SCHOOL OF MIDWIFERY

ST. PHILOMENA CATHOLIC HOSPITAL,

DAWSON ROAD, BENIN CITY

A SEMINAR WORK PRESENTED BY

IKPONMWOSA-IYOHA COMPASSION
EXAM NO: (2049)

TOPIC:
THE NURSING PROCESS & NURSING CARE PLAN

SUPERVISORS
MRS. AKPEJUNOR
MRS. IKEJI
MRS. IKOMI
MRS. OKPARA
MR. MARO

DATE PRESENTED: MAY, 2024

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TABLE OF CONTENT

INTRODUCTION

BACKGROUND AND HISTORY

CHARACTERISTICS OF NURSING PROCESS

PURPOSE OF NURSING PROCESS

THE STEPS OF THE NURSING PROCESS

PURPOSE OF ASSESSMENT

SOURCES OF DATA COLLECTION

METHODS OF DATA COLLECTION

PRINCIPLES OF HISTORY

EQUIPMENTS USED FOR PHYSICAL APPRAISAL

TYPES OF ASSESSMENT

TYPES OF NURSING DIAGNOSIS

DIAGNOSIS

PURPOSES OF NURSING DIAGNOSIS

CHARACTERISTICS OF NURSING DIAGNOSIS

COMPONENTS OF A NURSING DIAGNOSIS

DIFFERENCE BETWEEN NURSING & MEDICAL DIAGNOSIS

PLANNING

PURPOSE OF PLANNING

STAGES OF PLANNING

BENEFITS OF THE NURSING PROCESS TO THE CLIENT

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NURSING CARE PLAN

Types of Nursing Care Plans

Purposes of a Nursing Care Plan

Components

Writing a Nursing Care Plan

Short Term and Long Term Goals

Types of Nursing Interventions

REFERENCE

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INTRODUCTION

Nursing process is defined as an assertive, problem solving approach to the

identification and treatment of patient problems.

It provides an organizing framework for the practice of nursing and the knowledge,
judgments, and actions that nurses bring to patient care.

Nursing students are introduced to the nursing process during academic

preparation. The nursing process is a stepped approach to assess and care for
patients. It is a tool for both students and nurses to help ensure a consistent and
strategic approach to patient care.

BACKGROUND AND HISTORY

The term nursing process was introduced in 1955 by Lydia Hall who identified
three steps of nursing process as:
1. Observation
2. Administration of care and
3. Validation
In 1959, Dorothy Johnson described nursing as fostering the behavioral
functioning of the client. Johnson identified three steps of nursing process:
assessment, decision and nursing action. Johnson is known for the development the
Behavior System Model of Nursing which stressed the importance of research-
based knowledge about the effect of nursing care on patients. When she first
proposed the theory in 1968, she explained that it was to foster ―the efficient and
effective behavioral functioning in the patient to prevent illness.‖ The nursing
process of the Behavior System Model of Nursing begins with an assessment and
diagnosis of the patient. Once a diagnosis is made, the nurse and other healthcare
professionals develop a nursing care plan of interventions and setting them in
motion. The process ends with an evaluation, which is based on the balance of the
subsystems.

In 1961 Ida Jean Orlando-Pelletier introduced the ―Deliberative Nursing Process

Theory- which included five stages: assessment, diagnosis, planning,
implementation, and evaluation. (ADPIE).Orlando‘s nursing theory stressed the

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reciprocal relationship between patient and nurse; what the nurse and the patient
say and do affects them both. The result was an effective nursing care plan that
could be easily adapted when and if any complications arise with the patient.

In 1963, Lois Knowles at the University of Florida used a five step nursing process
called the ‗five Ds‘: discover, delve, decide, do and discriminate‖. The discover
and delve steps are relates to assessment phase, decide is the planning stage, do is
the implementation stage; discriminate is the evaluation phase of client responses
to nursing interventions.

In 1967—Helen Yura and Mary [Link]. Published The Nursing Process, which
identified 4 strategic nursing care steps – also referred to as APIE:- Assessment,
Planning, Implement and Evaluation.

CHARACTERISTICS OF NURSING PROCESS:

 It is a framework that enables a nurse to give nursing care to individuals,

families and communities.

