Priority Setting – the process establishing a
o Fit the unique needs of each client usually
both pre-authored and nurse-created
sections.
o For predictable, commonly occurring
problems.
o Individual plan for unusual problems or
problems needing special attention.
1. Date and sign the plan.
2. Use category headings
3. Use standardized / approved medical or
English symbols and key words rather than
complete sentences to communicate your
ideas unless agency policy dictates
otherwise.
4. Be specific.
5. Refer to procedure books or other sources
of information rather than including all the
steps on a written care plan.
6. Tailor the plan to the unique characteristics
of the client by ensuring that the client’s
choices, such as preferences about the
times of care and methods used, are
included.
7. Ensure that the nursing plan incorporates
preventive and health maintenance
aspects as well as restorative plans.
8. Ensure that the plan contains 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.
preferential sequence for addressing nursing
diagnoses and interventions.
Factors to consider:
o Client’s health values and beliefs.
o Client’s priorities.
o Resources available to the nurse and
client.
o Urgency of the health problem.
o Medical treatment plan
Establishing client goals / desired outcomes –
describe what the nurse hopes to achieve by
implementing the nursing interventions.\
Goal: Broad statement about client’s status
Desired Outcomes: ore specific, observable
criteria used to evaluate whether the goals have
been met.
Ex. Goal: Improved status, Desired Outcomes:
Gain 5lbs by April 25
The nursing outcomes classification (NOC)
o Made more specific by identifying indicators
that apply to a particular client.
o Stated in neutral terms.
o Each outcome includes a five-point sale to
rate the client’s status.
o To write a desired outcome using NOC
taxonomy, indicate:
- Label
- Indicators that ppl to client
- Initial client status
- Location on the measuring scale
desired for each indicator.
o Can be stated in traditional (lay) language.
Short-term / long-term goals
o By the end of the week or in over th course
of many weeks.
o Short-term goals useful for client who: 2
Criteria for Choosing Nursing Interventions - Level 3 ; interventions
1) Safe and appropriate for the client’s age, o Interventions
health, and condition - More than 542 developed
2) Achievable with the resources available - Each includes:
3) Congruent with the client’s values, beliefs, 1) A label (name)
and culture. 2) A definition
4) Congruent with other therapies 3) A list of activities that outline key actions
5) Based on Nursing knowledge and - Linked to NANDA Diagnostic labels
experience or knowledge from relevant - Select appropriate intervention and
sciences. customize.
6) Within established standards of care as
determined by state laws, professional
associations, and the policies of the
institutions.

Writing Individualized Nursing

Interventions:
o Date when they were written
o Verb: Action verb starts the
interventions and must be precise.
o Conditions
o Modifiers
o Time-Element: How long or how often
the nursing action is to occur.

Relationship of Nursing Interventions to

problem status:
o Observations
o Prevent interventions
o Treatments
o Health promotion interventions

Delegating Implementation:
o Occurs during the planning Phase
o Transfer of responsibility for the
performance of an activity from one
person to another while retaining.

Nursing Intervention classification:

o Taxonomy of nursing interventions
o Developed by Iowa Intervention
o First published in 1992
o Updated every 4 years
o 3 Levels:
- Level 1 ; domains
- Level 2: interventions
 - Require healthcare for a short time.
- Are frustrated by long-term goals that
seem difficult to attain.
- Need the satisfaction of achieving a
short-term goal.
EX. THE PLANNING PROCESS
o Long term and short-term goals
- Long term: Client will gain 5lbs by April
25
- Short term: Client will gain 1lbs at the
end of the week.
Relationship of goals or desired outcomes
to nursing diagnoses:
o Goals derived from diagnostic labels
o Diagnostic labels contain the unhealthy
response (problem).
o Goal is the opposite, a healthy response is
achieved (observable, time-limited).
o Achieving a goal demonstrates resolution of
the problem.
Subject Verb
Conditions or Criterion of desired
modifiers. performance
1. Write in terms of how the client responded.
2. Must be realistic
3. Ensure compatibility with therapies of other
professionals.
4. Derive from only one nursing diagnosis.
5. Use observable, measurable items.
6. Make sure client considers goals important
S.M.A.R.T – Specific, Measurable, Attainable,
Realistic, Time-bound
Selecting nursing interventions:
o Actions nurse performs to achieve goals.
o Focus on eliminating or reducing etiology of
nursing diagnosis.
o Treat signs and symptoms and defining
characteristics
o Intervention for risk nursing diagnoses should
focus on reducing client’s risk factors.
Types of nursing interventions
1. Independent – Those activities that nurses
are licensed to initiate on the basis of their
knowledge and skills.
2. Dependent – Activities carried out under
physician’s orders or supervision or
according to specific routines.
3. Collaborative – Actions that the nurse
carries out in collaboration with other health
team members.
Selecting of nursing interventions & Activities
o Considering the Consequences of Each
Intervention
o choose those that are most likely to
achieve the desired client outcomes’
o Requires nursing knowledge and
experience.
3

Planning – A deliberative, systematic phase of the
nursing process that involves decision making and
problem solving.
Nursing Intervention – Any treatment based
upon clinical judgement and knowledge that a
nurse performs to enhance client outcomes.
1) Initial Planning – Usually performed by the
nurse during admission.
2) Ongoing Planning – Done by all nurses who
work with the client. Occurs at the beginning of
a shift.
3) Discharge Planning – Process of anticipating
and planning for needs after discharge.
Involves comprehensive and ongoing
assessment.
Developing Nursing Care Plans
o Informal nursing care plan
A strategy for action that exists in nurse’s
mind.
o Formal Nursing Care Plan
Written or computerized guide.
o Standardized care plan
A formal plan that specifies actions for a
group of clients with common needs.
o Individualized care plan
Tailored to meet the unique needs of a
specific client
Standardized approach to care planning
- Established to ensure minimal criteria for
care are met.
- Established for efficient use of time.
- Standards of care:
a. nursing actions for clients with similar
medical conditions.
b. achievable rather than ideal nursing
care.
c. interventions for which nurses are
accountable.
d. Usually, there are agency records that
may be referred to in the client's care
plan.
e. written from the perspective of the
nurse’s responsibilities.
f. do not contain medical interventions.
g. kept with the client's individualized care
plan, then permanent medical record.
h. provide detailed interventions.
i. written in the nursing process format.
o Indicate actions commonly required for a
particular group of clients.
o May include both primary care provider’s
orders and nursing interventions.
o Ex. Protocol for admitting a client to the
intensive care unit.
Policies and procedures:
o developed to govern handling of frequently
occurring situations.
o cover situations pertinent to client care.
o ex: policy specifying the number of visitors a
client may have.
Standing order:
o written document
o policies
o rules
o regulations
o orders regarding patient care
o gives the nurse authority to carry out specific
actions under certain circumstances.
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