Four phases of the third stage of nursing process: nsetting priorities, predicting outcomes, planning nursing interventions, ndocumentation of care plan. The fourth stage of nursing process – nimplementation of the plan. The fifth stage of nursing process.
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lanning, the third step of the nursing process includes the formulation of nguidelines that establish the proposed course of nursing action in the nresolution of nursing diagnoses and the development of the client’s plan of ncare. Preceding this step is the collection of assessment data and the nformulation of nursing diagnoses.
After a nurse thoroughly assesses a client and determines the client’s nunique nursing diagnoses (or problems), a plan of action is developed with nspecific goals to resolve the nursing diagnoses or health problems of the nclient. Following the planning component, the nursing process continues with nimplementation of nursing interventions and evaluation of the client’s plan of ncare.
The four critical elements of planning include:
• nEstablishing priorities
• nSetting goals and developing expected noutcomes (outcome identification)
• nPlanning nursing interventions (with ncollaboration and consultation as needed)
• nDocumenting
The purpose, as well as the entire process, of the planning concept is nillustrated with theory and examples. Strategies for effective planning of nquality nursing care are described together with problems frequently nencountered in this stage of the nursing process. The role of critical thinking nin planning and outcome identification is emphasized.
PURPOSES OF OUTCOME IDENTIFICATION AND PLANNING
The American Nurses Association (1998), in its Standards of Clinical nNursing Practice, identifies outcome identification and planning as essential nprinciples for ensuring the delivery of competent nursing care and outlines nthese components in terms of their significance within the nursing process. nAlthough the overall purpose of a client’s plan of care should be to maintaior improve health at an optimal level, planning is a framework on which to base nscientific nursing practice.
Therefore, nthe purposes of the planning component of the nursing process are to provide nadequate direction to ensure quality nursing care for individual clients, to npresent a vehicle to improve staff communication, and to provide continuity ithe delivery of individualized, quality nursing care to all clients.
The five steps of the nursing process are at the very core in using nscientific reasoning for the delivery of individualized, quality nursing care nin any setting (Doenges, Moorhouse, & Geissler, 1997). nThe ability to make appropriate decisions based on a strong knowledge base and nproblem-solving strategies is an expected behavior of the professional nurse.
CRITICAL THINKING
More specifically, professional nurses are expected to think critically nto process data and to make convincing, intelligent decisions concerning the nplanning, management, and evaluation of health care for their clients (Prechter, 1993). By combining the critical-thinking skills ninherent in the nursing process with the client’s identified nursing diagnoses, nthe nurse can focus on resolving the client’s nursing diagnoses with greater nproficiency.
The planning of nursing care occurs in three phases: initial, ongoing, nand discharge. Each type of planning contributes to the coordination of the nclient’s comprehensive plan of care.
Initial planning involves development of nbeginning of care by the nurse who performs the admission assessment and gathers nthe comprehensive admission assessment data. Because of progressively shorter nlengths of hospitalization, initial planning is important in addressing each nprioritized problem, identifying appropriate client goals, and correlating nnursing care to hasten resolution of the client’s problems.
Ongoing planning entails continuous nupdating of the client’s plan of care.
Every nnurse who cares for the client is involved in ongoing planning. As new ninformation about the client is gathered and evaluated, revisions may be nformulated and the initial plan of care becomes further individualized to the nclient.
Discharge planning involves critical nanticipation and planning for the client’s needs after discharge. Planning is nsequential, dynamic, and future-oriented.
Planning nincludes establishing priorities, identifying goals and expected outcomes, ndeveloping nursing interventions, and documenting the client’s plan of care.
Appropriate nguidelines are used to prioritize urgent needs. The client’s nursing diagnoses nare determined and then ranked by mutual agreement of the nurse and client or nsignificant others. The planning component continues with thorough examinatioof this prioritized list of nursing diagnoses and determination of the client’s ngoals and desired expected outcomes. After a clear picture is obtained nregarding the diagnoses and goals, the nursing interventions can be planned to nachieve the desired outcomes.
In the planning phase, the nurse organizes “thought processes for nclinical decision making” (Doenges et al., 1997). To nthink critically is to examine an issue purposefully from a goal-directed nperspective. Critical thinking “is based on principles of science and nscientific method” (Alfaro-LeFevre, 1998). Therefore, ncritical thinking is a useful procedure in the development of objectives and ithe formulation of a blueprint to achieve those objectives. The formulation of nobjectives is accomplished by using valid and reliable data previously gathered nduring the assessment component of the nursing process.
