Practical Manual ----

Nursing Foundation UNIT 3 DEVELOPMENT OF NURSING

CARE PLAN USING NURSING
PROCESS
Structure
3.0 Objectives

3.1 Introduction

3.2 Review of Steps of Nursing Process

3.2.1 Definition
3.2.2 Purposes
3.2.3 Steps

3.3 Development of Nursing Care Plan

3.3.1 Assessment----Data Collection
3.3.2 Nursing Diagnosis
3.3.3 Planning
3.3.4 Implementation
3.3.5 Evaluation

3.4 Documentation of Nursing Care Plan

3.5 Format of Nursing Care Plan Based on Nursing Process

3.6 Let Us Sum Up

3.7 Answers to Check Your Progress

3.8 Activities

3.0 OBJECTIVES
At the end of this unit, you should be able to:

obtain assessment data from client and document the data collected.;

analyze the data;

formulate appropriate nursing diagnosis;

formulate nursing outcomes/goals for the selected nursing diagnosis based on priority;

implement nursing activities to achieve the goals;

evaluate the care to measure the effectiveness of nursing actions; and

develop nursing care plan using nursing process format for documentation.

3.1 INTRODUCTION
All health care professionals are striving to upgrade client care. Nurses are concerned to
provide health care to both well and ill clients in different settings. In 1950s the term ‘‘Nursing
Process’’ was first used and ‘‘nursing diagnosis’’ was considered as ‘‘the weak link’’. In 1972
both the terms emerged as having ‘‘the strong link’’ in nursing practice. Today in the era of cost
containment the value of one’s contribution to the health care delivery system must be
measurable and demonstrable. The combinations of nursing care plan based on nursing
diagnosis gives nurse a concrete instrument to quantify nursing. Nursing care plans are the
keys to professional nursing care and must be written for specific nursing diagnosis to
document the care needed the care given and the clients responses.
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 Development of Nursing
3.2 REVIEW OF STEPS OF NURSING PROCESS Care Plan Using
Nursing Process

3.2.1 Definition
Nursing process is a framework that enables the nurse and the client together to resolve health
related problems of the client in a systematic, organized and logical way.

3.2.2 Purposes
1) It provides a framework within which nurses can identify client’s health status and
provide quality care and checks its outcomes through evaluation.

2) It helps in rendering individualized care.

3) It avoids unnecessary (duplication of) nursing actions thus saves time.

4) It helps in providing organized priority based care.

5) It encourages clients and family participation in care.

3.2.3 Steps
Nursing process consists of the following steps:

1) Assessment

2) Nursing Diagnosis

3) Planning

4) Implementation

5) Evaluation

Assessment
Evaluation

Nursing is a Nursing Diagnosis

Continuous Process
Implementation

Planning

Fig. 3.1: Steps of nursing process

Assessment

Assessment is the foundation step of nursing process. It consists of systematic and orderly
collection of information pertaining to and about the health status of the client. The information
obtained helps to make nursing diagnosis and to develop a plan of care. Informations are
obtained by data collection.

Data Collection

Data collection includes accumulation of comprehensive information about the client on initial
assessment. The initial assessment provides baseline data. The data involves information about
clients health problem, specific factors that contribute to the problem. The client has health
problem (s) with which hes/he gets admitted and may also develop additional problem during
his stay in the hospital, because of this course of illness, and the treatment modalities. 55
Practical Manual ---- As you have already read in unit 5 of this block under section 1.3.6 that data collected by the
Nursing Foundation
nurse during assessment are:

Subjective Data

Objective Data

Subjective Data

Subjective data includes client’s description of his personal health status, problem e.g. feeling,
description pain, weakness, nausea. This data also include information supplied by client’s
family members. The data are not observable and are difficult to measure objectively.

Objective Data

Objective data are usually the one that is obtained through senses --sight, smell, hearing, touch
and during physical examination of the client. Objective data are observable and measurable.
For example: rate of pulse, weight, presence of oedema. The data collected by the nurse can be
historical data and current data.

