April 22, 2008 · 3 Comments
- involves determining before and the strategies or course of actions to be taken before implementation of nursing care. To be effective, the client and his family should be involve in planning.
- To determine the goals of care and the course of actions to be undertaken during the implementation phase.
- To promote continuity of care.
- To focus charting requirements.
- To allow for delegation of specific activities.
1. Establish/Set priorities
Priority – is something that takes precedence in position, and considered the most important among several items. It is a decision making process that ranks the order of nursing diagnosis in terms of importance to the client.
Guideline for setting priorities:
- Life-threatening situations should be given highest priority.
- Use the principle of ABC’s (airway, breathing, circulation)
- Use Maslow’s hierarchy of needs.
- Consider something that is very important to the client.
- Actual problems take precedence over potential concerns.
- Clients with unstable condition should be given priority over those with stable conditions. Ex: attend to client with fever before attending to client who is scheduled for physical therapy in the afternoon.
- Consider the amount of time, materials, equipment required to care for clients. Ex: attend to client who requires dressing change for postop wound before attending to client who requires health teachings & is ready to be discharged late in the afternoon.
- Attend to client before equipment. Ex: assess the client before checking IV fluids, urinary catheter, drainage tube.
2. Plan nursing interventions/nursing orders to direct activities to be carried out in the implementation phase.
- any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes.
- they are used to monitor health status; prevent, resolve or control a problem; assist with activities of daily living; or promote optimum health and independence.
- They maybe independent, dependent and independent/collaborative activities that a nurses carry out to provide client care.
Independent Nsg. Intervention – those activities that the nurse is licensed to initiate as a result of the nurse’s own knowledge and skills.
Dependent Nsg. Intervention – those activities carried out on the order of a physician, under a physician’s supervision, or according to specific routines.
Interdependent/Collaborative – those activities the nurse carries out in collaboration or in relation with other members of the health care team.
3. Write a Nursing Care Plan
- a written summary of the care that a client is to receive.
- it is the “blueprint” of the nursing process.
- It is nursing centered in that the nurse remains in the scope of nursing practice domain in treating human responses to actual or potential health problems.
- It is s step-by-step process as evidence by:
- 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, which is the justification or reason for carrying out the intervention.
- Evaluation must address whether each goal was completely met, partially met or completely unmet.