NURSING AS A SCIENCE

Fundamentals of nursing

Nursing As A Science

A. Problem Solving Process

B. Nursing Process
1.Assessment
A.Subjective: Health History
B.Objective: Physical Examination and Diagnostic Tests
2. Nursing Diagnosis
•NANDA
•NANDA TAXONOMY II

Critical thinking
is the process of intentional higher level thinking to define a client’s problem, examine the evidence-
based practice in caring for the client, and make choices in the delivery of care.
Clinical reasoning
is the cognitive process that uses thinking strategies to gather and analyze client information,
evaluate the relevance of the information, and decide on possible nursing actions to improve the
client’s physiologic and psycho-social outcome.

Applying Critical Thinking to Nursing Practice

When a nurse uses intentional thinking, a relationship develops among the knowledge, skills, and
attitudes that are ascribed to critical thinking and clinical reasoning, the nursing process, and the
problem-solving process.
PROBLEM-SOLVING PROCESS
Problem-solving is a mental activity in which a problem is identified that represents an unsteady state.

In Problem Solving
The nurse obtains Then carefully The situation is The nurse does not
information that evaluates the possible carefully monitored discard the other
clarifies the nature of solutions and chooses over time to ensure its solutions but holds
the problem and the best one to initial and continued them in reserve in the
suggests possible implement. effectiveness. event that the first
solutions. solution is not
effective

The nurse may also encounter a similar problem in a different client situation where an alternative
solution is determined to be the most effective. Therefore, problem solving for one situation
contributes to the nurse’s body of knowledge for problem solving in similar situations.

Commonly used approaches to problem solving

Trial and Error
One way to solve problems is through trial and error, in which a number of approaches are tried until
a solution is found.

Intuition
Intuition is the understanding or learning of things without the conscious use of reasoning. It is also
known as sixth sense, hunch, instinct, feeling, or suspicion.

Research Process
It is important that nurses identify evidence that supports effective nursing care One critical source of
this evidence is research.
The nursing process

The nursing process is a systematic, rational method of planning and providing individualized nursing
care. Its purpose is to identify a client’s health status and actual or potential health care problems or
needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to
meet those needs. The client may be an individual, a family, a community, or a group.

Assessment
 Assessing is the systematic and continuous collection, organization, validation, and
documentation of data (information).
 In effect, assessing is a continuous process carried out during all phases of the nursing process.
 e.g.: in the evaluation phase, assessment is done to determine the outcomes of the nursing
strategies and to evaluate goal achievement.
Collecting Data
Data collection is the process of gathering information about a client’s health status. It must be both
systematic and continuous to prevent the omission of significant data and reflect a client’s changing
health status.
A database contains all the information about a client; it includes the nursing health history physical
assessment, primary care provider’s history and physical examination, results of laboratory and
diagnostic tests, and material contributed by other health personnel.

BIOGRAPHIC DATA
Client’s name, address, age, sex, marital status, occupation, religious preference, health care
financing, and usual source of medical care
CHIEF COMPLAINT OR REASON FOR VISIT
The answer given to the question “What is troubling you?” or “Describe the reason you came to the
hospital or clinic today.” The chief complaint should be recorded in the client’s own words.
HISTORY OF PRESENT ILLNESS
■ When the symptoms started
■ Whether the onset of symptoms was sudden or gradual
■ How often the problem occurs
■ Exact location of the distress
■ Character of the complaint (e.g., intensity of pain or quality of sputum, emesis, or discharge)
■ Activity in which the client was involved when the problem occurred
■ Phenomena or symptoms associated with the chief complaint
■ Factors that aggravate or alleviate the problem
PAST HISTORY
■ Illnesses, such as chickenpox, mumps, measles, rubella (German measles), rubeola (red measles),
streptococcal infections, scarlet fever, rheumatic fever, hepatitis, polio, and other significant illnesses
■ Immunizations and the date of the last tetanus shot
■ Allergies to drugs, animals, insects, or other environmental agents, the type of reaction that occurs,
and how the reaction is treated
■ Accidents and injuries: how, when, and where the incident occurred, type of injury, treatment
received, and any complications
■ Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery performed,
course of recovery, and any complications
■ Medications: all currently used prescription and over-the counter medications, such as aspirin,
nasal spray, vitamins, or laxatives

FAMILY HISTORY OF ILLNESS

To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their
current state of health or, if they are deceased, the cause of death are obtained. Particular attention
should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies,
arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders.

