Prepared by:

The nursing process is a process by which nurses deliver

care to patients, supported by nursing models or
philosophies. The nursing process was originally an adapted
form of problem-solving and is classified as a deductive
theory.

Nursing process is a patient centered, goal oriented method

of caring that provides a framework to nursing care. It
involves five major steps of assessment, nursing diagnosis,
planning, implementation/intervention and evaluating.
 Provides an orderly & systematic method for planning & providing
care
 Enhances nursing efficiency by standardizing nursing practice
 Facilitates documentation of care
 Provides a unity of language for the nursing profession
 Is economical
 Stresses the independent function of nurses
 Increases care quality through the use of deliberate actions
 Continuity of care
 Prevention of duplication
 Individualized care
 Standards of care
 Increased client participation
 Collaboration of care
 To Achieve Scientifically- Based,
Holistic, Individualized Care For
The Client

 To Achieve The Opportunity To

Work Collaboratively With
Clients, Others

 To Achieve Continuity Of Care

 Systematic
 The nursing process has an ordered sequence of
activities and each activity depends on the
accuracy of the activity that precedes it and
influences the activity following it.
 Dynamic
 The nursing process has great interaction and
overlapping among the activities and each
activity is fluid and flows into the next activity
 Interpersonal
 The nursing process ensures that nurses are
client-centered rather than task-centered and
encourages them to work to enhance client’s
strengths and meet human needs
Goal-directed
The nursing process is a means for nurses and
clients to work together to identify specific
goals (wellness promotion, disease and illness
prevention, health restoration, coping and
altered functioning) that are most important to
the client, and to match them with the
appropriate nursing actions

Universally applicable
The nursing process allows nurses to
practice nursing with well or ill people,
young or old, in any type of practice setting
 Assessment
◦ Data collection
 Diagnosis
◦ Analysis of data
 Planning
◦ Goals prioritized
 Implementation
◦ Interventions
 Evaluation
◦ Goals met?
◦ Reassessment
 Key Activities
◦ Collecting data
◦ Validating data
◦ Organizing (clustering) data
◦ Identifying patterns
◦ Testing first impressions
◦ Reporting & recording data
 Assessment

•it is systematic and continuous collection, validation

and communication of client data as compared to what
is standard/norm.

•it includes the client’s perceived needs, health

problems, related experiences, health practices, values
and lifestyles.

Assessment = Observation of the patient + Interview of

patient & family + examination of the patient + Review
of medical record
 Collection of data
◦ Direct
◦ Indirect
 Comprehensive
◦ Before you see client
◦ When you see client
◦ After you see clients
 Methods
◦ Interview
◦ Physical exam
 Check labs & diagnostics
 Types of Assessment:

a. Initial assessment – assessment performed within a

specified time on admission
Ex: nursing admission assessment

b. Problem-focused assessment – use to determine

status of a specific problem identified in an earlier
assessment
Ex: problem on urination-assess on fluid intake & urine
output hourly
c. Emergency assessment – rapid assessment done
during any physiologic/physiologic crisis of the client to
identify life threatening problems.
Ex: assessment of a client’s airway, breathing status &
circulation after a cardiac arrest.

d. Time-lapsed assessment – reassessment of client’s

functional health pattern done several months after
initial assessment to compare the clients current status
to baseline data previously obtained.
I. Collection of data
gathering of information about the client
includes physical, psychological, emotion, socio-
cultural, spiritual factors that may affect client’s health
status
includes past health history of client (allergies, past
surgeries, chronic diseases, use of folk healing methods)
includes current/present problems of client (pain,
nausea, sleep pattern, religious practices, meds or
treatment the client is taking now)
 Types of Data

1.Subjective data
• also referred to as Symptom/Covert data
• information from the client’s point of view or are described by
the person experiencing it.
• information supplied by family members, significant others,
other health professionals are considered subjective data.
Example: pain, dizziness, ringing of ears/Tinnitus

2. Objective data
• also referred to as Sign/Overt data
• those that can be detected, observed or measured/tested using
accepted standard or norm.
Example: pallor, diaphoresis, BP=150/100, yellow discoloration
of skin
 Characteristics of data

•Purposeful
•Complete
•Factual and accurate
•relevant
Methods of Data Collection:
1.Interview
•a planned, purposeful conversation/communication with
the client to get information, identify problems, evaluate
change, to teach, or to provide support or counseling.
•it is used while taking the nursing history of a client

1.Observation – use to gather data by using the 5

senses and instruments.
1.Examination
•systematic data collection to detect health problems using unit of
measurements, physical examination techniques (IPPA),
interpretation of laboratory results.

