Nursing Diagnostics and Planning: Page-by-Page Notes (Pages 1–72)

Page 1

• Course: Nursing Fundamentals Day 5 – The Nursing Process 2: Nursing Diagnosis and Planning, Implementing and Evaluating Care, Documenting and Reporting.
• Program: Marian College Vocational Nursing Program.

Page 2

• Chapter 35: Nursing Diagnosis and Planning.

Page 3

• Introduction to Chapter 35:
  • The second step of the nursing process is identifying the nursing diagnosis.
  • Uses objective and subjective data collected to determine the nursing care problem.
  • Once the issue is identified, proceed to determine the best way to assist the client.

Page 4

• Nursing Diagnosis definitions and characteristics:
  • A statement about actual or potential health concerns of the client that can be managed through independent nursing intervention.
  • Concise, clear, client-centered, client-specific statements.
  • An approved label identifying the client’s problems in nursing terminology.
  • May be considered a duty of the RN; LVN/LPN must understand its meaning and how it’s used to plan and implement care.

Page 5

• History of Nursing Diagnoses (NND/NANDA):
  • Early descriptions of nursing concerns varied among nurses.
  • 1982: North American Nursing Diagnosis Association (NANDA) created.
  • 2002: Became NANDA International (NANDA-I).
  • Standardization of nursing terminology as a highly effective nursing tool.
  • Leads to standardized, generalized communication describing a client’s problem or concern.
  • Most healthcare facilities maintain their own version of the current NANDA-I.
  • Nursing diagnoses remain a basic component and foundation for prioritization of the nursing care plan.

Page 6

• Medical Diagnosis vs. Nursing Diagnosis:
  • Medical diagnosis: identifies the disease; physician determines via physiological manifestations and etiology; basis for prognosis and medical treatment decisions.
  • Nursing diagnosis: based on nursing observation and data collection; suggests nursing actions/interventions; recognizes client’s self-care abilities and coping with problems.

Page 7

• Question #1: True/False
  • Statement: The NANDA-I list is not really reliable because it changes every few years.

Page 8

• Answer to Question #1: False
  • Fact: Most healthcare facilities post their current NANDA-I version centrally; the list is updated periodically but remains a foundational framework.

Page 9

• Purposes of the Nursing Diagnosis #1:
  • Identifying nursing priorities.
  • Directing nursing interventions to meet high-priority client needs.
  • Directing interventions to meet short- and long-term goals.
  • Guiding discharge planning, educational needs, or postdischarge follow-up.

Page 10

• Purposes of the Nursing Diagnosis #2:
  • Communicating in a common language.
  • Integrating actions and goals among nursing staff and the healthcare team.
  • Forming a process to evaluate benefits of nursing care.
  • Assisting in determining the client’s acuity level and needs for nursing care.

Page 11

• The Diagnostic Statement (example):

  • A comprehensive diagnostic statement: "Airway clearance ineffective manifested by shortness of breath on exertion."

  • Components:

  • Problem: describes the health problem in nursing terms (e.g., airway clearance, ineffective).

  • Etiology: the cause of the problem (e.g., related factors such as excessive mucus or obstruction).

  • Signs and symptoms: data collected during assessment (e.g., shortness of breath on exertion).

  • Note: The etiology is typically expressed with "related to" (R/T) and the signs/symptoms with "as evidenced by" (AEB).

Page 12

• Writing the Diagnostic Statement:
  • Connects problem, etiology, and signs/symptoms.
  • Linking phrases:
  • Problem and etiology: use "related to" (R/T).
  • Signs/symptoms with etiology: use "as evidenced by" (AEB).
  • Example:
  • ext{Ineffective Airway Clearance related to physiologic effects of pneumonia as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea.}

Page 13

• Question #2: True/False
  • Question: Is etiologic factor always pathophysiologic?

Page 14

• Answer to Question #2: False
  • Etiology may be physiologic, pathophysiologic, psychological, sociologic, spiritual, or environmental.
  • Example: Pneumonia physiology contributes to the etiology of the problem “Ineffective Airway Clearance.”

