NURSING AS A SCIENCE 3.

​ Generating Possible Solutions:

●​ “Body of abstract knowledge” arrived a.​ Identify and generate all
through scientific research and logical possible solutions.
analysis. b.​ Consider each potential idea for
●​ The scientific knowledge and skills in a solution without discarding it
assisting individuals to achieve optimal through value judgement (A value
health. judgment is an opinion about how good
or bad something or someone is)
●​ The diagnosis and treatment of human
responses to actual or potential
problems.
4.​ Analyzing the Solutions:
a.​ Investigate various factors about
each potential solutions.
b.​ All positive and negative
PROBLEM-SOLVING PROCESS
aspects of the solution/s are
Problem Solving – A mental activity in which a
analyzed.
problem is identified that represents an unsteady
state.
5.​ Selecting the Best Solutions:
-​ Requires the nurse to obtain information
a.​ An attempt to compare hte
that clarifies the nature of the problem
available solutions.
and suggests possible solutions
b.​ The best solution is selected
-​ The implementation of critical thought
based on careful judgement.
may or may not be required throught the
problem-solving process in working
6.​ Implementing the Solutions:
toward a solution. (Wilkinson, 2012).
a.​ Final step–solving the problem
by implementing the selected
PROCESS:
solution/s.
1.​ Problem Definition:
a.​ There is a need to write down
7.​ Evaluation and Revision
what exactly the problem
a.​ After implementation, evaluate
entails, which helps the real
to judge the efficacy of the
problem that is under study &
solution.
needs an immediate solution.
b.​ Redefining the problem and
revise the process may also help
2.​ Problem Analysis:
in case the initial solution fails.
a.​ Analyze how the problem
affects the researcher and their
current situation and other
people involved in the situation.
b.​ Determining the gravity of the
problem and all the factors
contributing to it.
 Problem-Solving Process and
2.​ Client Centered:
Nursing Process
a.​ Organization of plans according
Data Collection Assessment to client problems rather than
nursing goals.
Data Collection
b.​ Collection of data to determine
Data Interpretation the client’s habits, routines, and
needs, which enables the nurse
Problem Definition Nursing Diagnosis to incorporate client routines
Plan Plan into the care plan as much as
possible.
Goal Setting Goal Identification

Identify Solution Plan Intervention 3.​ An Adaptation of Problem-Solving

and Systems Theory:
Implementation Implementation a.​ Begins with data gathering and
Evaluate and Revise Evaluation and analysis;
Process Modification b.​ Base actions (intervention and
treatment) on problem statement
(nursing or medical diagnosis);
and
c.​ Includes an evaluative
component.

4.​ Decision Making:

