Nurse's Pocket Guide

1. Nursing is Defined by Diagnosing and Treating Human Responses.

In 1980, the American Nurses Association (ANA) developed the first Social Policy Statement defining nursing as “the diagnosis and treatment of human responses to actual or potential health problems.”

A unique focus. This definition shifted nursing's focus from solely assisting physicians to identifying and addressing the client's reactions to health problems and life processes. It emphasizes the nurse's independent role in managing human responses, whether physical, psychological, social, cultural, or spiritual. This distinct domain differentiates nursing from medicine, which focuses on diagnosing and treating disease.

Beyond the medical model. While nurses work within medical and psychosocial domains, their primary concern is the client's experience of health and illness, not just the underlying pathology. This includes responses to wellness and personal growth needs, not limited to just "problems" to be fixed. The nurse integrates objective data with the client's subjective experience.

Caring and science. Contemporary nursing practice combines the application of scientific knowledge for diagnosis and treatment with the provision of a caring relationship. This holistic approach addresses the full range of human experiences and facilitates health and healing. The nurse uses a broad theoretical framework and caring skills to provide comprehensive care.

2. The Nursing Process is the Systematic Method for Providing Care.

This process incorporates an interactive/interpersonal approach with a problem-solving and decision-making process.

A dynamic cycle. The nursing process is a systematic, five-step method used by nurses to provide effective client care: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Introduced in the 1950s and expanded over time, it is now the widely accepted basis for nursing practice. It is a continuous cycle of thought and action.

Accepted standard. The nursing process is included in the conceptual framework of all nursing curricula, accepted in the legal definition of nursing in most Nurse Practice Acts, and included in the ANA Standards of Clinical Nursing Practice. It provides a structured approach to care delivery, ensuring consistency and quality. It requires critical thinking and clinical judgment at each step.

Problem-solving approach. At its core, the nursing process is a problem-solving method. It involves observing, measuring, gathering data, analyzing findings, making decisions, and taking action. This systematic approach helps nurses prioritize needs, develop targeted interventions, and evaluate the effectiveness of care.

3. Assessment is the Foundation: Gather and Organize Client Data.

Assessment is an organized dynamic process involving three basic activities: a) systematically gathering data, b) sorting and organizing the collected data, and c) documenting the data in a retrievable fashion.

Building the database. The first step of the nursing process is assessment, which involves collecting comprehensive data about the client. This includes both subjective data (what the client reports, believes, or feels) and objective data (what is observed, measured, or obtained from other sources like physical exams, lab results, and records). Data is gathered from various sources, including client interviews and physical assessments.

Holistic view. The assessment aims to create a complete profile of the client's health status, encompassing physical, psychological, sociocultural, spiritual, cognitive, and developmental levels, as well as economic status, functional abilities, and lifestyle. Using a nursing-focused assessment tool helps ensure that data relevant to nursing diagnoses are collected systematically. This organized data forms the client database.

Continuous activity. Assessment is not a one-time event but an ongoing process. Nurses continuously collect and update data throughout the client's care to identify changing needs and responses. Accurate and thorough assessment is crucial because it forms the basis for all subsequent steps of the nursing process.

4. Nursing Diagnosis Identifies Client Needs Using Standardized Language.

a nursing diagnosis (ND) is a decision about a need/problem that requires nursing intervention and management.

Clinical judgment. Nursing diagnosis is the second step of the nursing process, involving the analysis of assessment data to identify the client's actual or potential health problems or needs. It is a clinical judgment about an individual's, family's, or community's responses to actual or potential health problems/life processes. This process uses diagnostic reasoning to interpret the collected data.

Standardized labels. NANDA International (formerly the North American Nursing Diagnosis Association) develops and refines standardized nursing diagnosis labels. These labels provide a common language for nurses to describe client needs. A complete client diagnostic statement often uses the PES format: Problem (the NANDA label), Etiology (related factors), and Signs/Symptoms (defining characteristics).

Focusing nursing care. Identifying the correct nursing diagnosis directs nursing interventions and management. It focuses attention on the specific human response requiring nursing action. Unlike medical diagnoses, nursing diagnoses can change as the client's condition evolves, reflecting the dynamic nature of nursing care.

5. Planning Involves Setting Goals, Outcomes, and Interventions.

Planning includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing interventions.

Charting the course. The planning phase involves developing a strategy to address the identified nursing diagnoses. This begins with prioritizing the client's needs, which is a dynamic process based on the client's condition. Goals are then established, indicating the general direction of expected progress. Goals can be short-term (met during the current care episode) or long-term (extending beyond discharge).

Measurable outcomes. From the goals, desired outcomes are formulated. These are specific, measurable, achievable, realistic, and time-bound (SMART) client responses that indicate progress toward the goals. Outcomes serve as criteria for evaluating the effectiveness of care. Client and significant other input is crucial in setting outcomes to promote client responsibility and buy-in.

