What Is The Assessment Phase?
|The first phase of the nursing process is the assessment phase. In this phase, the nurse collects and organizes data related to the patient. Data includes information about the patient, family, caregivers, or the patient's community or environment as it is relevant to his health and well-being.|
What Are The Top 3 Reasons Why The Assessment Phase Is Important?
|All phases of the nursing process are essential. The following are a few reasons why the assessment phase is important for nurses to provide care.
1. In the assessment phase of the nursing process steps, the nurse gathers all pertinent information that will be used to establish a care plan.
2. Every other step of the nursing process builds upon the previous. Without a thorough assessment, the other steps of nursing care may be negatively impacted, resulting in unfavorable outcomes.
3. When assessments are performed correctly, they help reduce risks to patient safety which could occur when symptoms or other factors are not considered.
What Are The 5 Main Objectives Of The Assessment Phase?
|The assessment phase of the nursing process involves gathering information about the patient which is used to guide planning care, setting goals for recovery, and evaluating patient progress. Nurses can obtain information about the patient by implementing the following objectives.
1. Establish communication with the patient.The patient is the nurse’s main source of information. Therefore, it is essential to establish rapport with them as soon as possible.
2. Establish communicationwith the patient's family or caregivers when appropriate. Family members, friends, or other caregivers often offer insight into what is going on with the patient. It is important for nurses to listen to the patient’s support people and gather any information available.
3. Conduct a patient interview.When the patient feels comfortable, it makes it easier to get the necessary information that will be used to establish a plan of care. The patient interview is one of the main sources of information used to plan patient care.
4. Collect objective data.Any information that is measurable or observable such as vital signs and test results is considered objective data.
5. Collect subjective data.Subjective data is information gathered from the patient.
What Skills Are Required For The Assessment Phase?
|Assessments are vital to the nursing process. The information gathered in the assessment phase impacts every component of patient care. Nurses must demonstrate excellent verbal and written communication skills, strong attention to detail, and possess an in-depth understanding of body systems. The most frequently used clinical skills for patient assessment are inspection, percussion, palpation, and auscultation.|
What Exactly Does The Assessment Phase Involve?
| The assessment phase is a critical component of the nursing process. Information gathered in this phase is used to establish a foundation upon which all patient care moving forward is established. Remember, it is normal for patients to feel nervous or fearful when they are sick and in an unfamiliar place, like a hospital. Therefore, the nurse needs to establish an environment conducive to patient comfort.
The assessment may include but is not limited to, the following aspects: environmental, physical, cultural, psychological, safety, and psychosocial assessments.
The following is a guideline of what should happen during the assessment phase.
Data Collection:During the assessment phase, the nurse collects objective and subjective data using proven methods to assess the patient. The most common methods for collecting data are the patient interview, physical examination, and observation.
The patient interview is a deliberate or intended communication or conversation with the patient. It is used to obtain information, identify problems that concern the patient and/or the nurse, evaluate changes, provide support, and educate the patient and family/caregivers.
The nurse will also conduct a head-to-toe nursing assessment addressing each body system and noting any abnormalities, complaints, or concerns. Observation requires the nurse to use all their senses (sight, touch, smell, hearing) to learn about the patient.
Organize and Validate Data:After collecting data, the nurse must organize and validate data and document about the patient's health status. Validation is the process of verifying data to be sure it is factual and accurate. Nurses must be careful to not come to conclusions without adequate data to support their conclusion.
It is also necessary to understand the difference between inferences and cues. Cues are signals the patient uses to alert the nurse about a concern or question or objective data the nurse can observe or measure. Inferences are the nurse's conclusion or interpretation based on cues.
For example, the patient may complain about a painful incision two days post-operatively, and the nurse may observe the incision site is red and feels hot. These are cues. The nurse then makes an inference that the operative incision is infected.
Documenting Data:After data from the assessment is collected, organized, and validated, it must be recorded. One thing I always tell nursing students and cannot stress enough to any nurse is, "If you didn't document it, you didn't do it." While that may seem harsh, from a legal standpoint, if a nurse is asked to verify care or treatment and there is no supporting documentation, there is no way to prove the care occurred.
Thorough documentation is one of the best ways for everyone involved in patient care to be aware of changes in the patient's status, and it helps promote effective collaboration within the interdisciplinary team.
5 Common Challenges You Will Face During the Assessment Phase And How To Overcome
|While all the nursing process steps are essential, without a thorough assessment, the other steps of the nursing process are not as easy to follow through. Nurses must recognize barriers that could impede the assessment phase and find ways to overcome them. The following are five common challenges you may face during the assessment phase and some suggestions on how to overcome them.
Challenge #1: Limited Time
About the Challenge:There are days when nurses feel as though there aren’t enough hours to accomplish all the work that needs to be done. When you are short-staffed or have several patients waiting for a nursing assessment before you can initiate care, it can feel a bit overwhelming.
How to Overcome:Even on the busiest of days, it is important for nurses to perform thorough nursing assessments for all patients assigned to them. That means it is necessary to learn to manage time efficiently. The first step in overcoming limited time is to be familiar with the format or forms your employer uses to record assessments.
For example, the Health Information Technology for Economic and Clinical Health Act of 2009 advanced the adoption and use of electronic health records. Nearly one hundred percent of hospitals use some type of EHR. Electronic health records have helped improve workflow by eliminating time spent pulling physical charts or documenting in paper charts.
Challenge #2: Interruptions
About the Challenge:It is not uncommon for interruptions to occur when nurses are performing assessments. While some interruptions may be necessary, all are not. Interruptions during patient assessments can delay care and could result in errors or omissions.
How to Overcome:The best way to overcome the challenge of interruptions during the assessment step of the nursing process is to provide for privacy before you begin the assessment.
Whether you are working in triage, assessing a patient newly admitted to your floor, or in a busy emergency room, it is possible to reduce interruption. Pull the privacy curtain closed if you are in an area with more than one patient or several staff close by. Some facilities use "Do Not Disturb" or "Room in Use" signs to provide privacy for nurses and patients.
Challenge #3: Inexperience
About the Challenge:Every nurse knows the importance of a good nursing assessment. Newly graduated nurses are less experienced than other nurses and may feel uneasy about performing a nursing assessment alone. Additionally, if your facility changes its documentation format or implements a new program for charting, and you've not yet used the program, your inexperience could pose a challenge when doing an assessment.
How to Overcome:The only way to overcome inexperience is to become experienced. Nursing assessments are typically classified as either a Complete Health Assessment or a Problem-Focused Assessment. Know which type of assessment you need to perform.
Gather basic equipment: gloves, thermometer, blood pressure cuff, stethoscope, penlight, and watch. Establish a sense of trust and respect between the patient and yourself.
No matter which type of assessment you perform, it should be systematic, making sure you cover each body system. If you assess each body system and make notes about what is normal/abnormal, you decrease the chances of omissions in documentation. Remember, take your time, trust your instincts, and if you need help, ask for it.
Challenge #4: Patient Anxiety
About the Challenge:Patient anxiety can create a significant challenge for nurses during a patient assessment. Anxiety can hinder communication making it difficult to gather all the necessary data. If anxiety is bad enough, it can cause changes in vital signs, which could be misinterpreted as something more than an anxious reaction.
How to Overcome:Before beginning an assessment, take the time to make your patient comfortable. While you may not have time for a long conversation or "get to know you" session, you can ease your patient's anxiety by being calm and friendly.
Some questions may make patients feel uncomfortable, especially teenagers. Allow them time to answer your questions without feeling rushed. Verify their understanding by asking if they can explain what you've discussed in their own words.
Remember, everyone gets nervous or anxious at times, and when we are sick, it can be worse. It's nothing personal against you or your skills. Make everything about the patient.