LIFESTYLE
■ Personal habits: the amount, frequency, and duration of substance use (tobacco, alcohol, coffee,
cola, tea, and illegal or recreational drugs)
■ Diet: description of a typical diet on a normal day or any special diet, number of meals and snacks
per day, who cooks and shops for food, ethnic food patterns, and allergies
■ Sleep patterns: usual daily sleep/wake times, difficulties sleeping, and remedies used for difficulties
Activities of daily living (ADLs): any difficulties experienced in the basic activities of eating, grooming,
dressing, elimination, and locomotion
■ Instrumental ADLs: any difficulties experienced in food
preparation, shopping, transportation, housekeeping,
laundry, and ability to use the telephone, handle finances,
and manage medications
■ Recreation/hobbies: exercise activity and tolerance,
hobbies and other interests, and vacations
SOCIAL DATA
■ Family relationships/friendships: the client’s support system in times of stress (who helps in time of
need?), what effect the client’s illness has on the family, and whether any family problems are
affecting the client.
■ Ethnic affiliation: health customs and beliefs; cultural practices that may affect health care and
recovery.
■ Educational history: Data about the client’s highest level of education attained and any past
difficulties with learning.
■ Occupational history: current employment status, the number of days missed from work because of
illness, any history of accidents on the job, any occupational hazards with a potential for future
disease or accident, the client’s need to change jobs because of past illness, the employment status of
spouses or partners and the way child care is handled, and the client’s overall satisfaction with the
work.
■ Economic status: information about how the client is paying for medical care (including what kind of
medical and hospitalization coverage the client has), and whether the client’s illness presents financial
concerns.
■ Home and neighborhood conditions: home safety measures and adjustments in physical facilities
that may be required to help the client manage a physical disability, activity intolerance, and activities
of daily living; the availability of neighborhood and community services to meet the client’s needs.

PSYCHOLOGICAL DATA
■ Major stressors experienced and the client’s perception of them
■ Usual coping pattern for a serious problem or a high level of stress
■ Communication style: ability to verbalize appropriate emotion; nonverbal communication—such as
eye movements, gestures, use of touch, and posture; interactions with support persons; and the
congruence of nonverbal behavior and verbal expression.
PATTERNS OF HEALTH CARE
All health care resources the client is currently using and has used in the past. These include the
primary care provider, specialists (e.g., ophthalmologist or gynecologist), dentist, folk practitioners
(e.g., herbalist or curandero), health clinic, or health center; whether the client considers the care
being provided adequate; and whether access to health care is a problem.

Types of Data
Subjective data, also referred to as symptoms or covert data, are apparent only to the person
affected and can be described or verified only by that person. Itching, pain, and feelings of worry are
examples of subjective data. Subjective data include the client’s sensations, feelings, values, beliefs,
attitudes, and perception of personal health status and life situation.

Objective data, also referred to as signs or overt data, are

detectable by an observer or can be measured or tested against an accepted standard. They can be
seen, heard, felt, or smelled, and they are obtained by observation or physical examination.

Sources of Data
Primary- Client

Secondary
Support People:
Family members or other support persons
Client Records: records and reports, laboratory and diagnostic analyses,
Health Care Professionals: other health professionals,
Relevant literature

Data Collection Methods

The principal methods used to collect data are:
Observing - occurs whenever the nurse is in contact with the client or support persons.
Interviewing - used mainly while taking the nursing health history
Examining - the major method used in the physical health assessment.

1. Nursing Observation
Determines the patient’s current responses (physical and emotional)
Determines the patient’s current ability to manage care
Determines the immediate environment and its safety
Determines the larger environment (hospital or community)

OBSERVATIONAL SKILLS

INTERVIEW
A planned communication or a conversation with a purpose ( to give info., identify problems of
mutual concern, evaluate change, teach, provide support, or provide counseling or therapy)

There are two approaches to interviewing

Directive interview - The nurse establishes the purpose of the interview and controls the interview, at
least at the outset.
Non directive interview - or rapport building interview, the nurse allows the client to control the
purpose, subject matter, and pacing.
Rapport is an understanding between two or more people.

Type of Questions Used in Interviews

Closed questions- used in the directive interview, are restrictive and generally require only “yes” or
“no” or short factual answers giving specific information. Closed questions often begin with “when,”
“where,” “who,” “what,” “do (did, does),” or “is (are, was).” Examples of closed questions are “What
medication did you take?”
Open-ended questions - associated with the non directive interview, invite clients to discover and
explore, elaborate, clarify, illustrate their thoughts or feelings. E.g. “What brought you to the
hospital?” “Would you describe more about how you relate to your child?”
Neutral question is a question the client can answer without
direction or pressure from the nurse, is open ended, and is
used in non directive interviews.
Examples :
“How do you feel about that?”
“What do you think led to the operation?”