ESTABLISHING PRIORITIES
The establishment of priorities is the first element of planning. Iestablishing priorities, the nurse examines the client’s nursing diagnoses and nranks them in order of physiological or psychological importance. This method norganizes a client’s nursing diagnoses into an operational format for the nplanning of nursing care. These diagnoses should be mutually ranked by the nnurse and client or family and significant others. Involving the client ishared decision-making power helps motivate the client and gives the client a nfeeling of control, which inspires successful achievement of each goal (Doenges et al., 1997).
When an individual client has more than one diagnosis, the nurse and nclient need to establish priorities to identify which nursing diagnosis will be naddressed initially in the plan of care (Carpenito, n1999). By communicating this decision-making process to other members of the nhealth care team, the nurse encourages an orderly approach to the achievement nof optimal health for each client.
Various nguidelines are used in the establishment of priorities for determining which nnursing diagnosis will be addressed initially. The client’s basic needs, nsafety, and desires, as well as anticipation of future diagnoses must be nconsidered. One of the most common methods of selecting priorities is the nconsideration of Maslow’s nhierarchy of needs, which requires that a nlife-threatening diagnosis be given more urgency than a non–life threatening ndiagnosis. Once the basic physiological needs (e.g., respiration, nutrition, nhydration, elimination) are met to some degree, the nurse may consider needs othe next level of the hierarchy (e.g., safe environment, stable living ncondition) and so on up the hierarchy until all the client’s nursing diagnoses have nbeen prioritized.
Following ntable illustrates this process
A useful guide for the beginning nursing student would be to examine neach nursing diagnosis, determine its level of need, and rank the need in order nof priority.
Another consideration in the designation of priorities is client npreferences. If at all possible, the client should nalways be involved in the decision-making process of establishing priorities. nIf the nurse and the client do not mutually set priorities, there may be a ncontradictory course of direction and motivation, which may lead to nnoncompliance and nonresolution of the client’s nnursing diagnoses. The client must participate in the identification of npriorities so that the nature of the problem, as well as the client’s values, nare reflected in the selected course of action.
Aadditional point regarding the establishment of priorities is the anticipatioof future diagnoses. Nursing diagnoses of low and moderate priorities often involve nthe prevention of anticipated potential or risk diagnoses. Although potential nnursing diagnoses may not be a current threat to the client, their seriousness nmay require that the nurse consider the development of nursing interventions ndirected toward prevention of the problem. For example, a client in the Postanesthesia Care Unit may have a high-priority nursing ndiagnosis of Ineffective Breathing Pattern related to nthe anesthesia and sedative drugs. Despite the fact that the client currently nhas no problem in this area, this diagnosis is indeed the basis for the Postanesthesia Care Unit protocol of monitoring the client nclosely.
Establishing npriorities does not mean that one diagnosis must be totally resolved before ngiving attention to another diagnosis. Nursing interventions for several ndiagnoses may be carried out simultaneously. However, at times, it is crucial nthat the nurse and client correctly identify the order of priority of the nclient’s nursing diagnoses so that maximum effort can be directed toward nresolution of the most urgent diagnosis.
Following ntable illustrates this process:
ESTABLISHING GOALS AND EXPECTED OUTCOMES
After nassessing the client, formulating nursing diagnoses, and establishing npriorities, the nurse sets goals and identifies and establishes expected noutcomes for each nursing diagnosis. The purposes of setting goals and nexpected outcomes are to provide guidelines for individualized nursing ninterventions and to establish evaluation criteria to measure the effectiveness nof the nursing care plan.
A goal is an aim, nan intent, or an end. A goal is a broad or globally written statement ndescribing the intended or desired change in the client’s behavior, response, nor outcome. An expected outcome is a ndetailed, specific statement that describes the methods through which the goal nwill be achieved. It includes aspects such as direct nursing care and client nteaching.
WRITING GOALS
Written goals need to be constructed clearly. Clear, precise terminology nimproves the chances that goals will be achieved. When goals are clearly nwritten, their establishment provides direction for the nursing plan of care nand for determination of effectiveness in the evaluation of nursing ninterventions. A guideline is provided for the desired change in the client, nand the client has a clear idea of the direction to be taken for achieving nresolution of each nursing diagnosis. Goals establish appropriate evaluatiocriteria to measure the effectiveness of planned nursing interventions for the nresolution of the client’s individual nursing diagnoses.