Challenge #5: Patients Not Being Forthcoming About Symptoms
About the Challenge:Whether it is fear of the unknown, embarrassment, or another reason, there are times when patients may be apprehensive about sharing personal information.
Lack of information or omission of details that the patient may think is irrelevant may negatively impact the process of care planning. Therefore, while it is easy to understand a patient's apprehension, it is crucial for nurses to gather as much information as possible when performing a nursing assessment.
How to Overcome:It can be easy to feel frustrated if a patient is not forthcoming about symptoms during an assessment. Keep in mind, being sick and needing medical care can be frightening.
The best way to get patients to talk to you is to be accepting of them, no matter what. Be sure to tell your patient you are there for them and will work with them to help them get better. When you say things like you will "work with them," it lets your patient know you are going to do your part, but you expect them to do theirs as well.
If you feel like your patient is withholding information, instead of making an accusation, try to rephrase the question. Make your questions clear so the patient knows what information you need.
Real-World Example Of The Assessment Phase
|The format for recording nursing assessment data may vary from one facility to another. However, the information gathered for the assessment is relatively similar. The following are examples of content the nurse should include in the initial nursing assessment phase of the nursing process.
Admission NotesDate of Admission: 04/19/22 Time: 13.30
Transported By: J. Mock, LPN
Age: 54 yrs. 2 mos. Sex: M Height: 6’2” Weight: 268lbs 4oz
Attending Physician: Dr. Michael Coulvan
Date of Birth: 03/04/1968
Admitting Diagnosis: CHF, acute
Vital Signs on Admission: Temp 98.8, Resp. 20, Pulse 76, BP 136/80
Allergies: NKDA, no food allergies
Patient DemographicsPatient Name: Jerold R. Collie
Address: 123 Blakely Lane, Clayton, MO. 1234
Phone: (318) 555-1234
Physical Assessment• Neurological: Alert & Oriented x3; PERRLA, Unaided hearing; Bilateral hand grips equal; Bilateral foot push equal; no evidence of tremors; denies tingling, burning, loss of consciousness, hallucinations, disorientation, visual disturbances, or hx/o brain injury or stroke.
• Cardiovascular: Pulses present, regular, and strong: x2 upper extremities (Radial); present X2 lower extremities (Pedal); heart rate regular, strong; capillary refill <3 second upper and lower extremities
• Respiratory Status: Respirations even, labored; Dyspnea on exertion; Lungs: Bilateral rales in lung bases; Cough: Nonproductive; Oxygen: 2L per NC
• Gastrointestinal: Reports 10 lb weight gain in last two weeks. Continent of bowel; Last BM 4/19/22; Laxatives: No, Enemas: No; Hx of Constipation: No
• Genitourinary: Continent of bladder; Uses urinal prn; urinal emptied of approximately 200 cc clear, amber urine
• Integumentary: Skin is pink, warm, and dry; Mucous membranes pink and moist
• Musculoskeletal: Reports pain and stiffness in joints of hands mostly in the a.m.; denies history of gout, arthritis, bursitis, or fractures; Negative paralysis; Negative contractures, No congenital anomalies; No prosthetic devices; Able to carry out most ADLs with minimal assist but may require periods of rest r/t dyspnea with exertion; Uses walker for ambulation.
Pain AssessmentLocation: Headache Intensity: Constant, throbbing Pain Scale: 5
Functional Status: Full weight-bearing; Ambulatory with 1 person assist; Client uses walker occasionally; No supportive devices
Psychosocial: Client is alert, friendly, and answers questions readily; Comprehension: rapid.
Marital Status: Divorced; Client lives alone in his own home; Has two adult children who live nearby and visit frequently; Client reports he has several close friends who call or visit often.
Prior Medical History: History of hypertension; Denies any other medical issues prior to this admission.
Substance Use: Client reports previous substance abuse, methamphetamine was his drug of choice. Client states he has been substance and alcohol-free for three years.
Family Medical History: Paternal hx/o CHF, HTN, and Lung Ca. Maternal hx/o DM, and HTN.
*In addition to the information the nurse will gather during her assessment, the assessment phase of the nursing process includes gathering objective data such as copies of laboratory or diagnostic testing. If the facility uses electronic health records, as most do, this information will probably already be uploaded to the patient’s electronic chart. It is, however, the nurse’s responsibility to gather and verify all data is available.
Frequently Asked Questions About The Assessment Phase
1. Why Is Assessment The First Step Of The Nursing Process?The assessment phase of the nursing process lays the foundation upon which all other nursing process steps build. The information gathered during the nursing assessment tells the nurse about the patient’s history, current complaints, medications, and any other pertinent information that may impact care planning. Without a thorough, proper patient assessment, it is impossible to develop a patient-specific care plan.
2. How Is The Data For Assessment Obtained?Nurses collect data during the assessment phase by communicating with the patient, spouse, and caregivers, reading patient records, nursing observation, and collecting measurable data such as vital signs.
3. What Subjective Data Is Collected When Assessing A Patient?Subjective data is any information the nurse collects through communication. A few examples of subjective data include the reason for the patient’s visit to the doctor, patient or family medical history, medications the patient is taking, and any symptoms such as chills, aches, or pain.
4. What Objective Data Is Collected When Assessing A Patient?Objective data is any measurable information obtained from sources other than the patient. For example, the patient’s height, weight, vital signs, and laboratory or diagnostic test results are objective data collected during a patient assessment.
5. How Do Nurses Collect Verbal Data?Nurses collect verbal data by talking to patients, their family members (when appropriate), and other members of the healthcare team. Subjective matter is usually often the result of verbal communication during the patient interview.
6. How Do Nurses Collect Nonverbal Data?Nonverbal data is collected during the assessment phase of the nursing process by observing the patient's body language, reading patient charts, or medical test results. For example, the patient may not offer a verbal report of pain, but the nurse may observe him clutching or guarding his side, which could indicate pain.
The nurse can use the nonverbal data to form assessment questions as a way of following up with what she has observed or read.
7. What Are The Sources From Where Data Is Collected?The primary source of data collection during the nursing assessment is the patient. Other sources include family, friends, caregivers, and other members of the healthcare team. Data are also collected from laboratory or diagnostic reports, the patient’s medical records, and the nurse’s observations.
8. What Does Tertiary Source Of Data Mean?Tertiary data are data gathered from sources such as the patient's chart, lab, or x-ray reports. Nurses may also use tertiary sources such as diagnostic manuals or textbooks to verify or compare information.
9. How Do Nurses Verify Whether The Collected Data Is Accurate Or Not?Nurses can use a few methods to verify the accuracy of data collected during the assessment phase of the nursing process.
A few ways to verify data is to clarify information with the patient by asking additional questions, compare objective and subjective data to see if there are any discrepancies, recheck data by repeating the assessment, and verifying data with another nurse or healthcare team member.
One example of verifying data is to perform repeat vital sign check. For instance, if Mr. Jones has a blood pressure reading of 220/100 but has no history of hypertension, the nurse should retake his blood pressure to validate its accuracy. If the nurse feels it is necessary, they may use different equipment or ask someone else to perform the vital sign check to check for accuracy.
10. What Methods Do Nurses Use To Collect Data?The primary methods nurses use to collect data are observation, patient interviews, and head-to-toe assessments.
11. What Tools And Equipment Are Used To Collect Data?Nurses use various tools and equipment to help gather data about patients. A few examples of tools and equipment nurses use include a stethoscope, blood pressure cuff, thermometer, pulse oximeter, and scales. You may need a glucometer and lancets to check blood sugar, as well.
