DOCTOR’S HOSPITAL

COLLEGE OF NURSING
FUNDAMENTAL OF NURSING
UNIT NO:12

THE NURSING PROCESS

BY: IZEN FERNANDUS

THE NURSING PROCESS

➢It is a systematic method that directs the nurse and

patient in planning patient care, and enables you to
organize and deliver nursing care
➢It is patient centered and outcome oriented
➢The steps are interrelated and dependent on the
accuracy of each of the preceding steps
➢It is used to identify, diagnose, and treat human
responses to health and illness.
➢It is universally applicable.
PURPOSE OF NURSING
PROCESS
➢To identify the patient health status and actual or
potential health care problems.
➢To identify potential health needs.
➢To established plan to meet the identify needs.
➢To deliver specific nursing interventions to meet those
needs.
➢To determine weather to continue, modify , or terminate
the plan of care.
PHASES OF THE NURSING
PROCESS

➢Assessment
➢Nursing Diagnosis
➢Planning
➢Implementation
➢Evaluation
CHARACTERISTICS OF THE
NURSING PROCESS

➢Interpersonal or Collaborative
➢Decision Making- based on knowledge-requiring
critical thinking
➢Planned-organized and systematic
➢Client-centered- client habits, routines and needs
➢Goal-directed
➢Prioritized
➢Dynamic or cyclic
DEVELOPING NURSING CARE
PLANS

➢Informal NCP- is a strategy or Action that exist in the nurse mind’s.

➢Formal NCP- is a written or computerized that organizes information
about client’s care.
➢Standardized NCP- is a formal plan that specify the nursing care for
groups of clients with common needs e.g., All MI patients
➢Individualized NCP- is tailored to meet the unique needs of a specify
client-needs that are not addressed by standardized plan.
STANDARDIZED APPROACHES
TO CARE PLAN

• Protocols- are predeveloped to indicate the actions. For

example an agency have a protocol for admitting a client to ICU
• Policies and Procedures- are developed to govern the
handling of frequently occurring situations. E.g., specify the no of
visitors
• Standing Order- is a written document about policies, rules,
regulations or orders regarding client care
FORMAT OF NCP
1. COMPUTERIZED CARE PLAN: THE COMPUTER CAN GENERATE BOTH
STANDARDIZED AND INDIVIDUAL CARE PLAN.
[Link] CARE PLAN:
Assessment Nursing Planning Implementing Evaluation
diagnosis
Nursing Rationales
intervention

1. Subjective Diagnosis 1. Short Independent Outcomes

Data. term intervention met or not
Actual or goals 1. ----- 1.--------
2. Objective potential 2. ----- 2.-------
Data. 2. Long Collaborative
terms Interventions
goals 1. -------- 1. -------
2. .-------- 2.--------
CONCEPT MAP
Is a visual tool in which the data or ideas enclosed in a circles or boxes of
some shapes and relationship between them indicated by connecting lines or
arrows.
MULTIDISCIPLINARY CARE
PLANS

➢Is a standardized plan that outlines the care required for clients with common,
predictable- usually medical conditions. Such plans also to referred to as
Collaborative care plans or critical pathways.
GUIDELINES FOR WRITING
PLAN

➢Date and Sign

➢Use Category headings
➢Use standardized approved medical or English symbols or key words rather
than complete sentence
➢Be specify
➢Refer to procedure or books
➢Refer to client choices
GUIDELINES FOR WRITING PLAN

➢NCP incorporates preventive and health maintenance

aspects as well as restorative ones
➢Include incorporative and coordination activities in the plan
➢Include plans for the discharge and home care needs.
DISCUSS THE REQUIREMENTS FOR
EFFECTIVE USE OF THE NURSING
PROCESS
➢The process should be open and flexible to meet the unique needs
of client , family group or community.
➢It should cyclic or dynamic.
➢It must be client centered.
➢It must be goal directed.
➢It should be planned.
➢It must be interpersonal and collaborative, because it requires the
nurse to communicate directly with the client.
DISCUSS THE REQUIREMENTS
FOR EFFECTIVE USE OF THE
NURSING PROCESS

