NURSING CARE PLAN / NURSING PROCESS

NURSING PROCESS
1. Assessment
2. Nursing Diagnosis (Whats the problem? What are the patients needs?)
3. Planning (What needs to be done?)
4. mplementation (Do !hat needs to be done to meet the patients needs.)
". #$aluate % &eassess ('a$e the patients needs been met?)
(. Do)umentation (* +ou dont !rite it, +ou didnt do it--)
. do)umentation allo!s *or thorough assessments to be passed to others and *ollo!ed up
STEP I ASSESSMENT
subjective data (covert) / in*ormation that the patient gi$es to the )are pro$ider
objective data (overt) / in*ormation that +ou gather *rom assessing (loo0ing, tou)hing, hearing) the patient
. ma+ better de*ine patients )ondition and help in planning )are
. gather data that is indi$iduali1ed to the patient
. )ontinuous )olle)tion, $alidation, and )ommuni)ation o* patient data
. in)ludes all pertinent patient in*ormation )olle)ted b+ the nurse and other health)are pro*essionals
. enables a )om2prehensi$e and e**e)ti$e plan o* )are to be designed and implemented *or
the patient
. )olle)tion o* patient data is a $ital step in the nursing pro)ess be)ause the remaining steps
depend on )omplete, a))urate, *a)tual and rele$ant data
. initial )omprehensi$e nursing assessment results in baseline data that enable the nurse to3
ma0e a 4udgement about patients health status, abilit+ to manage his%her health)are, and
need *or nursing
re*er the patient to ph+si)ian or other health)are pro*essional
plan and deli$er indi$iduali1ed, holisti) nursing )are
. sour)es *or data in)lude patient, patients *amil+ and signi*i)ant others, patient re)ord, patients
health)are pro*essional, and literature
. medi)al assessments target data pointing to pathologi) )onditions, !hereas nursing assessments
*o)us primaril+ on the patients responses to health problems and *un)tional abilities
. purpose *or !hi)h an assessment is being per*ormed o**ers the best guideline about !hat t+pe and
ho! mu)h data to )olle)t
. priorities are in*luen)ed b+ patients health orientation, de$elopmental stage, and need *or
nursing
. in)lude appraisal o* health status, identi*i)ation o* health problems, and establishment o*
data *or nursing inter$ention
. methods used to )olle)t data are inspe)tion, palpation, per)ussion, and aus)ultation
. data needs to be3
)omplete / as mu)h as possible
*a)tual and a))urate / allo!s other health)are pro*essionals to e5plore )auses o* the beha$ior
rele$ant / onl+ e5perien)e tea)hes nurses !hat data is needed in spe)i*i) )ases
. obser$ation is 0e+ / obser$ation o* the )ons)ious and deliberate, use the *i$e senses
!hat are the patients )urrent responses / be alert to signs o* distress and things out o* the
ordinar+
!hat is the patients )urrent abilit+ to manage his%her )are
!hat is the immediate en$ironment / sa*et+, people, temperature, et).
!hat is the larger en$ironment / hospital or )ommunit+
STEP ANAL!SIS
. begin the !or0 o* interpreting and anal+1ing data !hile still )olle)ting (assessing)
. group data or )ues that point to the e5isten)e o* a patient health problem (separating into 6li0e piles7)
. nursing diagnoses should al!a+s be deri$ed *rom )lusters o* signi*i)ant data rather than *rom a single )ue
. !hen the nurse re)ogni1es a )luster o* signi*i)ant patient data indi)ating a health problem that )an
be treated b+ independent nursing inter$entions, a nursing diagnosis should be !ritten
. nursing diagnosis is !ritten either as t!o.part statements listing the patients problem and its )ause
or as three.part statements that also in)lude the problems de*ining )hara)teristi)s
STEP " #IAGNOSIS
. )lassi*+ing
. purpose is to identi*+ ho! an indi$idual responds to a)tual or potential health and li*e pro)esses, identi*+
*a)tors that )ontribute to or )ause health problems (etiologies), and identi*+ resour)es or strengths that