a.​ Involved in every phase or the
nursing process.
b.​ Facilitates the individualization
NURSING PROCESS of the nurse’s plan of care.
-​ A critical thinking process that c.​ Nurses can be highly creative in
professional nurses use to apply the best determining when and how to
available evidence to caregiving and use data to make decisions.
promoting human functions and 5.​ Interpersonal and Collaborative:
responses to health and illness a.​ Requires nurses to consistently
(American Nurses Association, 2010). communicate directly with
clients and families to meet their
needs.
Nursing Process | Characteristics b.​ Requires nurses to collaborate
1.​ Cyclic and Dynamic: in a joint effort to provide
a.​ Data from each phase provide quality client care.
input into the next phase.
b.​ Nursing process is a regularly 6.​ Universally Applicable:
repeated event or sequence of a.​ Used as a framework for
events (a cycle), that is dynamic nursing in a types of health care
rather than static.
 settings, with clients of all age the person affected and can be
groups. described or verified only by
that person. Itching, pain, and
Nurses must use a variety of critical thinking feelings of worry are examples
skills to carry out critical thinking in the nursing of subjective data.
process. b.​ includes the client's sensations,
-​ Utilize clinical reasoning throughout the values, beliefs, feelings,
delivery of nursing care. perception of personal health
-​ By reflecting, the nurse determines status (Hx) and life situation.
whether the outcome of care was
appropriate. 2.​ Objective data:
a.​ also referred to as signs or overt
data, are detectable by an
NURSING ASSESSMENT observer or can be measured or
ASSESSING–is the systematic and continuous tested against an accepted
collection, organization, validation, and standard. They can be seen,
documentation of data (information) heard, felt, or smelled, and they
●​ 2 step process are obtained by observation or
a.​ Collection and Verification of physical examination. Have at
data & Analysis of data least 5 or more objectives to be
b.​ Establishes a data base about able to create nursing
client needs, health problems, diagnosis
responses, related experiences, i.​ a discoloration of the
health practices, values. skin or a blood pressure
lifestyle, & expectations reading is objective
●​ All phases of the nursing process data.
depend on the accurate and complete ii.​ The nurse obtains
collection of data. objective data to
validate subjective data
and to complete the
assessment phase of the
COLLECTING DATA
nursing process.
-​ Data collection is the process of
gathering information about a client's
health status. Data collection must be
both systematic and continuous to COMPARING SUBJECTIVE &
prevent the omission of significant data OBJECTIVE DATA
and reflect a client's changing health Description Data elicited and verified Data
status by the client directly or
indirectly
TYPES OF DATA observed
1.​ Subjective data: through
measureme
a.​ also referred to as symptoms or nt
covert data, are apparent only to
Sources ●​ Family and S.O.
●​ Client record Examples of Subjective and Objective
●​ Other healthcare Data
professionals
●​ Client Interview
Subjective Objective

Methods of Interview and therapeutic Observatio Mr X, tells me that I Patient has

obtaining communication skills. n and am worried abot my ●​ Poor eye
data physical disease (Prostate contact
exam cancer). What will be ●​ Facial
Skills ●​ Caring ability my future? expression
needed to and empathy. Inspection ●​ Clenches
obtain data ●​ Listening Skills Palpation hands
Percussion ●​ restlessness
Auscultatio
n ; Anxiety

Examples “I have a heaedache” Respiration

“It frightens me” is 16 per
METHODS OF DATA COLLECTION
“I am not hungry” minute.
BP 180/100 -​ The methods used to collect data are
mHg, observation, interview and examination.
apical
pulse 80 ●​ Observation:
bpm and
○​ It is gathering data by using the
irregular.
X-ray film senses. Vision, Smell and
reveals Hearing are used.
fractured ●​ Interview:
ribs. ○​ An interview is a planned
communication or a
conversation with a purpose.

There are two approaches to interviewing:

directive and nondirective.
●​ The directive interview is highly
structured and directly ask the questions.
And the nurse controls the interview.
●​ A nondirective interview, or rapport
building interview and the nurse allows
the client to control the interview.