Leading question, by contrast, is usually closed, used in a directive interview, and thus directs the
client’s answer. Example:
“You’re stressed about surgery tomorrow, aren’t you?”
“You will take your medicine, won’t you?”
Examining
The physical examination or physical assessment is a systematic data collection method that uses
observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. To conduct
the examination the nurse uses techniques of inspection, auscultation, palpation, and percussion

ORGANIZING DATA
The nurse uses a written (or electronic) format that organizes the assessment data systematically. This
is often referred to as a nursing health history, nursing assessment, or nursing database form. The
format may be modified according to the client’s physical status such as one focused on
musculoskeletal data for orthopedic clients.

Conceptual Models/Frameworks
Most schools of nursing and health care agencies have developed their own structured assessment
format. Many of these are based on selected nursing models or frameworks

Three examples are:

Gordon’s functional health pattern framework
Gordon (2010) provides a framework of 11 functional health patterns. Gordon uses the word pattern
to signify a sequence of recurring behavior. The nurse collects data about dysfunctional as well as
functional behavior. Thus, by using Gordon’s framework to organize data, nurses are able to discern
emerging patterns.

Orem’s self-care model

Orem (2001) delineates eight universal self-care requisites of humans
Roy’s adaptation model.
Roy (2008) outlines the data to be collected according to the Roy adaptation model and classifies
observable behavior into four categories: physiological, self-concept, role function, and
interdependence.

Wellness Models
Nurses use wellness models to assist clients to identify health risks and to explore lifestyle habits and
health behaviors, beliefs, values, and attitudes that influence levels of wellness.
Such models generally include the following:
■ Health history
■ Physical fitness evaluation
■ Nutritional assessment
■ Life-stress analysis
■ Lifestyle and health habits

Non nursing Models

Frameworks and models from other disciplines may also be helpful for organizing data. These
frameworks are narrower than the model required in nursing; therefore, the nurse usually needs to
combine these with other approaches to obtain a complete history.

VALIDATING
The information gathered during the assessment phase must be complete, factual, and accurate
because the nursing diagnoses and interventions are based on this information.
Validation is the act of “double-checking” or verifying data to confirm that it is accurate and factual.
Validating data helps the nurse complete these tasks:
■ Ensure that assessment information is complete.
■ Ensure that objective and related subjective data agree
■ Obtain additional information that may have been overlooked.
■ Differentiate between cues and inferences. Cues are subjective or objective data that can be
directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel,
smell, or measure. Inferences are the nurse’s interpretation or conclusions made based on the cues
(e.g., a nurse observes the cues that an incision is red, hot, and swollen; the nurse makes the
inference that the incision is infected).
■ Avoid jumping to conclusions and focusing in the wrong direction to identify problems.

DOCUMENTING
To complete the assessment phase, the nurse records client data. Accurate documentation is
essential and should include all data collected about the client’s health status.
A judgment or conclusion such as “appetite good” or “normal appetite” may have different meanings
for different people.
To increase accuracy, the nurse records subjective data in the client’s own words, using quotation
marks. Restating in other words what someone says increases the chance of changing the original
meaning.
DIAGNOSING
Diagnosing is the second phase of the nursing process. In this phase, nurses use critical thinking skills
to interpret assessment data and identify client strengths and problems.
Definitions
Diagnosing- Refers to the reasoning process
Diagnosis- A statement or conclusion regarding the nature of a phenomenon
Diagnostic labels- Standardized NANDA names for diagnoses
Etiology- Causal relationship between ad problem and its related factors
Nursing diagnosis- Problem statement consisting of diagnostic label plus etiology
NANDA
-International recognition came with the First Canadian Conference in Toronto in 1977 and the
International Nursing Conference in May 1987 in Calgary, Alberta, Canada.
-In 1982, the conference group accepted the name North American Nursing Diagnosis Association
(NANDA), recognizing the participation and contributions of nurses in the United States and Canada.
-In 2002, the organization changed its name to NANDA International to further reflect the worldwide
interest in nursing diagnosis.
The purpose of NANDA International is to define, refine, and promote a taxonomy of nursing
diagnostic terminology of general use to professional nurses.
A taxonomy is a classification system or set of categories arranged based on a single principle or set
of principles.

