Question

the act of carrying out the planned interventions

Answer 1

Answer

The nursing process is an evidence-based, five-step scientific method used to ensure that the patient is assessed, diagnosed and receives continuity of care across appropriate healthcare providers and departments.

The five steps are as follows:

1. Assessment phase
2. Diagnosing phase
3. Planning phase
4. Implementing phase
5. Evaluation phase

Nursing interventions are the actual treatments and actions that are performed to help the patient to reach the goals that are set for them. The nurse uses his/ her knowledge, experience and critical-thinking skills to decide which interventions will help the patient the most.

Planning involves determining before and the strategies or course of actions to be taken before implementation of nursing care. To be effective, the client and his family should be involve in planning.

The purpose of planning is to 1) determine the goals of care and the course of actions to be undertaken during the implementation phase 2) To promote continuity of care. 30  To focus charting requirements. 4) To allow for delegation of specific activities.

STEPS IN PLANNING AN INTERVENTION

Step 1 : The first step in planning is to set priorities.

Priority is something that takes precedence in position, and considered the most important among several items. It is a decision making process that ranks the order of nursing diagnosis in terms of importance to the client.

Certain guidelines must be followed while setting priorities as described below : -

a] Life-threatening situations should be given highest priority.

b] Use the principle of ABC’s (airway, breathing, circulation)

c] Use Maslow’s hierarchy of needs.

Maslow's hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid.

From the bottom of the hierarchy upwards, the needs are : physiological, safety, love and belonging, esteem, and self-actualization.

d] Consider something that is very important to the client

e] Actual problems take precedence over potential concerns.

f] Clients with unstable condition must be given priority over those with relatively stable conditions.

For example, attending to client with fever is more important , and is to be done before attending to client who is scheduled for physical therapy in the afternoon.

g] Consider the amount of time, materials, equipment required to care for clients.

For example , attending to client who requires dressing change for post operative wound, before attending to client who requires  health teachings & is ready to be discharged late in the afternoon.

h] Attend to the client before equipment. Example , assess the client before checking IV fluids, urinary catheter, and drainage tube.

Step 2 :Once the priorities have been established ,the next step is to plan nursing interventions to direct activities to be carried out in the implementation phase.

Nursing interventions implies any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes.

They are used to monitor health status; prevent, resolve or control a problem; assist with activities of daily living; or promote optimum health and independence.

They may be independent, dependent and interdependent/collaborative activities that nurses carry out to provide client care.

• Independent Nursing Intervention are those activities that the nurse is licensed to initiate as a result of the nurse’s own knowledge and skills.
• Dependent Nursing Intervention are those activities carried out on the order of a physician, under a physician’s supervision, or according to specific routines.
• Interdependent/Collaborative are those activities the nurse carries out in collaboration or in relation with other members of the health care team.

Step 3 : Write a Nursing Care Plan

The Nursing Care Plan is a written summary of the care that a client is to receive.It is the “blueprint” of the nursing process.

It is nursing centered in that the nurse remains in the scope of nursing practice domain in treating human responses to actual or potential health problems.

It is a stepwise process performed as follows :-

• Sufficient data are collected to substantiate the nursing diagnosis.
• At least one goal must be stated for each nursing diagnosis.
• Outcome criteria must be identified for each goal.
• Nursing interventions must be specifically designed to meet the identified goal.
• Each intervention must be supported by a scientific rationale, which is the justification or reason for carrying out the intervention.
• Evaluation must address whether each goal was completely met, partially met or completely unmet.