PLANNING AND IMPLEMENTING

Ns. Heni Dwi Windarwati, M.Kep.Sp.Kep.J

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3rd component of the Nursing Process- Planning:

• The establishment of client goals/outcomes– Working with the client, to prevent, reduce, or

resolve problems

– To determine related nursing interventions (actions) that are most likely to assist client in achieving goals

– This is about improving the quality of life for your patient.

– This is about what your patient needs to do to improve his health status or better cope with his illness.

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During Planning, the provider:

• A. Establishes Priorities

• B. Writes Client Goals/Outcomes And Develops An Evaluative Strategy

• C. Selects Nursing Interventions

• D. Communicates The Plan

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The four critical elements of planning include:

• Establishing priorities• Setting goals and developing expected

outcomes (outcome identification)• Planning nursing interventions (with

collaboration and consultation as needed)• Documenting

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1- Establishing PrioritiesThe establishment of priorities is the first element

of planning. In establishing priorities, the nurse examines the client’s nursing diagnoses and ranks them in order of physiological or psychological importance.

Various guidelines are used in the establishment of priorities for determining which nursing diagnosis will be addressed initially. 5

The client’s basic needs, safety, and desires, as well as anticipation of future diagnoses must be considered. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life-threatening diagnosis be given more urgency than a non life threatening diagnosis.

The client must participate in the identification of priorities so that the nature of the problem, as well as the client’s values, are reflected in the selected course of action.

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2- Establishing Goals and Expected OutcomesThe purposes of setting goals and expected

outcomes are to provide guidelines for individualized nursing interventions and to establish evaluation criteria to measure the effectiveness of the nursing care plan.

A goal is an aim, an intent, or an end.

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A goal is a broad or globally written statement describing the intended or desired change in the client’s behavior, response, or outcome.

An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved.

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Goals should be established to meet the immediate, as well as long-term prevention and rehabilitation, needs of the client.

A short-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a few hours or days.

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A long-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis over a longer period of time, usually over weeks or months.

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Guidelines for Writing Outcomes

Written outcomes can be evaluated by seeing if they conform to the following criteria:• Each set of outcomes is derived from only one

nursing diagnosis.• At least one of the outcomes shows a direct

resolution of the problem statement in the nursing diagnosis.

• Both long-term and short-term outcomes are identified as necessary.

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• Cognitive, psychomotor, and affective outcomes appropriately signal the type of change needed by the patient.

• The patient and family value the outcomes.• Each outcome is brief and specific (clearly describes

one observable, measurable patient behavior/manifestation), is phrased positively, and specifies a time line.

• The outcomes are supportive of the total treatment plan

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Example NURSING DIAGNOSIS: Disturbed Sleep

PatternGoal: Client will sleep uninterrupted for 6 hours.EXPECTED OUTCOMES• Client will request back massage for relaxation.• Client will set limits to family and significant

other visits. 

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3- Planning Nursing InterventionsOnce the goals have been mutually agreed on by

the nurse and client, the nurse should use a decision-making process to select appropriate nursing interventions.

Nursing interventions are treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient / client outcomes.

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Writing a client plan of care

Two important concepts guide a client plan of care: 1- The plan of care is client centered. 2- The plan of care is a step – by step process.

– Sufficient data are collected to substantiate nursing diagnoses.

– At least one goal must be stated for each nursing diagnosis

– Outcome criteria must be identified for each goal

 

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• Nursing interventions must be specifically designed to meet the identified goal.

• Each intervention should be supported by a scientific rationale.

• Evaluation must address whether each goal was completely met, partially met, or completely unmet.

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4th Component of the Nursing Process- Implementing:

• The provider carries out the plan of care

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Implementing

Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders.

The first three nursing process phases-assessing, diagnosing, and planning-provide the basis for the nursing actions performed during the implementing step.

In turn, the implementing phase, provide the actual nursing activities and client responses that are examined in the final phase, the evaluating phase.

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While implementing nursing orders, the nurse continues to reassess the client at every contact, gathering data about the client’s responses to nursing activities and about any new problems that may develop.

To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. These skills are distinct from one another.

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The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity.

Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another, this depends on the ability of the nurse to communicate effectively with others. It is necessary for all nursing activities, caring, comforting, advocating, referring, counseling, and supporting others.

Technical skills are hands-on skills such as manipulating equipments, giving injections and bandaging, moving lifting, and repositioning clients. These are called procedures, tasks, or psychomotor skills.

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Process of Implementing

• Reassessing the client• Determining the nurse’s need for assistance• Implementing the nursing interventions• Supervising the delegated care• Documenting nursing activities

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Reassess the Client, to make sure the intervention is still needed.

Even though an order is written on the care plan, the client’s condition may have changed.

The nurse also provides supportive communication to help alleviate the client’s stress.

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Determining the Nurse’s Need for Assistance, for one of the following reasons:

• The nurse is unable to implement the nursing activities safely alone

• Assistance would reduce stress on the client• The nurse lacks the knowledge or skills to

implement a particular nursing activities

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Implementing the nursing Interventions, it is important to explain to the client what interventions will be done, what sensations to expect, what the client is expected to do, and what the outcome is.

Ensure client privacy, coordinate client care, and involve scheduling client contacts with other departments.

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When implementing interventions, nurses should follow these guidelines:

• Base nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible.

• Clearly understand the order to be implemented and question any that are not understood.

• Adapt activities to the individual client, a client’s beliefs, values; age, health status, and environment are factors that can affect the success of a nursing action.

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• Implement safe care• Provide teaching, support and comfort to enhance the

effectiveness of nursing care plans.• Be holistic; view the client as a whole.• Respect the dignity of the client and enhance the

client’s self- esteem• Encourage client to participate actively in

implementing the nursing interventions.

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Supervising Delegating Care, if care has been delegated to other health care personnel, the nurse responsible for all the client’s care must ensure that the activities have been implemented according to the care plan.

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Documenting Nursing Activities, the nurse complete the implementing phase by recording the interventions and client responses in the nursing process notes. The nurse may record routine or recurring activities

such as mouth care in the client record at the end of shift, while some actions recorded in special worksheets according to agency policy.

Immediate recording helps safeguard the client to prevent double actions.

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During Implementing, the care provider:

• Carries Out The Plan Of Nursing Care or Setting your plans in motion and delegating responsibilities for each step.

• Continues Data Collection And Modifies The Plan Of Care As Needed

• Documents Care32

• Kasus :– Dari hasil pengkajian yang dilakukan oleh

perawat pada pasien ditemukana bahwa pasien post operasi hari 2, mengeluh nyeri di bagian luka post operasidengan skala 5 dari 0-10, TD 120/80 mmHg, Selain itu klien juga mengeluh mual dan males makan

– Pertanyaan:• Buatlah rencana asuhan keperawatan

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hewinda@yahoo.com 085214555180

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