•should be conducted systematically:

1. Cephalocaudal approach – head-to-toe assessment
2. Body System approach – examine all the body system
3. Review of System approach – examine only particular area
affected
Source of data:
•Primary source – data directly gathered from the client
using interview and physical examination.

•Secondary source – data gathered from client’s family

members, significant others, client’s medical
records/chart, other members of health team, and
related care literature/journals.

In the Assessment Phase, obtain a Nursing Health

History – a structured interview designed to collect
specific data and to obtain a detailed health record of a
client.
 Components of a Nursing Health History:

•Biographic data – name, address, age, sex, martial

status, occupation, religion.
•Reason for visit/Chief complaint – primary reason why
client seek consultation or hospitalization.
•History of present Illness – includes: usual health
status, chronological story, family history, disability
assessment.
•Past Health History – includes all previous
immunizations, experiences with illness.
•Family History – reveals risk factors for certain disease
diseases (Diabetes, hypertension, cancer, mental illness).
•Review of systems – review of all health problems by
body systems
•Lifestyle – include personal habits, diets, sleep or rest
patterns, activities of daily living, recreation or hobbies.
•Social data – include family relationships, ethnic and
educational background, economic status, home and
neighborhood conditions.
•Psychological data – information about the client’s
emotional state.
•Pattern of health care – includes all health care
resources: hospitals, clinics, health centers, family
doctors
II. Validation of Data –
The act of “double-checking” or verifying data to confirm that it is
accurate and complete.

Purposes of data validation

•Ensure that data collection is complete
•Ensure that objective and subjective data agree
•Obtain additional data that may have been overlooked
•Avoid jumping to conclusion
•Differentiate cues and inferences
Cues – subjective or objective data observed by the nurse; it is
what the client says, or what the nurse can see, hear, feel, smell
or measure.
Inferences – the nurse interpretation or conclusion based on the
cues.
Example: red, swollen wound = infected wound
Dry skin = dehydrated
III. Organization of Data –

Uses a written or computerized format that organizes assessment data

systematically.
- Maslow’s basic needs
- Body System Model
- Gordon’s Functional Health Patterns:
IV. Analyze data –
Compare data against standard and identify significant cues.
Standard/norm are generally accepted measurements, model,
pattern:
Ex: Normal vital signs, standard Weight and Height, normal
laboratory/diagnostic values, normal growth and development
pattern
V. Communicate/Record/Document Data
•Nurse records all data collected about the client’s health
status
•Data are recorded in a factual manner not as
interpreted by the nurse
•Record subjective data in client’s word; restating in
other words what client says might change its original
meaning.
 Nursing Diagnoses

A nursing diagnosis is a health issue that can be

prevented, reduced, resolved, or enhanced through independent
nursing measures. It is an exclusive nursing responsibility.
Nursing diagnoses are categorized into five
groups:

1. Actual,
2. Risk,
3. Possible,
4. Syndrome,
5. Wellness
 CATEGORIES OF EXPLANATION AND EXAMPLE
NURSING
DIAGNOSES

Actual diagnosis A problem that currently exists impaired Physical Mobility related to
pain as evidenced by limited range of motion, reluctance to move

Risk diagnosis A problem the client is uniquely at risk for developing Risk for
Deficient Fluid Volume related to persistent vomiting

Possible A problem may be present, but requires more data collection

diagnosis to rule out or confirm its existence Possible Parental Role Conflict
related to impending divorce

