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INTRODUCTION

Nurses face endless variety situation. In every clinical situation it is important for a nurse to
think critically and make sound judgement, so that the client ultimately receives the best
nursing care. The nursing process is a variation of scientific reasoning that allows nurses to
organize and systematize nursing practice. The nurse makes interference about the meaning
of a clients response to health care problems or generalizes about the clients functional state
of health. The nursing process is a problem-solving approach used by nurses to meet the need
of the client. It is a deliberate method that relies on the use of cognitive, interpersonal and
psychomotor skills. Nursing process have five step; 1) Assessment 2) Nursing diagnosis 3)
Planning 4) implementation 5) Evaluation.

PLANNING
INTRODUCTION
Planning, the third phase of nursing process refers to the development of nursing strategies
designed to ameliorate client problems. A plan of care is developed to direct nursing care
activities related to the person for whom the goals and outcome criteria were developed. A
written plan of care directs of the activities of the nursing staff in the provision of client care.

Purpose of Planning

Direct client care activities.


Promote continuity of care.
Focus charting requirements.
Allow for delegation of specific activities

The Planning Process


The planning process includes the following activities;

Setting priorities
Establishing client goals/ expected outcomes.
Selecting nursing strategies
Developing nursing care plans

1. Setting Priorities
Priority setting is a process of establishing a preference order for nursing strategies. The nurse
and the client begin planning by deciding which nursing diagnosis requires attention first,
which second, and so on. Instead of rank ordering diagnosis, nurses can group them as having
high, medium and low priority.
Life threatening problems such as loss of respiratory and cardiac functioning are designated
as high priority, for example high risk for aspiration.

Health threatening problems, such as acute illness and decreased coping ability , may result in
delayed development or cause destructive physical or emotional changes; thus they are
usually assigned medium priority , e g. Impaired physical mobility.
A low priority problem is one that arises from normal developmental needs or that requires
only minimal nursing support. Using a framework makes priority setting easier. Although it is
not, a nursing framework, nurses frequently use Maslows hierarchy of needs when setting
priority.
In Maslows hierarchy, physiological needs such as air, food and water, are basic to life and
receive higher priority than the need for security and activity. Growth needs, such as self
esteem, are not perceived as basic in this frame work. Thus, when the nurse plans care for a
client with unmet physiological needs receive first priority. Priority setting does not require
that all the high priority diagnosis be resolved before the nurse addresses any others. The
nurse may partially address a high priority diagnosis and then deal with a diagnosis of lesser
priority. The priorities assigned to problems do not remain fixed; rather they change as the
client responses, problems and therapies change. The nurse assigns priorities on the basis of
nursing judgement and insofar as possible, client preference. The nurse must consider a
variety of factors for example, the clients values and priorities and the available resources.
Nursing diagnosis provide the frame work for establishing outcomes for care.

2. Establishing Client Goals/ Expected Outcomes


After establishing priorities the nurse sets goals for each nursing diagnosis. A goal is a desired
outcome or change in client behaviour. Goal attainment is the resolution of the problem
specified in the nursing diagnosis. On a care plan the goals describe, in terms of observable
client responses, what the nurse hopes to achieve by implementing the nursing orders. A
distinction is made between the goals and expected outcomes, goals are the broad statements
about what the clients state will be after the nursing intervention is carried out e. g ;
nutritional status will improve. Expected outcomes are the more specific , measurable,
realistic statements of goal attainment e. g; will gain 5 lb by the end of the week. They may
restate the goal, but they also present information that will guide the evaluation phase of the
nursing process. Some sources also use the terms outcome criteria, objective and predicted
outcome. When goals are defined broadly, the clients care plan must include both goals and
expected outcomes. In fact they are sometimes combined into one statement linked by the
words as evidenced by for e.g.; Nutritional status will improve, as evidenced by weight gain
of 5lb by end of the week. Writing the broad goals first may help to think of the specific
outcomes that are needed but even though broad goals can be a starting point for planning, it
is the specific, measurable outcome that must be written on the care plan. For example, Goal
is to improve mobility, expected outcome is client will ambulate with crutches by the end of
the week.

2.1) Criteria for Expected Outcome


According to ANA:- The nurse identifies expected outcomes individualized to the client.
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Outcomes are derived from the diagnosis.


Outcomes are documented as measurable goals.
Outcomes are mutually formulated with the client and health care providers, when
possible.
Outcomes are attainable in relation to resources available to the client.
Outcomes are realistic in relation to the clients present and potential capabilities.
Outcomes include a time estimate for attainment. Outcomes provide direction for
continuity of care.

2.2) Purpose of Goals/ Expected Outcomes


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. Although developed in the planning
step of the nursing process, the expected outcomes serve as criteria for judging
nursing interventions and client progress in the evaluation step.
Enable the client and nurse to determine when the problem has been resolved.
Help motivate the client and nurse by providing a sense of achievement.

2.3)Long Term and Short Term Goals


Goals may be short term or long term. A short term goal can be met in a relatively short
period (within days or less than 1 week). A long term goal requires more time perhaps several
weeks or months. A long term requires more time, perhaps several weeks or months. A short
term goal might be client will raise right arm to shoulder height by Friday.
In the same context a long term goal might be client will regain full use of right arm in 6
weeks. In the acute care setting, much of nurses time is spent on the clients immediate
needs, so most goals are short term. Short term goals also enable the nurse to evaluate client
progress more accurately. Long term goals are often used for clients who live at homes and
have chronic health problems and for clients in nursing homes, extended care facilities, and
rehabilitation centres.
Short Term Goals Are Useful
For clients who require health care for short time and for those who are frustrated by long
term goals that seem difficult to attain who need the satisfaction for achieving a short term
goal.

