NURSIN
G CARE
PL AN
MS. HANADI STEITIYEH RN, MSN
FA C U LT Y O F H E A LT H S C I E N C E S , N U R S I N G
D E PA RT M E N T
S U M M E R- 2 0 2 5
WHAT IS THE
NURSING PROCESS?
• A step-by-step method used to provide effective,
personalized care.
• Helps nurses assess, diagnose, plan, implement, and
evaluate patient care.
• Think of it like a recipe or a map for patient care!
THE 5 STEPS OF THE
NURSING PROCESS
1. Assessment – Gather data (subjective and objective)
• Collect data (look, listen, ask)
Patient says, ‘I can’t breathe’ (subjective).
O2 sat is 88% (objective)
THE 5 STEPS OF THE
NURSING PROCESS
2. Diagnosis – Identify the patient's nursing problem.
• Identify the problem (NANDA)
Impaired Gas Exchange R/T asthma AEB low O2 sat.
THE 5 STEPS OF THE
NURSING PROCESS
3. Planning – Set SMART goals and select interventions
• Set a SMART goal
O2 sat will improve to 95% in 1 hour with oxygen
therapy.
THE 5 STEPS OF THE
NURSING PROCESS
4. Implementation – Put the plan into action
• Take action (nurse-driven!)
Give 2L O2 via nasal cannula.
THE 5 STEPS OF THE
NURSING PROCESS
5. Evaluation – Check if the goals were met and revise if
needed
• Check if it worked
Recheck O2 sat → Goal met? Adjust plan if not.
NANDA NURSING
DIAGNOSIS FORMAT
• Problem + Related To (R/T) + As Evidenced By (AEB)
• Example:
• Acute Pain R/T surgical incision AEB pain score 8/10
• Risk for Falls R/T unsteady gait AEB recent dizziness
ATTENTION
• ❌ "Patient has diabetes.” (Not a nursing diagnosis!)
• ✅ "Risk for Unstable Blood Glucose R/T lack of diabetes
education."*
ATTENTION
Aspect Nursing Diagnosis Medical Diagnosis
Identifies a
Identifies the disease or
Definition patient's response to health
condition
problems
Patient-centered; how illness Disease-centered; pathology
Focus
affects daily life and its treatment
Guides nursing care and Guides medical
Purpose
interventions treatment and diagnosis
- Impaired Gas - Pneumonia - Diabetes
Examples
Exchange - Risk for Falls Mellitus
Yes – as the patient’s
No – remains until the disease
Can It Change? condition improves or
is resolved or stabilized
worsens
Patient's assessment and Diagnostic tests, exams,
Based On
nursing judgment and clinical findings
Independent or collaborative Medical or surgical
Intervention Type
nursing interventions treatments
SETTING SMART
GOALS
• S – Specific: Clear and focused
• M – Measurable: Can be tracked
• A – Attainable: Realistic for the patient
• R – Relevant: Matches the diagnosis
• T – Time-bound: Has a deadline
• Example: Patient will walk 10 steps with assistance by
end of shift
CASE STUDY
ACTIVITY
• Patient: Ms. Lee, 70 years old, admitted with heart
failure.
• Complains of fatigue and swollen ankles.
• Vitals: BP 150/90, Pulse 102, Edema +2 in legs.
• Instructions:
1. Identify assessment data (subjective/objective)
2. Write a nursing diagnosis
3. Create 1 SMART goal
4. Suggest 2 interventions
CARE PLAN
1. Fatigue and edema
2. Fluid Volume Excess R/T heart failure AEB edema
3. Decrease in the scale of edema to +1 in the coming 3
days.
4. Monitor weight daily
Daily assessment of edema scale
Monitor I/O
Fluid restriction
Elevate patient legs
