3.3 Nursing Diagnosis, Person-Centred Care Planning & Evaluation
Key Takeaways
- The five-phase nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation - ADPIE) serves as the core critical-thinking framework mandated by the Singapore Nursing Board (SNB).
- Nursing diagnoses must use standardized taxonomy (e.g., NANDA-I framework) and follow the three-part PES format: Problem (P), Etiology/Related Factors (E), and Signs/Symptoms/Defining Characteristics (S).
- Care goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-bound) and co-created with patients and families to embody person-centred care principles within Singapore's multicultural context.
- Continuous evaluation requires measuring patient outcomes against SMART goals, critically reflecting on intervention effectiveness, and modifying care plans dynamically when goals are unmet.
3.3 Nursing Diagnosis, Person-Centred Care Planning & Evaluation
The nursing process is a systematic, person-centred, critical-thinking framework that guides Registered Nurses in delivering individualized, safe, and effective nursing care. Enshrined in the Singapore Nursing Board (SNB) Core Competencies and Generic Skills for Registered Nurses (2023), the nursing process comprises five sequential yet dynamic and overlapping phases: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Rather than operating as a rigid, linear checklist, ADPIE provides an adaptable cycle where continuous re-assessment and critical reflection drive care plan modifications.
Formulating NANDA-I Nursing Diagnoses: The PES Format
A nursing diagnosis is a clinical judgment concerning a human response to health conditions, life processes, or vulnerability for that response by an individual, family, or community. It differs fundamentally from a medical diagnosis: medical diagnoses focus on pathophysiology and disease entities (e.g., Acute Myocardial Infarction, Diabetes Mellitus), whereas nursing diagnoses focus on the holistic human response to illness, functional impairments, and patient needs (e.g., Ineffective Airway Clearance, Impaired Physical Mobility, Anxiety).
Standardized taxonomy established by NANDA International (NANDA-I) is utilized across Singapore hospitals. A complete, problem-focused nursing diagnosis statement must follow the three-part PES format:
- P — Problem (Diagnostic Label): Concise description of the patient's health response (e.g., Impaired Gas Exchange).
- E — Etiology (Related Factors / r/t): Pathophysiological, treatment-related, or environmental factors causing or contributing to the problem (e.g., related to alveolar-capillary membrane changes secondary to pneumonia).
- S — Signs & Symptoms (Defining Characteristics / aeb): Objective assessment data and subjective statements demonstrating the presence of the problem (e.g., as evidenced by SpO2 89% on room air, tachypnoea at 26 breaths/min, and patient statement of shortness of breath).
Note: For Risk Diagnoses (e.g., Risk for Impaired Skin Integrity), only a two-part format (Problem + Etiology/Risk Factors) is used, because the problem has not yet occurred and signs/symptoms are absent.
| Medical Diagnosis | Diagnostic Type | NANDA-I Nursing Diagnosis (PES Format) |
|---|---|---|
| Ischaemic Stroke (CVA) | Problem-Focused | Impaired Physical Mobility r/t neuromuscular weakness of right upper and lower limbs aeb muscle strength 2/5 in right leg, inability to ambulate unassisted, and dependence in ADLs. |
| Heart Failure (NYHA Class III) | Problem-Focused | Excess Fluid Volume r/t compromised regulatory mechanisms and sodium retention aeb 2+ bilateral lower limb edema, 3 kg weight gain over 48 hours, and bibasilar lung crackles. |
| Total Hip Replacement | Risk Diagnosis | Risk for Infection r/t surgical skin incision, invasive indwelling urinary catheter, and presence of wound drain. (No 'aeb' required) |
| End-Stage Renal Failure | Health Promotion | Readiness for Enhanced Health Management aeb patient expression of desire to learn home peritoneal dialysis self-care techniques. |
Person-Centred Care Planning & SMART Outcome Formulation
In alignment with Ministry of Health (MOH) Healthcare Quality and Care Transformation strategies, nursing care plans must embody Person-Centred Care (PCC). In Singapore's multi-ethnic society (comprising Chinese, Malay, Tamil, and Eurasian communities, alongside international populations), person-centred planning requires incorporating cultural, religious, and dietary preferences, language accommodations, and family involvement (e.g., respecting Halal/Vegetarian dietary restrictions, modest touch preferences, and involving primary family caregivers in discharge planning).
During the Planning phase, nurses collaborate with the patient to establish prioritized nursing diagnoses and set SMART outcome goals:
- S — Specific: Clear, precise statement of the expected patient behavior or physiological change.
- M — Measurable: Objective, quantifiable criteria (e.g., pain scale score, distance walked in meters, blood glucose range).