2.4) Relationship of Goals/ Expected Outcomes to Nursing Diagnosis


Goals expected outcomes are derived from and relate to the clients nursing diagnosisprimarily from the first clause (problem). The problem clause contains the unhealthy
response; it states what should change. Therefore, the essential client goals are derived from
the problem clause. For example, if the nursing diagnosis is High risk for fluid volume deficit
related to diarrhoea and inadequate intake to secondary to nausea, the essential goal statement
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might be clients fluid balance will be maintained , as evidenced by urinary and stool output
in balance with fluid intake, normal skin turgor and moist mucus membranes. In this a
general goal fluid balance) is stated as the opposite of the problem (Fluid volume deficit) and
then followed by list of measurable expected out come. If achieved the expected outcome
would be evidence that the problem has been prevented. Goals may occasionally be derived
from second clause (etiology of diagnosis) but they are different from those derived from the
problem. Their achievement may help to resolve the problem, but they might also be
achieved without resolving the problem. In the above example the following expected
outcome can be derived from the etiology. Client will have daily fluid intake of 1500ml. Note
that drinking 1500ml of fluid would help the client achieve fluid balance; however if the
nurse discontinued the care plan on the basis of achieving this outcome, then the clients
needs would not be met. The fact that the client intake was 1500ml does not prove that the
problem was prevented. For example, continued diarrhoea or a high fever that cause the client
to lose more than 1500ml of fluid could still create a problem of fluid volume deficit. For
every nursing diagnosis the nurse must write at least one outcome criterion that when
achieved , directly demonstrates resolution of the problem clause.
When developing outcome criteria, ask the following questions;

What is the problem clause?


What is the opposite healthy response?
How will the client look or behave if the healthy response is achieved?
What must the client do and how well must the client do it to demonstrate problem
resolution or for demonstrate the capability of resolving the problem?

2.5) Components of Goal / Expected Outcome Statement


Goal expected outcome statements generally have the following four components;
1) Subject
The subject is the client or some attribute of the client such as clients pulse or urinary output,
often the subject is omitted in nursing care plan goals; it is assumed that the subject is the
client unless indicated otherwise.
2) Verb
The verb denotes an action the client is to perform, for e. g; what the client is to do learn or
experience. Verbs that denote directly observable behaviours, such as administer demonstrate,
show, walk, and and so on are used.
Examples of verb actions
Apply ,arrange, assemble, breathe, choose, communicate, compare, construct, calculate,
classify, define, demonstrate, describe, design, differentiate, discuss, draw, drink, explain,
express, help, identify, inject, list maintain, move, name, prepare, perform, practise, report,
recall, recite, share, stand, sleep, state, show, talk, take transfer, turn, use, verbalize, walk.
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3) Conditions Or Modifiers
Conditions or modifiers may be added to the verb to explain the circumstances under which
the behaviour is to be performed. They explain what, where, when, or how. For e .g;

Walks with the help walker (how)


After attending two group diabetes classes, list sign and symptoms of diabetes (when)
When at home maintains weight at existing level (where)
Discuss four food groups and recommended daily servings (what)

Conditions need not be included if the criterion of performance clearly indicates what is
expected.
4) Criterion of Desired Performance
The criterion indicates the standard by which a performance is evaluated or the level at which
the client will perform the specified behaviour. These criteria may specify time or speed ,
accuracy, distance, and quality.
To establish a time achievement criterion the nurse needs to ask
How long? To establish an accuracy criterion How well?
How far? And
What is the expected standard? To establish distance and quality criteria, respectively.
For e g;
Weighs 75 kg by April (time)
Lists five out of six signs of diabetes (accuracy)
Walks one block per day (time and distance)
Administers insulin using aseptic technique(quality)

2.6) Guidelines for Writing Goals/Expected Outcomes


Write goals or outcome criteria in terms of client behaviour. Begin each goal and
outcome criteria with the client. Outcome criteria should focus on what the client will
accomplish not what the nurse will do.
Avoid statements that start with enable, facilitate, allow, let, permit or similar verbs
followed by the work client. These words indicate what the nurse hopes to accomplish
not what the client will do.
Make sure that the goal statement is appropriate to the nursing diagnosis. Validate the
outcomes. If the outcomes are accomplished, will the clients nursing diagnosis be
resolved?
Be sure that the outcomes are the realistic for the clients capabilities, limitations and
designated life span, if it is indicated. Limitations are to finances, equipment, family
support, social services, physical and mental condition and time.
Make sure that the client considers the goals/ outcome important and values them.
Some outcome such as those for problems related to self esteem, parenting, and
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communication, involve choices that are best made by client or in collaboration with
the client.
Ensure that the goals and outcome are compatible with the work and therapies of
other professionals.
Make sure that each goal is derived from only one nursing diagnosis.
When writing expected outcome, use observable, measurable terms, avoid words that
are vague and require interpretation or judgement by the observer.

2.7) Characteristics of Well Stated Goals/ Expected Outcomes


A well stated expected outcome is;

Derived primarily from the first clause of the nursing diagnosis.


Possible Derived to achieve.
Stated in terms of client responses rather than nursing activities.
Statement of one specific client behaviour.
Specific and concrete.
Appraisable or measurable.
Valued by the client and family.
Compatible with the therapies of other professionals.

3. Selecting Nursing Strategies


This involves selecting action that enables the person to achieve the outcomes and to resolve
the related factors in the nursing diagnosis. These selected actions or strategies are called
nursing interventions. The specific strategies chosen should focus on eliminating or reducing
the etiology of the nursing diagnosis, which is the second clause of the diagnostic statement.
Correct identification of the etiology during the diagnosis phase provides the frame work for
choosing successful nursing interventions. Often the nurse and the client can establish a
number of nursing strategies for each problem statement. Too many alternatives can be
confusing. Usually three to five alternative nursing strategies for each health problem are
satisfactory.
Considering the consequences of each strategy
Once the nurse identifies a number of possible strategies to implement the next step is to
consider the risks and benefits of each action. Often an action will have more than one
consequence. Determining the consequence of each strategy requires nursing knowledge and
experience.