Goals should be established to meet the immediate, as well as long-term nprevention and rehabilitation, needs of the client.
A short-term goal is a statement written in objective format ndemonstrating an expectation to be achieved in resolution of the nursing ndiagnosis in a short period of time, usually in a few hours or days.
A long-term goal is a statement written in objective format ndemonstrating an expectation to be achieved in resolution of the nursing ndiagnosis over a longer period of time, usually over weeks or months (Alfaro-LeFevre, 1997). See the accompanying display for examples nof short-term and long-term goals.
Another nconsideration is the accuracy in identifying the etiology of the problem. If nthe etiology of the problem is incorrectly identified, the client may meet the nshort-term goal but the problem will not be resolved. Thus, it is important to ncorrectly identify the etiology of the problem.
Setting nlong-term goals is important in successful discharge planning. It assists icoordinating all health care team members to accomplish the same overall npurpose, that is, client discharge. Coordination promotes continuity of care ninto settings such as restorative care or home health (see the accompanying ndisplay).
EXPECTED OUTCOMES
After nthe goal is established, the expected outcomes can be identified based on the ngoal. Given the client’s unique situation and resources, expected outcomes are nconstructed to be:
• nRealistic
• nMutually desired by the client and nurse
• nAttainable within a defined time period
These ndesired outcomes are the measurable steps toward achieving the previously nestablished goals (Doenges et al., 1997). Because nnursing care is based on a holistic approach, expected outcomes may be writtein the spiritual, emotional, physiological, developmental, and social ndimensions. An expected outcome depicts measurable behavioral change or nevidence of change in the client when the goal has been met. Several expected noutcomes may be required for each goal. Expected outcomes are used in the nevaluation process by providing a standard for comparison to determine if the nclient successfully accomplished the goals.
In the nconstruction of both goals and expected outcome objectives, essential ncomponents include: subject, task statement, criteria, the conditions (if nnecessary), and time frame (Doenges et al., 1997). nWhen goals and outcomes are written clearly, the nurse can select nursing ninterventions to ensure that the client’s baseline data are thoroughly nassessed, individual client needs are identified, and appropriate approaches nare used in the plan of care. Usually, each nursing diagnosis has one global ngoal and several expected outcomes. In writing the goal statement, the nurse nconsiders the nursing diagnosis for the formulation of a suitable client nbehavior that illustrates reduction or alleviation of the nursing diagnosis.
These nconcepts are demonstrated in the Nursing Process Highlight.
Each ncomponent of an appropriately written goal is discussed in the following nparagraphs. For clarity of each concept, examples are provided with related ndiscussion. The examples are designed with the intent of developing skills ithe construction of goals.
SUBJECT
The ncomponent to be considered initially in writing a goal is the subject. The nsubject identifies the person who will perform the desired behavior or meet the ngoal. In a client-centered plan of nursing care, the client is the person who nneeds to achieve a desired change in behavior. See the accompanying display for nan application of the subject component.
TASK STATEMENT
The nnext component in writing goals is the task statement or the action verb. This ncomponent describes what the client (or subject) will do to obtain an expected nchange in behavior. The task statement enables the evaluator to determine nachievement of observable behavior. When the actual behavior is stated as a ntask statement that can be clearly and directly measured, the nurse cadetermine whether the client is demonstrating achievement of the goal.
Only none task statement should be used for each goal. It is clearer to write nseparate goals than to try to accurately measure a combination of tasks.
See nthe accompanying display for an application of the task statement.
CRITERIA
The next essential component is the criteria of a goal.
Criteria are standards used to evaluate nwhether the behavior demonstrated indicates accomplishment of the goal. nCriteria may be written in a variety of ways.
Criteria nmay include:
• nA time limit
• nAmount of activity
• nImportant characteristics of accurate nperformance
• nDescription of the performance to be nfollowed
The nnurse should specify the precise performance to be considered acceptable iaccomplishment of the goal. It is not always possible to specify a criterion with nas much detail as one would like; however, the nurse should continue to ncommunicate precise criteria as explicitly as possible. To provide better ndirection to the client, the nurse considers how well the client, family nmember, or significant other should perform the task.
See nthe accompanying display for an application of criteria.