What Is The Diagnosis Phase?
|Diagnosis is the second phase of the nursing process. It is also designated by the American Nurses Association as the second Standard of Practice. The standard is defined by the ANA stating, "The registered nurse’s analysis of assessment data to determine actual or potential diagnoses, problems, and issues.” The nursing diagnosis reflects the nurse’s clinical judgment about a patient’s response to potential or actual health issues or needs.|
What Are The Top 3 Reasons Why The Diagnosis Phase Is Important?
|Before a plan of care can be established, nurses must determine which nursing diagnosis/diagnoses apply to their patients. The following are a few reasons why the diagnosis phase of the nursing process is important.
1. The diagnosis phase of the nursing process helps nurses view the patient from a holistic perspective.
2. Using a nursing diagnosis can lead to higher quality nursing care and improved patient safety, as care is based upon the needs outlined in the diagnosis.
3. The diagnosis phase helps increase the nurse’s awareness and can strengthen their professional role.
What Are The 5 Main Objectives Of The Diagnosis Phase?
|In the diagnosis phase, the nurse follows a set of objectives that end with developing the nursing diagnosis/diagnoses used to establish patient care. These are the main objectives of the diagnosis phase:
1. Identify and Define the Problem(s):The nurse must identify what problem the patient is experiencing related to the medical diagnosis.
2. Identify Risk Factors:Any situation or problem that could result because of the patient’s medical diagnosis is a risk factor for a nursing diagnosis and must be addressed.
3. Analyze Data:All data gathered during the assessment phase of the nursing process must be compiled, validated, and analyzed to support an appropriate nursing diagnosis.
4. Develop a theory/hypothesis:Nursing theories involve an organized framework of concepts and purposes that guide nursing practices. A nurse’s theory is their unique perspective about the patient’s status and measures needed to improve the patient’s outcome.
5. Establish a nursing diagnosis:After identifying problems and risk factors, analyzing data, and developing a nursing theory, the nurse can then establish a nursing diagnosis or diagnoses which is used to establish a nursing care plan.
What Skills Are Required For The Diagnosis Phase?
|Nurses will utilize several skills in the diagnosis phase of the nursing process steps. Critical thinking, problem-solving, and communication skills are necessary to work in this phase. Nurses must also demonstrate the ability to prioritize patient needs.|
What Exactly Does The Diagnosis Phase Involve?
|The diagnosis phase of the nursing process involves three main steps: data analysis, identification of the patient’s health problems, risks, and strengths, and formation of diagnostic statements.
• Data Analysis involves the nurse clustering cues, comparing patient data against standards, and identifying inconsistencies or gaps in the data.
• After data analysis, the nurse will work with the client to identify actual, risk, and possible diagnoses. In this step, the nurse will determine if an identified problem classifies as a nursing diagnosis, medical diagnosis, or collaborative diagnosis/problem. It is important to involve the patient in this step whenever possible, to identify the client's resources, coping abilities, and strengths.
• The last step of the diagnosis phase involves creating a nursing diagnosis. The nursing diagnosis may have up to three components: a NANDA-I approved nursing diagnosis, a diagnosis statement which defines the cause of the diagnosis, and an as evidenced by statement that uses patient-specific data to justify the diagnosis and diagnostic statement.
5 Common Challenges You Will Face During The Diagnosis Phase And How To Overcome
|The nursing diagnosis is different from a medical diagnosis. It requires careful consideration of the patient’s individual problems, situation, and needs to develop appropriate nursing diagnoses. Here are a few examples of challenges that may occur during the diagnosis phase of the nursing process and some suggestions on how to overcome them.
Challenge #1: Creating a Nursing Diagnosis Is Often a Complex Process
About the Challenge:Although there are resources and guidelines to help nurses develop nursing diagnoses, the process can be complex. Before nurses can create a nursing diagnosis, they must interview and assess the patient and review data, which can be time-consuming.
How to Overcome:While you may not overcome the complexities of creating nursing diagnoses, it is possible to make the process easier.
For example, be sure to review all objective data, including baseline vitals, laboratory or diagnostic test results, and subjective data. Make sure the patient's medical history is accurate and find answers to any questions not yet answered. The more information you have to work with, the easier it becomes to develop diagnoses based on that data.
Challenge #2: Nurses May Interpret Data Differently
About the Challenge:Some data are taken at face value, such as laboratory or diagnostic test results or vital signs, which are measurable. Subjective data is data reported by the patient. It is information given to the nurse by the patient based on the patient’s perception of what he is feeling. Despite efforts to appreciate the patient’s perception, nurses sometimes interpret data differently. When this happens, it can create a challenge when developing nursing diagnoses for the nursing care plan.
How to Overcome:It is essential for nurses to have a clear understanding of which data is objective or subjective. Once the differences in data are realized, nurses must be careful to not rely upon only one piece of data or their own perception of data to create a nursing diagnosis. Instead, establishing nursing diagnoses should be a collaborative effort among the nursing care team. Nurses assigned to a patient’s care should discuss their perception of data and make informed decisions based on all data.
Challenge #3: Insufficient Data to Support a Nursing Diagnosis
About the Challenge:Nurses must review all available data, including but not limited to subjective and objective findings, lab and diagnostic test results, and narrative notes from the patient interview before a nursing diagnosis can be made. If the nurse does not obtain enough data during the assessment, it will be difficult to establish appropriate nursing diagnoses.
How to Overcome:The best way to overcome the challenge of insufficient data is to perform a thorough assessment, patient and/or family interview, and make sure all results from any tests are readily available for review.
If you have reached the diagnosis phase of the nursing process and find you do not have enough data, go back to the sources of information and gather data. You may find that you need to reassess the patient or ask additional questions.
Challenge #4: Lack of Communication Between Nursing Staff
About the Challenge:Although patients are assigned a primary nurse, nursing is a team effort that requires collaboration. When there is a lack of communication between nursing team members, information may be inadvertently omitted from notes or reports. This failure in communication makes getting a complete view of the patient's status difficult, resulting in challenges in developing appropriate nursing diagnoses.
How to Overcome:Nurses must be alert and responsive to patients and one another. End of shift report is an excellent way for nurses to communicate changes in a patient's status. Nurses should make notes of anything pertinent before handing off care to the next shift nurse and clearly communicate concerns about the patient's progress or lack thereof.
When the lack of communication is resolved, nurses can compare information to use when establishing nursing diagnoses, ensuring the patient gets the best care possible.
Challenge #5: Deciding the Type of Nursing Diagnose to Use
About the Challenge:There are four main types of nursing diagnoses: Problem-focused, Risk, Health Promotion, and Syndrome.
When nurses get to the diagnosis phase of the nursing process, they must determine which type or types of diagnoses are relevant to their patients. While experienced nurses may find it easier to decide which type of diagnosis to use, new or less experienced nurses may find it challenging.
Additionally, some healthcare facilities prefer nurses to use a specific type of diagnosis, which can be frustrating, especially if the nurse feels a different type of nursing diagnosis is more appropriate.
How to Overcome:Overcoming the challenge of choosing the right type of nursing diagnosis requires understanding when each type is most appropriate. If the nurse has sufficient data from the assessment phase, they can then identify potential diagnoses and determine which type of diagnosis to use.
The following are the four types of nursing diagnoses and examples of each.
• Problem-Focused Nursing Diagnoses focus on a specific problem the patient is experiencing. This type of diagnosis has three components: a nursing diagnosis, related factors or diagnosis statement, and defining characteristics or the as evidenced by statement.
For example, the patient with chronic obstructive pulmonary disease (COPD) could have a problem-focused nursing diagnosis of "Ineffective Breathing Pattern related to decreased lung expansion as evidenced by dyspnea and ineffective cough."
• Risk Nursing Diagnoses identify potential problems or risks the patient may experience because of his medical diagnosis. A risk nursing diagnosis typically has two components, the diagnosis, and risk factors. The patient with COPD may have a risk diagnosis of "Risk for Ineffective Airway Clearance related to decreased lung capacity."