Historical data has information related to the events that have occurred prior to the present.
The event might be previous hospitalization, presence of chronic disease, pattern of bowel
movement in the past, childhood illness in an adult patient.

Current data refer to the events that are occurring at present e.g. pain, vomiting, inability to
pass urine and present illness.

It is always necessary to validate subjective with objective data, historical with current data. For
example, subjective data of feeling of pain is validated by objective findings of pallor, increased
sweating and hypotension. Similarly, historical data e.g. passing stool once every day and
bowels not moved for two days (current) may initiate a strategy to help patient move his
bowels. But when substantiated with historical data the client may inform that movement of
bowel on every alternate day is his routine at home. Thus the information obtained earlier
becomes valid. Therefore, validation of the data is necessary before planning care.

Nursing Diagnosis

The diagnostic process involves processing the data by classification interpretation and
validation. Writing nursing diagnostic statement is the basis of identifying client’s problems
and strengths. The health problem and the etiological factor are reflected in the formulation of
diagnostic statement. The diagnosis is verified with the client and documented.

Planning

Planning includes setting priorities and writing outcomes. The different problems of the client
identified in the nursing diagnosis needs to be prioritized. The nurse can determine priority
problems related to needs of client.

Outcomes/goals are written from the diagnostic statement in terms of client’s behaviour that are
desired to be achieved by the nurse in the limited time. The characteristic features of outcomes
are:

client centered

observable and measurable

time limited and realistic.

The areas in which outcomes are written include:

appearance and functioning of the body,

specific symptoms,

knowledge,

psychomotor skills and emotional status.

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Implementation Development of Nursing
Care Plan Using
Nursing Process
Implementation involves preparation for executing the plan and carrying the interventions to
resolve client’s problem. The interventions include all those independent, dependent and
interdependent nursing actions carried out by the nurse to restore health, prevent illness,
promote wellness and facilitate copying with altered functioning. The implementation of nursing
action is followed by complete and accurate documentation of events.

Evaluation

Evaluation is used to judge each component of nursing process. It measures the effectiveness
of nursing interventions. It consists of comparing and judging the data about client’s progress.
The client’s response to the nursing interventions will guide the nurse to continue with the plan
care, modify it or terminate. In case the plan of care needs modification the nurse will reassess
and carryout the remaining steps of nursing process. When the care is continued the ongoing
process of assessment and evaluation is continued.

Check Your Progress 1

Match each phase/step of the nursing process with the examples of activities that occur in that
phase. Select the term given in column I and place it on column II.

a) Assessment 1) Writing nursing orders on the care plan.

b) Diagnosis 2) Using data base to decide if goals have been met

c) Planning 3) Mrs. R.S. has blood pressure 120/70, her pulse is 84, she is
10kg overweight

d) Implementation 4) Nurse analyzes the data, diagnose that no problem exists, and
concludes no interventions are needed.

e) Evaluation 5) Becomes aware of ways in which her lifestyle can either

increase or decrease risk of disease.

6) Giving client pamphlet on “stop smoking”

7) Charting the care given to the client

8) Change dressing using betadine at Coccyx at 9 A.M.

9) Nurse prepares the client to be taken out on a wheel chair and

observes that the client has become pale and c/o dizziness

10) Nurse classifies, searches for a clearer understanding of the cues

3.3 DEVELOPMENT OF NURSING CARE PLAN

You have learnt about the phases of the nursing process in theory course (BNS-101) Block 2,
Unit 1. Documentation of planned care is involved in nursing process. It becomes clear then
that in order to develop nursing care plan the nurse must accomplish the steps of the nursing
process i.e. assessment, nursing diagnosis and planning. In this section you will learn the
performance phases through examples.

