Nursing Process

UNIT 1 NURSING PROCESS

Structure

1.0 Objectives
1.1 Introduction
1.2 Concept of Nursing Process
1.2.1 Definition
1.2.2 Phases of Nursing Process
1.2.3 Purposes/Uses
1.2.4 Characteristics
1.2.5 Factors Affecting Nursing Process
1.3 Assessment
1.3.1 Data Collection
1.3.2 Documentation
1.4 Nursing Diagnosis
1.4.1 Definitions and Meaning
1.4.2 Data Processing/Diagnostic Process
1.4.3 Parts of the Diagnostic Statement
1.4.4 Writing the Diagnostic Statement
1.4.5 Verification of the Diagnosis
1.4.6 Documentation
1.5 Planning
1.5.1 Setting Priorities
1.5.2 Writing Outcomes
1.5.3 Nursing Orders
1.5.4 Documentation
1.6 Implementation
1.6.1 Planning or Preparation
1.6.2 Intervention of Nursing Actions
1.6.3 Documentation
1.7 Evaluation
1.7.1 Gathering Data about Client’s Health Status
1.7.2 Making Judgements about Progress
1.7.3 Decumentation
1.8 Let Us Sum Up
1.9 Key Words
1.10 Answers to Check Your Progress
1.11 Further Readings

1.0 OBJECTIVES
 After going through this unit, you will be able to:
 define nursing process;
 state the purposes;
 list the characteristics; 161
Quality Nursing Practices  write the implications;
 discuss the factors affecting nursing process;
 explain with examples the phases of nursing assessment, nursing diagnosis,
planning care, implementation and evaluation of care; and
 describe the documentation process in each phase .

1.1 INTRODUCTION
“Let no women suppose that obedience to doctors is not absolsutely essential.”
“Not to let the physician make himself the head nurse.”
Notes on Nursing: Florence Nightingale
Practice of nursing is caring which is directed by the way the nurses view the
client, the client’s environment, health and the purpose of nursing. To nurses the
nursing process provides a useful description of how nursing should be performed.
As nurses remain in constant interaction with their clients, professional colleagues,
medical and health care team members, they have the best opportunity to assess
the patient’s needs and provide evidence based care.
In this unit you will learn the science of nursing that explains about nursing
process, concept, purposes, implications of nursing process and its phases in
detail.
The nursing process was first described by Hall in 1955 as a three step process.
In 1967, Yura and Walsh added assessment to the three steps and described a four
phase process. In the mid-1970s an addition of diagnostic phase resulted into a
five step process. After 1980 the nursing process was added to the General Nursing
Curriculm in India.
In this unit you will learn the five phases of nursing process widely accepted and
practiced by nurses all over the globe in various clinical settings. The steps of
each process are explained.

1.2 CONCEPT OF NURSING PROCESS

Nursing is perceived to be both as science and an art. In Nursing we use integrated
skills of biomedical, social and behavioural sciences for the care of the client.
Therefore, nurses require knowledge and understanding of the principles of the
disciplines from where it adopts and forms its base. The nursing is described in
two ways: descriptive - the way the nursing actually happens and as normative -
the way the nursing should be performed.
Traditionally nurses have focused on the needs namely comfort and sleep,
nutrition, elimination, safety etc. to look after the patient as a whole. With changing
times and also with advancement the design of nursing practice also changed. In
the early 1970s nurses recognised the interaction between the various principles
and the use of thinking logical process in planning nursing care.
You have read in Unit 6 of Block 1 about the development of nursing theories
and various Models of Nursing. The basic concepts were Nursing, Person,
162 Environment, and Health. The interrelationship between these elements
established the foundation of professional nursing. The method by which the Nursing Process
integrated knowledge is used to meet the needs of the client is given the name of
Nursing Process. Nursing process evloved as a means to apply the various theories
and models of nursing into nursing practice. The nursing practice is guided by
holistic model that reflects the interrelationship of body- mind-spirit in order to
maintaining, regaining, and promoting health.
In the year 1979, the American Nurses Association (ANA) defined nursing as
“the diagnosis and treatment of human responses to actual or potential health
problems.”
The two words of nursing process are significant Nursing and Process. Let us
review what is Nursing and what is process to understand the combination of the
two words.
Nursing
The description of nursing in all the definitions involves caring the clients during
times of illness and assisting the client. to achieve maximum health potential
throughout the life cycle.
Process
Process is a series of rational thoughts, decisions and acts to achieve a goal. It
implies a movement which has beginning, middle and an ending.

1.2.1 Definition
Nursing Process (NP) is defined as a systematic, continuous and dynamic method
of providing care to clients. It comprises series of sequential phases built upon
the preceding step. Each phase logically leads to the next. As one step leads to
the next step it results into ultimate achievement of mutually determined nursing
outcomes/goals.

1.2.2 Phases of Nursing Process

The five phases of nursing process are given below:
 Assessment involves collection of information or details about the client
from different sources, e.g., observation, interview, physical examination
clinical examination and reviewing records.
 Nursing diagnosis is analysing the information collected to draw conclusions
to identify the clients problems. Information collected to draw conclusions
or to identify the client’s problem(s).
 Planning is development of strategies to alleviate client’s problem identified
in nursing diagnosis through a series of steps.
 Implementation is starting and completing the strategies planned with help
of client, family members and health care team members.
 Evluation is assessment of strategies planned to alleviate the clients’ suffering
or otherwise replan and revise the care.
It is for the purpose of explaining the phases of nursing process that each phase is
taken up separately, but all the steps are interrelated as you see in the Fig. 1.1
below. 163
Quality Nursing Practices

Fig. 1.1: The Nursing Process

Fig. 1.1 illustrates the phases showing overlapping between each step to explain
the relationship between the phases. Assessment is always the first and evaluation
the last phase. Assessment is continuous with other phases and is simultaneously
used with other steps. There is alwlays progression from one phase to another in
a cyclic manner. Evaluation gives feedback to all other phases during each phase
or at the end of implementation phase. Evaluation helps to reassess, revise
diagnosis, replan and implement the revised strategies. The success of achieving
the goal lies in careful progression from each phase of nursing process to the
next.
Each phase of nursing process is explained in detail under sections 1.3 to 1.7 of
this unit.

1.2.3 Purposes/Uses
The nursing process provides a framework within which:
 Nurses can identify client’s health status, and within which the individualised
needs of the client, family and community can be met. Meeting the needs of
the client can either be to achieve a level of optimal wellness or to contribute
to his quality of life through maximising his resources.
 It avoids unnecessary nursing actions. Although the phases are used
concurrently, the process uses an organised approach and client’s problems
are removed on the basis of the assessment.
 It makes client and family feel important and participative in whole process
of the care.
 The nursing process is theoretically based and therefore uses the principles
of biosciences, nursing and allied sciences i.e., behavioural, social sciences.
 It is a time saving device even though it takes time in the beginning.

1.2.4 Characteristics
The following characteristics describe the nature and vastness of the nursing
process:
Dynamic and Cyclic
The dynamic nature involves continuous assessment and evaluation of changing
164 client’s responses to nursing interventions so as to achieve the outcomes. Back
and forth movement between the phases ensures quality care. Thus there is no Nursing Process
absolute beginning or end.
Client-centered
The plan of care is organised in terms of client problems rather than nursing
goals. The nurse-client relationship is shaped around the needs of the client.
Clients are encouraged to the extent that they are able to exercise control over
their health and to make decisions about their case.
Planned and Goal-directed
Inverventions are considered according to the nursing diagnoses and are based
on scientific principles rather than tradition. The nursing orders are chosen for
the purpose of achieving client goals.
Universally Applicable
Nursing process can be used with clients of any age, with any medical diagnosis,
and at any point on the wellness-illness continuum. It is useful in any setting
(e.g. school, clinic, hospitals, homes, industries) and across specialities (e.g.,
hospice nursing, maternity nursing, pediatric nursing etc.)
Problem-oriented
Care plans are organised according to client’s problems. Interventions are carried
out to eliminate the problems related to any aspect of an individual. When
problems cannot be eliminated, the nurse relieves them to the degree possible,
supports the client’s strengths in coping with the problem, and helps clients to
understand and find meaning in their situation.
Cognitive Process
Nursing process involves the use of intellectual skills in making judgements,
decisions and eliminating client’s problems. By way of critical thinking the nurse
applies nursing knowledge systematically and logically to collect data that are
meaningful and use the data to plan ‘appropriate care.

1.2.5 Factors Affecting Nursing Process

Nurses knowledge, beliefs and technical skills are some factors that affect the
phases of nursing process. How these factors affect the phase of nursing process
is explained below.
Knowledge
Nursing process is the application of the nurses knowledge. Nurse has a knowledge
base from both physical, biological and behavioural sciences. As part of her/his
academic preparation nurse learns basic concepts of biochemistry, biophysics,
microbiology, anatomy, physiology, psychology, sociology, nutrition. The
knowledge of these sciences enables the nurse to recognise the problem more
clearly and also determine how the client’s health is getting disturbed. By virtue
of the knowledge of the nurse she/he is able to understand the interrelationship
between client’s health, her/his health problem and her/his environment.
When a client has been brought in a critical condition the nurse can be flexible to
select the right timing to collect health history as the nurse knows the demand of
the situation. In such a situation she proceeds to the next phases of nursing process, 165
Quality Nursing Practices coordinate with other departments to provide treatment strategies planned for
the client.
Skills
Nurse uses technical and interpersonal skills to collect information about the
client. The effectiveness of the nursing process depends on the intellectual
(cognitive) skills of the nurse that she uses in creative and critical thinking, and
decision making.
Technical skills are specific nursing skills performed to assess client’s health status
e.g. using thermometers, sphygmomanometer to measure blood pressure, performing
procedures i.e., taking pulse, listening to the respiratory, heart, bowel sounds.
Interpersonal skills help establish relationship between nurse, client, family and
health care team. The nurse through use of communication skills determine client’s
problem, help the client perceive actual or potential problem, prioritise problem,
mutually sets goals to be achieved.
Beliefs
The nurse’s personal belief about nursing, health, the client as an individual, as a
health care consumer forms the basis of nursing practice e.g. when a patient with
AIDS with an attempt to commit suicide is admitted in the ward, the care of such
a client gets affected by nurses personal beliefs that client with HIV infection
should not be admitted in general ward. The nurse is also faced with a moral and
ethical dilemma of providing care to such a client and his family members. If
‘the client wishes to get discharge from hospital to stay at home with his family
then the nurse’s belief that the goal of nursing care is to help the client to be in a
state of comfort, free from infection, and so on. Therefore, the nurse teaches the
family on prevention of infection and suggests referral to hospice centre. She
also respects the client’s right to make decision about himself.

Check Your Progress 1

2) Define the following:
a) Nursing as defined by ANA
..............................................................................................................
..............................................................................................................
b) Nursing Process
..............................................................................................................
..............................................................................................................
c) Assessment
..............................................................................................................
..............................................................................................................
d) Implementation
.............................................................................................................
.............................................................................................................
166
 Nursing Process
e) Evaluation
..............................................................................................................
..............................................................................................................
2) List the factors affecting Nursing Process.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
3) List the purposes of Nursing Process.
a) ............................................................................................................
b) .............................................................................................................
4) List the characteristics of the Nursing Process.
a) ............................................................................................................
b) ............................................................................................................
c) ............................................................................................................
d) ............................................................................................................
e) ............................................................................................................
f) ............................................................................................................

1.3 ASSESSMENT
Assessment is the foundation step of nursing process. It consists of systematic
and orderly collection of information pertaining to and about the health status of
the client. The information obtained helps to make nursing diagnoses and to
develop a plan of care.
The two components of assessment phase are Data Collection and
Documentation.

