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The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in
action.
Planning
• Setting goals to improve the outcomes for the patient are a primary focus of the nursing process. Based on the nursing diagnoses, what are the
expectations for this patient? This not about nursing goals. This is about improving the quality of life for your patient. This is about what your patient
needs to do to improve his health status or better cope with his illness.
• Planning also involves making plans to carry out the necessary interventions to achieve those goals.
• The product of the planning phase is a written care plan used to coordinate the care provided by all the health team members.
Implementation
ASSESSMENT DATA NURSING PLAN INTERVENTIONS RATIONALE FOR EVALUATION
SUBJECTIVE/ DIAGNOSIS OUTCOME (NURSE CENTERED) INTERVENTIONS
OBJECTIVE CRITERIA
(CLIENT
CENTERED)
Include subjective Use a NANDA State the overall Make the interventions State the principle or Look at the
and objective diagnosis which plan as NURSE centered. scientific rationale for outcome criteria.
components. has three (3) CLIENTcentered, the nursing
parts: e.g.,: Indicate what the nurse will intervention(s). State whether the
Assess physiological, do to assist the client in client achieved the
psychosocial, •Part I: NANDA •"The client achieving the outcome Include the reference for outcome criteria,
developmental, statement of will..." criteria, e.g., the rationale. e.g.,
cultural and spiritual nursing problem
dimensions. Relate the plan •The nurse will..." "The client gained 2
"Alternation in to the nursing lbs within the past
•Subjective nutrition: Less diagnosis: State frequency/time 7 days..."
Document client's than body /amount so any nurse can
exact words relevant requirements" •."have carry out the plan: NOTE:
to the diagnosis. adequate If the outcome
nutritional 1) Document all food criteria was not
"I'm not hungry" •Part 2: relating intake" intake for 3 days. achieved or only
to a nursing partially achieved,
•Objective etiology: Indicate a 2) Determine and make the nurse needs to
Document data that measurable available client's favorite go back to the
is measurable, "related to outcome criteria foods by day 2. beginning, e.g., the
specific, and relevant inadequate by including time "assessment" and
to the nursing nutritional frame/amount/ra 3) Provide oral care 3.) Improved oral make revisions or
diagnosis. intake" nge: before meals. hygiene can enhance changes as
•"as evidenced appetite and improve necessary.
Recent by..." oral intake (Ulrich,
weight •Part 3: canale, and Wendell,
loss("Weigh manifested by the 1) the ability to 1986, p. 570). Reduces
t = 48 Kg") assessed signs create a unpleasant taste and
anorexia and symptoms: balanced meal stimulates appetite
"Lack of "as plan by day (brunner and Suddarth,
subcutaneou manifested/evi (7). 1988, p. 878)
s fat" denced by low
Cachectic body weight 2) gaining 1-2 4. Offer small, frequent 4. There may be
appearnace and lbs/wk. feedings. difficulty in consuming
Poor muscle emaciation." a large meal (Dudek,
tone 1987, p. 398). Small
Pale meals are easier to
conjunctiva tolerate ( Brunner and
and mucous Suddarth, 1988, p. 399)
membranes
fatigue
• Setting your plans in motion and delegating responsibilities for each step.
• Communication is essential to the nursing process.
• All members of the health care team should be informed of the patient's status and nursing diagnosis, the goals and the plans.
• They are also responsible to report back to the RN all significant findings and to document their observations and interventions as well as the
patient's response and outcomes.
Evaluation
Evaluating is assessing the client’s response to nursing interventions and then comparing the response to the goals or outcome criteria written in the
planning phase.
The nursing process is an ongoing event. Evaluation involves not only analyzing the success of the goals and interventions, but examining the need for
adjustments and changes as well. Evaluation leads back to Assessment and the whole process begin again. The evaluation incorporates all input from the
entire health care team, including the patient.
The Nursing Care Plan (also referred to as the client care plan) is a written guide that organizes information about a client’s care into a meaningful whole.
It includes the actions nurses must take to address the client’s nursing diagnoses and meet the stated goals.
The nurse starts the care plan as soon as the client is admitted to the health care agency and constantly updates it throughout the client’s stay, in response
to changes in the client’s condition and evaluations of goal achievement.
1. Nursing Assessment.
First level assessment:
Subjective and Objective Data
Data must support the nursing diagnosis and should include both normal and abnormal assessment values and observations
Subjective Data
Also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person.
Subjective data include the client’s sensations, feelings, values, beliefs, attitudes, and perceptions of personal health status and life situation.
Information supplied by family members, significant others, or other health professionals is also considered subjective, if it is based on
opinion rather than fact.
Objective Data
Also referred to as signs or overt data, are detectable by an observer or can be tested against an accepted standard.
They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.
Remove any information that is NOT directly linked to the one Nursing Diagnosis on which you are working.
2. Nursing Diagnosis.
The cause of the problem and all other factors in the patient’s environment that contribute to the problem.
It describes the client’s health problem or response for which nursing therapy is given.
It describes the client’s health status clearly and concisely in a few words.
All nursing diagnoses must be phrased in NANDA terms and must be chosen from your approved nursing diagnosis list or a nursing
care plan text.
Do not make up your own nursing diagnosis.
Qualifiers are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement; for example:
It identifies the one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the
nurse to individualize client’s care.
It may include the client’s behaviors, environmental factors, or interaction of the two.
NANDA uses the term related factor to describe the etiology or likely cause of the actual nursing diagnoses.
