1. Chapter 13 Outcome Identification and Planning Dr. James Pelletier The Swain Department of Nursing The Citadel

2. Hector Davies is a 37 year old mildly obese Caucasian male who was brought to the ED by his wife with complaints of excessive thirst, nausea and vomiting, abdominal pain, fatigue, and confusion. On admission, his blood glucose level was 640 mg/dl. Mr. Davies was admitted for work-up of suspected new onset Type II diabetes.

3. Goal of Outcome Identification and Planning Step Establish priorities. Identify and write expected patient outcomes. Select evidence-based nursing interventions. Communicate the plan of care.

4. Outcome Identification and Planning

5. Standards to Apply to Outcome Identification and Planning The Law National practice standards Specialty professional organizations The Joint Commission The Agency for Healthcare Research and Quality (AHRQ) Your employer

6. A Formal Plan of Care Allows the Nurse to: Individualize care that maximizes outcome achievement Set priorities Facilitate communication among nursing personnel and colleagues Promote continuity of high-quality, cost-effective care Coordinate care Evaluate patient response to nursing care Create a record used for evaluation, research, reimbursement, and legal reasons Promote nurse’s professional development

7. Outcome Identification, Planning, and Clinical Reasoning Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Remember that the goal of patient-centered care is to keep the patient and the patient’s interests and preferences central in every aspect of planning and outcome identification. Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions?

8. Outcome Identification, Planning, and Clinical Reasoning Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice. Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan. Recognize your personal biases and keep an open mind.

9. Three Elements of Comprehensive Planning Initial Ongoing Discharge

10. Deriving Patient Goals/Outcomes and Nursing Orders from Nursing Diagnoses

11. Initial Planning Developed by the nurse who performs the nursing history and physical assessment Addresses each problem listed in the prioritized nursing diagnoses Identifies appropriate patient goals and related nursing care

12. Ongoing Planning Carried out by any nurse who interacts with patient Keeps the plan up to date, manages risk factors, promotes function States nursing diagnoses more clearly Develops new diagnoses Makes outcomes more realistic and develops new outcomes as needed Identifies nursing interventions to accomplish patient goals

13. Discharge Planning Carried out by the nurse who worked most closely with the patient Begins when the patient is admitted for treatment Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently

14. Prioritizing Nursing Diagnoses High priority: greatest threat to patient well-being Medium priority: nonthreatening diagnoses Low priority: diagnoses not specifically related to current health problem

15. Maslow’s Hierarchy of Human Needs Physiologic needs Safety needs Love and belonging needs Self-esteem needs Self-actualization needs

16. Clinical Reasoning and Establishing Priorities What problems need immediate attention and which ones can wait? Which problems are your responsibility and which do you need to refer to someone else? Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)? Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge?

17. Clinical Reasoning and Establishing Priorities (cont.) Have changes in the patient’s health status influenced the priority of nursing diagnoses? Are there relationships among diagnoses that require that one be worked on before another can be resolved? Can several patient problems be dealt with together?

18. Long-Term vs. Short-Term Outcomes Long-term outcomes require a longer period to be achieved and may be used as discharge goals. Short-term outcomes may be accomplished in a specified period of time.

19. IOM’s Six Aims to be Met by Health Care Systems Regarding Quality of Care Safe: avoiding injury Effective: avoiding overuse and underuse Patient-centered: responding to patient preferences, needs, and values Timely: reducing waits and delays Efficient: avoiding waste Equitable: providing care that does not vary in quality to all recipients

20. Categories of Outcomes Cognitive: describes increases in patient knowledge or intellectual behaviors Psychomotor: describes patient’s achievement of new skills Affective: describes changes in patient values, beliefs, and attitudes

21. Clinical, Functional, and Quality- of-Life Outcomes Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved. Functional outcomes describe the person’s ability to function in relation to the desired usual activities. Quality-of-life outcomes focus on key factors that affect someone’s ability to enjoy life and achieve personal goals.

22. Types of Nursing Interventions Nurse-initiated: actions performed by a nurse without a physician’s order Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders Collaborative: treatments initiated by other providers and carried out by a nurse

23. Actions Performed in Nurse-Initiated Interventions (Alfaro, 2002) Monitor health status. Reduce risks. Resolve, prevent, or manage a problem. Facilitate independence or assist with ADLs. Promote optimum sense of physical, psychological, and spiritual well- being.

24. Types of Institutional Plans of Care Computerized plans of care Concept map plans of care Change of shift reports Multidisciplinary (collaborative) plans of care Student plans of care