 It is systematic and orderly. Each nursing activity is part of an ordered sequence

of activities. The nursing process directs each step of nursing care in a
sequentially ordered manner.

 It is dynamic. Each step in nursing process flows on to the next step. In some
nursing situations, all the stages occur almost simultaneously.

 It is interpersonal. Human being is always the heart of nursing. In this nurses

are client-centered and not task oriented.

 The nursing process encourages nurses to work together to help clients to use
their strengths to meet all human needs. This also helps nurses to explore their
own strengths and limitations and to grow personally and professionally.

 It is outcome-oriented. The client benefit from continuity of care and each

nurse‘s care moves the clients closer to outcome achievement.

 This process is universally applicable in all nursing situations.

 This can be used throughout the life span.

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PURPOSE OF NURSING PROCESS

 Defines patients goals

 Promotes holistic treatment

 Determines the nurses role

 Provides consistency of care

 Provides quality patients care

THE STEPS OF THE NURSING PROCESS INCLUDE;

1. Assessment
2. Nursing diagnosis
3. Planning
4. Intervention
5. Evaluation

These five steps are used cyclically and repeatedly during patient care. The
sequence must be followed from start to finish to ensure that the needs of the
patient are addressed (Morris, 2006).

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• ASSESSMENT

This is the first step of the nursing process. The nurse gathers key information in
completing a comprehensive patient assessment. Assessment establishes a data
base by interviewing the individual and/or family members, observing their
behavior and physical examination to identify problem(s). Assessment requires
listening, critical thinking skills and data collection.

PURPOSE OF ASSESSMENT:

 Gather data about the client (individual, family or community)

 Use the data for diagnosing, identifying outcomes, planning and implementing
care.
 Identify the client‘s health status and the ability to manage the problems and
need for nursing care.
 Decide about the client‘s risk for dysfunctions and presence of any dysfunctions.
 Identify client‘s strengths based on which to plan individualized holistic care.
 Bring about positive changes in the client‘s health status.

SOURCES OF DATA COLLECTION CAN BE DIVIDED INTO;

 PRIMARY SOURCE~ information obtained from the client during an

interaction.

 SECONDARY SOURCE~ includes information obtained from family

members or significant others , health record, laboratory tests and diagnostic
procedures, health team members

 TERTIARY SOURCES~ information gotten from text books and

professional journals eg nursing journals.

Data collection can also be described as;

1. Subjective data: involves verbal statements from the patient or caregiver.

2. Objective data is measurable, tangible data such as vital signs, intake and
output, and height and weight. Data may come from the patient directly or
from primary caregivers who may or may not be direct relation family

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 members. e.g. blood test, x-rays etc. The data is recorded objectively and
accurately. Fata is then organized and analyzed to formulate a nursing
diagnosis, goals and desired outcomes.

METHODS OF DATA COLLECTION

History taking: This is an important aspect of patients care. It provides a database

assessment for the patient which helps in diagnosis to care for an existing or
potential problem.

PRINCIPLES OF HISTORY TAKING INVOLVE:

• Listening: listening is an art and a skill. Allow patient to talk freely after which
questions can be asked to redirect his thoughts and elicit more information on
those aspects that requires clarifications. Questions should be simple.
• Observation-this begins the very moment the nurse meets the client it makes
use of five physical senses (sight, touch, taste, small and hearing). Things to
observe include general appearance, response and reaction to questions, state of
mind and attitude.
• Integration- it is the most difficult of all three principles. it requires bringing
together into a written form all information obtained from and about the client
through listening observations and questioning.

2. The physical examination or physical assessment is a systematic data-collection

method that uses observational skills, such as the senses of sight, hearing, smell,
and touch, to detect health problems. To conduct the examination the nurse uses
techniques of inspection, palpation, percussion and auscultation.

 Inspection: This is visual examination of patients for detection of significant

physical features.
 Palpation: This is the process of examining the body using the sense of touch
to access the characteristics of the body structures through the skin.

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  Percussion: This involves sticking and thumbing the body surface to produce
sounds which enables the examiner to determine the size, position, and
density of structures.
 Auscultation: This is the process of listening to sound produced by various
body organs to detect deviation from normal.