Page 15

• Planning Care #1:
  • Planning involves developing goals to prevent, reduce, or eliminate problems and identifying nursing interventions to meet those goals.
  • Prioritization: ranked by importance, including survival, safety, social, and psychological needs.

Page 16

• Planning Care #2: Establishing expected outcomes
  • Expected outcome: a measurable client behavior indicating achievement of benefits from nursing care.
  • Characteristics: client-oriented, specific, reasonable, measurable.
  • Short-term objectives: attainable in hours or days.
  • Long-term objectives: achievable after discharge.

Page 17

• Establishing a Nursing Care Plan:
  • Selecting nursing interventions or orders based on scientific rationale.
  • Writing a nursing care plan: developed at a nursing care conference by the entire nursing team; includes nursing diagnoses, expected outcomes, and nursing orders.

Page 18

• Written or Electronic Nursing Care Plans:
  • Care plans can be handwritten or computerized (MIS/EMR).
  • Documentation of a nursing care plan is required by agencies such as Joint Commission, nursing home regulators, and Medicare.
  • Ideal care plan is individualized for each client.

Page 19

• Question #3: Which objective is a long-term objective for a client recovering from a fall?
  • Options:
  • a. Walk around the room once a day
  • b. Walk up and down the hall once per shift
  • c. Participate in the college basketball tournament
  • d. Avoid use of bedpan and walk to the bathroom
  • e. Walk around the hall for 5 minutes

Page 20

• Answer to Question #3: c. Participate in the college basketball tournament
  • Rationale: A long-term objective is an outcome the client hopes to achieve over a longer period; the other options are short-term.

Page 21

• Chapter 36: Implementing and Evaluating Care.
• Chapter title indicates transition from planning to execution and assessment.

Page 22

• Introduction to Implementing and Evaluating:
  • The nursing process includes: Assessing, Diagnosing, Planning, Implementing, Evaluating.
  • Implementation involves performance of nursing actions and continued data collection.
  • Communication with the healthcare team and documentation are key components of implementation.

Page 23

• Implementing Nursing Care:
  • Core motto: “Do it”; “share it”; “write it down.”
  • Do nursing care with and for the client.
  • Share results by communicating with client and healthcare team.
  • Write information by documentation.
  • Adequate communication and documentation facilitate continuity of care.

Page 24

• Dependent, Interdependent, and Independent Actions—“Do It” #1:
  • Dependent actions: Based on orders or directions from a healthcare provider; explicit instructions.
  • Interdependent actions: Collaborative actions with other care providers for collaborative problems.
  • Independent actions: Nursing actions that do not require orders; based on professional judgment.

Page 25

• Dependent, Interdependent, and Independent Actions—“Do It” #2:
  • Accountability: Nurse is responsible for all actions (regardless of type).
  • Emphasizes legal requirements of nursing practice.
  • Critical thinking greatly aids in making safe, helpful client decisions.

Page 26

• Skills Used in Implementing Nursing Care:
  • Intellectual skills: Understanding essential information; critical thinking.
  • Interpersonal skills: Belief, behavior, and relationship-building with others.
  • Technical skills: Ability to perform tasks; requires ongoing training, practice, and confidence.

Page 27

• The Nursing Care Plan in Action #1:
  • Nursing team reviews whether the care plan makes sense.
  • Critical-thinking questions when reviewing a care plan:
  • Does it protect the client’s safety?
  • Is it developed using a scientific problem-solving approach and sound nursing knowledge?
  • Do the orders logically achieve the desired results; are they in a sensible sequence?

Page 28

• The Nursing Care Plan in Action #2:
  • Continuing critical-thinking questions (cont.)
  • Do the nursing orders enhance care and progress toward recovery and goal achievement?
  • Is the client active in the plan; can the client contribute ideas about its appropriateness?
  • Emphasis on continuing data collection as care proceeds; observe and reassess to determine effectiveness of orders.

Page 29

• Question #1: Which of these is NOT a step in nursing implementation?
  • a. Putting the nursing care plan into action
  • b. Continuing the collection of data
  • c. Communicating care with the healthcare team
  • d. Identifying strengths and problems
  • e. Documenting care

Page 30

• Answer to Question #1: d. Identifying strengths and problems
  • Rationale: Implementation steps include action, data collection, communication, and documentation. Strengths and problems are identified during assessment.

