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
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