)an be dra!n on to pre$ent o* resol$e problems
$ursi$% dia%$oses / a)tual or potential health problems that )an be pre$ented or resol$ed b+
independent nursing inter$ention
. )lini)al 4udgment about indi$idual responses to a)tual or potential health problems%li*e
pro)esses
. pro$ides the basis *or sele)tion o* nursing inter$entions to a)hie$e out)omes
. N#8#& a medi)al diagnosis
. medi)al diagnoses identi*+ diseases, !hereas nursing diagnoses *o)us on unhealth+ responses to health and
illness
. medi)al diagnoses remains the same *or as long as the disease is present, !hereas nursing
diagnosis ma+ )hange *rom da+ to da+ as the patients responses )hange
. nurses monitor )ertain ph+siologi) )ompli)ations to dete)t onset or )hanges in status
. in$ol$es potential )ompli)ations that must be identi*ied earl+ so that pre$enti$e nursing )are )an be
instituted earl+
Do)umentation 9ormat3 P / problem : !hat is it re&ated to ;;;
. identi*ies !hat is unhealth+ about the patient, indi)ating the need *or )hange
. )lear, )on)ise statement o* patients health problem
. suggests patient out)omes
E / etiolog+ : !hat is )ausing it as 'a$i(ested b) ;;;
. identi*ies *a)tors (ph+siologi), ps+)hologi)al, so)iologi), spiritual,
en$ironmental) that are maintaining the unhealth+ state or response
. )ontributing or )ausati$e *a)tor
. dire)ts nursing inter$ention
S / signs and s+mptoms gathered *rom ob4e)ti$e and sub4e)ti$e assessment
. identi*+ the sub4e)ti$e and ob4e)ti$e data that signal the e5isten)e o* the
problem
;;;<in0ing !ords that must be used in )are plan to lin0 potential )ompli)ations and problem;;;
=uidelines *or Writing Nursing Diagnoses
*+ Phrase nursing diagnosis as patient problem or alteration in health state rather than as patient need
+ >he)0 to ensure patient problem pre)edes etiolog+ and the t!o are lin0ed b+ the phrase 6related to7
"+ De*ining )hara)teristi)s in nursing diagnosis should *ollo! etiolog+ and lin0ed b+ the phrase 6as
mani*ested b+7 or 6as e$iden)ed b+7
,+ ?se non4udgmental language
-+ @e sure problem state indi)ates !hat is unhealth+ about patient or !hat needs to be )hanged
.+ A$oid de*ining )hara)teristi)s, medi)al diagnoses, or something that )annot be )hanged in the
problem statement
/+ #nsure problem statement suggests patient out)omes and that etiolog+ dire)t sele)tion o* nursing
measures
STEP , CLIENT GOALS AN# OUTCOMES
%oa& / aim or end
0atie$t outco'e / e5pe)ted )on)lusion to patient health problem, or in the e$ent o* a !ellness diagnosis, an
e5pe)ted )on)lusion to patients health e5pe)tation
0&a$ o( $ursi$% care (0atie$t care 0&a$) / !ritten guide that dire)ts the e**orts o* the nursing team as nurses
!or0 !ith patients to meet their health goals
. spe)i*ies nursing diagnoses, out)omes, and asso)iated nursing inter$entions
. patient )entered to 0eep the patient and patients interest and pre*eren)es )entral in e$er+ aspe)t o*
planning and out)ome identi*i)ation
. goals are indi)ated b+ phrases li0e 6Ahe patient !ill BBBBBBB7
. measurable (something that )an be )ounted or s)aled) )riteria used to e$aluate the e5tent to !hi)h a
goal has been met !ithin the spe)i*ied time limits
. i* out)omes spe)i*ied are not $alued b+ the patient or do not )ontribute to the pre$ention,
resolution, or redu)tion o* the patients problems or the a)hie$ement o* the patients
health e5pe)tations, the plan o* )are ma+ be meaningless
. parameters o* de*inition are indi)ated b+ phrases li0e 6as e$iden)ed b+7
. primar+ purpose o* out)ome identi*i)ation and planning is to design a plan o* )are *or and !ith the
patient that, on)e implemented, results in the pre$ention, redu)tion, or resolution o* patient
health problems and attainment o* patients health e5pe)tations, as identi*ied in out)omes
. broad aims are to promote !ellness, pre$ent disease and illness, promote re)o$er+, and