Components of a NANDA Nursing Diagnosis

(1) A nursing diagnosis has three components:
the problem and its definition
(2)the etiology, and
(3) the defining characteristics.
Each component serves a specific purpose.

Problem (diagnostic label) and definition

 Describes the client's health problem or response
 May require specification
 Qualifiers added to give additional meaning
 Such as Deficient, Impaired, Decreased, Ineffective, and Compromised
Etiology (related factors and risk factors)
 Identifies one or more probable causes of the health problem
 Gives direction to the required nursing therapy
 Enables the nurse to individualize the client's care
Defining Characteristic
 Cluster of existing signs and symptoms indicates actual diagnosis
Clients have signs and symptoms.
 Cluster of factors that cause client to be more vulnerable to a problem indicates "risk for"
diagnosis
 No subjective or objective data exist at present

Nursing diagnosis
 Professional nurses responsible for making
 Includes only those health states that nurses are educated and licensed to treat
 Judgment made only after thorough, systematic data collection
 Continuum of health states
Actual diagnosis
 Problem presents at the time of assessment.
 Presence of associated signs and symptoms (Examples are Ineffective Breathing Pattern and
Anxiety)
Health promotion diagnosis
-Preparedness to implement behaviors to improve their health condition
Example: Readiness for Enhanced Nutrition
Risk nursing diagnosis
-Problem does not exist.
-Presence of risk factors (Example: Risk for Infection)
Wellness diagnosis
-Describes human responses to levels of wellness in an individual, family or community
-Readiness for Enhanced Spiritual Well-Being or Readiness for Enhanced Family Coping.
Differentiating Nursing Diagnoses from Medical Diagnoses
Nursing diagnosis
-A statement of nursing judgment based on education, experience, expertise and license to treat
-Describes human response, the client's physical, sociocultural, psychological, and spiritual responses
to an illness or health problem
-Changes when client's responses change
-Independent nursing functions
(areas of health care that are unique to nursing, separate and distinct from medical management)
Medical diagnosis
-Made by a physician
-Refers to a disease process
-Remains the same as long as the disease process is present
-Dependent nursing functions (physician-prescribed therapies and treatments)

Differentiating Nursing Diagnoses from Collaborative Problems

-Use both independent and dependent (physician-prescribed) interventions
-Require monitoring of client's condition and prevention of potential complications
-Occur when a particular disease or treatment is present

The Diagnostic Process

The diagnostic process uses the critical thinking skills of analysis
and synthesis.
Critical thinking- Reviewing data and considering explanations before forming opinions
Analysis- Separation into components (deductive reasoning)
Synthesis- Putting together of parts into whole (inductive reasoning)
Analyzing data Identifying health problems, Formulating diagnostic
risks, and strengths statements

DIAGNOSING
Analyzing Data
 Comparing data with standards
 Standard or norm
 Generally accepted measure, rule, model, or pattern
 Cue considered significant if:
 Points to negative, positive change in client's health status or pattern
 Varies from norms of client population
 Indicates a developmental delay

-Clustering cues
 -Determine relatedness of facts
-Inductively or with a framework
-Identifying gaps and inconsistencies in data
-Conflicting data
-All inconsistencies must be clarified before a valid pattern can be established.

Identifying Health Problems, Risks, and Strengths

Determining problems and risks
-Problems that support tentative or actual risks and possible diagnoses
-Determine whether problem is a nursing diagnosis, medical diagnosis, or collaborative problem
Determining problems and risks
-Problems that support tentative or actual risks and possible diagnoses
-Determine whether problem is a nursing diagnosis, medical diagnosis, or collaborative problem
Determining strengths
-Resources and abilities to cope
-Can be an aid to mobilizing health and regenerative processes
-Can include home life, education, recreation, exercise, work, family and friends, religious beliefs,
and sense of humor
Formulating Diagnostic Statements
Basic two-part statements
Problem (P)
Etiology (E)
Joined by the words "related to"
Add words if NANDA label contains the word Specify

Basic three-part statements

PES format
Problem (P)
Etiology €
Signs and symptoms (S)
Recommended for beginning diagnosticians
List signs and symptoms grouped by subjective and objective data

