What happens during the planning phase of the nursing process?
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The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Show Assessment Diagnosis Outcomes / Planning Implementation Evaluation Four phases of the third stage of nursing process: setting priorities, predicting outcomes, planning nursing interventions, documentation of care plan. The fourth stage of nursing process - implementation of the plan. The fifth stage of nursing process. lanning, the third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. Preceding this step is the collection of assessment data and the formulation of nursing diagnoses. After a nurse thoroughly assesses a client and determines the client’s unique nursing diagnoses (or problems), a plan of action is developed with specific goals to resolve the nursing diagnoses or health problems of the client. Following the planning component, the nursing process continues with implementation of nursing interventions and evaluation of the client’s plan of care. The four critical elements of planning include: • Establishing priorities • Setting goals and developing expected outcomes (outcome identification) • Planning nursing interventions (with collaboration and consultation as needed) • Documenting The purpose, as well as the entire process, of the planning concept is illustrated with theory and examples. Strategies for effective planning of quality nursing care are described together with problems frequently encountered in this stage of the nursing process. The role of critical thinking in planning and outcome identification is emphasized. PURPOSES OF OUTCOME IDENTIFICATION AND PLANNING The American Nurses Association (1998), in its Standards of Clinical Nursing Practice, identifies outcome identification and planning as essential principles for ensuring the delivery of competent nursing care and outlines these components in terms of their significance within the nursing process. Although the overall purpose of a client’s plan of care should be to maintain or improve health at an optimal level, planning is a framework on which to base scientific nursing practice. Therefore, the purposes of the planning component of the nursing process are to provide adequate direction to ensure quality nursing care for individual clients, to present a vehicle to improve staff communication, and to provide continuity in the delivery of individualized, quality nursing care to all clients. The five steps of the nursing process are at the very core in using scientific reasoning for the delivery of individualized, quality nursing care in any setting (Doenges, Moorhouse, & Geissler, 1997). The ability to make appropriate decisions based on a strong knowledge base and problem-solving strategies is an expected behavior of the professional nurse. CRITICAL THINKING More specifically, professional nurses are expected to think critically to process data and to make convincing, intelligent decisions concerning the planning, management, and evaluation of health care for their clients (Prechter, 1993). By combining the critical-thinking skills inherent in the nursing process with the client’s identified nursing diagnoses, the nurse can focus on resolving the client’s nursing diagnoses with greater proficiency. The planning of nursing care occurs in three phases: initial, ongoing, and discharge. Each type of planning contributes to the coordination of the client’s comprehensive plan of care. Initial planning involves development of beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Because of progressively shorter lengths of hospitalization, initial planning is important in addressing each prioritized problem, identifying appropriate client goals, and correlating nursing care to hasten resolution of the client’s problems. Ongoing planning entails continuous updating of the client’s plan of care. Every nurse who cares for the client is involved in ongoing planning. As new information about the client is gathered and evaluated, revisions may be formulated and the initial plan of care becomes further individualized to the client. Discharge planning involves critical anticipation and planning for the client’s needs after discharge. Planning is sequential, dynamic, and future-oriented. Planning includes establishing priorities, identifying goals and expected outcomes, developing nursing interventions, and documenting the client’s plan of care. Appropriate guidelines are used to prioritize urgent needs. The client’s nursing diagnoses are determined and then ranked by mutual agreement of the nurse and client or significant others. The planning component continues with thorough examination of this prioritized list of nursing diagnoses and determination of the client’s goals and desired expected outcomes. After a clear picture is obtained regarding the diagnoses and goals, the nursing interventions can be planned to achieve the desired outcomes. In the planning phase, the nurse organizes “thought processes for clinical decision making” (Doenges et al., 1997). To think critically is to examine an issue purposefully from a goal-directed perspective. Critical thinking “is based on principles of science and scientific method” (Alfaro-LeFevre, 1998). Therefore, critical thinking is a useful procedure in the development of objectives and in the formulation of a blueprint to achieve those objectives. The formulation of objectives is accomplished by using valid and reliable data previously gathered during the assessment component of the nursing process. ESTABLISHING PRIORITIES The establishment of priorities is the first element of planning. In establishing priorities, the nurse examines the client’s nursing diagnoses and ranks them in order of physiological or psychological importance. This method organizes a client’s nursing diagnoses into an operational format for the planning of nursing care. These diagnoses should be mutually ranked by the nurse and client or family and significant others. Involving the client in shared decision-making power helps motivate the client and gives the client a feeling 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 client need to establish priorities to identify which nursing diagnosis will be addressed initially in the plan of care (Carpenito, 1999). By communicating this decision-making process to other members of the health care team, the nurse encourages an orderly approach to the achievement of optimal health for each client. Various guidelines are used in the establishment of priorities for determining which nursing diagnosis will be addressed initially. The client’s basic needs, safety, and desires, as well as anticipation of future diagnoses must be considered. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life-threatening diagnosis be given more urgency than a non–life threatening diagnosis. Once the basic physiological needs (e.g., respiration, nutrition, hydration, elimination) are met to some degree, the nurse may consider needs on the next level of the hierarchy (e.g., safe environment, stable living condition) and so on up the hierarchy until all the client’s nursing diagnoses have been prioritized. Following table illustrates this process A useful guide for the beginning nursing student would be to examine each nursing diagnosis, determine its level of need, and rank the need in order of priority. Another consideration in the designation of priorities is client preferences. If at all possible, the client should always be involved in the decision-making process of establishing priorities. If the nurse and the client do not mutually set priorities, there may be a contradictory course of direction and motivation, which may lead to noncompliance and nonresolution of the client’s nursing diagnoses. The client must participate in the identification of priorities so that the nature of the problem, as well as the client’s values, are reflected in the selected course of action. An additional point regarding the establishment of priorities is the anticipation of future diagnoses. Nursing diagnoses of low and moderate priorities often involve the prevention of anticipated potential or risk diagnoses. Although potential nursing diagnoses may not be a current threat to the client, their seriousness may require that the nurse consider the development of nursing interventions directed toward prevention of the problem. For example, a client in the Postanesthesia Care Unit may have a high-priority nursing diagnosis of Ineffective Breathing Pattern related to the anesthesia and sedative drugs. Despite the fact that the client currently has no problem in this area, this diagnosis is indeed the basis for the Postanesthesia Care Unit protocol of monitoring the client closely. Establishing priorities does not mean that one diagnosis must be totally resolved before giving attention to another diagnosis. Nursing interventions for several diagnoses may be carried out simultaneously. However, at times, it is crucial that the nurse and client correctly identify the order of priority of the client’s nursing diagnoses so that maximum effort can be directed toward resolution of the most urgent diagnosis. Following table illustrates this process: ESTABLISHING GOALS AND EXPECTED OUTCOMES After assessing the client, formulating nursing diagnoses, and establishing priorities, the nurse sets goals and identifies and establishes expected outcomes for each nursing diagnosis. The purposes of setting goals and expected outcomes are to provide guidelines for individualized nursing interventions and to establish evaluation criteria to measure the effectiveness of the nursing care plan. A goal is an aim, an intent, or an end. A goal is a broad or globally written statement describing the intended or desired change in the client’s behavior, response, or outcome. An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved. It includes aspects such as direct nursing care and client teaching. WRITING GOALS Written goals need to be constructed clearly. Clear, precise terminology improves the chances that goals will be achieved. When goals are clearly written, their establishment provides direction for the nursing plan of care and for determination of effectiveness in the evaluation of nursing interventions. A guideline is provided for the desired change in the client, and the client has a clear idea of the direction to be taken for achieving resolution of each nursing diagnosis. Goals establish appropriate evaluation criteria to measure the effectiveness of planned nursing interventions for the resolution of the client’s individual nursing diagnoses. Goals should be established to meet the immediate, as well as long-term prevention and rehabilitation, needs of the client. A short-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a few hours or days. A long-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis over a longer period of time, usually over weeks or months (Alfaro-LeFevre, 1997). See the accompanying display for examples of short-term and long-term goals. Another consideration is the accuracy in identifying the etiology of the problem. If the etiology of the problem is incorrectly identified, the client may meet the short-term goal but the problem will not be resolved. Thus, it is important to correctly identify the etiology of the problem. Setting long-term goals is important in successful discharge planning. It assists in coordinating all health care team members to accomplish the same overall purpose, that is, client discharge. Coordination promotes continuity of care into settings such as restorative care or home health (see the accompanying display). EXPECTED OUTCOMES After the goal is established, the expected outcomes can be identified based on the goal. Given the client’s unique situation and resources, expected outcomes are constructed