CONDITIONS
The next component to be included in writing proper goals is the nconditions under which the client should perform or demonstrate mastery of the ntask. Although this component is optional in terms of writing goals, conditions nmay provide clarity and assist the client in demonstrating the expected nbehavior. The conditions may include the experiences that the client is nexpected to have before performing the task.
See the accompanying display for an application of conditions.
TIME FRAME
The last component to be included in writing goals appropriately is the ntime frame in which the client should perform or demonstrate mastery of the ntask.
PROBLEMS FREQUENTLY ENCOUNTERED IN PLANNING
Nursing students, as beginners in the use of the nursing process, oftefall into some common pitfalls when applying the steps to practice. These npitfalls are described with the intent of providing a clear direction for the nuse of this process and proposing suggestions for avoiding these common errors.
Iregard to writing goals, the errors frequently observed in this component ninvolve improper format.
Format errors include goals that are nurse-centered instead of nclient-centered, unrealistic, negative rather than positive, generically copied nfrom a reference and not individualized to the client, unmeasurable, nnonspecific, nonbehavioral, vague, wordy, and without na time frame.
Another challenge in the development of goals and expected outcomes is nthe establishment of appropriate time frames for accomplishment of the intended nresults.
Although this component may be difficult at first to master, nursing nstudents should practice writing goals that are realistic and include nappropriate time frames using available literature and resources to gaiexpertise. It is preferable for a goal to include an excessively short, rather nthan an excessively long, time frame, because the goal is brought to attentioin the evaluation process more frequently. By inserting the time frame “daily” nfor specific goals, the expected outcome will be brought up frequently for nevaluation. Through a process of building on continued professional growth and nexperience, students and beginning nurses will nbecome more adept and realistic in applying the nursing process to client nsituations.
Finally, nnovices as well as experienced nurses tend to make decisions for clients in a npaternalistic fashion by deciding what is best for the client without input from nthe client. To correct this problem, the nurse must establish a trusting nnurse-client relationship that promotes mutual understanding and caring. The nnurse should encourage clients to make their own decisions regarding health ncare.
PLANNING NURSING INTERVENTIONS
Once the goals have been mutually agreed on by the nurse and client, the nnurse should use a decision-making process to select appropriate nursing ninterventions.
A nursing intervention is an action performed by a nurse that nhelps the client to achieve the results specified by the goals and expected noutcome. These terms are based on scientific principles and knowledge from nbehavioral and physical sciences. Usually, several nursing interventions are ndeveloped for each of the goals identified for the client (Sparks & Taylor, n1993). It is important to identify as many nursing interventions as possible so nthat if one proves to be unsuitable, others are readily available.
The interventions are prioritized according to the order in which they will nbe implemented. With the inclusion of scientific problem solving and critical nthinking, the delivery of quality, individualized nursing care is greatly nenhanced. Through critical thinking, sound conclusions are reached in the nselection of nursing interventions to prevent, reduce, or eliminate the nursing ndiagnoses or problems. The nurse studies the entire issue thoroughly in the nplanning component of the nursing process by examining the assessment data and nnursing diagnoses, analyzing the client’s goals and expected outcomes, and nselecting which nursing interventions should be used from a multitude of npossibilities to ensure the delivery of quality nursing care for each client.
Several factors can assist the nurse in selecting nursing interventions. nJust as the client’s goals can be derived from the nursing diagnosis, the nnursing interventions can be developed from the etiology of each nursing ndiagnosis. The effective nurse plans interventions that are directed toward the ncause of the client’s nursing diagnosis or problem. For example, for a client nwith angina who may have the nursing diagnosis of Pain related to nmyocardial ischemia, an appropriate nursing intervention would be to help the nclient conserve energy (i.e., bedrest).
The nnurse may use various guidelines in selecting appropriate nursing ninterventions. These guidelines include the individual nurse practice acts, nstate boards of nursing standards, and the Joint Commission on Accreditation of nHealthcare Organizations (JCAHO) standards for nursing care. Other determining nfactors of appropriate nursing interventions include whether aaction is realistic in terms of the abilities of the client and nurse, and if nit is compatible with available resources, the client’s values and beliefs, and nother therapies planned for the client.
Idetermining which nursing interventions to use, the nurse should critically nconsider the consequences and the risks of each intervention. After considering nthese factors, the nurse selects those that are most likely to be effective nwith the minimum of risk.
This table applies the guidelines for selection of nappropriate nursing interventions for a specific nursing diagnosis.
