PLANNING 08 DEVELOPING DISCHARGE PLAN
❖ Informal Nursing Care Plan
At the end of 1 month, patient will demonstrate stable weight with
no sign of weakness and with increase appetite.
At the end of 20-30min., patient body temperature will be lowered
to 37oC.
Planning
Impaired skin integrity: At the end of 24 hours, patient
demonstrates techniques to promote healing and displays timely
wound healing.
Ineffective airway clearance: At the end of 8 hours, patient will
maintain patent airway, expectorate secretions without assistance
and improve airway clearance.
Acute Pain: At the end of 20 mins., patients will report relieved of
pain and discomfort, display relaxed manner and able to sleep well.
Activity intolerance: At the end of the day, patient will be able to
participate in necessary/desired activities and reports increase in
activity tolerance.
PLANNING
> Prioritize Problem/Diagnosis
> Formulate goals/desired outcomes.
> Select nursing interventions.
> Write nursing orders.
▪ Is a deliberative, systematic phase of the nursing process that
involves decision making and problem solving
▪ In this phase, the nurse refers to the client’s assessment data and
diagnostic statements for:
✓ direction in formulating client goals
✓ Designing the nursing interventions required to:
• Prevent
• Reduce or
• Eliminate the client health problems
NURSING INTERVENTIONS
• Is any treatment, based upon clinical judgement and knowledge,
that a nurse performs to enhance patient/client outcomes.
The product of the planning phase is Client Care Plan
TYPES OF PLANNING
1. Initial Planning
✓The nurse who performs the admission assessment
usually develops the initial comprehensive plan of care.
✓Should be initiated as soon as possible after the initial
assessment, especially because of the trend toward shorter
hospital days.
2. Ongoing Planning
✓Is done by all nurses who work with the client.
✓Occurs at the beginning of the shift as the nurse plans the
care to be given that day.
✓The nurse carries out the daily planning for the following
purposes:
• To determine whether the client’s health status
has changed.
• To set priorities for the client’s care during the
shift.
• To decide which problems to focus on during the
shift.
• To coordinate the nurse’s activities so that more
than one problem can be addressed at each client
contact.
3. Discharge Planning
✓the process of anticipating and planning for needs after
discharge.
✓Is a crucial part of comprehensive health care and should
be addressed in each client’s care plan.
✓Effective discharge planning begins at the first contact of
the patient to obtain information about the client’s ongoing
needs.
✓ is a strategy for action that exist in the nurse’s mind
❖Formal Nursing Care Plan
✓ is a written or computerized guide that organizes
information about the client’s care. ✓It provides continuity
of care.
❖Standardize Care Plan
✓is a formal plan that specifies the nursing care for groups
of clients with common needs.(e.g. All clients with
myocardial infarction)
❖Individualized Care Plan
✓ is tailored to meet the unique needs of the specific
client.
Guidelines for writing Nursing Care Plan
1. Date and sign the plan
2. Use category headings
3. Use standardized or approved medical or English
symbols and key words rather than complete sentences to
communicate your ideas.
Ex. “Turn and reposition q2h” rather than “Turn and
reposition the client every two hours.”
4. Be specific.
5. Refer to procedure books or other sources of
information rather than including all the steps on a written
plan.
6. Tailor the plan to the unique characteristics of the client
by ensuring that the client’s choices are included.
7. Ensure that the nursing plan incorporates preventive and
health maintenance aspects as well as restorative ones.
8. Ensure that the plan contains interventions for ongoing
assessment of the client.
9. Include collaborative and coordination activities in the
plan.
10. Include plans for the client’s discharge and home care
needs.
THE PLANNING PROCESS
1. SETTING PRIORITIES
• Is the process of establishing a preferential sequence
for addressing nursing diagnoses and interventions.
• The nurse and the client should decide which nursing
diagnosis requires attention first, which is second , and
so forth….
• Nurse can group then as:
✓Life-threatening problems (Loss of respiratory and
cardiac functions)
✓Health-threatening problems (acute illness and
decrease coping ability)
✓Low priority problems. (arise from normal
developmental needs)
2. ESTABLISHING CLIENT GOALS/DESIRED OUTCOMES
• The nurse and client set goals for each nursing diagnosis.
• What the nurse hopes to achieve by implementing the
nursing interventions.
• GOAL (BROAD) : Improved nutritional status
• DESIRED OUTCOME (SPECIFIC) : Gain 5 lbs
by April 25
• 4 components of goal/desired outcome statement
✓Subject – client/patient
 ✓Verb – action the client perform 4. WRITING NURSING ORDERS
✓Conditions or modifiers –may be added to the verb to • Nursing Orders – are instruction for specific individualized
explain the circumstances under which the behavior is to be activities the nurse performs to help the client meet
performed. They explain what, where, when or how established health care goals.
✓Criterion of desired performance. Components of the nursing orders
✓Date
EXAMPLES OF ACTION VERBS ✓Action verb
Apply, Assemble, Breathe, Choose Compare, Define Demonstrate, ✓Content area
Describe, Differentiate, Discuss, Drink Explain, Help, Identify, Inject, ✓Time element
List, Move, Name, Prepare, Report, Select, Share, Sit, Sleep, State, ✓Signature
Talk, Transfer, Turn, Verbalize.
09 IMPLEMENTING AND EVALUATION
IMPLEMENTING
> Reassessing the client
> Determining the nurse’s need for assessment
> Implementing the nursing interventions
> Supervising and delegated care Documented nursing
activities

