NURSING PROCESS

MAJ DAYAO NC
Planning
Planning

⦿ the third step of the nursing process

⦿ Includes:
⌾ the formulation of guidelines that establish the proposed
course of nursing action in the resolution of nursing
diagnoses
⌾ and the development of the client’s plan of care.
The Planning Process

Setting/ Setting Goals Planning

Establishing and Expected Nursing
Priorities Outcomes Interventions
 Setting Priorities According to:

⦿ Methods of Prioritizing:

⌾ High-priority nursing diagnoses

⌾ Intermediate-priority nursing diagnoses

⌾ Low-priority nursing diagnoses

 Setting Priorities According to:

⦿ ABCs (Airway, Breathing, Circulation)

⦿ Maslow’s Hierarchy of Needs
⦿ Client’s Perception, Values, Culture and Beliefs
⦿ Consider also:
⌾ Effects of high risk problems
⌾ Costs, resources, available personnel, time needed
Critical thinking enables the nurse to make decisions
about which diagnoses are the most important and
need attention first!!!
 Maslow’s Hierarchy of Needs
and Priority Setting
-Problems interfering with ability to maintain
physiological life processes, such as ability to
breath, maintaining patent airway, maintaining
adequate circulation.

Priority 1: - Problems interfering with hemostatic

physiological responses within the body like
Physiologic Needs respiration, circulation, hydration.

- Problems interfering with ability to be free of

offensive stimuli such as pain, nausea, and other
physical irritation.

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 Maslow’s Hierarchy of Needs
and Priority Setting
- Problems interfering with safety and security
Priority 2: such as anxiety, fear, environmental hazards,
Safety and Security physical activity deficit, violence towards self
and others.

-Problems interfering with love and belonging such

Priority 3: as sensory perceptual losses, inability to
Love and Belonging maintain family and significant others,
isolation, lost of loved one.

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 Maslow’s Hierarchy of Needs
and Priority Setting
- Inability to perform normal daily activities,
Priority 4:
change in physical structure or function of
Self-Esteem
body part.

Priority 5: - Problems interfering with ability for self-

Self-Actualization actualization, such as, positive assessment of
life events, achieving personal goals.

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Prioritizing the nursing diagnoses
⦿ Health problems that do not fit in the mentioned
categories

⌾ Ex: if acute pain causes breathing problems, managing the

pain may have the higher priority
⌾ Ex: if abnormal lab values are life-threatening, then they
have a higher priority
 Setting Priorities

⦿ Questions to ask when setting priorities: (Actual – Potential

 Which are the problems that must be taken cared of immediately?
(ex. Life threatening)
 Of the problems that you will work today, which will you work on
first... second... third...?
 Which are the problems that you will work to prevent, reduce, or
resolve today?
 Setting Priorities

⦿ Questions to ask when setting priorities:

 Is there a relationship between any of the problems that

necessitates one being resolved before another can be resolved?
 Pain r/t LBM
 Are there any problems that can be worked on the same time?
The Planning Process

Establishing
Planning
Setting Goals and
Nursing
Priorities Expected
Interventions
Outcomes
 Establishing Goals/Expected Outcomes

⦿ Goals

⌾ An aim or an end.

⌾ Broad statement

⌾ Client Centered
 Establishing Goals/Expected Outcomes
⦿ Goals
⌾ Short Term Goal
• An objective that is expected to be achieved within a short time frame,
usually less than a week.
• Ex: Acute Pain r/t tissue trauma of surgical incision

⌾ Long Term Goal

• An objective that that is expected to be achieved over a longer time
frame, usually over weeks or months.
• Ex: Deficient Knowledge regarding postoperative home care r/t
inexperience
 Establishing Goals/Expected Outcomes

⦿ Expected Outcome (Objectives)

 Specific measurable change in a
client’s status that is expected to
occur in response to nursing care.
 An objective criterion for measuring
goal achievement.
 Provides focus for nursing care.
 Guidelines in Writing Goals and Expected
Outcomes

1. Client Centered
 Reflect the client behavior
and responses expected
as a result of nursing
interventions.
 Not the nurses’ goals.
Patient Behavior Vs. Nursing Action

Patient Outcomes Nursing Action

Client will perform deep breathing Assist client to perform deep
exercises three times a day. breathing exercises three times a day.

Offer the patient with urinal every 2

Client will void by 6 pm. hours.
Put on warm blankets and a heating
Client’s temperature will be up to 37C pad on the patient and recheck after 1
within 1 hour. hour.
 Guidelines in Writing Goals and Expected
Outcomes
2. Deriving Outcomes from Nursing Diagnoses.
⌾ For an actual nursing diagnosis, the outcome is a patient
behavior that demonstrates reduction or alleviation of
the problem.