Syndrome Cluster of problems predicted to be present because of an event

diagnosis or situation (Carpenito, 2004) Rape Trauma Syndrome and Disuse
Syndrome

Wellness A health-related problem with which a healthy person obtains

diagnosis nursing assistance to maintain or perform at a higher level
Potential for Enhanced Breastfeeding
 3 activities in Diagnosing:

DIAGNOSING = Data Analysis + Problem Identification

+ Formulation of Nsg Diagnosis
Characteristics of Nursing Diagnosis:
•It states a clear and concise health problem.
•It is derived from existing evidences about the client.
•It is the basis for planning and carrying out nursing
care.
 Components of a nursing diagnosis:

PES or PE
Problem statement/diagnostic label/definition = P
Etiology/related factors/causes = E
Defining characteristics/signs and symptoms = S

Therefore may be written as 2-Part or a 3-Part

statement.
Parts of a Nursing Diagnostic Statement.

1. Disturbed Sleep Pattern = problem

2. Related to excessive intake of coffee = etiology
3. As manifested by difficulty in falling asleep, feeling
tired during the day,
and irritability with others = signs and symptoms
 Actual
◦ Presence of major defining characteristics (cluster
of signs & symptoms often associated with the
diagnosis)
◦ Data base contains evidence of signs & symptoms
or defining characteristics
◦ Monitor signs & symptoms to determine
improvement or deterioration in the condition
◦ Identify interventions to reduce or eliminate the
cause of the problem
Examples:
•Imbalanced Nutrition: Less than body requirements r/t decreased
appetite nausea.
•Disturbed Sleep Pattern r/t cough, fever and pain.
•Constipation r/t long term use of laxative.
•Ineffective airway clearance r/t to viscous secretions
•Noncompliance (Medication) r/t unknown etiology
•Noncompliance (Diabetic diet) r/t unresolved anger about
Diagnosis
•Acute Pain (Chest) r/t cough 2nrdary to pneumonia
•Activity Intolerance r/t general weakness.
•Anxiety r/t difficulty of breathing & concerns over work
2. Possible Nursing diagnosis – one in which evidence
about a health problem is incomplete or unclear therefore requires
more data to support or reject it; or the causative factors are
unknown but a problem is only considered possible to occur.

Examples:
Possible nutritional deficit
Possible low self-esteem r/t loss job
Possible altered thought processes r/t unfamiliar surroundings
3. Risk Nursing diagnosis – is a clinical judgment that a
problem does not exist, therefore no S/S are present, but the
presence of RISK FACTORS is indicates that a problem is only
likely to develop unless nurse intervene or do something about it.

No subjective or objective cues are present therefore the factors

that cause the client to be more vulnerable to the problem is the
etiology of a risk nursing diagnosis.
 Two – Part
◦ Risk for or possible nursing diagnosis
◦ Problem + Etiology or Cause and Risk Factors
◦ “Related to” links risk/possible problem with the
related factors present
Examples:

•Risk for Impaired skin integrity (left ankle) r/t decrease

peripheral circulation in diabetes.
•Risk for interrupted family processes r/t mother’s illness &
unavailability to provide child care.
•Risk for Constipation r/t inactivity and insufficient fluid intake
•Risk for infection r/t compromised immune system.
•Risk for injury r/t decreased vision after cataract surgery.
Disturbed Sleep Pattern Related to excessive intake of coffee
As manifested by difficulty in falling asleep, feeling tired
during the day, and irritability with others
1. Disturbed Sleep Pattern = problem
2. Related to excessive intake of coffee = etiology
3. As manifested by difficulty in falling asleep, feeling tired during the day,
and irritability with others = signs and symptoms
•Impaired Physical Mobility related to pain as evidenced by limited range of motion,
reluctance to move

•Risk for Deficient Fluid Volume related to persistent vomiting

•Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea A/E
by loss of 5kg weight in 3months duration.

•Disturbed Sleep Pattern r/t cough, fever and pain A/E by experiencing drowsiness in
day time.

•Constipation r/t long term use of laxative.

