significant harm to a patient, which may include suicidal or homicidal ideations. 

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Revised in 2015 to include 9 provisions, the ANA’s nursing code of ethics now includes interpretative statements that can provide more specific guidance for nursing practice.

9 Provisions of the Nursing Code of Ethics 

Currently, the nurse’s code of ethics contains 9 main provisions:

• The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
• The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
• The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
• The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.
• The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
• The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
• The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
• The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
• The profession of nursing, collectively through its professional organization, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

The nine provisions were implemented to help guide nurses in ethical decision-making throughout their practice. 

Unfortunately, nurses are often unable to make complex ethical decisions based solely on the four principles and nine provisions. In these instances, it is important to consult the ethics committee before making any major decisions. Often, other resources are needed when making major ethical decisions.

Interestingly, the nursing code of ethics is suggested to have been founded in 1893 and named the “Nightingale Pledge” after Florence Nightingale , the founder of modern nursing. As a modification of the Hippocratic Oath, taken by medical doctors, the Nightingale Pledge has been recited by nursing students at graduations with little changes since inception. 

The formal code of ethics was developed in the 1950s by the American Nurses Association (ANA) and has undergone numerous modifications since. The most significant recent change was in 2015 when 9 interpretative statements or provisions were added to the code of ethics to help guide nursing practice in a more definitive way. 

Many states include the ANA’s nursing code of ethics in their practice statements. Even though the code of ethics is primarily ethics-related, it also has legal implications. Given the importance of the code to the nursing profession, revisions continue on a regular basis.

Knowing the nursing code of ethics is essential for nurses because it will help guide everyday practice and navigate the daily complexities of the healthcare profession. Nurses often use the four major ethical principles throughout a shift, even if not fully aware of them. 

This may include,

• Providing pain medication to a post-operative hip replacement
• Holding the hand of a dying patient who is alone
• Advocating for the patient that wants to end chemotherapy and enter hospice care

Nursing is consistently regarded as the most honest and ethical profession and practicing with the nursing code of ethics is essential to ensuring that patients and their families receive the care they have come to know and expect. Utilizing the ethical codes of justice, nonmaleficence, autonomy, and beneficence on a daily basis allows nurses to provide the safest and most compassionate care for their patients. 

What are the five codes of ethics in nursing? 

• The 5 nursing ethic codes are: nonmaleficence, beneficence, autonomy, justice, and privacy/confidentiality. 

What is the Professional Code of Ethics for Nurses?

• The Professional Code of Ethics for Nurses is the guiding outline for how nurses should behave ethically within their profession and how they should decide to act if they encounter barriers that prevent them from fulfilling their professional obligations. 

Why is the code of ethics important in nursing? 

• It can guide nurses’ professional behavior, provide a framework for decision-making when faced with challenges, and provide support and help prevent moral distress. 

What is the code of ethics in healthcare? 

• There is not one board ethical code for every healthcare professional, although it has been proposed. Instead, each branch of healthcare, from quality control to medical directors to physicians to nursing, has its own ethical codes. 

What is scholarly ethics in nursing? 

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Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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3.1 Delegation & Supervision Introduction

Learning objectives.

• Explain principles of delegation
• Evaluate the criteria used for delegation
• Apply effective communication techniques when delegating care
• Determine specific barriers to delegation
• Evaluate team members’ performance based on delegation and supervision principles
• Incorporate principles of supervision and evaluation in the delegation process
• Identify scope of practice of the RN, LPN/VN, and unlicensed assistive personnel roles
• Identify tasks that can and cannot be delegated to members of the nursing team

As health care technology continues to advance, clients require increasingly complex nursing care, and as staffing becomes more challenging, health care agencies respond with an evolving variety of nursing and assistive personnel roles and responsibilities to meet these demands. As an RN, you are on the front lines caring for ill or injured clients and their families, advocating for clients’ rights, creating nursing care plans, educating clients on how to self-manage their health, and providing leadership throughout the complex health care system. Delivering safe, effective, quality client care requires the RN to coordinate care by the nursing team as tasks are assigned, delegated, and supervised. Nursing team members include advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and unlicensed assistive personnel (UAP). [1]

Unlicensed assistive personnel (UAP)  are any assistive personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes, but is not limited to, certified nursing assistants or aides (CNAs), patient-care technicians (PCTs), certified medical assistants (CMAs), certified medication aides, and home health aides. [2] Making assignments, delegating tasks, and supervising delegatees are essential components of the RN role and can also provide the RN more time to focus on the complex needs of clients. For example, an RN may delegate to UAP the attainment of vital signs for clients who are stable, thus providing the nurse more time to closely monitor the effectiveness of interventions in maintaining complex clients’ hemodynamics, thermoregulation, and oxygenation. Collaboration among the nursing care team members allows for the delivery of optimal care as various skill sets are implemented to care for the client.

Properly assigning and delegating tasks to nursing team members can promote efficient client care. However, inappropriate assignments or delegation can compromise client safety and produce unsatisfactory client outcomes that may result in legal issues. How does the RN know what tasks can be assigned or delegated to nursing team members and assistive personnel? What steps should the RN follow when determining if care can be delegated? After assignments and delegations are established, what is the role and responsibility of the RN in supervising client care? This chapter will explore and define the fundamental concepts involved in assigning, delegating, and supervising client care according to the most recent joint national delegation guidelines published by the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA). [3]

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation.   https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf ↵
• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵

Advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).