STAGES OF AN INTERVIEW
An interview has three major stages.
1.​ The opening or introduction
2.​ The body or development
3.​ The closing
 NURSING DIAGNOSIS
ORGANIZING DATA -​ Nursing diagnosis is a clinical judgment
●​ The nurse uses a written (or electronic) about individual, family, or community
format that organizes the assessment responses to actual or potential health
data systematically. problems/life processes.
●​ This is often referred to as a nursing -​ Nursing diagnoses provide the basis for
health history, nursing assessment, or selection of nursing interventions to
nursing database form. achieve outcomes for which the nurse is
●​ The format may be modified according accountable (NANDA, 1997).
to the client's physical status such as one
focused on musculoskeletal data for Example:
orthopedic clients. "Ineffective breathing patterns related to
pulmonary hypoplasia as evidenced by
intermittent subcostal and intercostal
Conceptual Models/Frameworks retractions, tachypnea, abdominal breathing,
Examples of these conceptual framework are and the need for ongoing oxygen support."
those of
1.​ Gordon's functional health pattern
framework PURPOSE OF NURSING DIAGNOSIS
2.​ Orem's self-care model 1.​ Sharpen problem-solving and critical
3.​ Roy's adaptation model. thinking skills
2.​ Helps in identifyin nursing priorities and
direct nursing interventions based on
identified priorities
3.​ Helps in formulating expected outcomes
Validation of data for quality assurance requirements of
-​ The information gathered during the third-party payers.
assessment is "double-checked" or 4.​ Helps in identifying how a client or
verified to confirm that it is accurate and group responds to actual or potential
complete. health and life porcesses and kowing
their available resources of strengths
that can be drawn upon to prevent or
Documentation of data
resolve problems.
-​ To complete the assessment phase.
5.​ Provides a comon language and forms a
-​ the nurse records client data. Accurate
basis for communication
documentation is essential and should
6.​ Provides a basis for evaluation to
include all data collected about the
determine if nursing care was beneficial
client's health status.
to the client and cost-effective.
Steps: b.​ Nursing interventions should be
Each Nursing Diagnosis has three components: aimed at etiological factors in
●​ Label an actual or potential health order to remove the underlying
problems that Nursing care can affect. cause of the nursing diagnosis.
●​ Related factors- Factors that may c.​ Etiology is linked with the
precede, contribute to or be associated problem statement with the
with the human response. phrase "related to"
●​ Evidence - Signs symptoms that point to
the Nursing Diagnosis. for example:
a.​ Activity intolerance related to
generalized weakness.
3 Components of a Nursing Diagnosis b.​ Decreased cardiac output related to
1.​ Problem and Definition: abnormality in blood profile
a.​ The problem statement, or the
diagnostic label, describes the 3.​ Defining Characteristics OR
client's health problem or a.​ Defining characteristics are the
response to which nursing clusters of signs and symptoms
therapy is given concisely. that indicate the presence of a
b.​ It has two parts: qualifier and particular diagnostic label.
focus of the diagnosis. b.​ In actual nursing diagnosis, the
i.​ Qualifiers (also called defining characteristics are the
modifiers) are words identified signs and symptoms
that have been added of the client.
to some diagnostic c.​ For risk nursing diagnosis, no
labels to give signs and symptoms are present
additional meaning, therefore the factors that cause
limit, or specify the the client to be more susceptible
diagnostic statement. to the problem form the etiology
of a risk nursing diagnosis.
Exempted in this rule are one-word nursing d.​ Defining characteristics are
diagnoses (e.g., Anxiety, Constipation, written following the phrase "as
Diarrhea, Nausea, etc.) where their qualifier evidenced by" or "as
