Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4
PLANNING
Deliberative, systematic phase of the
nursing process that involves decision-
making and problem-solving.
Serve as reference and guide of nurses in
formulating client goals and designing
nursing interventions are:
 Client's assessment data
 Diagnostic statements
ls a nursing behavior in which client
centered goals are established and
interventions are designed to achieve the
goals.
During planning nurses set priorities,
determine goals, develop expected
outcomes, and formulate a plan of care.
Nursing Intervention - "any treatment,
based upon clinical judgment and
knowledge, that a nurse performs to
enhance patient/client outcomes"
(Bulechek, Butcher, Dochterman, &
Wagner, 2013, p. xv).
Types of Planning
1. Initial Planning
- The planning completed shortly
after the initial (usually the
admission) assessment
Purpose:
 to develop the patient's
individualized initial
comprehensive care plan
 Developed by the nurse who
performs the admission nursing
history and the physical
assessment
 Comprehensive plan that
addresses each problem listed in
the prioritized nursing diagnosis
and identifies appropriate patient
goals and the related nursing care
2. Ongoing Planning
- Planning done by all nurses who
work with the patient.
- Occurs as nurses obtain new
information and evaluate client's
responses to care
- It also occurs at the beginning of a
shift as the nurse plans the care
to be given that day.
Purpose:
 to individualize the patient's initial
care plan even more/ furthermore
than the initial planning
1
- Using ongoing assessment data,
the nurse carries out daily
planning for the following
purposes:
(1) To determine whether the client's
health status has changed
(2) To set priorities for the client's
care during the shift
(3) To decide which problems to
focus on during the shift
(4) To coordinate the nurse's
activities so that more than one
problem can be addressed at
each client contact
3. Discharge Planning
- Planning started on the initial
(usually the admission)
assessment
- A crucial part of a comprehensive
health care plan and should be
because more often than not,
people are sometimes discharged
still needing care
Purpose:
 to anticipate and plan for the
needs of the patient after
discharge
4. Client Care Plan
- End product of the planning phase
5. Informal Nursing Care Plan
- Is a strategy for action that exists
in the nurse's mind.
Example: The nurse may think, "Mrs.
Phan is very tired. I will need to
reinforce her teaching after she is
rested.''
6. Standardized Care Plan
- A formal plan that specifies the
nursing care for groups of clients
with common needs
Example: all clients with myocardial
infarction
7. Individualized Care Plan
- is tailored to meet the, unique
needs of a specific client
- Needs that are not addressed by
the standardized plan.
- Caregivers must use approaches
shown to be effective with a
particular client
*When nurses use the client’s, nursing
diagnoses to develop goals and nursing
interventions, the result is holistic
individualized plan of care that will meet
the client’s unique needs*
During the Planning Phase
The nurse must:
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4
(a) decide which of the client'§ problems
need individualized plans and which
problems can be addressed by
standardized plans and routine care,
(b) write individualized desired outcomes
and nursing interventions for client
problems that require nursing attention
beyond preplanned, routine care.
Simple documents needed in a
Complete Plan of Care
- Routine care -needed to meet basic
needs Example: bathing, nutrition
- Care that address the client's nursing
diagnoses and collaborative
problems
- Documents that specify the nurse
responsibilities if carrying out the
medical plan of care
Example: keeping the client from
eating or drinking before surgery;
scheduling a laboratory test)
Standards of Care
- Describe nursing actions for clients
with similar medical conditions rather
than individuals, and they describe
achievable rather than ideal nursing
care
- Define the interventions for which
nurses are held accountable; do not
contain medical interventions
Example: a nurse might write "See
unit standards of care for cardiac
catheterization"
- May or may not be organized
according to problems or nursing
diagnoses
Standardized Care Plans
- Are kept with the client's individualized
care plan nursing Unit
> Upon discharge - becomes part of
the permanent medical record.
- Provide detailed interventions and contain
additions or deletions from the standards of
care of the agency.
- Typically, are written in the nursing
process format: Problem > Goals/Desired
Outcomes > Nursing Interventions
>Evaluation
- Frequently include checklists, blank lines,
or empty spaces to allow the nurse to
individualize goals and nursing intervention
2
- Standardized care plans are used by '
nurses for predictable, commonly occurring
problems Example Case: Patient with
pneumonia
 Deficient Fluid Volume direct nurses
to assess for hydration status of the
patient
- Individual plans are created by nurses for
unusual problem or problems, needing
special attention
Example:
 Risk for Interrupted Family
Processes
- Predeveloped guides for the nursing care
of a client who has a need that arises
frequently in the agency
Example:
 a specific nursing diagnosis or all nursing
diagnoses associated, a particular
medicinal-condition
- Written from the perspective of what care
the client can expect
Protocols
- Are predeveloped to indicate the
actions commonly required for a
particular group of clients
- May include both the primary care
provider's orders and nursing
interventions
Example:
 Admitting a client to the intensive
care unit
 Caring for a client receiving
continuous epidural analgesia
- Depending on the agency, protocols
may or may not be included in the
client's permanent record.
Policies and Procedures
- Are developed to govern the handling
of frequently occurring situations
Example: a policy specifying the
number of visitors a client may have.
- Are similar to protocols and specify
what is to be done
Example: in the case of cardiac
arrest
- Policies are institutional records and
do not become a part of the care plan
or permanent record.
- If a policy covers a situation pertinent
to client care, it is usually noted on
the care plan
Example: "Make social service
referral according to Policy Manual''
Standing Order
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4
- A written document about policies,
rules, regulations, or orders regarding
client care.
- It gives nurses the authority to carry
out specific actions under certain
circumstances, often when a primary
care provider is not immediately
available
1. In a hospital critical care unit
- a common example is the
administration of emergency
antiarrhythmic medications when
a client's cardiac monitoring
pattern changes
2. In a home care setting
- a primary care provider may write
a standing order for the nurse to
obtain blood tests for a client who
has been on a certain therapy for
a prescribed amount of time
3
• Which problems are my responsibility and
which should I refer to someone else?
• Which problems are the most important to
the patient?
• Which problem has the highest level of
need based on Maslow's Hierarchy?
Basic needs must be met before a person
can focus on higher ones; patient needs
may be prioritized according to Maslow’s
Hierarchy.
- Physiologic
- Safety
- Love and belonging