⌾ For risk diagnosis, the outcome is a patient behavior that

demonstrates maintenance of the current health status
or functioning.
 Nursing Diagnosis  Outcome
Nursing Diagnosis
Ineffective Airway Clearance
related to increased pulmonary
secretions as manifested by
wheezing, tachypnea and
ineffective cough
Outcomes
Goal: Client will be able to establish clear
airway.
Objectives:
-Patient’s airway will be free of tracheal mucus
within the next ½ hour.
- Patient will have productive cough by 12
hours.
-Patient will have clear breath sounds in 24
hours.
-Patient will demonstrate proper coughing
techniques with nurse’s supervision within the
next ½ hours.
Nursing Diagnosis  Outcome
Nursing Diagnosis
Constipation related to decrease
activity and bedrest as manifested by
hard to pass stools and no bowel
movement for 5 days
Outcomes
Goal: Client will be able to re-
establish normal bowel pattern by
discharge.
Objectives:
-Patient will have bowel movement by
3 pm today after Fleet enema.
- Patient will have bowel movement
tomorrow without use of enema.
 Guidelines in Writing Goals and Expected
Outcomes
Specific:
 Singular Goal or Outcome
 Should address only one behavior or
response to ensure precise method of
evaluation.
• Ex: Wrong > Client’s pain scale will
decrease from 8/10 to 6/10, and anxiety
will decrease into a manageable level.
 Guidelines in Writing Goals and Expected
Outcomes
Measurable:
 Gives the nurse a standard
against which to measure the
client’s response to nursing care.
 Means to quantify changes in
client’s health status.
 Components of an Outcome Statement
⦿ Some of the Measurable Verbs ⦿ Non-measurable Verbs
⌾ Identify  Increase in
⌾ Describe ⌾ Know
 Decrease in

⌾ Perform  Absence of ⌾ Understand

⌾ Relate  Eat
⌾ Appreciate
 Cough
⌾ State ⌾ Think
 Walk
⌾ List
 Stand ⌾ Accept
⌾ Ambulate
⌾ Demonstrate
 Communicate
⌾ Feel
 Verbalize
⌾ Share
 Guidelines in Writing Goals and Expected
Outcomes
Attainable:
 More attainable or achievable
when you mutually set them with
client

This Photo by
Unknown Author
is licensed under
CC BY-ND
 Guidelines in Writing Goals and Expected
Outcomes
Realistic:
 Realistic and relevant for
patients
 Consider patient’s
preferences and needs and
the resources of health care
agency, family and patient
 Guidelines in Writing Goals and Expected
Outcomes

Time Bound:
 Indicates when the change should
occur.
 Shows if progress is being attained at
a reasonable rate.
 Guidelines in Writing Goals and Expected
Outcomes
Has the following characteristics

S = pecific
M = easurable
A = ttainable
R = ealistic
T = ime Bound
 Guidelines in Writing Goals and Expected
Outcomes
Has the following characteristics

S = pecific
M = easurable
A = ttainable
R = ealistic
T = ime Bound
Example

⦿ “ Client will independently monitor daily blood glucose levels

using specified electronic device by 4/24”.

⦿ Formulate Nsg Dx and a SMART plan

⌾ pain
⌾ lack of knowledge
⌾ fever
Components of an Outcome Statement

Performance
Behavior
Subject Criteria / Condition Time
(verb)
(Who) Measure (How) When
(What)
(How well)
Describe in
Desired observable and Under which the When the
The patient behavior for measurable term behavior should behavior
the patient (how long, how occur should occur
much, how far)
Example:

Will Proper coughing With nurses’ Within the

The patient
Demonstrate technique supervision next ½ hour.
Components of an Outcome Statement

Performance
Behavior
Subject Criteria / Condition Time
(verb)
(Who) Measure (How) When
(What)
(How well)
Example:

By noon, April
The patient Will drink 300 ml of water unassisted
20, 2009
Components of an Outcome Statement

Performance
Behavior
Subject Criteria / Condition Time
(verb)
(Who) Measure (How) When
(What)
(How well)
Example:

After 2 hours
The patient’s
Will reduce From 9/10 to 5/10 ------ of nursing
pain scale
intervention
Common Mistakes When Writing Patient
Outcomes / Goals
Incorrect Example
Focus on nursing action. “Offer Mr. Smith 60 ml fluid every 2 hours
while awake.”
Unrealistic goal for the client. “Mr. Polo will stop smoking in 2 days.”
Lacks time frame.
“Mrs. Kitty will ambulate 10 feet unassisted.”

More than one task or behavior to

“Patient will list alternative activities for
be accomplished in one goal
smoking and stop smoking.”
statement.
Use of verbs that are not
“Mrs. Lopez will know how to bathe her
measurable or observable.
newborn after 15 minutes of health teaching.”
The Planning Process

Establishing
Planning
Setting Goals and
Nursing
Priorities Expected
Interventions
Outcomes
Implementation
 Designing Nursing Interventions

⦿ Nursing Interventions
⌾ Any treatment or action based on clinical judgement and
knowledge that nurses perform to enhance client’s
outcome.