3.3.1 Assessment – Data Collection

1) Subjective Data
a) Identification Data
Name : ...................................................................................................
Age : ...................................................................................................
Sex : ...................................................................................................
Marital Status : ...................................................................................................
Religion : ...................................................................................................
Ward : ...................................................................................................
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Practical Manual ---- Bed No. : ...................................................................................................
Nursing Foundation
Reg. No. : ...................................................................................................
Diagnosis : ...................................................................................................
Education : ...................................................................................................
Occupation : ...................................................................................................
Income : ...................................................................................................
Address : ...................................................................................................
...................................................................................................
Date of Admission : ...................................................................................................
Date of Discharge : ...................................................................................................
Date of Physical
Examination : ...................................................................................................

b) History

i) Family history:

---- nuclear/joint

---- number of members

---- health status of members

---- specific disease in the family

---- IPM

ii) Personal history:

---- life style

---- health habits

---- exercise

---- use of alcohol

---- smoking/tobacco

---- elimination pattern

---- sleep pattern

iii) Health history

---- past h/o illness : medical

: surgical

: psychiatric

---- present h/o illness

---- present complaint

2) Objective Data
i) Observation
---- general appearance/built
---- mental alertness
---- evidence of pain
---- position of patient
ii) Physical Examination
a) Vital signs
58 b) Height and Weight
c) Head to foot Examination Development of Nursing
Care Plan Using
l Skin: Colour, pigmentation, scars, edema, moisture, nails, allergy, turgor etc. Nursing Process

l Head: Symmetry of skull, face, hair colour, distribution, lesions, hair texture etc.

l Eyes and Vision: h/o burning, pain, vision problems etc. observe external eye structure
for any abnormality. Pupils size, reaction to light etc. movement of eye visual field,
findings of fundoscopic examination.

l Ears and Hearing: Auricles, Tympansic membrane, presence of discharge growth etc,
otoscopic findings.

l Nose: Any deformity, discharge, polyp sinus for tenderness.

l Mouth and Throat: Lips colour, ulcers we light and tongue-depressor observes teeth
gum, tongue tonsils, phanyx etc. for any abnormality observes voice for hoarseness.

l Neck: Range of motion, thyroid gland, jugular, vein, lymph nodes.

l Breast: (Female) areola and nipple size, symmetry, palpation for any lumps, nodes etc.
any discharge.

l Throat and Lungs: Symmetry of chest, any structure deformity, movement of chest
wall. Auscultate the chest for breath sounds.

l Heart: All pulses, (radial, brachial and femoral) auscultate heart sound

l Abdomen: Contour, symmetry, visible peristatis , scars, rashes, shape of umbilicus,

auscultate for bowel sounds. Palpate for mass, tenderness etc.

l Genitalia: Hygiene, discharge, tumors, lesions etc.

l Extremities: Range of motions, muscle strength, symmetry, mass, deformity etc.

l Neurological: Mental status, alertness, orientation to time, place and person, function
of cranial nerves, reflexes etc.

iii) Laboratory Data/Investigations

---- Laboratory values of various investigations done in the patient -X-rays

---- Special investigations if any.

Based on the above-mentioned objective and subjective data you can formulate nursing diagnosis
according to priority.

3.3.2 Nursing Diagnosis

It is a statement of a patient’s problem that is arrived at by making inferences from the collected
data. Examples of nursing diagnosis are as follows:
Table 3.1: Nursing Diagnosis

Subjective Data Objective Data Nursing Diagnosis

---- Anorexia, nausea, weakness, ---- Diarrhoea, vomiting, vomiting, ---- Fluid volume deficit
abdominal cramps dry skin related to disease
condition
---- Scared to go for surgery patient ---- Tearful, facial, muscles tense, ---- Anxiety related to surgery
feels he may not survive after nube l00/ml, teandstrembling ---- Formulation of nursing
surgery diagnosis

3.3.3 Planning
It is the third phase of nursing process begins after formulation of nursing diagnosis. Planning
includes goals and outcomes for nursing actions, which are based on priorities.

Planning involve the following: 59

Practical Manual ---- ----- Setting priorities
Nursing Foundation
----- Establishing goals/expected outcomes

----- Planning nursing actions/interventions

----- Documenting the plan of nursing care.

Setting Priorities

Today’s nurse must learn how to set priorities. The first step in setting priorities is that of
making a list of the problems that you have identified during the assessment phase. You must
then study the list and decide which are the most Important problems.

Next you will have to decide the order of nursing care (i.e. what problems you will look after first)

Here are some suggestions of the questions, you ask yourself when setting priorities.