1.3.1 Data Collection

Data collection includes accumulation of comprehensive information about the
client on initial assessment. The initial assessment provides baseline data. The
data involves information about client’s health problem, specific factors that
contribute to the problem. The client has health problem(s) with which s/he gets
admitted and may also develop additional problem during her/his stay in the
hospital because of the course of illness, and the treatment modalities. As is
illustrated in Fig. 1.1 assessment is an ongoing process. The assessment during
other phases allows the nurse to compare the initial information to subsequent
data to bring about change in diagnosis and plan of care, if any.
The gathering of information about the client’s well-being status includes:
 strengths as well as weaknesses of patient, 167
Quality Nursing Practices  response of patient to his health concerns,
 analysis of the circumstances associated with patient’s well-being status,
 knowledge related to health and well-being,
 beliefs and values about health,
 life-style,
 health-related goals, and
 support system.
The nurse views the client as a whole person and views nursing as collaborative
with other health care professions and providers.
Types of Data
Data collected by the nurse is
a) Subjective
b) Objective
OR
c) Historical
d) Current
c) Subjective data includes client’s description of his personal health status,
problem e.g., feeling, description of pain, weakness, nausea. The data are
not observable and are difficult to measure objectivity. This data also include
information supplied by client’s family members, friends, other members of
the health team.
b) Objective data are usually the one that is obtained through senses - sight,
smell, hearing, touch and during the physical examination of the client.
Objective data are observable and measurable. For example, rate of pulse,
weight, B.P., presence of oedema, Head to foot examination, etc. The data
collected by nurse can be historical data and/or current data.
The data may be classified as historical and current data.
a) Historical data refers to the information related to the events that have
occurred prior to the present. The event might be previous hospitalisation,
presence of chronic disease, pattern of bowel movement in the past, childhood
illness in an adult patient. This is usually obtained from record & reports.
b) Current data refer to the events that are occurring at present e.g., pain,
vomiting, inability to pass urine, present illness. This is usually obtained
from the information provided by the clients.
It is always necessary to validate subjective with objective data, historical with
current data e.g. subjective data of feeling of pain is validated by objective findings
of facial expression, increased sweating and hypotension. Similarly, historical
data e.g., passing stool once every day and bowels not moved for two days (current)
may initiate a strategy to help patient move his bowels. But when substantiated
with historical data the client may inform that movement of bowel on every alteranate
day is his routine at home. Thus the information obtained earlier becomes invalid.
168 Therefore, validation of the data is necessary before planning care.
To complete the data all types of data should be collected. Nursing Process

Check Your Progress 2

Read the following statements and put a tick mark (3) in the appropriate column
against each statement.
Data Statement Objective Subjective
a) “I feel tired today”
b) “She seems nervous”
c) Dirt under nails
d) Respiratory rate 24 per minute
e) Absent bowel sounds
f) Injury mark on right cheek
g) Pain in knee joint
h) Respiratory stidor present
Data Statement Historical Current
a) Warm dry skin
b) No prior surgery
c) Smoked 20 cigarettes a day
d) One episode of acute abdominal
pain 3 months back
e) Weight 4 kg.
f) “I am allergic to egg”
g) Temperature 38.5o C
h) Hospitalised with head injury
about one year back

Sources of Data
Data are collected from two sources primary and secondary.
a) Primary
The client is the only primary source to collect subjective data. The client not
only provides personal information related to health and illness, identify goals or
problems but also helps to evaluate the subsequent phases of nursing process.
b) Secondary
Sources other than the client used to collect information are secondary sources.
These sources are used for additional information and in situations when client
is not able to give history e.g., an unconscious client. The secondary sources
include client’s family members, friends, relatives, colleagues, individuals in the
client’s immediate hospital environment e.g., other client’s visitors, and other 169
Quality Nursing Practices members of the health team. Medical records are also secondary sources to provide
information about the client. This information also relates to diagnostic tests,
laboratory and radiological findings. The information documented by other health
team members.
Nurse must exercise restraint to get information about which the client might
like to keep silence e.g., drinking behaviour, sexual life of client. An attempt to
obtain such information privacy of the client can be maintained and using her
(nurse’s) interpersonal skills tactfully such sensitive information should be
obtained.
Methods of Data Collection
The three major methods used to gather information are interview, observation
and physical examination. The data gathered helps to make nursing diagnosis
and plan of care.
a) Interview
The client interview is conducted to gather specific information about the client.
The purposes of interview in this phase of assessment are:
 To collect specific information required for diagnosis and planning.
 To establish a trusting nurse-client relationship.
 The allow the client to participate in identification of problems and goal
setting.
 The assist nurse to determine areas for specific investigation during the process
of assessment.
 To assist nurse to gain insight into client’s ability to function, severity of his
illness and his behaviour.
b) Observation
Observation is a method of data collection through the conscious use of senses -
sight, smell, hearing and feeling (touch).
Observation is a skill that requires practice. Through the use of senses the nurse
collects data about client, his family and his environment. Through observation,
nurse can also understand the interaction between the client and the environment.
Each observation finding requires further investigation to confirm the impression.
c) Physical Examination
Substantial data are also obtained by physical examination of the client.
Nurse uses physical examination with the following purposes:
 To define the client’s response to the disease process.
 To establish baseline data to evaluate the nursing interventions.
 To compare the efficiency of medical and nursing interventions.
 To substantiate subjective data obtained during interview and other nurse-
170 client interation.
Physical examination includes various techniques such as inspection, palpitation, Nursing Process
percussion, auscultation.

Check Your Progress 3

1) List the sources of data collection.
a) .............................................................................................................
b) .............................................................................................................
2) List the methods of data collection.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................

1.3.2 Documentation
The documentation is recording of data accumulated during the assessment. It is
the integral part of all the phases of the nursing process.
The purposes of documentation are:
 To communicate the information to the other members of the health team
and thereby prevent repetition of asking same questions by other personnel.
 To facilitate the delivery of quality client care. The information collected
allows the nurse to develop preliminary nursing diagnoses, outcomes and
nursing interventions, which later on can be updated, clarified to provide
quality’ care.
 To provide a mechanism for the evaluation of individual client care.
 To provide a legal record of the care provided to the client.
 To serve as a source for identification of research topics for-nursing practice.
The documentation of nursing assessment includes information about factors
affecting clients’ health status, ability to function, the findings of observation,
interview and physical examination and functional health patterns. The
information helps to identify nursing interventions.
Guidelines for Documentation for a Nurse
 Make entries very objectively without personal opinion, biases. Use quotation
marks to clearly identify the statements e.g. client’s description of illness: “I
have a lump in the abdomen and have come to get it operated”.
 Support description or interpretations of objective data by specific observation
e.g. nurse interprets excessive crying (subjective data) as moderate
hypothermia in a baby.
Objective data: Baby looking pale, skin mottled, skin temperature 35o C.
Nurse’s interpretation is supported with objective information about the baby.
 Avoid using generalised terms e.g., “good”, “fair”, “normal”. These
descriptions are subjective in nature. What is “good” for one person may 171
Quality Nursing Practices mean “fair” to another e.g. instead of writing bowel pattern normal, record
“bowels movement present without the use of laxatives.”
 Avoid using superfluous information in absence of records e.g. “The child
had swallowed kerosene, one year back and was taken to nursing home,
there the child was kept in ICU and discharged after one week.”
This information can be written as “History of kerosene poisoning one year
back, treated in private agency and discharged after one week.”
 Record the findings with description like size and shape e.g. description of
wound will include information related to colour, size, location, drainage etc.
These kinds of descriptions are important to evaluate the effectiveness of
nursing intervention at a later date.
 Write legibly and correct any errors by drawing a line so that the original
entry is also readable e.g. Pain chronic
 Use correct language and spelling.
 Use standard & Universal abbreviations.
Computers and Nursing Assessment
In today’s state-of-the-art information technology computers provide on-line
connectivity with instant display of Electronic Patient Record (EPR). Computers
can be used in almost all phases of nursing process.
Computers can be applied to the use of nursing process to feed assessment data
and information related to subsequent phases.

Check Your Progress 4

1) List the purposes of documentation.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
e) .............................................................................................................
2) List the guidelines that a nurse should follow to document the assessment.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................
e) .............................................................................................................
f) .............................................................................................................
g) .............................................................................................................
h) .............................................................................................................
172
 Nursing Process
1.4 NURSING DIAGNOSIS
1.4.1 Definitions and Meaning
Definitions
There has been different definitions of Nursing diagnosis. Some of the definitions
are given below:
 A Nursing diagnosis is a statement of a patient problem that is arrived at by
making inferences from the collected data (Mundiger and Jauron, 1975),
 American Nurses’ Association has implied nursing diagnosis in the definition
of nursing: Nursing is the diagnosis and treatment of human responses to
actual or potential health problems (ANA, 1980).
 Nursing diagnosis: “A clinical judgement about individual, family, or
community responses to actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection of nursing interventions to
achieve outcome for which the nurse is accountable.” (NANDA, March 1990).
Meaning
The word “diagnosis” is singular and “diagnoses” is plural. The nursing diagnoses
are involved with human responses to stressors or other factors that adversely
effect achievement of optimum health. Treatment is directed towards causes of
the responses or factors influencing it. One must understand that nursing diagnoses
are different from medical diagnoses. The differences between the nursing and
medical concerns is given in Table 1.1. .

Table 1.1: Comparison of Nursing and Medical Concerns

Nursing Medical

 Diagnose and treat human responses  Diagnose and treat disease

 Care for client  Cure disease
 Holistic-effects on whole individual  Biological and or physical
effects
 Teach clients to do selfcare and  Teach clients about treatments
become more independent in daily for their disease
activities

To enhance the standardization and development of nursing diagnoses, NANDA

created Unitary Person Framework that focuses on the patterns and organisation
of individuals as a way of describing their state of health. Within this framework
the individuals’ health is evaluated by assessing the Nine Human Response
Patterns e.g. communication, knowing, valuing, relating, feeling, moving,
perceiving, exchanging and choosing (refer Annexure I):
Americal Nurses Association (ANA) is jointly working with NANDA to develop
a coding translation of the Nursing diagnoses on Taxonomy I. The efforts are on
to include the Taxonomy I in the World Health Organisation’s International
Classification of Diseases (WHO ICD-10). The accepted list of nursing diagnoses
present in Annexure II is based on eleven Functional Health Pattern given by
Gordon and can also be used selecting the individualised nursing diagnostic label. 173
Quality Nursing Practices Actual Nursing Diagnoses
Actual nursing diagnoses is a problem identified from the client assessment that
represents a pattern of related clues.

1.4.2 Diagnostic Process/Data Processing

The essentials of diagnostic process are:
 Clinical knowledge of the nurse.
 Accurate and complete data base.
 Accurate interpretation.
The information collected about the client’s needs is first processed, and then the
statement of nursing diagnosis is written. It is reminded here that data processing
occur continuously throughout the nursing process. Let us consider the steps of
diagnostic process/data processing. The steps of diagnostic process/data
processing are:
a) Classification — for example, past medical history, family history, history
of cardiovascular
b) Interpretation — includes :
i) identification of significant data e.g. date and time of irregular type of
pain, etc.,
o
ii) comparison with standards or norms e.g. temperature above 100 F, WBC
above 15,000 per cubic millimeter, with red area and discharge is
interpreted as sign of infection,
iii) recognition of pattern of trends e.g.,
 Pattern of pain
 Pattern of fever
 Pattern of drinking leading to sympstoms of withdrawal
(iv) Severity of problem e.g.
 degree of pain (mild, moderate, severe)
 degree of malnutrition
c) Validation : In validation the nurse attempts to verify the accuracy of data
interpretation. Validation can be done by direct interaction with the patient
or from secondary sources. Secondary sources can be records or comparison
with the books.
For example:
Nurse : You seem anxious Mrs. Bhalla?
Client : Yes, I am upset
Nurse : Upset? (reflective statement)
Client : I am worried about my two year old child at home who is having
174 fever. My husband took her to the doctor. He has not yet come
 or called me up to tell me what the doctor found. I am so afraid, Nursing Process
she had pneumonia.
In this situation, the nurse’s interpretation was validated by the presence of anxiety
where the client was actually concered about the welfare of her child. The nurse
validated her inference with the client directly and the use of reflective statement
highlighted the source of anxiety. Therefore, the nurse would use this information
to direct her intervention to assist the client to resolve her fear about the child at
home.

1.4.3 Parts of the Diagnostic Statement

A nursing diagnostic statement consists of two parts: (i) problem of the client
and (ii) the related factor (contributing factor).
i) The Problem
The problem in the statement is as identified by the nurse during the assessment
phase. The nurse needs to consider two areas while identifying the problem.
What is the problem that is inferred by assessment data?
For example:
 Client worried about surgery planned for the next day.
 High glucose level due to lack of knowledge about right selection of food
items.
 Pupil dilated with medicine for eye testing.
 Not able to sleep in changed setting of hospital.
 Feeling of loneliness.
To what degree is the problem present?
A degree of problem can be explained as:
For example:
 Post-operative patient on first day require assistance to brush his teeth.
 A malnourished child is at risk for acquiring infection, hypothermia.
 A nurse observes indifferent behaviour of mother towards the child.
ii) The Related Factor
The related factors are “conditions or circumstances that can cause or contribute
to the development of a diagnosis.”
Examples of related factors are given below:
Environmental – Excessive noise, light, fumes, pollutants.
Psychological – Fear of death, feeling of loneliness, impaired parent-child
bonding.
Socio-cultural – Inability to procure food, lack of support system, lack of
finances, literacy level. 175
Quality Nursing Practices Physiological – Abnormal fluid loss, sensory deficit, loss of skin integrity,
breathing difficulty.
Spiritual – Inability to practice religious rituals, conflict between
religious beliefs and prescribed health regimen.