Page 31

• Communication with the Healthcare Team—“Share It”:
  • Client planning conference: information about client shared with the healthcare team.
  • Discharge planning conference.
  • Interdisciplinary planning conferences.
  • Responsible for providing both verbal and written information to attendees.

Page 32

• Written Communication with the Healthcare Team—“Write It Down”:
  • Document all care given to the client.
  • Documentation can be handwritten or computerized.
  • Verbal communication is temporary; written documentation can be reviewed later.
  • Legal considerations: If it is not written, it was not done.

Page 33

• Question #2: Which are steps of the evaluation stage? (Select all that apply.)
  • a. Modify goals and interventions
  • b. Collect data
  • c. Plan future care
  • d. Document care
  • e. Recognize data clusters

Page 34

• Answer to Question #2: a and c
  • Rationale: Evaluation steps include modifying goals/interventions and planning future care.
  • Collecting data and recognizing data clusters are assessment-stage activities.
  • Documentation is part of Implementation of care.

Page 35

• Evaluating Nursing Care #1:
  • Conceptual flow: Evaluate whether goals and interventions were successful.
  • If outcomes were not achieved, modify goals/interventions and revise the care plan.
  • If outcomes were achieved, they can be removed from the updated plan.
  • Identify factors contributing to success or failure; plan future care accordingly.

Page 36

• Evaluating Nursing Care #2:
  • How to evaluate effectiveness:
  • Client is the primary source of evaluation criteria.
  • Team conference: plan care, evaluate effectiveness, design discharge plan.
  • After discharge, community agencies may be involved in follow-up.

Page 37

• Analyzing the Client’s Response:
  • Previously established goals and objectives become standards/criteria to measure progress.
  • Evaluate whether the nursing care plan helped the client meet self-care goals.

Page 38

• Identifying Factors Contributing to Success or Failure:
  • Evaluation is not a simple positive/negative judgment; it reflects the client’s overall responses.
  • The nurse must be objective, focusing on goals, data, and logical reasoning.
  • The nurse’s own knowledge and skills should be high quality; sometimes the nurse is a contributing factor to outcomes.

Page 39

• Discharge Planning #1:
  • When problems are resolved, goals are updated to reflect new plans.
  • Ongoing evaluation of goals: if not met, re-evaluate and adjust.
  • Preparation for continued care outside the facility or independent living at home.
  • Discharge planning begins at admission and is ongoing; individualized.
  • Conferences with client, family, caregiver, and healthcare team; both verbal and written instructions provided.

Page 40

• Discharge Planning #2: Components of discharge planning
  • Equipment needed at home
  • Dietary needs or special diet
  • Medications and/or procedures
  • Resources
  • Emergency response: danger signs
  • Activity recommendations
  • Summary of care and instructions

Page 41

• Question #3: True/False
  • Statement: Discharge planning begins on admission of the client into the facility.

Page 42

• Answer to Question #3: True
  • Rationale: Early planning helps ensure clients/families are taught gradually and can receive written, demonstrated, or verbal teaching as they prepare for discharge.

Page 43

• Chapter 37: Documenting and Reporting.
• Section focus: Documentation and reporting in nursing practice.

Page 44

• Documentation Overview:
  • Health record: manual or electronic account of client information.
  • Records are chronological and systematic regarding health status, past/current problems, tests, treatments, responses, discharge planning.
  • Documentation must be clear, accurate, and frequent.
  • Charting is a core activity.

Page 45

• Purposes of the Health Record:
  • Maintain effective communication among caregivers.
  • Provide written evidence of accountability.
  • Meet legal, regulatory, and financial requirements.
  • Provide data for research and educational purposes.

Page 46

• Communication #1:
  • Health record as a primary communication tool among caregivers.
  • Enables continuity by documenting client problems, treatments, and responses.
  • Provides documentation of the client’s health status for specific needs.
  • How nurses facilitate communication: maintain confidentiality, skillful client interviewing.

Page 47

• Communication #2 (cont.)
  • Roles of nurses: listen, teach clients/families, document care plans, report to team members, participate in conferences, treat each client as a unique individual.