----- Which are the problems that must be taken care of immediately?

----- Which are the problems that you will work to prevent, reduce or resolve today?

----- Of the problems you with work on today, which will you work on first, second, third?

----- Are there any problems that can be worked on at same time (for example you may choose
to work on promoting communication about fears and concerns about illness while
assisting the client wit morning care).

Establishing Goals/Expected Outcomes

Nursing care planned according to priority setting will reflect the goals of care established by
the client and nurse. Setting goals is an activity that includes the family and significant others
as well as the client.

Goals should not only meet the immediate needs of the client, but should also include
prevention and rehabilitation. Goal setting establishes the framework for the nursing care plan.
Ultimately, goal results in development of expected outcome of the nursing intervention.

The expected outcome is the specific, desired change in the client’s condition in the
psychological, social, emotional spiritual dimensions. The nurse also uses the outcomes as
criteria to evaluate the effectiveness of nursing activities.

Example:

Table 3.2: Establishing Goals/ Expecteed Outcome

Problem Goal Expected Outcome

Potential ineffective Lungs remain Clien able to

airways clearance clear immediately clear airway
postoperatively after surgery with deep
related to abdominal breathing and
incisional pain. coughing. Lungs clear
on auscultation

Check Your Progress 2

List the four activities involved in the planning process.

a) .............................................................................................................................................

b) .............................................................................................................................................

c) .............................................................................................................................................

d) .............................................................................................................................................
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3. 3.4 Implementation Development of Nursing
Care Plan Using
Nursing Process
It is the execution nursing actions to achieve the goals/expected outcomes. Thus meeting the
needs of the client and relieving the problems.

Example:

Table 3.3: Implementing Nursing Actions

Nursing Diagnosis Planning (goal/outcome) Implementation

Fluid deficit related to ----- Maintenance of normal ----- Encourage oral fluids
disease condition fluid volume ----- I/v as ordered
----- Maintenance of ----- I/o chart
proper tissue perfusion ----- Assess hydration
----- Prevention of complications ----- Check vital signs, BP

In order to plan nursing interventions, the expected outcomes of the plan of care should be
considered as well as the cause of the problem. This will help you to determine exactly what
nursing actions will help this particular patient achieve the expected outcomes.

Guidelines: Planning Nursing Interventions/Actions

----- Always check or reassess the status of the problem before determining appropriate
nursing interventions.

----- Look for intervention that will reduce or eliminate the cause of the problem.

----- Consider the expected outcome to be sure that your interventions are specific for that
particular patient.

----- Identify the strengths of the client and family that can be encouraged so that they can
participate in correcting the problem.

----- Individualize nursing actions. What may work for one person may not for another?

----- Utilize scientific rationale as a basis for your actions (i.e. know why you are performing a
nursing intervention).

----- Create opportunities for teaching and learning wherever possible (e.g. teach the patient
the reasons for the nursing actions that you have chosen).

----- Consult other professionals whenever necessary (e.g. doctors dietitian, physiotherapist etc).

3.3.5 Evaluation

It is used to judge each component of the nursing process and is done by comparison of
clrent’s health status with the outcome. Evaluation reflects whether the patient’s problems are
resolved or not. If the expected outcomes are achieved, then further assessment planning and
intervention are to be reinforced. Since evaluation is an ongoing and continuous process.
Example of evaluation is as follows:
Table 3.4: Evaluation of Nursing Actions

Nursing Diagnosis Planning Implementation Evaluation

Fluid volume
Maintenance of
Encourage oral Skin turgor normal:
related to disease normal fluid volume fluids ----- Lips and mucous
condition
Maintenance of
I/V as prescribed membrane of
proper tissue perfusion
I/O chart mouth moist

Prevention of
Assess hydration ----- Fluid intake 3500
of complications
Check vital signs,BP output 1800ml

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Practical Manual ----
Nursing Foundation 3.4 DOCUMENTATION OF NURSING CARE PLAN
Documenting the plan of nursing care or writing the nursing care plan, is the final product
planning process. If you fail to document your plan of nursing care, you waste all the effort that
you have done in determining an individualized care plan for your patient. No one will know the
work that has been done. Nursing care plan serves five purposes:

1) To validate that there has been a thorough plan of care formulated for each patient.

