Nursing Process (Planning-Evaluation) Flashcards
Types of planning
- Initial planning - done at admission, ASAP after initial assessment
- Ongoing planning - individualized; to determine if health status has changed
- Discharge planning - for needs after discharge; begins at first contact
Types of nursing care plans
- Informal - in mind
- Formal - written; serves as guide to organize client info and ensures continuity care
- Standardized - usual or common needs
- Individualized - tailored to unique needs of a specific client and to patient’s diagnosis and planned actions
- Student - learning activity and are more lengthy and detailed
- Computerized - list of standard goals and interventions given according to chosen diagnosis
Guidelines for writing nursing care plans
- Date and sign for accountability
- Use headings from nursing process
- Use abbreviation, symbols and terminologies that are acceptable
- Tailor to unique characteristics
- Include preventative, health maintainable and restorative aspects
- Include ongoing assessments to be done
- Include collaborative and coordination of activities
- Include plans for discharge and home care needs
Planning phase
- Deliberate and systematic part of the nursing process
- Refer assessment data and nursing diagnosis to set priorities
- Determine and write client’s health outcomes/goals
- Plan and write nursing interventions/orders
Steps for planning phase
- Set priorities
- Write goals/desired health outcomes
- Select nursing interventions and activities
- Write nursing orders
Setting priorities
Factors to consider:
• Life threatening
• Health threatening
• Developmental needs
Can also use:
• Maslow’s hierarchy of needs
• ABCDE (airway, breathing, circulation, disability, everything else)
Priorities change as client’s condition changes
Consider: • Client's health values and beliefs • Client's priorities • Resources available • Urgency of problem • Medical treatment plan
Writing goals/desired health outcomes
- Observable client responses
- Are derived directly from nursing diagnosis
- Must be SMART
Criteria:
• Subject
• Verb
• Condition or modifiers - content of action
• Criterion - time and desired performance
Selecting nursing interventions and activities
• Actions that the nurse will do to help the client achieve the patient’s goals
- Independent interventions - does not require authorization and are based on knowledge and skills
- Dependent interventions - carried out under doctor’s orders or supervision or according to specified routines
- Collaborative interventions - with other health care team members
Criteria:
• Safe and appropriate to age, health and condition
• Congruent with beliefs, vales and culture
• Congruent with other therapies
• Based on evidence
• Within standards of care and within scope of practice
Writing nursing orders
• Focus on eliminating the factors (related to) that contribute to the problem
Criteria: • How - action • What - content • When - frequency or time limit • What are you doing? How are you doing it? When are you doing it? **give rationale**
Implementation phase
- Putting nursing care plan into action
- Includes doing, delegating and recording
Guidelines:
• Interventions should be clearly understood
• Adapted to the individual client
• Always safe care
• Provide teaching, support and comfort
• Use holistic approach
• Respect client’s dignity and enhance client’s self esteem
Evaluation phase
- Judge, appraise and evaluate the nursing care plan
- Determine client’s response and progress towards goals and effectiveness of the nursing care plan
- Decide to either continue, discontinue or terminate
Components:
• Collect data
• Compare data to client goals - goals met, partially met or not met?
• Relate nursing orders to client’s goals
• Draw conclusions about problem
• Continue, modify or terminate care plan
