Nursing taxonomy

 This is theoretical study of systematic classifications including

their bases, principles, procedure and rules.
 A way of classifying things into categories
 In nursing, the body responsible for classifying nursing

diagnosis, intervention and outcome internationally is the

NANDA (North America Nurses Diagnosis Association).
Nursing process
 The nursing process is a deliberate, problem-solving
approach to meeting the health care and nursing needs of
patients.
 It involves assessment (data collection), nursing diagnosis,

planning, implementation, and evaluation

 The process as a whole is cyclical, with the steps being

interrelated, interdependent, and recurrent

Scenario
 Madam Pretty Ama reports to the out-patient department of
Salaga Municipal hospital where you work. She said ‘I am so
tired’ and was diagnosed of hypertension by the medical
doctor.
 An excerpt of the assessment data collected by the nurse for

Madam Ama is presented below;

Cont.
‘Madam Pretty Ama, I dislike fruit’, 65 years of age, house wife, ‘
patient’s parents both have high blood pressure, husband (Kofi, a
laborer), 2 children, has financial problems paying bills and buying food,
height 5’1”, BP- 200/110mmHg, family income below the state poverty
level, states pants heavily after climbing one flight of stairs recently, skin
pale and warmth to touch, responsibly for cooking, weighed 80kg,
favorites foods are fried rice, pizza, indome, no regular eating schedule,
a Frafra by tribe, a committed Adventist, severe headache a day ago.
Cont.
Categories the assessment data under the following headings
1. Patient’s biographical data
2. Family medical and socio-economic history
3. Life styles and hobbies
4. Patient’s present medical history
Types of assessment
 Initial assessment: Performed within specified time after
admission to a hospital to establish a complete database for
problem identification, reference, and future comparison.
Example is nursing admission assessment
 Problem-focused assessment: This is ongoing process

integrated with nursing care to determine the status of a

specific problem identified in an earlier assessment. For
examples include hourly assessment of patient’s fluid intake
and urinary output in critical units and assessment of client’s
ability to perform self-care while assisting a client to bathe
Emergency assessment
 This is performed during any physiological or psychological

crisis of the patient to identify life-threatening problems and

new or overlooked problems.
 Examples includes; rapid assessment of an individual’s

airway, breathing status, and circulation during a cardiac

arrest and assessment of suicidal tendencies or potential for
violence
Time-lapsed reassessment
 This is performed several months after initial assessment to

compare the client’s current status to baseline data previously

obtained
Phases of the nursing process
NURSING DIAGNOSIS
 This is the second phase of the nursing process and it
involves making conclusion from the assessment.
 The nursing diagnosis is the nurse’s clinical judgment about

actual and potential health or life process occurring with

client (individual, family, group and community).
Con’t
 The nursing diagnosis can also be defined as a description of
the client/family health problem.
 It is formulated by adding the related cause or factor to the

health problem.
 NANDA upgrades and provides lists of approved nursing

diagnosis periodically.
 This serves as a guide for writing nursing diagnosis
Purpose of diagnosis

 To identify patient strengths and health problems

 To develop a list of nursing problems
Nursing activities
 Interpret and analyze data
 Identify patient’s strengths, risks, and actual problems
 Formulate nursing diagnostic statements
 Document nursing diagnoses on the care plan
Analyzing data
 This involves clustering or grouping of patient’s data and
comparing the data to standards or norms
Data cluster or group data
 Data clustering is the process the nurse uses to group related

data. These data are usually signs and symptoms indicating a

general problem.
 The nurse cluster data as they related to the client’s mental

status, individual body systems, and risk factors family data.

 For example; dyspnea, fatigue, pallor, and weakness, which

pertain to problems with oxygenation
Comparing data with standards
 Base on the nurse/midwife knowledge and experience, data
collected from the patient is compared with standards and
norms to identify important and appropriate cues.
1. growth and development patterns
2. normal vital signs
3. laboratory values.
Compare data against standards

 For example; amber, clear urine verses cloudy urine or tea

colored urine.
Identification of Client’s Health Problems and Strengths

Client health problems

 The client health problems are his/her unmet health needs.