3.1) Criteria for choosing nursing strategies


The following criteria can help the nurse choose the best nursing strategy. The planned action
must be
Safe and appropriate for the individuals age, health, and so on.
Achievable with the resources available.
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Congruent with the clients values and beliefs.


Congruent with other therapies.
Based on nursing knowledge and experience or knowledge from relevant
sciences( based on rationale).
Within established standards of care as determined by state laws, professional
associations and the policies of the institution.

3.2) Types of Nursing Strategies


Nursing strategies are identified and written during the planning step of the nursing process;
however they are actually performed during the implemented step. A nursing intervention is
any direct care treatment that a nurse performs on the behalf of a client, whether nurse
initiated or physician initiated.

Independent Intervention
These are those activities that nurses are licensed to initiate on the basis of their knowledge
and skills. They include physical care, ongoing assessment, emotional support and comfort ,
teaching, counselling, environmental ,management and making referrals to other health care
professionals. McCloskey and Bulechek refer to these as nurse initiated treatments.
Mundinger prefers the term autonomous nursing practise. She states Knowing why, when
and how to position clients and doing it skilfully makes the function an autonomous therapy.

Dependent Interventions
These are those activities carried out under the physicians order or supervision, or according
to specific routines. McCloskey and Bulechek call these physician initiated treatments.
Medical orders commonly include orders for medications, intravenous therapy, diagnostic
tests, treatments, diet and activity. The nurse is responsible for explaining assessing the need
for and administering the medical orders. Dependent interventions are usually directly related
to the clients disease, and their importance should not be minimized.

Collaborative Interventions
These are actions the nurse carries out in collaboration with other health team members, such
as physical therapists, social workers, dieticians and physicians. Collaborative nursing
activities reflect the overlapping responsibilities of and collegial relationships between ,
health personal. Tom achieve collaborative nursing practice nurses must be clinically
competen , feel confident in their knowledge and skills and assume responsibility for their
own actions.

3.3) Writing Nursing Orders


After choosing the appropriate nursing interventions the nurse writes them on them on the
care plan as nursing orders. Nursing orders are instructions for the specific activities the nurse
performs to help the client meet established health care goals. The team order connotes a
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sense of accountability for nurse who gives the order and for the nurse who carries it out.
Carnevali and Thomas used the term nursing directives.
A complete well written nursing order is composed of five components;
Date: Nursing orders are dated when they are written and reviewed regularly at
intervals that depend on the individuals needs.
Specific action verb such as instruct place, supervise, and observe. Sometimes a
modifier, such as actively softly, firmly helps clarify the verb.
Content area: The content is the where and what of the order.
Time element: the time element answers when, how long or how often the nursing
actions are to occur.
Signature: The signature of the nurse prescribing the orders shows the nurses
accountability and has legal significance.

1) Developing Nursing Plans


The nursing care plan is written guide that organizes information about a clients care into
meaningful whole. It includes the actions nurses must take to address the clients nursing
diagnosis 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 clients stay, in
response to changes in the clients condition and evaluations of goal achievement.

4.1) Purpose of a written Care Plan


To provide direction for individualized care of the client.
To provide for continuity of care.
To provide direction about what needs to be documented on the clients progress
notes.
To serve as a guide for assigning staff to care for the client.
To serve as a guide for reimbursement from medical insurance companies, often
called third party reimbursement.
To provide for individual and family participation in the nursing care plan.
To outline a programme for health education of individuals and significant others.
To encourage adequate discharge planning.
To provide a source of information for quality improvement and research.

4.2) Writing a Nursing Planning Of Care


A nursing plan of care documents the problem solving process. The ability to create the
nursing plan of care has become a standard expected of every nurse. The plan is a critical
element in focusing nursing activity. To serve as evaluation criteria and meet the standards of
the Joint commission for accreditation of Healthcare Organisations (JACHO 1966), the plan

must be developed by a registered nurse it must be documented in the clients health record
and it must reflect the standards of care established by the institution and the profession.
Two important concepts guide a nursing plan of care
The plan of care is nursing centred.
The plan of care is a step by step process.
Keeping the plan of care nursing centred is essential to identify the scope and depth of
nursing practise. By focusing on the treatment of human resources to actual or potential
health problems, the nurse remains in the nursing practice domains.

4.3)A step by step process is evidenced by the following

Sufficient data are collected to substantiate nursing diagnosis.


At least one goal must be stated for each nursing diagnosis.
Outcome criteria must be identified for each goal.
Nursing interventions must be specifically designed to meet the identified goal.
Each intervention should be supported by a scientific rationale.
Evaluation must address whether each goal was completely met partially met, or
completely met.

4.4) Guidelines for writing Nursing Care Plans


1.
2.

Date and sign the plan


Use the category headings
Nursing diagnosis
Goals/ outcome criteria
Nursing orders
Evaluation and include a date for the evaluation of each goal.

3) Use standardised medical or English symbols and key words rather than complete
sentences to communicate your ideas.
4) Refer to procedure books or other sources of information rather than including all the steps
on a written plan.
5) Tailor the plan to the unique characteristics of the client by ensuring that the clients
choices such as preferences about the time of care and the methods used are included. This
reinforces the clients individuality and sense of control.
6) Ensure that the nursing plan incorporates preventive and health maintenance aspects as
well as restorative.
7) Ensure that the plan contains orders for ongoing assessment of the client.
8) Include collaborative and coordination activities in the plan.
9) Include plans for the clients discharge and home care needs

4.5) Types of Nursing care Plans


As you care for people in various health care facilities, you will discover a variety of nursing
care plan formats. The documentation of the plan of care is also changing as federal, state,
and accrediting agencies examine and modify their standards. It can be written in various
ways. The most common formats for care plans include student nursing care plan,
individually developed nursing care plan, practise guidelines, critical path or case
management plan and computerized nursing care plans.