▪ Is the phase in which the nurse implements the nursing

• Purposes of desired outcomes/goals
✓Provide direction for planning nursing interventions.
✓Serves as criteria for evaluating client progress
✓Enable the client and nurse to determine when the
problem has been resolved
✓Help motivate the client and nurse by providing a sense of
achievement
interventions.
▪ It consists of doing and documenting activities that are specific
nursing actions needed to carry out the interventions
▪ The nurse performs or delegates the nursing activities for the
interventions that were developed in the planning step.
The first three phases of nursing process which is the assessing,
diagnosing and planning.
➢Provide the basis for the nursing actions performed
during the implementing phase.

Characteristics of Outcome Criteria: In the implementing phase

• S - SPECIFIC
➢Provides the actual nursing activities and the client
• M - MEASURABLE
responses are examined in the final phase (Evaluation)
• A - ATTAINABLE
➢While implementing nursing orders, the nurse continues
• R - REALISTIC
to reassess the client at every contact, gathering data about
• T - TIME – FRAMED
the client’s responses of the nursing activities.
• Long-term and short-term goals
✓A short-term goal might be:
IMPLEMENTING SKILLS
• “Client will raise right arm to shoulder height by
1. Cognitive Skills (intellectual skills)
tomorrow”
➢Includes problem solving, decision making, critical
• are useful for clients who require health care for a
thinking and creativity
short period of time.
➢They are crucial to safe, intelligent care
✓A long-term goal might be:
2. Interpersonal Skills
• “Client will regain full use of arm in 6 weeks”
• Often used for clients who lived at home and have ➢ are all activities, verbal and non-verbal, people use when
chronic health problems and in nursing homes. interacting directly with one another.
3. SELECTING NURSING INTERVENTIONS AND ACTIVITIES ➢The effectiveness of the nursing actions often depends on
• Nursing interventions and activities – are actions that a the nurse’s ability to communicate with others.
nurse performs to achieve clients goals. ➢The nurse uses therapeutic communication to understand
• Specific interventions should focus on eliminating or the client and in turn be understood.
reducing the etiology of the nursing diagnosis. 3. Technical skills
• Types of nursing interventions ➢ are “hands-on” skill such as manipulating equipment,
✓ INDEPENDENT INTERVENTIONS – are those activities that giving injections and bandaging, moving, lifting, and
nurses are licensed to initiate on the basis on their repositioning clients
knowledge and skills. ➢Also called tasks, procedures, or psychomotor skills.
✓They include: ➢Required knowledge and frequently manual dexterity.
• Physical care
• Ongoing assessment IMPLEMENTING SKILLS
• Emotional support and comfort Example: When inserting urinary catheter, the nurse needs
• Teaching cognitive knowledge of the principles and steps of the
• Counseling procedures, interpersonal skills is to inform and reassure
• Environmental management the client, and technical skills in draping the client and
• Making referrals manipulating the equipment.
✓ DEPENDENT INTERVENTIONS – are those activities
carried out under the physician’s orders or supervision,
according to specified routines.
✓Physician’s orders commonly include: PROCESS OF IMPLEMENTING
• Medications 1. Reassessing the client
• Intravenous therapy ➢Before implementing, the nurse must reassess the client to
• Diagnostic tests make sure the interventions is still needed.
• Treatments 2. Determining the nurse’s need for assistance
• Diet ➢The nurse need assistance for one of the following
• Activity reasons:
✓ COLLABORATIVE INTERVENTIONS – are those actions the ✓The nurse is unable to implement the nursing activity
nurse carries out in collaboration with other health team safely alone.
members, such as physical therapist, social workers, ✓Assistance would reduce stress to the client
dietitians, and physicians. ✓The nurse lacks the knowledge or skills to implement a
particular nursing activity.
3. Implementing the nursing interventions
➢It is important to explain to the client what interventions will
be done, what the client is expected to do, and what the
expected outcome is.
➢Nurse should follow this guideline in implementing:
✓Base nursing interventions on scientific knowledge, nursing
research and professional standard of care whenever possible.
✓Clearly understand the orders to be implemented and
questions any that are not understood.
✓Adapt activities to individual client .
✓Implement safe care
➢Nurse should follow this guidelines in implementing:
✓Provide teaching, support and comfort.
✓Be holistic.
✓Respect the dignity of the client and enhance the client’s self-
esteem
✓Encourage client to participate actively in implementing the
nursing interventions
4. Supervising delegated care
➢If care has been delegated, the nurse responsible for the
client’s overall care must ensure that the activities have been
implemented according to the care plan.
➢The nurse validates and responds to any adverse findings or
client’s responses.
5. Documenting nursing activities