After nsetting the goals and planning the appropriate nursing interventions, the nurse nwrites nursing orders to communicate the exact nursing interventions that are nto be implemented for the client. A nursing norder is a statement written by the nurse that nis within the realm of nursing practice to plan and initiate. These statements nspecify direction and individualize the client’s plan of care. For example, a nhealth care practitioner’s order to force fluids must be specified in the nnursing order as the number of milliliters per hour or per shift (e.g., 100 nml/h or Day shift = 800 ml; Evening shift = 800 ml; Night shift = 400 ml).
Ensuring nthat nursing orders are well written requires several essential elements. These nelements include: the nursing order date, action verb, detailed description, ntime frame, and signature (Wilkinson, 1998).
See the naccompanying display for a summary of the elements of a nursing order.
The type of nursing order written is determined by the client problem. nThe nurse is responsible for writing nursing orders that involve health promotion, nobservation, prevention, and treatment (Wilkinson, 1998).
This ntable gives examples of types of nursing norders.
CATEGORIES OF NURSING INTERVENTIONS
Nursing interventions are classified according to three categories: nindependent, interdependent, and dependent.
Independent nursing interventions are nnursing actions initiated by the nurse that do not require direction or aorder from another health care professional.These ninterventions are sanctioned by professional nurse practice acts derived from nlicensure laws. In many states, the nurse practice acts allow independent nnursing interventions regarding activities of daily living, health education, nhealth promotion, and counseling. An example of an independent nursing nintervention is the nurse’s action to elevate a client’s edematous extremity.
Interdependent nursing interventions are nthose actions that are implemented in a collaborative manner by the nurse with nother health care professionals.
Collaboration is a partnership in which nall parties are valued for their contribution. Collaboration is used to gather ndata, plan, implement, evaluate, and gain objectivity by examining another’s nviewpoint. Interdependent nursing interventions allow the client’s nursing ndiagnoses to be resolved on the basis of recommendations of ainterdisciplinary health care team approach. For example, a client care nconference or a discharge planning committee uses an interdisciplinary approach nthat includes health care members such as a nursing supervisor, a home health care nnurse, a dietitian, a social worker, a physical therapist, and occasionally a nphysician.
The nurse assumes the responsibility of being both the primary ncoordinator of the client’s plan of nursing care and intermediary of ninterdepartmental collaboration (Doenges et al., n1997).
Iaddition to collaboration, the planning of interdependent nursing interventions nmay also include consultation.
Consultation is a method of soliciting nhelp from a specialist in order to resolve nursing diagnoses. The need for consultatioarises when an individual nurse identifies a problem that cannot be solved nusing own knowledge, skills, or resources. In the management of the client’s nplan of care, nurses may consult with other health care personnel including nhealth care practitioners, clinical nurse specialists, nutritionists, physical ntherapists, and social workers. Nurses frequently consult to verify assessment ndata or to obtain clinical advice: for example, discussing the effects of nchemotherapy on a client’s self-esteem with an oncology clinical nurse nspecialist.
Consultation can be informal or formal. An informal consultation may nsimply involve another health care practitioner’s ideas regarding a nursing nproblem. Some agencies have a formal protocol for the consultation of a health nprofessional and may require that certain forms be completed. Steps in formal nconsultation reflect a logical sequence. and include:
• nIdentifying the problem
• nCollecting all relevant data
• nSelecting a suitable consultant
• nCommunicating unbiased data regarding the nproblem
• nDiscussing recommendations with the nconsultant
• nIncorporating the recommendations into the nclient’s plan of care
The consultation process often generates new approaches to the client’s nindividualized plan of care.
Acquiring nsupplementary knowledge may help in ensuring that the best conceivable plan of ncare is being developed. In addition, nurses who have sought the help of a nconsultant are presented with an opportunity to learn from the recommendations nfor future situations.
Dependent nursing interventions are nthose actions that require an order from another health care professional.
An example of a dependent intervention is administration of a nmedication. Although this intervention requires specific nursing knowledge and nresponsibilities, it is not within the realm of legal nursing practice in many nstates to prescribe medications. The nurse may not order medications but, wheadministering them, the nurse is responsible for knowing the classification, nthe pharmacologic action, normal dosage, adverse effects, contraindications, nand nursing implications of the drugs. Therefore, dependent nursing ninterventions must always be guided by appropriate knowledge and judgment. It nshould be noted that many state nurse practice acts sanction advanced practice nregistered nurses to prescribe medications. In those states, prescriptive nauthority is an independent intervention for nurses in advanced practice.
