Nursing Process : PLANNING

BY : CATHERINE KUCKYT, RN

The planning phase of the Nursing Process involves the devlopment 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 examplaes 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 writng nursing orders remember to include:

1. What
2. Where
3. When
4. How much
5. and How long.

The steps in Nursing Care Planning are:

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

Measurement Criteria(2):

1. The plan is individualized to the client's condition.
2. The plan is devloped with the client and significant others if appropriate.
3. The plan reflects current nursing practice.
4. The plan is documented.
5. 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 and diabetes. He has been admitted to ICU on three previous occassions for liver disease.

Sample Nursing Care Plan

Nursing Diagnosis
Imbalance Nutrition:Less than Body Requirements related to anorexia, metabolic imbalance

Goals and Outcome Criteria
Adequate nutrition:Stable body weight, consumes meals

Nursing Diagnosis
Activity Intolerance related to fatigue

Goals and Outcome Criteria
Improved activity tolerance:Performs actvities of daily living without excessive fatigue

Nursing Diagnosis
Risk for Impaired Skin Integrity related to edema, immobility, pruritis, hypoproteinemia

Goals and Outcome Criteria
ntact skin: No redness or breaks in skin.No scratching

Nursing Diagnosis
Ineffective Breathing Patterns related to ascites

Goals and Outcome Criteria
Effective breathing:Respiratory rate of 12-20 per minute without dyspnea

Nursing Diagnosis
Risk for Injury related to impaired coagulation

Goals and Outcome Criteria
Absence of bleeding: No blood in emesis or stool, vital signs consistent with patient norms

Nursing Diagnosis
Disturbed Thought Processes related to elevated blood ammonia

Goals and Outcome Criteria
Normal cognitive functions: Mentally alert, oriented