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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
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.
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;
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;
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)
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.
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.
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.
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.
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
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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.
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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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.
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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.
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.
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.
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.
implementing nursing care and use alternatives if resources are not appropriate to provide
quality care.
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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10.)
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.)
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.
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.
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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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