Figure n8-1 illustrates the three categories of nursing interventions.
All nursing interventions require critical thinking in making nappropriate nursing judgments. Alfaro-LeFevre (1998) nstates that the development of critical reasoning skills by nurses is a nprogressive process that requires a dedication to examine common health nproblems, participate in diverse clinical experiences, and prepare for delivery nof care in clinical settings. Given the emphasis on critical thinking in the nplanning step of the nursing process, the nurse does not automatically carry nout a health care practitioner’s order without due consideration. All requested norders are given consideration for their appropriateness.
An in-depth knowledge base is necessary to recognize an error and seek nclarification. The use of rationales helps the nurse practice decision making nand substantiate judgments. The rationales should accompany the nursing nintervention or nursing order statement on the written plan of nursing care. A rationale nis an explanation based on theories and scientific principles of natural nand behavioral sciences and the humanities.
EVALUATING CARE
Evaluating care involves determining the client’s progress toward nachievement of expected outcomes.
Effective nplanning is essential if evaluation is to be effective. In other words, the nplanned outcomes are the yardsticks by which effectiveness of therapies are nevaluated. If there is no stated expectation of care (i.e., client outcome), nhow can progress be measured?
NURSING OUTCOMES CLASSIFICATION (NOC)
Measuring outcomes iursing began with Nightingale, who relied omortality statistics as an indicator of quality of care for British soldiers ithe Crimean War. Nightingale proved that the mortality rate for soldiers ndeclined as a result of improved sanitation (Oermann n& Huber, 1999). Recently, there has been increased emphasis by the nursing ncommunity on evaluating outcomes. Nurse researchers (Mass & Johnson, 1997) nat the
Aoutcome classification system can be used to enhance decision-making iclinical practice and research.
Linking nursing interventions to improved client outcomes through nscientific research is important. Nurse researchers who are observing, measuring, nand studying client outcomes believe that outcomes indicate the quality or neffectiveness of the nursing interventions provided.
Porter-O’Grady (1999) states that nurses need to provide empirical nevidence of the “insights and intuition of their practice. Strengthening the nlinks betweeursing interventions and client outcomes will benefit not only nclients, but nursing as well. Having solid research evidence that documents the neffectiveness of nursing care on client outcomes will influence political and nfinancial decisions relative to nursing. “By measuring patient outcomes, nurses ncan answer two pivotal questions; Do our patients benefit from our care? And if nso, how?” (Oermann & Huber, 1999, p. 41). The NOC ntaxonomy focuses on function, physiology, psychosocial aspects, health nknowledge and behavior, and perceived self-health and family health. The NOC nsystem, which defines over 190 client outcomes that are sensitive to nursing ninterventions, allows nurses to evaluate client status over time.
PLAN OF CARE
The plan of care is a written guide that organizes data about a nclient’s care into a formal statement of the strategies that will be nimplemented to help the client achieve optimal health. Nursing care plans nusually include components such as assessment, nursing diagnoses, goals and nexpected outcomes, nursing interventions, and evaluations. The nurse begins the nnursing care plan on the day of admission and continually updates and nindividualizes the client’s plan of care until discharge.
The plan of care directs the efforts of the entire health care team nregarding each client. This plan promotes the health care team’s delivery of nquality, holistic, individualized, and goal-oriented care to the client. nAttention to a comprehensive assessment of the entire person allows for a nholistic approach. Individualization is enhanced by continous nreviewing and updating of the plan of care. A carefully formulated written plaof care prioritizes problems and addresses short- and long-term needs of the nclient. JCAHO standards state that each client will be assessed and reassessed naccording to the health care facility policy (JCAHO, 2000). The written plan of ncare authenticates activeities of assessment by nmaintaining written records and providing evidence of nursing interventions, nthe client’s response to nursing interventions, and changes in the client’s ncondition.
Although plans of care differ in various institutions from handwritteto computerized forms, they all have the same basic elements in common. The nplan of care is realistically designed and customized to each individual nclient’s health status and is the final result of the planning component of the nnursing process. The nursing plan of care documents health care needs, ncoordinates nursing care, promotes continuity of care, encourages communicatiowithin the health care team, and promotes quality nursing care.
