NURSING CARE PLAN - A document that provides direction on the type of nursing care the individual/family/community

may need. This facilitates standardized, evidence-based and holistic care.

NURSING PROCESS - tool used by nurses to promote organization and utilization of the steps to achieve desired
outcomes, that is, goal attainment and problem resolution.

STEP 1. ASSESSMENT includes collection, validation, organization, and interpretation of data. Data clustering is used to
determine the relatedness of facts, to find patterns, and to determine if further data are needed.
Subjective Data Objective Data

Non-smoker Abdominal guarding (hand holding the

epigastric area)
History of Appendectomy Purplish discoloration of the umbilical area

Pain scale of 9 out of 10 RR – 26 breaths per minute

Shallow respirations
HR – 110 beats per minute
Clustering Data

Pain Hydration Physical Regulation

(+) mid epigastric pain Occasional nausea Drinks alcohol for the past 10 years
Pain scale of 9 out of 10 and vomiting History of Appendectomy

STEP 2. DIAGNOSIS involves critical thought and judgment to analyze, organize, and interpret assessment data.
Problems, risk problems, and strengths are identified and labeled with NANDA nursing diagnoses.

 Acute pain related to inflammation of the pancreas as evidenced by guarding behavior, pain scale of 9/10,
increased heart rate and respiratory rate.
 Risk for deficient fluid volume risk factors include excessing gastric losses (vomiting).

STEP 3. PLANNING The planning step should involve discussing the plan with the client for input and collaboration. This
encourages client participation and promotes the client’s sense of control. Careful, effective planning advocates and
ensures delivery of quality care.

STEP 4. IMPLEMENTATION Planned nursing interventions are executed during implementation. Each interaction with
the client, during this phase, is an opportunity to assess and reassess, and collect ongoing data and comparing it to
baseline.

STEP 5. EVALUATION measures the effectiveness of nursing care and the quality of care provided. Evaluation will help
the nurse decide whether to modify, sustain or to end the plan of care.