⌾ Actions nurses take to help the client meet the established

goals and client objectives.
6 Important Factors:
⦿ Desired Patient Outcomes
⦿ Characteristics of the Nursing Diagnoses
⦿ Research Base
⦿ Feasibility
⦿ Acceptability to the Patient
⦿ Capability of the Nurse

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 Designing Nursing Interventions
⦿ Nursing Interventions Must:
 Be safe for the patient
 Be congruent with other therapies
 Be based on the etiology part of nursing diagnosis.
 Consider achieving lower level survival needs before higher level needs.
 Be realistic.
• For the patient (age, strength, disease, willingness)
• Number of hospital staff; skills of the nurse
• Available equipment
Designing Nursing Interventions

⦿ Types of Nursing Interventions

⌾ Nurse-initiated
⌾ Physician Initiated
⌾ Other provider initiated
(Collaborative Interventions)
Designing Nursing Interventions
⦿ Types of Nursing Interventions
⌾ Nurse-initiated
• Autonomous and independent
response of the nurse to the
client’s health care needs and
nursing diagnosis.
• Actions within the Scope of
Nursing Practice
Nurse Initiated Nursing Interventions:

Health teaching and health promotion.

Health counselling to help clients make informed choices.

Referrals to other nurses or health care professionals.

Specific nursing interventions: ambulating, turning,
positioning
Providing support, comfort, encouragement.
Assessment of patient status or response after treatments
ordered by physicians, nurses and other health care professional.
Designing Nursing Interventions

⦿ Types of Nursing Interventions Wound Dressing

Change
⌾ Physician Initiated
• Based on physician’s response to
treat or mange medical diagnosis.
Administering
• Requires specific nursing Medications
responsibilities and technical
Orders for
nursing knowledge. Laboratory
Procedure
Designing Nursing Interventions

⦿ Types of Nursing Interventions

⌾ Other provider initiated
(Collaborative Interventions)
• Requires knowledge, skill and
expertise of multiple health
care professionals.
Evaluation
 Evaluation

⦿ the fifth step in the nursing process, involves

determining whether the client goals have
been met, partially met, or not met.

⦿ Determines if after the application of nursing

process, the client’s condition or well-being
improves.
 Evaluation Process

Compare Understanding
Examine the results of care achieved effects patient situation,
Recognize errors
according to clinical data with goals and participating in
or omissions
collected expected self-reflection and
outcomes correcting errors

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Evaluative Measures to Determine Success f Goals and
Expected Outcomes

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Objective Evaluation of Goal Achievement

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 It nurse uses the judgments about
goal achievement to determine
whether the care plan was effective
in resolving, reducing or preventing
client problems
After drawing conclusions about the
status of the clients problems, the
nurse modifies the care plan as
indicated

Whether or not goals were met,

there are a number of decisions to
make about continuing, modifying or
terminating nursing care for each
problem
 Evaluation of Goal Achievement
Goal Met Goal Partially Met
Goal Not Met

Review Nursing Process and Plan of Care

• Problem Resolved Reassessment • Problem still exists
• No New Problems • New Problems
• Client not at Risk for Evaluate Goal diagnosed
Reoccurrence Achievement • Client at risk for
• Maximal Level of reoccurrence
Functioning is Reached Implement • Maximal level of
functioning not achieved
Replanning: new goal, new intervention, continue plan
End of Nursing Care
 Guidelines in Writing an
Evaluative Statement
Actual
Outcome Met Patient
Outcome Partially Behavior as Outcome
Evidence Evaluative
Met Statement
Outcome Not Met

Nursing Diagnosis: Impaired Skin Integrity r/t prolonged pressure as manifested by skin breakdown
over sacrum and coccyx
Outcome Statement: 03/20/24: Pressure ulcer will be healed in 1 month without complications.
Outcome Evaluation: (done on 04/20/24)
- Outcome Met: Pressure ulcer healed
- Outcome Partially Met: Pressure ulcer is still present but ½ in size.
- Outcome not Met: Pressure ulcer broken open and draining.
DOCUMENTATION
 Methods of Documentation

Method Description
Narrative Traditional method of nursing documentation; a story format describing
Charting the client’s status, interventions, treatments and the client’s response to
treatments.
Problems SOAP (Subjective, Objective, Analysis, Planning)
Oriented SOAPIE (Subjective, Objective, Analysis, Planning, Intervention,
Charting Evaluation)
(POMR or SOAPIER (Subjective, Objective, Analysis, Planning, Intervention,
POR) Evaluation, Re-evaluation)
Focus Charting Include data, action and response.
Elements of Effective Documentation

Use common vocabulary Write legibly and

– improves intra team neatly – lessens
vocabulary and lessen the chance of errors
misunderstanding

Follow factual Use authorized

and time abbreviations
sequenced and symbols
organization
Document accurately
(factual, descriptive,
Treat all client information in
observations); including any
CONFIDENTIAL and
ERRORS that occurred
PROFESSIONAL MANNER
References:

⦿ Potter & Perry. 10th edition. Fundamental of Nursing.

⦿ Kozier & Erb. 10th edition. Fundamental of Nursing.
⦿ Taylor, Lillis, Lyn. 8th edition. Fundamental of Nursing.

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Thank you!