EQUIPMENTS USED FOR PHYSICAL APPRAISAL INCLUDE;

 Diagnostic set
 Stethoscope
 Sphygmanometer
 Patella hammer
 Turning fork
 Weighing scale
 Thermometer
 Stationeries e.g. pencil, biro, paper

3) Validating Data: Validation is the act of double checking or verifying data to

confirm that they are accurate and factual. Validating data ensures that assessment
information is complete. The objective and subjective data agree. You may also
obtain additional information that may have been overlooked. Validating data is
done by comparing subjective and objective data, clarifying ambiguous statements,
making sure that the data consist of what the clients says, and by using references,
such as textbooks, journals, and research reports.

4) Organizing Data: The nurse uses a framework to organize the data collected.
Most schools of nursing and health care providers have developed their own
structured assessment tools which can be based on nursing theories. Example of
these nursing models are the Roy Adaptation Model and Orem‘s Self-Care Model.
Example of non-nursing model is Maslow‘s Hierarchy of Needs.

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TYPES OF ASSESSMENT

1) Initial Assessment

The initial assessment, also known as triage, helps to determine the nature of the
problem and prepares the way for the ensuing assessment stages. Components may
include obtaining a patient's medical history or putting him through a physical
exam, or preparing a psychosocial assessment for a mental health patient. Other
components may include obtaining a patient's vital signs and taking subjective
statements from the patient, as well as double-checking the subjective symptoms
with the objective signs of the condition.

2) Focused Assessment

The focused assessment is the stage in which the problem is exposed and treated.
Due to the importance of vital signs and their ever-changing nature, they are
continuously monitored during all parts of the assessment. Part of the goal of the
focused assessment is to diagnose and treat the patient in order to stabilize her
condition. Focused assessments may also include X-rays or other types of tests.

3) Time-Lapsed Assessment

Once treatment has been implemented, a time-lapsed assessment must be

conducted to ensure that the patient is recovering and his condition has stabilized.
It can be one week , two weeks, 6 months depending on when the doctor wants to
see the patient.

4) Emergency Assessments

During emergency procedures, a nurse is focused on rapidly identifying the root

causes of concern for the patient and assessing the airway, breathing and
circulation (ABCs) of the patient. Once the ABCs are stabilized, the emergency
assessment may turn into an initial or focused assessment, depending on the
situation. If the nurse is not in a health care setting, emergency assessments must
also include an assessment for scene safety so that no other individuals, including
the nurse himself, are hurt during the rescue and emergency response process.

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•DIAGNOSIS

According to NANDA-I, the official definition of the nursing diagnosis is:

―Nursing diagnosis is a clinical judgment about individual, family, or community

responses to actual or potential health problems/life processes. Nursing diagnosis
provides the basis for selection of nursing interventions to achieve outcomes for
which the nurse is accountable.

TYPES OF NURSING DIAGNOSIS

1) Actual Nursing Diagnosis

An actual nursing diagnosis is a clinical judgment about a current patient health

problem, which is present at the time of the nursing assessment, verified by
presence of the major defining symptoms, signs and characteristics, and would
benefit from nursing care. Examples of an actual nursing diagnosis statement are
anxiety, pain etc

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2) Risk Nursing Diagnosis

A risk nursing diagnosis is clinical judgment about a health problem which does
not yet exist. These risk factors lead to the conclusion that the patient is at a higher
risk for developing the health problem in the near future than others.

3)Syndrome Nursing Diagnosis

A syndrome nursing diagnosis statement is a clinical judgment, which is associated

with a cluster of predicted high-risk or actual nursing diagnosis, related to a certain
situation or event. There are five types of syndrome diagnosis: post-trauma
syndrome, rape trauma syndrome, relocation stress syndrome, impaired
environmental interpretation syndrome and disuse syndrome. An example of a
syndrome nursing diagnosis statement is rape trauma syndrome manifested by
sleep pattern disturbance, anger and genitourinary discomfort and related to feeling
anxious about possible resulting health problems.