• Health Promotion Nursing Diagnoses (a.k.a. Wellness Nursing Diagnosis) is based on the nurse's clinical judgment about the patient's desire and motivation to increase his well-being. These diagnoses focus on the client's transition from one level of wellness to a higher level of wellness.
Health promotion nursing diagnoses are usually one-part statements or include only a diagnostic statement. The COPD patient's Health Promotion Nursing Diagnosis may state "Readiness for Enhanced Wellness."
• Syndrome Nursing Diagnoses are clinical judgments related to a cluster of risk nursing diagnoses predicted to occur because of a particular event or situation. The syndrome nursing diagnosis is also written as a one-part statement. For example, the COPD patient may have a syndrome diagnosis of “Ineffective Airway Clearance, Impaired Gas Exchange, Ineffective Breathing Pattern.”
Real-World Example Of The Diagnosis Phase
|After reviewing the data collected in the assessment phase of the nursing process, the nurse determines which type of diagnosis is appropriate and moves to the planning phase. In the case of Mr. Collie, the nurse chooses a problem-focused nursing diagnosis and a risk nursing diagnosis.
Nursing Diagnoses• Decreased Cardiac Output r/t impaired contractility and increased preload and afterload AEB irregular heartrate of 118, fatigue, and dyspnea on exertion (Problem-focused)
• Risk for Impaired Skin Integrity r/t edema, decreased tissue perfusion, and decreased activity. (Risk)
Frequently Asked Questions About The Diagnosis Phase
1. What Is The Difference Between Nursing Diagnosis And Medical Diagnosis?Although they share similarities, nursing and medical diagnoses are different. The nursing diagnosis is used by a nurse to identify a patient’s actual or potential risk(s), wellness, or responses to a health problem, condition, or state. A medical diagnosis is used by physicians to determine or identify a specific condition, disease, or pathologic state.
2. What Is The Meaning Of NANDA-I?NANDA-I stands for North American Nursing Diagnosis Association International. NANDA-I is a professional organization that researches, develops, disseminates, and refines nursing diagnosis terminology. The organization was formed as NANDA in 1982, it was renamed NANDA-I in 2002 because of its increased worldwide membership.
3. What Are The Components Of A Nursing Diagnosis?Each nursing diagnosis is made up of four main components: problem and its definition, etiology, risk factors, and defining characteristics.
4. What Is The Purpose Of Establishing A Nursing Diagnosis?The primary purpose of establishing a nursing diagnosis is to communicate the healthcare needs of the patient among members of the healthcare team and within the delivery system. The nursing diagnosis allows nurses to facilitate individualized care for the patient and family and strengthens the profession.
5. Why Is It Important to Form an Accurate Nursing Diagnosis?The nursing diagnosis serves as the basis for selecting nursing interventions, which have a significant impact on patient outcomes. If an accurate nursing diagnosis is not chosen, the plan of care and subsequent nursing interventions may not address the patient’s issues appropriately resulting in negative patient outcomes.
6. How Do Nurses Rank Nursing Diagnoses?Nursing diagnoses are ranked in order of importance. Immediate life-threatening problems or issues related to survival are given the highest priority.
7. Can Two Patients with the Same Medical Diagnosis Have Different Nursing Diagnoses?Nursing diagnoses focus on the patient’s response to health conditions, and patients often respond differently. Therefore, it is not uncommon for patients with the same medical diagnosis to have different nursing diagnoses.
What Is The Planning Phase?
|The planning phase of the nursing process is the stage where nursing care plans that outline goals and outcomes are created. The goals and outcomes formulated during this phase directly impact patient care and are based on evidence-based nursing practices.|
What Are The Top 3 Reasons Why The Planning Phase Is Important?
|The planning phase of the nursing process is essential in promoting high-quality patient care. It is considered the framework upon which scientific nursing practice is based. The following are three of the top reasons why the planning phase is so important.
1. Care planning provides direction for personalized patient care based on the client's unique needs.
2. The planning phase enhances communication between patients, nurses, and other members of the healthcare team.
3. Planning encourages continuity of care across the healthcare continuum and promotes positive patient outcomes.
What Are The 5 Main Objectives Of The Planning Phase?
|The American Nurses Association's Standards of Clinical Nursing Practice identifies planning as one of the essential principles for promoting the delivery of competent nursing care. The planning phase of the nursing process has five main objectives, all of which focus on nursing interventions to promote positive patient outcomes. The following are the main objectives of the planning phase.
1. Establish Priorities:The nurse reviews the nursing diagnoses and prioritizes them according to physiological and psychological importance. This step helps the nurse organize the patient’s nursing diagnoses into a format that promotes effective planning.
2. Develop SMART goals:This objective of the planning phase of the nursing process involves setting goals related to each diagnosis. Goal setting helps to provide guidelines for nursing interventions and establishes criteria by which the care plan's effectiveness is evaluated.
Remember the acronym SMART when developing goals. SMART goals are Specific, Measurable, Relevant, and Time-bound.
3. Establish Expected Outcomes:After goals are established, the nurse can identify expected outcomes based on each goal. Outcomes should be realistic, mutually desired by the patient and nurse, and attainable within a designated amount of time.
4. Identify Interventions:After goals are agreed upon and established, the nurse then implements decision-making skills to select nursing interventions that are relevant to the nursing diagnoses. Interventions are prioritized in order of planned implementation.
5. Document the Care Plan:After priorities, goals, outcomes, and interventions are established, the nurse must document the care plan.
Documentation of the care plan includes nursing orders which communicate the interventions the nursing staff will implement for the client. Nursing orders must be well-written and should include the order date, which action will be performed, a detailed description, the time frame in which the intervention will be performed, and the nurse's signature.
What Skills Are Required For The Planning Phase?
|Nurses utilize many of the same skills for each of the nursing process steps. In the planning phase, nurses must have strong communication skills, time management and organizational skills, and a willingness to work collaboratively with the patient and interdisciplinary team. Nurses must have strong critical thinking skills, as they must weigh the risks and consequences of each intervention.|
What Exactly Does The Planning Phase Involve?
|The planning phase of the nursing process is when nurses formulate goals and outcomes that impact patient care. This step involves prioritizing patient needs, identifying expected outcomes, establishing nursing interventions, and identifying patient-centered goals.
In the planning phase, nurses identify goals and outcomes for patient care based on evidence-based practice guidelines. Once objectives of planning are met, the nurse creates a written plan of care, or care plan.
The care plan is a written guide organizing data about the patient's care into a formal statement of strategies or interventions the nurse will enact to help the patient achieve optimal outcomes.
5 Common Challenges You Will Face During The Planning Phase And How To Overcome
|It is normal to face challenges, no matter which phase of patient care you are involved with. The planning phase can feel a bit tricky because nurses need to be careful to develop plans considering the individuality of the patient. The following are a few examples of challenges you could phase when you begin planning patient care.
Challenge #1: Not Knowing How to Format the Care Plan
About the Challenge:There are different formats for creating a care plan. If nurses do not know the format their facility uses, it can be easy to overlook components of the plan, which may impact the delivery of care and patient outcomes.
How to Overcome:Not knowing how to format a care plan is probably one of the easiest challenges to overcome in the planning phase. With the implementation of electronic health records and programs that help nurses choose nursing diagnoses and interventions, creating care plans has become easier.
As a nurse creating a care plan, your job is to make sure all relevant information is included in the plan. The nursing diagnosis, interventions and expected outcomes, time frames in which outcomes should be accomplished, and a place to document evaluations should all be included.
Challenge #2: Not Establishing Goals and Expected Outcomes
About the Challenge:Have you ever heard the saying, "Failure to plan is planning to fail"? That principle applies to everything in life, including patient care. No care plan is complete without clear goals and outcome identification. If there are no goals or an insufficient number of goals relevant to the nursing diagnoses, deciding on interventions is impossible.
