REVIEW OF NURSING PROCESS
PLANNING
▪ DEFINITION OF TERMS:
▪ PLANNING :Thinking in advance what you want to do in the future
Preparing
Organizing
▪ PLAN A scheme or guide of action
DEFINITION OF TERMS:
▪ PLANNING NURSING CARE
Determining how to prevent, reduce, or resolve the client’s identified problem; how to
support client’s strength and how to implement nsg interventions in an organized,
individualized and goal directed manner.
▪ PLANNING is essential for several reasons:
▪ Enables the nurse to categorize problem
▪ Helps the nurse to individualized nursing care
▪ Consideration of urgent needs
▪ Continuity of care
▪ Basis for evaluation of care
▪ NURSING CARE PLAN (NCP)
Guide to implement appropriate nursing action
▪ REASONS FOR DEVELOPING A PLAN OF CARE
▪ Individualized care
▪ Set priorities
▪ Help communication among nursing personnel
▪ Promote continuity of care
▪ To coordinate care – all health team
▪ Evaluate nursing care responses
▪ Promote nurse’s personal development
▪ Establishing
Setting Priorities
a preferential sequence for addressing nursing diagnoses and interventions
▪ High priority (life-threatening)
▪ Medium priority (health-threatening)
▪ Low priority (developmental needs)
▪ PRIORITY SETTING
• Based on Maslow’s Hierarchy of Needs
• Guidelines in determination of priorities (KRONNS)
o Problem r/t basic survival & safety come first
▪ A–B–C–S
o Actual problems or needs for w/c the patient & family requested
o Needs & problems w/c are unrecognized by the patient but the nurse realizes
may have serious complication
o Actual or potential problems
▪ BASIS oOF Patient’s
PLANNING:
health care needs
o Selected goals
o Strategies
▪ FORMULATION OF [Link] OBJECTIVE
Either GOALS and OBJECTIVES should be:
▪S M A R T
▪ OBJECTIVE:
An aim or an end
Describes an expected outcome
▪ Long-term Objective
Future oriented
Achieved over a longer period of time
Usually weeks or months
▪ Short-term Objective
▪ Achieved w/in a short time frame
▪ Usually less than a week
▪ Day to day oriented
▪ Advantages of short-term objectives:
▪ Small increments in progress can be observe readily
▪ N-P can enjoy seeing satisfaction of the progress being made in attaining goals
▪ Patient is unlikely to be off-track and reinforce bad habits on his way to long term
goals
▪ OBJECTIVES use action verbs to express the expected behaviors:
Remember! Never use verbs open to many interpretations;
Learn Understand Improve
Use SPECIFIC verbs instead:
Describe Identify Compare Demonstrate
Discuss Enumerate Define Select
▪ Objectives should be phrased in POSITIVE rather than negative terms:
EX: a case of Zanjo w/ post-op incision.
[Link]: Potential for infection r/t abdominal incision
OBJECTIVE:
o Zanjo’s abdominal incision will not develop any infection with my care. (wrong)
o Zanjo’s abdominal incision will completely heal in 3 weeks. (correct)
▪Subject:
Components of expected Outcome
Who is the person expected to achieve the outcome?
Verb: What actions must the person take to achieve the outcome?
Condition; Under what circumstances is the person to perform the actions?
Performance criteria: How well is the person to perform the actions:
Target time: By when is the person expected to be able to perform the actions?
▪ Mr. Smith will walk with a cane at least to the end of the hall and back by Friday
Subject: Mr. Smith
Verb: will walk
Condition; with a cane
Performance criteria at least to the end of the hall and back
Target time: by Friday
▪ Identify if the statement are written correctly
John will know the four basic food groups by 12/30/18 X
The verb is not measurable
John will list the four basic food groups by 12/30/18 (correct)
▪ IDENTIFYING ALTERNATIVES OF NURSING CARE
▪ CATEGORIES OF NURSING INTERVENTIONS
➢ Nurse-initiated interventions (independent nursing interventions)
➢ Physician-initiated interventions (dependent nursing interventions)
➢ Collaborative interventions (interdependent nursing interventions)
▪ Nurse-initiated interventions (independent nursing interventions)
o Independent response of the nurse to the client’s health needs and
[Link]
o The nurse is able to act w/in his/her own scope of practice
o Autonomous actions by the nurse
▪ Physician-initiated interventions (dependent nursing interventions)
o Based on physicians response to treat or manage a medical diagnosis
o Physicians order carried out by the nurse
▪ Therapies
Collaborative interventions (interdependent nursing interventions)
that require the knowledge, skill and expertise of multiple health care
professionals
▪ SELECTING MEASURES
Nursing measures (interventions) should be REALISTIC.
▪ IMPORTANT FACTORS WHEN CHOOSING INTERVENTIONS
1. Characteristics of nursing diagnosis
2. Expected outcomes
3. Knowledge on the nursing intervention
4. Feasibility of the interventions
5. Acceptability to the client
6. Competencies of the nurse
Let’s make NCP.