 The health need may be physiological (limited mobility),

psychological (anxiety), social (social isolation), or spiritual
(inability to pray).
Types of patient’s health problem
Actual health problem
 This refers to health problems that presently exist and are

being experienced at the time of nursing assessment

Cont.
Risk patient’ health problem
 These are problems that are likely to develop or occur and

therefore needs immediate intervention to prevent its from

occurrence.
Cont.
The patient’s health problems should be stated in a narrative or
statement form.
For examples;
1. Patient is weak
2. Patient is anxious
3. Patient is restless
4. Patient says ‘I can’t sleep at night’
Case scenario
 Miss. Pretty Ama, a 40 year old house wife who lives with her
husband a retired policeman and 2 unemployed grow up children in
a two bed room apartment, was admitted into the female medical
ward of Salaga Municipal hospital with the diagnosis of severe
hypertension.
 She complaints of frequent vomiting and inability to sleep at night

due to severe headache unless she takes hot bath. She also
complaints of inability to pay her hospital bill and buy food and that
her figure nails breaks easily.
 Her best foods are fry rice and Tuo-Zaafi with groundnut soup. She

tolerates oral fluids. She said, she dislikes vegetable, meat and
fruits.
Cont.
 She said, she recently experienced hives, pruritus and
shortness of breath after taken penicillin she bought from the
drug store and not has not drunk alcohol for the past 1 week.
 On examination, she weight 80kg, height: 4’2’’, temperature

38.7, respiration 25, pulse 89 and blood pressure of

180/100. She looks pale, warm to touch and with unkempt
hair
Patient’s Strengths
 Client strengths are elements or factors related to the client
that facilitates nursing care of the clients.
 The two types of clients strengths are; general and specific

strengths.
 Specific client strengths: Factors that helps with solving the

identified health problems of client/family.

Con’t
 They related to the client health problem
 e.g. client having severe diarrhoea but can drinks copious

amount of fluids, client with abdominal pain but relieve pain

by changing position.
 General client strengths are those strengths which do not

directly related to client health problem

 e.g. client benefitting from the national health insurance
Con’t
 Client strengths may include healthy physiological, emotional
health, cognitive abilities, coping skill, internal strengths and
spiritual strengths, presence of support persons, adequate
finances and healthy environment.
 These client strengths are considered at the nursing care

planning stage.
 What can client do for self e.g. eating, where client need help

e.g. bathing.
Case scenario
 Miss. Pretty Ama, a 40 year old house wife who lives with her
husband a retired policeman and 2 unemployed grow up children in
a two bed room apartment, was admitted into the female medical
ward of Salaga Municipal hospital with the diagnosis of severe
hypertension.
 She complaints of frequent vomiting and inability to sleep at night

due to severe headache unless she takes hot bath. She also
complaints of inability to pay her hospital bill and buy food and that
her figure nails breaks easily.
 On examination, she weight 80kg, height: 4’2’’, temperature 38.7,

respiration 25, pulse 89 and blood pressure of 180/100. She looks

pale, warm to touch and with unkempt hair
Cont.
 Shesaid, she recently experienced hives, pruritus and
shortness of breath after taken penicillin she bought from the
drug store and not has not drunk alcohol for the past 1 week.
Formulating Diagnostic Statements
 The statement of the nursing diagnosis identifies an actual or
potential health problem, deficit, or area of concern that may
be amenable to nursing actions.
 It is a statement of client’s potential or actual alteration of

health status.
Components of Nursing Diagnosis
 Problem( Diagnostic Label)-based on your assessment of
client (collected data), pick a problem from the NANDA
list...
 Etiology- determine what the problem is caused by or
related to (R/T)...
 Defining characteristics- then state as evidenced by (AEB)
the specific facts the problem is based on...
Categories of Nursing Diagnosis
 One-part nursing diagnosis e.g. insomnia, pain, anxiety
 Two-part nursing diagnosis e.g. limited mobility related to

severe joint pain

 Three-part nursing diagnosis e.g. fluid volume deficit related

to severe diarrhoea, vomiting manifested by sunken eyes and

bodily weakness
Formulating a nursing diagnosis
1. For the two-part nursing diagnosis: Problem (Diagnostic
Label) plus + (related to) Etiology
2. For the three-part nursing diagnosis: Problem (Diagnostic
Label) plus + (related to) Etiology + as evidenced by (AEB)
defining characteristics
NDx = problem (p) + Etiology
The plus (+) sign is substituted with “related to” (RT)
TYPES OF NURSING DIAGNOSIS

ACTUAL NURSING DIADNOSIS

 A clinical judgment about the client’s response to a health

problem that is present at the time of nursing assessment.