How to Overcome:The nursing care plan should always be patient-centered and individualized. Goals and outcomes should be tailored to meet each patient's needs and should be considerate of the patient's cultural beliefs and values.
Nurses use the nursing care plan as a road map that all members of the nursing team use to help the patient reach goals. It is vital that nurses establish goals that are attainable and relevant to the patient's specific needs.
In the planning phase of the nursing process, the nurse should establish short-term and long-term goals and determine the outcome associated with achieving those goals. Establishing goals and outcomes is vital to this step in the nursing process. Therefore, nurses should take the time to consider each goal and outcome carefully and discuss the plan with the patient and healthcare team.
Challenge #3: Unrealistic Goals
About the Challenge:While it is okay to be optimistic about a patient’s ability to achieve goals, it is essential for nurses to be realistic about what their patients can or cannot do. If goals are unrealistic, patients can quickly become frustrated. Frustration often leads to noncompliance, which can negatively affect patient outcomes.
How to Overcome:After carefully determining nursing diagnoses, the nurse must determine which goals the patient can achieve realistically. Realistic goals are specific and well-defined, measurable, achievable, relevant to the patient's status and needs, and achievable within a specific timeframe.
To overcome the challenge of unrealistic goals, identify what is essential in helping the patient achieve optimal outcomes. Discuss goals with the patient, family, care providers, and nurse manager. Once realistic goals are identified, offer support and encouragement to the patient. The nurse should continually monitor and assess the patient's progress toward meeting goals.
Challenge #4: Limited Patient Input
About the Challenge:Although nurses can create nursing care plans independent of patient input, excluding patients from plans about their care may lead to distrust or confusion. If a patient feels he cannot communicate with nurses or his opinion is not valued, it can result in noncompliance with the care plan and negatively impact the patient’s outcome.
How to Overcome:When patients are involved in their care, the processes of planning and implementation seem to flow easier.
Nurses can overcome the challenge of limited patient output by promoting a comfortable, trusting nurse-patient relationship which encourages patient participation. Ask the patient about their health goals and what limits they feel may affect their ability to reach goals. Offer suggestions about desired goals and expected outcomes and explain why they are relevant to the patient's health and long-term well-being.
Challenge #5 Being Unsure of Appropriate Time Frames to Meet Expected Outcomes/Goals
About the Challenge:It is possible for nurses to create realistic goals and expected outcomes in the care plan but to set unrealistic time frames in which the patient is expected to meet those goals.
One reason this challenge occurs is nurses sometimes fail to plan care based on an individual patient’s abilities. Instead, they establish goals based on their perception of what any patient with the same diagnosis may be capable of achieving.
How to Overcome:When working through the planning phase of the nursing process, nurses must consider patients as individuals with specific needs and abilities. The nurse should specify a time frame for achieving goals that is reasonable and that does not create undue stress or worry for the patient.
When discussing the care plan with the patient, it is important to explain each goal to the patient. Include education about why there is an anticipated time for accomplishing goals and what each person's responsibilities are to help make achieving the goals possible.
Real-World Example Of The Planning Phase
|Once the nursing diagnosis or diagnoses are established, the nurse completes the planning phase of the nursing process by determining patient goals and expected outcomes and establishing which nursing interventions to initiate.
The following are goals and expected outcomes for Mr. Collie based on the nursing diagnoses of Decreased Cardiac Output and Risk for Impaired Skin Integrity.
Decreased Cardiac OutputGoals and Expected Outcomes
1. The client will verbalize understanding of activities and lifestyle changes focused on reducing cardiac workload.
2. The client will demonstrate adequate cardiac output AEB vital signs within normal limits.
3. The client will report decreased episodes of dyspnea.
1. Monitor vital signs.
2. Palpate peripheral pulses.
3. Assess for signs of edema.
4. Monitor for signs of pallor or cyanosis.
Risk for Impaired Skin IntegrityGoals and Expected Outcomes
1. Maintain skin integrity.
2. The client will verbalize understanding of techniques/behaviors to prevent skin breakdown by end of shift.
1. Inspect skin, noting areas of altered circulation, bony prominences, and/or signs of emaciation.
2. Encourage frequent position changes
3. Provide alternating pressure mattress, heel protectors, and elbow protectors
Frequently Asked Questions About The Planning Phase
1. What Are The Components Of A Care Plan?There are four main components of a nursing care plan: Client Assessment, including medical and diagnostic reports, Nursing Diagnosis, Desired Outcomes/Goals, Nursing Interventions with evidence-based rationale, and Evaluation.
2. How To Write A Nursing Care Plan?The best way to write a nursing care plan is to include information associated with the nursing process steps.
• Assess the client: Review all relevant data, medical history, vital signs and assessment data, physical, emotional, spiritual, ad psychosocial needs, identify areas where improvement is needed, and establish risk factors.
• Identify Nursing Diagnoses: A nursing diagnosis is an actual or potential health problem that nurses can address without physician intervention. A few examples include risk for falls, risk for compromised skin integrity, and risk for dehydration.
• Set Goals: Setting goals requires establishing desired outcomes and identifying measures by which the patient will achieve them. Although there may be situations where it is not possible, it is ideal to set goals with the patient when they are able.
• Implement Nursing Interventions: Nursing interventions are actions taken by the nurse to help patients achieve goals and meet desired outcomes. Nursing interventions include initiating fall precautions, administering medications, and assessing the patient’s pain level.
• Evaluate effectiveness of the plan and change or update, as needed or indicated.
The next two FAQs about the planning phase are related to setting goals. Goals are statements of purpose describing an objective to be accomplished. All goals in the nursing care plan should be client-centered and measurable.
Each goal should focus on the problem, measures to resolve the problem, and rehabilitation. The time frame given to accomplish goals in the care plan varies, depending on the setting where patient care is provided.
A tip I always share with students is, if you are not sure how to write a goal, try converting the nursing diagnosis into a positive statement of action.
3. How To Set Goals For Short-Term Nursing Care Plans?A short-term goal in nursing care plans is a goal focused on demonstrating a change in behavior. Short-term goals can be completed in as little as a few minutes or up to a few days. The nurse should consider what behavior the patient can most easily exhibit or identify to show understanding of goals and attempts to achieve goals.
For example, let’s consider the following nursing diagnosis and determine a short-term goal.
“Ineffective airway clearance related to decreased energy, fatigue, and pneumonia as evidenced by dyspnea, decreased breath sounds over affected lung, and ineffective cough.”
Short-term goal example: “Patient will identify and demonstrate behaviors to achieve airway clearance within eight hours of nursing intervention as evidenced by respiratory rate not greater than sixteen breaths per minute, and absence of dyspnea and cyanosis.”
4. How To Set Goals For Long-Term Nursing Care Plans?Long-term goals are the desired outcome related to accomplishing one or more short-term goals for an extended period. In some cases, long-term goals can take weeks, months, or even years, to achieve.
Sample nursing diagnosis: “Situational low self-esteem related to change in functional abilities due to loss of body part as evidenced by preoccupation with missing limb, not looking at or touching stump following right above the knee amputation.”
Long-term goal examples: “Client will demonstrate adaptation to physical changes and acceptance of self as an amputee within ninety days following surgery; Client will develop plans for adapting to role modification and demonstrate positive self-esteem within six months.”
5. Are There Different Types of Planning in the Nursing Process?Planning occurs in three stages: initial, ongoing, and discharge. Initial planning occurs when the nurse performing the admission assessment develops a preliminary plan of care. Ongoing planning is the process of updating the patient’s plan of care as new information is collected and evaluated. Discharge planning begins at admission and involves the anticipation of the client’s needs and plans to meet those needs after discharge from care.