- Self esteem
Planning Purposes and Activities
- Self actualization
Purposes

- Direct client care activities

High-priority Nursing Diagnosis
- Promote continuity of care
- are life-threatening and require immediate
- Focus charting requirement action

- Allow for delegation of specific activities Example:

Activities
• Ineffective airway clearance
- Plan nursing interventions plan
• Ineffective breathing pattern
- Write a nursing plan of care
• Decreased cardiac output

Four stages of the planning process

Medium-priority Nursing
Stage One: Setting Priorities Diagnoses

• During this step of this stage - are health-threatening and require prompt
action
- the nurse prioritizes nursing
diagnoses by grouping them, typically by Example:
utilization of a framework such as Maslow's
• Impaired skin integrity
hierarchy of needs, according to whether
they are of
• Constipation
• High, Medium, or Low-priority
• Diarrhea

Establish Priorities

• Which problems require my immediate

Low-priority Nursing Diagnoses
attention?
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4 4
- are not life-threatening or health- - Promote client participation
threatening and require timely action
- Plan care that is realistic and measurable
Example:
- Select evidenced based nursing care
• Interrupted breast-feeding
- Communicate the plan of care
• Self-care deficit: dressing/grooming

• High risk for loneliness

Components of Goal Statements

Establishing Priorities - Opposite, healthy response of the

problem statement (diagnostic label) of the
• a nurse does not need to resolve all high- nursing diagnosis
priority nursing diagnoses before
addressing medium or low-priority nursing Example:
diagnoses
- Nursing Diagnosis statement: Ineffective
• priorities assigned to nursing diagnoses airway clearance
are not static; they change as a patient's
responses, problems, and therapies - Goal would be "The patient will
change
demonstrate effective airway clearance"
• When prioritizing nursing diagnoses, the
nurse must take into consideration the
following factors:
Relationship of Goals to Nursing
- The patient's health values and beliefs Diagnoses

- The patient's priorities • For every nursing diagnosis,

- Resources available to the patient and - The nurse must write at least one goal
nurse that, when achieved, directly demonstrates
resolution of the problem statement
- The urgency of the patient's health (diagnostic label) of the nursing diagnosis
problem

- The patient's medical treatment plan

Goals of Care

• Must be patient centered

Stage Two: Establishing Patient
Goals/Expected Outcomes • Must reflect the patient's highest level of
functioning
• Goals
• It is a prediction of the resolution of a
- During this step of this stage, the nurse problem
establishes broad statements about the
desired outcome or change in a patient's • Each goal is written with a time limitation,
behavior which depends on the nature of the
problem
Example: ''The patient will demonstrate an
effective airway clearance" - Short term