 For example Incisional pain related to surgical incision
RISK NURSING DIAGNOSIS
A clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to
develop.
 For example;

1. Risk for fluid volume deficit related to severe diarrhoea

2. Risk for injury related to impaired mobility and disorientation
Wellness diagnosis
 Identifythe individual or aggregate condition or state that
may be enhanced by health promoting activities.
 These consist of a one-part statement use the word potential

for enhanced.
 For example; if a patient says ‘I wish I were a better parent ’
 The nursing diagnosis will be ‘potential for enhanced

parenting
Qualifiers and meaning
These are words used to describe changes in condition or state .
They have been added to some NANDA labels or problem
statement to give additional meaning to the diagnostic
statement
 Decease – smaller in size
 Increase – greater in size
 Excessive – greater than necessary
 Deplete – emptied
Con’t
 Disturbances – agitate, interrupt
 Altered – a change from baseline
 Ineffective – not producing the desired effect
 Deficient – inadequate in amount, quality
 Impaired – made worse, weakened, deteriorated
 Acute – severe, sudden
 Compromise – takes vulnerable to treat
Guidelines for writing nursing diagnosis
statements
 Write statements in terms of a problem instead of a need. For
example;
 Correct: - Deficient fluid volume related to high body

temperature
 Incorrect: - Fluids replacement related to high body

temperature
 Write the statement so that it is legally acceptable. For

example;
 Correct: Impaired skin integrity related to immobility
 Incorrect: impaired skin integrity related improper positioning
Cont.
 Avoid using judgmental statements. For example;
 Correct: Spiritual distress related to inability to attend church services
secondary to immobility
 Incorrect: Spiritual distress related to strict rules necessitating church
attendance
 Be sure both elements of the statement do not say the same thing. For
example;
 Correct: Impaired skin integrity related to immobility
 Incorrect: Impaired skin integrity related to ulceration of the scapular
 Be sure cause and effect are stated correctly. For example;
 Correct: Pain (severe headache) related to increased intracranial pressure
 Incorrect: Severe pain related headache
Cont.
 Write the diagnosis specifically and precisely
 Correct: Impaired oral mucus membrane related to decreased
salivation secondary to radiation therapy of neck.
 Incorrect: Impaired oral mucus membrane related to noxious
agent
 Use nursing terminology rather than medical terminology in
writing nursing diagnosis. For example;
 Correct: Risk for ineffective airway clearance related to
accumulation of secretion in the lungs
 Incorrect: Risk for ineffective airway clearance related to
pneumonia
SAMPLES OF NANDA DIAGNOSTIC LABEL
 Interrupted family processes
 Ineffective relationship
 Risk for ineffective relationship
 Readiness for enhanced relationship
 Parental role conflict
 Ineffective role performance
 Impaired social interaction
 Sexual dysfunction
 Ineffective sexuality pattern
 Risk for allergy reaction
Cont.
 Risk for latex allergy reaction
 Hyperthermia
 Hypothermia
 Risk for hypothermia
 Risk for perioperative hypothermia
 Ineffective thermoregulation
 Risk for ineffective thermoregulation
 Readiness for enhanced comfort
 Nausea
 Acute pain
 Chronic pain
Cont.
 Impaired verbal communication
 Hopelessness
 Readiness for enhanced hope
 Risk for compromised human dignity
 Disturbed personal identity
 DIFF. BETWEEN MEDICAL DIAGNOSIS AND NURSING DIAGNOSIS

Medical diagnosis Nursing diagnosis

1. Is the identification of a disease condition based 1. Nursing diagnosis identifies any of the client’s
on a specific evaluation of signs, symptoms, history, health care needs for which the nurse may provide
laboratory tests and procedures care either independently or in conjunction with
other health care provides,.

2. The goals of a medical diagnosis are to identify 2. The goal of nursing diagnosis is to identify actual
and cure the pathological process and potential health problems of the client.

3. The objectives of medical diagnosis are to 3. The objective of a nursing diagnosis is to develop
prescribe treatment and cure the client. a plan of care so that the client and family are able
to adapt to changes resulting from health.

4. The focus of medical diagnosis is curative 4. Nursing diagnosis focuses on helping the client
reach a maximal level of wellness

5. Stay the same as long as the diseases is present 5. Change from day to day as the client’s response
Definition of some nursing diagnoses
1. In effective breathing pattern related to increase rate of
respirations associated with fear and anxiety, and feeling of
air hunger
2. Impaired gas exchange related to narrowing or obstruction of
small air ways
3. Ineffective airway clearance related to Narrowing of the air
ways associate with excessive mucous production,
inflammation and bronchospasm
Cont.
 Inspiration and /or expiration that does not provide adequate
ventilation; inability to clear secretions or obstructions from
the respiratory track to maintain a clear airway.
cont.
ACTIVITY INTOLERANCE related to tissue hypoxia associated with
impaired gas exchange, Inadequate nutrition status
 Difficulty resting and sleeping associated with dyspnea,

excessive coughing, fear, anxiety, treatment and side effects of

medications therapy.
 Increased energy expenditure associated with strenuous

breathing effort and persistent coughing

Definition
 Insufficient physiological or psychological energy to endure or

complete desired daily activities.