to be: • Realistic • Mutually desired by the client and nurse • Attainable within a defined time period These desired outcomes are the measurable steps toward achieving the previously established goals (Doenges et al., 1997). Because nursing care is based on a holistic approach, expected outcomes may be written in the spiritual, emotional, physiological, developmental, and social dimensions. An expected outcome depicts measurable behavioral change or evidence of change in the client when the goal has been met. Several expected outcomes may be required for each goal. Expected outcomes are used in the evaluation process by providing a standard for comparison to determine if the client successfully accomplished the goals. In the construction of both goals and expected outcome objectives, essential components include: subject, task statement, criteria, the conditions (if necessary), and time frame (Doenges et al., 1997). When goals and outcomes are written clearly, the nurse can select nursing interventions to ensure that the client’s baseline data are thoroughly assessed, individual client needs are identified, and appropriate approaches are used in the plan of care. Usually, each nursing diagnosis has one global goal and several expected outcomes. In writing the goal statement, the nurse considers the nursing diagnosis for the formulation of a suitable client behavior that illustrates reduction or alleviation of the nursing diagnosis. These concepts are demonstrated in the Nursing Process Highlight. Each component of an appropriately written goal is discussed in the following paragraphs. For clarity of each concept, examples are provided with related discussion. The examples are designed with the intent of developing skills in the construction of goals. SUBJECT The component to be considered initially in writing a goal is the subject. The subject identifies the person who will perform the desired behavior or meet the goal. In a client-centered plan of nursing care, the client is the person who needs to achieve a desired change in behavior. See the accompanying display for an application of the subject component. TASK STATEMENT The next component in writing goals is the task statement or the action verb. This component describes what the client (or subject) will do to obtain an expected change in behavior. The task statement enables the evaluator to determine achievement of observable behavior. When the actual behavior is stated as a task statement that can be clearly and directly measured, the nurse can determine whether the client is demonstrating achievement of the goal. Only one task statement should be used for each goal. It is clearer to write separate goals than to try to accurately measure a combination of tasks. See the 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 whether the behavior demonstrated indicates accomplishment of the goal. Criteria may be written in a variety of ways. Criteria may include: • A time limit • Amount of activity • Important characteristics of accurate performance • Description of the performance to be followed The nurse should specify the precise performance to be considered acceptable in accomplishment of the goal. It is not always possible to specify a criterion with as much detail as one would like; however, the nurse should continue to communicate precise criteria as explicitly as possible. To provide better direction to the client, the nurse considers how well the client, family member, or significant other should perform the task. See the accompanying display for an application of criteria. CONDITIONS The next component to be included in writing proper goals is the conditions under which the client should perform or demonstrate mastery of the task. Although this component is optional in terms of writing goals, conditions may provide clarity and assist the client in demonstrating the expected behavior. The conditions may include the experiences that the client is expected 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 time frame in which the client should perform or demonstrate mastery of the task. PROBLEMS FREQUENTLY ENCOUNTERED IN PLANNING Nursing students, as beginners in the use of the nursing process, often fall into some common pitfalls when applying the steps to practice. These pitfalls are described with the intent of providing a clear direction for the use of this process and proposing suggestions for avoiding these common errors. In regard to writing goals, the errors frequently observed in this component involve improper format. Format errors include goals that are nurse-centered instead of client-centered, unrealistic, negative rather than positive, generically copied from a reference and not individualized to the client, unmeasurable, nonspecific, nonbehavioral, vague, wordy, and without a time frame. Another challenge in the development of goals and expected outcomes is the establishment of appropriate time frames for accomplishment of the intended results. Although this component may be difficult at first to master, nursing students should practice writing goals that are realistic and include appropriate time frames using available literature and resources to gain expertise. It is preferable for a goal to include an excessively short, rather than an excessively long, time frame, because the goal is brought to attention in the evaluation process more frequently. By inserting the time frame “daily” for specific goals, the expected outcome will be brought up frequently for evaluation. Through a process of building on continued professional growth and experience, students and beginning nurses will become more adept and realistic in applying the nursing process to client situations. Finally, novices as well as experienced nurses tend to make decisions for clients in a paternalistic fashion by deciding what is best for the client without input from the client. To correct this problem, the