This document outlines the five phases of nursing care according to the American Nurses Association standards: assessing, diagnosing, planning, implementing, and evaluating. The first phase, assessing, involves collecting client data through various methods such as interviews, observations, and examinations. The second phase, diagnosing, analyzes the collected data to identify client health problems, risks, and strengths to form nursing diagnoses. The third phase, planning, prioritizes problems and formulates goals and interventions. The fourth phase, implementing, carries out the planned nursing interventions. The fifth and final phase, evaluating, determines if goals were met and problems resolved.

1. NURSING NOTES http://www.nursingnotes.info/
FIVE (5) PHASES OF NURSING CARE
(American Nurses Association (ANA) Standards of Clinical Nursing Practice)
I. ASSESING – is the systematic and continuous collection, organizing, validation, and
documentation of data.
PURPOSE: To establish a database about client’s response to health concerns or
illness and the ability to manage health care needs.
TYPES OF ASSESSMENT:
TYPE TIME PERFORMED PURPOSE EXAMPLE
Initial Assessment Within specified time To establish a Nursing admission
after admission complete data base assessment
for problem
identification,
reference and future
comparison
Problem-focused Ongoing process To determine status I & O q 1 hr in ICU
assessment integrated with of specific problem
nursing care identified in an
earlier assessment
To identify new or Assess client’s ability
overlooked problems to perform self care
while assisting to
bathe
Emergency During any To identify life- Rapid assessment of
Assessment physiologic and threatening ABC during cardiac
psychologic crisis of problems arrest
the client Assessment for
suicidal tendencies
and potential for
violence
Time-lapsed Several months after To compare client’s Reassessment of
reassessment initial assessment current status to client’s functional
baseline data health patterns.
previously obtained
A. DATA COLLECTION – is the process of gathering info about a client’s health status.

2. DATABASE – is all info about the client; includes nursing health history, physical assessment,
doctor’s history and physical exam, results of lab and diagnostic tests, and material contributed
by other health personel.
CLIENT DATA – past history and current problems.
TYPES OF DATA:
1. SUBJECTIVE DATA – symptoms or covert (secret) data. It is described or verified only by
the affected person.
Examples: itching, pain, worry, sensations, feelings, values, attitudes, perception of
personal status and life situation.
2. OBJECTIVE DATA – signs or overt (obvious) data. It is detectable by the observer, can be
measured or tested against accepted standard. They can be seen, heard and felt, or
smelled, can be obtained by observation or physical exam.
SOURCES OF DATA:
1. PRIMARY DATA – from the CLIENT, it is the best source of data unless too ill, young,
confused to communicate clearly.
2. SECONDARY DATA – are SUPPORT PEOPLE(family members, friends, caregivers), CLIENT
RECORD, HEALTH CARE PROFESSIONALS(doctors, nurses, physiotherapist, social
workers), LITERATURE (standards/norms,cultural and health practices, spiritual beliefs)
DATA COLLECTION METHODS
1. OBSERVATION – is a conscious, deliberate skill that is developed through effort and with
an organized approach.
2. INTERVIEW – is planned communication or a conversation with a purpose.
TWO APPROACHES:
a. DIRECTIVE INTERVIEW. The nurse establishes the purpose and controls the
interview. The client responds to questions but may limited opportunity to ask
questions or discuss concerns
b. NONDIRECTIVE INTERVIEW – rapport-building interview. The nurse allows the client
to control the purpose, subject matter, and pacing.