1.4.4 Writing the Diagnostic Statement

Nurse can determine the problem by considering the list of NANDA nursing
diagnosis. A list of associated nursing diagnoses and contributing factor in
reference to eleven functional health patterns (physical and emotional) is given
in Annexure III. While preparing a nursing care plan the diagnostic statements
as given by NANDA and Gordon can be used. Formulation of a nursing diagnostic
statement is a skill and requires practice. Consider the following guidelines to
formulate nursing diagnostic statements.
There are several ways to state nursing diagnoses. The widely accepted diagnostic
statement is as given by National Conference System (NCS). The NCS suggest
PES of writing the nursing diagnoses.
P stands for the Problem is clear, concise statement of client’s existing or potential
health problem or unhealthful response. The statement of problem provides a
clear indication of what needs to change.
E stands for etiology explaining the factors believed to be related to or contributing
to the health problem. The related factors are the socio-cultural, environmental,
physiological, psychological and spiritual factors.
S refers to the signs and symptoms identified during assessment. These signs and
symptoms form the basis for nursing inferences and subsequent nursing diagnoses.
They are recorded in the database. Let us now read some of the examples.
Example:
Alteration in health maintenance related to lack of knowledge of the effects of
the medicine, smoking, obesity on hypertension.
The nursing diagnosis can also be written as a three-part statement, including
and defining characteristics. The clinical definition of characteristics are the
diagnostic cues that can be used as manifestations of a nursing diagnosis. While
using PES format simply add AMB, followed by the signs and symptoms that
lead you to make the diagnosis. Use the following format:
Problems r/t AMB Symptoms
   
(NANDA tabel) (Related to) According to Maslow (Defining
basic needs characteristics)
   
Self-esteem Being rejected AMB Hypersensitive to criticism
disturbance by husband (Annexure IV) states I do not know, if I
can manage by myself.
Rejects positive feedback
The defining characteristics are obtained from the assessment that identify signs
and symptoms or behaviours representing the diagnostic label. For example,
176 anxiety related to impending cardiac surgery as manifested by (AMB) expressed
feelings of uncertainty, concern about future. You as beginners to implement Nursing Process

nursing diagnoses in the clinical setting should attempt to write three part
statement.
Three part statement helps to link the findings from the clinical assessment to the
diagnosis.
Nurse can determine the problem by considering the list of NANDA nursing
diagnosis given in Annexure I. A list of associated nursing diagnoses and
contributing factor in reference to eleven functional health patterns (physical
and emotional) is given in Annexure II. While preparing a nursing care plan
the diagnostic statements as given by NANDA and Gordon can be used.
Formulation of-a nursing diagnostic statement is a skill and requires practice.
Consider the following guidelines to formulate nursing diagnostic
statements.
First write an actual or high-risk health problem and not an environmental problem.
State environmental factors in the second part e.g.:
Wrong: Excessive environmental stimuli related to monitoring equipment
Right: Sensory perceptual alterations (auditory and visual) related to excessive
environmental stimuli
Do not write several unrelated problems in the first part even though the related
factor of the problem may be the same. Judge the problems as unrelated when
the nursing plan requires separate interventions for each problem e.g.:
Wrong: Anxiety and activity intolerance related to frequent episodes of chest
pain
Right: Activity intolerance related to frequent episodes of chest pain
Right: Anxiety related to frequent episodes of chest pain
Write the diagnostic statement in a manner that both the problem and related
factors refer to different findings e.g.:
Wrong: Self-feeding deficit related to inability to feed self.
Right: Self-feeding deficit related to muscle weakness.
Write the diagnosis in legally advisable terms e.g.:
Wrong: Ineffective airway clearance related to inadequate suction.
Right: Ineffective airway clearance related to effects of sedation.
Write the nursing diagnosis in terms of response rather than the need e.g.:
Wrong: Need for maintenance of nutritional intake.
Right: Altered nutrition (less than body requirements) related to nausea and
vomiting.
The purpose of nursing diagnosis is to keep the planning care focused on problems
that are amenable to nursing interventions. 177
Quality Nursing Practices 1.4.5 Verification of the Diagnosis
The accuracy of nursing diagnosis is verified by the nurse asking the following
questions.
 Is the data base sufficient and accurate?
 Does a pattern exist?
 Is the nursing diagnosis based on nursing knowledge?
 Can the nursing diagnosis be altered by independent nursing actions?

Check Your Progress 5

1) Define Nursing Diagnosis (NANDA 1990).
....................................................................................................................
....................................................................................................................
....................................................................................................................

2) What are the two parts of nursing diagnostic statement? Give example of
each.
a) .............................................................................................................
b) .............................................................................................................

3) List the guidelines for writing a nursing diagnosis.

a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................
e) .............................................................................................................

1.4.4 Documentation
After developing and verifying nursing diagnosis the nurse documents the
statements on the chart and care plan. The statement must also be included on
nurses notes or progress notes, discharge summary and referral forms.
Diagnostic statements are reviewed and revised when it is necessary.
Computer-Assisted Diagnosis (CAD)
Computers are used to organise data collected during assessment phase. Initial
assessment data is entered into the computer. The computer draws up a list of
actual, potential, and possible nursing diagnoses, The diagnosis may be altered
to individualise it for the client. The ability of the computer to generate nursing
diagnoses will depend on the program on which the computer is based.
178
 Nursing Process
1.5 PLANNING
Planning is the third phase of nursing process. This phase begins after the
formulation of the diagnostic statement and concludes with actual documentation
of the plan of care. The steps’ of planning phase are:
 Setting priorities
 Developing outcomes
 Developing nursing orders and
 Documentation

1.5.1 Setting Priorities

The nurse formulates a list of nursing diagnoses of actual or potential response
of the client. Almost all nursing diagnoses require interventions. Since all the
nursing diagnoses can not be considered at a time, it becomes essential to identify
which nursing diagnosis or diagnoses will be considered first. Often problems
that are life threatening (physiological) are given priority by nursing and medical
staff over other problems. Therefore, a system must be established to determine
“which nursing diagnosis needs to be first” (prioritising).
Virginia Henderson’s (1966) 14 basic needs, and Faye Abdellah’s (1960) 21
clincial problems provide a framework to classify various diagnosis into different
systems and determine priorities. A complete mechanism of human needs as
given by Abraham Maslow (1943) describes the hierarchy on five levels that best
suits as system to prioritise the health response of the client. You may recall the
five levels of maslow’s hierarchy of needs (Refer BNS-205 Block-1, Unit-3).
The five levels are:
 Physiological
 Safety/security
 Social
 Esteem
 Self-actualization.
Physiological needs are generally of greater priority to the client than the others.
The clients progress up the hierarchy of needs. If these needs are unmet the client
is unable to deal with higher level needs. However, the nurse may note that the
clients may have unsatisfied needs on more than one level at the same time e.g.
the client’s immediate concern relates to the survival needs i.e., relief from
breathing difficulty, fever (physiological), but at the same time the client also is
worried about security of the wife at home (safety/security), verbalises separation
from the children (Love and belonging need). Hence, generally the problems
related to physiological needs are given priority.

1.5.2 Writing Outcomes

Outcomes are also referred to as “goals” and written as “behavioural objectives”.
Outcomes indicate what the client will be able to do as a result of the nursing
intervention. The outcomes are written in a specific format so that the nurse is
179
Quality Nursing Practices able to evaluate the effectiveness of nursing interventions. The problem identified
in the first part of the nursing diagnosis statement should appear in outcome as
an alternative healthful response(s). The healthful response of the client can be
classified into the following headings:
Appearance and Functioning of the Body: Within 48 hours after surgery, the
client expels flatus, the abdomen is soft, bowel sounds are present. By the time
of discharge, client returns to normal elimination pattern.
Specific Symptoms: These refer to symptoms iriterfering with the client’s health
status such as nausea, vomiting, burning sensation, pain, frequent urination,
weakness and so on. The example of an outcome is: “verbalises freedom from
burning sensation in epigastric within half an hour of administering antacid.”
“Asks for pain medication when needed; expresses relief after initiation of comfort
measures.”
Knowledge: Knowledge refers to client’s ability to recall the information taught
e.g. by the end of first session, the client lists three common problems of pregnancy,
explains the relationship between diet and pregnancy.
Psychomotor Skills: The outcome statements identify what the client should be
able to do/perform as a result of the teaching plan e.g. by the time of discharge
the client is able to transfer from bed to wheel chair, test urine for sugar, take
injection insulin.
Emotional Status: The outcomes address how the client or family is responding
to a stressful event e.g. prior to discharge verbalise feelings about loss of limb,
initiate positive interactions with staff, friends, family members.
Outcomes should be determined by the client and nurse together.
When the client is not involved, a situation might occur that client might be in
conflict with the nurses strategies e.g. a client with paraplegia may not be wanting
to go back home with weak support system. The client might just refuses to
participate in the plan of care. The nurse requires to explore his reason for refusal
and plan alternate approaches like help from social welfare services.

1.5.3 Nursing Orders/Interventions

Nursing order is a specific written directive for a nursing intervention and flow
directly from the outcomes. Nursing orders are based on the related factors of the
nursing diagnostic statement. These should be written clearly using action verb,
and should be dated. Who, what, where, when, how and how much make the
nursing orders meaningful. Nursing orders should be signed by the nurse. The
signature shows accountability of the nurse.
Component of Nursing Orders
Each nursing order should consist of:
a) Date to identify the origin of order
b) Action verb and modifier to clearly communicate the expected outcome.
Action verb defines the specific action. For example “Teach the insulin
injection”, could mean
– demonstrate insulin injection
180
 – identify the appropriate size of syringe and needle Nursing Process

– provide instructions and discuss the procedure with the client.

Therefore, the verb “teach” is not precise. Action verb like demonstrate, perform,
write, replace, calculate, apply, dissect, should be used while writing nursing
orders.
c) Who, What, Where, When, How and How Much make the nursing orders
meaningful e.g. if a nursing order states “dress wound” then the implementor
needs to know
– Which wound – perhaps the client has more than one
– Who will dress – the nurse, the client, the family member? The dresser
– When to dress – once a day? Whenever soaked?
– How to dress – with betadine, Eusol, dry dressing?
Putting all these specifications the nursing order may read like 10/5:
– Dress the incisional wound on abdomen once using spirit and povidone -
iodine solution
– Replace the dressing using two sterile gauge 8" x 8"
– Use paper tape (client allergic to zinc oxide plaster strips)
d) Modifications in Treatment
Write the title of the procedure in the nursing order and not the detailed steps.
The procedure performed are usually as per the nursing manual or standarised
protocols of procedures given in the nursing manuals. At times when modifications
are required then they should be specified e.g. first post operative dressing is
done by the surgeon incharge or his junior assistant (s). Then the nursing order
can be written as Do not change first dressing. To be changed by surgeon/assistant.
e) Signature
The final component is the signature of the nurse. The signature shows
accountability of the nurse, It also communicates to other nurses, health team
members to give feedback on the effectiveness of order. Signature helps to obtain
clarification and to obtain rationale for the order.
Characteristics of Orders
Nursing orders are written in a specific format, and precisely so that each members
of nursing staff and that of the health team interpret them in a similar manner.
Nursing orders should have following characteristics:
Be consistent with the plan of care
The nursing orders should not be in conflict with the therapeutic approaches of
other members of the health team.
Be based on scientific principles
For example: The statement of nursing order, “Teach client to rotate insulin
injection site” the scientific principle entails repeated use of the same site causes
fibrosis, scarring and decreased insulin absorption. 181
Quality Nursing Practices Be individualised to the specific situation
For example: Nursing diagnosis on “Potential alteration in skin integrity related
to immobility” will have different nursing orders for different clients and
situations.
Nursing Orders for a young client after an accident and on traction.
– Apply foam mattress to bed
– Massage bony prominences with lotion every 4 hourly.
– Encourage client to use trapeze to change position in bed.
Nursing orders for old client, thin built, dehydrated, confined to bed
– Apply air mattress to bed
– Assist client to change position include prone position once in every shift
– Massage bony prominences with lotion every 4 hourly
Categories
Nursing orders based on nursing activities can be categorised as dependent,
interdependent, or independent.
a) Dependent Orders
Dependent orders relate to the implementation of medical orders e.g. physician
writes to weigh the newborn every alternate day. The nurse clarifies the order
as follows: “weigh Monday, Wednesday and Friday. Use beam type scale.”
b) Interdependent Orders
Interdependent nursing orders describe the activities that the nurse carries out in
cooperation with other health team members. The orders may involve
collaboration with social worker, nutritionist, physiotherapist, technician, and
physicians e.g. physician orders, “1500 calories, diabetic diet for a NIDDM client”.
The nurse plans for diet in coordination with the nutritionist. Together they
calculate a day’s menu for the NIDDM client.
The nursing orders are as follows:
 Client with NIDDM to get 1500 calories, diabetic diet
 Calories 1500, Protein (20%), CHO (5%) Fat (30%)
8 A.M. - Milk 200ml without sugar, two dry toast, one boiled egg
10 A.M. - Tea 150ml (with one tab. sugar free), two salty biscuits
c) Independent Orders
Independent nursing orders are the activities that may be performed by the
nurse without a direct physician’s order. Independent orders are defined by
nursing diagnosis. The independent orders are those nursing prescriptions
that a nurse can treat by virtue of her education and experience.
Example: A client with NIDDM expresses to the nurse that she better learns
taking insulin herself, I do not want to be dependent on others. The nurse
182 writes the following orders:
  Teach client measuring the prescribed dose of plain insulin and the Nursing Process
equipment needed - needle and syringe and sites of injection.
 Demonstrate the method of injection.
 Encourage client to take insulin injection as taught under supervision of
the nurse.
 Takes insulin injection without supervision prior to discharge.
Development of Nursing Orders
Once the nursing diagnosis and outcomes have been established the nurse decides
on how to meet the outcome and how to promote, maintain, restore client’s health,
and facilitate coping with altered functioning. Following steps are adopted to
develop nursing orders.
 Identify all possible alternatives, that are most likely to be effective.
 Judge each alternative in terms of its feasibility and probability of success.
 Select the viable alternatives.
 Write in the form of nursing order. Write a set of nursing orders for each
outcome.
 Communicate the nursing order both verbally and in writing (plan of care).