•Ineffective airway clearance r/t to viscous secretions
•Noncompliance (Medication) r/t unknown etiology
•Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
•Acute Pain (Chest) r/t cough 2nrdary to pneumonia
•Activity Intolerance r/t general weakness.
•Anxiety r/t difficulty of breathing & concerns over work

1
Examples:

•Risk for Impaired skin integrity (left ankle) r/t decrease peripheral
circulation in diabetes.
•Risk for interrupted family processes r/t mother’s illness &
unavailability to provide child care.
•Risk for Constipation r/t inactivity and insufficient fluid intake
•Risk for infection r/t compromised immune system.
•Risk for injury r/t decreased vision after cataract surgery.
 Sample
◦ Impaired Communication related to language
barrier as evidenced by inability to speak or
understand marathi & by use of tamil
◦ Diarrhea related to dumping syndrome as
evidenced by liquid stools & abdominal cramping
NANDA definition of syndrome diagnosis

•A cluster or group of nursing diagnoses that almost always occur

together. It describes a clinical picture of health conditions/life
processes that cluster together in a pattern of nursing diagnoses
(Herdman, 2008)
Syndromes in medicine are sets of symptoms occurring together :
examples
•AIDS
•Restless Leg Syndrome
•Chronic Fatigue Syndrome
•Metabolic Syndrome-cluster of signs related to CVD but many
“signs” are diagnoses (hypertension, DM, obesity,
hypertriglyceridemia)
 Approved NANDA Syndrome Diagnoses
•Rape Trauma Syndrome
Anxiety
Disturbed sleep pattern
Fear
High risk for ineffective sexuality patterns grieving
pain
•Disuse Syndrome
Risk for infection
Risk for thrombosis
Risk for activity intolerance
Risk for injury
Risk for disturbed body image
Risk for powerlessness
•Post-trauma Syndrome
•Relocation Stress Syndrome
•Impaired Environmental Interpretation Syndrome
Wellness nursing diagnoses:A wellness diagnosis describes
human responses to levels of wellness in an individual, family
or community that have the potential for enhancement to a
higher state.

Focus on the patient's progress or potential progress towards

healthier behaviors rather than on a problem.
They were created to remedy a situation in which only negative
issues were addressed, leaving out diagnoses for patients in a
healthy setting.

A wellness diagnosis indicates a readiness to advance from the

current level of health to a higher level.
There are two prerequisites for a wellness diagnosis---
•a desire to advance
•an ability to do so.
Emotional Readiness
The first requirement for a wellness diagnosis is a desire
to attain a higher level of well-being. The patient must
express emotional readiness to engage in interventions
that will help him reach that next level.

For example, a patient recently had knee replacement

surgery and the doctor feels he is ready to start
ambulating with assistance. The patient tells you he just
doesn't feel up to it, he's too tired and he thinks it's just
going to be too hard. At this point, the patient is not
expressing a readiness to enhance his well-being and a
wellness diagnosis cannot be written.
 Status and Function
•The second prerequisite for a wellness diagnosis is the presence
of status or function required to perform tasks related to the
diagnosis.

The knee replacement patient expresses an emotional readiness

to begin doing exercises that will enable him to regain optimum
function in his knee. However he has recently developed a clot in
his leg from his immobility and the doctor doesn't want him
ambulating until it dissolves. Although the patient is emotionally
ready to begin taking charge of his health, he is not physically
able to perform the interventions.
 Writing the Diagnosis
While most nursing diagnoses require at least two parts, the
diagnosis and the "related to" factors, wellness diagnoses are
written a little different. They are started with the word
"readiness" followed by the action or health-seeking behavior
that will be enhanced.
For example, "readiness for enhanced nutrition" indicates that
the patient has expressed a desire and ability to learn more
about proper nutrition as it relates to his condition.
Examples
"Readiness for enhanced management of therapeutic regimen"
describes a patient who is willing and able to participate in her
own treatment by following recommendations and helping set
new goals for herself.

"readiness for enhanced coping.“ A patient who has expressed a

desire to come to terms with his illness and requests help with
this.

