Nursing Process: PLANNING

planning

The planning phase of the Nursing Process involves the development of a nursing care plan for the client based on the nursing diagnosis. The nursing care plan is a communication tool used by Nurses to care for their clients. Care plans that are kept up to date are vital tools to provide continuity of care, prevent complications and provide for health teaching and discharge planning. Goals should be stated in terms of client outcomes. Nursing outcomes examples are: Skin and Mucous Membranes, Wound Healing, Primary Intention, and Urinary Continence. Each of these nursing sensitive outcomes is labeled, defined, and includes criteria for the assessing the status of the outcome over time.

Nursing orders are the actions for interventions prescribed to help achieve the stated goals and objectives. When writing nursing orders remember to include:

What
Where
When
How much
and How long.

The steps in Nursing Care Planning are:

Determine priorities from the list of nursing diagnoses.
Set long-term and short-term goals to determine outcomes of care.
Develop objectives to reach the goals.
and Write nursing orders to direct care to meet the goals.

Measurement Criteria:

The plan is individualized to the client's condition.
The plan is developed with the client and significant others if appropriate.
The plan reflects current nursing practice.
The plan is documented.
The plan provides for continuity of care.

NOTE: For the purpose of examples of Nursing Process , I will be using the following Case Study through out this report.

Case Study:

Client with Liver Disease - Cirrhosis

Mr. K is a 45 year old polish male. Married with three children. He is currently unemployed. He has worked in the service industry for his entire life. He has been socially drinking since he was 13 yrs. He has a family history of alcoholism an diabetes. He has been admitted to ICU on three previous occasions for liver disease.

Sample Nursing Care Plan:

Nursing Diagnosis	Goals and Outcome Criteria
Imbalance Nutrition: Less than Body Requirements related to anorexia, metabolic imbalance	Adequate nutrition: Stable body weight, consumes meals
Activity Intolerance related to fatigue	Improved activity tolerance: Performs activities of daily living without excessive fatigue
Risk for Impaired Skin Integrity related to edema, immobility, pruritis, hypoproteinemia	Intact skin: No redness or breaks in skin. No scratching
Ineffective Breathing Patterns related to ascites	Effective breathing: Respiratory rate of 12-20 per minute without dyspnea
Risk for Injury related to impaired coagulation	Absence of bleeding: No blood in emesis or stool, vital signs consistent with patient norms
Disturbed Thought Processes related to elevated blood ammonia	Normal cognitive functions: Mentally alert, oriented

Nursing Process: Definition | Critical Thinking | Guidelines

Critical Thinking: Characteristics | Skills, Elements, Standards

Nursing Process: Assessment | Nursing Diagnosis | Planning | Implementation | Evaluation

Lecture Outline Notes

Grades

John Philip Tiongco, MD