Student Nursing Care Plans


Each school of nursing has a care plan format adopted by or developed by the faculty for
student use. Because s tudent plans are used as learning tools, they are usually more
comprehensive and detailed than the care plans utilized by graduate staff nurses. Student care
plans focus heavily on documenting signs and symptoms and proving the rationale for
specific nursing interventions. This information is no less important to the graduate nurse.
However the experienced nurse is capable of high level assessment and synthesis of data,
which are still step by step for the student. The components usually include nursing diagnosis
client goals, outcome criteria, nursing interventions, scientific rationale and evaluation.

Individually Developed Nursing Care Plans


The individually developed nursing care plan is the most traditional and oldest method of
documenting the plan of care. It typically consists of three columns, which are labelled
according to the setting as nursing diagnosis or problems outcomes or goals and nursing
interventions or orders. Additional columns may be added to the format to include a spot for
the date and initials of the nurse who developed the plan, the date for the out come
achievement and the date the nursing diagnosis was resolved. Individual care plans are
intended to focus on the specific needs of the person and are to be updated as the persons
condition changes. The individually developed the plan, the date for the outcome
achievement and the date the nursing diagnosis was resolved. Individual care plans are
intended to focus on the specific needs of the person and are to be updated as the persons
conditions changes. The individually developed nursing care plan, like the other formats fgor
the plan of care, usually combined with a Kardex. A Karedex is an abbreviated form that
contains 1) basic demographic information about the person such as name age , sex, medical
diagnosis , surgical procedures and physician name,2) basic care information such as type of
bath , frequency of vital signs, allowable activity, ordered treatments and so on.
Advantages
The advantages of individually developed nursing care plans include their specificity to a
particular person. They contain only the pertinent nursing diagnosis outcomes and
interventions.
Disadvantages

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The primary disadvantage of this is the time consuming aspect of the development process.
Also as is true with other formats for care plans, the individually developed nursing care plan
may not accurately reflect the persons current problems if it has not been updated.

Standardized Nursing Care Plans


Printed care plans known standardized care plans are developed commercially or by an
individual health care facility. The direct nursing care for people with specific medical
diagnosis (e g; myocardial infarction) with certain nursing diagnosis such as pain or anxiety
or who are undergoing special procedures such as cardiac catheterization. These care plans
are typed pre printed, duplicated and made available to the appropriate units in the health care
facility. The format is designed to leave space for the nurse to individualize the care plan by
filling in specific related factors associated with nursing diagnosis adding deadlines to the
outcomes and clarifying the interventions with additional details. For example , the
intervention could be individualized by adding frequencies, amounts, times, and the clients
preferences.
Advantages
Reduced amount of writing needed to record routine nursing interventions and help to
the staff by highlighting necessary interventions.
These are usually developed by a group of nurses who use their collective expertise
and experience to produce a well researched tool.
Particularly helpful to nurses who may be asked to work in an unfamiliar area.

Disadvantages

Nurse may use these care plans without individualizing them for a particular person.
Many of the nursing diagnosis, outcomes, and interventions may not ne applicable.
These may tend to be long.
Frustrated by the amount of time it takes simply to read them, some nurses have not
found them to be helpful. This problem can be reduced by developing concise
standardized care plans that contain only the essential information.

Teaching Plans
Teaching plans are a specialized form of nursing care plans. Individually developed teaching
plans may be hand written or computer generated for individuals with complex teaching
needs. An agency may have a variety of standardized teaching plans prepared for people with
commonly seen teaching needs. The nurse modifies the standard teaching plan as needed and
uses the form to document the outcome of the teaching.
Practice Guidelines
Practice guidelines also called Protocols; specify nursing management of broad clinical like
maintenance of skin integrity phases of hospitalization such as postoperative care or
independent clinical issues for e g; management of s person receiving a certain type of potent
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medication , such as cardiac medication given intravenously in ICUs. Whereas the


standardized care plan or individually developed care plan contains information about a
variety of nursing diagnosis, the practice guidelines typically address one issue, problem or
nursing diagnosis. Practise guidelines are usually developed by experts and reviewed by a
group of nurses for validity. When a practise guideline address an interdependent clinical
issue that includes both medical and nursing management of a particular concern, physician
committee review of the medical orders is usually needed. These plans illustrate the manner
in which health care professional collaborately manage treatment. Practise guidelines aer
used commonly in short stay areas of a hospital, such as Emergency departments and Post
Anaesthesia care units. Certain commonalities exist among people in these areas, making it
possible to manage their care according to practise guidelines.
Advantages
They clearly specify well researched and agreed upon management of certain
problems.
Once the initial work of developing practise guidelines is completed, their use saves
much time by quickly transmitting information that does not need to be documented
for each person for whom it is applicable.
Practice guidelines are not considered standards.
Disadvantages
The temptation to follow uncritically the interventions without individualizing them
for a particular person.
Non prepared plan of care no matter what its format replaces the judgement and
critical thinking of the nurse.

Case Management Care Plans


Case management is a method of delivering care that has evolved from the emphasis on
decreasing the length of stay in hospitals and the focus on achieving timely client outcomes.
Case management is designed to organise care to achieve certain specific outcome with in a
time frame permitted by the reimbursement system. The Case management plan is a
standardized care plan that consists of nursing diagnosis, outcomes, deadlines, nursing
interventions and physician interventions. The plan is developed collaboratively by nurses,
physicians and other health care professionals and is reviewed and individualized for a
particular person. The comprehensive case management plan is often summarized in the form
of a critical path or patient outcome timelines.
Critical path improve quality of care by Allowing health care professionals to share knowledge with each other.
Educating clients by thoroughly explaining the treatment plan.
Permitting comparison of outcomes or results of various treatment methods.
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Identifying and reinforcing steps critical to the desired outcome.


