Nursing process planning

• Nursing Process


  The nursing process consists of five steps: Assessment, Diagnosis, Planning, Implementation, Evaluation

  
• Nursing Process Steps

  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation

  
• ADPIE

  An easy way to remember the components of the nursing process
• Planning

  Formulating client goals (short or long-term) and designing the nursing interventions required to prevent, reduce or eliminate the client's health problems

  
• Nursing Care Plans

  • Provide a course of direction for personalized care tailored to an individual's unique needs
  • Enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum

  
• Types of Planning

  • Initial Planning
  • Ongoing Planning
  • Discharge Planning
• Initial Planning

  1. Done by the nurse who conducts the admission assessment

  2. The same nurse would create the initial comprehensive plan of care

  
• Ongoing Planning

  1. Done by all the nurses who work with the client

  2. As a nurse obtains new information and evaluates the client's responses to care, they can individualize the initial care plan further

  3. Occurs at the beginning of a shift to determine if the client's health status has changed, set priorities, decide which problem to focus on, and coordinate with nurses

  
• Discharge Planning

  1. The process of anticipating and planning for needs after discharge

  2. Start discharge planning for all clients when they are admitted

  3. Involve the client and the client's family or support persons

  4. Collaborate with other health care professionals to ensure biopsychosocial, cultural, and spiritual needs are met
• Planning Process

  1. Setting priorities - Nurse decides which nursing diagnosis requires attention first

  2. Establishing client goals/desired outcomes - Short-term and long-term goals

  3. Selecting nursing interventions and activities - Independent, dependent, collaborative

  4. Writing individualized nursing interventions on care plans

  
• Characteristics of a well-stated outcome criteria

  • Specific, Measurable, Attainable, Realistic, Time-framed
• Nursing Interventions

  • Independent - Activities done by nurses using their knowledge and skills
  • Dependent - Activities carried out under the orders or supervision of a licensed physician
  • Collaborative - Actions the nurse carries out in collaboration with other health care practitioners
• A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks

  
• Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes
• Without the nursing care planning process, the quality and consistency of patient care would be lost
• Components of a Nursing Care Plan

  • Nursing Diagnosis
  • Cues
  • Goals and Outcomes Criteria
  • Nursing Actions and Nursing Orders
  • Rationale of Nursing Orders
  • Evaluation

  
• Evaluation

  • Goal Met
  • Goal Partially Met
  • Goal Not Met
• Rationale of Nursing Orders

  • Independent (Cite reference)
  • Dependent (Cite reference)
  • Interdependent/Collaborative (Cite reference)
• Nursing Actions and Nursing Orders

  • Independent
  • Dependent
  • Interdependent/Collaborative

  
• Goals and Outcomes Criteria

  • General
  • Specific (Cite reference)
• Nursing Diagnosis

  • Subjective
  • Objective (Nanda)