Formulating Diagnostic Statements

One-part statements
-Health promotion diagnoses beginning with Readiness for Enhanced
-Seven syndrome diagnoses
Variations of basic formats
-Unknown etiology
-Defining characteristics present but cause, contributing factors unknown
Variations of basic formats
-Complex factors
-When too many etiologic factors to state briefly
-Possible
-Either problem or etiology
Variations of basic formats
-Secondary to
-Divide etiology into two parts
-Adding a second part to make it more precise
-Indicate location, etc.
Collaborative problems
-Begin with Potential Complication (PC)
-Etiology may be useful in some situations.
Evaluating the quality of the diagnostic statement
-Validate with client
-Compare signs and symptoms to NANDA defining characteristics
Avoiding Errors in Diagnostic Reasoning
-Verify data
-Build a good knowledge base and acquire clinical experience
-Have a working knowledge of what is normal -Consult resources
-Base diagnoses on patterns rather than an isolated incident -Improve critical thinking skills
Ongoing Development of Nursing Diagnoses
-The first taxonomy was alphabetical.
-Later version based on "human response patterns"
-Taxonomy II has three levels.
-Domains -Classes
-Nursing diagnoses

Introduction
Planning
-Deliberate, systematic, problem-solving phase of nursing process
Nursing interventions
-Treatment that a nurse performs to enhance patient/client outcomes
Nurse responsible, but input from client essential

Types of Planning
 Begins with first client contact
 Continues until nurse–client relationship ends (discharge)
 Is multidisciplinary (involves all health care providers interacting with the client) and includes the
client and family to the fullest extent possible in every step.
Initial Planning
 Develops initial comprehensive plan of care
 Begun after initial assessment
Ongoing Planning
 Done by all nurses who work with the client
 Individualization of initial care plan
 At the beginning of a shift
 Using ongoing assessment data, the nurse carries out daily planning for the following purposes:
 Determine whether client's health status has changed
 Set priorities for client's care during shift
 Using ongoing assessment data, the nurse carries out daily planning for the following purposes:
 Decide which problems to focus on during shift
 Coordinate nurse's activities so that more than one problem can be addressed at each client
contact
Discharge Planning
 Process of anticipating and planning for needs after discharge
 Addressed in each client's care plan
 Begins at first client contact
 Involves comprehensive and ongoing assessment
Developing Nursing Care Plans
The end product of the planning phase of the nursing
process is a formal or informal plan of care.
 Informal nursing care plan
 A strategy for action that exists in nurse's mind
 Formal nursing care plan
 Written or computerized guide
 Standardized care plan
 A formal plan that specifies actions for a group of clients with common needs
 Individualized care plan
 Tailored to meet the unique needs of a specific client
Developing Nursing Care Plans
 Standardized care plan
 A formal plan that specifies actions for a group of clients with common needs
 Individualized care plan
 Tailored to meet the unique needs of a specific client
Standardized Approaches to Care Planning
 Established to ensure minimal criteria for care are met
 Established for efficient use of time
 Standards of care
 Nursing actions for clients with similar medical conditions
 Achievable rather than ideal nursing care
 Interventions for which nurses are accountable
 Usually, there are agency records that may be referred to in client's care plan.
 Standards of care
 Written from the perspective of the nurse's responsibilities
 Do not contain medical interventions
 Standardized care plans
 Predeveloped guides for nursing care of client with a need arising frequently in agency
 Written from the perspective of what care the client can expect
 Protocols
 Indicate actions commonly required for a particular groups of clients
 May include both primary care provider's orders and nursing interventions
 Example: Protocol for admitting a client to the intensive care unit
 Policies and procedures
 Developed to govern handling of frequently occurring situations
 Cover situations pertinent to client care
 Example: Policy specifying the number of visitors a client may have
 Standing order
 Written document
 Policies
 Rules
 Regulations
 Orders regarding patient care
 Gives the nurse authority to carry out specific actions under certain circumstances
 Individualization of standardized care plans
 Fit the unique needs of each client
 Usually both preauthored and nurse-created sections
 For predictable, commonly occurring problems
 Individual plan for unusual problems or problems needing special attention
Standardized Approaches to Care Planning
Formats for Nursing Care Plans
Although formats differ from agency to agency, the care plan is often organized into four sections:
(1) problem/nursing diagnoses,
(2) goals/desired outcomes
(3) nursing interventions
(4) evaluation.
 Student care plans
 Rationale
 Evidence-based principle given as the reason for selecting a particular nursing intervention
 Concept maps
 Visual tool in which ideas or data are enclosed in circles or boxes with relationships
indicated by lines or arrows
 Computerized care plans
 Create and store nursing care plans
 Can be accessed at a centrally located terminal at nurses' station or in clients' rooms
 Appropriate diagnoses selected from a menu suggested by the computer

Guidelines for Writing Nursing Care Plans

The nurse should use the following guidelines when writing nursing care plans:

