The Nursing ProcessThe Nursing Process

Kalyani Mohanraj Kalyani Mohanraj

Associate ProfessorAssociate Professor

CCNCCN

Planning Planning

• Deliberate systematic phase of the nursing process that involves problem solving and decision making.– Prioritizing problems (nursing diagnosis)– Formulate goals/desired outcomes– Select nursing interventions– Write nursing orders

Types of PlanningTypes of Planning

• Initial planning– Initiated soon after the initial assessment– Comprehensive plan based on the data

• Ongoing planning/daily planning– Individualize the initial plan– Modified every shift– Evaluate effectiveness of care

• Discharge planning– Deals with care needs at home/hospice

Setting PrioritiesSetting Priorities

• Establishing preferential sequence of addressing nursing diagnoses and interventions.– High priority – life threatening conditions– Medium priority – health threatening problems– Low priority – minimum nursing interventions

Guide Lines to Set PrioritiesGuide Lines to Set Priorities

• Abraham Maslow’s hierarchy of needs

• Clients preference

• Resources available

• Health beliefs and values of client

• Medical treatment plan

Setting Outcome CriteriaSetting Outcome Criteria

• They describe in observable client responses what the nurse hopes to achieve by implementing the nursing interventions.– Goals/desired outcome/objective/outcome

criteria/expected outcome all these terms are used interchangeably.

Components of GoalsComponents of Goals

• Derived from the problem in the nursing diagnoses

• It is stated as the opposite healthy client response

• Must have the following clauses– Subject – client/part or attribute of client – Verb – action the client is expected to perform– Conditions/modifiers – what/when/where/how– Criterion of performance – standard/quality of

perfomance

Guide Lines for Writing GoalsGuide Lines for Writing Goals

• In terms of client responses

• Realistic/Achievable

• Address one nursing diagnosis

• Observable and measurable terms

• In collaboration with client

SamplesSamples

Nursing Diagnoses Goals/desired outcome

Impaired physical mobility

Improved mobility -

Ambulates with crutches by the end of this week

Ineffective airway clearance

Effective airway clearance – coughs and deep breathes every two hours

Subject

Verb Conditions/

Modifiers

Criterion

Client Drinks 2500ml of fluid Daily (time)

Client Administers

Correct insulin dose

Using aseptic technique (quality standard)

Client Lists 3 hazards of smoking

Accuracy

Nursing InterventionsNursing Interventions

• Actions taken by the nurse to achieve the goals/expected outcome

• Focus on eliminating/reducing/modifying the etiology of the nursing diagnosis

• If not possible, to treat the signs and symptoms (defining characteristics)– E.g.

• Anxiety related to hospitalization• Pain related to surgical incision

Types of Nursing InterventionsTypes of Nursing Interventions

• Independent interventions– Activities the nurses are licensed to initiate on the

basis of their knowledge and skills

• Dependent interventions– Activities carried out under the physicians’ orders or

supervision or according to specified routines

• Collaborative interventions– With other health team members e.g.

physiotherapists, social workers dieticians etc.,

Criteria for selecting the Criteria for selecting the InterventionsInterventions

• Safe and appropriate

• Achievable with the resources available

• Congruent with the client’s values and beliefs

• Compatible with other therapies

• Based on nursing knowledge or experience

• Within established standards of care

Formats of Care PlansFormats of Care Plans

• Student care plans

• Computer generated care plans– Standardized care plans– Individualized care plans

• Concept maps

• Collaborative care plans/Critical path ways

Student care planStudent care plan

Assessment data

Nursing diagnosis

Goals Planning

Rationale

Implementation

Evaluation

Implementing Implementing

• The phase in which the nurse carries out or delegates the planned interventions.

– Reassess the client– Determine the need for assistance– Implement the intervention– Supervise delegated care– Document nursing activities