Chapter 18 Planning Nursing Care Planning constitutes the third step of the nursing process. After you have identified your client’s nursing diagnosis, planning the appropriate care comes next. During the planning process you will identify nursing behaviors in which client-centered goals, expected outcomes, and nursing interventions are developed. Planning will require the use of your critical thinking skills, in which decision-making and problem-solving techniques are incorporated. A plan of care is dynamic and will change as your client’s needs change or as you identify new needs.

Establishing Priorities Helps nurses to anticipate and sequence nursing interventions Classification of priorities: High Intermediate Low No doubt, clients will have multiple nursing diagnoses and problems. In order to care for one client and groups of clients (which is the norm) you will need to rank and deal with individual and aggregate nursing diagnoses so you can recognize those most important problems to organize your client care day. It will be important to classify priorities as high, intermediate, or low. Tasks associated with high-priority diagnoses typically revolve around safety, adequate oxygenation, and circulation. However, you must always consider each client’s unique situation. These priorities can be physiological, psychological, or related to other basic human needs. A task for an intermediate-priority diagnosis involves the nonemergent, non–life threatening needs of the client. The low-priority nursing diagnosis may not be related to a specific illness or prognosis but may call for an intervention that affects the client’s future well-being. Many of these deal with the client's long-term health care needs.

Time Factor in Setting Priorities The planning of nursing care occurs in three phases: Initial Ongoing Discharge planning Initial planning involves the development of a preliminary care plan following the client’s initial assessment and initial selection of nursing diagnoses. This phase can be challenging due to the short length of client stay. Ongoing planning involves continuous updating of the client's plan of care. As the client condition changes, for better or worse, continual assessments need to be made, and revisions may be necessary. The third phase, discharge planning, involves the important aspects and preparations needed for the client to go home. A clue to planning is to think holistically about the client and the client’s specific needs. Prioritizing specific interventions or strategies will help you and the client meet optimal goals and outcomes.

Critical Thinking in Establishing Goals and Expected Outcomes A broad statement that describes the desired change in a client’s condition or behavior An aim, intent, or end Expected outcome Measurable criteria to evaluate goal achievement Having goals and expected outcomes serves two purposes: it gives a clear direction for the selecting and using nursing interventions and provides focus for evaluating the effectiveness of the interventions. Figure 18-3 illustrates the relationship between nursing diagnoses, expected outcomes, and nursing interventions.

Goals of Care Client-centered goal Short-term goal Long-term goal A specific and measurable behavior or response Short-term goal An objective behavior or response expected within hours to a week Long-term goal An objective behavior or response expected within days, weeks, or months Client-centered goals reflect a client’s highest possible level of wellness and independence in function. A goal must be realistic and based on the client’s needs and resources. A client goal represents predicted resolution of a diagnosis or problem, evidence of progress toward resolution, progress toward improved health status, or continued maintenance of good health or function. Each goal must be time limited so that the health care team has a common time frame for problem resolution. The time frame depends on the nature of the problem, its etiology, the client’s overall condition, and treatment setting. A short-term goal is what you expect the client to achieve in a short period of time. Since hospital stays are shorter than before, these goals may last several hours to days. Long-term goals are expected to be achieved in longer period of time. Tale 18-1 presents examples of goal setting with expected outcome for a client.

Expected Outcomes A specific, measurable change in a client’s status Provide focus or direction Determine when a specific, client-centered goal has been met Most important, outcomes must be measurable. Expected outcomes provide a focus or direction for nursing care because they are physiological, psychological, social developmental, or spiritual responses that indicate resolution of a client’s health problem. Usually several expected outcomes are developed for each nursing diagnosis and goal. Expected outcomes should be written in a sequential time frame. The time frames give progressive steps in which a client moves toward recovery and impose an order on nursing interventions. Time frames also set limits for problem resolution. Note to instructor: If your college/university utilizes NOC (nursing outcomes classification), please include a discussion on this use in your program.