2) To serve as a record that can later be studied to evaluate patient care.

3) To communicate to other nurses the specific problems, goals and interventions that have
been identified for the patient.

4) To same; time and avoid duplication of work.

5) To help in legal purposes.

Check Your Progress 3

Write whether the following informations are subjective or objective data.

a) Temperature of 39°C: ............................................................................................................

b) Heart rate 96/mt: ...................................................................................................................

c) Pain in the leg .......................................................................................................................

d) Feeling fatigue .....................................................................................................................

3.5 FORMAT OF NURSING CARE PLAN BASED ON

NURSING PROCESS
i) Identification data

Name : ...................................................................................................

Age : ...................................................................................................

Sex : ...................................................................................................

Religion : ...................................................................................................

Marital Status : ...................................................................................................

Educational Background : ...................................................................................................

Occupation : ...................................................................................................

Date of Admission : ...................................................................................................

M.R.D. No. : ...................................................................................................

Diagnosis : ...................................................................................................

Ward : ...................................................................................................

Bed No. : ...................................................................................................

Address : ...................................................................................................

...................................................................................................

Date of Discharge : ...................................................................................................

Date of Planning : ...................................................................................................

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ii) Brief Socio-Eeconomic History Development of Nursing
Care Plan Using
1) Family history Nursing Process

a) Type of family-----Nuclear/joint

b) Numbers of family members

c) Any specific disease in members

d) Health status of family members

e) Total Income

f) Dietary habits

g) Housing condition ---- Own/Rental/Water/Electricity Supply etc.

h) I.P.R. Among Family Members

2) Personal history -- Hygine and grooming

-- Any H/O Allergy

-- H/O smoking, alcohol, tobacco, drinking etc.

-- Life style flabits--exercises-drugs etc.

3) Hisotry of fast illness

4) History of present illness ---- Present complaints

5) Examination by doctor (from casesheet)

6) Investigations:

Date Name of Investigation Findings in patient Normal Value

7) Doctors Ordes:

Sl. No. Dr’s Prescription Purposes

8) Assessment:
a) Subjective Assessment:
b) Objective Assessment : vital signs
Head to foot examination
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Practical Manual ---- 9) Nursing Care Plan
Nursing Foundation
Nursing Dignosis Planning Goals/ Implementation Evaluation
Expected outcome

10) Health Teachings

11) Progress Notes---- (Day wise)

12) Activity

a) Write three nursing care plans using nursing process.

Select patient from anyone of the following setting

OPD

Medical/surgical ward

ICU, CCU, RR, Neuro ICU
b) Discuss nursing process with your supervisor?
c) Write five objective and subjective data?

3.6 LET US SUM UP

In this practical you learnt about writing a nursing care plan by using nursing process. In
assessment you learnt regarding data collection to identify actual or potential health problems.
Systematic physical examination helps in retaining objective data. Planning and nursing
diagnosis are based on assessment. Other than the medical diagnosis which physician makes
you will be able to make nursing diagnosis which helps you to write nursing care plan. Thus
provides comprehensive nursing care to client in all the shifts of duty. It is an important steps
towards professional writing nursing care plan is an excellent documentation for continuity of
care, as well as for further reference and self improvement.

3.7 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
a) 9
b) 1
c) 8
d) 7
e) 4
Check Your Progress 2
a) Objective
b) Objective
c) Subjective
d) Subjective
Check Your Progress 3
a) Setting Priorities
b) Establish goal/outcome
c) Plan nursing action
d) Documenting the actions
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 Development of Nursing
3.8 ACTIVITIES Care Plan Using
Nursing Process
Activity 1

Select a patient from your clinical setting take a case history of the patient:

i) Write five objective and five subjective data

ii) Make nursing diagnosis and list down the desired outcome as expected.

iii) Write a nursing care plan using nursing process. You may follow format given in unit 3,
Section 3.5.

iv) Discus nursing process with your supervisor.

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