Advantages
Easy to identify appropriate steps in achieving the outcomes.
Resources of the nursing staff and hospital are used more effectively as they become
directed at moving the person through the hospitalization.
The person is actively involved in reviewing the plan of care.
Nurses are given more authority to make changes in the system to facilitate the
achievement of outcomes.
Disadvantages
A great deal of planning needed to implement this method of delivering care.
It may be difficult in some instance to gain the cooperation of physician in defining
how to manage certain types of clients and to collaborate with nurses on professional
level.
Certain people will have pre-existing conditions or complications that will prevent the
achievement of outcomes at specified time periods.

Computerized Nursing Care Plans


Many software vendors have developed computerized nursing care plans and critical paths.
Computerized plans of care are generated from assessment data entered into a computer
about a specific client. The plan is written by experts in the area and the content is similar to
that of standardized plan of care. Once the plan is on the computer screen the nurse has
opportunity to customize it for the client.
Advantages

Legibility
Reduction in the amount of time needed to develop and update the plan.
Access to plans developed by expert clinicians.
Ability to collect information about groups of patients for research.

Disadvantages
It require a critical analyse of a pre existing plan to ensure that it is appropriate and
current .
It is critical that all pertinent information be collected and entered in to the system.

IMPLEMENTATIION
Introduction
The nursing process is a deliberate, problem solving approach to meeting the health care and
nursing needs of patients. It involves assessment, diagnosis, and outcome identification,
planning implementation and evaluation wit subsequent modification used as feedback
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mechanisms that promote the resolution of the nursing diagnosis. The process as whole is
cyclical the steps being interrelated interdependent and recurrent. The nursing process is
action oriented client centred , and goal directed. After developing a plan of care based on the
assessing and diagnosing phases the nurse puts the plan into effect and evaluates the results.
Based on this evaluation the plan of care is continued , modified or terminated. As in all
phases of the nursing process clients and support persons are encouraged to participate as
much as possible. The degree of participation depends on the clients health status. After the
nurse and the client identify the problems and strengths, they plan together methods of
helping the client maintain or return to healthy function. Outcome criteria are set for goals
and a plan of care is developed. Now they are ready for the implementation phase of the
nursing process, the activity that provides planned care and the evaluation phase in which the
clients status is measured in response to the nursing care provided.

Definition
Implementation refers to the action phase of the nursing process in which nursing care is
provided. It is the actual initiation of the plan and recording of nursing actions. Its purpose is
to provide technical and therapeutic nursing care required to help the client achieve an
optimal level of health.
Bulecheck define nursing interventions as any direct care treatment that nurse performs on
behalf of a client. These treatment include nurse initiated treatments resulting from medical
diagnosis and the performance of the daily essential functions for the client who that cannot
do these.

Implementation Skills
The implementation phase of the nursing process draws heavily on the intellectual,
interpersonal and technical skills of the nurse. These are also known as cognitive affective
and connective skills. Decision making, observation and communication are significant skills,
enhancing the success of action. These skills are utilized by the client , the nurse, nursing
team members and health team members. Competence in intellectual , interpersonal and
technical skills are required to carry out the implementation phase.

Intellectual / Cognitive Skills


The intellectual skills used in implantation include problem solving, decision making, critical
thinking and teaching. To solve problems nurses ask clients pertinent questions discuss
alternatives, and open new ideas. To enrich the decision making abilities of clients, nurses
give them opportunities to choose which treatments are performed, when and in what
sequence. Teaching requires knowledge about teaching learning principles and information to
convey.

Interpersonal /Affective Skills

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The ability to work with others to accomplish goals is critical to nursing . nurses use
communication skills to carry out planned nursing interventions. Verbal and nonverbal
communication skills are utilized when you interact with the health care team. These skills
are often crucial in the successful implementation of nursing care. People often judge nurses
not by their technical skills alone but by whether they are kind concerned and caring. The
ability to use effective interpersonal skills when communicating with physicians, social
workers, and other personal will also affect the success of the implementation phase. It is
essential that the nurses be able to use cognitive skills to solve problems and make decisions
and use interpersonal skills to implement those decisions.

Technical / Cognitive Skills


Psychomotor or technical skills are the third major category of skills used during
implementation of nursing care. These skills are used to carry out treatments and procedures.
Nurses learn the specific skills through clinical practise. Technical competence means being
able to use equipment machines and supplies in particular speciality. For example nurses
working delivery rooms must be familiar with foetal monitoring positioning on delivery room
table , and neonatal resuscitation devices. On the other hand nurses working on medical units
may need technical competence in using hypothermia blankets, therapeutic beds or feeding
pumps. Nurses often find that when technical skills are unfamiliar, it is difficult to incorporate
the cognitive and interpersonal components.

Implementation Activities
The activities of implementation include the following

Reassessing
Setting priorities.
Performing nursing intervention.
Recording nursing actions.

1.) Reassess
Assessing is carried out throughout the nursing process, whenever the nurse has contact with
the client. Just before implementing, the nurse must reassess whether the intervention is still
needed because a clients condition can change quickly and dramatically. For example the
client who experiences pain may become quite and withdraw from external stimuli.
Recognizing such as a change nurses can intervene, validate and assist the client to become
more comfortable. As they initiate the nursing plan of care, nurses must ensure that the
planned interventions are still relevant.

2.) Set priorities


Because a person condition changes priorities also may change. Priorities are based on
information collected during assessment. When setting priorities nurses rank nursing
problems in order of importance based on several factor.
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The clients condition.


