Assessment

Nursing
Evaluation Diagnosis
Prepared by:
Amurao, Ian

NURSING PROCESS
Majid, Nur-Amira
Pedida, Annie-Den
Peña, Eunice Andrea

Implementation Planning
 Planning
• It is a category of nursing behaviors in which client-
centered goals and expected outcomes are established
and nursing interventions are selected.
• During planning, priorities are set because a client often
has more than one nursing diagnosis and a variety of
proposed interventions.
• A plan of care is dynamic and will change as the client’s
need are met or as new needs are identified.
Establishing priorities

• Priority seething involves ranking nursing

diagnosis in order of importance.
• This is to help the nurse anticipate and sequence
nursing interventions when a client has multiples
problems or alternatives.
• Classified as high, intermediate or low.
Goals
• It should be realistic and based in client
needs and resources.
- expected to be
achieved within a short time frame, usually
less than a week.
Example: The patient has a fever with the
temperature of 38.5°C. The nurse will perform
TSB ( Tepid Sponge Bath ) to reduce the
temperature.
o Focus on prevention, rehabilitation, discharge and
health education. - expected to be achieved over a
longer time frame, usually over weeks or months
o It is more appropriate for problem resolution after
discharge, especially from acute care setting.
Example: The client has asthma and the nurse
will instruct the client to avoid vigorous and stressful
activities to prevent asthma from reoccurring.
Expected outcomes

• It is a specific measurable change in a client’d status that

is expected to occur in response to nursing care.
• An outcome is an objective criterion for measuring goal
achievement.
• It determines when a specific, client-centered goal has
been met and evaluate the response to nursing care and
the resolution of the etiology of a nursing diagnosis.
 Nursing Diagnosis Goal Expected outcome

Acute pain related to Client will achieve Client will report pain
tissue trauma of pain control within 48 severity below 4 on a
surgical incision. hours. scale of 0.10 by 24
hours.
 Guidelines for Writing Goals and
Expected Outcomes
• Client-centered - Outcomes and goals should reflect the
clients behavior and responses expected as a result of
nursing interventions.
• Singular goal or outcome - Each goal and expected
outcome statement should address only one behavior or
response. This ensures a precise method to evaluate the
clients response to a nursing intervention.
• Observable - The nurse must be able to determine
through observation if change has taken place.
• Measurable - Goals and expected outcomes are
written to give the nurse a standard against
which to measure the clients response to nursing
care.
• Time limited - The time frame for each goal and
expected outcome indicated when the expected
response should occur.
• Mutual factors - Mutually set goals and exoected
outcomes ensure that the client and nurse agree on
the direction and time limits of care.

• Realistic - The nurse set goals and expected

outcomes that can be achieved.
Thank you for listening! 

• Prepared by:
Amurao, Ian
Majid, Nur-Amira
Pedida, Annie-Den
Peña, Eunice Andrea

• Reference: Fundamentals of Nursing by Potter and Perry, 6th

edition