There are several types of care plans. These different types include nstudent-oriented, standardized, institutional, and computerized care plans. The nstudent-oriented care plan promotes learning of problem-solving skills, the nnursing process, verbal and written communication skills, and organizational nskills. This comprehensive care plan has great depth for teaching the process nof planning care. Educational programs vary, but usually the student-oriented ncare plan begins with assessment and proceeds in a sequential manner until it nconcludes with the plan of care evaluation.
The standardized care plan is a preplanned, preprinted guide for the nnursing care of client groups with commoeeds. This type of care plagenerally follows the nursing process format (i.e., problem, goals, nursing norders, and evaluation). The nurse may use standardized care plans when a nclient has predictable, commonly occurring problems. Individualization may be naccomplished by the inclusion of additional handwritteotes on unusual nproblems.
Institutional nursing care plans are concise documents that become a npart of the client’s medical record after discharge. The Kardex nnursing care plan is an example of this type of care plan and is frequently nused. The institutional nursing care plan may simply include the problem, goal, nand nursing action. In addition, the Kardex nursing ncare plan may be expanded to include assessment, nursing diagnosis, goal, nimplementation, and evaluation.
Figure 8-2 provides an example of ainstitutional care plan.
Computers are used for creating and storing nursing care plans and can generate nboth standardized and individualized nursing care plans. The nurse selects nappropriate diagnoses from a menu suggested by the computer, which then lists npossible goals and nursing interventions. The nurse has the noption of reading the
client’s plaof care from the computer screen or printing out an updated working copy.
Figure 8-3 npresents an example of a computerized nursing care plan.
STRATEGIES FOR EFFECTIVE CARE PLANNING
Iplanning quality nursing care for each client, the nurse assumes responsibility nfor the coordination of total nursing care. The nurse coordinates the nparticipation of various health care team members to nimplement their recommendations into the delivery of nquality nursing care. Critical thinking assists the nurse nin establishing collaborative relationships with other members of the nhealth ncare team and managing complex nursing systems.
Aimportant strategy for effective planning is clear communication of the nclient’s plan of care to other health care personnel. The nurse must always ncommunicate the plan of care in clear, precise terms. Avoid using vague nterminology such as improved, adequate, and normal.
Another nstrategy for effective planning is to establish a realistic nursing plan of ncare because this will avoid setting a goal that is too difficult or impossible nto achieve. If a goal is too ambitious or is unattainable, the client and nurse nmay become discouraged or apathetic about the resolution of nursing diagnoses. nIn addition, goals should be measurable. Quantitative terms assist in the ndetermination of measurement. Finally, the goals should be futureoriented. nBecause a goal is an aim or a desired achievement, goals should be written ifuture tense format. Once appropriate nursing diagnoses are individualized
to the client, nthe plan of care has a stable framework on which an optimum level of wellness nfor the client can be reached. Although some clients may not achieve complete nresolution of all nursing diagnoses, the nursing plan of care that is nindividualized can improve health to the client’s optimal level.
K E Y C ONCEPTS
• The noutcome identification and planning component of the nursing process is a nsequential, orderly method of using problem-solving skills and critical nthinking to formulate a nursing plan of care to resolve nursing diagnoses.
• The nplanning component of the nursing process includes establishing priorities, nsetting goals, developing expected outcomes, selecting nursing interventions, nand documenting the plan of care.
• The npurposes of outcome identification and planning are to provide direction for nnursing care, to improve staff communication, and to provide continuity of nnursing care.
• The nestablishment of priorities may be guided by such factors as endangerment of well-being, nMaslow’s hierarchy of needs, client preferences, and nanticipation of future diagnoses.
• Setting ngoals and expected outcomes provides guidelines for directing nursing ninterventions and establishes evaluation criteria by deciding on goals that illustrate na desired change in the client’s behavior.
• Goals nand expected outcome objectives include the components of subject, task nstatement, criteria, conditions, and time frame.
• Two ncommon problems frequently encountered in planning in regard to goals are the nimproper format and unrealistic and nonmeasurable nqualities of this
component.
• Iplanning nursing care, the nurse uses an expansive scientific knowledge base nand critical thinking to select independent, interdependent, and dependent nnursing interventions guided by local and federal standards of care.
• The nplan of care documents health care needs, coordinates nursing care, promotes ncontinuity of care, encourages communication within the health care team, and npromotes quality nursing care.
