Nurse's Pocket Guide

• It provides for the safety of the client by ensuring that the
care provided will do no harm.
• The client diagnostic statements are supported by the client
data.
• The goals and outcomes are measurable/observable and
can be achieved.
• The interventions can benefit the client/family/significant
others in a predictable way in achieving the identified outcomes,
and they are arranged in a logical sequence.
• It demonstrates individualized client care by reflecting the
concerns of the client and significant others, as well as their
physical, psychosocial, and cultural needs and capabilities.
Once the plan of care is put into action, changes in the client’s
needs must be continually monitored because care is provided
in a dynamic environment, and flexibility is required to allow
changing circumstances. Periodic review of the client’s response
to nursing interventions and progress toward attaining the
desired outcomes helps determine the effectiveness of the plan
of care. Based on the findings, the plan may need to be modified
or revised, referrals to other resources made, or the client may
be ready for discharge from the care setting.
Summary
Healthcare providers have a responsibility for planning with the
client and family for continuation of care to the eventual outcome
of an optimal state of wellness or a dignified death. Today,
the act of diagnosing client problems/needs is well-established
and the use of standardized nursing language to describe what
nursing does is rapidly becoming an integral part of an effective
system of nursing practice. Although not yet comprehensive, the
current NANDA-I list of diagnostic labels defines/refines professional
nursing activity. With repeated use of NANDA-I NDs,
strengths and weaknesses of the NDs can be identified, promoting
research and further development.
Planning, setting goals, and choosing appropriate interventions
are essential to the construction of a plan of care and
delivery of quality nursing care. These nursing activities constitute
the planning phase of the nursing process and are documented
in the plan of care for a particular client. As a part of the
client’s permanent record, the plan of care not only provides a
means for the nurse who is actively caring for the client to be
aware of the client’s needs (NDs), goals, and actions to be taken,
but also substantiates the care provided for review by thirdparty
payers and accreditation agencies, while meeting legal
requirements.
16 NURSE’S POCKET GUIDE