Certified nursing assistants (CNA), client care technicians (PCT), certified medical assistants (CMA), certified medication aides, and home health aides.

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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Why Ethics in Nursing Matters

3 min read • April, 25 2023

Registered nurses routinely encounter issues that may have ethical implications. Nurses work with patients whose lives may be at stake. It’s a nurse’s job to follow protocol and best practices while treating the patient as an individual with their own wishes and preferences for care. These decisions may warrant discussion with the larger care team, or they may require swift action in a moment of crisis. Understanding ethics and the consequences of their actions can help a nurse make the best decision when it isn’t always apparent.

What Is the Nursing Code of Ethics?

The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (Code of Ethics) has been a guide and reference for registered nurses since its development in the 1950s. It serves as a moral compass to promote high levels of care, an ethical standard for those entering the nursing profession, and a commitment to society affirming the responsibilities of the registered nurse.

The Code of Ethics has been revised over time to reflect technological advances, societal changes, and the expansion of the nursing practice. Every day, nurses draw upon ethical nursing principles to make patient care decisions. That’s one reason that for over two decades, nurses have led Gallup’s annual ranking of professions for high honesty and ethics.

Four Ethical Principles in Nursing

The Code’s provisions require that a registered nurse advocate for patients by providing safe care with compassion and a commitment to the patient’s primary interest. Ethical principles of nursing include looking beyond the bedside to individual self-regard and human rights while striving to maintain health care advancement and social justice.

Developing an ethical awareness can ensure quality care. Nursing ethical principles can be broadly categorized into four major ethical nursing principles:

• Autonomy : The right to self-determination. Autonomy in nursing means providing adequate information to allow patients to make their own decisions based on their beliefs and values, even if they aren’t the ones the nurse chooses. Autonomy also relates to only providing nursing care within the scope of practice defined by state and organizational rules. Examples of autonomy in nursing include administering PRN medications or assigning nursing duties based on levels of competence.
• Beneficence : The promotion of good. Beneficence in nursing relates to ensuring that the patient's best interest is considered, regardless of the nurse's personal opinion. Examples of beneficence in nursing include providing comfort to a dying patient or assisting with tasks a patient cannot perform independently.
• Justice : Fairness or an equal distribution of benefits. Justice in nursing relates to impartiality regarding a patient's age, ethnicity, economic status, religion, or sexual orientation. Examples of justice in nursing include impartiality when assigning clinical or prioritizing patient care.
• Nonmaleficence : The avoidance or minimization of harm. Nonmaleficence in nursing requires the provision of safe, effective, high-quality care. Examples of nonmaleficence in nursing include holding a medication due to adverse reactions or taking steps to ensure a safe work environment.

Ethical Decision Making in Nursing

A health care organization’s support of ethical principles unifies its nursing practices and settings. Registered nurses are trusted with a range of responsibilities in various roles in clinical practice, education, leadership , or research. The nurse may be required to make decisions beneficial to the patient, nursing student, employee, or organization.

If a nursing action ignores a patient's preference or conflicts with ethical principles, the registered nurse may be acting unethically. Emphasizing ethical principles in nursing will increase decision-making confidence across any nursing practice. Performing nursing care according to the Code of Ethics may require the registered nurse to risk adverse personal outcomes such as employer or peer backlash, but it ensures that the focus remains on the patient. Registered nurses are faced with difficult decisions each day that may affect the lives of others. A foundation based in ethics helps ensure those decisions are the best route forward.

Trust in the nursing profession by individuals and society isn’t to be taken lightly. Increasing ethical awareness in nursing can help ensure that the nursing profession maintains that trust, supports nursing colleagues, and continues to develop the future of nursing.

Explore our continuing education materials on ethics and nursing including articles, books, webinars and the Code of Ethics.

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The Nurse-Patient Assignment: Purposes and Decision Factors

Affiliation.

• 1 Author Affiliation: Assistant Professor, Pace University, Pleasantville, New York.
• PMID: 26565641
• DOI: 10.1097/NNA.0000000000000276

Objective: Identify purposes and decision factors of the nurse-patient assignment process.

Background: Nurse-patient assignments can positively impact patient, nurse, and environmental outcomes.

Methods: This was an exploratory study involving interviews with 14 charge nurses from 11 different nursing units in 1 community hospital.

Results: Charge nurses identified 14 purposes and 17 decision factors of the nurse-patient assignment process.

Conclusions: The nurse-patient assignment is a complex process driven by the patient, nurse, and environment. Further study is needed to identify factors linked to patient safety, nurse, and environmental outcomes.

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.

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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.
• PDF version of this title (216M)

In this Page

• NURSING PROCESS INTRODUCTION
• BASIC CONCEPTS
• OUTCOME IDENTIFICATION
• IMPLEMENTATION OF INTERVENTIONS
• SUMMARY OF THE NURSING PROCESS
• LEARNING ACTIVITIES

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