4) Wellness Nursing Diagnosis

A wellness nursing diagnosis statement is a clinical judgment that an individual,

family or community is able to transition to a level of higher wellness. Before
giving a diagnosis of wellness, two factors must be present. An individual, family
or community must possess effective present function or status and show a desire
for increased wellness.

5) Potential Problem Nursing Diagnosis

problems that may be present that require additional data to confirm it.

An actual nursing diagnosis is written as the problem/diagnosis related to (r/t) x

factor/cause as evidenced by data/observations.

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PURPOSES OF NURSING DIAGNOSIS

The purpose of the nursing diagnosis is as follows:

1) Helps identify nursing priorities and help direct nursing interventions based on
identified priorities.

2) Helps the formulation of expected outcomes for quality assurance requirements

of third-party payers.

3)Nursing diagnoses help identify how a client or group responds to actual or

potential health and life processes and knowing their available resources of
strengths that can be drawn upon to prevent or resolve problems.

4) Provides a common language and forms a basis for communication and

understanding between nursing professionals and the healthcare team.

5) Provides a basis of evaluation to determine if nursing care was beneficial to the

client and cost-effective.

For nursing students,

6) Nursing diagnoses are an effective teaching tool to help sharpen their problem-
solving and critical thinking skills.

CHARACTERISTICS OF NURSING DIAGNOSIS

 It states a clear and concise health problem.

 It is derived from existing evidences about the
 client.
 It is potentially amenable to nursing therapy.
 It is the basis for planning and carrying out`
 nursing care.

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COMPONENTS OF A NURSING DIAGNOSIS

Problem statement/diagnostic label/definition=P (related to)

Etiology/related factors/causes = E ( related to)

Defining characteristics/signs and symptoms = S ( as evidenced by)

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DIFFERENCE BETWEEN NURSING & MEDICAL DIAGNOSIS

 Nursing Diagnosis is within the scope of nursing practice while medical

diagnosis is within the scope of medical practice.
 Nursing diagnosis identify responses to health
 and illness while medical diagnosis focuses on curing pathology.
 Nursing diagnosis can change from day to day while medical diagnosis stays
the same as long as the
 disease is present.

•PLANNING (Goal Setting )

Planning is the process of developing a plan and establishing SMART goals in

order to achieve a desired outcome.

PURPOSE OF PLANNING

 To determine the goals of care and the course of actions to be undertaken

during the implementation phase.
 To promote continuity of care.

STAGES OF PLANNING

 Setting priorities: Priority setting is the process of establishing a preferential

sequence for addressing nursing diagnosis and Intervention. Nurses
frequently use Maslow‘s hierarchy of needs when setting priorities.
 Establishing client goals: It provide direction for planning nursing
interventions and serve as a criteria for evaluating client progress. it is
divided into short term goals( these are actions that can be met quickly
within hours or days eg clients temperature will subside to 36.5°c with 2
hours, client will breath at the rate of 16-20 cycles per minutes within two
hours )and long term goals(these are outcomes that cover a long time span
eg client will brush his teeth unaided within 2 weeks).

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GUILDLINES FOR GOAL WRITING

 It should be client centered

 Write goals that are observable and Measurable
 Goals should be realistic and short as possible
 Make sure client considers the goals important and value
 There should be a specific time for achieving the set goal
 Selecting nursing interventions/action~ are the actions that a nurse performs
to achieve the client goals.

GUIDELINES FOR WRITING NURSING ACTION

 Nursing action must be safe and appropriate for the client to use.
 it must be based on principles and knowledge integrated form previous
nursing education, research findings and experience.
 Each goal of nursing care should be accompanied by appropriate set of
nursing actions.
 Involve your client in choosing nursing action
 consider the lower level of needs before the higher level of needs.
 Writing the care plan~ After choosing appropriate interventions the nurse
write them on the care plan. Nursing care plan describes the arrangement of
a plan of care by the nurse to solve various problems of a client identified
during assessment and through out the nursing process.

COMPONENTS OF NURSING CARE PLAN

 Serial number
 Date and time
 Nursing diagnosis
 Nursing objectives
 Nursing intervention
 scientific rationale
 Evaluation

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IMPLEMENTATION

The implementation phase of the process is the actionable part of the process. The
implementation phase may be performed using a combination of direct care and
indirect care.