➢It should permit creativity for the nurse and

client to solve the problem.
➢It should emphasize feedback.
➢It should be universally applicable.
DESCRIBE THE FUNCTIONAL HEALTH
APPROACH TO THE NURSING PROCESS

➢ Gordon's functional health patterns is a method used by

nurses in the nursing process to provide a more comprehensive
nursing assessment of the patient.
➢ The following areas are assessed through questions asked by the
nurse and medical examinations to provide an overview of the
individual's health status and health practices that are used to reach
the current level of health or wellness
➢ Health Perception and Management
➢ Nutritional / metabolic
DESCRIBE THE FUNCTIONAL HEALTH
APPROACH TO THE NURSING PROCESS

➢ Elimination-excretion patterns and problems need to be

evaluated (constipation , incontinence, diarrhea).

➢ Activity exercise- whether one is able to do daily activities normally

without any problem, self care activities.
➢ Sleep rest- do they have hypersomnia, insomnia, do they have normal
sleeping patterns
➢ Cognitive-perceptual-assessment of neurological function is done
to assess, check the person's ability to comprehend information.
DESCRIBE THE FUNCTIONAL HEALTH
APPROACH TO THE NURSING PROCESS

➢Self perception/self concept

➢Role relationship
➢Sexuality reproductive
➢Coping-stress tolerance
➢Value-Belief Pattern
1ST PHASE

ASSESSMENT
ASSESSMENT
Assessing is the systematic and continuous collection, organization,
validation and documentation of data.
➢It is the process that is done in almost all phases of nursing process.

Types of assessment (Table 11-3):

➢ Initial Assessment
➢ Problem-focused assessment
➢ Emergency assessment
➢ Time-lapsed assessment
DISCUSS THE PURPOSE OF
ASSESSMENT IN NURSING PROCESS
➢ To Establish a database about client's health status.
➢ To understand client's response to illness.
➢ Is used to identify current and future patient care needs.
➢ To identify Client's strength.
➢ To identify need for health teaching.
➢ It incorporates the recognition of normal versus abnormal body
physiology.
➢ Early recognition of changes + skill of critical thinking allows the nurse
to identify and prioritize appropriate interventions.
CONT’D
(PROCESS OF DATA COLLECTION)
The assessment process involves four closely related
activities.
1. Collecting data
2. Organizing data
3. Validating data
4. Documenting data
[Link] OF DATA

Data collection is the process of gathering information about a

client’s status.
➢A Database contains all information about a client. It includes
nursing health history.
Components of nursing health history (Box 11-1)
➢Biographic data.
➢Chief complaint or reason of visit.
➢History of present illness.
➢Past history.
CONT’D

➢Family history of illness.

➢Lifestyle.
➢Social data.
➢Pshychologic data.
➢Patterns of health care
TYPES OF DATA

1. Subjective data from the client also referred to as

symptom or covert data. It includes the client’s
sensation, feelings, values, beliefs, attitudes and perception
of personal health status and life styles.
➢Example: “I have a headache”
2. Objective data observable data also referred to as sign
or overt data
➢Example: Blood Pressure 120/80
3. Constant data is information that does not change
overtime such as race or blood type.
4. Variable data can change quickly, frequently, or rarely
and include such as blood pressure, age, and level of pain.
SOURCES OF DATA

➢Gather Information/Collect Data

➢Sources:
➢Client
➢Support people
➢Client records
➢Health care professionals
➢literature
➢ Primary Source - Client / Family
➢ Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic
tests…..
DATA COLLECTION
METHODS
1. Observing- two aspects
➢ Noticing the data
➢ Selecting, organizing, interpreting

2. Interviewing- is a planned communication or conversation

with purpose
➢ Directive interview
➢ Nondirective Interview
➢ Rapport building interview
TYPES OF INTERVIEW
QUESTIONS
Close Ended- Short Yes or no Begins with “when”,
where, who, what, do or is…

Open ended- to discover, explore, elaborate, clarify

Neutral question- the client can answer without

direction or pressure from the nurse.

