13 Planning

Directory Classroom Response System Questions Lecture Note Presentation

Classroom Response System Questions

Question 1 After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? Initial Ongoing Discharge Strategic

Question 1 Answer Initial Ongoing Discharge Strategic

Question 1 Rationales The client requires initial planning since he has just arrived on the orthopedic unit for the first time. Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires ongoing planning necessary to determine care appropriate for this shift. Discharge planning starts on admission to ensure adequate client preparation for managing health needs outside the health agency. Correct. Strategic planning is an ongoing process focused on organizational change rather than on individual clients so it is least useful.

Question 2 The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? Hospital policies Standardized care plans Orthopedic protocols Standards of care

Question 2 Answer Hospital policies Standardized care plans Orthopedic protocols Standards of care

Question 2 Rationales Correct. Policy and procedure documents provide data about how certain situations are handled. Note: Even hospital policies are not absolute. Each situation must be analyzed and responded to individually. Standardized care plans are written for groups of clients with similar medical or nursing diagnoses. They generally do not address questions such as hospital routines and nonmedical client needs. Orthopedic protocols would address elements specifically associated with the surgery. Standards of care are written for groups of clients with similar medical or nursing diagnoses. They usually do not address hospital routine or nonmedical client needs.

Question 3 The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when aroused. The client’s pain is 2 on a scale of 0 to 10; vital signs are within preoperative range; extremities are warm with good pulses but very dry skin. The client declines oral fluids due to nausea and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element would likely be high priority for the current care plan? Pain Nausea Constipation Potential for wound infection

Question 3 Answer Pain Nausea Constipation Potential for wound infection

Question 3 Rationales The client’s pain level is not extreme considering his recent surgery, and pain intervention can be assumed to be effective. Correct. A more detailed assessment data and consultation with the client would be needed to confirm the priority. Postoperative nausea that inhibits oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. Although the constipation is probably bordering abnormal, nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. Wound infection can occur but there are no data to indicate that this requires a change in the current plan.

Question 4 The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and a surgical incision. Which of the following represents a properly stated outcome/goal? The client will: Turn in bed q2h. Report the importance of applying lotion to skin daily. Have healthy intact skin during hospitalization. Use a pressure-reducing mattress.

Question 4 Answer Turn in bed q2h. Report the importance of applying lotion to skin daily. Have healthy intact skin during hospitalization. Use a pressure-reducing mattress.

Question 4 Rationales Turning in bed is an intervention that may result in achieving the goal, but the goal or outcome should state the opposite of the nursing diagnosis stem. The goal or outcome should state the opposite of the nursing diagnosis stem. Applying lotion is an intervention that may help in achieving the goal. Correct. The goal or outcome should state the opposite of the nursing diagnosis stem; healthy intact skin is the opposite of impaired skin integrity. The goal or outcome should state the opposite of the nursing diagnosis stem. Using a pressure-reducing mattress is an intervention that may result in achieving the goal.

Question 5 The care plan includes a nursing intervention “4/2/11 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted? Action verb Content Time None

Question 5 Answer Action verb Content Time None

Question 5 Rationales Incorrect. In the sentence, “measure” is an action verb. Incorrect. Content is not missing. Correct. Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done “routinely” or at specific intervals (e.g., q4h). However, critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings. Incorrect. A time element was missing.

Lecture Note Presentation

Learning Outcomes Identify activities that occur in the planning process. Compare and contrast initial planning, ongoing planning, and discharge planning. Explain how standards of care and preprinted care plans can be individualized and used in creating a comprehensive nursing care plan.

Learning Outcomes (cont'd) Identify essential guidelines for writing nursing care plans. Identify factors that the nurse must consider when setting priorities. State the purposes of establishing client goals/desired outcomes.

Learning Outcomes (cont'd) Discuss the Nursing Outcomes Classification, including an explanation of how to use the outcomes and indicators in care planning. Identify guidelines for writing goals/desired outcomes. Describe the process of selecting and choosing nursing interventions.

Learning Outcomes (cont'd) Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning.

Planning Deliberate, systematic, problem-solving phase of nursing process Decide on nursing interventions Nurse responsible, but input from client essential

Figure 13-1 Planning. The third phase of the nursing process, in which the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client’s health problems. 25

Planning (cont’d) Begins with first client contact Continues until nurse-client relationship ends (discharge) Is multidisciplinary

Initial Planning Develops initial comprehensive plan of care Begun after initial assessment

Ongoing Planning Done by all nurses who work with the client Individualization of initial care plan Also occurs at the beginning of a shift

Discharge Planning Process of anticipating and planning for needs after discharge Addressed in each client’s care plan Begins at first client contact Involves comprehensive and ongoing assessment

Developing Nursing Care Plans Informal nursing care plan A strategy for action that exists in nurse’s mind Formal nursing care plan Written or computerized guide Standardized care plan A formal plan that specifies actions for a group of clients with common needs

Developing Nursing Care Plans (cont'd) Individualized care plan Tailored to meet the unique needs of a specific client

Standardized Approaches to Planning Established to ensure minimal criteria for care are met Established for efficient use of time

Standards of Care Describe nursing actions for clients with similar medical conditions Describe achievable rather than ideal nursing care Define interventions for which nurses are accountable Usually agency records that may be referred to in client’s care plan

