1. Chapter 18 Planning Nursing Care
Planning constitutes the third step of the nursing process. Planning will require the use of your critical thinking skills, in which decision-making and problem-solving techniques are incorporated.
After you have identified your patient’s nursing diagnosis, planning appropriate care comes next.
Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions.
A plan of care is dynamic and will change as your patient’s needs change, or as you identify new needs.
Planning requires working closely with patients, their families, and the health care team through communication and ongoing consultation.

2. Establishing Priorities
Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions.
Helps nurses anticipate and sequence nursing interventions
Classification of priorities:
High—Emergent
Intermediate
Low—Affect patients’ future well-being
No doubt, patients will have multiple nursing diagnoses and problems. To care for one patient and groups of patients, you will need to rank and deal with individual and aggregate nursing diagnoses so you can recognize those most important problems to organize your day. It will be important to classify priorities as high, intermediate, or low.
By ranking a patient’s nursing diagnoses in order of importance, you attend to each patient’s most important needs and better organize ongoing care activities.
Nursing diagnoses that, if untreated, result in harm to a patient or others have the highest priority and typically revolve around safety, adequate oxygenation, and circulation. However, you must always consider each patient’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 patient.
The low-priority nursing diagnosis may not be related to a specific illness or prognosis but may call for an intervention that affects the patient’s future well-being. Many of these deal with the patient's long-term health care needs.
Together with your patients, you select mutually agreed-on priorities based on the urgency of the problems, the patient’s safety and desires, the nature of the treatment indicated, and the relationship among the diagnoses.

3. Establishing Priorities (cont’d)
The order of priorities changes as a patient’s condition changes.
Priority setting begins at a holistic level when you identify and prioritize a patient’s main diagnoses or problems.
Patient-centered care requires you to know a patient’s preferences, values, and expressed needs.
Ethical care is a part of priority setting.
Each time you begin a sequence of care such as at the beginning of a hospital shift or a patient’s clinic visit, it is important to reorder priorities.
You also need to prioritize the specific interventions or strategies that you will use.
Involve patients in priority setting whenever possible. Consulting with the patient to learn the patient’s concerns does not relieve you of the responsibility to act in a patient’s best interests. Always assign priorities on the basis of good nursing judgment.
When ethical issues make priorities less clear, it is important to have open dialogue with the patient, the family, and other health care providers

4. Priorities in Practice
This model for priority setting is Fig (from text p. 238 A model for priority setting). (Modified from Hendry C, Walker A: Priority setting in clinical nursing practice, J Adv Nurs 47:427, 2004.)
Many factors within the health care environment affect your ability to set priorities.
The same factors that influence your minute-by-minute ability to prioritize nursing actions affect your ability to prioritize nursing diagnoses for groups of patients. The nature of nursing work challenges your ability to cognitively attend to a given patient’s priorities when you care for more than one patient.
Always work from your plan of care and use your patients’ priorities to organize the order for delivering interventions and documenting care.

5. Case Study
Fulmala is a first semester nursing student who is assigned to Ms. Nadine Skyfall, a 35 y/o American Indian patient diagnosed with severe anemia secondary to a bleeding peptic ulcer. Ms. Skyfall experiences pain because of the ulcer and weakness and fatigue resulting from the anemia.
Fulmala develops Ms. Skyfall’s plan of care, which addresses pain, weakness, and fatigue. Fulmala includes nutrition and patient safety as part of the plan of care.
[Ask the class: Why aren’t anemia and peptic ulcer part of the care plan? Then discuss. Remind the class that nursing care plans do not directly address the medical diagnosis.]

6. Critical Thinking in Setting Goals and Expected Outcomes
A broad statement that describes the desired change in a patient’s condition or behavior
An aim, intent, or end
Expected outcome
Measurable criteria to evaluate goal achievement
Once you identify nursing diagnoses for a patient, ask yourself, “What is the best approach to address and resolve each problem? What do I plan to achieve?”
Goals and expected outcomes are specific statements of patient behavior or physiological responses that you set to resolve a nursing diagnosis or collaborative problem.
Having goals and expected outcomes serves two purposes: It gives a clear direction for selecting and using nursing interventions and for evaluating the effectiveness of the interventions.
[See Fig (on text p. 239) Critical thinking and the process of planning care.]
Once an outcome is met, you know that a goal has been at least partially achieved.
Selection of goals, expected outcomes, and interventions requires consideration of your previous experience with similar patient problems and any established standards for clinical problem management.
Goals and outcomes need to meet established intellectual standards by being relevant to patient needs, specific, singular, observable, measurable, and time limited. You use critical thinking attitudes in selecting interventions with the greatest likelihood of success.