➢The nurse completes the implementing phase by
recording the interventions and clients responses in the
nursing progress notes or in the chart.
➢The nurse may record routine and recurring activities in
the client record at the end of the shift.
EVALUATING
> Collecting data related to outcomes
> Comparing data with outcomes
>Relating nursing activities to outcomes
> Drawing conclusions about problem status
> Continuing, modifying, or terminating the nursing care plan.
➢ To evaluate is to judge or to appraise.
➢ EVALUATING is a planned, ongoing, purposeful activity in
which clients and health care professionals determine
A. The client’s progress toward achievement of
goal/outcomes
B. Effectiveness of the nursing care plan
➢It is an important aspect of the nursing process because
conclusions drawn from the evaluation whether the nursing
interventions should be terminated, continued, or changed.
❖ EVALUATION IN CONTINUOUS.
• Evaluation is done while or immediately after implementing a
nursing order to enable the nurse to make on-the-spot
modification of the intervention.
• Evaluation at specified intervals shows the extent of progress
towards goal achievement and enables the nurse to correct any
deficiencies and modify the care plan needed.
• Evaluation continues until the client achieves the health goals
or is discharged from nursing care.
• Evaluation at discharge includes the status of goal
achievement and the client’s self-care abilities with regard to
follow-up care.
HEART OF THE NURSING PROCESS…
•KNOWLEDGE
•SKILLS - manual, intellectual, interpersonal.
•CARING - willingness and ability to care.
10- DOCUMENTING/RECORDING & REPORTING
“Effective communication among health professionals is vital to
the quality of client care.”
DISCUSSION - is an informal oral consideration of a subject by two
or more health care personnel to identify a problem or establish
strategies to resolve a problem.
REPORT - Is oral, written, or computer-based communication
intended to convey information to others.
RECORD - is a written or computer based
RECORDING - also called charting or documenting.
- is the process of making an entry on a client record
CLINICAL RECORD - also called chart or client record.
- It is a formal, legal document that provides
evidence of a client’s care.
ETHICAL AND LEGAL PRINCIPLES
1. “The nurse has a duty to maintain confidentiality of all
patient information.”
2. “The client’s record is also protected legally as a private
record of the client’s care.”
3. “Access to the record is restricted to health professionals
involved in giving care to the client.”
4. “The institution r agency is the rightful owner of the client’s
record.”
PURPOSES OF CLIENT RECORDS
▪ Communication
▪ Planning client care
▪ Auditing Health Agencies
▪ Research
▪ Education
▪ Reimbursement
▪ Legal Documentation
▪ Health Care Analysis
DOCUMENTATION SYSTEMS
(1) SOURCE-ORIENTED RECORD
➢ the traditional client record
➢ each person or department makes notations in a separate
section/s of the client’s record
➢Examples:
• the admission dept. – Admission sheet
• the physician – Doctor’s order sheet
• A physician’s history sheet
• Progress notes
Narrative Charting - is the traditional part of the source-oriented
record.
- It consists of written notes that include routine
care, normal findings, and client problems.
(2) PROBLEM-ORIENTED MEDICAL RECORD (POMR)
➢Established by Lawrence Weed in the 1960s
➢the data arranged according to the problems the client has rather
than the source of the information
➢has the four basic components:
✓ Database – consists of all information known about the client
when the client first enters the health Care agency
✓ Problem List – problems are listed in the order in which they are
identified, and the list is continually updated as new problems are
identified and others are resolved.
✓ Plan of Care – the initial list of orders or plan of care is made with
reference to the active problems.
✓ Progress Notes – is a chart entry made by all health professionals
involved in client’s care. It has different format:
• SOAP – subjective data, objective data, analysis and planning
• SOAPIE or SOAPIER – same above with Interventions, evaluation,
and revision.
• PIE – Problems, Interventions, and Evaluation
 PROBLEM-ORIENTED MEDICAL RECORD (POMR) 4. Flow Sheets
➢ enables nurses to record nursing data quickly and concisely
Continuation….. and provides an easy-to-read record of the client’s condition
➢ The advantages of POMR: over time.
✓ It encourages collaboration ➢ It includes:
✓ The problem list in the front of the chart alerts caregivers to the ✓Graphic record
client’s needs and make it easier to track the status of its problems. ✓Intake and output Record
➢Its disadvantages are: ✓Medication Administration Record
✓Caregivers differ in their ability to use the required charting ✓Skin Assessment Record
format.
✓It takes constant vigilance to maintain an up-to-date problem list 5. Progress Notes
✓It is somewhat inefficient because assessments and interventions ➢ made by nurses to provide information about the progress a
that apply to more than one problem must be repeated. client is making toward achieving desired outcomes.