Cont.
FEAR / ANXIETY
 Definition
 Fear: Response to perceived threat that is consciously

recognized as a danger
 Anxiety: Vague, uneasy feeling of discomfort, dread

accompanied by an autonomic response (the source is often

nonspecific or unknown to the individual) a feeling of
apprehension caused by anticipation of danger. It is an
alerting signal that warns of impending danger and enables
the individual to take measures to deal with the threat.
PLANNING PHASE
 This is the third step of the Nursing Process.
 Planning is the developing and producing a working

document to guide nursing care.

 It entails the setting of client care objectives or outcome

criteria and writing out the nursing care strategies or actions

on paper to form the plan of care.
Types of Planning
Initial Planning
 The nurse who performs the admission assessment usually

develops the initial comprehensive plan of care.

 This nurse has the benefit of seeing the client’s body

language and can also gather some intuitive kinds of

information that are not available solely from the written
database.
 Planning should be initiated as soon as possible after the

initial assessment.
Cont.
Ongoing Planning
 All nurses who work with the client do ongoing planning. As

nurses obtain new information and evaluate the client’s

responses to care, they can individualize the initial care plan
further.
 Ongoing planning also occurs at the beginning of a shift as

the nurse plans the care to be given that day.

Cont.
Using ongoing assessment data, the nurse carries out daily
planning for the following purposes: to………
◦ Determine changes in the health status
◦ Set priorities for the client’s care during the shift
◦ Decide which problems to focus on during the shift
◦ Plan nursing activities during the shift
Cont.
Discharge Planning
 Discharge planning, the process of anticipating and planning

for needs after discharge, is a crucial part of a comprehensive

health care plan and should be addressed in each client’s care
plan.
 Because the average stay of clients in acute care hospitals has

become shorter, people are sometimes discharged still needing

care.
 Although many clients are discharged to other agencies (e.g.,

long-term care facilities), such care is increasingly being

delivered in the home.
Cont.
 Effective discharge planning begins at first client contact and
involves comprehensive and ongoing assessment to obtain
information about the client’s ongoing needs.
 It includes: follow up care, referral, medications, diet

modifications, significant other/care provider, and health

teachings, which signs and symptoms to watch for.
Nursing activities
 Prioritizeproblems/diagnosis
 Formulate goals/desired outcome
 Selecting nursing interventions
 Writing nursing care plan
Setting priorities
 The process of establishing a preferential order for nursing
strategies.
 As soon as patient’s problems are identified, priorities are set

to provide direction for nursing intervention.

 Life-threatening problems should be given highest priority
 ABC’s (airway, breathing, circulation)
Cont.
 Maslow’s hierarchy of needs i.e. physiology, safety, social,
esteem and self actualization
 Unstable clients verse clients with stable conditions
 Actual problems verses risk concerns
Establishing outcomes (goals/objectives)
 This refers to formulating and documenting measurable,
realistic, client-focused goals.
 The nurse and patient set realistic and measurable expected

outcomes, which are derived from the diagnosis

 It provides the basis for evaluating nursing diagnosis and

interventions
GOALS
A client goal, thus is a broad statement of expected or desired
changes in his health status after he/she receives nursing
care.
 In the nursing process, a goal is the desired outcome of

nursing interventions
Purpose of goal
 Provide direction for planning nursing interventions.
 Ideas for interventions come more easily if the desired

outcomes state clearly and specifically what the nurse hopes

to achieve.\
 Serve as criteria for evaluating client progress.

 Although developed in the planning step of the nursing

process, desired outcomes serve as the criteria for judging

the effectiveness of nursing interventions and client progress
in the evaluation step
Cont.
 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.
 As goals are met, both client and nurse can see that their

efforts have been worthwhile.

Types of client’s goals
1. Short- term
 What can be achieved in relatively short time period; before

patient is discharge.
 Can be met fairly and quickly (hours to days)

E.g.
 Patient will demonstrate relieve of pain within 24 hours
 Patient will sleep without difficulty at night within 24 hours
 Patient will raise left arm to shoulder height in 3 days.
Cont.
Long-term
 These take long time to achieve and involve prevention, patient

teaching and rehabilitation. It covers a longer period of time.

