Writing : Nursing Intervention

Learning Objectives
After completed this chapter, students will be able to:
1. Writing demographic data of a patient
2. Writing nursing intervention of a patient.

What Are Nursing Interventions?

Nursing interventions are actions that nurses take to promote health, prevent disease,
and help patients heal and recover from illness and injury.

In other words, interventions are the things that nurses do to care for their patients.
Ideally, they’re evidence-based and are aimed at achieving specific outcomes.

Common nursing interventions include:

 Providing patient education

 Administering medication
 Maintaining a safe environment

Nurses play an important role in promoting self-care and helping patients to make
lifestyle changes that can improve their overall health and well-being. Nursing
interventions are tailored to meet the needs of each patient, family, or group and can be
modified as the patient’s or family’s needs change.

How to Write a Nursing Care Plan

Before writing a nursing care plan, determine the most significant problems affecting
the patient. Think about medical problems but also psychosocial problems. At times, a
patient's psychosocial concerns might be more pressing or even holding up discharge
instead of the actual medical issues.

After making a list of problems affecting the patient and corresponding nursing
diagnosis, determine which are the most important. Generally, this is done by
considering the ABCs (Airway, Breathing, Circulation). However, these will not
ALWAYS be the most significant or even relevant for your patient.
Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and
objective data. Subjective data is what the patient tells us their symptoms are,
including feelings, perceptions, and concerns. Objective data is observable and
measurable.

This information can come from,

 Verbal statements from the patient and family

 Vital signs

o Blood pressure

o Heart rate

o Respirations

o Temperature

o Oxygen Saturation

 Physical complaints

o Pain

o Headache

o Nausea

o Vomiting

 Body conditions

o Head-to-toe assessment findings

 Medical history

 Height and weight

 Intake and output

  Patient feelings, concerns, perceptions

 Laboratory data

 Diagnostic testing

o Echocardiogram

o X-Ray

o EKG

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that
best fits the patient, the goals, and the objectives for the patient’s hospitalization.

According to North American Nursing Diagnosis Association (NANDA), defines a

nursing diagnosis as “a clinical judgment about the human response to health
conditions/life processes, or a vulnerability for that response, by an individual, family,
group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps

prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the
patient’s problems through nursing implementations are determined in the next step.

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on
evidence-based practices. SMART is an acronym that stands for,

 Specific

 Measurable

 Achievable

 Relevant

 Time-Bound
It is important to consider the patient’s medical diagnosis, overall condition, and all of
the data collected. A medical diagnosis is made by a physician or advanced
healthcare practitioner. It’s important to remember that a medical diagnosis does not
change if the condition is resolved, and it remains part of the patient’s health history
forever.

Examples of medical diagnosis include,

 Chronic Lung Disease (CLD)

 Alzheimer’s Disease

 Endocarditis

 Plagiocephaly

 Congenital Torticollis

 Chronic Kidney Disease (CKD)

It is also during this time you will consider goals for the patient and outcomes for the
short and long term. These goals must be realistic and desired by the patient. For
example, if a goal is for the patient to seek counseling for alcohol dependency during
the hospitalization but the patient is currently detoxing and having mental distress - this
might not be a realistic goal.

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the
patient achieve the goals. While some of the actions will show immediate results (ex.
giving a patient with constipation a suppository to elicit a bowel movement) others might
not be seen until later on in the hospitalization.

The implementation phase means performing the nursing interventions outlined in the
care plan. Interventions are classified into seven categories:

 Family

 Behavioral
  Physiological

 Complex physiological

 Community

 Safety

 Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are
completed each shift for every patient:

 Pain assessment

 Position changes

 Fall prevention

 Providing cluster care

 Infection control

Step 5: Evaluation

The fifth and final step of the nursing care plan is the evaluation phase. This is when
you evaluate if the desired outcome has been met during the shift. There are three
possible outcomes,

 Met

 Ongoing

 Not Met

Based on the evaluation, it can determine if the goals and interventions need to be
altered. Ideally, by the time of discharge, all nursing care plans, including goals should
be met. Unfortunately, this is not always the case - especially if a patient is being
discharged to hospice, home care, or a long-term care facility. Initially, you will find that
most care plans will have ongoing goals that might be met within a few days or may
take weeks. It depends on the status of the patient as well as the desired goals.
Consider picking goals that are achievable and can be met by the patient. This will help
the patient feel like they are making progress but also provide relief to the nurse
because they can track the patient’s overall progress.