- Long term

Writing Goals • Are written in terms of “patient will”

• Purpose • When developing goal statements, ask

the following questions:
- Provide individualized care
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4 5
(1) What is the problem statement patients:
(diagnostic label) of the nursing
diagnosis? • Those who require healthcare for a long
(2) What is the opposite healthy time
response of the problem state
(diagnostic label) of the nursing Example:
diagnosis?
those patients in nursing homes, private
Goals must me: homes, extended care facilities,
rehabilitation center
R- Realistic

U- Unambiguous
Stage Two: Establishing Patient
M- Measurable Goals/Expected Outcomes

B- Behavioral

A-Attainable • Expected Outcomes

T- Time-bound - more specific, measurable statements

about the desired outcome or change in a
patient's behavior that are used to evaluate
whether a goal has been met
S- Specific
Example: "Patient's lung will be clear to
M- Measurable auscultation during the entire postoperative
period"
A- Attainable

R- Realistic
Components of Expected Outcome
T- Time-bound Statements

1. The Subject

Short-term goals -the patient

• Are goals that generally require less than -any part of the patient
a week to achieve and are useful for the
following patients: Example: the patient's ankle

- Those who require health care for a short
time
Example: hospitalized patients
- Those who are frustrated by long-term
goals that seem difficult to obtain
- Those who need the satisfaction of
achieving a short-term goal
-some attribute of the patient
Example: the patient's urinary output
2. The Verb
-the action the patient is to perform; what
the patient is to do, learn, or experience
Example: action verbs such as
administer, show, walk, drink, choose

3. The Conditions or Modifiers

-The circumstances under which the

Long-term goals behavior is to be performed (how, where,
what, and when)
-Are goals that generally require more than
a week to achieve and How = Example: "Walks with the
help of a walker'
are useful for the following
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4
Where= Example: "When at home,
maintains; weight at existing level"
What= Example: "Discusses four
food groups and recommended daily
servings"
When= Example: "After attending two
group diabetes classes, lists signs and
symptoms df diabetes"
4. The criterion of desired performance
-The standard or level by which a
performance is evaluated or the level at
which the patient will perform the specific
behavior (time, accuracy! time and distance,
quality)
-Time= Example: "weighs 75 kg by
April 25''
-Accuracy= Example: "lists five out of
six signs of, diabetes"
-Time and distance= Example: "walk
one block per day"
-Quality = Example: “administers
insulin using aseptic technique"
Relationship of Expected Outcome
Statements to Nursing Diagnosis
• Expected outcome statements are derived
by stating the expected outcomes as the
opposite of the problem statement
(diagnostic label) of the nursing diagnosis
Example: Nursing Problem (diagnostic
label) I Ineffective Airway Clearance:
-An expected outcome might be "the
patient’s lungs will be clear to auscultation
during the entire postoperative period"
• For every nursing diagnosis, the nurse
must write at least one expected outcome
statement that when achieved, directly
demonstrates resolution of the problem
statement (diagnostic label) of the nursing
diagnosis
• When developing goal/expected outcome
statements, ask the following questions:
-How will the patient look of behave if
the opposite, healthy response of the
problem statement (diagnostic label) of the
nursing diagnosis is achieved?
6
-What must the patient do and how
well must the patient do it to demonstrate
resolution or the capacity of resolving the
problem statement (diagnostic label) of the
nursing diagnosis?
• A patient's care plan usually reflects both
goals/expected outcomes which are usually
combined in one statement by the words
"as evidenced by"
Example: "the patient will demonstrate
effective airway clearance, as evidenced by
his/her lungs being clear to auscultation
during the entire postoperative period"
Guidelines for Writing Goals/Outcomes
• Write goals/expected outcome statements
in terms of patient behavior
• Make sure the goal statement is
appropriate for the nursing diagnosis
• Be sure that the goals/expected outcomes
are realistic for the patient's capabilities,
limitations, and designated time span if it is
indicated
• Make sure the patient considers the
goals/expected outcomes important and
values them
• Ensure that the goals/expected outcomes
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 outcomes, use
observable, measurable terms; avoid terms
that are vague and require interpretation or
judgment by the observer
Writing Measurable Goals
• To be measurable, outcomes need:
-Subject: the patient or some part of
the patient
-Verb: indicates the action the patient
will perform
-Performance criteria: describe in
observable, measurable, terms the
expected patient behavior or manifestation
-Target time: specifies when the patient
is expected to be able to achieve the
outcome
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4 7
Outcome Examples: 2. Action verb
Example: "5/16/02 Measure and
1. Nursing Diagnosis: Pain; Outcome: The record the posterior tibial pulse of the
patient will report a decrease in pain from left ankle daily at 0900 x's 48 hrs. S.
an 8 on the pain scale to a 4 within 30 Yeager, RN"
minutes 3. Content area (what, where)
What
2. Nursing Diagnosis: Imbalanced Nutrition: Example: "5/16/02 Measure
More than body requirements; Outcome: By and record the posterior tibial pulse
5/5/07, patient will reach target weight of of the left ankle daily at 0900 x's 48
122 tbs hrs. S. Yeager, RN"
Where
3. Nursing diagnosis: Impaired mobility; Example: "5/16/02 Measure
Outcome criteria: before dismissal, patient and record the posterior tibial pulse
dismissal, patient will ambulate the length of the left ankle daily at 0900 x’s 48
of the hallway independently hrs. S. Yeager. RN"
4. Time element
Long-Term vs. Short-Term Outcomes When
Example: "5/16/02 Measure
Long-term outcomes require a longer and record the posterior tibial pulse
period of time. Typically, long-term goals of the left ankle dally at 0900 x's 48
require more than a week to resolve. May hrs. S. Yeager, RN’'
be used as dismissal goals How long
Example: 5/16/02 Measure
Short term goals can be hours to days and record the posterior tibial pulse
usually less than a week of the left ankle dally at 0900 x's 48
hrs. S. Yeager, RN"
How often
Example: 5/16/02 Measure
Helpful Verbs for Measurable Outcomes
and record the posterior tibial pulse
• Define • Describe of the left -ankle daily at 0900 x's 48
hrs. S. Yeager, RN"
• Prepare • Choose 5. Signature
Example: "5/16/02 Measure
• Identify • Explain and record the posterior tibial pulse
of the left ankle daily at _0900 x's 48
• Design • Select apply hrs. S. Yeager, RN"