1.5.4 Documentation
Documentation in planning phase is accomplished by recording nursing diagnoses,
outcomes, and pursing orders.
For many years nursing care plans were the keystones of nursing care. They also
served as a guide for formulating nursing notes. The Nursing care plans were
written incorporating the assessment, planning, implementation and evaluation
processes. Nurses even today are more familiar with term nursing care plans than
nursing process. Nursing care plans are written only by students just to please their
teachers. But here you will learn the serious side of nursing care plan.
Definition
Nursing care plan is a document containing statements of nursing diagnosis,
outcomes and nursing orders in an organised fashion.
Purpose
The purposes of nursing care plan are to:
 Give quality care to the client,
 Provide continuity of care,
 Communicate to the members of the health team
 Evaluate the feedback of the effectiveness and success of nursing outcomes
and orders.
Structure of Nursing Care Plans
The nursing care plans can be structured in several ways depending on the system 183
Quality Nursing Practices used in your agency. However, the components remains the same i.e., nursing
diagnoses, client outcomes and nursing orders/interventions.
The nursing care plans are frequently supplemented by the use of a Kardex. The
diagnosis, outcomes and orders are directly written on the Kardex.
The diagnostic tests, treatment are recorded on Kardex at specific areas. An
example of commonly used format of nursing care plan of a client with right side
hemiplegia is given below in Table 1.2 :

Table 1.2 : Nursing Care Plan

Nursing Diagnosis Client Outcome Nursing Orders

Potential injury related to Experiences no injuries – Keep frequently used

visual changes, decreased throughout hospitalization objects on unaffected
sensation, confusion side (left)
on right side – Approach client from left
side (unaffected)
– Teach client and family to
safeguard right side of body
with diminished sensation
from heat/cold, pain and
pressure
– Use side rails

Type of Care Plans

The types of care plans commonly used are individualised, standardized,
modified standardized, and computerised care plans. The characteristic features,
advantages and disadvantages of each are explained in Table 1.2.

Check Your Progress 6

1) List the hierarchy of needs given by Abraham Maslow’s.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................
e) .............................................................................................................
2) Briefly explain the following terms:
a) Nursing outcomes
.............................................................................................................
.............................................................................................................
.............................................................................................................
b) Nursing orders
.............................................................................................................
.............................................................................................................
.............................................................................................................
184
 Nursing Process
3) Define nursing care plan and list its purposes.
....................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
4) List the three elements that form the structure of care plan.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
5) List the types of nursing care plans commonly used.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................

Table 1.3 : Types of Care Plans

Individualised Standardized Modified Computerised

Standardized Definition

Definition

Contains standard It is a specific They are like The standard format

three column format protocol of care that standardized plans of care plan is
of diagnoses, is appropriate for but has scope for available in an
outcomes and clientis who are individualisation plan automatic system.
orders. experiencing the of care. There are The data is fed and
usual or predictable blank spaces the care plan can be
problems associated provided in the developed at a
with a given format to write system available at
diagnosis or disease additional client central location at
process. specific nursing client’s bedside.
They consist of diagnosis, outcomes The printed version
actual, potential or and orders. can be obtained
possible nursing daily, each shift or
diagnoses, outcomes on demand. The
and interventions commonly used
that are printed in a systems to generate
care plan format. computerised care
Nurse can develop plans are:
the care plan out of  Standardized
the print format. plans based on
185
Quality Nursing Practices
Individualised Standardized Modified Computerised
Standardized Definition

These plans are medical

available in books, diagnoses.
journal articles.  Standardized
plans based on
nursing diagnosis.
 Individually
constructed plans.

Advantages
 Contains  Developed by Provides advantage  Facilitate frequent
documentation clinical experts. of both individualized updating of the
pertinent to a  Educating to and standardized plan by deleting
particular client nurses who are care plans enhance the problems from
 Does not contain not familiar with the quality of care the plan that have
extraneous or any medical or nursing and documentation. been resolved.
inapplicable diagnosis.  Allows options to
information  Reduce time spent revise, add nursing
in writing care diagnoses,
plan. outcomes and
 Increases orders .
efficiency of  Increases the accuracy.
nursing care  Provides thorough
planning. documentation of
the delivery of care.
 Some systems
allows active
participation of
client in selection
of outcomes and
interventions.
Disadvantages
It is time  Does not consider Same as that of
consuming the individual individualised and
differen-ces seen standardized.
in clients e.g., the
problem in nursing
diagnoses might
be same but not
the etiology .
 It does not
consider client’s
input.
 It may contain
interventions not
related to the
client.

1.6 IMPLEMENTATION
The fourth phase of nursing process starts with nursing activities as documented
186 in the care plan. Majority of the nurses are employed in the hospital care settings.
In hospital nurses organise and carryout the nursing activities in three different Nursing Process
approaches. These approaches are:
 functional nursing
 team nursing
 primary nursing
You have learnt about these approaches in Block I, Unit 4. The nurses deliver
care adopting one single approach or combination of these approaches. The choice
of approach depends upon the philosophy of the agency, type of agency, type of
unit (critical care, ambulatory care) and the availability of nursing manpower
and care assignment. The process of implementation would involve the following
two steps:
 Planning or preparation
 Interventions or nursing actions.

1.6.1 Planning or Preparation

The first step of implementation phase requires the nurse to prepare for starting
the nursing actions. The planning involves accomplishment of series of activities.
The various activities are explained below:
Reviewing the Nursing Actions Identified in the Planning Phase
Once again the nurse reviews the nursing order in relation to nursing actions to
ensure the achievement of outcomes, and quality nursing care.
Analysing Knowledge and Skills Required
The various nursing orders listed in the plan require different levels of skills -
basic and advanced. The orders also require knowledge base and understanding
of the relationships between the order and the nursing actions e.g. for a nursing
order in child with pneumonia “perform postural drainage with percussion B.D.
while awake 8 A.M., 4 P.M. after nebulizer treatment.”
To carry out the nursing order the nurse must realise the relationship between
adequate ventilation, removal of secretions and respiratory complications. The
order also requires skill to explain the rational, demonstrate the procedure and
encourage child to cough out secretions.
The nurse determines that the senior nurse in the ward is capable of starting the
order. The nurse also recognises the involvement of respiratory therapist in the
implementation of the order. Therefore, the order is assigned to the senior nurse
capable of initiating the order.
Recognising Potential Complications
The nurse must recognise the potential risk of complications involved in certain
nursing procedures, e.g., surgical dressing, endotracheal suctioning, passing
urinary catheter, administering total parenteral nutrition (TPN). Before attempting
to carryout the procedure the nurse needs to be aware of the common complications
associated with the activities specific to the client’s nursing orders e.g. for the
nursing procedures listed above involves risk of introducing microorganism. The
nurse must practice maintenance of strict aseptic technique to carryout such 187
Quality Nursing Practices nursing orders. Risk of complications is involved in non-invasive procedures
e.g., turning a client with hip spica, giving eye care, calculating and adjusting
flow rate, care of chest drainage tube. The nurse must recognise the potential
risks prior to initiating the nursing action, so that preventive approach can be
adopted.
Providing Necessary Resources
When planning to implement care plan the important resources to be considered
are: time, personnel and equipment.
Time: The right selection of appropriate time to carryout specific intervention
needs to be planned e.g. a client receiving sedation at 10 p.m. and a dose of an
antibiotic (8 hourly) at (2 A.M. 10 A.M. and 6 P.M.). The nurse realises that it is
not appropriate to disturb the client’s sleep. The nurse reschedules the 8 hourly
timings as 6 A.M., 2 P.M. and 10 P.M. In a situation Nursing order may dictate
the evening shift staff to teach breathing exercises to the client (5 p.m.). A nurse
may find it inappropriate to carryout in the evening shift as the client is having
visitors. So the appropriate time may be in the morning after routine care is over
i.e., at 11 A.M. A careful consideration of time is necessary and avoids hasty
implementation.
Personnel: The nurse should also need to ensure the availability of sufficient
number of personnel to implement the intervention e.g. to transfer post operative
client from trolley to bed requires help of nursing assistant. This will also be
essential to avoid any discomfort and injury to the client.
Equipment: Anticipation of required equipment ensures implementation of
individualised and quality care to the client. The nurse must identify and procure
the necessary supplies well in time to implement nursing orders. This also avoids
waste of time.
Preparing a Conducive Environment
Consideration of client’s comfort, and safety are foremost in planning the
implementation to achieve successful outcomes. Comfortable environment
involves both physical (room space, privacy, freedom from noise, odour, adequate
lighting and temperature) and psychosocial components. The psychosocial
component involves use of interpersonal skills both verbal and non-verbal to
provide an environment in which client is comfortable to express his fears,
feelings, emotions, desires, needs. Creation of safe environment includes
consideration of client’s age, degree of mobility, sensory deficits, and level of
consciousness.
Age: Although unfamiliar environment can be hazardous to any age group yet
young and elderly clients are at greater risk of injury.
Degree of Mobility: Client’s degree of mobility gets affected by disease, trauma,
external restrictions such as traction, plaster, cast, eye bandage.
Sensory Deficits: Clients with decreased perception in sight, hearing, smell, or
touch are at risk for injury. The nurse may need to make necessary modifications
in clientis physical environment for protection against any accidents.
Level of Consciousness/Orientation: Clients with decreased level of
consciousness, or disorientation often require special attention to promote safety.
188 Nurse needs to plan special interventions for such clients.
Identifying Legal and Ethical Concerns Nursing Process

In planning to implement nursing interventions the nurse must consider: client’s

rights, nursing ethics and legal issues.
You will learn about these legal and ethical issue in Unit 3 of this block.
Documentation of nursing records is important as the records often reflect the
care provided to the client and also serve as defence for a nurse, physician and
other members of the health team.

