NURSING PROCESS /
NURSING CARE PLAN
Nursing Process
Definition
Purpose or Goals
Steps of the Nursing Process
Nursing Process
A systematic and
rational method of
providing nursing care.
Purpose or Goals of the Nursing Process
1) Identify client’s health care status &
actual or potential health problems.
2) Establish plans to meet the identified
needs.
3) Deliver the specific nursing interventions
to meet those needs.
Skills Needed to Successfully use the Nursing Process
1) Cognitive Skills
2) Technical Skills
3) Interpersonal Skills
4) Ethico & Legal Skills
FORMULATING DIAGNOSTIC STATEMENTS
3 Essential Components of a Nursing Diagnosis
1) (P) Problem – statement of the client’s response
2) (E) Etiology – factors contributing to or a probable
cause of the response
3) (S) Signs and Symptoms – defining characteristics
manifested by the client.
Sample Diagnostic Statements
3-Part Statement: (Actual Diagnosis)
P E S
Impaired Physical Mobility related to decreased muscle control as evidenced by
inability to control lower extremities.
2-Part Statement: (Risk Diagnosis)
P E
Risk for Fall as evidenced by non-functional siderails.
Impaired Skin Integrity related to pressure over
bony prominence as evidenced by pain,
bleeding, redness, wound drainage.
Risk for Fall as evidenced by muscle weakness
SETTING PRIORITIES
HIGH – life threatening problems such
as loss of respiratory or cardiac
function
MEDIUM – health threatening
problems such as acute illness and
decreased coping ability.
LOW – arises from normal
developmental needs or that requires
only minimal nursing support.
GOAL
➢ A broad or globally written statement describing
the intended or desired change in the client’s
behavior, response or outcome.
➢ Defined as the result of nursing interventions&
patient responses that are specific, measurable,
attainable, realistic, time bound (SMART)
➢ Two Types of Goal
✓ Short term goal – usually few hours or days
✓ Long term goal – over weeks or months
Nursing Intervention
Is any treatment based upon clinical judgement and
knowledge, that a nurse performs to enhance client
outcomes.
It is the prescription for specific behaviors expected
from the patient& /or action carried out by nurses.
The product of the planning phase is a client CARE
PLAN
Planning begins with the first client contact and
continues until the nurse-client relationship ends.
Rationale
It is stated to provide
pathophysiological basis to assist
the nurse in deciding about the
specific intervention for an
individual patient situation.
Types of Nursing Intervention
1) Independent – 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,
teaching etc.
2) Dependent – are activities carried out under the physician’s
order or supervision, or according to specified routines
3) Interdependent/Collaborative – are actions the nurse carries
out in collaboration with other health team members.
Purpose of a Written Care Plan
1) Provide directions for individualized plan of care
2) Provide for continuity of care
3) Provide direction about what needs to be
documented on the client’s progress notes
4) Serve as a guide for reimbursement from medical
insurance companies
5) Serve as a guide for assigning staff to care for the
client
Process of Implementation
reassessing the client
determining the need for nursing
assistance
implementing the nursing strategies
supervising the delegated care
documenting nursing activities
Components of Evaluation
1) Collecting data related to the desired
outcomes.
2) Comparing the data with desired
outcomes.
3) Relating nursing activities to outcomes.
4) Drawing conclusions about problem
status.
5) Continuing, modifying, or terminating the
nursing care plan.
Evaluation Statement:
When determining whether a goal has been achieved, the
nurse can draw one of three possible conclusions:
▪ The goal was met; that is, the client response is the same as
the desired outcome.
▪ The goal was partially met; that is, either a short-term outcome
was achieved but the long-term goal was not, or the desired
goal was incompletely attained.
▪ The goal was not met. After determining whether or not a goal
has been met.
Evaluation Statement:
An evaluation statement consists of two parts: a conclusion
and supporting data.
The conclusion is a statement that the goal/desired
outcome was met, partially met, or not met.
The supporting data are the list of client responses that
support the conclusion, for example: Goal met: Oral intake
300 mL more than output; skin turgor resilient; mucous
membranes moist.
Format for the NCP:
Nursing Goal Intervention Rationale Evaluation
Diagnosis
Problem related Must be SMART Independent: Goal met as evidenced
by
to 1.
Etiology as Within _ hours, 2. Goal partially met as
evidenced by ____ will be able 3. evidenced by
Signs and to 4.
Goal unmet as
Symptoms. 5. Atleast 5 evidenced by
Dependent:
1. Atleast 1
Problem as
evidenced by Collaborative:
Etiology 1. Atleast 1
SAMPLE CASE
(NCP Making)