Direct care is care that is given directly to the patient in either a physical or verbal
manner such as assisting the patient with mobility, performing physical care such
as wound care or educating the patient and/or family in caring for a member of
their family.

Indirect care is care that is given while away from the patient such as remote
cardiac monitoring or supervising nursing assistants and advocating on behalf of
the individual.

PURPOSE

• To carry out planned nursing interventions to help the client attain goals and
achieve optimal level of health.

• To describe the activities that nurses perform.

ACTIVITIES DURING IMPLEMENTATION

 REASSESSING: To ensure prompt attention to emerging problems.

 SET PRIORITIES: To determine the order in which nursing interventions are
carried out.
 PERFORM NURSING INTERVENTIONS: These may be independent,
dependent or collaborative measures.
 RECORD ACTIONS: To complete nursing interventions, relevant
documentation should be done.

REQUIREMENTS OF IMPLEMENTATION:

 Knowledge: include intellectual skills like problem-solving, decision-

making and teaching.
 Technical skills : to carry out treatment and procedures

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  Communication skills: use of verbal and non-verbal communication to carry
out planned
 Nursing interventions: Therapeutic use of self – is being willing and being
able to care.

EVALUATION

Here you evaluate if the plan is working and bringing the individual closer to
his/her goals. This phase also includes recognition of difficulties in meeting goals
and possible causes requiring changes in the plan of care. Once all nursing
intervention actions have taken place, the nurse completes an evaluation to
determine the goals for patient wellness have been met. The possible patient
outcomes are generally described under three terms: patient's condition improved,
patient's condition stabilized, and patient's condition deteriorated, died, or
discharged. In the event the condition of the patient has shown no improvement, or
if the wellness goals were not met, the nursing process begins again from the first
step.

All nurses must be familiar with the steps of the nursing process. If you're planning
on studying to become a nurse, be prepared to use these phases everyday in your
new care.

BENEFITS OF THE NURSING PROCESS TO THE CLIENT

1) It promotes continuity of care

2) Prevention of omission and duplication

3) Individualized care

4) Increased client participation

BENEFITS OF THE NURSING PROCESS TO THE NURSE

 Job satisfaction
 Continual learning
 Increased self- confidence

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  Staffing assignments
 Standards of practice
 Professional growth
 Avoidance of legal action
 Meeting professional nursing standards
 Meeting standards of accredited hospitals

BENEFITS OF NURSING PROCESS TO THE PROFESSION

 promotes collaboration
 helps people to understand what nurses do

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NURSING CARE PLAN

What is a nursing care plan?

A nursing care plan (NCP) is a formal process that includes correctly identifying
existing needs, as well as recognizing potential needs or risks. Care plans also
provide a means of communication among nurses, their patients, and other
healthcare providers to achieve health care outcomes. Without the nursing care
planning process, quality and consistency in patient care would be lost.

Nursing care planning begins when the client is admitted to the agency and is
continuously updated throughout in response to client‘s changes in condition and
evaluation of goal achievement. Planning and delivering individualized or patient-
centered care is the basis for excellence in nursing practice.

Types of Nursing Care Plans

CARE PLANS CAN BE INFORMAL OR FORMAL: Informal nursing care

plan is a strategy of action that exists in the nurse‘s mind. A formal nursing care
plan is a written or computerized guide that organizes information about the
client‘s care. Formal care plans are further subdivided into standardized care plan,
and individualized care plan: Standardized care plans specify the nursing care for
groups of clients with everyday needs. Individualized care plans are tailored to
meet the unique needs of a specific client or needs that are not addressed by the
standardized care plan.

Objectives
The following are the goals and objectives of writing a nursing care plan:

 Promote evidence-based nursing care and to render pleasant and familiar

conditions in hospitals or health centers.
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  Support holistic care which involves the whole person including physical,
psychological, social and spiritual in relation to management and prevention
of the disease.
 Establish programs such as care pathways and care bundles. Care pathways
involve a team effort in order to come to a consensus with regards to
standards of care and expected outcomes while care bundles are related to
best practice with regards to care given for a specific disease.
 Identify and distinguish goals and expected outcome.
 Review communication and documentation of the care plan.
 Measure nursing care.