6. Should Patients Be Involved in the Planning Phase of the Nursing Process?When possible, the patient should be included in all phases of the nursing process. The patient is the best source of data, the person being treated, and usually the most reliable source of information used to determine the patient’s strengths, weaknesses, and likelihood of compliance with a plan of care.
What Is The Implementation Phase?
|The fourth phase of the nursing process is the implementation phase. This phase is when nurses initiate the interventions established during the planning phase.|
What Are The Top 3 Reasons Why The Implementation Phase Is Important?
|After the nursing assessment is performed, nursing diagnoses are established, and a care plan is developed, the plan must be initiated. All phases of the nursing process are essential. The following are three of the top reasons why the implementation phase is so important.
1. Implementation of the nursing process is significant because it involves action on the nurse's part to promote positive patient outcomes. Conversely, if the care plan is not implemented, there is a lack of nursing care, negatively impacting patient outcomes.
2. When the nursing care plan is implemented (implementation phase), nurses can begin to gauge patient responses to interventions.
3. Implementation supports continuity of care. Care begins from the first patient encounter and continues until discharge.
What Are The 5 Main Objectives Of The Implementation Phase?
|The implementation phase of the nursing process is an ongoing process in patient care. From the time a plan is established, the implementation process continues in a cycle which includes the five objectives below.
1. Ongoing Assessment:The nursing care plan is developed based on data from the initial nursing assessment. However, because a patient's condition can change quickly or nurses may obtain new data, ongoing assessments are necessary to validate the need for proposed interventions. Ongoing observations and assessments provide information supporting adaptations of the nursing care plan to promote improved, individualized care.
2. Establishing Priorities:Utilizing data from initial and going assessments, the nurse then establishes priorities for implementing care. Prioritization is based upon which problems are considered most important by the nurse, patient, family/significant others, previously scheduled tests/treatments (diagnostic tests, surgery, therapy), and available resources.
3. Allocating Resources:Before implementing nursing interventions, the nurse must review proposed interventions and determine the skills and knowledge level required to safely and effectively implement them. For example, the nurse will consider if the patient can independently perform an activity, if a family member may assist, or if the activity requires assistance from a healthcare professional.
Although some interventions require the skills and knowledge of a registered nurse, others are less complex and may be delegated to licensed practical/vocational nurses or assistive personnel. The nurse allocates personnel resources by determining the needs of the client, the type of personnel who are available, and facility protocol for care.
4. Initiating Nursing Interventions:After verifying priorities and determining resources, the nurse can initiate nursing interventions. Interventions are determined by the cause of the problem and often vary among patients with similar nursing diagnoses depending on expected outcomes for each patient.
When initiating nursing interventions, the patient's preference and developmental level should be considered. Additionally, nurses must review the physician's orders which may impact nursing interventions by imposing restrictions on specific factors such as the patient's allowed activity level or diet.
5. Documenting Interventions and Patient Response:Nurses are legally obligated to document all interventions and any observations concerning the patient's response to those interventions. Documentation may be done on checklists, flow sheets, or in narrative form. Any verbal communication between the patient and nurse or among the healthcare team related to interventions and patient responses should be recorded, as well.
What Skills Are Required For The Implementation Phase?
|Like the other nursing process steps, the implementation phase requires broad clinical knowledge, critical thinking and analysis skills, and strong judgment.
Whether a nurse is caring for one patient, or several patients, careful planning and time management skills are essential in this phase. Nurses must have psychomotor, interpersonal, and cognitive skills as these serve as competencies through which high-quality nursing care is delivered.
Psychomotor skills are necessary to safely perform nursing activities such as handling medical equipment competently.
Interpersonal skills help nurses establish therapeutic nurse-patient relationships and promote interdisciplinary collaboration.
Cognitive skills are necessary to help the nurse understand the rationale for proposed interventions and make appropriate observations.
What Exactly Does The Implementation Phase Involve?
|Implementation involves a focus on accomplishing predetermined goals and continuous progress toward achieving desired outcomes. This phase of the nursing process involves prioritizing nursing interventions, assessing patient safety during nursing interventions, delegating interventions when appropriate, and documenting all interventions performed.|
5 Common Challenges You Will Face During The Implementation Phase And How To Overcome
|Nursing interventions vary depending on the patient and the setting where care is provided. The following are examples of common challenges nurses face during the implementation phase of the nursing process and suggestions for how to overcome them.
Challenge #1: Lack of Clinical Experience
About the Challenge:Even when goals and desired outcomes are clearly defined, inexperienced nurses may find implementing nursing interventions challenging. Inexperience may occur because the nurse is newly graduated or if a nurse is transferred to a department where they have never worked.
How to Overcome:While the most effective way to overcome a lack of clinical experience is to work as much as you can and gain experience, patient care cannot wait for us to feel comfortable performing unfamiliar tasks.
When nurses face challenges implementing patient care because of inexperience, the best way to overcome it is to speak up and ask for help. As a nursing instructor, I always encouraged my students to ask questions about everything. The only bad question is the one you do not ask. Nurse leaders, supervisors, and administrators appreciate nurses who readily admit when they need help or guidance.
Challenge #2: Patient Noncompliance
About the Challenge:Noncompliance is recognized by NANDA-I as a nursing diagnosis. It is defined as “the behavior of a patient or caregiver that does not correspond with the therapeutic plan agreed upon by the individual, family or guardian, and healthcare provider.” Noncompliance can negatively impact patient outcomes, reduce the patient’s quality of life, and result in increased healthcare costs.
How to Overcome:One of the best ways to prevent or stop patient noncompliance is to involve the patient in all aspects of care planning.
Nurses should ensure the patient is educated about their illness, plans to manage the illness, and expected outcomes of therapies. Education should also include information about how noncompliance may negatively affect the patient's outcome. The patient's understanding of all education should be verified, and if the nurse is unsure the patient clearly understands, teaching should be repeated.
Challenge #3: Psychosocial Factors
About the Challenge:Psychosocial factors can impact all aspects of patient care. For example, if there is a presence of domestic abuse or violence, the patient may be afraid to discuss important issues related to care, which could result in misunderstanding established goals.
How to Overcome:Psychosocial factors may seem a little tricky to navigate. However, if they become a factor affecting the implementation of the nursing process steps, nurses must find a way to try and address the issues.
For instance, if the nurse suspects a patient is afraid to discuss certain issues in the presence of others, the nurse should ask for privacy while talking to the patient. By doing so, the nurse offers the patient the opportunity to speak openly without fear of retaliation by an abuser. Then the nurse can discuss options for care with the patient and how to proceed moving forward.
Challenge #4: Nursing Care Plan Does Not Reflect Appropriate Care for the Nursing Diagnoses
About the Challenge:Every step of the nursing process builds upon the previous step. Nurses must perform a thorough assessment and collect sufficient data before making nursing diagnoses. After a nursing diagnosis is established, interventions are planned to help resolve the issue(s) the patient is experiencing. If the planned interventions do not align appropriately with the care expected for a nursing diagnosis, implementing the care plan properly cannot occur.
How to Overcome:It is vital for nurses to handle each phase of the nursing process with deliberate care and appropriate actions. Nursing care plans should be evaluated by the nursing team to ensure that the patient’s needs are addressed, and planned interventions are relevant to the nursing diagnosis/diagnoses.
Challenge #5: Nursing Shortage
About the Challenge:The World Health Organization estimates a shortage of more than four million nurses in the United States. No matter how well-written a nursing care plan is, if there is not enough staff to carry out the nursing interventions, the plan cannot be successfully implemented.
How to Overcome:While it is understandable that one nurse cannot remedy the nursing shortage, there are things all nurses can do to help relieve the impact the shortage causes.
Real-World Example Of The Implementation Phase
|Implementation of the nursing care plan involves educating the patient and helping him achieve goals and expected outcomes. It also involves putting the planned nursing interventions into action. To implement the care plan, the nurse will establish priorities, delegate tasks to appropriate staff, initiate interventions, and document interventions and the patient’s response.
