The Nursing Process is key to helping nurses make clinical judgments that are appropriate for
clients.
Steps of the Nursing Process (Registered Nurse [RN])
1) Assessment: Assess the objective and subjective data that pertains to the client.
2) Analysis: Determine the client problems.
3) Planning: Create a plan to address client problems.
4) Implementation: Take action to provide care as outlined in planning.
5) Evaluation: Evaluate the effectiveness of the interventions provided and document the
client’s response.
Steps of the Nursing Process (Licensed Practical Nurse [LPN])
1) Data collection: Collect subjective and objective data about the client and report
changes to the RN.
2) Planning: Create a plan to address client problems under the supervision and guidance
of the RN.
3) Implementation: Collaborate with the RN to take action as outlined in planning.
4) Evaluation: Evaluate the effectiveness of the interventions provided, within the LPN
scope of practice, and under the supervision of the RN.
Assessment: Always just subjective or objective
• Assessment (Data Collection) = Observation + Interview + Examination
• You should always assess first before evaluating
• Every time a patient come into hospital they need a new care plan to be generated despite
readmission
Observation- general survey
Interview- Just talking and know past medical history, medications, present health status,
biographic, reason for seeking care, family history, immunization, Last examinations, personal
and psychosocial history,
- INITIAL INTERVIEW IS neurological assessment (orientation 4x)
- Examination: physical/focus assessment
- A nursing/health history identifies the client's health status, strengths, health problems,
health risks, and need for nursing care.
When assessing, the primary source of client information is the client.
- Other sources the nurse should consider include the client's support people, the client
record, family members accompanying the client, and other health care professionals.
- It would not be appropriate to use other clients as a source, because this would violate
confidentiality.
Examination- Put hands on them (Inspect, Percuss, Palpate, Auscultate)
Cue clustering refers to the grouping of cues (subjective and objective data) that deviate from
standards or from what is considered normal
Objective data
• Is there a difference between an objective and subjective data?
A nurse is explaining about Objective data. Which of the following is the correct answer?
1. pain score 8/10
2. Low level of pain tolerance
, 3. Leg swelling pitting edema +2
4. I cannot take it anymore I want to die
(1 and 3); pain score 8/10 is objective because it is measurable
Subjective data is not necessarily always in quotation marks
Nursing diagnosis
• Diagnosis = Analysis + identification + Formulation of
• Nursing Diagnosis
• Nursing Diagnoses are Organized by Basic Human Need
• Please Write a nursing diagnosis for a previous patient from your last clinical.
1. The nurse assesses that a client uses accessory muscles, breathes shallowly, and has a
pulse oximetry reading of 94%. Which nursing diagnosis will the nurse assign?
ineffective breathing patterns
• Use of accessory muscles and shallow breathing are consistent with “ineffective
breathing patterns,” not the other choices. The client’s pulse oximetry is not so low that
“impaired gas exchange” applies.
• The client's diminished breath sounds can be addressed by the
independent nursing interventions of turn, cough, and deep breathe.
The temperature, elevated blood pressure, and pain medication will
require orders from the health care provider.
A client who is scheduled for coronary angioplasty is concerned about whether the surgery is
safe and wonders whether it would be beneficial. Which nursing diagnosis relates to this client's
condition?
Correct response:
Fear related to potential risk and surgical outcomes
Explanation:
The client expresses fear of the risks related to unknown outcome of surgery. The appropriate
nursing diagnosis is Fear related to potential risk and surgical outcomes. Fear is always related to
a known source; in this case it is the surgery. Anxiety is always related to unknown sources and
is not applicable in this case. Coping and knowledge deficit are not related to fear of surgery.
PES- PROBLEM FOCUSED
“P” stands for the health related issue or problem.
,“E” stands for the etiology or cause. The name of the nursing diagnosis is linked to the etiology
with the phrase “related to”
“S” stands for the signs/symptoms or defining characteristics. identified with the phrase “as
manifested by.” “as evidence by”
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have
this infant, but I have always believed that abortion is a sin. I don't know what to do." What
nursing diagnosis would be most appropriate for the nurse to formulate?
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's
statement
Nausea related to motion sickness as evidence by client stating, “I feel nauseas when sitting in a
car”
The risk nursing diagnoses are written as two-part statements because they do not include
defining characteristics.
Actual nursing diagnosis describes human response to a health problem.
Health promotion nursing diagnoses describe potential for enhancement to a higher state.
Possible nursing diagnosis is made when not enough evidence supports the problem.
