NURSING PROCESS -PLANNING PREPARED AND PRESENTED BYMRS.S.ANUKRISHNAN,VICE PRINCIPAL CUM HOD OBG NURSING,P.D.BHARATESH COLLEGE OF NURSING,HALAGA, BELGAUM.
Introduction Planning is a deliberative, systematic phase of the nursing process Involves decision making and problem solving. Refer to the client’s assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent reduce or eliminate the client’s health problems.
1] Initial planning Admission assessment based on the initial care. As nurse obtain new information and evaluate the clients responses to care, they can individualize the initial care plan further.
2] Ongoing Planning Done by all nurses who work with the client. Ongoing planning also occurs at the beginning of a shift as the nurse plans the care.
3] Discharge planning Is the process of anticipating and planning for needs after discharge, Is a crucial part of comprehensive health care and should be addressed in each client’s care plan to be given that day.
Purposes of ongoing planning1] To determine any changes in client’s health status.2] To set priorities for the client’s care3] To decide which problems to focus on during the shift4] To Co-ordinate the nurse’s activities so that more than one problem can be addressed at each client contact.
Developing nursing care plans An informal nursing care plan A formal nursing care plan A Standardized care plan An individualized care plan
An informal nursing care plan Is a strategy for action that exists in the nurses mind.
A formal nursing care plan Is a written or computerized guide that organizes information about the client’s care. It provides continuity of care.
A Standardized care plan Is a formal plan that specifies the nursing care for groups of clients with common needs. (All clients with myocardial infarction)
An individualized care plan Is tailored to meet the unique needs of a specific client needs that are not addressed by standardized plan.
Guidelines for writing Nursing Care plans1] Date and sign the plan2]Use category headings assessment/ nursing diagnoses/ planning /Implementation /Evaluation.3] Use standardized Medical or English symbols and key words rather than complete sentences to communicate your ideas.Eg. Clean wound with H2O2 b.i.d rather than “clean the client’s wound morning & evening with Hydrogen peroxide twice a day.
Guidelines for writing Nursing Care plans4] Be specific. Because Nurses are now working shifts of different lengths, some working 12 hrs. & some working 8 hour shifts it is even more to be specific about expected timing of an intervention. If the order reads “change incision dressing q shift”5] Refer to procedure books or other sources of information rather than including all the steps on a written plan.
Guidelines for writing Nursing Care plans6] Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices, such as preferences about the times of care & the methods used are included.7] Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones.
Guidelines for writing Nursing Care plans8] Ensure that the plan contains interventions for ongoing assessment of the client (eg. Inspect incision q8h)9] Include collaborative and co-ordination activities in the plan.10] Include plans for the client’s discharge and home care needs.
Assessinga. Collect datab. Organize datac. Validate datad. Document data Diagnosing a. Analyze data b. Identify health problems, risks and strength, c. Formulating nursing diagnosis Planning a. Setting priorities b. Establishing client goals, desired outcomes c. Selecting nursing interventions d. Writing nursing orders
1) Setting priorities It is the process of establishing a preferential sequence for addressing nursing diagnoses & interventions. The client & nurse decides which nursing diagnosis requires attention Primarily, which secondary and so on. Instead of rank ordering diagnoses, nurses can group then as having high, Medium, or Low priority requires minimal nursing support.
High: Life threatening problems such as loss of respiratory or cardiac function Medium: Health threatening problems like acute illness, decreased coping. Use Maslow’s hierarchy The nurse must consider some factors when assigning priorities, it includes. Client’s health values and beliefs Client’s priorities Resources available to the nurse & client. Urgency of health problem Medical treatment plan.
2) Establishing client goals & Desired outcomes After establishing priorities, the nurse & client set goals for each nursing diagnosis. Goal-(Broad) –improved nutritional status, desired outcome (specific) - Gain ½ kg by 2 weeks. Short term goals: - than 6 weeks of period. Long term goals: - Goal achieved by 6 weeks & more
3) Selecting Nursing interventions & activities Nursing interventions & activities are the action not a nurse performs to achieve client goals. Types of nursing interventions1] Independent Interventions: - activities that are nurses are licensed to initiate. Eg. Physical care, ongoing assessment, counseling, Emotional support, environmental Management.2] Dependent Interventions: - activities carried out under physicians order. Eg. Medications, diagnostic tests, diet Activity.3] Collaborative Interventions: - Nurse carries out in collaboration with other health team members - Such as physiotherapies social workers, dietitians, physicians, Eg. Crutch walking.
4) Writing Nursing orders•After choosing appropriate nursing interventions the nursewrite those on care plan on nursing orders.• Components of Nursing order Date Action Content Time Sign. verb area Element4/4/06 Monitor Vital signs Every q4h Auscultate Abdomen q6h