3. RAPPORT- is the understanding b/w 2 or more people.
TYPES OF INTERVIEW:
a. CLOSED QUESTION – (directive interview) restrictive and answered by YES/NO,
questions begin by WHEN, WHERE, WHO, WHAT, DO or IS.
b. OPEN-ENDED QUESTIONS – (indirective interview) invite clients to discover, explore,
elaborate, clarify, or illustrate their thoughts and feelings. It may begin with WHAT/
HOW.
c. NEUTRAL QUESTION – (open ended and indirective) is a question a client can
answer without direction or pressure from the nurse ( regarding feelings and point
of views)
d. LEADING QUESTIONS – (closed and directive) directs the client’s answer. It gives the
client less opportunity to decide whether the answer is true or not. (Ex. You’re
stressed about the surgery tomorrow, aren’t you?)
PLANNING AND SETTING OF INTERVIEW
a. Time. comfortable and unhurried
b. Place. Well lighted, well ventilated, moderate sized room, free from noise,
movements and interruptions.
c. Seating arrangement.
• Two parties are seated on two chairs placed at right angles to a desk or table /
few feet apart without table between.
• A horseshoe or circular chair arrangements
• When a client in bed, sit at a 45 degrees angle to bed, not standing and looking
down the client who is in bed.
d. Distance. Maintaining a distance of 2 to 3 feet.
PROXEMICS – term for the study of human use and perception of social and
personal space.
• INTIMATE ZONE (0-18 inches) –use for comforting, protecting, counseling
and preserved for people who feel close.
• PERSONAL ZONE (18 inches to 3 feet) – maintained with friends or in some
counseling interactions
• SOCIAL/PUBLIC ZONE (3 – 6 feet) – used when impersonal business is
conducted or with people who are working together.

4. e. Language. Failure to communicate is a form of discrimination.
• Translate medical terminologies into common English understandable to
both client and family members.
STAGES OF INTERVIEW
1. The Opening – most important part.
Purpose: to establish rapport (process of creating a goodwill and trust) and orient the
interviewee.
• begin with a greeting, self intro accompanied by smile or handshake
• Explain the purpose and nature of interview
• Tell the client how the info will be used and usually states the client’s right not
to provide the info.
2. The Body – the client communicates what he feels or thinks. Knows, and
perceives in response to questions from the nurse.
3. The Closing – the termination is important for maintaining rapport and trust
and for facilitating future interactions.
TECHNIQUES:
a. Offer to answer questions. Do u have any questions?
b. Conclude by saying “Well, ….” , that generally signals that the need of interactions
c. Thank the client.
d. Express concern for person’s welfare and future. “Take care of urself….”
e. Plan for the next meeting, if there’s a need.
f. Provide summary to verify accuracy and agreement.
3. EXAMING – a physical exam/ assessment is the systematic data-collection method used
observation (the senses) to detect health problems.
APPROACHES:
a. CEPAHALOCAUDAL / HEAD-TO-TOE APPROACHES – begins the examination at the
head, progresses to the neck, thorax, abdomen, and extremities, and ends at the
toes.
b. BODY SYSTEMS APPROACH – investigates each systems individually. That is,
respiratory, circulatory, nervous systems, and so on.
c. SCREENING EXAMINATION/ REVIEW OF SYSTEMS – is a brief review of a screening
examination measured against norms/standards, such as ideal wt & ht for body tem /
BP.

5. B. ORGANIZING DATA – the nurse uses a written/computerized format that organizes the
assessment data systematically.
OTHER TERM: Nursing Health History, Nursing Assessment, Nursing Database Form
NURSING CONCEPTUAL MODELS
1. Gordon (2000) –provides a framework of 11 functional health patterns. It collects
data about dysfunctional as well as functional behavior.
2. Orem, Taylor, and Renpenning (2000) – delineate 8 universal self care requisites of
humans.
3. Roy and Andrews (1998) – classify observable behavior into 4 categories: self
concept, role function and interdependence.
4. Others
WELLNESS MODELS – to assist clients to identify health risks and to explore lifestyle
habits and health behaviors, beliefs, beliefs, values, and attitudes that influence levbels
of wellness.
NONNURSING MODELS
1. BODY SYSTEMS MODEL – focuses on abnormalities in anatomic systems of the body.
2. MASLOW’S HIERARCHY OF NEEDS
3. DEVELOPMENTAL THEORIES – for physical, psychosocial, cognitive and moral
developmental theories.
C. VALIDATING DATA – is verifying data to confirm that it is accurate and factual
CUES – are subjective or objective data that can be directly observed by the nurse.
INFERENCES – nurse’s interpretation or conclusions made based on the cues.
D. DOCUMENTING DATA – the nurse records the data.
ACCURATE DOCUMENTAION – is essential and should include all data collected about
the client’s health status.
II. DIAGNOSING – is analyzing data; identification of health problems, risks and strengths; and
formulation of diagnostic statement.
Diagnostic Labels – are standardized NANDA names for diagnoses
Diagnosis – is the statement or conclusion regarding the nature of phenomenon.