Purposes of a Nursing Care Plan

The following are the purposes and importance of writing a nursing care plan:

 Defines nurse’s role. It helps to identify the unique role of nurses in

attending the overall health and well-being of clients without having to rely
entirely on a physician‘s orders or interventions.
 Provides direction for individualized care of the client. It allows the nurse
to think critically about each client and to develop interventions that are
directly tailored to the individual.
 Continuity of care. Nurses from different shifts or different floors can use
the data to render the same quality and type of interventions to care for
clients, therefore allowing clients to receive the most benefit from treatment.
 Documentation. It should accurately outline which observations to make,
what nursing actions to carry out, and what instructions the client or family
members require. If nursing care is not documented correctly in the care plan,
there is no evidence the care was provided.
 Serves as guide for assigning a specific staff to a specific client. There are
instances when client‘s care needs to be assigned to a staff with particular
and precise skills.

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  Serves as guide for reimbursement. The medical record is used by the
insurance companies to determine what they will pay in relation to the
hospital care received by the client.
 Defines client’s goals. It does not only benefit nurses but also the clients by
involving them in their own treatment and care.

Components

A nursing care plan (NCP) usually includes nursing diagnoses, client problems,
expected outcomes, and nursing interventions and rationales. These components
are elaborated below:

1. Client health assessment, medical results, and diagnostic reports. This is the
first measure in order to be able to design a care plan. In particular, client
assessment is related to the following areas and abilities: physical, emotional,
sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional,
age-related, economic and environmental. Information in this area can be
subjective and objective.
2. Expected client outcomes are outlined. These may be long and short term.
3. Nursing interventions are documented in the care plan.
4. Rationale for interventions in order to be evidence-based care.
5. Evaluation. This documents the outcome of nursing interventions.

Care Plan Formats

Nursing care plan formats are usually categorized or organized into four columns:
(1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions,
and (4) evaluation. Some agencies use a three-column plan wherein goals and

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evaluation are in the same column. Other agencies have a five-column plan that
includes a column for assessment cues.

Student nursing care plans are more detailed

Care plans by student nurses are usually required to be handwritten and have an
additional column for ―Rationale‖ or ―Scientific Explanation‖ after the nursing
interventions column. Rationales are scientific principles that explains the reasons
for selecting a particular nursing interventions.

Writing a Nursing Care Plan

How do you write a nursing care plan (NCP)? Just follow the steps below to
develop a care plan for your client.

Step 1: Data Collection or Assessment

The first step in writing a nursing care plan is to create a client database using
assessment techniques and data collection methods (physical assessment, health
history, interview, medical records review, diagnostic studies). A client database
includes all the health information gathered. In this step, the nurse can identify
the related or risk factors and defining characteristics that can be used to formulate
a nursing diagnosis. Some agencies or nursing schools have their own assessment
formats you can use.

Step 2: Data Analysis and Organization

Now that you have information about the client‘s health, analyze, cluster, and
organize the data to formulate your nursing diagnosis, priorities, and desired
outcomes.

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Step 3: Formulating Your Nursing Diagnoses

NANDA nursing diagnoses are a uniform way of identifying, focusing on, and
dealing with specific client needs and responses to actual and high-risk
problems. Actual or potential health problems that can be prevented or resolved by
independent nursing intervention are termed nursing diagnoses. We‘ve detailed the
steps on how to formulate your nursing diagnoses in this guide: Nursing
Diagnosis (NDx): Complete Guide and List for 2019

Step 4: Setting Priorities

Setting priorities is the process of establishing a preferential sequence for address

nursing diagnoses and interventions. In this step, the nurse and the client begin
planning which nursing diagnosis requires attention first. Diagnoses can be ranked
and grouped as to having a high, medium, or low priority. Life-threatening
problems should be given high priority.

Maslow‘s hierarchy of needs is

frequently used when setting priorities.

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Client‘s health values and beliefs, client‘s own priorities, resources available, and
urgency are some of the factors the nurse must consider when assigning priorities.
Involve the client in the process to enhance cooperation.

