NURSING PROSES

CDH

Planning
Planning is to formulate the way to manage the problem
The third step of the nursing process includes the
formulation of guidelines that establish the proposed
course of nursing action in the resolution of nursing
diagnoses and the development of the clients plan of care.
Planning consists three stage:
- Initial planning
- On-going planning
- Discharge planning

Step of Planning
Initial planning
- Done by the nurse who perform admission assessment in
order to prioritize problem, identity goals and correlate
nursing care to resolve the problem
Ongoing planning
- Involves continuous updating of the clients plan of care.
Every nurse who cares for the client is involved in ongoing
planning
Discharge planning
- Involves anticipation and planning for the clients after
discharge

Elements of Planning
Prioritizing the problems/ nursing diagnosis
Formulate goals/desired outcomes
Short term ( to resolve in few hours or days )
Long term ( to resolve over weeks or month )
Select nursing intervention
Write nursing intervention

Example of goals/ outcomes to relieve

problem
Problem statement of the
Related patient
Nursing Diagnosis

Goal/Outcome

Pain

Within 8 hours, patient will

report pain is absent or
diminished

Imbalanced Nutrition More

Than body Requirement

Impaired Physical Mobility

By 1/12/16, patient will reach

target weight of 20-30gm
Before discharge, patient will
ambulate length of hallway
independently

Evaluation
The last phase of the nursing process which
include the judgment of the effectiveness of
nursing care to meet client goals based on
the clients behavioural responses
This step determine the success/effectiveness
of the whole nursing process and the decision
either to continue, modify or repeat the
process is depend on evaluation

Evaluation
While documenting evaluation phase, the
nurse can draw one of the three possible
conclusion
The goal was met,
- Either a short term goal was achieved but
the long term was not, or the desired
outcome was not only partially attained
- The goal was not met

assessm NURSING
ent
DIAGNOS
Innefective
breathing
patern
related to
decrease
pulmonary
blood flow.

GOAL

INTERVENTION

EVALUATION

Maintain of
adequate
respiratory status.
Patern airway is
achieve and there
is improvement in
the airway
clearance

1. Perform endotracheal
suctioning to reduce
secretion effectively.
2. Position infant with
affected side down to
aid ventilation of the
good lung.
3. Monitor saturation.
4. Monitor blood gases as
ordered.

Suction PRN
to allow
unaffected
lung
expansion.
Show normal
blood gases.

Infant will
receive
adequate fluid
and
electrolyte.

1. Maintain
strict intake
output
chart
2. Adminitrate
d iv drip as
odered
3. Monitor
blood
glucose
4hly
4. Monitor
serum
electrolyte.

Exhibits
Fluid volume
evidence of
deficit related
balance fluid
to disease
-normal serum
electrolyte
-normal urine
output

Nursing diagnose

goal

Acute pain related

to surgical
intervention

less of pain

intervention

evaluation
Less pain

1.Administrated pain
medication as indicated
and ordered.
2.Minimal handling.
3.Reduce invasive
procedur.

Risk of infection Infant free from

due to incision
infection.
side.
(post op)

1. Monitor vital
No infection
sign.
2. Monitor sign and
symptom of
infection.
3. Administrated
antibiotic as
ordered.
4. Individual item.
5. 5 movement
Hand hygiene to
prevent
nosocomial
infection.

Nursing
diagnose

goal

intervention

Activity
Exhibits increasing 1. Provide minimal
intolerance related activity tolerance
stimulation
to ventilator
environment.
compromise,
2. Minimize
environmental
conversation at
stimulation.
bedside.
3. Cluster care as
tolerate.
4. Dim light or darken
room.
5. Minimal handling.

evaluation
Baby reduce
stress and
calm.

Knowledge
deficit related to
infant condition
course and
management

Parents maintain 1. Discuss

Parent
active
disease
understood
involvement in
process with and
discussion of
parent
compliance
their infants
2. Discuss
with treatment
care
managemen
t strategies
as they are
implemente
d or
questioned
by parents