1.6.2 Intervention of Nursing Actions

What comes after the initiation of the nursing orders is intervention. Intervention
is the second step involved in the implementation phase. The interventions
involves the doing, the interacting directly with the client his family members to
achieve the desired outcomes.
The nursing interventions comprise of several nursing actions classified as
dependent, interdependent and independent actions to meet physical and
emotional individual needs of each client.
The steps of nursing process (assessment, diagnosis, planning) explained above
are also part of the implementation phase. Assessment during implementation
involves ongoing collection and processing of data before, during and after the
initiation of nursing interventions e.g. before sending an infant to radiology
department for an X-ray the nurse observes that the infant is having difficulty in
breathing and is cold to touch. Based on these findings the nurse assesses the
respiratory rate of the infant to be fast and therefore, chooses to arrange for bedside
X-ray. This change in nursing order is as a result of ongoing assessment. Ongoing
assessment tells the nurse to continue, discontinue or modify the individual order.
The planning component of nursing process also continues during implementation
process e.g. while giving breathing exercises to post operative client, the nurse
observes that the client is perspiring and on further assessment count the pulse
and finds to be rapid, client complaints of weakness, sinking feeling. The nurse
decides to discontinue the intervention and reassess the client and formulate
nursing outcomes and revises orders.
In your experience you will agree that most of the nursing interventions fall in
the following four categories:
 Observation – results of observation help resolve client’s problem
 Therapy – nursing actions done on the client with the client,
for the client to treat the problem and promote
health.
 Education – formal, informal exchange, giving of information
ranges from giving simple instructions to teaching
therapeutic skills.
 Counselling/Guiding – helping clients to make necessary adjustments,
solve problems, counselling in special settings,
disaster situation, behaviour modification, crisis
intervention to rehabilitation. 189
Quality Nursing Practices 1.6.3 Documentation
Documentation of the care implemention must be done accurately and completely.
The types of records kept to document client care are:
a. Source-oriented records
b. Problem-oriented records
c. Computer-assisted records
Each of the type of record used to document client’s care given is explained
below:
a) Source Oriented Records
The source oriented system involves recording of information in a chronological
order within specific time periods. It is one of the traditional method of recording
seen in most of the hospitals.
The total medical record of the client is divided into sections according to the
source of the data. Each health team member involved in the care of the client
records information on a separate section e.g., nurses notes, physician progress
notes, laboratory data, physical therapy notes, respiratory therapy notes. Each
professional member of team is a source in the record.
The frequency of the documentation depends upon the client’s condition. In an
acute care setting the notes may be documented every few minutes. The nurses
documents once in each shift and includes assessment data, implementation of
nursing and medical orders and client’s responses to nursing and medical
interventions. Whereas in an ambulatory setting the documents are written less
frequently daily, weekly or monthly.
The advantage of this system is easy access to the location.
The disadvantages include:
– Fragmentation of the documentation of the client’s care according to the
provider.
– Does not provide clear definition to the client’s problem.
– Lacks integration of client’s response to intervention.
– Inconsistent documentation of teaching when accomplished by many
disciplines - nursing, nutritionist, physiotherapist.
– Difficult to audit to evaluate quality of care delivered.
b) Problem Oriented Records (POR)
Unlike source-oriented record, problem-oriented record as the name suggests
focuses on the problem of the client. The system of Problem-Oriented Medical
Records (POMR) was developed by Dr. Lawrence L.Weed, Professor of Medicine,
University of Vermont.
Problem Oriented System of documentation parallels the five phases of nursing
process. POR format has four components:

190 – Data base

– Problem list Nursing Process

– Plan
– Progress notes
Data Base
The data base in POR includes the clients profile, history, physical and diagnostic
studies, The method of preparing data base is explained in section 1.3 (method
of data collection). Depending upon the practice on the hospital or agency nurse
may complete a portion of this record if integrated, or she may utilise an adapted
form that reflects the areas of nursing responsibility. The information in the data
base serves as a source from which client’s needs and problems are identified.
Problem List
The problem list is an exhaustive accumulation of past, current, actual, and
potential problems of the client. Each problem is provided with a number. The
number reflects the sequence in which the problem have been identified rather
than their priority or intensity. Problems may be identified by specific health care
provider independently or in collaboration with other team members,
interdisciplinary conferences. The problem list is usually placed on the front of
the client’s medical record and serves as the index. Table 1.3 shows a sample of
problem list.
When the client’s condition improves and sign or symptom subsides it is
eliminated from the problem list with date. The number of other unresolved
problem is not changed.

Table 1.4: Problem List

SI. No. Problem Date entered Date resolved

1. Cholecystitis 2017 2018

2. Pneumonia 2017 2017

3. Fractured Left hip 02/02/20

4. Impaired physical mobility

a) Pain 02/02/20

b) Edema 02/02/20

5. Potential for injury 02/02/20

The nurse can also transfer her numbered problems (nursing diagnosis), outcomes
and nursing order on Kardex when the initial plan is complete. However, some
nurses use Kardex to record care plan directly to save on time.
Plan
Plan of nursing care is developed for the client after identifying the problem. The
initial plan of care usually include diagnostic, therapeutic, and educational
components. It may include gathering additional data from the client e.g., from
clients’ family members, client, observations of client’s feelings of specific skill
or limitation. 191
Quality Nursing Practices Table 1.4 shows sample of initial plan of care developed on the basis of the
problems identified.

Table 1.5: Nursing Care Plan for Problem listed in Table 1.4

Problem 5 Outcome Orders

Potential for injury No evidence of  Consultation with ophthalmologist to

further accident evaluate visual acuity (diagnostic)
or injury  Assist client to identify potential
environmental hazard in the home
(treatment)
 Instruct client and husband in basic
safety measures designed to prevent
injury (education)

Progress Notes
The fourth component of the POR system is to document client’s response to the
plan. Progress notes can be written by nurses, physicians, other health team
members in a narrative form. The frequency can be hourly, once in a shift, daily,
monthly depending upon the clientis condition, and type of care unit.
The format for progress notes is specific and structured. This format is identified
by the acronym SOAPIE where each letter represent as given below:
S : Subjective data (Client’s feeling’s symptoms, concerns)
O : Objective data (Client’s findings to members of health team e.g., blood
pressure, Hb level, lung sounds)
A : Assessment (Nurses interpretation of Sand 0)
P : Plan (Steps taken to assist client to resolve the problem)
I : Implementation of nursing care
E : Evaluation (Client’s response to the interventions)
Table 1.6 shows the sample progress notes using SOAPIE format.
Table 1.6: SOAPIE Progress Notes

Date and Time Problem Notes

02.02.01 5 Potential S : “I must get my contact lenses and be careful

8.30 a.m. for injury in future at home, I don’t want to hurt myself.”
O: Tense, expressions concern about hurting self,
worried about husband.
A : Aware of the relationship between hazards in
the home and occurrences of injuries.
Motivated to avoid harm to self.
P : Encourage to recognise and correct hazards in
home environment
I : Encourage the client to attend his/her needs.
E : Plans to request maintenance department to
repair work prior to discharge.
192
Advantages Nursing Process

 Facilitates quality care as all health care team members focus on the identified
problems.
 Provides ready access to data.
 Encourages multidisciplinary collaboration.
 Avoids chances of duplication as each discipline can see in the record what
others have done.
 Deficiencies can be easily identified.
 Facilitates research as the data is complete and accurate.
Disadvantages
 Educating variety of disciplines in the utilisation of POR system is time
consuming and costly.
 Some resistance to use by members of some disciplines.
 Criticism by members may dissuade others.
c) Computer Assisted Records
Use of Computerised Information System in health care agencies has resulted in
the development of a variety of documentation methods. Depending upon the
format available in the system the nurse can obtain worksheet with sections
defining independent and dependent nursing activities for each client. The nurse
puts her initials for the interventions implemented. The discontinued orders can
be deleted from the system at any time. Computerised system can also utilise
POR system.
Progress notes can be documented by two ways: (i) One is by choosing specific
interventions to document with description as “completed” or “not completed”.
(ii) The second approach to document is when the system sorts out into SOAPE
format. SOAPIE format is built by selection of data from the displays.
The system can also have additional forms to documenting nursing interventions,
such as administration of medications. The nurse puts her initials on the printed
forms for medications that are administered by her.

Check Your Progress 7

1) List the steps involved in the planning step of implementation phase of
nursing process.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................
e) .............................................................................................................
f) .............................................................................................................
193
Quality Nursing Practices
2) List the four categories of nursing interventions with examples.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................
3) List the types of documents used to keep record of client care
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
4) List the components of POR
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................
5) Describe the format used to write progress notes.
.....................................................................................................................
.....................................................................................................................

1.7 EVALUATION
Evaluation is performed to judge each component of the nursing process.
Evaluation is done by comparison of client’s health status with the outcomes.
The nurse judges the achievement of the desired nursing outcomes.
The evaluation process consists of two steps:
 Gathering data about client’s health status
 Comparing and judging data about client’s progress.

1.7.1 Gathering Data about Client’s Health Status

The data gathered in the evaluation phase of the nursing process involves use of
assessment skills. The data is gathered about the areas for which outcomes are
written:
a) Appearance and Functioning of the Body
The outcomes written related to appearance and functioning of body covers various
aspects of client health status. The evaluation is focused on changes in appearance
and body functioning. The nurse can gather data by:
– direct observation
– examination of the medical record.
194
Careful and thorough observation data of the client’s appearance and activities is Nursing Process
gathered. The data is compared with the data base gathered during initial
assessment phase and during subsequent interactions with the client e.g. for
outcome: Throughout hospitalisation, no evidence of skin breakdown over bony
prominences. The nurse carefully inspects the skin over bony prominences elbow,
heels, trochanteric region, sacrum as an ongoing part of care while giving bath,
changing position. The nurse compares the data with the initial baseline data and
subsequent observation to evaluate the success of outcome.
Examination of the client’s medical record is useful too to evaluate the functions
of the client’s body. The nurse’s notes provides information about changes in
client’s condition as a result of nursing care. The results of laboratory studies
helps to evaluate client’s progress. The nurse also notes the client’s response to
treatments of other departments such as dietician, respiratory therapist, child
psychologist.
b) Special Symptoms
The outcome related to specific symptoms that affects client’s health status can
be evaluated by:
– Direct observation
– Client interview
– Examination of the medical record.
Signs like grunting can be evaluated by direct observation of the client, and also
by auscultation of the chest for breath sounds. Symptom is a subjective feeling of
the client. Therefore, by asking directly to the client the nurse evaluates the client’s
symptoms e.g., by asking if the pain has subsided after giving medication for
pain.
Symptoms and their duration like pattern of temperature, weight record, vomiting,
oedema, can be evaluated by looking at the client’s progress notes, flow sheets,
graphic records.
c) Knowledge
Nursing outcomes identify the specific knowledge that client should acquire as a
result of interventions related to teaching. The specific areas to evaluate the clients
are knowledge about the disease, symptoms, medications, diet, activities,
prevention and control of symptoms, warning signs needing reporting, potential
complications, resources available in the community. Outcomes can be evaluated
through the use of paper and pencil tests, and interview with the client.
Paper and pencil tests are not common as constructing tests requires skill, client
feels intimidated and has limited value when the client’s reading skills are poor.
Client interview is the best way to evaluate client’s knowledge.
d) Psychomotor Skills
Evaluation of psychomotor skills is fairly easy. Watching the client perform certain
activities e.g., preparation of ORS solution, doing a clean dressing. Taking an
injection, measuring dose of a medication. The nurse compares the actual
performance with the behaviour described in the outcome. The nurse should
ensure that the materials used by the client to perform an activity should be same
as that available at home. 195
Quality Nursing Practices For Example: To prepare ORS solution. The nurse must provide the client with
ORS packet, bowl, measuring bottle or glass (as would be available at home),
scissors, water, and a spoon. The nurse observes the client perform following
steps.
– Wash hands
– Read the packet for how much fluid is needed for. (one liter or 200ml)
– Measure the right quantity of water and pour in the bow!.
– Mix the contents of the ORS packet into the bowl of water.
e) Emotional Status
Emotions are subjective in nature and therefore, difficult to measure. The terms
of behaviour used to write outcomes give an indication of client’s emotional
status e.g., “shares feeling about,” “reports less anxiety”, “verbalises feeling”,
“initiates conversation” The wordings of the outcomes enables nurse to evaluate
achievement of outcome. The methods used to evaluate emotional status include:
direct observation and feedback from other staff.
Observation of client’s facial expressions, body posture, tone of voice, content
of verbal message are useful in evaluating emotional status of the client. The
nurse can get information about the client from neighbouring clients, from
members of health team through patient-centered conferences, reports and records
of the client.