- A — Achievable: Realistic given the patient's physical condition, age, and baseline capabilities.
- R — Relevant: Directly addresses the primary nursing diagnosis and patient priorities.
- T — Time-bound: Explicit target deadline or time horizon for achievement (e.g., within 30 minutes, by Day 3 post-op, prior to discharge).
| Non-SMART Outcome Goal (Incorrect) | Correct SMART Outcome Goal (SNB Compliant) | Rationale for SMART Compliance |
|---|---|---|
| "Patient will feel less pain soon." | "Patient will report a surgical pain score <= 3/10 on the numeric rating scale within 45 minutes after administration of prescribed IV morphine." | Specific (pain score), Measurable (<= 3/10), Achievable, Relevant, and Time-bound (45 min post-medication). |
| "Nurse will ambulate the patient." | "Patient will ambulate 15 meters along the ward corridor using a walking frame with 1-person assistance by 16:00 on Post-Op Day 2." | Focuses on patient outcome rather than nurse action; includes quantifiable distance, assistance level, and specific deadline. |
| "Patient will understand diabetic diet." | "Patient will correctly select 3 Halal low-glycemic index meal options from the hospital menu prior to discharge on 15 May." | Measurable demonstration of knowledge incorporating cultural/dietary relevance and a clear time boundary. |
Implementation & Dynamic Evaluation
Implementation involves carrying out planned nursing interventions, categorised into:
- Independent Nursing Actions: Autonomous interventions within RN scope of practice (e.g., patient positioning, skin barrier hygiene, deep breathing exercises, patient education, wound dressing changes).
- Dependent Nursing Actions: Interventions requiring a licensed physician's order (e.g., administering prescription medications, initiating IV blood transfusions, starting parenteral nutrition).
- Interdependent / Collaborative Actions: Interventions executed in coordination with transdisciplinary team members (e.g., co-managing mobility goals with Physiotherapy, swallowing rehab with Speech Therapy, post-discharge support with Medical Social Work).
Evaluation is the continuous process of comparing actual patient progress against the established SMART goals. Evaluation determines whether the care plan was effective and yields one of three formal conclusions:
- Goal Met: Patient achieved the specified SMART outcome. The nurse determines whether to resolve the nursing diagnosis or maintain supportive care.
- Goal Partially Met: Patient demonstrated progress toward the goal but did not achieve full criteria within the specified timeframe. The nurse re-evaluates barriers and extends or modifies the time frame.
- Goal Unmet: Patient showed no progress or deteriorated. The nurse must re-assess the patient, review the accuracy of the nursing diagnosis, identify unmet needs, and completely revise the care plan.
Applied Clinical Scenario: Care Planning at Changi General Hospital (CGH)
Scenario: Mdm. Rosnah, a 79-year-old female, was admitted to Changi General Hospital (CGH) following a left neck of femur fracture repair. On Post-Op Day 1, she refuses to move out of bed, crying quietly and stating she fears ripping her surgical stitches.
Assessment Data:
- Subjective: "I'm afraid to step down, it hurts too much and my leg will break again."
- Objective: Left hip surgical site clean/intact, pain score 7/10 on movement, grimacing, muscle strength 3/5 left leg, respiratory rate 22 breaths/min.
Care Plan Formulation:
- Nursing Diagnosis: Fear r/t anticipated pain and surgical site disruption aeb patient verbalization of fear, crying, refusal to ambulate, and grimacing.
- SMART Goal: Mdm. Rosnah will report fear score <= 2/10 and participate in bedside edge-of-bed sitting for 10 minutes with Physiotherapy by 15:00 today.
- Interventions:
- Pre-medicate with prescribed oral analgesia 40 minutes prior to planned physiotherapy session.
- Educate Mdm. Rosnah using Malay language anatomical diagrams explaining surgical fixation strength and wound integrity.
- Provide positive reinforcement and encourage family presence during mobilization.
- Evaluation at 15:30: Mdm. Rosnah reported pain score 2/10, expressed confidence, and successfully sat at the edge of the bed for 12 minutes with assistance. Goal Met. Diagnosis updated to reflect progress.
A Registered Nurse formulates the following diagnostic statement: 'Risk for Impaired Skin Integrity related to prolonged immobility and fecal incontinence.' Why does this risk diagnosis not contain a third 'as evidenced by' (Signs/Symptoms) component?
Which of the following statements represents a correctly formulated SMART nursing outcome goal for a patient with fluid volume excess?
During the evaluation phase of the nursing process, the nurse notes that a patient's postoperative pain score remains 7/10 two hours after receiving prescribed analgesia, missing the target goal of <= 3/10. What is the nurse's immediate next action in the nursing process cycle?