Leading question- You are stressed about surgery

tomorrow?
PLANNING THE INTERVIEW
AND SETTING

➢Time
➢Place
➢Seating Arrangement (45 degree angle to the bed)
➢Distance(2 to 3 feet) (Box 11-3)
➢Language
STAGES OF AN INTERVIEW

Three major stages:

1. The Opening:
➢Step 1- Establish rapport
➢Step 2- Orientation
2. The Body- client communicates what he or she thinks
3. The Closing- Nurse Terminates interview
EXAMINING
The physical examination or physical assessment is a systematic data
collection method that uses observation (i.e., the sense of sight,
hearing smell and touch) to detect health problem.
1. General Physical Exam
➢Inspection
➢Palpation
➢Percussion
➢Auscultation
2. Cephalocaudal-Head-to-toe assessment
3. Screening examination-Review of Systems
2. ORGANIZING DATA

The nurses uses a written format that organizes the assessment

data systematically. This is often referred to;
➢Nursing health history
➢Nursing assessment or nursing data-base form.
Nursing conceptual models:
➢Gordon’s functional health patterns
➢Orem’s selfcare model
➢Roy’s adaptation model
GORDON'S TYPOLOGY OF 11
FUNCTIONAL HEALTH PATTERNS
➢ Health Perception and Health Management. Data collection is focused
on the person's perceived level of health and well-being, and on practices for
maintaining health.
➢ Nutrition and Metabolism. Assessment is focused on the pattern of food
and fluid consumption relative to metabolic need.
➢ Elimination. Data collection is focused on excretory patterns (bowel, bladder,
skin). Excretory problems such as incontinence, constipation, diarrhea, and
urinary retention may be identified.
➢ Activity and Exercise. Assessment is focused on the activities of daily living
requiring energy expenditure, including self-care activities, exercise, and
leisure activities.
GORDON'S TYPOLOGY OF 11
FUNCTIONAL HEALTH PATTERNS
➢ Cognition and Perception. Assessment is focused on the ability to
comprehend and use information and on the sensory functions.
➢ Sleep and Rest. Assessment is focused on the person's sleep, rest,
and relaxation practices. Dysfunctional sleep patterns, fatigue, and
responses to sleep deprivation may be identified.
➢ Self-Perception and Self-Concept. Assessment is focused on the
person's attitudes toward self, including identity, body image, and sense
of self-worth.
➢ Roles and Relationships. Assessment is focused on the person's
roles in the world and relationships with others.
GORDON'S TYPOLOGY OF 11
FUNCTIONAL HEALTH PATTERNS

➢Sexuality and Reproduction. Assessment is focused on the

person's satisfaction or dissatisfaction with sexuality patterns and
reproductive functions. Concerns with sexuality may he identified.
➢Coping and Stress Tolerance. Assessment is focused on the
person's perception of stress and on his or her coping strategies
Support systems are evaluated, and symptoms of stress are noted.•
➢Values and Belief. Assessment is focused on the person's values
and beliefs (including spiritual beliefs), or on the goals that guide his
or her choices or decisions.
OREM'S SELF CARE MODEL1
➢ The maintenance of a sufficient intake of air.
➢ The maintenance of a sufficient intake of water.
➢ The maintenance of a sufficient intake of food.
➢ The provision of care associated with elimination process and excrements.
➢ The maintenance of a balance between activity and rest.
➢ The maintenance of a balance between solitude and social interaction.
➢ The prevention of hazards to human life, human functioning, and human well-
being.
➢ The promotion of human functioning and development within social groups in
accord with human potential, known human limitations, and the human
desire to be normal.
ROY'S ADAPTATION MODEL