• List • Demonstrate
Relationship of Nursing Strategies
• Verbalize (Interventions), Written as Nursing
Orders, To Nursing Diagnoses
•Nursing strategies (interventions) for
actual, high-risk (potential) and possible
Stage Three: Selecting Nursing nursing diagnoses focus on reducing or
Strategies {Interventions) eliminating etiology (related or risk
factors) of the problem statement
• During this step of this stage, the nurse (diagnostic label)
establishes the nursing activities relating to - (diagnostic label) ineffective
a specific nursing diagnosis to be carried airway clearance.
out to achieve patient goals/expected - (intervention) might be
outcomes "9/15/1J2 encourage patient
to drink at least 2000 ml of
Components of nursing strategies fluid daily if not
(interventions) statements, which are contraindicated by cardiac
written as nursing orders or renal disease. S. Yeager,
RN
1. Date -To reduce or eliminate the
Example: "5/16/02 Measure and etiology (related or risk
record the posterior tibial pulse of the factor) of excessive, thick
left ankle daily at 0900 x's 48 hrs. S. tracheobronchial secretions
Yeager, RN"
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4
Interventions
Three Categories:
(1) Nurse Initiated Interventions
(2) Physician Initiated Interventions
(3) Collaborative Interventions
Nurse initiated- those interventions
a nurse can independently initiate to
manage a client’s healthcare needs
Physician initiated- involves specific
nursing responsibilities, scientific and
nursing knowledge and technical
competence (implementing and
invasive procedure)
Collaborative Intervention –
requires the combined knowledge, skill, and
expertise of multiple healthcare
professionals, PT, OT, nursing aid, nurse,
physician
•Any treatment based on clinical judgment
and knowledge that a nurse performs to
enhance patient outcomes
• An autonomous action based on scientific
rationale that a nurse executes to benefit
the patient in a predictable way related to
the nursing diagnosis and projected
outcomes
• Actions performed by the nurse to:
-Monitor health status
-Reduce risks
-Resolve, prevent, or manage a problem
-Facilitate independence or assist with
ADL's
-Promote optimal sense of physical,
psychological and spiritual well being
Using Evidenced Based Nursing
Interventions
• Determine what nursing science suggests
is the likelihood that this particular
intervention will help patient realize his or
her expected outcome?
• How can I tailor my interventions to
increase the benefit the patient?
• How likely is harm to result from this
intervention and how can I minimize the risk?
8
Identifying and Selecting Appropriate
Interventions
• Interventions must be directed toward
altering the signs and symptoms associated
with the diagnosis
• Outcomes are stated in measurable terms
• Use research to determine the
effectiveness of this intervention
• Consider the possibility of the interaction
with other interventions (cost and time
involved)
• Is the intervention acceptable to the
patient
• Can the intervention be carried out
Well Written Interventions
• They must meet specific criteria
• They must be concise and describe a
nursing action (answers who, what, where,
when, and how)
• They must be dated when written and
when the plan of care is reviewed
• Must be signed by the RN who assist with
the implementation
• Use only accepted abbreviations
Examples of interventions
Offer the patient 60 ml of water or juice q 2
hours while awake for a total minimum PO
intake of 500 mL
• Assist patient to the bathroom for toileting
z 2 hours while awake
Standardized Care Plans
• Prepared plans of care that identify the
nursing diagnosis, outcomes, and related
nursing interventions common to a specific
population or health problem
• Nurse must individualize plan of care and
direct time limitations
Communicating the Plan of Care
• Does this plan of care adequately address
the patient's priorities today?
• Is this plan of care individualized to my
patient
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4
• Can anyone reading plan of care know
how to intervene effectively with this patient?
• Does the Patient understand and agree
with the plan of care?
Consultations
• Vital part of care planning
• Use when you need to seek another care
giver for resources
• Always give unbiased information
• Be available for discussion
• incorporate the recommendations into the
care plan
Implementation
Implementing - Nursing actions planned
in-the previous step are carried out
Purpose:
- To assist the patient in achieving valued
health outcomes
- To promote health
- To prevent disease and illness
- To restore health
-To facilitate coping with altered function
• implementation includes:
-performing, assisting, or directing
-performance of activities of daily
living,
-counseling and teaching the client or
family
-providing direct care.
-Delegating and supervising
-Evaluating the work of staff
members
-Recording and exchanging
information relevant to the client's
continued healthcare
Activities of implementation
9
• Organize resources and care delivery
• Anticipate and prevent complications
• Communicate nursing interventions
• Reassess
• Review and revise the care plan
Reassessment
• Provides a way for you to determine
whether the proposed nursing action is still
appropriate for the client’s level of wellness
• It occurs each and every time you enter a
patient’s room
Example: You plan to ambulate a patient
following lunch. You enter the room and
find the patient short of breath and
increased fatigue, and must assist the
patient back to bed
Revising the Care Plan
• Revise the assessment data to reflect the
change
• Revise the nursing diagnosis
• Revise specific interventions
Anticipate and Prevent Complications
• Know pathophysiology of disease process
to help identify complications early
• Identify areas where assistance is needed
-Situations requiring additional
personnel vary
-You may need additional knowledge
-Check facilities policies caring for
patients
Communication of Nursing interventions
Remember: If it wasn't documented, it was
not done
• Document all nursing interventions
• Document the patient’s response to the
intervention
Evaluation
Basic Concepts of Nursing Notes By Lovely Jovellanos BSN 1-4 10
• Critical thinking skills • Modify the care plan after reassessment,
new nursing diagnosis, goal, and expected
• Five steps of objective evaluation outcomes

