1. 13
Planning

2. Directory Classroom Response System Questions
Lecture Note Presentation

3. Classroom Response System Questions

4. 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

5. Question 1 Answer
Initial
Ongoing
Discharge
Strategic

6. 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.

7. 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

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

9. 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.

10. 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

11. Question 3 Answer Pain Nausea Constipation
Potential for wound infection

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. Question 5 Answer
Action verb
Content
Time
None

18. 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.

19. Lecture Note Presentation

20. 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.

21. 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.

22. 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.

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

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

25. Figure 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

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

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

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

29. 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

30. 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

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

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

33. 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

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

35. 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

36. 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

37. 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

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

39. 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

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

41. Figure 13-5 A sample pathophysiology concept map.41

42. 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

43. 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

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

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

46. 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

47. 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

48. Table 13-2 Deriving Desired Outcomes from Nursing Diagnoses48

49. 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

50. 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

51. 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

52. 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

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

54. 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

55. 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

56. 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

57. 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

58. 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

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

60. 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

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

62. 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

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

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

65. 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

66. Concept Map
See Concept Map, Planning