For example
 Patient will gain skills in self-administration of injection insulin

on discharge
 Patient will recover without complications by the time of

discharge
 Patient will remain free of infection throughout the period of

hospitalization
 Patient will regain full use of the left arm in 5 weeks
Outcome Criteria/Objectives
 This is necessary to make the goals specific and directed
towards the desired and expected behaviour change.
 A criterion is a standard that can be used in judging outcome

criteria. They are statements that describe specific,

observable, measurable responses of the client
 They determine whether the stated goals have been achieved

and are therefore essential to the process of evaluation.

Cont.
 The objective should be stated exactly the behaviour you want
to see in the patient.
The objective has to be SMART
S – Specific – should be well defined and easy to identify
M – Measurable – quantify the goal
A – Achievable -
R – Realistic – should be relevant to your overall vision
T – Time bound – should have time frame
cont
For example;
Patient will eats 75% of meal serve within 72 hours
Patient will state pain level is acceptable 6 (0-10) within 24
hours
Components of goal/desired outcome statements

Subject: - This refers to the patient, any part of the patient, or some
attribute of the patient such as the patient’s pulse or urinary output.
Verb: - This specifies an action the patient is to perform, for
example, what the patient is to do, learn, or experience.
1. Choose

2. Identify

3. Sleep

4. Compare

5. Inject

6. State
Examples of action verbs
 Apply  Define
 Drink  List
 Select  Talk
 Explain  Demonstrate
 Share  Move
 Breathe  Transfer
 Help  Describe
 Sit  Turn
 Discuss  Differentiate
 Report  Prepare
 Verbalize
Cont.
Conditions or modifiers
 Conditions or modifiers may be added to the verb to explain the

circumstances under which the behavior is to be performed.

They explain what, where, when, or how.
For example
1. Walks with the help of a cane (how)

2. After attending two group diabetes classes, lists signs and

symptoms of diabetes (when)
3. When at home, maintains weight at existing level (where)

4. Discusses food pyramid and recommended daily servings (what)

Cont.
Criterion of desired performance.
 The criterion indicates the standard by which a performance is

evaluated or the level at which the client will perform the

specified behavior.
 These criteria may specify time or speed, accuracy, distance,

and quality.
Sample
Subject Verbs Modifier Criterion

Patient States The purpose of his medications Before discharge

Patient Walks The length of the hall without a By the date of discharge
cane

Patient Administers Correct insulin using aseptic technique

Patient’s ankle
Identifies Foods rich in salt from a Before discharge

prepared list

Patient
Drinks 2,500 mL of fluid Daily
Guidelines for writing goals/desired outcomes
1.Write goals and outcomes in terms of client responses, not
nursing activities.
 Beginning each goal statement with ‘The client will
 This help focus the goal on patient behaviors and responses.
Cont.
 Avoid statements that start with enable, facilitate, allow, let,
permit, or similar verbs followed by the word client.
 These verbs indicate what the nurse hopes to accomplish, not

what the client will do.

 Correct: The client will drink 100 mL of water per hour (client

behavior).
 Incorrect: Maintain client hydration (nursing action).
Cont.
2. Be sure that desired outcomes are realistic for the client’s
capabilities, limitations, and designated time span, if it is
indicated.
 Limitations refers to finances, equipment, family support,
social services, physical and mental condition, and time.
For example
 The outcome “Measures insulin accurately” may be unrealistic

for a client who has poor vision due to cataracts

Cont.
3. Ensure that the goals and desired outcomes are well-matched
with the therapies of other professionals.
For example
 The outcome “The client will increase the time spent out of

bed by 1hour each day”

 Isnot compatible with the doctor’s prescribed therapy of
complete bed rest.
Cont.
4. Make sure that each goal is derived from only one nursing
diagnosis.
For example
 The goal “The client will increase the amount of nutrients

ingested and show progress in the ability to feed self” is

derived from two nursing diagnoses, thus;
 Imbalanced Nutrition: Less than Body Requirements
 Feeding Self-Care Deficit.
Cont.
 Keeping the goal statement related to only one diagnosis
facilitates evaluation of care by ensuring that planned nursing
interventions are clearly related to the diagnosis.
Cont.
5. Use observable, measurable terms for outcomes.
 Avoid words that are vague and require interpretation or

judgment by the observer.