"Readiness for enhanced religiosity" can be applied to a patient

who previously stated she no longer believed in her religion but
later states that she wants to get back in touch with her spiritual
side.
Medical Diagnosis
• Describes a disease or pathology
• Conditions MD treats
• MD cares for a pt with Congestive Heart Failure (CHF)
- treats
pathology with meds, oxygen, diet & fluid Restriction
Nursing Diagnosis
• Describes pt’s response to a health problem
• Situations RNs can treat
• Nursing dx describe pt’s response to CHF: such as:
Anxiety; Activity Intolerance, Impaired
Peripheral Tissue Perfusion, Powerlessness
 Developed by the nurse who performs the
admission nursing history and the physical
assessment
 Comprehensive plan that addresses each
problem listed in the prioritized nursing
diagnosis and identifies appropriate patient
goals and the related nursing care
  S
◦ Specific
 M
◦ Measurable
 A
◦ Attainable
 R
◦ Realistic
 T
◦ Time frame
 Which problems require my immediate
attention?
 Which problems are my responsibility and
which should I refer to someone else?
 Which problems are the most important to
the patient?
 Which problem has the highest level of need
based on Maslow’s Hierarchy?
 Because basic needs must
be met before a person can
focus on higher ones,
patient needs may be
prioritized according to
Maslow’s Hierarchy
◦ Physiologic
◦ Safety
◦ Love and belonging
◦ Self esteem
◦ Self actualization
 Purpose
◦ Provide individualized care
◦ Promote client participation
◦ Plan care that is realistic and measurable
◦ Select evidenced based nursing care
◦ Communicate the plan of care
 Focus on the client
 Address only one goal or outcome
 Develop outcomes that are observable
 Write outcomes that can be measured
 Clearly state time frame
 Consult with the client
 Be realistic
 Nursing Diagnosis
◦ Imbalanced Nutrition: More than body requirements
 Outcome
◦ By 5/5/07, patient will reach target weight of 122
lbs
 Nursing diagnosis
◦ Impaired mobility
 Outcome criteria
◦ Before discharge, patient will ambulate the length
of the hallway independently
 Long-term outcomes  Short term goals can
require a longer period be hours to days
of time  Usually less than a
 Typically, long-term week
goals require more
than a week to resolve
 May be used as
dismissal goals
Interventions
 3 categories
◦ Nurse initiated interventions
◦ Physician initiated interventions
◦ Collaborative interventions
 Any treatment based on clinical judgment and
knowledge, that a nurse performs to enhance
patient outcomes

