nursing process

1. FORMULATION
OF NURSING
CARE PLANS

2. BENEFITS OF NURSING PROCESS
 Provides an orderly & systematic method for
planning & providing care
 Enhances nursing efficiency by standardizing
nursing practice
 Facilitates documentation of care
 Provides a unity of language for the nursing
profession
 Is economical
 Stresses the independent function of nurses
 Increases care quality through the use of
deliberate actions

3. BENEFITS OF USING THE NURSING
PROCESS
 Continuity of
care
 Prevention of
duplication
 Individualized
care
 Standards of
care
 Increased client
participation
 Collaboration of
care

4. PLANNING
 The process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable
goals or outcomes, selecting appropriate
interventions, and documenting the plan of care.
 The nurse consults with the client while
developing and revising the plan.

5. TYPES OF PLANNING
Initial planning
Ongoing planning
Discharge planning

6. STEPS OF PLANNING PROCESS
Setting priorities
Making goals
Planning nursing interventions
Writing the nursing care plan

7. GENERAL GUIDELINES FOR
SETTING PRIORITIES
1. Take care of immediate life-
threatening issues.
2. Safety issues.
3. Patient-identified issues.
4. Nurse-identified priorities based on the overall
picture, the patient as a whole person, and
availability of time and resources.

8. MAKING GOALS
Short term goals
Long term goals

9. PLANNING NURSING
INTERVENTIONS
Independent interventions
Dependent interventions
Collaborative interventions

10. NURSING CARE PLANS
 Individualized care plans
 Standardised care plans
 Student care plans
 Computerised care plans
 Multidisciplinary care plans

12. EVALUATION
1. Determining outcome achievement
2. Identifying the variables affecting outcome
achievement
3. Deciding whether to continue, modify, or
terminate the plan

13. IDENTIFYING VARIABLE
AFFECTING OUTCOME
ACHIEVEMENT
 Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for
this particular client?
3. Were changes made in the plan when
needed?
4. How does the client feel about the plan?

14. PREDICT, PREVENT, AND MANAGE
 Focus on early intervention
 Based on research
 Predict and anticipate problems
 Look for risk factors

15. DIAGNOSTIC STATEMENTS
 Name of the health-related issue or problem
as identified in the NANDA list
 Etiology (its cause)
 Signs and Symptoms
 The name of the nursing diagnosis is linked to
the etiology with the phrase “related to,” and
the signs and symptoms are identified with
the phrase “as manifested (or evidenced) by”

16. COLLABORATIVE PROBLEMS-
NURSE’S RESPONSIBILITY
 Correlating medical diagnoses or medical
treatment measures with the risk for unique
complications
 Documenting the complications for which clients
are at risk
 Making pertinent assessments to detect
complications

17. CONTINUED
 Reporting trends that suggest development of
complications
 Managing the emerging problem with nurse- and
physician-prescribed measures
 Evaluating the outcomes

18. THE NURSING PROCESS
Nursing Diagnosis
Judgment or conclusion about the risk for—or
actual—need/problem of the patient
NANDA format

19. NANDA – NORTH AMERICAN
NURSING DIAGNOSIS
ASSOCIATION
 Identifies nursing functions
 Creates classification system
 Establishes diagnostic labels
 Risk of infection related to compromised
nutritional state
 Potential complication of seizure disorder
related to medication compliance

20. PLANNING
 The process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable
goals or outcomes, selecting appropriate
interventions, and documenting the plan of care.
 The nurse consults with the client while
developing and revising the plan.

21. SETTING PRIORITIES
 Determine problems that require immediate
action
 Maslow’s Hierarchy of Human Needs

22. SHORT-TERM GOALS
 Outcomes achievable in a few days or 1 week
 Developed form the problem portion of the
diagnostic statement
 Client-centered
 Measurable
 Realistic
 Accompanied by a target date

23. LONG-TERM GOALS
 Desirable outcomes that take weeks or months to
accomplish for client’s with chronic health
problems

24. THE NURSING PROCESS
Planning
Identification of goals and outcome criteria
Prioritization
Time frame

25. SELECTING NURSING
INTERVENTIONS
 Planning the measures that the client and nurse
will use to accomplish identified goals involves
critical thinking.
 Nursing interventions are directed at eliminating
the etiologies.

26. SELECTING AN INTERVENTION
 The nurse selects strategies based on the
knowledge that certain nursing actions produce
desired effects.
 Nursing interventions must be safe, within the
legal scope of nursing practice, and compatible
with medical orders.

27. COMMUNICATING THE PLAN
 The nurse shares the plan of care with nursing
team members, the client, and client’s family.
 The plan is a permanent part of the record.

28. EVALUATION
 The way nurses determine whether a client has
reached a goal.
 It is the analysis of the client’s response,
evaluation helps to determine the effectiveness of
nursing care.

29. THE NURSING PROCESS
Evaluation
 Ongoing part of the nursing process
 Determining the status of the goals and
outcomes of care
 Monitoring the patient’s response to drug therapy