For example
 Phrases such as increase daily exercise and improve

knowledge of nutrition can mean different things to different

people.
Selecting nursing interventions / nursing orders
 Nursing intervention are activities that will most likely
produce the desired outcome or objective.
 It is any direct care, treatment that the nurse performs on

behalf of a client
 Any act by the nurse that implants the nursing care plan or

any specific objective of the plan.

Nursing orders
 Specific instructions or individualized activities nurse
performs on a patient to achieve health care goals/objectives
written in the form of orders/commands.
 Also, nursing orders describe the specific actions or activities

which are to be done by all nurses caring for that patient. The
orders should be appropriate in achieving the objective.
 The time element will define how long the nursing activity will

occur. Action verbs like; monitor, instruct, encourage, etc.

should be used and the part of the body where and what of
the order
Types of nursing interventions
1. Independent nursing actions
- activities nurses are licensed to carry out.
2. Dependent
- activities carried out under medical orders e.g.
medications, IV therapies, diagnostic tests, treatments,
special diet and activity.
3. Collaborative
- nurse carries out in collaboration with other health
personnel, physiotherapists, social workers dieticians,
physicians.
Writing a nursing care plan
 A care plan is a written summary of the care that a client is to
receive. It is the blueprint of the nursing process.
 A nursing care plan is a part of nursing process which outlines

the plan of action that will be implemented during a patient’s

medical care.
 The plan of care is a step-by-step process evidenced by the

following; sufficient data are collected to support nursing

diagnosis and at least one goal must be started for each
nursing diagnosis.
Purposes of the nursing care plan
 To provide direction for individual care of the patient; the plan
is organized according to each patient’s unique nursing care
needs
 To provide for continuity of care: the care plan is a means of

communicating and organizing the actions of a constantly

changing nursing staff
 To provide direction about what needs to be documented on

the patient progress notes. The care plan specifically outlines

which observation, what nursing action to carry out, and what
instructions the patient or family members require
 To serve as a guide for assigning staff to care for the patient
Format of the nursing care plan
 Nursing diagnosis
 Goal (objective/outcome criteria)
 Nursing orders
 Nursing intervention
 Evaluation
Cont.
 Date and sign the plan. The date the plan is written is
essential for evaluation, review, and future planning. The
nurse’s signature demonstrates accountability to the client
and to the nursing profession, since the effectiveness of
nursing actions can be evaluated.
 Use category headings. “Nursing Diagnoses,”

objective/Outcomes criteria,” “Nursing orders and

Interventions,” and “Evaluation”.
 The evaluation of each goal must have date
Cont.
 Use standardized/approved medical or English symbols and
key words rather than complete sentences to communicate
your ideas unless agency policy dictates otherwise.
For example, write “Turn and reposition q2h” rather than “Turn
and reposition the client every two hours.”
Cont.
 Be specific. Because nurses are now working shifts of different
lengths, with some working 12-hour shifts and some working
8-hour shifts, it is even more important to be specific about
expected timing of an intervention.
 If the intervention reads “change incisional dressing q shift,” it

could mean either twice in 24 hours, or three times in 24

hours, depending on the shift time.
Cont.
 This miscommunication becomes even more serious when
medications are ordered to be given “q shift.” Writing down
specific times during the 24-hour period will help clarify.
 Refer to procedure books or other sources of information

rather than including all the steps on a written plan. For

example, write “See unit procedure book for tracheostomy
care,” or attach a standard nursing plan about such
procedures as radiation-implantation care and preoperative or
postoperative care.
Cont.
 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 the methods used are included.
For example
 “Provide pineapple juice at breakfast rather than other juice”
 This shows that, the client was given a choice of beverages.
Cont.
 Ensure that the nursing plan incorporates preventive and
health maintenance aspects as well as restorative ones.
For example
 Provide active-assistance ROM exercises to affected limbs

q2h”
 preventing joint contractures
 maintaining muscle strength and joint mobility.
Cont.
 Ensure that the plan contains ongoing assessment of the
client
 e.g., “Inspect incision q8h”.
 Include collaborative and coordination activities in the plan.