➢ Physiological-Physical Mode The basic need of this mode is composed of the

needs associated with oxygenation, nutrition, elimination, activity and rest, and
protection.
➢ Self-Concept Group Identity Mode in this mode, the goal of coping is to
have a sense of unity, meaning the purposefulness in the universe, as well as a
sense of identity integrity. This includes body image and self-ideals.
➢ Role Function Mode This mode focuses on the primary, secondary and
tertiary roles that a person occupies in society, and knowing where he or she
stands as a member of society.
➢ Interdependence Mode This mode focuses on attaining relational integrity
through the giving and receiving of love, respect and value.
[Link] / VERIFYING DATA

Validation is the act of double check or verifying data to confirm

that it is accurate and factual. The information gathered during
the assessment phase must be:
➢ Complete
➢ Factual
➢ Accurate
The nursing diagnosis are based on this information. Validation
data helps the nurse to complete these tasks:
• Ensure that assessment information is complete.
CONT’D

➢Ensure that objective and related subjective data agree.

➢Obtain additional information that may have been over looked.
➢Difference between cues and inference.
Cues: Are the subjective and objective data that can be directly observed
by the nurse.
Inferences: Are the nurse interpretations or conclusions based on cues.
➢Avoid jumping to conclusion and focusing in the wrong direction to
identify problems.
4. DOCUMENTING DATA

➢To complete the assessment phase, the nurse record client’s

data.
➢Accurate documentation is essential and should include all the
data collected about the client’s health status.
➢Data is in factual manner and not interpreted by the nurse
Example: In breakfast “tea 250ml, juice 200ml,1 slice of toast”
rather than as a “Good appetite”.
PERFORM A NURSING ASSESSMENT USING
A FUNCTIONAL HEALTH APPROACH

➢Prepared Your Assignment (Functional Health patterns)

➢Topics (Health Perception Health Management pattern,
Nutritional Metabolic Patterns, Elimination patterns, Activity
& Exercise Pattern, Self Rest patterns, Cognitive Perceptual
Model, Self Perception Self Concept Model, Role Relation
Pattern, Value Belief Pattern, Coping Stress Tolerance
Pattern)
2ND PHASE

Diagnosing
NANDA NURSING DIAGNOSIING
(SAINT LOUIS UNIVERSITY SCHOOL OF NURSING AND
ALLIED HEALTH PROFESSIONS IN 1973)

The nurse use critical thinking skills to interpret assessment data and
identify client strength and problems.
➢Pivotal step
➢Analyze information
➢Identify health problems and strengths
➢Write statement of problem or Risk
➢Formulate diagnostics statements
NANDA NURSING DIAGNOSIS
(ADOPTED OFFICIALLY IN 1990)

➢Diagnosing Is a clinical judgment about the individual, families,

or community response to actual or potential processes
➢Diagnosing: The term refers to the reasoning process.
➢Diagnosis: This is an statement or conclusion the nature of
phenomenon.
➢Diagnostic Labels: The standardized NANDA names for the
diagnosis.
➢Etiology: Casual relationship between a problem and its
related or risk factors Called Nursing Diagnosis
PURPOSE OF NANDA
(NORTH AMERICAN NURSING
DIAGNOSIS ASSOCIATION IN 1982)

➢To define, refine, and promote taxonomy of Nursing

Diagnostic terminologies of professional nurses.
Taxonomy is a classification system or set of categories
arranged based on a single principle or set of principles
TYPES OF NURSING
DIAGNOSIS
➢Actual nursing diagnosis- client problem that present at
the time of assessment. An Actual diagnosis is based on the
presence of associated signs and symptoms
Example: Ineffective Breathing Pattern
➢Risk nursing diagnosis- is a clinical judgment, problem
does not exist, but the presence of risk factors.
Example: Risk of infection in the admitted patient in hospital
CONT’D

➢Syndrome diagnosis- associated with a

cluster of other diagnosis.
Currently 6 syndrome diagnosis are on the list
of international list
Risk for Disuse syndrome, For Example:
Experienced by long term bedridden clients.
CONT’D

➢ Possible Nursing diagnosis- It is a diagnosis in which

evidence about a health problem is unclear and in complete. It
is usually requires more data to accept or reject the diagnosis.