and focus are inherent in the one term. manifested by" in the
diagnostic statement
2.​ Etiology
a.​ The etiology, or related factors, Risk factors for risk nursing diagnosis
component of a nursing -​ Risk factors used instead of etiological
diagnosis label identifies one or factors for risk nursing diagnosis.
more probable causes of the -​ Risk factors are forces that put an
health problem, are the individual (or group) at an increased
conditions involved in the vulnerability to an unhealthy condition.
development of the problem, -​ Risk factors are written following the
and enables the nurse to phrase "as evidenced by" in the
individualize the client's care. diagnostic statement.
Example VARIATIONS ON BASIC STATEMENT
●​ Risk for falls as evidenced by old age FORMAT
and use of walker.
●​ Risk for infection as evidenced by break “Secondary to”
in skin integrity. -​ To divide the etiology into two parts to
make the diagnostic statement more
COMPONENTS IN NURSING descriptive and useful.
DIAGNOSIS (PES Format) -​ Example:
-​ “Risk for Decreased Cardiac
PES: Problem, Etiology, and Signs and Output related to reduced
Symptoms preload secondary to
myocardial infarction”
PES format is a structured approach used in “Complex factors”
nursing to formulate diagnostic statements. It -​ When there are too many etiological
consists of three key components: factors or when they are too complex to
state in a brief phrase.
●​ Problem (P): This is the nursing Example:
diagnosis itself, which identifies the “Chronic Low Self-Esteem related to complex
patient's primary issue or health factors”
concern.
●​ Etiology (E): This part describes the “Unknown Etiology”
underlying causes or related factors -​ When defining characteristics that are
contributing to the nursing diagnosis. It present but the nurse does not know the
is typically phrased as "related to" cause or contributing factors
(R/T). Example:
●​ Signs and Symptoms (S): This “Ineffective COping related to unknown etiology”
component outlines the defining
characteristics or clinical cues that Specifying a Second Part
indicate the presence of the problem. It -​ Specifying a second part of the general
is often expressed with phrases like "as response or diagnostic label to make it
evidenced by" (AEB) or "as manifested more precise.
by" (AMB). Example:
“Impaired Skin Integrity (Right Anterior CHest)
For example, a complete problem-focused related to disruption of skin surface secondary to
nursing diagnosis might be stated as follows: burn injury”
Excess Fluid Volume related to excessive fluid
intake as evidenced by bilateral basilar crackles
in the lungs, bilateral 2+ pitting edema of the
ankles and feet, an increase in weight of ten
pounds, and the client reports, “My ankles are
so swollen.”
GUIDELINES FOR WRITING A avoidance or
NURSING DIAGNOSIS narcotics due to fear
of addiction
1.​ State in terms of a problem, not a need. 6 Immpaired Oral Impaired Oral
2.​ Word the statement so that it is legally Mucous Membrane Mucous Membrane
advisable. related to decreased relted to noxious
salivation secondary agent (vague)
3.​ Use nonjudgmental statements.
to radiation of neck
4.​ Make sure that both the element of the (specific)
statements do not say the same thing.
5.​ Be sure that cause and effect are 7 Risk for Ineffective Risk for pneumonia
Airway Clearance (medical terminology)
correctly stated (i.e., the etiology causes related to
the problemor puts the client at risk for accumulation of
the problem). secretions in lungs
6.​ Word the diagnosis specifically and (nursing
terminologies)
precisely to provide direction for
planning nursing intervention. 8 Risk for Innefective Risk for Ineffective
7.​ Use nursing terminology to describe the Airway Clearance Airway Clearance
related to related to emphysema
client’s response.
accumulation of (medical terminology)
8.​ Use nursing terminology rather thn secretions in lungs
medical terminology to describe the (nursing terminology)
probbly cause of the clien’s response.