7. Goals of Care Patient-centered goal:
A specific and measurable behavior or response that reflects a patient’s highest possible level of wellness and independence in function
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
A patient-centered goal is realistic and is based on patient needs and resources. Patient-centered goals reflect a patient’s highest possible level of wellness and independence in function.
A patient 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 causes, the patient’s overall condition, and the treatment setting.
A short-term goal is what you expect the patient to achieve in a short period of time. Because hospital stays are shorter than before, these goals may last several hours to days.
Long-term goals are expected to be achieved over a longer period of time.
Table 18-1 (on text p. 240) shows the progression from nursing diagnoses to goals and expected outcomes and their relationship to nursing interventions.

8. Always partner with patients when setting their individualized goals.
Goals of Care (cont’d)
Always partner with patients when setting their individualized goals.
For patients to participate in goal setting, they need to be alert and must have some degree of independence in completing activities of daily living, problem solving, and decision making.
Patients need to understand and see the value of nursing therapies, even though they are often totally dependent on you as the nurse.
Mutual goal setting includes the patient and the family (when appropriate) in prioritizing the goals of care and developing a plan of action.
Unless goals are mutually set and a clear plan of action is decided, patients fail to fully participate in the plan of care.
When setting goals, act as an advocate or support for the patient to select nursing interventions that promote his or her return to health or prevent further deterioration when possible.

9. Expected Outcomes An objective criterion for goal achievement
A specific, measurable change in a patient’s status that you expect in response to nursing care
Direct nursing care
Determine when a specific, patient-centered goal has been met
Are written sequentially, with time frames
Usually, several are developed for each nursing diagnosis and goal.
Outcomes must be measurable.
Expected outcomes direct nursing care because they are the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patient’s health problems.
Expected outcomes should be written in a sequential time frame. The time frames give progressive steps in which a patient moves toward recovery and impose an order on nursing interventions. Time frames also set limits for problem resolution.
A patient’s willingness and capability to reach an expected outcome improves his or her likelihood of achieving it.
A list of the step-by-step expected outcomes gives you practical guidance in planning interventions.

10. Nursing Outcomes Classification
A nursing-sensitive patient outcome is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions.
The Iowa Intervention Project published the Nursing Outcomes Classification (NOC) and linked the outcomes to NANDA International nursing diagnoses.
NOC outcomes provide a common nursing language for continuity of care and measuring the success of nursing interventions.
Much attention in the health care environment is focused on measuring outcomes to gauge the quality of health care. If a chosen intervention repeatedly results in desired outcomes that benefit patients, it needs to become part of a standardized approach to a patient problem.
Nursing plays an important role in monitoring and managing patient conditions and diagnosing problems that are amenable to nursing intervention. Thus it is important to identify and measure patient outcomes that are influenced by nursing care.
For the nursing profession to become a full participant in clinical evaluation research, policy development, and interdisciplinary work, nurses need to identify and measure patient outcomes influenced by nursing interventions.
For each NANDA International nursing diagnosis, there are multiple NOC-suggested outcomes. These outcomes have labels for describing the focus of nursing care and include indicators to use in evaluating the success of nursing interventions.
Table 18-2 (on text p. 241) shows examples of NANDA International nursing diagnoses and suggested NOC linkages.
Efforts to measure outcomes and capture changes in the status of patients over time allow nurses to improve patient care quality and add to nursing knowledge.
The fourth edition of NOC is an excellent resource for use in developing care plans and concept maps.

11. Seven Guidelines for Writing Goals
Patient centered
Singular goal or outcome
Observable
Measurable
Time limited
Mutual factors
Realistic
A patient-centered goal is singular, observable, measurable, time limited, mutual, and realistic.
Outcomes and goals reflect patient behaviors and responses expected as a result of nursing interventions. Write a goal or outcome to reflect a patient’s specific behavior, not to reflect your goals or interventions.
A specific goal or outcome must be defined precisely before a patient response to a nursing action can be evaluated. Each goal or outcome addresses only one behavior or response.
Observable changes occur in physiological findings and in the patient’s knowledge, perceptions, and behavior.
You will learn how to write goals and expected outcomes that set standards against which to measure the patient'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 outcomes indicate when nurses expect identified responses to occur. Time frames enable nurses to help patients meet goals and make progress at a reasonable rate.
Mutual factors combine goals and expected outcomes to ensure that the patient and the nurse agree on the direction and time limits of care. By setting mutual goals and expected outcomes, nurses can increase the patient’s motivation and cooperation.
For the patient to succeed, goals and outcomes must be attainable. Because lengths of stay are now much shorter, this can be problematic. When setting goals and outcomes, make sure to factor in the patient’s physiological, emotional, cognitive, and sociocultural potential, as well as the economic costs and resources required to reach these in a timely manner.