Nursing documentation should be accurate and relevant to the patient. Use appropriate nursing language and facility-approved abbreviations. In the case of Mr. Collie, the nurse's documentation may look like the following narrative.
04/19/22 @ 1430: Discussed plan of care with client and son who was present in the room, including educating about goals and expected outcomes. The client verbalizes understanding of the importance of lifestyle and activity changes to reduce cardiac workload, the need for vital signs to be within normal limits, and measures to decrease episodes of dyspnea, and safety precautions. The client also verbalizes understanding of the risk for impaired skin integrity and verbally recalls skin integrity is at risk due to "bad circulation and swelling." The client voices understanding that frequent position changes and keeping the skin clean and dry will decrease the likelihood of skin breakdown. Assessed peripheral pulses, which are present and strong bilaterally in upper and lower extremities X2, 2+ pitting edema noted in bilateral lower extremities. Skin remains intact, pink, warm, and dry, no signs of redness or pallor. Heel and elbow protectors applied. Alternating pressure mattress in place and operational. ------------D. Leonard, RN
Frequently Asked Questions About The Implementation Phase
1. What Are The Steps In The Process Of Implementing A Nursing Plan?The first step in the process of implementing a nursing care plan is to determine what, how, and when an intervention should be performed. Once you know the what, how, and when, you can determine if the task can be delegated and to whom.
2. What Are The 3 Types Of Interventions That Are Implemented?The three types of interventions implemented in the nursing process are independent, dependent, and interdependent.
• Independent interventions are actions nurses can perform on their own and do not require assistance from other team members. For example, routine tasks such as monitoring vital signs or assessing the patient's pain level are independent nursing interventions.
• Dependent interventions require instructions or input from the physician. For instance, if the patient needs a new medication, the physician must prescribe the medication and order the amount and frequency. Dependent nursing interventions are interventions the nurse may not initiate on her own.
• Interdependent interventions are also known as collaborative interventions. These interventions involve all members of the interdisciplinary team. For example, if a patient had a total knee replacement, his recovery plan may include a prescription medication from the doctor, assistance with dressing from the nurse or unlicensed assistive personnel, and physical or occupational therapy by the physical therapist or occupational therapist.
3. Are Implementation And Intervention The Same In The Nursing Process?While many sources use the words interchangeably, intervention and implementation are defined somewhat differently. Interventions are planned nursing activities performed on a patient's behalf. They include assessment, adherence to medication therapy, and problem-solving. Implementation is the act of carrying out interventions.
4. How To Prioritize Nursing Interventions?Strategies to prioritize patient care typically include the use of nursing diagnoses combined with Maslow’s Hierarchy of Needs Theory.
Any nursing diagnosis that suggests a risk or threat to the patient’s survival should be the nurse’s first priority. Remember your ABCs: Airway, Breathing, Circulation.
Other physiological needs necessary for survival are considered.
Psychosocial needs are then addressed.
Psychological needs including a sense of love or belonging, self-esteem, and self-actualization are prioritized last.
5. Is Giving Meds Part Of Implementation In The Nursing Process?Medication administration is part of the implementation phase of the nursing process steps. The nursing interventions outlined in the planning phase should include information about medication administration. When the nurse initiates the action of administering the medication, she is implementing the plan of care.
6. Who Is Responsible for Implementing the Nursing Care Plan?All members of the nursing team have roles related to implementing the care plan. In the planning phase of the nursing process, the Registered Nurse determines which tasks may be delegated to Licensed Practical/Vocational Nurses, Nursing Assistants, or other members of the healthcare team. It is essential to remember that, even if a task is delegated, the RN in charge of the patient’s care is accountable for making sure all tasks are completed.
What Is The Evaluation Phase?
|Evaluation is the final phase of the nursing process. Although evaluation is considered the last of the nursing process steps, it does not indicate an end to the nursing process. Instead, evaluation should be an ongoing process carried out in daily nursing activities that ensures quality nursing interventions and the effectiveness of those interventions.|
What Are The Top 3 Reasons Why The Evaluation Phase Is Important?
|The evaluation phase of the nursing process is important because it fulfills several purposes. The following are the top three reasons why this phase is essential in the nursing process.
1. The primary purpose of an evaluation is to determine the patient’s progress toward achieving established goals and outcomes.
2. Through evaluation, it is possible to determine a healthcare agency’s ability to provide safe and effective healthcare services.
3. Evaluation provides a mechanism to help nurses define, explain, and measure the results of nursing interventions.
What Are The 5 Main Objectives Of The Evaluation Phase?
|The Standards of Clinical Nursing Practice established by the American Nurses Association designates evaluation as a fundamental component of the nursing process. This phase of the nursing process has the following objectives.
1. To determine if nursing interventions are helping clients achieve expected outcomes.The effectiveness of nursing interventions is determined by evaluating goals and expected outcomes to determine if they provide direction for patient care. It is essential to evaluate nursing interventions because they serve as standards by which patient progress is measured.
2. To verify the quality of nursing care provided.The evaluation phase is not meant to make nurses feel as if their work is being critiqued or judged. Evaluation allows nurses to verify if the care they are providing meets the standard of care for the patient’s needs.
3. To promote accountability among nurses.Evaluation involves reviewing all aspects of the patient’s care and determining its effectiveness in helping the patient recover. Because nurses work collaboratively with one another and other members of the healthcare team, the evaluation phase promotes the nurses’ sense of accountability to their patients and to one another.
4. To analyze current data.In the evaluation phase of the nursing process, nurses compare and analyze data from the time the patient was admitted to care and determine if positive or negative trends are occurring. This data is helpful in deciding the next course of action to take in patient care.
5. To promote continuity of care.Although the evaluation phase is the fifth and last step in the nursing process, nurses constantly evaluate patient progress. Evaluation allows nurses to establish a pattern of continuous care and attention, which helps promote positive patient outcomes.
What Skills Are Required For The Evaluation Phase?
|The evaluation phase of the nursing process is primarily based on the nurse's accurate and efficient use of observation, critical thinking, and communication skills.
Some changes in a patient's status may be subtle, requiring sharp observational skills. The ability to analyze reassessment data and use critical thinking are necessary to determine if outcomes have been met or decide if changes in the care plan are needed. As in other phases of patient care, the nurse must demonstrate strong communication skills, as evaluation includes the patient and all members of the healthcare team.
What Exactly Does The Evaluation Phase Involve?
|During the evaluation phase of the nursing process, nurses determine the patient’s response to interventions and whether goals have been met. The evaluation process consists of seven steps, as follows.
• Determine if Established Standards Were Met:Standards and goals are established during the planning phase of the nursing process steps and carried out in the implementation phase. Nurses use evaluation to determine the presence of changes in the patient's status relevant to the established standards.
• Data Collection:The nurse uses assessment skills early in the nursing process to gather data used to establish goals and expected outcomes. Those same skills are vital for comprehensive, effective evaluation to occur. Nurses gather data to help determine the success of nursing interventions.
• Using Data to Determine Goal Achievement:The data collected during the evaluation phase must answer the question, “Did the patient achieve the treatment goals and expected outcomes outlined in the care plan?” Nurses validate goal achievement by analyzing the patient’s response to nursing interventions outlined in the nursing care plan.
• Examine the Relationship of Nursing Interventions to the Patient’s Status:Effective nursing interventions address relevant patient needs. If the nursing intervention is efficient, it can be a primary factor related to helping clients resolve actual or potential problems or risk factors.
• Evaluate Whether the Nursing Interventions Contributed to Improved Patient Status:During the evaluation phase, the nurse must use critical thinking skills to determine which nursing actions contributed to improved patient outcomes and to what degree they were effective. This step in the evaluation process allows the nurse to analyze the patient's response to interventions, determine the benefits of those interventions, and identify opportunities or needs for change.