 An autonomous action based on scientific

rationale that a nurse executes to benefit the
patient in a predictable way related to the
nursing diagnosis and projected outcomes
 Actions performed by the nurse to:
◦ Monitor health status
◦ Reduce risks
◦ Resolve, prevent, or manage a problem
◦ Facilitate independence or assist with
ADL’s
◦ Promote optimal sense of physical,
psychological and spiritual well being
 They must meet specific criteria
 They must be concise and describe a
nursing action (answers who, what, where,
when, and how)
 They must be dated when written and when
the plan of care is reviewed
 Must be signed by the RN who assist with
the implementation
 Use only accepted abreviations
 Offer the patient 60 mL of water or juice q 2
hours while awake for a total minimum PO
intake of 500 mL
 Assist patient to the bathroom for toileting z
2 hours while awake
Implementation
 Actions necessary for achieving goals &
outcomes
 Based on ‘related factors’
 Performing, assisting, or directing
performance of ADLs
 Counseling & teaching
 Providing direct client care
 Supervising & evaluating staff members
 Recording & exchanging information
relevant to client’s continued health care
 Implementation includes:
◦ performing, assisting, or directing the
performance of activities of daily living,
◦ counseling and teaching the client or family,
◦ providing direct care.
◦ Delegating and supervising,
◦ Evaluating the work of staff members.
◦ Recording and exchanging information relevant
to the client’s continued health care
 C.T. is an 88-year-old woman transferred to
your unit from a skilled nursing facility. Her
history reveals that she had a “flu-like”
syndrome for the past five days with
persistent vomiting and diarrhea. Her vital
signs are BP 108/56, P 112, R 28, T 101.4.
Her mucous membranes are dry and her skin
turgor is delayed. She indicates that she feels
weak, tired, and thirsty.
 Nursing Diagnosis
◦ Fluid volume deficit r/t vomiting and diarrhea as
evidenced by dry mucous membranes, delayed skin
turgor, hypotension, tachycardia, tachypnea,
elevated temperature, weakness, and “feeling
thirsty”.
 Outcome
◦ Moist mucous membranes, normal skin turgor, vital
signs within normal limits for client within 48 hours
 Interventions
◦ Monitor & document VS, mental status q4h x 24
hours
◦ Assess & document frequency, color, & amount of
emesis & diarrhea
◦ Assess skin turgor, dryness, & mucous membranes
q4h x 24 hours, then q8h if vomiting & diarrhea
have subsided
 Interventions cont’d
◦ Monitor urine color & specific gravity q8h
◦ Monitor I & O q8h
◦ Encourage PO fluid intake as tolerated; provide
1500 mL per 24 hours
◦ Offer small amounts of fluid taken slowly
◦ Instruct client to inform nursing staff if thirsty
 Interventions cont’d
◦ Administer & evaluate effectiveness of medications
ordered to control vomiting & diarrhea
◦ Monitor serum electrolyte values and report
abnormalities
 Nursingactions planned
in the previous step are
carried out
 Provides a way for you to determine
whether the proposed nursing action is still
appropriate for the client’s level of wellness
 It occurs each and every time you enter a
patients room
 Ex.: you plan to ambulate a patient
following lunch. You enter the room and
find the patient short of breath and
increased fatigue, and must assist the
patient back to bed.
 Revise the assessment data to reflect the
change
 Revise the nursing diagnosis
 Revise specific interventions
Evaluation
 During this phase, the nurse
and the patient together
measure how well the patient
has achieved the outcomes
specified in the plan of care
 Five steps of objective evaluation
◦ Identify evaluative criteria and standards
◦ Collect data
◦ Interpret and summarize findings
◦ Document findings
◦ Terminate, continue, or revise the care plan
 Collect data to evaluate nursing care
 examine patient’s response to nursing
interventions
 Compare client’s response with outcome
criteria
 Appraise extent to which patient goals were
met
 Appraise involvement and collaboration of
others in healthcare decision
 Provide basis for revisions of care plan
 Monitor quality of nursing care and its effect
on client’s health status
 Discontinue the care plan to ensure other
nurses will not unnecessarily continue an
outdated plan
 Modify the care plan after reassessment, new
nursing diagnosis, goal, and expected
outcomes
 Knowledge of standards of care
 Knowledge of normal patient responses
 Ability to monitor effectiveness of nursing
interventions
 Awareness of clinical research
 Assessment
◦ Collecting client information
◦ Nursing assessment
 Diagnosis
◦ Analysis of assessment data by RN
◦ Data clustered into Orem’s self-care requisites
◦ Identify actual or potential problems
 Planning
◦ Prioritize
◦ Mutually established outcomes to reach goal
◦ Determine appropriate interventions to meet the
outcomes
◦ Write or individualize plan of care
 Implementation
◦ Put plan into action
◦ Re-assess client status
◦ Perform interventions
◦ Report & record
 Evaluation
◦ Determine if outcomes have been achieved
◦ Modify or terminate plan as indicated
ASSESSMENT

NURSING DIAGNOSIS
_______________________________________________

_______________________________________________

_______________________________________________

GOAL STATEMENT

Don’t forget: STG:___________________________________

_______________________________________
Nursing Diagnosis = Problem
Related To = Etiology
As Evidenced By = Signs/Symptoms
LTG:___________________________________
________________________________________
Goals: Specific
Realistic EVALUATION:__________________________
Timeframe ________________________________________
Measurable ________________________________________
Actual Diagnosis: Problem or need that is
________________________________________
currently present ________________________________________