1.7.2 Making Judgements about Progress

After gathering the data the nurse compares the data with the outcome. The nurse
makes judgements about the client’s achievements of the outcome. The
possibilities of the client’s achievements of the outcome could be:
 The client has achieved the outcome. Then the nurse would assess the client
for further problems or evaluate other outcomes e.g. the client’s blood sugar
level reaches normal range and the nurse continues to assist the client to lose
20 kg body weight.
 The client is in the process of achieving the outcome. The client may require
additional time, resources, and interventions before the outcome is achieved
e.g. the post-operative client may ambulate unassisted after 72 hours. but
may have pain and IV. fluids on flow. The nurse assists the client holding IV.
fluid bottle to ambulate. The client ambulates unassisted after say another 24
hours. Here the client is progressing towards achievement of desired goal
i.e., unassisted ambulation.
 The client has not achieved the outcome and is not likely to do in the future.
In such an instance the nurse should try to identify the reason. The reason for not
achieving the outcome can be - Unrealistic outcome and Inappropriate outcome.
The unrealistic outcome in terms of resources of the client, agency and nursing
staff. An example of the unrealistic outcome in terms of client is teaching the
client urine testing for sugar using uristix, when the client has financial constraint
to buy uristix.

196 Inapproprite nursing intervention to meet the outcome e.g. teaching the client
about the disease prevention and control by giving a pamphlet when the client Nursing Process
has limited reading skills.
There can also be situation when the client has no desire to achieve the outcome
e.g. a client who is depressed may not be interested to attend the support group
meeting as per the planned outcome.
In such situation the nurse reassesses the problem or response to identify if the
problem was identified accurately. Then the nurse may formulate a new outcome.

1.7.3 Documentation
The nurse documents the evaluation of outcomes achievement on the client’s
medical record. The concise statements and terminology that describes the
achievement is recorded. The terms such as “tolerated procedure well”, “appetite
poor” should be avoided. It is appropriate to record what the client said or did
that led to the conclusion e.g. statement of recording could include “The client
did not complaint of headache after LP, or complaint of pain at LP site.”

Check Your Progress 8

1) List the five areas on which the nurse focuses her outcomes and evaluation.
a) .............................................................................................................
b) .............................................................................................................
c) .............................................................................................................
d) .............................................................................................................
e) .............................................................................................................
2) List the method a nurse can use to gather data in each area of evaluation.
Answer the question in the format given below:

Area of Evaluation Method of Gathering Data

a)
b)
c)
d)
e)

3) List what can be the possibilities of the client’s achievements of nursing

outcome.
....................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
197
Quality Nursing Practices
1.8 LET US SUM UP
In this unit the concept of nursing is explained with shift of focus from need
based care to quality care concept. Today the value of nursing in hospitals needs
to be quantified, demonstrable and measurable. Nursing in the hospital is under
scrutiny for its quality of services. One such method of giving care to the client
that evolved in 1980s is nursing process (NP). The unit prescribes nursing process
as systematic continuous, and dynamic method of providing care to the clients,
and describes the purposes, characteristics, the factors affecting nursing process
and the steps of nursing process.
Assessment the first phase of NP consists of accumulation of data and
documentation of information about the client in the medical record. The data is
collected by interviewing, observation and physical examination. The technique
physical examination of Gordon’s eleven functional health pattern forms the
foundation of nursing.
The diagnostic phase of NP involves data processing by classifying, interpreting
and validating the data, and formulation of diagnostic statement. Each diagnostic
statement has two parts - the problem and the etiology. Formulation of diagnostic
statements is explained with examples that again need to be verified by the client
and documented.
Planning the third phase of NP consists of four stages - setting priorities,
developing outcomes, developing orders and documentation. Some considerations
that enables the nurse to formulate outcomes are that outcomes should be client
oriented, clear, concise, observable, measurable, realistic determined both of client
and nurse. The areas in which outcomes may be written include appearance and
functioning of the body, specific symptoms, knowledge, psychomotor skills, and
emotional status.
Nursing order are derived from the first part of the nursing diagnostic statement.
The characteristic features of nursing orders include consistent with plan of care,
based on scientific principles, individualised, used to provide safe and therapeutic
environment, include teaching-learning opportunities for the client and utilisation
of appropriate resources. Nursing orders are developed with date, precise action
verb, specific aspects of intervention and modifications in standard therapy.
The planning phase concludes with documentation of the plan of nursing care –
individualised, standardized, or computerized.
Implementation is the fourth phase of NP. Implementation involves three stages
– preparation, intervention, and documentation. Preparation includes reviewing
anticipated nursing actions, analyzing the nursing knowledge and skills required,
and recognising the potential complications associated with specific nursing order.
Preparation also involves determining and providing necessary resources,
preparing an environment conducive to the type of interventions required, and
identifying legal and ethical concerns. Most of the nursing interventions fall into
four categories i.e., observation, therapy, education and counselling.
Documentation of the nursing interventions can be done in source-oriented,
problem-oriented or computer-assisted records.
Evaluation of phases of nursing process is done at two stages - collecting data
198 about the client’s health status and comparing the gathered data with the outcomes
to make judgements about client’s progress towards achievement of outcomes. Nursing Process
The data gathered during evaluation phase is based on the nursing outcomes
written in observable terms related to appearance and functioning of body, special
symptoms, knowledge, psychomotor skills and emotional status.

1.9 KEY WORDS

Cognitive Skills The operation of mind process by which we become
aware of objects of thoughts and actions including all
aspects of perceiving, thinking and remembering.
Concurrently Something that is happening together.
Documentation Writing things, events, doings that furnishes evidences.
Ethical Rules or principles which govern right conduct. Each
professional practitioner is invested with the
responsibility to adhere to the standards of ethical
practice and conduct set by the profession.
Inferences Statement of conclusion drawn out of facts.
Kardex is a card, sheet from a loose, leaf notebook, or a computer
printout divided into sections to document plan of care.
The design of Kardex can vary from one agency to
another.
Moral Concerned with character, with distinction between right
and wrong.
Precipitating Factors Events that happen suddenly, quickly e.g., news of
unexpected events like death, accident, etc.
Predisposing Factors Cause, event that occurs before, makes a person
susceptible e.g., age, poor support system, stress, anxiety,
lack of mobility etc.
Priority Something that is taken up earlier over others in order,
time, or importance.
Problem A problem is any condition or situation that a client can’t
readily handle himself - one that requires intervention
by you or some other member of the health-care team.
Remember No problem can be exactly the same for each client,
because each client is an individual.

1.10 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
1) a) Nursing is the diagnosis and treatment of human responses to actual or
potential health problems.
b) Nursing Process (NP) is defined as a systematic, continuous and dynamic
method of providing care to clients. 199
Quality Nursing Practices c) Collection of information about the client obtained during interview,
physical and clinical examination using different methods, and from
different sources.
d) Starting and completing the strategies planned with help of client, family
members and health care team members.
e) Assessment of strategies planned to alleviate the clients’ suffering or
otherwise replan and revise the care.
2) a) Knowledge
b) Beliefs
c) Technical Skills
3) It provides a framework within which the nurse can identify client’s health
status and meet the individualised needs of the client, family and community
in order to achieve a level of optimal wellness, or to contribute to his quality
of life through maximising his resources.
4) a) Dynamic and cyclic
b) Client centered
c) Planned and goal directed
d) Universally applicable
e) Problem-oriented
f) Cognitive process

Check Your Progress 2

Data Statement Objective Subjective
a) “I feel tired today” 
b) “She seems nervous” 
c) Dirt under nails 
d) Respiratory rate 24 per minute 
e) Absent bowel sounds 
f) Injury mark on right cheek 
g) Pain in knee joint 
h) Respiratory stidor present 

Data Statement Historical Current

a) Warm dry skin 
b) No prior surgery 
c) Smoked 20 cigarettes a day 
200
 Nursing Process
d) One episode of acute abdominal 
pain 3 months back
e) Weight 4 kg. 
f) “I am allergic to egg” 
g) Temperature 38.5o C 
h) Hospitalised with head injury 
about one year back

Check Your Progress 3

1) a) Primary
b) Secondary
2) a) Interview
b) Observation
c) Physical Examination
Check Your Progress 4
1) a) To communicate the information to the other members of the health team.
b) To facilitate the delivery of quality client care.
c) To provide a mechanism for the evaluation of individual client care.
d) To provide a legal record of the care provided to the client.
e) To serve as a source for identification of research topics for nursing
practice.
2) a) Make entries very objectively without personal opinion, biases.
b) Support description or interpretations of objective data by specific
observation.
c) Avoid using generalised terms e.g., “good”, “fair”, “normal”.
d) Avoid using superfluous information.
e) Record the findings with description like size and shape.
f) Write legibly and correct any errors by drawing a line so that the original
entry is also readable.
g) Use correct language and spelling.
h) Use abbreviations approved for use.
Check Your Progress 5
1) Nursing ‘diagnosis is a statement of a patient problem that is arrived at by
making inferences from his collected data.
2) a) The problem of the client: High blood glucose level due to lack of
knowledge about right selection of food items. 201
Quality Nursing Practices Degree of problem - Alteration in nutrition - more than body requirement.
- Bathing/hygiene self-care deficit
b) The related factor (contributing factor) : Conditions or circumstances
that can cause or contribute to the development of a diagnosis. These
include environmental factors such as Excessive noise, light, fumes,
pollutants and Psychological factors such as Fear of death, feeling of
loneliness, impaired parent-child bonding.
3) a) First write an actual or high-risk health problem and not an environmental
problem. State environmental factors in the second part e.g.
Wrong:Excessive environmental stimuli related to monitoring
equipment
Right: Sensory perceptual alterations (auditory and visual) related to
b) Do not write several unrelated problems in the first part even though the
related factor of the problem may be the same. Judge the problem as
unrelated when the nursing plan requires separate interventions for each
problem e.g.
Wrong:Anxiety and activity intolerance related to frequent episodes of
chest pain.
Right: Activity intolerance related to frequent episodes of chest pain.
Right: Anxiety related to frequent episodes of chest pain.
c) Write the diagnostic statement in a manner that both the problem and
related factors refer to different findings e.g.
Wrong:Self-feeding deficit related to inability to feed self.
Right: Self-feeding deficit related to muscle weakness.
d) Write the diagnosis in legally advisable terms e.g.
Wrong:Ineffective airway clearance related to inadequate suction.
Right: Ineffective airway clearance related to effects of sedation.
e) Write the nursing diagnosis in terms of response rather than the need.
For example,
Wrong:Need for maintenance of nutritional intake
Right: Altered nutrition (less than body requirements) related to nausea
and vomiting.
Check Your Progress 6
1) a) Survival needs
b) Stimulation
c) Safety
d) Love and belonging
e) Esteem

202 f) Self-actualization
2) a) Nursing outcomes are the statements indicating what the client will be Nursing Process
able to do as a result of nursing intervention. Outcomes are also referred
to as “Goals” or “behavioural objectives”. Nursing outcomes are written
in clear, concise words, in observable and measurable terms based on
the nursing diagnosis. Nursing outcomes focus on the behaviour of the
client, responses of the client in relation to appearance and functioning
of the body, specific symptoms, knowledge, psychomotor skills and
emotional stutus.
The statement of the outcome should specify time limit within which
period the achievement is desired both by the client and the nurse e.g.
“within 48 hours after surgery expels flatus, abdomen soft.”
The outcome are written keeping in mind the resources of the client,
nursing staff and that of the health agency.
b) Nursing orders are lists of prescriptions describing what action and how
the nurse will do to achieve the proposed outcome. Nursing orders define
the activities required to deliminate factors contributing to the client’s
problem. Nursing orders focus on the activities required to promote,
maintain or restore the client’s health. facilitate coping with altered
functioning. A set of nursing orders is written to achieve each outcome.
Nursing activities are categorised as independent, dependent and
interdependent. Nursing orders flow from the client outcomes and are
based on the etiology part of the nursing diagnostic statement.
The characteristics of nursing orders are:
 Be consistent with the plan of care.
 Be based on scientific principles.
 Be indivisualised to the specific situation.
 Be used to provide a safe and therapeutic environment.
 Employ teaching learing opportunities for the client.
 Include utilisation of appropriate resources.
The nursing orders are developed by nurse hypothesizing on possible
alternatives based on her past experience, knowledge, skill and resources.
The nurse can also generate alternatives in meetings with her own
professional colleagues and by holding interdisciplinary team conference.
The components of nursing orders include Data; Action verb and
modifier; who, what, where, when, how and how much; modifications
of treatment; and signature of the nursing member.
3) Nursing care plan is a document containing statements of nursing diagnosis,
outcomes and nursing orders in an organised fashion.
a) Give quality care to the client
b) The care plan is prepared using scientific principles to assess and diagnose
the health problem of each client as an individual.
c) Provides continuity of care
d) Way to Communicate 203
Quality Nursing Practices 4) a) Nursing Diagnosis
b) Client Outcomes
c) Nursing Orders
5) a) Individualized
b) Standardized
c) Modified Standardized
d) Computerized
Check Your Progress 7
1) a) Reviewing the nursing actions identified in the planning phase
b) Analysing knowledge and skills required
c) Recognising potential complications
d) Providing Necessary Resources in terms of time personnel and equipment
e) Preparing a conducive Environment keeping in mind the age, degree of
mobility, sensory deficit, level of consciousness
f) Identifying legal and Ethical concerns
2) a) Observation - results of observation help resolve client’s problem
b) Therapy - nursing actions done on the client with the client, for the client
to treat the problem and promote health.
c) Education - formal, informal exchange, giving of information ranges
from giving simple instructions to teaching therapeutic skills.
d) Counselling and Guidance - helping clients to make necessary adjustments,
solve problems, counselling in special settings, disaster situation, behaviour
modification, crisis intervention to rehabilitation.
3) a) Source-oriented
b) Problem-oriented
c) Computer-assisted
4) a) Data base
b) Problem list
c) Plan
d) Progress notes
5) SOAPIE format
Check Your Progress 8
1) a) Appearance and functioning of the body
b) Specific Symptoms
c) Knowledge
d) Psychomotor Skills
204 e) Emotional Status
 Nursing Process
2) Area of Evaluation Method of Gathering Data
a) Appearance and functioning  Direct observation
of the body  Examination of medical record
b) Specific Symptoms  Direct observation
 Client Interview
 Examination of medical record
c) Knowledge  Client Interview
 Paper and pencil test
d) Psychomotor Skills  Performance of a task
e) Emotional Status  Direct observation
 Feedback from other staff

3) a) The client has achieved the outcome.

b) The client is in the process of achieving the outcome. The client may
require additional time, resources, and interventions before the outcome
is achieved.
c) The client has not achieved the outcome and is not likely to do in the
future.