Example- possible social isolation related to unknown etiology.

➢ Wellness Diagnosis- A diagnosis representing healthy
response of client who desires to achieve a higher level oof
wellness.
Example- Potential for enhanced nutrition.
COMPONENTS OF NURSING
DIAGNOSIS

[Link] problem and its definition: purpose is to direct

formation of client goals and desired outcome.
[Link] etiology ( Related factors or risks)
[Link] defining characteristics: are the clusters of signs and
symptoms that indicate the presence of diagnostic labels.
THE PROBLEM
The problem statement or diagnostic label describes the client's health
problem and response to therapy which the nurse have given to client.

➢ Purpose:

The purpose of diagnostic label is to direct the formation of client's goals

and desired outcomes it may also suggest some specific nursing
intervention.

➢ Characteristics of diagnostic label or problem:

To be clinically used, diagnostic label should be specific. For example

Knowledge deficit (medications)

Qualifiers are words that have been added to some NANDA labels to
give additional meanings.
THE ETIOLOGY

➢ It involves one or more probable causes of health problem,

gives direction to nursing therapy and helps the nurse to
initiate individualized nursing care.
➢Example: For the problem activity intolerance the
etiological causes will be sedentary lifestyle, generalized
weakness, impaired motor functions, lack of motivation,
obesity.
DEFINING CHARACTERISTICS

➢ They are the cluster of signs and symptoms that indicate the presence of a
particular diagnostic label.

➢ For Actual Diagnosis, the defining characteristics are the client's signs
and symptoms.
➢ For Risk Diagnosis, there are no signs and symptoms present

➢ Major defining characteristics must be present for valid diagnosis.

➢ Minor defining characteristics may or may not be present.

➢ Example: For a nurse to make diagnosis of Activity Intolerance, client

would need to exhibit the defining characters of altered response to activity,
which may be dyspnea or tachypnea etc.
4. DIFFERENTIATING B/W NURSING DIAGNOSIS FROM
MEDICAL DIAGNOSIS

Medical Diagnosis Nursing Diagnosis

➢ A MD is made by a physician and refers to a ➢ A ND is a statement of nursing Judgment
condition that only physician can treat. and refers to a condition that nurses, by
virtue of their education.
➢ MD refers to disease processes specific
path physiology responses that fairly ➢ ND describe the human responses, a client’s
uniform from one client to another. physical, sociocultural, psychological, and
cultural, spiritual responses to an illness or a
health problem.

➢ MD remains the same as the disease ➢ Nurses have responsibilities relate to both
process is present. MD & ND. ND relate primarily with the
➢ Dependent functions nurses
➢ Independent functions
CONT’D (TABLE 12-3)

5. Differentiating nursing diagnosis from collaborative

problems: A collaborative problem is a type of potential
problem that nurses manage using both independent and
physician prescribed intervention.
IDENTIFY THE CLINICAL SKILLS
NEEDED TO MAKE NURSING
DIAGNOSES.

➢The diagnostic process uses critical thinking skills of Analysis and synthesis.
➢ Critical thinking: It is a cognitive process during which a person reviews
data and considers explanations before forming an opinion.
➢Analysis: It is the separation of things/thoughts into parts
➢ Synthesis: It is just opposite to the Analysis, that is putting together the
parts into whole.
➢An expert nurse may enter the client's room and observe significant data
to form diagnostic statement while a novice nurse needs guidelines to
understand and formulate diagnostic statement
DIAGNOSTIC PROCESS

Diagnostic process has three steps

1. Analyzing data.
➢Comparing data with standards
➢Clustering cues
➢Identifying gaps and inconsistencies in data
2. Identifying health problems, risks, and strength.
➢Determining the problem and risk
➢Determining the strength
CONT’D

[Link] Diagnostic statements(Table 12-6)

Most of the nursing diagnosis are written as two parts or three parts statement.