Choosing actions. Nursing interventions are the specific actions or prescriptions designed to help the client achieve the desired outcomes. These interventions can be independent nursing actions or collaborative actions requiring orders from other disciplines. Interventions should be based on the nursing diagnosis, goals, outcomes, scientific principles, and the client's individual circumstances and capabilities.

6. Implementation Puts the Care Plan into Action.

Implementation occurs when the plan of care is put into action, and the nurse performs the planned interventions.

Executing the plan. This is the action phase of the nursing process where the nurse carries out the interventions identified in the plan of care. This involves performing direct care activities, treatments, and actions designed to help the client achieve the desired outcomes. It requires the nurse to have the necessary knowledge, skills, and expertise.

Flexibility and judgment. While the plan of care provides direction, implementation requires flexibility. The nurse must constantly monitor the client's response and adapt interventions as needed based on the client's changing condition or unexpected events. Clinical judgment is essential to ensure interventions are performed safely and appropriately.

Considering all factors. Before implementing interventions, the nurse must understand the rationale, expected effects, and potential hazards. Legal and ethical considerations, including respecting the client's wishes and involving the family, are paramount. Implementation also includes documenting the interventions performed and the client's immediate response.

7. Evaluation Measures Progress and Guides Plan Revision.

Evaluation is accomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated.

Checking effectiveness. Evaluation is the final, but continuous, step of the nursing process. It involves assessing the client's response to the interventions and determining whether the desired outcomes have been met. This is done through direct observation, interviewing the client and significant others, and reviewing the healthcare record.

Ongoing process. Evaluation is not a one-time activity but an ongoing process integrated throughout care. It helps determine the appropriateness of nursing actions, the need to revise interventions, the development of new client needs, and the need for referrals. It ensures the plan of care remains relevant and effective.

Improving care. Comparing client outcomes to the desired outcomes provides valuable data for refining the plan of care. If outcomes are not met, the nurse reassesses the client, revises the nursing diagnoses, modifies the goals and outcomes, or changes the interventions. Evaluation also contributes to quality improvement and research by validating nursing practices and outcomes.

8. Standardized Nursing Language Enhances Communication and Research.

The use of standardized terminology or NANDA International nursing diagnosis labels provides nurses with a common language for identifying client needs.

Common understanding. Standardized nursing languages, such as NANDA diagnoses, NIC (Nursing Interventions Classification), and NOC (Nursing Outcomes Classification), provide a uniform way for nurses to describe client needs, the care provided, and the client's response. This common language is essential for clear communication among healthcare providers across different settings.

Continuity and visibility. Standardized language ensures continuity of care as clients move between various healthcare environments (e.g., hospital, home health, rehabilitation). It also makes nursing's contribution to client outcomes more visible and measurable, which is crucial for demonstrating the value of nursing care and for reimbursement purposes.

Data and research. Standardized languages facilitate the collection and analysis of nursing data. This data can be coded for computer systems (like SNOMED) and used for research, quality improvement, and developing evidence-based practice. It supports telehealth and allows access to healthcare data across different systems.

9. Structured Tools Facilitate Assessment and Care Planning.

To facilitate the steps of assessment and diagnosis in the nursing process, an assessment tool... has been constructed using a nursing focus instead of the medical approach of “review of systems.”

Organizing data. Tools like nursing-focused assessment guides (often structured by Diagnostic Divisions based on human responses) help nurses systematically collect and cluster data relevant to nursing diagnoses. This approach directs the nurse's attention to the client's responses rather than just medical conditions.

Visualizing connections. Care planning tools, such as prototype plans of care or mind maps, help nurses organize and visualize the relationships between assessment data, nursing diagnoses, desired outcomes, and interventions. Mind mapping, for instance, uses a non-linear format to show interconnections between various client issues and care strategies.

Putting theory into practice. These tools translate the abstract concepts of the nursing process into practical application. They provide frameworks for documenting the assessment and planning phases, ensuring that care is individualized and comprehensive. Using these tools helps nurses move efficiently from data collection to developing a concrete plan of action.

10. Documentation is Essential for Communication, Accountability, and Evaluation.

The plan of care is the end product of the nursing process and documents client care in areas of accountability, quality assurance, and liability.

Record of care. Documentation is a critical component of the nursing process, occurring throughout all phases. It provides a permanent record of the client's assessment data, identified needs (nursing diagnoses), the plan of care, the interventions performed, and the client's response and outcomes.

Communication and continuity. Clear and timely documentation facilitates communication among all members of the healthcare team, ensuring continuity of care. It allows others to understand the client's status, the care provided, and the plan for ongoing management. It also serves as a teaching tool for students and new staff.

Legal and quality aspects. Documentation is essential for legal protection, demonstrating that appropriate standards of care were met. It is also used for quality assurance, auditing, and research. Formats like SOAP (Subjective, Objective, Analysis, Plan) or Focus Charting (Data, Action, Response) provide structured methods for recording client progress and the effectiveness of interventions.

Last updated: May 11, 2025