12. Quick Quiz!
1. A patient is suffering from shortness of breath. The correct goal statement would be written as A. The patient will be comfortable by the morning. B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. The patient will not complain of breathing problems within the next 8 hours. D. The patient will have a respiratory rate of 14 to 18 breaths per minute.
Answer: B
[Discuss how B addresses the seven guidelines for writing goals.]

13. Critical Thinking in Planning Care
Nursing interventions are treatments or actions based on clinical judgment and knowledge that nurses perform to meet patient outcomes.
Nurses need to:
Know the scientific rationale for the intervention
Possess the necessary psychomotor and interpersonal skills
Be able to function within a setting to use health care resources effectively
Part of the planning process is to select nursing interventions to meet the patient’s goals and outcomes.
Once nursing diagnoses have been identified and goals and outcomes selected, you choose interventions individualized for the patient’s situation.
During planning, you select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes.
Actual implementation of these interventions occurs during the implementation phase of the nursing process.

14. Types of Interventions
Nurse initiated
Independent—Actions that a nurse initiates
Physician initiated
Dependent—Require an order from a physician or other health care professional
Collaborative
Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals
Nurse-initiated interventions require no order and no supervision or direction from others. Nurse-initiated interventions are autonomous actions based on scientific rationale.
According to the Nurse Practice Acts in a majority of states, independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling.
The NIC taxonomy provides standardization to help nurses select suitable interventions for patients’ problems.
[Ask students to identify some independent nursing actions. ANSWERS can include elevating an extremity, providing patient education, showing how to splint.]
Physician-initiated interventions require specific nursing responsibilities and technical nursing knowledge. These interventions are based on the physician’s or the health care provider’s response to treat or manage a medical diagnosis. Each of these interventions requires nursing responsibilities and specific knowledge. Advanced practice nurses who work under collaborative agreements with physicians, or who are licensed independently by state practice acts, are able to write dependent interventions.
Typically, when you plan care for a patient, you review the necessary interventions and determine whether the collaboration of other health care disciplines is necessary. In a patient care conference, the multidisciplinary health care team selects and assigns interdependent nursing interventions.

15. Clarifying an Order
When preparing for physician-initiated or collaborative interventions, do not automatically implement the therapy, but determine whether it is appropriate for the patient.
The ability to recognize incorrect therapies is particularly important when administering medications or implementing procedures.
Every nurse faces an inappropriate or incorrect order at some time.
Clarifying an order is part of competent nursing practice, and it protects the patient and members of the health care team. When you carry out an incorrect or inappropriate intervention, it is as much your error as the person’s who wrote or transcribed the original order. You are legally responsible for any complications resulting from the error.

16. Case Study (cont’d)
Fulmala develops Ms. Skyfall’s plan of care, including writing the goals and expected outcomes.
Fulmala knows that the guidelines for writing goals and expected outcomes include which of the following?
(Select all that apply.)
A. Measurable
B. Time-limited
C. Observable
D. Diagnostic
E. Realistic
Answers: Measurable, time-limited, observable, realistic
Rationale: The seven guidelines for writing goals and expected outcomes are patient-centered, singular goals or outcomes; they are observable, measurable, and time-limited with mutual factors, and they are realistic.

17. Selection of Interventions
Six factors to consider:
Characteristics of nursing diagnosis
Goals and expected outcomes
Evidence base for interventions
Feasibility of the interventions
Acceptability to the patient
Nurse’s competency
When selecting interventions, review the patient’s needs, priorities, and previous health experiences. [See Box 18-1 (on text p. 243) Choosing Nursing Interventions.]
Correctly written nursing interventions include actions, frequency, quantity, method, and the person to perform them.

