Planning

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• 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.

Purpose:

• 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:

1. Life-threatening situations should be given highest priority.
2. Use the principle of ABC’s (airway, breathing, circulation)
3. Use Maslow’s hierarchy of needs.
4. Consider something that is very important to the client.
5. Actual problems take precedence over potential concerns.
6. 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.
7. 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.
8. 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.

Nursing interventions

• 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

NCP

• 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:

1. Sufficient data are collected to substantiate nursing diagnosis.
2. At least one goal must be stated for each nursing diagnosis.
3. Outcome criteria must be identified for each goal.
4. Nursing interventions must be specifically designed to meet the identified goal.
5. Each intervention should be supported by a scientific rationale, which is the justification or reason for carrying out the intervention.
6. Evaluation must address whether each goal was completely met, partially met or completely unmet.

Other Nursing Articles you may want to look at:

• NURSING PROCESS by: one of our best professor in NCM (Mrs. Cubon, RN, MAN) The term NURSING PROCESS was first used/mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation. Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE),
• IMPLEMENTATION is putting the nursing care plan into action. Purpose: To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health. Activities: Reassessing – to ensure prompt attention to emerging problems. Set priorities – to determine the order in which nursing interventions
• EVALUATION is assessment the client’s response to nursing interventions and then comparing that response to predetermined standards or outcome criteria. Purpose: To appraise the extent to which goals and outcome criteria of nursing care have been achieved. Activities: Collect data about the client’s response. Compare the client’s response to goals
• Outcome Identification refers to formulating and documenting measurable, realistic and client-focused goals that will provide the basis for evaluating nursing diagnosis. Purposes: To provide individualized care To promote client participation To plan care that is realistic and measurable To
• Diagnosis - Second Step in the Nursing Process Diagnosing is the 2nd step of the nursing process. the process of reasoning or the clinical act of identifying problems Purpose: To identify health care needs and prepare a Nursing Diagnosis. To diagnose in nursing: it means to analyze assessment information and derive meaning from this analysis. Nursing Diagnosis is a statement of a client’s potential or actual health problem resulting