Standards of Care (cont'd) Written from the perspective of the nurse’s responsibilities Do not contain medical interventions

Standardized Care Plans Predeveloped guides for nursing care of client with a need arising frequently in agency Written from the perspective of what care the client can expect

Protocols Indicate actions commonly required for a particular groups of clients May include both primary care provider’s orders and nursing interventions Example: protocol for admitting a client to the intensive care unit

Policies and Procedures Developed to govern handling of frequently occurring situations Cover situations pertinent to client care Example: policy specifying the number of visitors a client may have

Standing Order Written document Policies Rules Regulations Orders regarding patient care Gives the nurse authority to carry out specific actions under certain circumstances

Individualization of Standardized Care Plans Individualized to fit the unique needs of each client Usually consists of both preauthored and nurse-created sections Standardized care plans for predictable, commonly occurring problems Individual plan for unusual problems or problems needing special attention

Formats for Nursing Care Plans Student care plans, rationales Concept maps Computerized care plans Multidisciplinary (collaborative) care plans Also called critical pathways

Figure 13-5 A sample pathophysiology concept map. 41

Guidelines for Writing Nursing Care Plans Date and sign the plan Use category headings Use standardized/approved medical or English symbols and key words Be specific Refer to procedure book or other sources rather than including steps Tailor the plan to the client

Guidelines for Writing Nursing Care Plans (cont'd) Incorporate prevention and health maintenance Include ongoing assessment Include collaborative and coordination activities Include discharge planning and home care needs

The Planning Process Consists of following activities: Setting priorities Establishing client goals/desired outcomes Selecting nursing interventions Writing individualized nursing interventions on care plans

Setting Priorities Establishing a preferential sequence for addressing nursing diagnoses and interventions High priority (life-threatening) Medium priority (health-threatening) Low priority (developmental needs)

Factors to Consider When Setting Priorities Client’s health values and beliefs Client’s priorities Resources available to nurse and client Urgency of the health problem Medical treatment plan

Goals/Desired Outcomes Goals - broad statements about the client’s status Desired outcomes - more specific, observable criteria used to evaluate whether goals have been met

Table 13-2 Deriving Desired Outcomes from Nursing Diagnoses 48

Nursing Outcomes Classification (NOC) Taxonomy for describing client outcomes that respond to nursing interventions Outcomes broadly stated and conceptual Made more specific by identifying indicators that apply to a particular client Includes a five-point scale to rate the client’s status

Nursing Outcomes Classification (NOC) (cont’d) To write a desired outcome using NOC taxonomy, indicate: Label Indicators that apply to client Initial client status Location on the measuring scale desired for each indicator Can be stated in traditional (lay) language

Purpose of Desired Goals/ Outcomes Provide direction for planning interventions Serve as criteria for evaluating progress Enable the client and the nurse to determine when the problem has been resolved Help motivate the client and nurse by providing a sense of achievement

Relationship of Desired Goals/ Outcomes to Nursing Diagnosis Goals derived from diagnostic label Diagnostic label contains the unhealthy response (problem) Goal is opposite, healthy response How client will look or behave if health response is achieved (observable, time limited) Achieving goal demonstrates resolution of the problem

Components of Goal/Desired Outcome Statements Subject Verb Condition or modifier Criterion of desired performance

Guidelines for Writing Goals/Desired Outcomes Write in terms of client responses Must be realistic Ensure compatibility with therapies of other professionals Derive from only one nursing diagnosis Use observable, measurable terms Make sure client considers goals important

Nursing Interventions and Activities Actions nurse performs to achieve goals Focus on eliminating or reducing etiology of nursing diagnosis Treat signs and symptoms and defining characteristics Interventions for risk nursing diagnoses should focus on reducing client’s risk factors

Types of Nursing Interventions Independent interventions Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment) Dependent interventions Activities carried out under primary care provider’s orders or supervision, or according to specified routines

Types of Nursing Interventions (cont'd) Collaborative interventions Actions nurse carries out in collaboration with other health team members Reflect overlapping responsibilities of health care team

Criteria for Choosing Appropriate Interventions Safe and appropriate for the client’s age, health, and condition Achievable with the resources available Congruent with the client’s values, beliefs, and culture Congruent with other therapies

Criteria for Choosing Appropriate Interventions (cont'd) Based on nursing knowledge and experience or knowledge from relevant sciences Within established standards of care

Writing Individualized Nursing Interventions Date when they are written Verb Action verb starts the interventions and must be precise Conditions Modifiers Time element How long or how often the nursing action is to occur

Relationship of Nursing Interventions to Problem Status Observations Prevention interventions Treatments Health promotion interventions

Delegating Implementation Delegation occurs during planning Who does each task decided upon? Nurse is responsible for correct implementation of task delegated, analysis of data, and evaluation of outcome

Nursing Interventions Classification (NIC) Taxonomy of nursing interventions Developed by the Iowa Intervention Project First published in 1992 Updated every 4 years

Levels of NIC Consists of three levels: Level 1 - domains Level 2 - classes Level 3 - interventions

NIC Interventions More than 542 interventions developed Each intervention includes: A label (name) A definition A list of activities that outline key actions Linked to NANDA diagnostic labels Select appropriate intervention and customize

Concept Map See Concept Map, Planning