Correct Incorrect/Ambiguous Further reading for Nursing Diagnosis

Refer to:
1 Deficient fluid volume Fluid replacement
(problem) related to (need) related to fever https://nurseslabs.com/nursing-diagnosis/?f
fever bclid=IwZXh0bgNhZW0CMTEAAR1ROBIY
ITSvGeDx6F79m9PkVSVTu_MCX9aceWZ7t
2 Impaired skin integrity Impaired skin integrity
related to immobility related to improper VFtjZetpKP24AtcHNI_aem_ilxSU10V0wIqX
(legally acceptable) positioning (implies YqdshgQGw
legal liability)

3 Spiritual distress Spiritual distress

related to inability to related to strict rules
attend church services necessitating church
secondary to attendance
immobility(nonjudgme (judgmental)
ntal)

4 Risk for Impaired Skin Impaired Skin

Integrity related to Integrity related to
immobility ulceration of sacral
area (response and
probable cause are the
same)

5 Pain: Severe Pain: related to severe

Headache related to headache
NURSING PLANNING
-​ The third step of the nursing process;
includes the fomrultion of guidelines
that establish the proposed course of
nursing action in the resolution of
nursing diagnoses and the development
of the client’s plan of care.

PHASES OF PLANNING
1.​ Initial Planning:
a.​ Planning which is done after the
initial assessment
2.​ Ongoing Planning:
a.​ Continuous planning
3.​ Discharge PLanning:
a.​ Planning for needs after
discharge

FOUR CRITICAL ELEMENTS OF

PLANNING

1.​ ESTABLISHING PRIORITIES

a.​ The nurse examines the client’s
nursing diagnoses and ranks https://nurseslabs.com/nursing-care-plans/#google_vignette

them in order of physiological

or psychological importance.
b.​ One of the most common 2.​ SETTING GOALS AND
methods of selecting priorities is DEVELOPING EXPECTED
the consideration of Maslow’s OUTCOMES
Hierarchy of Needs, which a.​ A goal is a specific and
requires that a life-threatening measurable objective designed
diagnosis be given more to reflect the patient’s highest
urgency than a non life leel of wellness and
threatening diagnosis. independence in function.
b.​ Two Categoories in Goals:
i.​ Short term- can be met
fairly and quickly
(hours or days)
ii.​ Long term- cover a
long time span
Example: “The patient will be free of infection
throughout hospitalization” –can be long term or
short term, depending on the length of
hospitalization.
NURSING OUTCOME CLASSIFICATION
(NOC) [Nursing Outcomes Classification (NOC), 7th GOALS/OUTCOMES TO RELIEVE
Edition] PROBLEMS
-​ A comprehensive taxonomy of patient
outcomes influence by nursing care. Pain Within 8 hours, patient
Each outcome is ated as a variable will report pain is
concept measure on a five-point Likert absent or diminished
scale and includes a definition,
Imbalanced Nutrition: By 12/6/06, patient will
indicators, and references. More Than Body reach target weight of
-​ Standardizes the terminology Requirements 122 lb
and criteria needed to measure
Impaired Physical Before discharge,
and evaluate outcomes in all
Mobility patient will ambulate
care settings and with all patient length of hallway
populations independently
-​ Imprtant for the electronic
documentation of patient 4.​ PLANNING NURSING
records, clinical data and health INTERVENTIONS (with collaboration
care information systems. and consultation as needed)
-​ “Outcomes identification” a.​ Nursing interventions are
standard of practice is defined treatment, based upon clinical
as, ‘The registered nurse judgement and knowledge that a
identifies expected outcomes for nurse performed to enhance
a plan individualized to health patient/client outcomes.
care consumer or the situation.” b.​ Nursing care interventions must
The nurse sets measurable and be specifically designed to meet
achievable short-and long-term the identifiede goal.
goals and specific outcomes in c.​ Eac intervention should be
collaboration. supported by a scientific
rationale

3.​ DEVELOPING EXPECTED Nursing Interventions:

OUTCOMES 1.​ Dependent: nursing action based on
a.​ Define when a patient goals has instruction of another professional.
been met and assist in 2.​ Independent: requires no supervision
evaluating the extent to which 3.​ Interdependent: actions carried out by
the Nursing Diagnosis has been the nurse in collaboration with another
resolved. health care professional
Example:
​ Goal: The patient’s lung will remain clear
post operatively.
​ Expected outcomes:
-​ The Sputume will remain white
-​ The patient will remain afebrile
-​ The lungs will be clear to
auscultation
 NURSING INTERVENTION: SELECTION -​ Nursing interventions are the actual
GUIDELINES treatments and actions that are
performed to help the patient to reach
Nursing Diagnosis: Acute Etiology: Myocardial
the goals that are set for them.
Pain related to mmyocardial Ischemia -​ The nurse uses his or her knowledge,
ischemia experience and critical-thinking skills to
decide which interventions will help the
Goal: Client will resume Nursing Interventions: patient the most
normal activities of daily -​ Assess pain -​ Nursing interventions, the action steps
living characteristics that nurses take to care directly and
such as location,
indirectly for their patients, are the core
Expected outcome: Client quality, severity,
wil verbalize relief of pain duration, onset, of nursing and medical care.
and relief.
-​ At first sigs of pain, TYPES OF NURSING INTERVENTIONS
instruct client to
-​ The Nursing Interventions Classification
relax and
discontinue (NIC) project defines a nursing
activity. intervention as " any treatment based
-​ Instruct client to upon clinical judgment and knowledge
take sublingual
nitroglycerin.
that a nurse performs to enhance
-​ If pain continues patient/client outcomes " (McCloskey
after repeating Dochterman, & Bulechek, 2004)
doses every 5 -​ The Nursing Interventions Classification
minutes for a total
of three pills, notify (NIC) is the first comprehensive
the health care classification of treatments that nurses
practioner or nrse perform. It is a standardized language of
practicioner. both nurse-initiated and
-​ Administer oxygen
as prescribed. physician-initiated nursing treatments
-​ Note time interval -​ Nursing Interventions include both
between episodes direct and indirect care; those aimed at
of pain.
individuals, families and community;
and those for nurse-initiated and other
provider-initiated treatments.