Page 48

• Communication #3 (cont.)
  • Use both verbal and nonverbal communication; observe client reactions.
  • Use touch appropriately as a therapeutic modality.
  • Consider age, sex, ethnicity, religion, health state, life experiences, body image, language, and other personal factors.

Page 49

• Accountability #1:
  • Health records serve as documented evidence of responsible and effective care.
  • Required for legal, regulatory, and financial standards.
  • The Joint Commission and CMS developed core measures for standards of care.

Page 50

• Accountability #2:
  • Major issues: legal requirements; documentation criteria; financial accountability; research and education.
  • Proverbial reminder: If it wasn’t documented, it wasn’t done.

Page 51

• Question #1: True/False
  • Statement: If a nursing action is not documented in the medical record, the nurse is not responsible for the action.

Page 52

• Answer to Question #1: False
  • If health records are audited, if it was not documented, it was not done in the eyes of the law.
  • This does not exempt the nurse from responsibility for errors.

Page 53

• Documentation Systems #1:
  • Types: manual, electronic, or a combination.
  • Medical Information System (MIS): electronic document housed in a computer network.
  • Electronic Medical Records (EMR).
  • Manual records may be phased out; see Table 37-1.

Page 54

• Documentation Systems #2:
  • Computer records preserve and transmit information.
  • EMR systems use networks of terminals at bedside, nursing stations, COW/WOW, etc.
  • Internet access enables provider access without being at the client’s side.
  • Each facility’s computer system is unique; orientation and refresher training are offered.

Page 55

• Contents of the Health Record #1:
  • Assessment documents: admission record, medical history/physical, nursing admission history, minimum data set/RAP, labs, consultations.
  • Plans for care and treatment: problem list, orders, nursing care plan, teaching plan, clinical care path, consent for treatment.

Page 56

• Contents of the Health Record #2:
  • Formats of documentation: progress note entry format.
  • Establish baseline data; document accountability measures of admission; enter data at regular intervals; summarize condition; document changes; document responses to treatment.

Page 57

• Contents of the Health Record #3:
  • Typical formats: Narrative–chronological; Problem-Oriented Medical Records (POMR); discipline-area (multidisciplinary) documentation; charting by exception; system flow sheet; case management; critical pathways.

Page 58

• Contents of the Health Record #4:
  • Additional formats: collaborative pathway; care mapping; graphic flow sheet; Medication Administration Record (MAR).

Page 59

• Contents of the Health Record #5:
  • Narrative–chronological: thorough, day-to-day progress; time-consuming.
  • Area charting: focus on specific problems; POMR; includes subjective, objective data, assessment, plan, interventions, responses, education, evaluation.

Page 60

• Contents of the Health Record #6

Page 61

• Contents of the Health Record #7:
  • Discipline Area (Multidisciplinary) Documentation: separate notes for each discipline; allows quick access per specialty; risk of missing information if notes are not reviewed.
  • Charting by Exception (CBE): narrative progress notes use flow sheets; abnormal findings are flagged as exceptions.
  • Case Management: emphasis on quality care, cost-effectiveness; client-focused; includes care mapping and collaborative pathways.

Page 62

• Contents of the Health Record #8:
  • Graphic Flow Sheet: MAR (medication administration record) and other frequent checks (vital signs, I&O, ADLs, dietary patterns, neuro checks, restraints, etc.).

Page 63

• Contents of the Health Record #9:
  • Plans for continuity of care: length of stay varies; specific forms ensure continuity, consistency, effectiveness; teaching plans, transfer notes, discharge summaries.

Page 64

• Question #2: Charting by exception (CBE) uses a SOAPIER or system flow sheet format for certain progress notes.

Page 65

• Answer to Question #2: True
  • CBE uses SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision) or system-flow sheet formats; abnormal signs/symptoms are documented as exceptions.

Page 66

• Guidelines for Documentation #1:
  • Document what you see: objective observations; differentiate client quotes; avoid opinions.

Page 67

• Guidelines for Documentation #2:
  • Be prompt: document immediately after care; if late, mark as such.
  • Be clear and concise: correct spelling, punctuation, sentence structure; 24-hour clock; standard abbreviations; proper signature; avoid blank lines.
  • Refer to Boxes/Tables for guidance (Boxes 37-2 and 37-3; Tables 37-3 to 37-6).