*a)ilitate )oping !ith altered *un)tioning
. be)ause basi) needs must be met be*ore a person )an *o)us on higher ones, patient needs ma+ be
prioriti1ed a))ording to Caslo!s 'ierar)h+ o* 'uman Needs
ph+siologi)
sa*et+
lo$e and belonging
sel*.esteem
sel*.a)tuali1ation
. it is best to *irst meet the needs the patient thin0s are most important, i* this order does not inter*ere
!ith other $ital therapies
. e$aluati$e statements (patient has met, partiall+ met, or not met) in)lude a statement about
a)hie$ement o* desired out)ome and list a)tual patient beha$ior as e$iden)e supporting the
statement
. i* plan is not met, re)ommendations *or re$ising the plan o* )are are in)luded in the
e$aluati$e statement
=uidelines *or Writing Dut)omes
*+ #a)h set o* out)omes is deri$ed *rom onl+ one nursing diagnosis
+ At least one o* the out)omes sho!s a dire)t resolution o* the problem statement in the nursing
diagnosis
"+ @oth long.term and short.tem out)omes are identi*ied as ne)essar+
,+ >ogniti$e, ps+)homotor, and a**e)ti$e out)omes appropriatel+ signal the t+pe o* )hange needed b+
patient
-+ Patient and *amil+ $alue the out)omes
.+ #a)h out)ome is brie* and spe)i*i) ()learl+ des)ribes one obser$able, measurable patient
beha$ior%mani*estation) is phrases positi$el+, and spe)i*ies a time line
/+ Dut)omes are supporti$e o* total treatment plan
Ao be measurable, out)omes should ha$e3
subject / patient or some part o* the patient
verb / indi)ates the a)tion the patient !ill per*orm
. help*ul $erbs3 de*ine, prepare, identi*+, design, list, $erbali1e, des)ribe, )hoose,
e5plain, sele)t, appl+, demonstrate
conditions / spe)i*ies parti)ular )ir)umstan)es in or b+ !hi)h the out)ome is to be a)hie$ed
performance criteria / des)ribe in obser$able, measurable term the e5pe)ted patient beha$ior
or other mani*estation
target time / spe)i*ies !hen the patient is e5pe)ted to be able to a)hie$e out)omes
>ommonl+ #n)ountered Problems3 *ailure to in$ol$e the patient in the planning pro)ess, insu**i)ient data
)olle)tion, use o* ina))urate or insu**i)ient data to de$elop nursing
diagnoses, out)omes that are stated too broadl+
STEP - PLANNING
. gi$e the goal (a)ti$it+) and rationale *or nursing inter$entions
. edu)ate and%or o**er !a+s to meet out)omes % goals
STEP . INTER1ENTIONS
. nursing a)tions planned in pre$ious step are )arried out
. patient is primar+ in determining ho! nursing inter$entions are implemented
. su))ess*ul nurses modi*+ a)tions a))ording to patients )hanging abilit+ and !illingness to parti)ipate
in the plan o* )are and pre$ious responses to nursing inter$entions and progress to!ard
goal%out)ome a)hie$ement
$urse2i$itiated i$terve$tio$s / )arr+ing out nurse.pres)ribed inter$entions resulting *rom assessment o*
patient needs !ritten on nursing plan o* )are, as !ell as an+ other a)tions that nurses initiate !ithout
the dire)tion or super$ision o* another health)are pro*essional
03)sicia$2i$itiated i$terve$tio$s / )arr+ing out ph+si)ian.pres)ribed orders
. nurses are responsible *or not onl+ nurse.pres)ribed inter$entions but also *or the )lari*i)ation o* an+
Euestionable order
co&&aborative i$terve$tio$s / a)tions per*ormed 4ointl+ b+ nurses and other members o* the health)are team
STEP / E1ALUATION
. nurse and patient together measure ho! !ell the patient has a)hie$ed the out)omes spe)i*ied in the plan o*
)areF ho!e$er, the patient is al!a+s the nurses primar+ )on)ern
. *un)tions to determine !hether the out)omes ha$e been or are being met and then identi*+ing the
appropriate nursing response
; =oal Cet
; =oal Partiall+ Cet
; =oal Not Cet
. based on the patients responses to the plan o* )are (*eedba)0), the nurse de)ides to
terminate plan !hen ea)h e5pe)ted out)ome is a)hie$ed
modi*+ the plan i* there are di**i)ulties a)hie$ing the out)omes
)ontinue the plan i* more time is needed to a)hie$e the out)omes