New information from reassessment
Time and resources available for nursing interventions.
Feedback from the client family and health staff.
The nurses experience in assessing situations and setting priorities.

Priorities can be set every few minutes, hourly, daily, weekly or for longer periods. For
example in the critical care unit, priorities may need to be set every few minutes for an
unstable client with multiple traumas.

3.) Perform Nursing Interventions


Nurses carry out the nursing interventions listed on the nursing plan of care. If a nurse is
caring for several clients he or she develop a schedule so that all clients are cared in a timely
fashion.
Intervention for collaborative problems
Nurses manage collaborative problems using both nurse and physician prescribed
interventions to reduce risk of complications. Both types of interventions involve nursing
judgement, because both require legal mandates.

4.) Record actions


After carrying out nursing interventions nurses record them in the clients health record. Each
institution determines the specific requirements for documentation and should prepare written
guidelines for the use of all forms.

Types of Nursing Interventions


Nursing intervention fall within three major categories; those using cognitive skills those
using interpersonal skills, and those using technical skills. Selection of the type of nursing
intervention to be used in client situations depends on the clients dysfunction and functional
requirements.

a.) Cognitive Interventions


Educational interventions
Nurses carry out educational nursing interventions by applying general principles about the
teaching and learning process. They develop teaching plans and provide instructions about
health promotion or specific health care problems and their management. The ability to teach
clients requires knowledge of normal anatomy and physiology, usual patterns of client
response to health changes and pathphysiology of the disease process. Once a nurse is aware
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of the clients readiness for learning, he or she can implement outcome based teaching plans,
using instruction methods that optimize successful outcomes.
Supervisory Interventions
The term supervisory interventions are applied in the context of overseeing a clients overall
care. Supervisory nursing interventions include ensuring that other members of the nursing
team carry out specified aspects of the plan of care, and that those involved with the client or
family show return demonstration of skills. Supervising the client of family in skill
performance is essential, to provide encouragement give feed back about correct and
incorrect performance and facilitate introduction of new skills to be learned. Nurses include
clients and family members in planning and implementing initial care. They help clients and
families begin to assume responsibility for self management.

b) Interpersonal Interventions
Coordinating interventions
Coordinating client activities serves may purposes. Coordinating involves acting as a client
advocate, making referrals for follow up care, collaborating with other health care team
members and ensuring that the clients schedule is therapeutic. In the advocacy role the nurse
presents the clients point of view and suggests ways in which the clients requests can be
met. Nurses are in position to know what type of nursing follow up clients need. They make
referrals to home health agencies, visiting nurse associations or other healthcare providers to
facilitate return to optimal function.

Supportive Interventions
Supportive nursing interventions emphasize use of communication skills relief of spiritual
distress and caring behaviours. A combination of good communication and caring provides
comfort and promotes a healthy response to health problems. Nurses provide spiritual support
by giving clients time to carry out religious practices, meditate or read. Respecting the
clients privacy during these times conveys acceptance and understanding.
Psychosocial Interventions
Psycho social nursing intervention focus on resolving emotional , psychological or social
problems. Humour individual or group therapy, role modelling social skills and exploring
feelings are all ways of carrying out psychosocial nursing interventions. Providing individual
and group therapy is the nurses responsibility in various setting. For example, individual
therapy is used as a means of resolving psychological problems and group therapy is used to
provide support and guidance for clients with similar needs or problems.
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c) Technical Interventions
Maintenance Interventions
Maintenance nursing intervention help clients retain certain state of health , preventing
deterioration of physical or psychological functioning and preserving independence.
Maintenance intervention include basic hygiene, skin care and other routine nursing
activities.
Surveillance Interventions
Surveillance nursing g interventions include detecting changes from baseline data and
recognizing abnormal responses. This activity also can be categorized aas observation,
inspection or vigilance. Nurses really on the sense to detect changes : observing the
appearance and characteristics of client ;hearing by auscultation detecting odours and
comparing them with past experiences and using touch to assess body temperature and skin
condition. Nurses use all these surveillance activities to determine the status od clients and
changes from previous states.
Psychomotor Interventions
Psychomotor nursing interventions those requiring technical expertise include inserting ,
removing, changing, applying, administering, cleansing or any other activity that requires a
psychomotor action. The management and care of equipment , supplies, treatments and
procedures also falls in to this category of nursing interventions nurses gain technical
competence through practise.

Relationship of Implementation to Other Nursing Process Phases


Successful implementing depends, in parts on the quality of assessing, diagnosing and
planning that has been done. These first nursing process phases provide the basis for the
autonomous nursing actions performed during the implementing step. In turn the
implementing step provides the actual nursing activities and client responses that are
evaluated in the final step (evaluating). The nursing process phases are interdependent and
overlapping rather than separate and linear. Using data acquired during assessment the nurse
can be individualize the care given in the implementing phase, tailoring the interventions to
fit a specific client rather than applying them routinely to categories of clients. Ongoing
assessment occurs simultaneously with implementation. While implementing the nursing
orders, the nurse continues to reassess the client at every contact, gathering data about the
clients responses to the nursing actions and about the new problems that may develop.
Successful implementing also depends upon resources are sufficient ( manpower, time and
material), the quality care is provided to clients and the organizational and client centred
goals are achieved. Along with this the nurses have skills to utilize those resources while
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implementing nursing care and use alternatives if resources are not appropriate to provide
quality care.

Responsibilities in Implementation of Nursing Care


It is the professional responsibility to carry out the nursing care as the primary nurse, delegate
certain interventions to appropriate nursing or allied health professionals to carry out
physician orders, thereby integrating medical therapy in to overall care plan. Nursing care is
implemented to assist people in achieving the outcomes established in the plan of care, to
prevent disease and illness by promoting wellness, to restore functioning adn to facilitate
coping with illness.
The major responsibilities in implementing nursing care include:
1) Reviewing the planned interventions for appropriateness.
2) Scheduling and organizing the interventions.
3) Collaborating with other team members.
4) Supervising and delegating nursing care by other members of nursing team.
5) Achievement of the organizational and client care goals.
6) Providing direct nursing care.
7) Provide counselling.
8) Involving the client in health care.
9) Teaching the client and family.
10) Making referral to other health care professional.
11) Documenting nursing care provided.