 For example, the nurse may write interventions to ask a

nutritionist or physical therapist about specific aspects of the

client’s care.
Cont.
 Include plans for the client’s discharge and home care needs.
 The nurse begins discharge planning as soon as the client has

been admitted.
 It is often necessary to consult and make arrangements with

the community health nurse, social worker, and specific

agencies that supply client information and needed
equipment.
Case scenario
Miss. Pretty Ama, 1 ½ -year old girl was rushed into the Paediatric ward of Salaga
Municipal Hospital with the history of passing watery stool for the past 2 days. She
breast feed normally and could take in small amount meal served. Her vital signs were
checked and recorded as; temperature-39.50c, pulse- 100bpm and respiration-
26cpm. She weighed 10kg, 2kg less than her normal body weight. The mother
expressed fear of losing her child. The mother could mob the child with wet towel and
report to the nurses.
Using the scenario above;
1. State 4 Health Problems and the corresponding strengths of Miss. Pretty Ama

2. Formulate Nursing Diagnoses of the health problems identified in (a) above

3. What will be the objectives\outcome criteria of the Nursing Diagnoses formulated

in (b) above
NURSING CARE PLAN
 CANDIDATE’S INDEX NUMBER……………………………………….CANDIDATE’S SIGNITURE…………………………...
 PERSONAL DATA
 NAME………………………………………….………. WARD……………….……. BED NO……………………………………
 IN- PATIENT NO…………………………………… AGE …………...... SEX……………….. RELIGION………………….
 OCCUPATION………………………………………… DIAGNOSIS……………………………………………………..………..
 PHYSICIAN/SURGEON………………….………. OPERATION……………………………………….…………………….
 DATE OF ADMISSION…………………..……….. DATE OF DISCHARGE………………………..……………………..


 PATIENT’S PROBLEMS
 …………………………………………………………………………………………………………………………………………………….
 …………………………………………………………………………………………………………………………………………………….
 …………………………………………………………………………………………………………………………………………………….
 …………………………………………………………………………………………………………………………………………………….


 ALLERGIES
 ……………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………


 PATIENT’S STRENGHTS
 …………………………………………………………………………………………………………………………………………………….
 …………………………………………………………………………………………………………………………………………………….
 …………………………………………………………………………………………………………………………………………………….
 …………………………………………………………………………………………………………………………………………………….


 ROUTINE CARE
 ROUTINE CARE: ………………………………………………………………………………………………………………………….
 TPR: ……………………………………………………………………………………………………………………………………………
 BP: ……………………………………………………………………………………………………………………………………………..
 DIET: …………………………………………………………………………………………………………………………………………..
 FLUIDS: ……………………………………………………………………………………………………………………………………….
 INTAKE AND OUTPUT: ………………………………………………………………………………………………………………..
 ORAL HYGIENE: …………………………………………………………………………………………………………………………..
 BATH: ………………………………………………………………………………………………………………………………………….
 URINE TESTING:……………………………………………………………………………………………................................
 BODY WEIGHT:………………………………………………………………………………………………….…………………….....
 ACTIVITY:……………………………………………………………………………………………………………………….…….
Care plan

Date & time Nursing diagnosis Objective/outcome criteria Nursing order Nursing intervention Evaluation
 Medical orders
MEDICATIONS OTHER TREATMENT INVESTIGATIONS

DATE ORDER DATE COMPLETED DATE ORDERED ORDER DATE COMPLETED DATE ORDERED INVESTIGATION RESULTS

ORDERED
 Cont.
Date and Nursing Objective/outcome Nursing order Nursing intervention Evaluation
Time diagnosis criteria

00/01/2022 Ineffective Patient will regain 1. Assess SPO2 and 1. SPO2 and capillary refill time 00/02/2022 @

@ 3.00pm tissue adequate tissue capillary refill time every two hourly 3pm

perfusion perfusion within 24 2. Provide a calm restful 2. Patient was nursed in a bed Goal fully met as

related to hours as evidence by; environment to reduce devoid of crumps and creases with Spo2 was 100%

increased 1. SPO2 reading within anxiety and promote rest the head end elevated and the with capillary

vascular normal limit (98% - 3. Encourage patient not number of visitors restricted refill time less

resistance 100%) take beverages high in 3. Patient was asked to avoid than 2 seconds

2. Capillary refill time caffeine intake of coffee, tea and cola

less than 2 seconds 4. Limit activity of patient 4. She was assisted to performed
IMPLEMENTATING

 Implementation is the fourth step of the nursing process

and involves putting the nursing strategies listed in the
care plan into action.
 The purpose of which is to carry out planned nursing

interventions to help the client attain goals and achieve

optimal level of health. It is actual initiation of the nursing
care plan.
Cont.
 During this phase the client is assessed to determine whether
the interventions are effective.
 Implementation requires some nursing skills which include;
 Cognitive skills: - This includes problem solving, decision

making, critical thinking & creativity

 Interpersonal: - verbal and nonverbal
 Technical skills: - skill like manipulating equipment, giving