18. Nursing Interventions Classification (NIC)
The Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across health care settings and to compare outcomes.
The NIC model includes three levels: domains, classes, and interventions for ease of use.
NIC interventions are linked with NANDA International nursing diagnoses.
[If your college or university uses the Nursing Interventions Classification (NIC), discuss how you incorporate NIC into your plan of care.]
The domains are the highest level (level 1) of the model, and broad terms are used to organize the more specific classes and interventions.
[See Table 18-3 (on text pp ) Nursing Interventions Classification (NIC) Taxonomy.]
The second level of the model includes 30 classes, which offer useful clinical categories.
The third level of the model includes 542 interventions, defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Each intervention includes a variety of nursing activities from which to choose and which a nurse commonly uses in a plan of care. [See Boxes 18-2 and 18-3 (on text p. 243) Example of Interventions for Physical Comfort Promotion and Example of an Intervention and Associated Nursing Activities.]
You determine which interventions and activities best suit your patient’s individualized needs and situation.

19. Case Study (cont’d)
Fulmala knows that _________________ interventions require an order from a physician or another health care professional.
Answer: dependent nursing
Rationale: Dependent nursing interventions are actions that require an order from a physician or other health care professional.

20. Systems for Planning Nursing Care
Nursing care plan = Nursing diagnoses, goals and expected outcomes, and nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient’s clinical needs and situation
Reduces the risk for incomplete, incorrect, or inaccurate care
Changes as the patient’s problems and status change
Interdisciplinary care plan = Contributions from all disciplines involved in patient care.
In health care settings, nurses are responsible for providing a written nursing plan of care for all patients. The plan can take many forms, such as Kardex, standard care, or computerized plan.
Increasingly, hospitals are adopting electronic health records (EHRs) and a documentation system that includes software programs for nursing care plans.
Written care plans can be used for change-of-shift reports. The nursing care plan helps to ensure continuity of care by all nurses.
The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care.
A care plan includes a patient’s long-term needs.
Incorporating the goals of the care plan into discharge planning is important.

21. Change of Shift
A critical time, when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions
Change-of-shift report: Communicates information from offgoing to oncoming patient care personnel = “Nurse handoff”
Focus your reports on the nursing care, treatments, and expected outcomes documented in the care plans.
During a nursing handoff, nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions.
At the end of a shift, you discuss with the next caregivers your patients’ plans of care and their overall progress.
Thus all nurses are able to discuss current and relevant information about each patient’s plan of care.
No evidence has been found for one best nursing hand-off practice. [See Box 18-4 (on text p. 247) Evidence-Based Practice Nursing Hand-Offs.] In some agencies, the nursing handoff process occurs during walking rounds when nurses exchange information about patients at the bedside, giving patients the opportunity to also ask questions and confirm information.
Written care plans organize information exchanged by nurses in change-of-shift reports.
Avoid adding personal opinions about the patient because these are not relevant and could unnecessarily influence the oncoming nurse’s perception of him or her as an individual.

22. Student Care Plans A student care plan
Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation
Is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care
Planning care for patients in community-based settings involves
Educating the patient/family about care
Guiding them to assume more of the care over time
Student care plans are useful for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care.
The plan also helps you to apply theory you learned. Most commonly, a column format is used.
[Discuss the format you use.]
A six-column format includes (from left to right): (1) assessment data relevant to corresponding diagnosis, (2) goals, (3) outcomes identified for the patient, (4) implementation for the plan of care, (5) a scientific rationale (the reason that you chose a specific nursing action, based on supporting evidence), and (6) a section to evaluate your care. In the implementation section, you select interventions appropriate for the patient.
For care plans in community-based settings, you design a plan to (1) educate the patient/family about necessary care techniques and precautions, (2) teach the patient/family how to integrate care within family activities, and (3) guide the patient/family on how to assume a greater percentage of care over time. Finally, the plan includes nurses’ and the patient’s/family’s evaluation of expected outcomes.
[Review Table 18-4 (on text p. 247) Frequent Errors in Writing Nursing Interventions.]

23. Critical Pathways
Critical pathways are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially.
The main purpose of critical pathways is to deliver timely care at each phase of the care process for a specific type of patient.
Care plans and critical pathways increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another.
A critical pathway clearly defines transition points in patient progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficiently as possible.
Critical pathways improve continuity of care because they clearly define the responsibility of each health care discipline. Well-developed pathways include evidence-based interventions and therapies.