1.11 FURTHER READINGS

Doenges, Marilynn E., Moorhouse, Mary France et al., Application of Nursing
Process and Nursing Diagnosis: An Interactive Text/or Diagnostic Reasoning,
2nd edn., India: Jaypee Brothers. 1995.
Iyer Patricia W., Barbara 1. Taptich, and Donna Bemocchi n Losey, Nursing
Process and Nursing Diagnosis, Philadelphia: W.B. Saunder Company. 1986.
Kratz Charlotte R. (ed.), The Nursing Process, Bailliere Tindall.
Taylor, Carol Lillis, and Priscilla Lemone, Fundamentals of Nursing : The Art
and Science of Nursing Care, Philadelphia J.B. Lippincott Company.
Kelly, Jane and Janet Weber, Health Assessment in Nursing, Philadelphia, J.B.
Lippincott Co.

205
Quality Nursing Practices Annexure I
Approved NANDA Nursing Diagnosis
NANDA Nursing Diagnosis Class 4. Metabolism
Domain 1. Health promotion Risk for unstable blood glucose level
(Nursing care Plan)
Class 1. Health awareness
Neonatal hyperbilirubinemia
Decreased diversional activity engagement
Risk for neonatal hyperbilirubinemia
(Nursing Care Plan)
Risk for impaired liver function
Readiness for enhanced health literacy
Risk for metabolic imbalance syndrome
Sedentary lifestyle (Nursing care Plan)
Class 5. Hydration
Class 2. Health management Risk for electrolyte imbalance
Frail elderly syndrome (Nursing care Plan) Risk for imbalanced fluid volume
Risk for frail elderly syndrome
Deficient fluid volume (Nursing care Plan)
Deficient community health Risk-prone Risk for deficient fluid volume
health behaviour
Excess fluid volume (Nursing care Plan)
Ineffective health maintenance (Nursing care
Plan) NANDA Nursing Diagnosis
Ineffective health management Domain 3. Elimination and exchange
Readiness for enhanced health management Class 1. Urinary function
Ineffective family health management Impaired urinary elimination
Ineffective protection
Functional urinary incontinence
NANDA Nursing Diagnosis Overflow urinary incontinence
Domain 2. Nutrition Reflex urinary incontinence
Class 1. Ingestion Stress urinary incontinence
Imbalanced nutrition: less than body Urge urinary incontinence
requirements (Nursing care Plan) Risk for urge urinary incontinence
Readiness for enhanced nutrition Urinary retention
Insufficient breast milk production Class 2. Gastrointestinal function
Ineffective breastfeeding (Nursing care Plan) Constipation (Nursing care Plan)
Risk for constipation
Interrupted breastfeeding (Nursing care Plan)
Perceived constipation
Readiness for enhanced breastfeeding
Chronic functional constipation
Ineffective adolescent eating dynamics
Risk for chronic functional constipation
Ineffective child eating dynamics
Diarrhoea
Ineffective infant feeding dynamics Dysfunctional gastrointestinal motility
Ineffective infant feeding pattern (Nursing Risk for dysfunctional gastrointestinal motility
care Plan)
Bowel incontinence
Obesity Class 3. Integumentary function
Overweight This class does not currently contain any
diagnoses
Risk for overweight
Class 4. Respiratory function
Impaired swallowing (Nursing care Plan)
Impaired gas exchange
Class 2. Digestion
NANDA Nursing Diagnosis
This class does not currently contain any Domain 4. Activity/rest
diagnoses
Class 1. Sleep/rest
Class 3. Absorption
Insomnia
This class does not currently contain any
206 diagnoses Sleep deprivation
Readiness for enhanced sleep Class 3. Sensation/perception Nursing Process
Disturbed sleep pattern This class does not currently contain any
diagnoses
Class 2. Activity/exercise
Class 4. Cognition
Risk for disuse syndrome
Acute confusion
Impaired bed mobility
Risk for acute confusion
Impaired physical mobility
Impaired wheelchair mobility Chronic confusion

Impaired sitting Labile emotional control

Impaired standing Ineffective impulse control

Impaired transfer ability Deficient knowledge

Impaired walking Readiness for enhanced knowledge

Class 3. Energy balance Impaired memory

Imbalanced energy field Class 5. Communication

Fatigue Readiness for enhanced communication

Impaired verbal communication
Wandering
Class 4. Cardiovascular/pulmonary NANDA Nursing Diagnosis
responses Domain 6. Self-perception
Activity intolerance Class 1. Self-concept
Risk for activity intolerance Hopelessness
Ineffective breathing pattern Readiness for enhanced hope
Decreased cardiac output Risk for compromised human dignity
Risk for decreased cardiac output Disturbed personal identity
Impaired spontaneous ventilation Risk for disturbed personal identity
Risk for unstable blood pressure Readiness for enhanced self-concept
Risk for decreased cardiac tissue perfusion Class 2. Self-esteem
Risk for ineffective cerebral tissue perfusion Chronic low self-esteem
Ineffective peripheral tissue perfusion Risk for chronic low self-esteem
Risk for ineffective peripheral tissue Situational low self-esteem
perfusion
Risk for situational low self-esteem
Dysfunctional ventilatory weaning response
Class 3. Body image
Class 5. Self-care
Disturbed body image
Impaired home maintenance
Bathing self-care deficit NANDA Nursing Diagnosis
Domain 7. Role relationship
Dressing self-care deficit
Feeding self-care deficit Class 1. Caregiving roles
Toileting self-care deficit Caregiver role strain
Readiness for enhanced self-care Risk for caregiver role strain
Self-neglect Impaired parenting
Risk for impaired parenting
NANDA Nursing Diagnosis
Domain 5. Perception/cognition Readiness for enhanced parenting
Class 2. Family relationships
Class 1. Attention
Risk for impaired attachment
Unilateral neglect
Dysfunctional family processes
Class 2. Orientation
Interrupted family processes
This class does not currently contain any
diagnoses Readiness for enhanced family processes
207
Quality Nursing Practices Class 3. Role performance Grieving
Ineffective relationship Complicated grieving
Risk for ineffective relationship Risk for complicated grieving
Readiness for enhanced relationship Impaired mood regulation
Parental role conflict Powerlessness
Ineffective role performance Risk for powerlessness
Impaired social interaction Readiness for enhanced power

NANDA Nursing Diagnosis Impaired resilience

Domain 8. Sexuality Risk for impaired resilience

Class 1. Sexual identity Readiness for enhanced resilience

This class does not currently contain any Chronic sorrow

diagnoses Stress overload
Class 2. Sexual function Class 3. Neurobehavioral stress
Sexual dysfunction Ineffective sexuality Acute substance withdrawal syndrome
pattern
Risk for acute substance withdrawal
Class 3. Reproduction syndrome
Ineffective childbearing process Autonomic dysreflexia
Risk for ineffective childbearing process Risk for autonomic dysreflexia
Readiness for enhanced childbearing process Decreased intracranial adaptive capacity
Risk for disturbed maternal-fetal dyad Neonatal abstinence syndrome

NANDA Nursing Diagnosis Disorganized infant behaviour

Domain 9. Coping/stress tolerance Risk for disorganized infant behaviour

Class 1. Post-trauma responses Readiness for enhanced organized infant

behavior
Risk for complicated immigration transition
Post-trauma syndrome
NANDA Nursing Diagnosis
Domain 10. Life principles
Risk for post-trauma syndrome
Class 1. Values
Rape-trauma syndrome
This class does not currently contain any
Relocation stress syndrome
diagnoses
Risk for relocation stress syndrome
Class 2. Beliefs
Class 2. Coping responses
Readiness for enhanced spiritual well-being
Ineffective activity planning
Class 3. Value/belief/action congruence
Risk for ineffective activity planning
Readiness for enhanced decision-making
Anxiety (Nursing Care Plan)
Decisional conflict
Defensive coping
Impaired emancipated decision-making
Ineffective coping
Risk for impaired emancipated decision-
Readiness for enhanced coping making
Ineffective community coping Readiness for enhanced emancipated
Readiness for enhanced community coping decision-making

Compromised family coping Moral distress

Disabled family coping Impaired religiosity

Readiness for enhanced family coping Risk for impaired religiosity

Death anxiety Readiness for enhanced religiosity

Ineffective denial Spiritual distress

208 Fear Risk for spiritual distress

NANDA Nursing Diagnosis Class 4. Environmental hazards Nursing Process
Domain 11. Safety/protection Contamination
Class 1. Infection Risk for contamination
Risk for infection Risk for occupational injury
Risk for surgical site infection Risk for poisoning
Class 2. Physical injury Class 5. Defensive processes
Ineffective airway clearance Risk for adverse reaction to iodinated
Risk for aspiration contrast media

Risk for bleeding (Nursing Care plan) Risk for allergy reaction

Impaired dentition Latex allergy reaction

Risk for dry eye Risk for latex allergy reaction

Risk for dry mouth Class 6. Thermoregulation

Risk for falls Hyperthermia
Risk for corneal injury Hypothermia
Risk for injury Risk for hypothermia
Risk for urinary tract injury Risk for perioperative hypothermia
Risk for perioperative positioning injury Ineffective thermoregulation
Risk for thermal injury Risk for ineffective thermoregulation
Impaired oral mucous membrane integrity NANDA Nursing Diagnosis
Risk for impaired oral mucous membrane Domain 12. Comfort
integrity
Class 1. Physical comfort
Risk for peripheral neurovascular
dysfunction Impaired comfort

Risk for physical trauma Readiness for enhanced comfort

Risk for vascular trauma Nausea

Risk for pressure ulcer Acute pain Chronic pain

Risk for shock Chronic pain syndrome
Impaired skin integrity (Nursing Care Plan) Labor pain
Risk for impaired skin integrity Class 2. Environmental comfort
Risk for sudden infant death Impaired comfort
Risk for suffocation Readiness for enhanced comfort
Delayed surgical recovery Class 3. Social comfort
Risk for delayed surgical recovery Impaired comfort
Impaired tissue integrity Readiness for enhanced comfort
Risk for impaired tissue integrity Risk for loneliness
Risk for venous thromboembolism Social isolation
Class 3. Violence NANDA Nursing Diagnosis
Risk for female genital mutilation Domain 13. Growth/development
Risk for other-directed violence Class 1. Growth
Risk for self-directed violence This class does not currently contain any
Self-mutilation diagnoses