6. Nursing Diagnosis – the client’s problem statement, consisting of the diagnostic label plus the
etiology (casual relationship b/w a problem and its related or risk factors)
TYPES OF NURSING DIAGNOSES
1. ACTUAL DIAGNOSIS is a client problem that is present at the time of nursing assessment.
2. RISK NURSING DIAGNOSIS is a clinical judgment that a problem does not exist, but the
presence of risk factors indicates a problem is likely to develop unless nurse intervenes.
3. WELLNESS DIAGNOSIS – describe a human response to level of wellness that have a
readiness for enhancement.
4. POSSIBLE NURSING DIAGNOSIS is one in which evidence about a health problem is
incomplete or uncler.
5. SYNDROME DIAGNOSIS is a diagnosiss that is associated with a cluster of other
diagnosis.
THREE COMPONNETS OF NURSING DIAGNOSIS
1. PROBLEM and its definition – describes the client’s health problem or response for hich
nursing therapy is given.
QUALIFIERS – are words that have been added to some NANDA labels to give additional
meaning to the diagnostic statement.
• Deficient – inadequate, incomplete
• Impaired – made worse, weakened, damaged, reduced, deteriorated
• Decreased – lesser
• Ineffective – not producing a desired effect
• Compromised – to make vulnerable to threat
2. EtTOLOGY (Related factors/Risk factors) – identifies one/more probable causes of the
health problem, gives direction to the required nursing therapy, and enables the nurse
to individualized the client’s care.

7. 3. DEFINING CHARACTERISTICS – are the cluster of signs and symptoms that indicate the
presence of a particular diagnostic label.
THREE STEPS OF DIAGNOSTIC PROCESS
1. Analyzing data- a. compare data against standards/ norms (generally acceptable
measure, rule, model or pattern)
b. cluster cues
c. identify gaps and inconsistencies
2. Identify health problems, risks, and strengths – decision making process
3. Formulation diagnostic statements
• BASIC TWO-PART STATEMENTS (Problem + Etiology)
• BASIC THREE-PART STATEMENTS – PES format
(Problem + Etiology + Signs and Symptoms)
• ONE-PART STATEMENTS – NANDA LABEL ONLY (Wellness/Syndrome diagnosis)
BASIC FORMATS VARIATIONS:
a. Writing unknown etiology when the defining characteristics are present but the
nurse does not know the cause or contributing factors.
Ex: Noncompliance (medication Regimen) r/t unknown etiology
b. Using the phrase complex factors when there are too many etiologic factors or
when they are too complex to state in a brief phrase.
Ex: Chronic Low Self-Esteem r/t complex factors
c. Using word possible to describe either the problem of etiology.
Ex: Possible low self esteem r/t loss of job
Altered thought process possibly r/t unfamiliar surroundings