• Reassessment:In the evaluation phase of the nursing process, the nurse uses observation and assessment skills to reevaluate the patient's status. In this step, the nurse compares baseline data collected in the initial nursing assessment with the patient's current health status.
• Modifying the Nursing Care Plan:If the evaluation determines a lack of progress toward established goals, the nursing care plan is revised or modified. At this point, revisions are developed by beginning the nursing process anew. The client is reassessed (Assessment), more appropriate nursing diagnoses are established (Diagnosis), new or revised goals and outcomes are developed (Planning), new nursing interventions are implemented, or previous interventions are repeated to maximize effectiveness (Implementation). Then the patient's response is reevaluated (Evaluation).
5 Common Challenges You Will Face During The Evaluation Phase And How To Overcome
|The evaluation phase of the nursing process is the point where nurses and patients hope to see measurable improvement. The following are a few challenges nurses may face when in the evaluation phase.
Challenge #1: Incomplete Documentation
About the Challenge:Every nurse is responsible for documenting patient progress and other pertinent information. If one nurse fails to document and report patient changes or progress, or to record laboratory or diagnostic test results, it can lead to challenges when it is time for the evaluation phase.
How to Overcome:The most effective way to overcome this challenge is to avoid it happening altogether. Be sure to document information about your patients during each shift. Any change in status, progress or lack of progress, subjective and objective findings, or other relevant information should be readily available for any nurse caring for that patient.
Challenge #2: Patient Frustration
About the Challenge:In a perfect world, patients would be admitted to care, nursing interventions would be implemented, and we would see positive results. Unfortunately, it doesn’t always work that way. One of the challenges nurses face in the evaluation phase is frustration related to slow progress or failing to meet goals.
How to Overcome:Overcoming the challenges that occur when patients become frustrated takes patience and understanding.
If you find yourself in the evaluation phase of the nursing process steps and faced with this situation, take the time to talk to your patient. Assure them that progress does not always happen as quickly as we would like and encourage them to keep pressing forward.
Let your patient know that you are there to support and help them and that your priority is to see them improve. Sometimes all it takes to calm a patient and help them regain focus is an assuring word and calming presence.
Challenge #3: Patients Withholding Information
About the Challenge:It is not uncommon for patients to try and mask symptoms or deny concerns when nurses evaluate their progress. This is especially common when a patient has been hospitalized or in a care facility for an extended period and wants to return home.
How to Overcome:In situations like this, a strong nurse-patient relationship and good communication skills are necessary. If you feel your patient is not being forthcoming about their progress, or perhaps new symptoms have emerged that they do not want to discuss, ask direct questions. Explain the importance of transparency when reporting progress, problems, or concerns.
Challenge #4: Family Denial of the Patient’s Need for Continued Care
About the Challenge:As nurses, we naturally hope that interventions positively impact our patients and that we can see improvement when evaluating them. Family members hope to see their loved ones recover and return to normal, as well. A significant challenge nurses can face when evaluating patient progress occurs when the patient's status declines or there is little improvement and family members deny the reality of the patient's situation.
How to Overcome:Many times, the fear of the unknown or lack of understanding is what causes family denial. If family members struggle with accepting the idea of continued care or changes in the plan of care, the nurse should acknowledge their concerns and offer support. When appropriate, talk with the patient and family together and discuss the previous plan of care and any suggestions for alterations or changes and the rationale for them.
Challenge #5: Patient Wishing to Terminate Care Before Discharge Goals Are Met
About the Challenge:Nurses understand that patients respond differently to care with some progressing faster than others, and the evaluation process helps to identify those patients who need extra time or updated care plans.
Unfortunately, because patients do not always understand the complexities of interventions and expected outcomes, it can lead to feelings of despair. If patients slowly progress or fail to meet goals and expected outcomes, their frustration sometimes leads them to give up or desire to seek care elsewhere.
How to Overcome:When faced with this challenge, it is crucial for nurses to approach the patient with an attitude of empathy and attempt to discuss the patient's concerns. Depending on the patient's status and ability to understand, it may take some time and reinforced teaching to help them understand that slow progress is not failure. Explain your view of your patient's current status compared to his status on admission. Encourage the patient by assuring him that even slow progress is progress. Offer ideas of ways you think the care plan can be amended to suit his needs and ask for input.
Remember, despite your best efforts, there may be times when patients decide to terminate care. Unless the patient has been deemed incapable of making informed decisions, you may not interfere with his choice to leave your care. It is necessary to document everything you discuss with the patient and his response to your instructions and education.
If the patient decides to leave your facility's care, there is appropriate paperwork to be signed, called an A.M.A. (Against Medical Advice) discharge. The charge nurse or physician is usually responsible for having the patient sign this form and submitting it to administration.
Real-World Example Of The Evaluation Phase
|In the evaluation phase, the nurse reassesses the patient and determines if goals and outcomes are being met or if the care plan needs to be modified. Observations are recorded in the patient’s chart.
04/20/22 @ 1500: After twenty-four hours of nursing intervention, the client demonstrates adequate cardiac output as evidenced by decreased blood pressure of 130/78 and pulse rate of 72. The client states his breathing is less labored and that if he begins to feel short of breath, he lies still to rest. O2 per NC @ 2L continuous. Observed 500 cc clear, amber urine in the urinal. The patient continues to have 2+ pitting edema in bilateral lower extremities. MD notified, awaiting response/order. The client has turned/repositioned q2h to decrease the risk of impaired skin integrity. No signs of compromised skin integrity noted at this time. -------D. Leonard, RN
Frequently Asked Questions About The Evaluation Phase
1. What Is The Primary Purpose Of The Nursing Evaluation Process?The primary purpose of evaluation in the nursing process steps is to determine if patient goals and expected outcomes have been met or if the nursing care plan needs to be modified.
2. What Are The Steps In The Process Of Evaluation?The steps of evaluation in the nursing process include collecting data, comparing data with desired goals and expected outcomes, analyzing the patient’s response to nursing interventions, identifying factors impacting the success or failure of the nursing care plan, continuing, modifying, or terminating the care plan, and planning future nursing care.
3. How To Improve The Evaluation Process?Although the nursing process is focused on nursing diagnoses and interventions, each member of the patient’s healthcare team has a role and the actions they take in patient care can impact the effectiveness of the nursing care plan. Therefore, the most effective way of improving evaluation in the nursing process, is to include the patient, family (when appropriate), and all members of the interdisciplinary team in the process.
4. How Often Should A Nurse Evaluate A Patient?Although healthcare facilities and organizations have minimum guidelines for the frequency of nurse evaluations, it should be an ongoing process involved in patient care. The patient’s status and the effectiveness of nursing interventions should be continuously evaluated, and the care plan should be modified, when necessary.
5. What Information Does the Nurse Look For in the Evaluation Phase of the Nursing Process?In the evaluation phase, nurses gather much of the same type of information as what is gathered during the assessment. During this phase, nurses review current vital signs and laboratory or diagnostic test results. They use information entered into the patient’s chart, such as nurses’ notes, flow sheets, and other pertinent information. Additionally, during the evaluation, nurses reinterview the patient and look for both subjective and objective data to determine if the plan of care was effective.
6. Who Is Responsible For Evaluating the Effectiveness of the Nursing Care Plan?The registered nurse assigned to the patient’s care is the primary person responsible for the evaluation phase of the nursing process. The RN evaluates all information necessary to determine if the goals and expected outcomes were met or if alterations in the plan are needed. Keep in mind, however, every member of the nursing care team plays a vital role in the RN's ability to conduct a thorough evaluation because each person is responsible for documenting their work and the patient’s response.