1.) Reviewing the planned interventions for appropriateness


The first phase of implementation involves reviewing the planned interventions. Cognitive
skills are used to choose the appropriate nursing interventions. Developing a plan of action is
a two step process.

1) Develop interventions
Interventions are generated through processing information and using creativity. The
consideration of numerous interventions results in a creative solution to the diagnosis.
The specific ways in which interventions are developed :
Recall ways in which you handled a similar nursing diagnosis in past.
Considering the nursing diagnosis from various angles and in different ways.
Imagine how you would ideally like to see the nursing diagnosis resolved.
Discuss the interventions with the person and family, hear their ideas on solutions to
resolving the nursing diagnosis.
Talk with colleague or meet with a group of colleague and brainstorm possible
solutions to the diagnosis.

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Obtain expert advice and recommendations.


Review current literature.

2) Select the best intervention


The next step is to analyze the interventions and choose the one that seems best. In most
nursing care situations the best approach is the one promising the greatest benefit with the
least risk. To select such an intervention systematically examine all the available options. Ask
yourself the following questions and try to answer them objectively:
Has this type intervention been used before in a similar situation? If so what were the
results?
Will this particular intervention enable the person to meet outcomes within proposed
time limits?
Does this intervention take in to consideration the persons age , sex, lifestyle,
attitudes, religious and cultural traditions, social resources and coping abilities?
Is this intervention acceptable to the individual and family?
Is the intervention realistic? Are equipment, staff time, staff size and other resources
adequate?
What might be some undesirable consequences if this intervention is selected? Would
this particular solution bring more problems in its wake?

2.) Scheduling and organizing the interventions


Specific coordinating activities include meeting with other health care team members to plan
and organize care, scheduling the persons activities (scheduling appointment with dietician ,
determining the best time for physical or occupational therapy) discussing the persons
progress, consulting with the physician , arranging for discharge and long term needs.
Scheduling and coordinating nursing care requires time management skills. You will be
involved in balancing the requirements of several people, including several patients and
health care practitioners. As you become more comfortable with providing nursing care you
will be better able to organize your day and address the needs of many people.

3.) Collaborating with other team members


One should not be the primary nurse for every person in your clinical area. Therefore,
communication with and collaboration among team members are essential. These valuable
resources people are nurses prepared at the masters level who possess expertise in specific
clinical specialities. Staff nurses should also consult each other as professional colleagues , so
that nursing as a profession is strengthened. Collaboration with other professional nurse also
improves the quality of nursing care.

4.)Supervising and delegating nursing care by other members of the


nursing team

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As a professional, nurse will delegate appropriate responsibilities to the person, significant


others and other team members. The delegation of nursing care is based on six elements, as
defined by the Joint Commission of Accreditation of Health Organizations.
The complexity of the individuals condition and nursing care needs.
The stability of the persons status.
The complexity of the assessment required to care for the person properly, including
the knowledge and skills needed by the nursing staff member in order to complete the
assessment.
The type of technology or equipment employed in providing nursing care.
The degree of supervision required by the nursing staff member based on the nurses
level of competence.
The availability of supervision.
Delegation of nursing care also depends on the job description ad legal limitation of the scope
of practise of other team members, for example, a registered nurse could not ask a nursing
assistant to give a dose of intravenous medication.

5.) Achieving of the organizational and client care goals


The nursing team carries out the nursing orders detailed in the using plan of care. If the plan
of care is well constructed carrying out its orders is the most important task and should
receive top priority. The nursing actions planned to promote client goal or outcome
achievement and the resolution of health problems should be carefully executed. As the
quality care provided to clients and achieve the clients goals, ultimately the organizational
goals are achieved.

6.) Providing Direct Nursing Care


The nursing interventions may be independent or interdependent. They may also be
dependent which is carried out based on the physician orders e g: medication administration,
providing IV fluids etc. In some instances, there are standing orders that direct the care of the
client. Standing orders are typically developed when the facility is caring for a group of
people with clearly identified and anticipated needs. Both dependent interventions and
standing orders must be evaluated carefully to be sure they are appropriate for the person.
Nurses are legally responsible for questioning physicians orders that are inappropriate or
inaccurate.

7.) Providing Counselling


Counselling helps individuals with long term chronic illness and disabilities to come to terms
with their condition. In this case encourage people to verbalize fears or concerns by
establishing a warm , nonthreatening atmosphere. Counselling also involves helping people
cope successfully as they pass through the various developmental stages of a normal life. In
this case the counsellor not only discusses the persons problems but also talks about many
normal changes that occur during different developmental stages.
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8.) Involving the client in health care


There is a strong trend toward offering the client choices to enhance the acceptability of the
outcomes and interventions. The degree considered necessary or desirable by the client,
family members have a right to be informed about and involved in the provision of nursing
care.

9.) Making referrals to other health care professionals


Most health acre agencies have a referral procedure to simplify the transfer of information
from one health care facility or department to another. Referrals are written on special forms,
made over the phone, or requested in person. Clients are typically referred to dietitians ,
social workers, psychiatrists, physical and occupational therapists and various organizations.

10.)

Teaching the client and family

Teaching is a vital part of implementing the care plan and promoting change. Nurses assume
the role of teacher when clients when clients have identifiable learning needs. It helps clients
and family to develop the self care abilities that enables them to maximize their functioning
and quality of life.

11.)