NURSING INTERVIEW CLASSIFICATIONS

(NIC)
-​ It is the first comprehensive
classification of treatments that nurses
perform.
-​ Each NIC intervention is composed of a
label, a definition, a set of activities that
a nurse does to carry out the
intervention, and a short list of
background readings.
1.​ Direct Care Intervention supervision of another health
a.​ intervention is a treatment care professionals.
performed through interaction c.​ Health education is through
with the patients). health teaching to the client or
b.​ This includes both physiological significant others(SO) using
and psychosocial nursing health teaching plan (HTP)
actions.

2.​ Indirect Care Intervention Example

a.​ a treatment performed away Mrs. Smith has started a new medication for
from the patient but on behalf of her high blood pressure She is concerned
a patient or a group of patients. about the side-effects and is refusing to take
the medication. The nurse intervenes by
b.​ Registered nurses teach patients
educating the patient on the purpose of the
how to manage their illnesses or
medication, the side-effects of the
injuries. medication and the possible consequences of
c.​ Nursing actions aimed at the high blood pressure
management of the patient care
environment and
interdisciplinary collaboration 5.​ Dependent Nursing Action/Role
a.​ The activities that require an
3.​ Community or Public Health advanced practitioner's order,
Intervention Example:
a.​ is targeted to promote and Mrs. Smith's blood pressure is consistently
preserve the health of 180/100. The nurse reports this to the
populations physician. The physician orders
antihypertensive medication for the patient.
b.​ Community interventions
The nurse administers the oral medication to
emphasize the health promotion,
the patient as ordered
health maintenance and disease
prevention of population and
include strategies to address the 6.​ Interdependent
social and political climate in Interventions/Collaborative Role
which the populations resides a.​ The actions that involve one or
(McCloskey Dochterman and more disciplines, together make
Bulechek, 2004) up the types of nursing
interventions.
4.​ Independent Nursing Action/Role Examples:
a.​ Nurse initiated interventions Mrs. Smith reveals to the nurse that she
b.​ Involve carrying out consumes a diet very high in sodium. The
nurse-prescribed interventions nurse includes diet counseling in the patient
resulting from their assessment care plan. To help the patient even more,
of patient's needs written on the thenurse enlists the help of the dietician that
is available in their facility to spend time
nursing pian of care, as well as
with Mrs. Smith to educate her on the role
any other actions that nurses
that diet plays in the control of high blood
initiate without the direction or pressure.
 NURSING IMPLEMENTATION -​ The goal was partially met, that is
-​ While implementing nursing orders, the either a short term goal was
nurse continues to reassess the client at achieved but the long term was not,
or the desired outcome was only
every contact, gathering data about the
partially attained.
client's responses to nursing activities
-​ The goal was not met.
and about any new problems that may
develop. When goals have been partially met or when
-​ To implement the care plan successfully, goals have not been met, two conclusions may
nurses need cognitive, interpersonal, and be drawn:
technical skills. These skills are distinct -​ The care plan may need to be revised,
from one another. since the problem is only partially
-​ The cognitive skills (intellectual skills) resolved
include problem solving, decision -​ The care plan does not need revision,
making, critical thinking, and creativity. because the client merely needs more
time to achieve the previously
established goals.
DOCUMENTING NURSING -​ So the nurse must reassess why the
ACTIVITIES goals are not being partially achieved
-​ The nurse complete the implementing
phase by recording the interventions and
client responses in the nursing process DOCUMENTATION
notes. -​ Nurses are legally accountable for their
-​ The nurse may record routine or assessments and their nursing responses.