Risk for self-mutilation Class 2. Development

Risk for suicide Risk for delayed development

** List is a s per 2018-2020( 12 th edition) 209

Quality Nursing Practices Annexure II
Functional Health Pattern
Assessment Criteria
Health Perception-Health Management
Description of health (usual, current), preventive measures, previous hospitalizations
and expectations of current hospitalization, description of illness (onset, cause),
prior treatment (including compliance, anticipated self-care problems)
Nutritional-Metabolic
Usual daily food and fluid intake, appetite, food restrictions or preferences, food
supplements, current weight, recent weight change, height, swallowing, chewing,
feeding problems, status of skin and mucous membrane
Elimination
Bowel–usual time, frequency, colour, consistency, assistive devices (laxatives,
suppositories, enemas), constipation, diarrhoea
Bladder–usual frequency, problems with frequency, urgency, burning, retention,
incontinence, dribbling, dysuria, polyuria, assistive devices
Skin–condition, colour, temperature, turgor, lesions, edema, pruritus
Activity-Exercise
Usual daily/weekly activities, occupation, leaisure-exercise patterns, limitations
in ambulation, bathing, dressing, toileting, dyspnea, fatigue
Sleep-Rest
Usual sleep pattern–bedtime, hours, problems falling asleep, staying asleep
Cognitive-Perceptual
Sensory deficits–hearing, sight, touch, problems with vertigo, heat or cold
sensitivity, ability to read, write
Self-Perception
Major concerns, health goals, self-description, effects of illness on self-perception,
factors contributing to illness, recovery, health maintenance
Role-Relationship
Communication–language, clear and relevant speech, expression, understanding
Relationships–living arrangements, support system, family life, complaints
(parenting, relatives, abuse, marital problems)
Sexuality-Reproductive
Changes anticipated or experienced because of condition (fertility, libido, erection,
pregnancy, contraception, menstruation)
Coping-Stress Tolerance
Decision-making (independent, assisted), major life changes (past, future, desired),
stress management (eat, sleep, take medication, seek help), comfort/security needs
Value-Belief
Sources of strength, meaning, religion (importance, type, frequency of practice),
recent changes in values, beliefs, needs during hospitalization
Adapted from Gordon M: Nursing Diagnosis: Process and Applications. New York: McGraw-
210 Hill, 1982.
 Annexure III Nursing Process

NANDA Approved Diagnostic Labels

Grouped by Gordon’s Functional Health Patterns
Health Perception/Health Thermoregulation, ineffective
Management** Tissue integrity, impaired
Aspiration, risk for Elimination**
Denial, ineffective Constipation
Health maintenance, altered Constipation, colonic
Health-seeking behaviours (specify) Constipation, perceived
Infection, risk for Diarrhoea
Injury, risk for Incontinence, bowel
Noncompliance (specify) Incontinence intentional (urinary)
Poisoning, risk for Incontinence, reflex (urinary)
Protection, altered Incontinence, stress (urinary)
Suffocation, risk for Incontinence, reflex (urinary)
Therapeutic regimen (individual), Incontinence, total (urinary)
ineffective, management of Incontinence, urge (urinary)
Trauma, risk for Urinary elimination, altered
Nutritional-metabolic** Urinary retention
Body temperature, risk for altered Activity-exercise**
Breastfeeding, effective Activity intolerance
Breastfeeding, ineffective Activity intolerance, risk of
Breastfeeding, interrupted Airway clearance, ineffective
Dysreflexia Breathing pattern, ineffective
Fluid volume deficit Cardiac output, decreased
Fluid volume deficit, risk for Disuse syndrome, risk for
Fluid volume excess Diversional activity deficit
Hyperthermia Fatigue
Hypothermia Gas exchange, impaired
Infant feeding pattern, ineffective Home maintenance management,
Injury, risk for impaired
Nutrition, altered: less than body Mobility, impaired physical
requirements Peripheral neurovascular
Nutrition, altered: more than body dysfunction, risk for
requirements Self-care deficit, bathing/hygiene*
Nutrition, altered: potential for Self-care deficit, dressing/grooming
more than body requirements Self-care deficit, feeding*
Oral mucous membrane, altered Self-care deficit, toileting*
Skin integrity, impaired Tissue perfusion, altered (specify):
Skin integriy, risk for impaired cardiopulmonary, cerebral,
Swallowing, impaired gastrointestinal, peripheral, renal

* For all Self-care Detail diagnosis specify level (0-4+)

** The Diagnosis, Altered Growth and Development can occur in any of the Functional Health Patterns.
Used by permission of NANDA Nursing Diagnoses: Definitions and Classifications, 1995-1996,
Philadelphia: NANDA.
Adapted from Functional Health Patterns from Gordon, M. (1987), Nursing Diagnosis, Process
and Application, 2nd ed., New York: McGraw-Hill Book Company. 211
Quality Nursing Practices Ventilation, inability to sustain Grieving, anticipatory
spontaneous Grieving, dysfunctional
Ventilatory weaning response Parental role conflict
(dysfunctional) Parenting, altered
Sleep-rest** Parenting, risk for altered
Sleep-pattern disturbance Role performance, altered
Cognitive-perceptual** Social interaction, impaired
Decisional conflict (specify) Social isolation
Knowledge deficit (specify) Violence, risk for: self-directed
Pain or directed at others
Pain, chronic Value-belief**
Sensory/perceptual alterations Spiritual distress (distress of the
(specify): auditory, gustatory, human spirit)
kinesthetic, olfactory, tactile, Sexuality-reproductive**
visual Sexual dysfunction
Thought processes, altered Sexuality patterns, altered
Unilateral neglect Rape-trauma syndrome
Self-perception/Self-concept** Rape-trauma syndrome: compound
Anxiety reaction
Body image disturbance Rape-trauma syndrome: silent reaction
Fear Coping Stress Tolerance**
Hopelessness Adjustment, impaired
Personal identity disturbance Caregiver role strain
Powerlessness Caregiver role strain, risk for
Self-esteem, chronic low Coping (family), ineffective:
Self-esteem, disturbance Compromised
Self-esteem, situational low Coping (family), ineffective:
Spiritual distress (distress of the Disabling
human spirit) Coping (family), potential for growth
Role-relationship** Coping (individual), ineffective
Communication, impaired verbal Post-trauma response
Coping, defensive Relocation stress syndrome
Family processes, altered Self-mutilation, risk for
Critical Care Nursing Practice
Taxonomy I Revised (1990)
Pattern 1: Exchanging 1.2.1.1 Potential for infection
1.1.2.1 Altered nutrition: more than 1.2.2.1 Potential altered body
body requirements temperature
1.1.2.2 Altered nutrition: less than 1.2.2.2 Hypothermia
body requirements 1.2.2.3 Hyperthermia
1.1.2.3 Altered nutrition: potential for 1.2.2.4 Ineffective thermoregulation
more than body requirements 1.2.3.1 Dysreflexia

**The Diagnosis, Altered Growth and Development can occur in any of the Functional Health Patterns.
Used by permission of NANDA Nursing Diagnoses: Definitions and Classifications, 1995-1996,
Philadelphia: NANDA.
Adapted from Functional Health Patterns from Gordon, M. (1987), Nursing Diagnosis, Process and
Application. 2nd ed., New York: McGraw-Hill Book Company.
* Categories with modified label terminology.
+ New diagnostic categories approved in 1990.
Note: NANDA approved diagnoses currently designated as “will be labeled” “High Risk for” in 1992
212 (The North American Nursing Diagnosis Association, St. Louis, 1990)
1.3.1.1 Constipation* 3.2.2 Altered family processes Nursing Process
1.3.1.1.1 Perceived constipation 3.2.3.1 Parental role conflict
1.3.1.1.2 Colonic constipation 3.3 Altered sexuality patterns
1.3.1.2 Diarrhoea* Pattern 4: Valuing
1.3.1.3 Bowel incontinence* 4.1.1 Spiritual distress (distress
1.3.2 Altered urinary elemination of the human spirit)
1.3.2.1.1 Stress incontinence Pattern 5: Choosing
1.3.2.1.2 Reflex incontinence 5.1.1.1 Ineffective individual coping
1.3.2.1.3 Urge incontinence 5.1.1.1.1 Impaired adjustment
1.3.2.1.4 Functional incontinence 5.1.1.1.2 Defensive coping
1.3.2.1.5 Total incontinence 5.1.1.1.3 Ineffective denial
1.3.2.2 Urinary retention 5.1.2.1.1 Ineffective family coping:
1.4.1.1 Altered (specify type) tissue disabling
perfusion (renal, cerebral 5.1.2.1.2 Ineffective family coping:
cardiopulmonary, compromised
gastrointestinal, peripheral)” 5.1.2.2 Family coping: potential for
1.4.1.2.1 Fluid volume excess growth
1.4.1.2.2.1 Fluid volume deficit 5.2.1.1 Noncompliance (specify)
1.4.1.2.2.2 Potential fluid volume deficit 5.3.1.1 Decisional conflict (specify)
1.4.2.1 Decreased cardiac output” 5.4 Health seeking behaviours
1.5.·1.1 Impaired gas exchange (specify)
1.5.1.2 Ineffective airway clearance Pattern 6: Moving
1.5.1.3 Ineffective breathing pattern 6.1.1.1 Impaired physical mobility
1.6.1 Potential for injury 6.1.1.2 Activity intolerance
1.6.1.1 Potential for suffocation 6.1.1.2.1 Fatigue
1.6.1.2 Potential for poisoning 6.1.1.3 Potential activity intolerance
1.6.1.3 Potential for trauma 6.2.1 Sleep pattern disturbance
1.6.1.4 Potential for aspiration 6.3.1.1 Diversional activity deficit
1.6.1.5 Potential for disuse syndrome 6.4.1.1 Impaired home maintenance
1.6.2 Altered protection+ management
1.6.2.1 Impaired tissue integrity 6.4.2 Altered health maintenance
1.6.2.1.1 Altered oral mucous 6.5.1 Feeding self care deficit*
membrane” 6.5.1.1 Impaired swallowing
1.6.2.1.2.1 Impaired skin integrity 6.5.1.2 Ineffective breastfeeding
1.6.2.1.2.2 Potential impaired skin 6.5.1.3 Effective breastfeeding
integrity 6.5.2 Bathing/hygiene self care
Pattern 2: Communicating deficit*
2.1.1.1 Impaired verbal 6.5.3 Dressing/grooming self care
communication deficit*
Pattern 3: Relating 6.5.4 Toileting self care deficit*
3.1.1 Impaired social interaction 6.6 Altered growth and
3.1.2 Social isolation development
3.2.1 Altered role performance* Pattern 7: Perceiving
3.2.1.1.1 Altered parenting 7.1.1 Body image disturbance”
3.2.1.1.2 Potential altered parenting 7.1.2 Self esteem disturbance”
3.2.1.2.1 Sexual sysfunction 7.1.2.1 Chronic low self esteem

* Categories with modified label terminology. 213

Quality Nursing Practices 7.1.2.2 Situational low self esteem 9.2.1.1 Dysfunctional grieving
7.1.3 Personal identity disturbance* 9.2.1.2 Anticipatory grieving
7.2 Sensory/perceptual alterations 9.2.2 Potential for violence: self-
(specify) (visual, auditory, directed
kinesthetic, gustatory, tactile, or
olfactory) directed at others
7.2.1.1 Unilateral neglect 9.2.3 Post-trauma response
7.3.1 Hopelessness 9.2.3.1 Rape-trauma syndrome
7.3.2 Powerlessness 9.2.3.1.1 Rape-trauma syndrome:
Pattern 8: Knowing compound
8.1.1 Knowledge deficit (specify) reaction
8.3 Altered thought processes 9.2.3.1.2 Rape-trauma syndrome:
Pattern 9: Feeling silent reaction
9.1.1 Pain* 9.3.1 Anxiety
9.1.1.1 Chronic pain 9.3.2 Fear

214 * Categories with modified label terminology.

 Annexure IV Nursing Process

Organizing Data According to Maslow’s

Basic Human Needs
Data Categories (Needs) Examples of Data
Physiological Oxygen, nutrition, fluids, body temperature
(Basic survival needs) regulation, warmth, elimination, shelter, sex
Safety and Security Pysical safety (infection, falls, drug side
(Need to be safe and comfortable) effects); psychological security (knowledge
of procedures, bedtime rituals, usual
routines, fear of isolation dependence
needs); pain
Love and Belonging Information about significant others, social
(Need for love and affection) supports
Esteem and Self-Esteem Changes in body image (e.g., puberty,
(Need to feel good about self) surgery); changes in self-concept, (e.g.
ability to perform usual role in family);
pride in capabilities
Self-Actualization Extent to which potential is being
achieved,
(Need to achieve one’s maximum autonomy, motivation, problem-solving
potential; need for growth and change) abilities, ability to give and accept help,
feeling about accomplishments, roles.

Source: Maslow Motivation and Personality, 2nd ed., (New York: Harper & Row, 1970). 215