Documenting nursing care provided

During and after implementation of care nurse will record information in teh medical record.
This information includes data, observations, interventions and evaluation of the
effectiveness of care.

Overall, the ultimate intent of the implementation phase is the use of strategies to help the
person achieve the outcomes. By providing focused and planned care, you use your cognitive
interpersonal and technical skills to assist the person. The major responsibilities of nursing
care involves reviewing the planned interventions, scheduling, organizing, collaborating,
supervising, providing direct care, counselling, teaching, referring and documenting.

EVALUATION
Introduction
As part of professional accountability, nurses are answerable to themselves as practitioners ,
to individuals and significant others, to physicians and others who participate in giving care,
to agencies in which they practise and to the community. The use of evaluation helps fulfil
the nurses the duty to act in professionally responsible way.

Definition
To evaluate is TO JUDGE or TO APPRAISE
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Evaluation is planned , ongoing purposefully activity in which client and health care
professionals determine
1) The clients progress towards goal achievement.
2) The effectiveness of nursing care plan.
Evaluation is defined as the judgement of the effectiveness of nursing care to meet
client goals based on the clients behavioural responses.
This phase involves a through, systematic review of the effectiveness of nursing interventions
and a determination of client goal achievement. Nurses use a variety of skills to judge the
effectiveness of nursing care. These skills include knowledge of standards of care, normal
client responses and conceptual models and theories of nursing, ability to monitor the
effectiveness of nursing interventions and awareness of clinical research. Critical appraisal of
goal attainment is determined jointly by the nurse and the client.

Difference between assessment and evaluation


Assessment involves data gathering for the purpose of deriving a nursing diagnosis and
forming a plan. Therefore , the assessment phase consists of gathering information about the
existing problems and strengths of the person. The evaluation step of nursing process uses
your knowledge and skills to make a clinical judgement about the achievement of outcomes.
During evaluation you compare the current status of the person with the expected outcome.
when you evaluate the person you make a decision about how well the person achieved the
outcome and whether the plan of care should be continued modified or discontinued.

Purposes
To collect the objective and subjective data to make judgements about nursing care
delivered.
To examine the clients behavioural responses to nursing interventions.
To compare the clients behavioural responses with pre determined out come criteria.
To appraise the extent to which client goals were attained or problems resolved.
To appraise involvement and collaboration of client, family members, nurses and
health care team members in health care decisions.
To provide a basis for the revision of the nursing plan of the care evaluation.
To monitor the quality of nursing care and its effect on the clients health status.

Types
There are three types of evaluation:
1) Structure evaluation
Structure evaluation focuses on the attributes of the setting or surroundings where health care
provided. It deals with the environmental aspects that directly or indirectly influence the
quality of care provided. Availability of equipment layout of physical facilities nurse client
ratios, administrative support, and ,maintenance of nursing staff competence are some areas
of concern for structure evaluation.
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2) Process evaluation
Process evaluation focuses on the nurses performance and whether the nursing care provided
was appropriate and competent. The phases of the nursing process are used as the frame work
for the evaluation of nursing care. Areas of concern for this type of evaluation include the
type of information obtained by interview and physical assessment the validity of the nursing
diagnostic statements and the nurses technical competence.

3) Outcome evaluation
Outcome evaluation which focuses on the client and the clients function. Outcome
evaluation determines the extent to which the clients behavioural response to nursing
intervention reflects the desired client goal and outcome criteria. Outcome evaluation can
take place only after standards have been developed . an example of an outcome evaluation is
to establish standards of care for a specific diagnosis and then compare actual client outcome
with that standard.

Evaluation may also be Ongoing Intermittent or Terminal:


1) Ongoing evaluation
Ongoing evaluation is done while or immediately after implementing a nursing order; it
enables the nurse to make on the spot modifications in an intervention.
2) Intermittent evaluation
It is performed at specified interval (e g: once a week) shows the extent of progress towards
goal achievement and enable the nurse to correct any deficiencies and modify the care plan as
needed. Evaluation continues (either ongoing or intermittently) until the client achieve the
health goals or is discharged from nursing care.,
3) Terminal evaluation
It indicates the clients condition at the time of discharge. It includes the status of goal
achievement and an evaluation of the clients self care abilities with regard to follow up care.
Most agencies have a special discharge record for the terminal evaluation.

Relationship of Evaluation to other Nursing Process Phase


Evaluation depends on the effectiveness of the steps that precede it. Assessment data must be
accurate and complete so that the nurse can formulate appropriate expected outcomes in the
planning step. The expected outcome must be stated concretely in behavioural terms if they
are to be useful for evaluating client responses. And finally without the implementing phase
in which the plan is put into action there would be nothing to evaluate.

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Overall, the final phase of the nursing process, in which the nurse determines the clients
progress toward goal outcome achievement and the effectiveness of the nursing care plan.

CONCLUSION
The nursing process is a systematic rational method of planning and providing individualized
nursing care to client, families and communities. It is organized to five inter related and inter
dependent phase assessment, diagnosis, planning, implementation, ad evaluation. Planning
involves setting priorities, writing goal establishing care plan of interventions.
Implementation is carrying out of the nursing intervention. Evaluation is the process of
comparing client response to pre selected outcomes.

REFERENCES
1. Navdeep Kaur Brar,HC Rawat.Text of Advanced Nursing Practice.New Delhi:Jaypee
Brothers Medical Publishers;2015;p 723-729.
2. Shebeer. P. Basheer,S. Yaseen Khan.Text Book Of Advanced Nursing
Practice:Emmess Medical Publishers;2012;p503-534.
3. Potter and Perry.Fundamental of nursing.6th Edition.New Delhi:Mosby
Publication;2005;Pp 277-366.
4. https://en.wikipedia.org/wiki/Nursing process
5. study.com/academy/lesson/nursing-process-purpose-and-steps.html

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