The first step in formulating a nursing diagnosis is to analyze assessment data to identify
patterns. Next, the nurse validates the diagnosis and then writes the nursing diagnosis statement.
Indicators of dysfunction are described when the statement is formulated.
An older adult client's venous ulcer has become foul-smelling after the client began using strips
of a sheet to dress the wound due to running out of sterile dressing supplies. How should the
nurse document a nursing diagnosis statement related to this client's circumstances?
Correct response:
Risk for Infection related to knowledge deficit
Risk for Infection related to knowledge deficit is the correct answer. The client's use of nonsterile
items to dress a wound clearly indicates a lack of knowledge. Acute confusion describes a
change in cognition, not an inappropriate action. A risk for infection does not cause a knowledge
deficit. Indeed, sepsis can result from an infection, but infection is a medical diagnosis, not a
nursing diagnosis.
, Nurses write nursing diagnoses to describe client problems that nurses can
treat.
Nursing diagnoses found in the Perception/Cognition domain are defined as those that
involve the human information-processing system, including attention, orientation, sensation,
perception, cognition, and communication.
- A nursing diagnosis included in the Perception/Cognition domain is Impaired Verbal
Communication.
Health-Seeking Behaviors is included in the Health Promotion domain.
Readiness for Enhanced Sleep is included in the Activity/Rest domain.
Impaired Social Interaction is included in the Role Relationships domain.
Examples
• Oxygen Needs
1. Altered (specify) tissue perfusion (renal, cerebral, cardiopulmonary,
gastrointestinal, peripheral)
• Decreased cardiac output
• Impaired gas exchange
• Ineffective airway clearance
• Ineffective breathing pattern
• Potential for aspiration
• Potential for suffocation
2. Temperature Maintenance
Potential altered body temperature
• Hypothermia
• Hyperthermia
• Ineffective thermoregulation
Nursing Diagnosis: Actual
• Actual (present) diagnosis
• Actual
• Nursing Diagnosis - Patient Problem + Etiology+ signs and symptoms
• Please write an example of an actual diagnosis of your patient from last clinical
Nursing Diagnosis: Potential
• Nursing Diagnosis = Problem + Risk Factors (risk factor is etiology) (no s/s)
Risk for Aspiration possibly evidenced by left side paralysis.
clients.
Steps of the Nursing Process (Registered Nurse [RN])
1) Assessment: Assess the objective and subjective data that pertains to the client.
2) Analysis: Determine the client problems.
3) Planning: Create a plan to address client problems.
4) Implementation: Take action to provide care as outlined in planning.
5) Evaluation: Evaluate the effectiveness of the interventions provided and document the
client’s response.
Steps of the Nursing Process (Licensed Practical Nurse [LPN])
1) Data collection: Collect subjective and objective data about the client and report
changes to the RN.
2) Planning: Create a plan to address client problems under the supervision and guidance
of the RN.
3) Implementation: Collaborate with the RN to take action as outlined in planning.
4) Evaluation: Evaluate the effectiveness of the interventions provided, within the LPN
scope of practice, and under the supervision of the RN.
Assessment: Always just subjective or objective
• Assessment (Data Collection) = Observation + Interview + Examination
• You should always assess first before evaluating
• Every time a patient come into hospital they need a new care plan to be generated despite
readmission
Observation- general survey
Interview- Just talking and know past medical history, medications, present health status,
biographic, reason for seeking care, family history, immunization, Last examinations, personal
and psychosocial history,
- INITIAL INTERVIEW IS neurological assessment (orientation 4x)
- Examination: physical/focus assessment
- A nursing/health history identifies the client's health status, strengths, health problems,
health risks, and need for nursing care.
When assessing, the primary source of client information is the client.
- Other sources the nurse should consider include the client's support people, the client
record, family members accompanying the client, and other health care professionals.
- It would not be appropriate to use other clients as a source, because this would violate
confidentiality.
Examination- Put hands on them (Inspect, Percuss, Palpate, Auscultate)
Cue clustering refers to the grouping of cues (subjective and objective data) that deviate from
standards or from what is considered normal
Objective data
• Is there a difference between an objective and subjective data?
A nurse is explaining about Objective data. Which of the following is the correct answer?
1. pain score 8/10
2. Low level of pain tolerance
, 3. Leg swelling pitting edema +2
4. I cannot take it anymore I want to die
(1 and 3); pain score 8/10 is objective because it is measurable
Subjective data is not necessarily always in quotation marks
Nursing diagnosis
• Diagnosis = Analysis + identification + Formulation of
• Nursing Diagnosis
• Nursing Diagnoses are Organized by Basic Human Need
• Please Write a nursing diagnosis for a previous patient from your last clinical.