Step 5: Establishing Client Goals and Desired Outcomes

After assigning priorities for your nursing diagnosis, the nurse and the client set
goals for each determined priority. Goals or desired outcomes describe what the
nurse hopes to achieve by implementing the nursing interventions and are derived
from the client‘s nursing diagnoses. Goals provide direction for planning
interventions, serve as criteria for evaluating client progress, enable the client and
nurse to determine which problems have been resolved, and help motivate the
client and nurse by providing a sense of achievement.

One overall goal is determined for each nursing diagnosis. The terms goal,
outcome, and expected outcome are oftentimes used interchangeably.

Short Term and Long Term Goals

Goals and expected outcomes must be measurable and client-centered. Goals are
constructed by focusing on problem prevention, resolution, and/or
rehabilitation. Goals can be short term or long term. In an acute care setting, most
goals are short-term since much of the nurse‘s time is spent on the client‘s
immediate needs. Long-term goals are often used for clients who have chronic
health problems or who live at home, in nursing homes, or extended care facilities.

 Short-term goal – a statement distinguishing a shift in behavior that can be

completed immediately, usually within a few hours or days.

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  Long-term goal – indicates an objective to be completed over a longer
period, usually over weeks or months.
 Discharge planning – involves naming long-term goals, therefore
promoting continued restorative care and problem resolution through home
health, physical therapy, or various other referral sources.

When writing goals and desired outcomes, the nurse should follow these tips:

1. Write goals and outcomes in terms of client responses and not as activities of
the nurse. Begin each goal with “Client will […]” help focus the goal on
client behavior and responses.
2. Avoid writing goals on what the nurse hopes to accomplish, and focus on
what the client will do.
3. Use observable, measurable terms for outcomes. Avoid using vague words
that require interpretation or judgment of the observer.
4. Desired outcomes should be realistic for the client‘s resources, capabilities,
limitations, and on the designated time span of care.
5. Ensure that each goal is derived from only one nursing diagnosis. Keeping it
this way facilitates evaluation of care by ensuring that planned nursing
interventions are clearly related to the diagnosis set.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to achieve

client goals. Interventions chosen should focus on eliminating or reducing the
etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions
should focus on reducing the client‘s risk factors. In this step, nursing interventions
are identified and written during the planning step of the nursing process; however,
they are actually performed during the implementation step.

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Types of Nursing Interventions

Nursing interventions can be independent, dependent, or collaborative:

 Independent nursing interventions are activities that nurses are licensed to

initiate based on their sound judgement and skills. Includes: ongoing
assessment, emotional support, providing comfort, teaching, physical care,
and making referrals to other health care professionals.
 Dependent nursing interventions are activities carried out under the
physician‘s orders or supervision. Includes orders to direct the nurse to
provide medications, intravenous therapy, diagnostic tests, treatments, diet,
and activity or rest. Assessment and providing explanation while
administering medical orders are also part of the dependent nursing
interventions.
 Collaborative interventions are actions that the nurse carries out in
collaboration with other health team members, such as physicians, social
workers, dietitians, and therapists. These actions are developed in
consultation with other health care professionals to gain their professional
viewpoint.

Nursing interventions should be:

 Safe and appropriate for the client‘s age, health, and condition.
 Achievable with the resources and time available.
 Inline with the client‘s values, culture, and beliefs.
 Inline with other therapies.
 Based on nursing knowledge and experience or knowledge from relevant
sciences.

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Step 7: Providing Rationale

Rationales, also known as scientific explanation, are the underlying reasons for
which the nursing intervention was chosen for the NCP.

Step 8: Evaluation

Evaluating is a planned, ongoing, purposeful activity in which the client‘s

progress towards the achievement of goals or desired outcomes, and the
effectiveness of the nursing care plan (NCP). Evaluation is an important aspect of
the nursing process because conclusions drawn from this step determine whether
the nursing intervention should be terminated, continued, or changed.

Step 9: Putting it on Paper

The client‘s NCP is documented according to hospital policy and becomes part of
the client‘s permanent medical record which may be reviewed by the oncoming
nurse. Different nursing programs have different care plan formats, most are
designed so that the student systematically proceeds through the interrelated steps
of the nursing process, and many use a five-column format.

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