injection bandaging and moving and repositioning

Nursing activities at this phase
 Reassessing the client
 Identifying areas of assistance
 Perform nursing intervention
 Supervision delegated nursing care
 Documenting nursing activities
Reassessing the client
 Assessment is a continuous process, each interaction with the
client provide data that reflect the client’s health problems.
Before carrying out an intervention, the nurse must reassess
the patient to make sure the intervention is still needed.
 The patient’s condition may have changed, though an order is

written on the care plan. For example, a client has a nursing

diagnosis of Disturbed Sleep Pattern related to unfamiliar
surroundings. During rounds, the nurse notices that the
patient is sleeping and therefore defers the back massage that
had been planned as a relaxation plan.
Cont.
 Whenever new data are assessed and new client needs is
identified, the nurse modifies the nursing care plan.
 For example, a nurse begins to teach a client who has

amputated lower limb how to work with crutches. Shortly after

beginning the teaching, the nurse realizes that he is not
confortable.
 Subsequent discussion reveals that he has chest pain.

Realizing that the client’s level of discomfort is interfering

with his learning, the nurse ends the lesson to examine the
client’s for pain.
Cont.
Identifying areas of assistance
 Most nursing situation requires the nurse to seek help of

some type.
 The assistance can be additional personnel, knowledge and

nursing skills.
Perform nursing interventions
 Explain to the client what interventions will be done, what
sensations to expect, what the client is expected to do, and
what the expected outcome is.
 For many nursing activities it is also important to ensure the

client’s privacy, for example, by closing doors, pulling

curtains, or draping the client.
 This activity involves scheduling client contacts with other

departments (e.g., laboratory and x-ray technicians, physical

and respiratory therapists) and serving as a liaison among the
members of the health care team.
Guidelines to follow when implementing nursing
intervention
 Base nursing intervention on scientific knowledge, nursing
research and professional standard of care
 Clearly understand the orders to be implemented and

question any orders that are not understood

 Adopt activity to the individual client
 Implement safe care
 Provide teaching, support and comfort
 Respect the dignity of the client
 Encourage the client to participate actively in the

implementation
Supervising delegated care
 If care has been delegated to other health care personnel, the
nurse responsible for all the client care must ensure that the
activities have been implemented according to the care plan
Documenting nursing care activity

 This is final stage of the implementation phase of the nursing

process where the nurses record all the intervention and client
responses in the nurse’s progress notes.
 Documentation is done immediately nursing activities are

carried out.
 This help safeguard the client to prevent double action
EVALUATION OF CARE
 Evaluation constitutes the last step of the nursing process.
 Evaluation is the appraisal of the client’s behavior changes

that are a result of the actions of the nurse.

 It is assessing the client’s response to nursing intervention

and then comparing the response to outcome criteria or

predetermined standards.
 It is the judgment of the effectiveness of the nursing care to

meet goals based on client’s behavioral responses.

Cont.
 The main purpose is to appraise the extent to which goals and outcome
criteria of nursing care have been achieved.
 When determining whether a goal has been achieved, the nurse can draw
one of the three possible conclusions
 The goal was met, that is the client response is the same as desired
outcomes
 The goal was partially met, that is either a short term goal was achieved but
the long term goal was not, or the desired outcome was only partially
attained
 The goal was not met
 When goals have been partially met or when goals have not been met; the
care plan may need to be revised or modified, since the problem is only
partially resolved.
Five steps modifying the care plan

 Change the data in in the assessment column to reflect the

most present data
 Revise the nursing diagnosis to reflect the new data
 Revise the client’s goals, priorities and outcome criteria to

reflect the new nursing diagnosis

 Establish new nursing actions to corresponds with the new

nursing diagnosis
 Change the outcome criteria to reflect the other changes in

the plan
Nursing activities during evaluation
 Collect data about the client’s response
 Compare response to goal and outcome criteria
 Analyze reasons for outcomes
 Modify care plan as needed
Types of evaluation
 Evaluation is classified according to criteria and frequency and
time
 Classification of evaluation according to criteria
 Structured evaluation: - This relates to such thing as

appropriate equipment to assess the client or to carry out the

plan and record evaluation conclusion
 Process evaluation: - This focuses on the activities of the

nurse. Can be done during each phase of the nursing process

or it may be carry out at the end of the process
 Outcome evaluation:-This is based on be havioral changes
Classification according to frequency and time
 Ongoing evaluation: It is performed while implementing at
each patient contact
 Intermittent evaluation: It is performed at specific times,

which enables nurse to judge the progress toward goal

achievement and modify the care plan as needed
 Terminal evaluation: It describes the client health status and

progress toward goals at the time of discharge