1) PES format
➢ Problem: Statement of client’s response (NANADA LABEL)
➢ Etiology: Factors contributing to or probable causes of response.
➢ Signs and symptoms: Defining characteristics manifested by the client
2) One part statement.(Label only)

3) Basic two part statement (Box12-1).

4) Basic three part statement (Box 12-2).
AVOIDING ERRORS IN
DIAGNOSTIC REASONING
➢Verify.
➢Build a good knowledge base and acquire clinical experience.
➢Have a working knowledge of what is normal.
➢Consult resources.
➢Base diagnoses on patterns-that is, on behavior over time-
rather than on an isolated incident.
➢Improve critical-thinking skills.
(Must read box 12-4)
3RD PHASE

Planning
PLANNING
➢Planning is deliberative, systematic phase of
nursing process that involves decision making and
problem solving.
➢Establish the goals, interventions and outcomes
➢Nursing intervention is “any treatment , based
upon clinical judgment and knowledge, that a nurse
perform to enhance patient/client outcomes”
PLANNING

➢Prioritize the problem/ diagnosis

➢Establish the goals, interventions and
outcomes
➢Select nursing interventions
➢Write nursing interventions
OUTCOME IDENTIFICATION
➢ Outcomes identification refers to the formulation of specific, measurable,
achievable, realistic, and time-framed (SMART) outcomes:

➢ Specific: The outcome must be clearly defined and understandable to all team
members.

➢ Measurable: The team must be able to determine if the outcome is attainable

and what improvement or movement must be accomplished (increase, decrease,
size, and number).

➢ Achievable: All team members determine what the outcome should be.

➢ Realistic: The team agrees that the outcomes can be achieved with the current
clinical condition and resources available.

➢ Time-framed: The team identifies the time needed to achieve the outcome.
TYPES OF PLANNING

➢ Initial Planning- nurse who performs the admission assessment develop the initial
care plan

➢ Ongoing Planning- start at the beginning of a shift as the nurse plans the care to be
given that day.

The nurses carries out daily planning for the following purposes.
➢ To determine whether the client health status has changed.

➢ To set priorities for the client during shift.

➢ To decide which problem to focus on during shift

➢ To co-ordinate the nurse activities so that more than one problem can be addressed at
each client contact.
TYPES OF PLANNING

➢Discharge planning- the process of anticipating and planning for the needs
after discharge, is a crucial part of comprehensive health care and should be
addressed in each client’s care plan.
PURPOSES OF PLANNING AND
OUTCOME IDENTIFICATION

1. Provide adequate direction to ensure quality nursing care for individual client.

2. Present a vehicle to improve staff communication.

3. Provide continuity in delivery of care.

4. Involve patient and support people in actions which are required for treatment.

5. It helps to maintain a therapeutic/nurse-client's relationship.

6. Provides a Realistic pathway to follow, and to achieve specific & desired goals.

7. Serve as a criteria for evaluating client's progress.

8. Enable the client and Nurse to determine when the problem has been resolved.
COMPONENTS OF CARE PLAN

➢ Nursing Assessment :

Assessment is process of collecting, organizing, validating and

documenting data about a client and it is about a patient's
physiological, psychological, sociological, and spiritual status by a
licensed Registered Nurse.

➢ Nursing Diagnosis:
A nursing diagnosis may be part of the nursing process and is a
clinical judgment about individual, family, or community responses to
actual or potential health problems.
COMPONENTS OF CARE PLAN

The expected outcome qualifiers represent the goal of the patient

care and are documented in the future tense as: will improve, will
stabilize, or will deteriorate.

➢ Nursing Interventions :

Nursing interventions are the actual treatments and actions that are
performed to help the patient to reach the goals that are set for
them. The nurse uses his or her knowledge, experience and critical-
thinking skills to decide which interventions will help the patient the
most.