▪ CUES
OBJECTIVE CUES:
Physical injury: presence of post surgical wound
Facial mask of pain
Guarding/protective behaviors
SUBJECTIVE CUES:
Report of pain
▪ NURSING DIAGNOSIS
Alteration in comfort, Acute Pain related to disruption of skin, tissue and muscle
integrity secondary to surgery as manifested by report of pain, facial mask of
pain and guarding/protective behaviors
▪ RATIONALE: (PATHOPHYSIOLOGY)
o An attempt to explain your chosen nsg diagnosis
o May be in a diagram or narrative form
o Always starts with etiologic factors and predisposing factors and end with
manifestations
RATIONALE: (PATHOPHYSIOLOGY)
Etiologic Factors + Predisposing Factors
Pathophysiology
NURSING DIAGNOSIS
Manifestations
RATIONALE FOR ACUTE PAIN:
Tissue damage caused by surgical intervention
Activation of the peripheral nervous system
Activation of the Central Nervous System at the Spinal Cord Level
Transmission of the Pain Signal to the Brain
Pain
Facial mask of pain
Guarding/protective behaviors
▪ OBJECTIVES:
At the end of my 8 hour shift the patient will report controlled level of pain.
NSG INTERVENTION RATIONALE
INDEPENDENT • These variables may modify the
patient’s expression of his/her
• Assess the degree of factors that may contribute
experience.
to pain or relief of pain.
• Their definition of pain can directly
• Evaluate the meaning of pain to the individual.
influence the response.
• Assess the patient’s willingness or ability to
• Some patients may feel
explore techniques of pain control/mgt.
uncomfortable exploring
• Evaluate the pain regularly noting alternative methods of pain relief.
characteristics, location and intensity.
• Provides information about need
• Assess v/s noting tachycardia, HPN and for/effectiveness of interventions
increased perspiration
• Changes in these v/s may indicate
• Provide info about transitory nature of pain and discomfort.
discomfort, as appropriate.
• Understanding the cause of the
discomfort provides emotional
reassurance.
NSG INTERVENTION RATIONALE
• Reposition as indicated. • May relieve pain and enhance circulation.
• Encourage use of relaxation [Link], • Relieves muscle and emotional tension,
deep breathing, guided imagery, music, etc enhance sense of control and may improve
coping abilities.
COLLABORATIVE
• Pain medications immediately provides
• Administer medications as indicated.
more effective relief.
• Notify the physician if interventions are
• Frequent request for pain medications may
unsuccessful or any changes in the
require higher doses or more potent
complaint of pain.
analgesics.
▪ EVALUATION:
Statement of assessment of effectivity of nsg interventions given.
Should answer the objective.
Ex:
OBJ: At the end of my 8 hour shift the patient will report controlled level of pain.
EVAL: the patient reports controlled pain as evidenced by relaxed appearance
and able to rest.
▪ Activity: PRACTICE QUESTIONS
▪ AcareNurse is assigned to care for a patient receiving enteral feedings. The nurse plans
knowing that which of the following is a highest priority for the client
o altered nutrition
o risk for aspiration
o risk for fluid volume deficit
o risk for diarrhea
Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible
places a client at risk for aspiration.
- Options 1 and 4 maybe appropriate nursing diagnoses but are not of highest priority.
- Option 3 is not likely to occur
▪ Activity PRACTICE QUESTIONS
o Pain related to surgical incision as manifested by moaning, guarding incision site,
pain 10/10
o which part is etiology?
o which part is the problem?
▪ UNIT IV. IMPLEMENTATION and EVALUATION
▪ IMPLEMENTATION
▪ DEFINITION:
Carrying out phase
Putting into action the planned nursing interventions
▪ PURPOSE:
o To assist the client to meet the desired goals/outcomes to:
o Promote wellness
o Prevent illness / dse
o Restore health
o Facilitate coping with altered functioning
▪ ACTIVITIES UNDER IMPLEMENTATION:
o Reassess client to reupdate data base
o Determine the need for nsg assitance
o Perform planned nursing intervention
o Communicate what [Link] were implemented
▪ Document care and client response
▪ NURSING ACTIONS MUST BE:
Based on SAFE Nursing practice
Congruent or suitable with the medical plan as well as the nursing plan
▪ IMPLEMENTATION is based on:
o Accurate and complete assessment
o Interpretation of data
o Identified needs
o Nursing diagnosis
o Goals
▪ EVALUATION
▪ DEFINITION
o The final phase of the [Link]
o Measuring the degree to w/c goals or outcomes have been achieved and
identifying factors that positively or negatively influenced the goal achievements
o Determines inaccuracies/inadequacies
▪ PURPOSE:
To determine whether to continue, modify or terminate the plan of care
▪ QUESTIONS:
o Was the goal achieved?
o What part of the goals were not achieved?
o Did the nursing intervention accomplish the objective?
▪ ACTIVITIES UNDER EVALUATION:
o Collaborate w/ the client and collects data r/t desired outcomes
o Judge whether goals/outcomes have been achieved
o Relate [Link] to client outcomes
o Make decision about the problem status
o Review, modify or terminate plan of careDocument achievement of outcomes &
modifications done.