(3) FOCUS CHARTING GENERAL GUIDELINES FOR RECORDING

➢ is intended to make the client and client concerns and strengths • Date and Time
the focus of care. • Timing
➢ Three columns for recording are usually used: date and time, • Legibility
focus, and progress notes • Permanence
➢ Utilizes DAR: data, action and response • Accepted Terminology
• Correct Spelling
➢ Utilizes DAR: data, action and response
• Signature
➢Example:
• Accuracy
Date/hour Focus Progress Notes
• Sequence
2/11/2016 Pain D: Guarding abdominal
• Appropriateness
9 AM incision; Facial grimacing; Rates
• Completeness
pain at “8” on scale of 0-10
• Conciseness
A: Administered Morphine sulfate 4
• Legal prudence
mg IV
9:30am R: Rates pain at “1”. States willing
REPORTING
to ambulate.
Purpose:
➢ to communicate specific information to a person or group of
(4) CHARTING BY EXCEPTION
people.
➢ is a documentation system in which only abnormal or significant
findings or exceptions to norms are recorded.
REPORTING
➢ It incorporates three key elements:
❖ Change-of-Shift Reports
✓ Flow sheets – like graphic record, fluid balance record, daily
➢ is given to all nurses on the next shift.
nursing assessment record, client teaching record, client discharge
➢ Its purpose is to provide continuity of care
record and skin assessment record
❖ Telephone Reports
✓ Standard of nursing care – the agency’s printed standards of
nursing practice ➢ reports done through telephone
✓ Bedside access to chart forms – all flow sheets are kept at the ❖ Telephone Orders
client’s bedside ➢ orders made by physicians through telephone.
➢ Transcribed onto the physician’s order sheet and should
(5) COMPUTERIZED DOCUMENTATION be counter signed within 24 hours by the physician who
➢ are being developed as a way to manage the huge volume of made the order.
information required in contemporary health care. ❖ Care Plan Conference
➢ Nurses use computers to store the client’s database, add new ➢ is a meeting of a group of nurses to discuss possible
data, create and revise care plans and document client progress. solutions to certain problems of a client.
❖ Nursing Rounds
(6) CASE MANAGEMENT ➢ are procedures in which two or more nurses visit
➢ emphasizes quality, cost-effective care delivered within an selected clients at each client’s bedside.
established length of stay.
➢ Uses a multidisciplinary approach to planning and documenting
client care, using critical pathways.

DOCUMENTING NURSING ACTIVITIES

1. Admission Nursing Assessment

➢ also referred to as an initial database, nursing history, or
nursing assessment, is completed when the client is admitted
to the nursing unit.
2. Nursing Care Plans
➢ 2 types of NCP:
✓ Traditional Care Plan – is written for each client. Mostly, it
has 3 columns: nsg. diagnosis, expected outcomes, and nsg.
interventions.
✓ Standardized Care Plans – were developed to save
documentation time.
3. Kardexes
➢ is a widely used, concise method of organizing and recording
data about a client, making information quickly accessible to all
health professionals.
➢ the system consists of a series of cards kept in a portable
index file or on a computer-generated form.