➢ Expected Outcomes:
TYPES OF NURSING CARE PLANS

1) Informal Nursing care Plan: Is a plan of action that exist in

Nurse's mind. E.g. The Nurse may think "Mrs. John is very tired. I
will need to reinforce her teaching after she is rested".

2) Formal Nursing Care Plan: Is written guide that organizes

information about the client's care. It provides Continuity of
care.
3) Standardized care Plan: Specify the nursing care for groups of
clients with common needs(e.g. All clients with pneumonia).
4) Individualized care Plans: They are developed to meet the
unique needs of specific client, needs that are not addressed with
Standardized care Plans
THE PLANNING PROCESS

In the process of developing a care plan the nurse engage in

the following activities:
1. Setting Priorities
2. Establish Client goals/ desired outcomes
3. Selecting nursing Interventions
4. Writing Individualized nursing interventions on care plans
1. SETTING PRIORITIES
ACCORDING TO
GROUPS MASLOW’S HIERARCHY OTHERS FACTORS
HIGH= LIFE THREATENING PHYSIOLOGICAL NEEDS CLIENT’S HEALTH
PROBLEMS VALUES AND
BELIEFS

MEDIUM= HEALTH SAFETY AND SECURITY CLIENT’S

THREATENING PROBLEMS PRIORITIES

LOW= NORMAL LOVE AND BELONGING RESSOURCES

DEVELOPMENTAL NEEDS AVAILABLE

---------- SELF ESTEEM URGENCY OF

HEALTH PROBLEM

---------- SELF ACTUALIZATION MEDICAL

TREATMENT PLAN
2. ESTABLISH CLIENT GOALS/
DESIRED OUTCOMES

➢Goal/desire outcomes.
➢Nursing outcome classification.
➢Purpose of desired goals/outcomes.
➢Long term and short term goals.
➢Component of goal/desired outcome statement.
➢Guidelines for writing goal/desired outcome
GOAL SHOULD BE SMART

➢S - specific
➢M - measurable
➢A - achievable
➢R - realistic,
➢T - time-bound
FOUR COMPONENTS OF
GOALS

➢Subject: who is the person expected to achieve the

outcome?
➢Verb: what actions must the person take to achieve the
outcome?
➢Condition or modifiers: under what circumstances is
the person to perform the actions?
➢Criteria of desired performance: how well is the
person to perform the actions?
3. SELECTING NURSING
INTERVENTIONS

➢Considering the sequences

➢Safe and appropriate for individual’s age, health, and condition.
➢Congruent with the client’s values, beliefs and culture
➢Congruent with other therapies
➢Within established standards of care as determined by state
law, professional association and policies of the institution.
4. WRITING INDIVIDUALIZED
NURSING INTERVENTIONS ON
CARE PLANS

➢The format of written intervention is similar to that of

outcomes:
➢Verb
➢Conditions and modifiers
➢Plus time element
4TH PHASE

IMPLEMENTING
IMPLEMENTING

➢Is the action phase in which nurse performs the nursing interventions.
➢Consist of doing and documenting the activities.
IMPLEMENTING SKILLS

➢Cognitive Skills- Intellectual include problem solving,

decision making, critical thinking and creativity
➢Interpersonal Skills- are all of activities, verbal and non-
verbal
➢Technical Skills- are purposefully “hands on” skills such as
giving injections, bandaging, moving, lifting, repositioning clients.
DISCUSS THE PURPOSES OF
IMPLEMENTATION AND EVALUATION

Ø Purposes of implementation
Actions are taken to:
➢ Resolve client's problem.
➢ Achieve client's goals.
➢ Help out client to participate in treatment care plan.
➢ It is also used to provide physician initiated treatments to
medical diagnosis
DISCUSS THE PURPOSES OF
IMPLEMENTATION AND EVALUATION

➢ It helps Nurses to know about the quality of nursing care

provided.