24. Concept Maps
Provide a visually graphic way to show the relationship between patients’ nursing diagnoses and interventions
Group and categorize nursing concepts to give you a holistic view of your patient’s health care needs and help you make better clinical decisions in planning care
Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information
[If your program uses a concept map, lead a discussion on the use and format of concept maps in your nursing program.]
When planning care for each nursing diagnosis, analyze the relationships among the diagnoses. Draw dotted lines between nursing diagnoses to indicate their relationship to one another. [See Fig on text p. 248 for an example of a concept map showing these relationships.]
Because you care for patients who present with multiple health problems and related nursing diagnoses, it is often not realistic to have a written columnar plan developed for each nursing diagnosis.
It is important for you to make meaningful associations between one concept and another. The links need to be accurate, meaningful, and complete so you can explain why nursing diagnoses are related. Critical thinkers learn by organizing and relating cognitive concepts.

25. Case Study (cont’d)
What are some examples of independent nursing interventions that Fulmala may develop for Ms. Skyfall?
(Select all that apply.)
A. Medication administration
B. Medication teaching
C. Patient positioning
D. Family teaching
Answers: Medication teaching, patient positioning, family teaching
Rationale: Independent nursing interventions do not require an order from another health care professional. Examples of independent nursing interventions include patient positioning and education. Administering medication requires an order from a physician or other health care professional.

26. Quick Quiz!
2. When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a A. Critical pathway. B. Nursing care plan. C. Concept map. D. Diagnostic label.
Answer: C

27. Consulting Other Health Care Professionals
Planning involves consultation with members of the health care team.
Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies.
Consultation occurs at any step in the nursing process, most often during planning and implementation.
Consultation can occur at any step of the nursing process.
Consultation increases your knowledge about a patient’s problem and helps in learning skills and obtaining the resources needed to solve the problem.
When making a consultation, first identify the general problem, direct the consultation to the right professional, and provide the consultant with relevant information about the problem.
[Ask students whom they might want to consult with when caring for patients in the hospital setting. ANSWERS may include dietitians, respiratory therapists, physical therapists, wound care specialists, diabetic educators, and case managers.]
Do not be afraid to ask for a consultation. Consultations will increase your knowledge and will help you learn new skills and how to obtain additional resources.
You consult most often during planning and implementation.
During these times, you are more likely to identify a problem requiring additional knowledge, skills, or resources. This requires you to be aware of your strengths and limitations as a team member. Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies. The consultation process is important, so all health care providers are focused on common patient goals. Always be prepared before you make a consult. Consultation is based on the problem-solving approach, and the consultant is the stimulus for change. Often, an experienced nurse is a valuable consultant when you face an unfamiliar patient care situation such as a new procedure or a patient presenting a set of symptoms that you cannot identify.
In clinical nursing, consultation helps to solve problems in delivery of nursing care. For example, a nursing student consults a clinical specialist for wound care techniques or an educator for useful teaching resources. Nurses are consulted for their clinical expertise, patient education skills, or staff education skills. Nurses also consult with other members of the health care team such as physical therapists, nutritionists, and social workers. Again, the consultation focuses on problems in providing nursing care.

28. When and How to Consult When: The exact problem remains unclear
How: Begin with your understanding of the patient’s clinical problem.
Direct the consultation to the right professional.
Provide the consultant with relevant information about the problem area: Summary, methods used to date, and outcomes
Do not influence consultants.
Be available to discuss the consultant’s findings.
Incorporate the suggestions.
[See Box 18-5, Tips for Making Phone Consultations.]
Consultation occurs when you identify a problem that you are unable to solve using personal knowledge, skills, and resources.
The process requires good intrapersonal and interprofessional collaboration.
Consultation with other care providers increases your knowledge about the patient’s problems and helps you learn skills and obtain resources.
An objective consultant enters a clinical situation and more clearly assesses and identifies the nature of a problem, whether it is patient, personnel, or equipment oriented.
Share information from the patient’s medical record, conversations with other nurses, and the patient’s family.
Consultants are in the clinical setting to help identify and resolve a nursing problem, and biasing or prejudicing them blocks problem resolution.
Avoid bias by not overloading consultants with subjective and emotional conclusions about the patient and the problem.
When you request a consultation, provide a private, comfortable atmosphere for the consultant and the patient to meet.
A common mistake is turning the whole problem over to the consultant. The consultant is not there to take over the problem but to help you resolve it.
When possible, request the consultation for a time when both you and the consultant are able to discuss the patient’s situation with minimal interruptions or distractions.
The success of the advice depends on the implementation of the problem-solving techniques. Always give the consultant feedback regarding the outcome of the recommendations.

29. Case Study (cont’d)
Fumala works with the nutritionist to develop a meal plan for Ms. Skyfall.
True or False: Collaborative interventions are therapies that involve multiple health care professionals.
Answer: True
Rationale: Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

30. Quick Quiz!
3. Consultation occurs most often during which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: C