Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

BACHELOR OF SCIENCE IN NURSING

College of Health Sciences
1ST SEMESTER S/Y 2021-2022
NURSING PROCESS
Module 3: PLANNING
Learning Outcomes:
After completing this module, you will be able to:
1. Identify activities that occur in the planning process.
2. Compare and contrast initial planning, ongoing planning, and discharge planning.
3. Explain how standards of care and predeveloped care plans can be individualized and used in creating a
comprehensive nursing care plan.
4. Identify essential guidelines for writing nursing care plans.
5. Identify factors that the nurse must consider when setting priorities.
6. Discuss the Nursing Outcomes Classification, including an explanation of how to use the outcomes and
indicators in care planning.
7. State the purposes of establishing client goals/desired outcomes.
8. Identify guidelines for writing goals/desired outcomes.
9. Describe the process of selecting and choosing nursing interventions.
10. Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and
activities in care planning.

Introduction
Planning is a deliberative, systematic phase of the nursing process that involves decision making and
problem solving. In planning, the nurse refers to the client’s assessment data and diagnostic statements for
direction in formulating client goals and designing the nursing interventions required to prevent, reduce, or
eliminate the client’s health problems.
Although planning is basically the nurse’s responsibility, input from the client and support persons is
essential if a plan is to be effective. Nurses do not plan for the client, but encourage the client to participate
actively to the extent possible.

Types of Planning
1. Initial Planning
 Planning should be initiated as soon as possible after the initial assessment
 Planning which is done after the initial assessment.
2. Ongoing Planning
 It is a continuous planning
 Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be given
that day.
 Using ongoing assessment data, the nurse carries out daily planning for the following purposes:
 To determine whether the client’s health status has changed
 To set priorities for the client’s care during the shift
 To decide which problems to focus on during the shift
 To coordinate the nurse’s activities so that more than one problem can be addressed at
each client contact.
3. Discharge Planning
 the process of anticipating and planning for needs after discharge, is a crucial part of a
comprehensive health care plan and should be addressed in each client’s care plan.
 Planning for needs after discharge
Planning Process
In the process of developing client care plans, the nurse engages in the following activities:
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and activities
• Writing individualized nursing interventions on care plans.
1. Setting priorities
 The Nurse begin planning by deciding nursing diagnosis requires attention first, which
second, and so on.
 Priority setting is the process of establishing a preferential sequence for addressing
nursing diagnoses and interventions.
 The nurse frequently uses Maslow’s hierarchy of needs when setting priorities.

2. Establishing Client Goals/Desired Outcomes

 After establishing priorities, the nurse set goals for each nursing diagnosis. Goals may be
short term or long term.
 The terms goal and desired outcome are used interchangeably in this text, except when
discussing and using standardized language.
Example:
Goal (broad) = Improved Nutritional Status
Desired Outcome (Specific) = Gain 5 lbs. by April 25
Short Term and Long-Term Goal
 Goals may be short term or long term. A short-term goal might be “Client will raise right
arm to shoulder height by Friday.” In the same context, a long-term goal/outcome might
be “Client will regain full use of right arm in 6 weeks.”
 Short-term goals are useful for clients who
(a) require health care for a short time or
(b) are frustrated by long-term goals that seem difficult to attain and who need the
satisfaction of achieving a short-term goal.
 In an acute care setting, much of the nurse’s time is spent on the client’s immediate
needs, so most goals are short term.

3. Selecting Nursing Interventions and Activities

Nursing interventions and activities are the actions that a nurse performs to achieve client goals.
The specific interventions chosen should focus on eliminating or reducing the etiology of the nursing
diagnosis, which is the second clause of the diagnostic statement.

Types of Nursing Interventions

Nursing interventions are identified and written during the planning step of the nursing process;
however, they are actually performed during the implementing step. Nursing interventions include both
 direct and indirect care, as well as nurse-initiated, physician-initiated, and other provider-initiated
treatments.
 Direct care is an intervention performed by the nurse through interaction with the client.
 Indirect care is an intervention delegated by the nurse to another provider or performed
away from but on behalf of the client such as interdisciplinary collaboration or
management of the care environment.
Independent interventions 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,
counseling, environmental management, and making referrals to other health care professionals.
For Example
An independent action is planning and providing special mouth care for a client after diagnosing Impaired
Oral Mucous Membranes.

Dependent interventions are activities carried out under the orders or supervision of a licensed physician
or other health care provider authorized to write orders to nurses. Primary care providers’ orders commonly
direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity.
For Example:
For a medical order of “Progressive ambulation, as tolerated,” a nurse might write the following:
1. Dangle for 5 min, 12 hours postop.
2. Stand at bedside 24 hours postop; observe for pallor, dizziness, and weakness.
3. Check pulse before and after ambulating. Do not progress if pulse is greater than 110.

Collaborative interventions are actions the nurse carries out in collaboration with other health team
members, such as physical therapists, social workers, dietitians, and primary care providers. Collaborative nursing
activities reflect the overlapping responsibilities of, and collegial relationships among, health personnel.
For Example
the primary care provider might order physical therapy to teach the client crutch-walking. The nurse
would be responsible for informing the physical therapy department and for coordinating the client’s care
to include the physical therapy sessions. The nurse may assist with crutch-walking and collaborate with
the physical therapist to evaluate the client’s progress.

4. Writing Individualized Nursing Interventions

After choosing the appropriate nursing interventions, the nurse writes them on the care plan. Nursing
Care Plan is a written or computerized information about the client’s care.

Prepared by:
Jocyl Darrel B. Abinal, R.M, R.N, MAN
Clinical Instructor

Source: Kozier and Erb’s FUNDAMENTALS OF NURSING, concept, process and practice 10th edition Unit 3, Chapter 13