1. The nurse assesses that a client uses accessory muscles, breathes shallowly, and has a
pulse oximetry reading of 94%. Which nursing diagnosis will the nurse assign?
ineffective breathing patterns
• Use of accessory muscles and shallow breathing are consistent with “ineffective
breathing patterns,” not the other choices. The client’s pulse oximetry is not so low that
“impaired gas exchange” applies.
• The client's diminished breath sounds can be addressed by the
independent nursing interventions of turn, cough, and deep breathe.
The temperature, elevated blood pressure, and pain medication will
require orders from the health care provider.
A client who is scheduled for coronary angioplasty is concerned about whether the surgery is
safe and wonders whether it would be beneficial. Which nursing diagnosis relates to this client's
condition?
Correct response:
Fear related to potential risk and surgical outcomes
Explanation:
The client expresses fear of the risks related to unknown outcome of surgery. The appropriate
nursing diagnosis is Fear related to potential risk and surgical outcomes. Fear is always related to
a known source; in this case it is the surgery. Anxiety is always related to unknown sources and
is not applicable in this case. Coping and knowledge deficit are not related to fear of surgery.
PES- PROBLEM FOCUSED
“P” stands for the health related issue or problem.
,“E” stands for the etiology or cause. The name of the nursing diagnosis is linked to the etiology
with the phrase “related to”
“S” stands for the signs/symptoms or defining characteristics. identified with the phrase “as
manifested by.” “as evidence by”
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have
this infant, but I have always believed that abortion is a sin. I don't know what to do." What
nursing diagnosis would be most appropriate for the nurse to formulate?
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's
statement
Nausea related to motion sickness as evidence by client stating, “I feel nauseas when sitting in a
car”
The risk nursing diagnoses are written as two-part statements because they do not include
defining characteristics.
Actual nursing diagnosis describes human response to a health problem.
Health promotion nursing diagnoses describe potential for enhancement to a higher state.
Possible nursing diagnosis is made when not enough evidence supports the problem.
The first step in formulating a nursing diagnosis is to analyze assessment data to identify
patterns. Next, the nurse validates the diagnosis and then writes the nursing diagnosis statement.
Indicators of dysfunction are described when the statement is formulated.
An older adult client's venous ulcer has become foul-smelling after the client began using strips
of a sheet to dress the wound due to running out of sterile dressing supplies. How should the
nurse document a nursing diagnosis statement related to this client's circumstances?
Correct response:
Risk for Infection related to knowledge deficit
Risk for Infection related to knowledge deficit is the correct answer. The client's use of nonsterile
items to dress a wound clearly indicates a lack of knowledge. Acute confusion describes a
change in cognition, not an inappropriate action. A risk for infection does not cause a knowledge
deficit. Indeed, sepsis can result from an infection, but infection is a medical diagnosis, not a
nursing diagnosis.
, Nurses write nursing diagnoses to describe client problems that nurses can
treat.
Nursing diagnoses found in the Perception/Cognition domain are defined as those that
involve the human information-processing system, including attention, orientation, sensation,
perception, cognition, and communication.
- A nursing diagnosis included in the Perception/Cognition domain is Impaired Verbal
Communication.
Health-Seeking Behaviors is included in the Health Promotion domain.
Readiness for Enhanced Sleep is included in the Activity/Rest domain.
Impaired Social Interaction is included in the Role Relationships domain.
Examples
• Oxygen Needs
1. Altered (specify) tissue perfusion (renal, cerebral, cardiopulmonary,
gastrointestinal, peripheral)
• Decreased cardiac output
• Impaired gas exchange
• Ineffective airway clearance
• Ineffective breathing pattern
• Potential for aspiration
• Potential for suffocation
2. Temperature Maintenance
Potential altered body temperature
• Hypothermia
• Hyperthermia
• Ineffective thermoregulation
Nursing Diagnosis: Actual
• Actual (present) diagnosis
• Actual
• Nursing Diagnosis - Patient Problem + Etiology+ signs and symptoms
• Please write an example of an actual diagnosis of your patient from last clinical
Nursing Diagnosis: Potential
• Nursing Diagnosis = Problem + Risk Factors (risk factor is etiology) (no s/s)
Risk for Aspiration possibly evidenced by left side paralysis.