• Strategies nfor effective care planning include communication of the client’s plan of care nwithin the health care team, establishment of a realistic plan of care, and
formulation of measurable and nfuture-oriented goals.
C R I T I C A L T H I N K I N G AC T I V nI T I E S
1. Decide nwhether the following statements are
client-centered and place a mark in front nof all
client-centered goals.
_____ 1. nThe nursing assistant will ambulate
client in the hall three times a day by
Saturday.
_____ 2. nWill teach the client to plan a low-fat
diet for 24 hours.
_____ 3. nThe client will describe two purposes of
a low-fat diet by Wednesday.
_____ 4. nWill encourage the client to walk the
entire length of hallway two times a day
by Thursday.
2. Decide nwhether the following statements have
action verbs for their task assignment and nplace a
mark in front of all goals with actioverbs.
_____ 1. nThe client will know five reasons for
proper nutrition.
_____ 2. nThe client will be able to state where
diabetic injection equipment may be
purchased after discharge.
_____ 3. nThe client will explain the purpose of
maintaining asepsis in daily dressing
changes by Wednesday.
_____ 4. nThe client will understand how to
change dressings on abdomen.
3. Indicate nwhether the following statements have
criteria and place a mark in front of all ngoals with
criteria.
_____ 1. nThe client will describe two purposes of
the low-salt diet by Friday.
_____ 2. nThe client will know the cause of low
blood sugar.
_____ 3. nThe client will understand the importance
of returning for follow-up visits to
the health care practitioner.
_____ 4. nThe client will demonstrate crutch
walking the entire length of the hallway
twice a day.
4. Decide nwhether the following statements have conditions
and place a mark in front of all goals nwith
conditions.
_____ 1. nThe client will describe two purposes of
the low-salt diet by Friday.
_____ 2. nThe client will know the cause of low
blood sugar.
_____ 3. nThe client will understand the importance
of returning for follow-up visits to
the health care practitioner.
_____ 4. nThe client will demonstrate crutch
walking.
5. Decide nwhether the following statements have time
frames and place a mark in front of all ngoals with
time frames.
_____ 1. nThe client will describe two purposes of
the low-salt diet by Friday.
_____ 2. nThe client will know the cause of low
blood sugar.
_____ 3. nThe client will understand the importance
of returning for follow-up visits to
the health care practitioner.
_____ 4. nThe client will demonstrate crutch
walking.
CHAPTER 8 Outcome nIdentification and Planning 145
MULT I P L E C H O I C E Q U E S T I ONS
6. The nplan of nursing care includes:
a. Client nassessment data, medical treatment
regime and rationales, and diagnostic test nresults
and significance
b. Doctor’s norders, demographic data, and medication
administration and rationales
c. Collected ndocumentation of all team members
providing care for your client
d. Client’s nnursing diagnoses, goals and expected
outcome objectives, and nursing ninterventions
7. Wheestablishing priorities of a client’s plan of
nursing care, the nurse should rank the nhighest
priorities to life-threatening diagnoses nand the lowest
priorities to:
a. Safety-related nneeds
b. The nclient’s social, love, and belonging needs
c. Needs nof family members and friends who are
involved in plan of care
d. Needs nof client regarding referral agencies
8. What nis the main purpose of the expected outcome?
a. To ndescribe the education plans to be taught to
the client
b. To ndescribe the behavior the client is expected to
achieve as a result of nursing ninterventions
c. To nprovide a standard for evaluating the quality
of health care delivered to the client nduring the
hospital stay
d. To nmake sure that the client’s treatment does not
extend beyond the time allowed under the ndiagnosis-
related group system
9. What nare the essential components of an expected
outcome?
a. Nursing ndiagnosis, interventions, and expected
client behavior
b. Target ndate, nursing action, measurement criteria,
and desired client behavior
c. Nursing naction, client behavior, target date, and
conditions under which the behavior occurs
d. Client nbehavior, measurement criteria, conditions
under which the behavior occurs, and ntarget
date
10. Which nguideline is most appropriate when developing
nursing interventions?
a. Choose nactions that a nurse can perform without
leaving the unit or consulting with nmedical staff.
b. Make nintervention statements specific to ensure
continuity of care.
c. Write ninterventions in general terms to allow
maximum flexibility and creativity idelivering
nursing care.
d. Make nsure that nursing care activities receive priority
over nother aspects of the treatment regime.