➢ Evaluation helps a nurse to identify whether the goals are achieved

or not.
➢ It gives us information that problem has been resolved or not.

➢ Tells us about the medical condition of the patient.

➢ Effective evaluation declares that whether a nurse have to
Continue modify or terminate care plan.
PROCESS OF
IMPLEMENTATION
➢Reassess the client
➢Determining the nurse’s need for
assistance
➢Implementing the nursing interventions
➢Supervising the delegated care
➢Documenting nursing activities
REASSESS THE CLIENT

• Just before implementation the nurse must reassess the

client to make sure that the intervention is still needed.
Even though an order is written on care plan the client’s
condition may have changed.
• For Example: a nurse seems the client with diagnosis of
Disturbed sleeping pattern related to anxiety and unfamiliar
surroundings sleeping during round and defers back rub of
patient which she has to be done as a relaxation strategy.
DETERMINE THE NURSE’S
NEED FOR ASSISTANCE
• When implementing some nursing strategies the nurse may
require assistance for one of the following reasons.
• The Nurse is unable to implement the nursing strategies
safely alone.
• Assistance would reduced stress on the client.
• The nurse lacks the knowledge or skills to implement a
particular
• Nursing activity.
IMPLEMENTATING THE
NURSING INTERVENTIONS

• It is important to explain to the client what will be done,

what sensations to expect and what the client is expected
to do.
• Guidelines for implementing Nursing orders
• Nursing actions should be based on scientific knowledge,
nursing research, and professional standards of care.
• Nurses should understand clearly the orders to be
implemented and question any that are not understood.
• Nursing actions should be adapted to the individual client.
DELEGATING & SUPERVISING

• The ANA defines Delegation as: the transfer of

responsibility for the performance of an activity from one
to another person while retaining accountability for the
outcome.
• And Assignment is downward or lateral transfer of both
responsibility and accountability of an activity from one to
another person.
• The nurse has two responsibilities in making work
assignments 1-(appropriate delegation of duties) that is
assigning people duties within their scope of practice.
DOCUMENTING NURSING
ACTIONS
• After carrying out nursing orders, the Nurse completes
the implementing phase by recording the interventions
and client responses in the nursing progress notes the
are the part of agency’s permanent record for the
client.
• Nursing actions must not be recorded in advance
because the nurse may determine on reassessing the
client that the action should not or can’t be
implemented.
NURSING INTERVENTIONS

• Road maps directing the best ways to provide nursing

care.
• Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and independence.
TYPES OF CARE

➢Direct Care: actions performed through interaction with

clients.

➢Indirect Care: actions performed away from the client, on

behalf of a client or group of clients.
TYPES OF NURSING
INTERVENTIONS

➢Independent Interventions: Include physical Care, Ongoing assessment,

emotional support, comfort, teaching, counseling, environmental management.
➢Dependent interventions- are activities carried under the physicians
orders or supervision or according to specified routines.
➢Collaborative Interventions- are actions the nurse carries out in
collaboration with other health team.
5TH PHASE

EVALUATION
EVALUATING

➢Is the fifth phase or last phase of nursing process

➢Evaluating is the client progress toward achievement
or outcome.
PROCESS OF EVALUATING

➢Collecting data related to desired outcomes

➢Comparing the data
➢Relating Nursing Activities
➢Draw conclusions about problem status
➢Continuing, modifying, or terminating the nursing care plan
EVALUATING THE QUALITY
OF NURSING CARE
➢Quality assurance
➢Quality assurance program- ongoing systematic process design to
evaluate and promote excellence in the health care provided to clients.
➢Structure evaluation- focuses on the setting in which the care is
given
➢Process Evaluation- focuses on how the care was given
➢Outcome evaluation- focuses on demonstrable changes in the
client’s health as a result of nursing care
REFERENCES

➢Kozier and Erb’s fundamental of nursing

10th edition.

➢Elite Nursing Platform