Page 68

• Guidelines for Documentation #3:
  • Record all relevant information: read provider notes; document all communications with team.
  • Respect confidentiality: share information only with appropriate team members; avoid discussing with bystanders; protect computer screens.
  • Record documentation errors: cross out with one line, label as ERROR, initial; correct statement documented; computerized corrections as applicable.

Page 69

• Reporting:
  • "Report off" to other nurses; change-of-shift reporting methods:
  • In person, in writing, or by tape recorder;
  • May be brief or detailed;
  • May occur during walking rounds;
  • Outgoing nurse introduces incoming nurse.
  • See Nursing Care Guidelines 37-1 for specifics.

Page 70

• Question #3: Change-of-shift reporting methods (Select all that apply):
  • a. Team leader reports to the entire incoming shift
  • b. One caregiver reports to another caregiver
  • c. Written report from one caregiver to another
  • d. Verbal report at the client’s bedside
  • e. Report may be recorded on a tape recorder

Page 71

• Answer to Question #3: a, b, c, e are correct; d is not correct in most settings
  • Rationale: Verbal reports should be given in a location where clients/visitors cannot overhear; bedside verbal reports may breach confidentiality.
  • The statement also notes that a verbal report can be given, but not at the client’s bedside to protect privacy.

Page 72

• References:
  • Rosdahl, C.B. (2022). Rosdahl’s Textbook of Basic Nursing (12th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins.

Key Concepts and Connections

• NANDA-I: Standardized nursing diagnoses framework (R/T, AEB) used to organize care plans; foundational for prioritization and communication.
• Diagnostic Statement Structure: Problem (P) / Etiology (R/T) / Signs/Symptoms (AEB).
• Etiology Diversity: Not exclusively pathophysiologic; can be physiologic, psychological, sociologic, spiritual, environmental.
• Planning and Outcomes: Clear, measurable client outcomes; short-term vs long-term objectives; relevance to discharge planning.
• Nursing Care Plan: Collaborative process; requires scientific rationale; tailored to individual client.
• Implementation Varieties: Dependent, interdependent, independent actions; accountability and safety are central.
• Evaluation: Involves modifying goals/interventions and planning future care; client and team collaboration; data clusters as part of assessment.
• Discharge Planning: Initiated at admission; ongoing; involves client/family; includes written and verbal teaching.
• Documentation and Reporting: Health records as legal documents; emphasis on accuracy, timeliness, confidentiality, and organization; various documentation formats (Narrative, POMR, CBE, etc.).
• Communication: Written and verbal communication essential for continuity; confidentiality and patient-centered care are emphasized.

Formulas and Notation

• Diagnostic Statement (example):
  ext{Ineffective Airway Clearance related to physiologic effects of pneumonia as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea.}
• Concepts to remember:
  • ext{R/T} = related to
  • ext{AEB} = as evidenced by
  • ext{P} = Problem label;
  • ext{Etiology} = cause or related factors;
  • ext{Signs/Symptoms} = data defining characteristics

Real-World Relevance

• Standardized diagnoses support clearer communication across healthcare teams, improve care coordination, and facilitate documentation for regulatory bodies.
• Early discharge planning reduces readmission risk and supports patient education and safety at home.
• Proper documentation protects both patient safety and provider accountability in legal contexts.

Ethical and Practical Implications

• Accurate assessment and objective documentation protect client rights and ensure appropriate care allocation.
• Respecting confidentiality during handoffs and communications aligns with ethical standards and legal requirements.
• Ensuring client involvement in planning supports autonomy and informed consent.

Summary of Foundational Points

• NANDA-I provides standardized labels for client problems.
• Diagnostic statements link Problem, Etiology, and Signs/Symptoms using R/T and AEB.
• Planning translates diagnoses into concrete, measurable outcomes and interventions.
• Implementation requires appropriate delegation (dependent, interdependent, independent) and strong accountability.
• Evaluation closes the loop by assessing outcomes and guiding future care.
• Documentation and reporting are essential for continuity of care, legal compliance, and quality improvement.