- Identify evaluative criteria and Skills Needed to Evaluate the Care Plan
standards
- Collect data • Knowledge of standards of care
- Interpret and summarize findings
- Document findings • Knowledge of normal patient responses
- Terminate, continue, or revise the
care plan • Ability to monitor effectiveness of nursing
interventions
• During this phase, the nurse and the
patient together. Measure how well the • Awareness of clinical research
patient has achieved the outcomes
specified in the plan of care Care Plan Revision and Critical Thinking

Purpose of Evaluation • Discontinuing a care plan

• Collect data to evaluate nursing care • Modifying a care plan

• Examine patient's response to nursing -Reassessment

interventions
-Nursing diagnoses
• Compare client’s response with outcome
criteria -Goals and expected outcomes

• Appraise extent to which patient goals -Interventions

were met
• Appropriateness of care
• Appraise involvement and collaboration of
others in healthcare decision • Correct application of
interventions
• Provide basis for revisions of care plan

• Monitor quality of nursing care and its

effect on client's health state

Evaluation Activities

• Review client goals and outcome criteria

• Collect data

• Measure goal attainment

• Record appraisal or measurement of goal

attainment

• Revise or modify nursing plan of care if

indicated

• Is the goal fully met? partially met? or not

met at all?

What to do After Evaluation?

• Discontinue the care plan to ensure other

nurses will not unnecessarily continue an
outdated plan