recurring activities such as mouth care
in the client record at the end of shift, Protocols
while some actions recorded in special -​ written plans that detail the nursing
worksheets according to agency policy. activities to be executed in a specific
-​ Immediate recording helps safeguard the situations.
client to prevent double actions.
Standing Orders
-​ other protocols that empower the nurse
EVALUATION to initiate actions that ordinarily require
-​ The last phase of the nursing process, the order or supervision of a physician.
follows implementation of the plan of Example: ER Orders
care, it's the judgment of the
effectiveness of nursing care to meet
client goals based on the client's
behavioral responses.
-​ 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 the desired
outcomes.
NURSING CARE PLAN (NCP) Standardized Care Plans
-​ are pre-developed guides by the nursing
●​ Is a formal process that correctly staff and health care agencies to ensure
identifies existing needs and recognizes that patients with a particular condition
a client's potential needs or risks receive consistent care. These care plans
●​ Care plans provide a way of are used to ensure that minimally
communication among nurses, their acceptable criteria are met and to
patients, and other healthcare providers promote the efficient use of the nurse’s
to achieve healthcare outcomes. time by removing the need to develop
●​ Without the nursing care planning common activities that are done
process, the quality and consistency of repeatedly for many of the clients on a
patient care would be lost nursing unit.
●​ Nursing care planning begins when the -​ Standardized care plans are not tailored
client is admitted to the agency and is to a patient’s specific needs and goals
continuously updated throughout in and can provide a starting point for
response to the client's changes in developing an individualized care plan.
condition and evaluation of goal -​ Care plans listed in this guide are
achievement. standard care plans which can serve as a
●​ Planning and delivering individualized framework or direction to develop an
or patient-centered care is the basis for individualized care plan.
excellence in nursing practice.
Individualized Care Plans
Types of Nursing Care Plans -​ An individualized care plan care plan
-​ Care plans can be informal or formal: involves tailoring a standardized care
An informal nursing care plan is a plan to meet the specific needs and goals
strategy of action that exists in the of the individual client and use
nurse‘s mind. A formal nursing care approaches shown to be effective for a
plan is a written or computerized guide particular client. This approach allows
that organizes the client’s care more personalized and holistic care
information. better suited to the client’s unique needs,
-​ Formal care plans are further subdivided strengths, and goals.
into standardized care plans and -​ Additionally, individualized care plans
individualized care plans: Standardized can improve patient satisfaction. When
care plans specify the nursing care for patients feel that their care is tailored to
groups of clients with everyday needs. their specific needs, they are more likely
Individualized care plans are tailored to to feel heard and valued, leading to
meet a specific client’s unique needs or increased satisfaction with their care.
needs that are not addressed by the This is particularly important in today’s
standardized care plan. healthcare environment, where patient
satisfaction is increasingly used as a
quality measure.
Tips on how to individualize a nursing
care plan:
1.​ Perform a comprehensive assessment of
the patient’s health, history, health
status, and desired goals.
2.​ Involve the patient in the care planning
process by asking them about their
health goals and preferences. By
involving the client, nurses can ensure
that the care plan is aligned with the
patient’s goals and preferences which
can improve patient engagement and
compliance with the care plan.
3.​ Perform an ongoing assessment and
evaluation as the patient’s health and
goals can change. Adjust the care plan
accordingly.