8. d. Using secondary to divide the etiology into two parts, thereby making the
statements more descriptive and useful. The part following the secondary to is often
the pathophysiology/disease process.
Ex: Risk for impaired skin integrity r/t decreased peripheral circulation secondary to
diabetes.
e. Adding a second part to the general response or NANDA label to make it more
precise.
Ex: Impaired skin integrity (Left lateral ankle) r/t decreased peripheral circulation
III.PLANNING – is a deliberative, systematic phase that involves decision making and problem
solving. It begins with the first client contact and continues until the nurse-client relationship
ends, usually when client is discharged from the health care agency.
• Prioritize problems/diagnosis
• Formulate goals/desired outcomes
• Select nursing interventions
• Write nursing orders
NURSING INTERVENTION- is any treatment, based upon clinical judgment and knowledge that a
nurse performs to enhance patient’s outcomes.
TYPES OF PLANNING
• Initial Planning. Planning is initiated as soon as possible after initial assessment
• Ongoing Planning. Planning occurs at the beginning of a shift to the end of the shift.
• Discharge Planning. The process of anticipating and planning for the needs after
discharge.
NURSING CARE PLAN. Is the end product of the planning phase of the nursing process

9. • Informal nursing care plan. Is a strategy of action that exists in the nurse’s mind.
• Formal nursing care plan. A written/computerized guide that organizes info about the
client’s care.
• Standardized care plan. A formal plan that specifies the nursing care fro groups of
clients with common needs.
• Individualized care plan. Is tailored to meet the unique needs of a epecific client –
needs that are not addressed by the standardized plan.
STANDARDS OF CARE. It describes nursing actions forclients with similar medical conditions
rather than individuals, and they describe achievable rather than ideal nursing care.
PROTOCOLS. They are preprinted to indicate actions commonly required for a particular group
of clients.
STANDARDIZED CARE PLANS. They are preprinted guides for the nursing care of a client who
has a need that arises frequently in the agency. They written from the perspective of what care
the client can expect.
POLICIES AND PROCEDURES. They are developed to govern a handling of frequent occurring
situations.(institutional records)
STANDING ORDER. Is a written document about policies, rules, regulations, or orders regarding
client care. It gives nurses the authority to carry out specific actions under certain
circumstances, often when a physician is not immediately available.
• STUDENT CARE PLANS – plan of care made by the students with a” rationale” column.
RATIONALE - is the scientific principle given as the reason for selecting a particular nursing
intervention.
CONCEPT MAP – is a visual tool in which ideas or data are enclosed in circles or boxes of some
shape and relationships b/w these are indicated by connecting lines and arrows.
• COMPUTERIZED CARE PLANS – computer are used to create and store NCP.

10. • MULTIDISCIPLINARY (Collaborative) CARE PLAN – standardized paln outlines the care
required for clients with common, predictable – usually medical – conditions.
THE PLANNING PROCESS
1. PRIORITY SETTING is the process of establishing a preferential sequence for addressing
nursing diagnoses and interventions
2. ESTABLISHING CLIENT GOALS/DESIRED OTCOMES – what the nurse hopes to achieve by
implementing the nursing interventions.
COMPONENTS
a. Subject. Is the client, any part of the client, or some attributes such as BP/ Temp.
b. Verb. It specifies an action the client is to perform.
c. Conditions/ modifiers. It may be added to the verb to explain the circumstances
under which the behavior is to be performed. They explain what, where, when and
how.
d. Criterion of desired outcome. It indicates the standard by which a performance is
evaluated or at the level at which the client will perform the specified behavior. It
specifies time or speed, accuracy, distance and quality.
3. SELECTING NURSING INTERVENTIONS.
• INDEPENEDENT INTERVENTIONS - are those activities that nurses are licensed
to initiate on the basis of their knowledge and skills.
• DEPENDENT INTERVENTIONS - are activities carried out under the physician’s
orders or supervision, or according to specified routines.
• Collaborative interventions – are actions the nurse caries out in collaboration
with other health team members, such as PT, SW, Dietitians, and physicians.

11. IV.IMPLEMENTING – consist of doing and documenting the activities that are the specific
nursing actions needed to carry out the interventions.
IMPLEMENTING SKILLS
• COGNITIVE (intellectual) SKILLS – includes problem solving, decision making. Critical
thinking and creativity
• INTERPERSONAL SKILLS -