Guidelines for Writing Goals Combining goals and outcomes statements Client centered Singular goal or outcome Observable Measurable Time limited Mutual factors Realistic Combining goals and outcome statements: Many school and health care institutions use a format for presenting goals and outcomes in one statement. Some places use the terms goal and outcome interchangeably. Client-centered outcomes and goals reflect the client behavior and responses expected as a result of nursing interventions. The goal must be written to reflect the desires of the client rather than the nurse. A specific goal or outcome must be defined precisely before a client response to a nursing action can be evaluated. Each goal and outcome addresses only one behavior or response. Observable changes occur in physiological findings and the client’s knowledge, perceptions, and behavior. Measurable outcomes are of paramount importance. You will learn how to write goals and expected outcomes that set standards against which to measure the client's response to nursing care. Do not use vague terms or qualifiers such as “normal,” “acceptable,” or “stable.” Instead use terms that can be evaluated precisely—for example, terms that describe quality, quantity, frequency, length, or weight. Time-limited time frames for each goal and expected outcome indicate when nurses expect the identified response to occur. Time frames enable nurses to help clients meet goals and make progress at a reasonable rate. Mutual factors combine goals and expected outcomes to ensure that the client and nurse agree on the direction and time limits of care. By setting mutual goals and expected outcomes, nurses can increase the client’s motivation and cooperation. For the client to succeed, the goals and outcomes must be attainable. Since lengths of stay are now much shorter, this can be problematic. When setting goals and outcomes, make sure to factor in the client’s physiological, emotional, cognitive, and sociocultural potential as well as the economic cost and resources available to reach these in a timely manner.

Types of Interventions Nurse initiated Independent Physician initiated Dependent Collaborative Interdependent When choosing interventions, you nurses need to be competent in three areas: 1. Knowing the scientific rationale for the interventions 2. Possessing the necessary psychomotor and interpersonal skills 3. Being able to use available health care resources effectively Nurse-initiated interventions are the independent interventions or actions that a nurse initiates. These actions are based on scientific rationale and do not require direction from another health care professional. Each state has developed Nurse Practice Acts that delineate nursing interventions. Most of these relate to activities of daily living, health education, and promotion and counseling. ASK students to identify some independent nursing actions? ANSWERS can include: elevating an extremity, client education, how to cough and splint. Physician-initiated interventions depend on nursing interventions. These actions require an order from a physician or other health care professional. Each one of these interventions requires nursing responsibilities and specific knowledge. When administering medications, nurses need to know the drug, action, dose, side effects, and nursing interventions. Collaborative or interdependent nursing interventions are therapies that require the combined knowledge, skills, and expertise of multiple health care professionals. In a client care conference the multidisciplinary health care team selects and assigns interdependent nursing interventions.

Selection of Interventions Six factors to include Characteristics of nursing diagnosis Goals and expected outcomes Evidence base for interventions Feasibility of the intervention Acceptability to the client Nurse’s competency When selecting interventions, review the client’s needs, priorities, and previous health experiences. If your college or university uses the Nursing Interventions Classification (NIC), discuss how you incorporate NIC into your plan of care.

Planning Nursing Care Nursing care plan Student care plan Institutional care plan Concept map In health care settings, nurses are responsible for providing a written plan of care. The plan can take many forms, such as Kardex, standard care, or computerized plan. The plan includes nursing diagnoses, goals and expected outcomes, and nursing interventions. Written care plans can also be used for change of shift reports. The nursing care plan helps to ensure continuity of care by all nurses. Student care plans help you organize your plan for the day. The plan also helps you to apply theory you learned. Most commonly a column format is used. Note in instructor: Discuss the format you use. The institutional care plan is part of the client’s legal record. Health care facilities use some type of electronic health record, and the care plan is part of the record. Standardized care plans are individualized to each client. Many health care facilities use critical pathways, which are multidisciplinary treatment plans. Most pathways are based on the medical diagnosis and not the nursing diagnosis. The pathway details day-to-day activities a client must achieve before discharge. We have discussed concept maps in Chapter 16. If your college/university uses a concept map, lead a discussion on the use and format of concept maps in your nursing program.

Consulting Other Health Care Professionals Consultation is a process in which you seek the expertise of a specialist to identify ways to handle problems in client management or the planning and implementation of therapies. Consultation can occur at any step of the nursing process. Consultation is based on a problem-solving approach. Oftentimes, the consultant is the stimulus for change. Ask students who they might want to consult with when caring for clients in the hospital setting? ANSWERS may include: dieticians, respiratory therapists, physical therapists, wound care specialist, diabetic educator, case manager. Importantly, do not be afraid to ask for a consultation. Consultations will increase your knowledge and help you learn new skills and how to obtain additional resources.