Use a SMART Nursing Process
for your Plan of Care


How essential really is Nursing Process for ALL nurses? Very Crucial.

Benjamin Franklin once wrote that failing to have a plan is planning for failure. These wise words echo as true today as they did over 200 years ago.

"Failing to PLAN is planning to FAIL"

Just like architects who makes elaborate and detailed blue prints before building any structure or work of art. Nurses' use Nursing Process - a patient centered, problem-solving approach, goal oriented method of caring, that enables the nurse to provide care in an organized scientific manner.

The objective of Nursing Process is to help patients alleviate, minimize, or prevent actual or potential health problems. Through effective communication between nurse and patients in any variety of settings this process is being carried out continually.


Summary of Five-Step Nursing Process


Purpose Key Actions
ASSESSMENT -To gather, verify, and communicate data about client so data base is established Collect nursing health history.Perform physical examination.Collect laboratory data.
DIAGNOSIS -To identify health care needs of client; to formulate nursing diagnoses Interpret data, including data validation and clustering.Formulate nursing diagnoses (see NANDA Approved Nursing Diagnosis)
PLANNING -To identify client goals; to determine priorities of care; to design nursing strategies to achieve expected outcomes of care; to determine outcome criteria- SMART – goal should be Specific, Measurable, Attainable and Realistically Time-bound. Identify expected outcomes.Select nursing actions.Delegate actions.Consult.Write nursing care plan.Ex. To reduce fever within the baseline data of 35.5 by giving prn antipyretic medication and performing tepid sponge bath for 4 hrs.
IMPLEMENTATION -To complete nursing actions necessary for accomplishing plan Reassess client.Review and modify existing care plan.Perform nursing actions.
EVALUATION -To determine extent to which expected outcomes have been achieved. Very important to DOCUMENT your action! This is very essential for legal matters. Establish evaluation criteria. Compare client response to outcome criteria. Analyze reasons for result and conclusions. Modify care plan.

Since I was a student and up to now that I am a Registered Nurse with years of experience I still follow this methodology. Achieving my desired goal gives me a feeling of accomplishment by the end of the day, week or semester.

I help out my patient through safe and competent care, how good it can be! Assisting my patients' support system through evidence-based health teachings. I gain and improved my self-esteem as a nurse and made my clinical instructor feel "effective" because of the progress.

Initially the steps are followed in sequence. After the process has begun, it becomes a continuous cycle. As you gain more experience and make use of it the more it sinks into your subconscious always ready for retrieval. Truly, using a SMART nursing process is a win-win strategy!


NURSING PROCESS


A. NURSING ASSESSMENT
Sources of Client Data

1. Patient itself
  • observe for level of consciousness (ask for admission history)
  • call for an interpreter if patient has a native tongue
  • inquire about Support System available
  • ask about “discharge status” lives alone and services on hand or need (keep in mind discharge planning starts upon admission!)
  • 2. History
  • Past medical history from the chart and from the patient
  • Family history
  • Environmental history
  • Psychosocial history
  • transfer sheet if the patient came from a care center
  • 3. Physical Examination
    4. Laboratory and diagnostic tests
    5. Health team members
  • report from EMS, ER
  • or even police report
  • 6. Family and significant others
  • observe for objective and subjective data



  • B. NURSING DIAGNOSIS
    Click the link below to see NANDA – Approved Nursing Diagnoses



    Click here for Nursing Diagnosis- NANDA



    C. NURSING PLANNING

    1. Setting goals and priorities for patient

  • consulting with other members of health care team
  • working WITH client (nurse-patient relationship)
  • - working with family and significant others
  • Priorities are classified as high, intermediate or low
  • Goals are concerned with nursing diagnosis and may indicate ongoing or continuing behaviors expected to occur regularly.
  • Ex. If pt. has a continuing or chronic condition.
  • Expected outcomes are small step-by-step objectives.
  • Criteria of expected outcomes should be SMART:

    S - Specific and focused to the client – reflecting clients behavior
    ex. “the client will perform deep breathing twice a day”
    M - Measurable – to quantify desired response objectively
    ex. “the client’s systolic BP will be less than 160 mm Hg by 1/7.”
    A - Attainable or perceivable – avoid statements “will be able to”
    ex. “on the day of heart surgery, the client will demonstrate relief of anxiety by stating that all questions have been answered.”
    R - Realistic – includes pts. Support system, emotional and physical condition,level of intelligence, health values, availability of workforce and equipments.
    T - Time bound or time limited – so that nurse has a standard whether progress is being reasonable and to assist in setting priorities.
    ex. To reduce fever within the baseline data of 35.5 by giving prn antipyretic medication and performing tepid sponge bath for 4 hrs.

    2. Prioritizing nursing interventions to achieve desired goals

    a)Independent – practices that require no supervision or direction from others
    b)Interdependent – teamwork with other staff ex. Protocol
    c)Dependent – instructions and orders of another professional

    3. Documenting care plan

  • to evaluate or determine client responses to nursing actions.
  • to document client needs, coordinate nursing care and promote continuity of care.


  • D. NURSING IMPLEMENTATION
    - this is the ACTION oriented phase of nursing process

    1. Reassess client
    - Therapeutic communication - communicates properly and effectively is very essential. Like analysis, communication is an ongoing aspect of nursing process.
  • upon admission of pt. assessment happens simultaneously
  • as pts condition change reassessment is essential to determine if nursing action is appropriate for client.


  • 2. Review and revise care plan
    - changes in diagnosis, interventions and evaluation to further indicate the desired level of wellness and indicate when the need has been resolved and nursing diagnosis is no loner relevant.

    3. Organize
  • Equipment – from bed making to client-teaching, supplies are gathered
  • Personnel – actual care, delegation and coordination As a leader - nurses delegate to accomplish quality care for patients.


  • 4. Prepare
  • Environment – safety is always the first concern ex. For Fall Risk patient it is best to move him closer to nursing station.
  • Client and Family – make sure to introduce yourself and explain the course of action you will be doing performing and encourage questions to alleviate fear and promote a relaxed feeling.


  • 5. Anticipate and prevent complications
    - being a patient advocate through precautionary measures
    ex. Feeding a swallowing compromised client – nurse assist patient to a sitting upright position and crushing pills to swallow properly.

    E. NURSING EVALUATION

  • determines the effectiveness of the nursing care plan
  • the nurse compares client response with goals and expected outcomes which serve as evaluation criteria.
  • Since nursing is an ongoing care – remodification shows the continuous nature of nursing process.


  • Whew all done! This is the overview of Nursing Process.



    "Thank you for your kind words."


    I am a first year student nurse and I use this Nursing Process steps for my assessment as well. I found this to be extremely helpful during studying for my exams. Thank you!

    from Shalini - New Zealand

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