The term risk factor is used to describe the etiology of high risk (potential) nursing diagnoses, because there are no subjective and
objective signs present.
3. Defining Characteristics
It is the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
For actual nursing diagnoses, the defining characteristics are the client’s signs and symptoms.
For high risk nursing diagnoses, the defining characteristics are the same as the etiology: the risk factors that cause the client to be more than
“normally” vulnerable to the problem.
The basic two-part statement is used for actual, high risk, and possible nursing diagnoses. It includes the following:
Noncompliance (specify)
Noncompliance (diabetic diet) related to denial of having disease.
For ease in alphabetizing, many NANDA lists are arranged with qualifying words after the main word.
e.g.:
1. Infection, high risk for
2. Cardiac Ouput, decreased
Avoid writing diagnostic statement in this manner; instead, write them as they would be stated in normal conversation (eg, High risk for infection
and Decreased cardiac Output ).
The basic three-part nursing diagnosis statement is called the PES format and includes
Actual Nursing diagnoses can be documented by using the three-part statement (using related to and as manifested by, or as evidenced by),
because the signs and symptoms have been identified.
However the PES format cannot be used for high risk diagnoses, because the client does not have signs and symptoms of the diagnosis.
Variation of the basic one-, two-,and three-part statements include the following:
1. Writing “unknown etiology” when the defining characteristics are present but the nurse does not know the cause of contributing factors.
Noncompliance (medication regimen) related to unknown etiology.
2. Using the phrase “complex factors” when there are too many etiologic factors or when they are too complex to state in brief phrase.
Decisional conflict/ Chronic self-esteem related to complex factors
3. Using the word “possible” to describe either the problem or the etiology. When the nurse believes more data is needed about the client’s response
(problem) or the etiology, the word possible is inserted.
Possible low self-esteem related to loss of job and rejection by family
Altered thought processes possibly related to unfamiliar surroundings
4. Using “secondary to” divide the etiology into two parts, thereby making the statement more descriptive and useful. The part “secondary to” is often a
pathophysiologic or disease process, as in
High risk for impaired skin integrity related to decreased peripheral circulation secondary to diabetes.
5. Adding a second part to the general response or NANDA label to make it more precise.
Impaired physical mobility: inability to walk r/t knee joint stiffness and pain secondary to muscle atrophy
Pain: severe headache r/t fear of addiction to narcotics
• Provide direction for planning nursing interventions that will achieve the desired changes in the client. Ideas for interventions come more easily if the
goals state clearly and specifically what the nurse hopes to achieve.
• Provide a time span for planned activities.
• Serve as criteria for evaluation of client progress.
• Enable the client and nurse to determine when the problem has been resolved.
Goals are derived from and relate to the client’s nursing diagnoses-primarily from the first clause (problem).
The problem clause contains the unhealthy response; it states what should change.
Nursing diagnosis: High risk for fluid volume deficit r/t diarrhea and inadequate intake secondary to nausea.
Goal: After 8 hours of nursing interventions, Client’s fluid balance will be maintained, as evidenced by urinary and stool output in balance with
fluid intake, normal skin turgor, and moist mucous membranes
Rule: for every nursing diagnosis, the nurse must write at least one outcome criterion that, when achieved, directly demonstrates resolution of
the problem clause.
• Expected outcomes are derived primarily from the first clause of the nursing diagnosis.
Their achievement demonstrates problem resolution or prevention.
• The expected outcome is possible to achieve.
• The expected outcome is stated in terms of client responses rather than nursing activities.
• Each expected outcome is specific and concrete, to facilitate measurement.
• Each expected outcome is measurable, that is outcome can be seen, heard, felt, or measured by another person.
• The goal is valued by the client and family.
• The goal is compatible with the therapies of other professionals.
4.1. Immediately following each goal that you write, list specific nursing actions you used to work toward that goal.
4.2. Nursing actions must be specific, not global, appropriate, and without important omissions. In most cases several interventions are needed to
achieve any one goal.
4.3 If your idea to use a nursing action comes from a Care Plan book or other source, cite the source.
4.4 After each nursing action give the scientific rationale for selecting the action. Cite your source for this rationale. Sources might include a book,
lecture, discussion with a health professional or media source.
4.5 Rationale must be logical and relevant.
Interventions should be prioritized and specific to the patient.
Interventions should be obtained from professional nursing care plan resources or your medical surgical nursing book.
Adapt standardized care plan interventions to your patient. Include only those interventions that relate to your specific patient.
You should have a minimum of seven interventions for your identified priority problems.
Types of Nursing Strategies/Interventions:
i. Independent interventions- are those activities that are licensed to initiate on the basis of their knowledge and skills.
They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and
making referrals to other health care professionals.
ii. Dependent interventions- are those activities carried out under the physician’s orders or supervision, or according to specified routines.
Medical orders commonly include orders for medication, intravenous therapy, diagnostic tests, treatments, diet, and activity.
iii. Collaborative intervention- are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social
workers, dieticians, and physicians.
For example, the doctor might order for physical therapy to teach the patient crutch-walking. The nurse assists with crutchwalking and
collaborates with the physical therapist to evaluate the client’s progress.
5. EVALUATION
• Use the measures you designated for goal achievement to state your client's degree of success. (For example: "the client evaluated her anxiety
as 4 on a 10-point scale."
• Draw conclusions on the interventions used related to the outcome. (For example: "Helping the client to talk about her feelings reduced her
sense of isolation.")
F.T.Santiago,RN.,MN.