deliberative, systematic phase of the nursing process that involves decision-making and problem-solving
Three types of planning
initial planning
planning completed shortly after the initial (usually the admission) assessment to develop the patient's individualized initial care plan
ongoing planning
planning done by all nurses who work with the patient to individualize the patient's initial care plan even more than initial planning
discharge planning
planning started on the initial (usually the admission) assessment to anticipate and plan for the needs of the patient after discharge
Four stages of the planning process
stage one: setting priorities
during this step of this stage, the nurse prioritizes nursing diagnoses by grouping them, typically by utilization of a framework such as Maslow's hierarchy of needs, according to whether they are of high, medium, or low-priority
high-priority nursing diagnoses
are life-threatening and require immediate action, e.g.:
Ineffective airway clearance
Ineffective breathing pattern
Decreased cardiac output
medium-priority nursing diagnoses
are health-threatening and require prompt action, e.g.:
Impaired skin integrity
Constipation
Diarrhea
low-priority nursing diagnoses
are not life-threatening or health-threatening and require timely action, e.g.:
Interrupted breast-feeding
Self-care deficit: dressing/grooming
High risk for loneliness
a nurse does not need to resolve all high-priority nursing diagnoses before addressing medium or low-priority nursing diagnoses
priorities assigned to nursing diagnoses are not static; they change as a patient's responses, problems, and therapies change
when prioritizing nursing diagnoses, the nurse must take into consideration the following factors:
during this step of this stage, the nurse establishes broad statements about the desired outcome or change in a patient's behavior
e.g., "The patient will demonstrate an effective airway clearance"
components of goal statements
opposite, healthy response of the problem statement (diagnostic label) of the nursing diagnosis
relationship of goals to nursing diagnoses
a goal is derived by stating the goal as the opposite, healthy response of the problem statement (diagnostic label) of the nursing diagnosis
as such, for the problem statement (diagnostic label) of Ineffective airway clearance, the goal would be "The patient will demonstrate effective airway clearance"
for every nursing diagnosis, the nurse must write at least one goal that, when achieved, directly demonstrates resolution of the problem statement (diagnostic label) of the nursing diagnosis
when developing goal statements, ask the following questions
what is the problem statement (diagnostic label) of the nursing diagnosis?
what is the opposite, healthy response of the problem statement (diagnostic label) of the nursing diagnosis?
short-term goals
are goals that generally require less than a week to achieve and are useful for the following patients:
those who require health care for a short time
e.g., hospitalized patients
those who are frustrated by long-term goals that seem difficult to obtain
those who need the satisfaction of achieving a short-term goal
long-term goals
are goals that generally require more than a week to achieve and are useful for the following patients:
those who require health care for a long time
e.g., those patients in nursing homes, private homes, extended care facilities, rehabilitation centers
expected outcomes
more specific, measurable statements about the desired outcome or change in a patient's behavior that are used to evaluate whether a goal has been met
e.g., "Patient's lungs will be clear to auscultation during the entire postoperative period"
components of expected outcome statements
the subject
the patient
any part of the patient
e.g., the patient's ankle
some attribute of the patient
e.g., the patient's urinary output
the verb
the action the patient is to perform; what the patient is to do, learn, or experience
e.g., action verbs such as administer, show, walk, drink, choose
the conditions or modifiers
the circumstances under which the behavior is to be performed (how, where, what, and when)
how
e.g., "walks with the help of a walker"
where
e.g., "when at home, maintains weight at existing level"
what
e.g., "discusses four food groups and recommended daily servings"
when
e.g., "after attending two group diabetes classes, lists signs and symptoms of diabetes"
the criterion of desired performance
the standard or level by which a performance is evaluated or the level at which the patient will perform the specific behavior (time, accuracy, time and distance, quality)
time
e.g., "weighs 75 kg by April 25"
accuracy
e.g., "lists five out of six signs of diabetes"
time and distance
e.g., "walks one block per day"
quality
e.g., "administers insulin using aseptic technique"
relationship of expected outcome statements to nursing diagnoses
expected outcome statements are derived by stating the expected outcomes as the opposite of the problem statement (diagnostic label) of the nursing diagnosis
as such, for the problem statement (diagnostic label) Ineffective airway clearance, an expected outcome might be "The patient's lungs will be clear to auscultation during the entire postoperative period"
for every nursing diagnosis, the nurse must write at least one expected outcome statement that, when achieved, directly demonstrates resolution of the problem statement (diagnostic label) of the nursing diagnosis
when developing goal/expected outcome statements, ask the following questions:
how will the patient look or behave if the opposite, healthy response of the problem statement (diagnostic label) of the nursing diagnosis is achieved?
what must the patient do and how well must the patient do it to demonstrate resolution or the capacity of resolving the problem statement (diagnostic label) of the nursing diagnosis?