Risk For Diagnosis: Problem or need that

could develop
Mrs. Pathak is an 88-year-old woman
transferred to your unit from a skilled nursing
facility. Her history reveals that she had a
“flu-like” syndrome for the past five days with
persistent vomiting and diarrhea. Her vital
signs are BP 108/56, P 112, R 28, T 101.4o F
Her mucous membranes are dry and her skin
turgor is delayed. She indicates that she feels
weak, tired, and thirsty.
 Nursing Diagnosis
◦ Fluid volume deficit r/t vomiting and diarrhea as
evidenced by dry mucous membranes, delayed skin
turgor, hypotension, tachycardia, tachypnea,
elevated temperature, weakness, and “feeling
thirsty”.
 Outcome
◦ Moist mucous membranes, normal skin turgor, vital
signs within normal limits for client within 48 hours
 Mrs. Jini. is admitted to Rm. 108 with a
medical dx of f# Lt. femur. She is a 68yr
house wife with a h/o of osteoporosis,
NIDDM, and gall bladder stone. Her leg has
been surgically repaired (ORIF) 2 days ago.
◦ What type of assessment data might you need to
collect?
◦ Find at least 2 nursing dx, plan, interventions,
and possible evaluation outcomes.
Alterations in Cardiac Output: Decreased
Related To:
[Check those that apply](_) Cardiac factors
(_) Pulmonary disorders
(_) Endocrine disorders
(_) Hematological disorders
(_) Fluid & electrolyte disturbances
(_) Surgery/anesthesia
(_) Vagal stimulation
(_) Stress
(_) Shock
(_) Allergic response
(_) Medications
As evidenced by:
[Check those that apply](_) Angina
(_) Cardiac arrythmia
(_) Cyanosis
(_) Dyspnea
(_) Edema (periph./sacral) (_) Fatigability
(_) Hypotention
(_) Oliguria
(_) Restlessness
(_) Tachycardia
The patient will:

(_) Demonstrate imporved cardiac output A.E.B.:

vital signs within normal limits for patient. [BP____] [P___]
color pink
chest clear
balanced I & O
minimal or absent edema

(_) Other:) Assess color, BP, pulse, respirations q___ hours.

(_) Listen to breath sounds q___ hours.
(_) Check for edema of feet, legs, and sacrum q___ hours.
(_) Daily weights at ____ a.m./p.m. using same scale.
(_) Measure intake and output q 8 hours.
(_) Organize care to maximize periods of uninterrupted rest. Needs ______ rest
periods/day. (Specify:): ________________________

(_) Explore with patient potential etiological factors for decreased cardiac output
and provide health teaching. (See Discharge Plan)
 Final phase of nursing process
 Occurs whenever nurse interacts with client
 Determining status of outcomes
 Systematic & ongoing
◦ Was the outcome achieved
◦ Was the outcome appropriate
◦ Was the nursing diagnosis resolved
◦ Were the interventions appropriate
◦ Does the plan of care need revisions
 Relationship between goals & evaluation
◦ Comparison of data to outcomes & judgment of
client’s progress
◦ Reassess responses
◦ Identify variables affecting outcome achievement
 Three possible outcomes of evaluation
◦ Outcomes not met – continue plan as written
◦ Outcomes not met – modify the plan
◦ Outcomes met – terminate the plan
 Planning
◦ You set a goal of drinking at least 2500 ml/day
 Implementation
◦ You offer preferred fluids at set intervals during a 24 hour
period
 Evaluation
◦ You determine if he’s meeting the established goal of
drinking 2500 ml/day of liquid. If not, you determine why
not, and make the necessary changes. If his condition is
improved and he no longer has even a potential for fluid
volume deficit, then you terminate the plan and allow the
person to determine his own pattern of drinking fluids.
 Given the following scenario:
◦ Collect data
◦ Define problem(s)
◦ Provide a nursing dx
◦ Develop a goal
◦ Assign interventions
◦ Evaluate outcome (may not be possible with
scenario)