1. Date and sign the plan

2. Use category headings (“Nursing Diagnoses,” “Goals/Desired
3. Outcomes,” “Nursing Interventions,” and “Evaluation)
4. Use standardized/approved medical or English symbols and key words rather than complete
sentences to communicate your ideas unless agency policy dictates otherwise (e.g q4, PRN)
5. Be specific
6. Refer to procedure books or other sources of information rather than including all the steps on a
written care plan
7. Tailor the plan to the unique characteristics of the client by ensuring that the client's choices,
such as preferences about the times of care and methods used, are included.
8. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as
restorative ones
9. Ensure that the plan contains ongoing assessment of the client
10. Include collaborative and coordination activities in the plan
11. Include plans for the client's discharge and home care needs

The Planning Process

 Consists of the following activities:
 Setting priorities
 Establishing client goals/desired outcomes
 Selecting nursing interventions
 Writing individualized nursing interventions on care plans

 Setting priorities
 Establishing client goals/desired outcomes
 Selecting nursing interventions
 Writing individualized nursing interventions on care plans
 Establishing a preferential sequence for addressing nursing diagnoses and interventions
 High priority (life-threatening)
 Medium priority (health-threatening)
 Low priority (developmental needs)
 Factors to consider
 Client's health values and beliefs
 Client's priorities
 Resources available to nurse and client
 Urgency of the health problem
 Medical treatment plan

Establishing Client Goals/Desired Outcomes

 Goals
 Broad statements about the client's status
 Desired outcomes
 More specific, observable criteria used to evaluate whether goals have been met
 The nursing outcomes classification
 Taxonomy for describing client outcomes that respond to nursing interventions
 Outcomes broadly stated and conceptual
 The nursing outcomes classification
 Made more specific by identifying indicators that apply to a particular client
 Stated in neutral terms
 Each outcome includes a five-point scale to rate the client's status.
 The nursing outcomes classification
 To write a desired outcome using Nursing Outcomes Classification (NOC), taxonomy,
indicate:
 Label
 Indicators that apply to client
 Initial client status
 Location on the measuring scale desired for each indicator
 Can be stated in traditional (lay) language
 Purpose of desired goals/outcomes
 Provide direction for planning interventions
 Serve as criteria for evaluating progress
 Enable the client and the nurse to determine when the problem has been resolved
 Help motivate the client and nurse by providing a sense of achievement
 Short-term and long-term goals
 By the end of the week or in over the course of many weeks
 Short-term goals useful for clients who:
 Require health care for a short time
 Are frustrated by long-term goals that seem difficult to attain
 Need the satisfaction of achieving a short-term goal
 Relationship of goals/desired outcomes to nursing diagnoses
 Goals derived from diagnostic label
 Diagnostic label contains the unhealthy response (problem)
 Goal is opposite, healthy response.
 Relationship of goals/desired outcomes to nursing diagnoses
  How client will look or behave if health response is achieved (observable, time-limited)
 Achieving goal demonstrates resolution of the problem
 Components of goal/desired outcome statements
 Subject (urine output)
 Verb (walk, talk, explain)
 Conditions or modifiers (how, when, where)
 Criterion of desired performance (Walks with the help of a cane)
 Guidelines for writing goals/desired outcomes
 Write in terms of client responses
 Must be realistic
 Ensure compatibility with therapies of other professionals

 Guidelines for writing goals/desired outcomes

 Derive from only one nursing diagnosis
 Use observable, measurable terms
 Make sure client considers goals important

Selecting Nursing Interventions and Activities

 Actions nurse performs to achieve goals
 Focus on eliminating or reducing etiology of nursing diagnosis
 Treat signs and symptoms and defining characteristics
 Interventions for risk nursing diagnoses should focus on reducing client's risk factors

 Types of nursing interventions

 Independent interventions
 Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
 Dependent interventions
 Activities carried out under primary care provider's orders or supervision, or according to
specified routines
 Collaborative interventions
 Actions nurse carries out in collaboration with other health team members
 Reflect overlapping responsibilities of health care team
 Considering the consequences of each intervention
 Choose those that are most likely to achieve the desired client outcomes'
 Requires nursing knowledge and experience
 Criteria for choosing nursing interventions
 Safe and appropriate for the client's age, health, and condition
 Achievable with the resources available
 Congruent with the client's values, beliefs, and culture
 Congruent with other therapies
 Criteria for choosing nursing interventions
 Based on nursing knowledge and experience or knowledge from relevant sciences
 Within established standards of care