a patient's care plan usually reflects both goals/expected outcomes which are usually combined in one statement by the words "as evidenced by"
e.g., "The patient will demonstrate effective airway clearance, as evidenced by his/her lungs being clear to auscultation during the entire postoperative period"
purposes of goals/expected outcome statements
provide direction for planning nursing strategies (interventions) that will achieve the desired changes in the patient
provide a time span for planned activities
serve as criteria for evaluation of patient progress
enable the patient and nurse to determine when the problem has been resolved
help motivate the patient and nurse by providing a sense of accomplishment
guidelines for writing goals/expected outcome statements
write goals/expected outcome statements in terms of patient behavior
make sure the goal statement is appropriate for the nursing diagnosis
be sure that the goals/expected outcomes are realistic for the patient's capabilities, limitations, and designated time span, if it is indicated
make sure the patient considers the goals/expected outcomes important and values them
ensure that the goals/expected outcomes are compatible with the work and therapies of other professionals
make sure that each goal is derived from only one nursing diagnosis
when writing expected outcomes, use observable, measurable terms; avoid terms that are vague and require interpretation or judgment by the observer
durng this step of this stage, the nurse establishes the nursing activities relating to a specific nursing diagnosis to be carried out to achieve patient goals/expected outcomes
components of nursing strategies (interventions) statements, which are written as nursing orders
date
e.g., "5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
action verb
e.g., "5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
content area (what, where)
what
e.g., "5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
where
e.g., "5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
time element
when
e.g., "5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
how long
"e.g., 5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
how often
e.g., "5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
signature
e.g., "5/16/02 Measure and record the posterior tibial pulse of the left ankle daily at 0900 x's 48 hrs. S. Yeager, RN"
relationship of nursing strategies (interventions), written as nursing orders, to nursing diagnoses
nursing strategies (interventions) for actual, high-risk (potential), and possible nursing diagnoses focus on reducing or eliminating the etiology (related or risk factors) of the problem statement (diagnostic label)
as such, for the problem statement (diagnostic label) Ineffective airway clearance, a nursing strategy (intervention) might be "9/15/02 Encourage patient to drink at least 2000 mL of fluid daily if not contraindicated by cardiac or renal disease. S. Yeager, RN" to reduce or eliminate the etiology (related or risk factor) of excessive, thick tracheobronchial secretions
independent nursing strategies (interventions), written as nursing orders
those activities that nurses are licensed to initiate on the basis of their knowledge and skills
e.g., physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, making referrals to other health care professionals
e.g., "5/16/02 Administer prescribed expectorant q 4hrs. S. Yeager, RN"
collaborative nursing strategies (interventions), written as nursing orders
those activities the nurse carries out in collaboration with other health team members
e.g., "5/16/02 Turn off tube feedings 1 hr. at 0700, 1100, 1500, 1900 to coincide with 1 hr. prior to each respiratory therapy treatment. S. Yeager, RN"
relationship of nursing strategies (interventions), written as nursing orders, to health problems
observation nursing orders
utilized to determine if a health problem in a patient is developing
e.g., "5/16/02 Auscultate lungs q 4 hrs. S. Yeager, RN" (helps observe for congestion in the lungs)
prevention nursing orders
utilized to prevent a health problem from developing in a patient
e.g., "5/16/02 Turn, cough, deep breath q 2 hrs., S. Yeager, RN" (helps prevent congestion in the lungs)
treatment nursing orders
utilized to treat a health problem that is present in a patient
e.g., " 5/16/02 Administer O2 @ 2L per nasal prongs prn, S. Yeager, RN" (helps treat hypoxia resulting from congestion in the lungs)
health promotion nursing orders
utilized to help identify areas for improvement of a patient's health that will lead him/her to a higher level of wellness and actualize his/her overall health potential
e.g., "5/16/02 Discuss the importance of enrolling in a cigarette cessation program during the next clinic visit, S. Yeager, RN" (helps promote the health of the lungs)
guidelines for selecting nursing strategies (interventions), written as nursing orders
consider the consequences of each nursing strategy (intervention)
must be safe and appropriate for the patient's age, health, and so on
achievable with the resources available
congruent with a patient's values and beliefs
congruent with other therapies
based on nursing knowledge and experience or knowledge from relevant sciences
e.g., based on a rationale
within standards of care as determined by state laws, professional associations, and the policies of the institution
developing nursing care plans
during this step of this stage, the nurse develops a written guide that organizes information about a patient's nursing care into a meaningful whole
components of nursing care plans
nursing diagnoses
goals/expected outcomes
nursing strategies (interventions)
evaluation
types of nursing care plans
individual care plan
a care plan writen by hand for each patient by a registered nurse that delineates the necessary nursing care for an individual patient
standardized care plan
a pre-planned, pre-printed nursing care plan written by a group of registered nurses who are experts in a given area of practice that delineates the necessary nursing care for a group of patients with common needs
computerized care plan
a nursing care plan generated by a computer for each patient by a registered nurse that delineates the necessary nursing care for an individual patient
the nurse chooses an appropriate nursing diagnosis for his/her patient from a menu suggested by the computer
the computer then provides the nurse with a menu of possible goals/expected outcomes and nursing strategies (interventions) for the chosen nursing diagnosis
the nurse then chooses the appropriate goals/expected outcomes and nursing strategies (interventions) for the nursing diagnosis from the menu suggested by the computer
the nurse can also type in additional goals/expected outcomes and nursing strategies (interventions) to individualize the care plan for his/her patient
case management care plan
a pre-planned, pre-printed multidisciplinary care plan written by a multidisciplinary team that delineates and sequences the necessary care that needs to be provided each day to a patient during the projected length of stay for a specific type of case
purposes of nursing care plans
to provide direction for individualized care of the patient
to provide continuity of care
to provide direction about what needs to be documented on the patient's progress notes
to serve as a guide for assigning staff to care for the patient
to serve as a guide for reimbursement from medical insurance companies
guidelines for writing nursing care plans
date and sign the nursing care plan
use the category headings: "nursing diagnoses", "goals/expected outcome", "nursing strategies (interventions)", and "evaluation" (including a date for the evaluation of each goal)
use standardized medical or English symbols and key words rather than complete sentences to communicate your ideas
refer to procedure books or other sources of information rather than including all the steps on the nursing care plan
tailor the plan to the unique characteristics of the patient by ensuring that the patient's choices, such as preferences about the times of care and the methods used, are included
ensure that the nursing plan incorporates preventive and maintenance aspects as well as restorative
ensure that the plan contains nursing strategies (interventions) for ongoing assessment of the patient
ensure that the nursing care plan includes collaborative and coordination of activities in the plan
include nursing strategies (interventions) for the patient's discharge and home care needs