nurse must establish a trusting nurse-client relationship that promotes mutual understanding and caring. The nurse should encourage clients to make their own decisions regarding health care. PLANNING NURSING INTERVENTIONS Once the goals have been mutually agreed on by the nurse and client, the nurse should use a decision-making process to select appropriate nursing interventions. A nursing intervention is an action performed by a nurse that helps the client to achieve the results specified by the goals and expected outcome. These terms are based on scientific principles and knowledge from behavioral and physical sciences. Usually, several nursing interventions are developed for each of the goals identified for the client (Sparks & Taylor, 1993). It is important to identify as many nursing interventions as possible so that if one proves to be unsuitable, others are readily available. The interventions are prioritized according to the order in which they will be implemented. With the inclusion of scientific problem solving and critical thinking, the delivery of quality, individualized nursing care is greatly enhanced. Through critical thinking, sound conclusions are reached in the selection of nursing interventions to prevent, reduce, or eliminate the nursing diagnoses or problems. The nurse studies the entire issue thoroughly in the planning component of the nursing process by examining the assessment data and nursing diagnoses, analyzing the client’s goals and expected outcomes, and selecting which nursing interventions should be used from a multitude of possibilities to ensure the delivery of quality nursing care for each client. Several factors can assist the nurse in selecting nursing interventions. Just as the client’s goals can be derived from the nursing diagnosis, the nursing interventions can be developed from the etiology of each nursing diagnosis. The effective nurse plans interventions that are directed toward the cause of the client’s nursing diagnosis or problem. For example, for a client with angina who may have the nursing diagnosis of Pain related to myocardial ischemia, an appropriate nursing intervention would be to help the client conserve energy (i.e., bedrest). The nurse may use various guidelines in selecting appropriate nursing interventions. These guidelines include the individual nurse practice acts, state boards of nursing standards, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for nursing care. Other determining factors of appropriate nursing interventions include whether an action is realistic in terms of the abilities of the client and nurse, and if it is compatible with available resources, the client’s values and beliefs, and other therapies planned for the client. In determining which nursing interventions to use, the nurse should critically consider the consequences and the risks of each intervention. After considering these factors, the nurse selects those that are most likely to be effective with the minimum of risk. This table applies the guidelines for selection of appropriate nursing interventions for a specific nursing diagnosis. After setting the goals and planning the appropriate nursing interventions, the nurse writes nursing orders to communicate the exact nursing interventions that are to be implemented for the client. A nursing order is a statement written by the nurse that is within the realm of nursing practice to plan and initiate. These statements specify direction and individualize the client’s plan of care. For example, a health care practitioner’s order to force fluids must be specified in the nursing order as the number of milliliters per hour or per shift (e.g., 100 ml/h or Day shift = 800 ml; Evening shift = 800 ml; Night shift = 400 ml). Ensuring that nursing orders are well written requires several essential elements. These elements include: the nursing order date, action verb, detailed description, time frame, and signature (Wilkinson, 1998). See the accompanying display for a summary of the elements of a nursing order. The type of nursing order written is determined by the client problem. The nurse is responsible for writing nursing orders that involve health promotion, observation, prevention, and treatment (Wilkinson, 1998). This table gives examples of types of nursing orders. CATEGORIES OF NURSING INTERVENTIONS Nursing interventions are classified according to three categories: independent, interdependent, and dependent. Independent nursing interventions are nursing actions initiated by the nurse that do not require direction or an order from another health care professional.These interventions are sanctioned by professional nurse practice acts derived from licensure laws. In many states, the nurse practice acts allow independent nursing interventions regarding activities of daily living, health education, health promotion, and counseling. An example of an independent nursing intervention is the nurse’s action to elevate a client’s edematous extremity. Interdependent nursing interventions are those actions that are implemented in a collaborative manner by the nurse with other health care professionals. Collaboration is a partnership in which all parties are valued for their contribution. Collaboration is used to gather data, plan, implement, evaluate, and gain objectivity by examining another’s viewpoint. Interdependent nursing interventions allow the client’s nursing diagnoses to be resolved on the basis of recommendations of an interdisciplinary health care team approach. For example, a client care conference or a discharge planning committee uses an interdisciplinary approach that includes health care members such as a nursing supervisor, a home health care nurse, a dietitian, a social worker, a physical therapist, and occasionally a physician. The nurse assumes the responsibility of being both the primary coordinator of the client’s plan of nursing care and intermediary of interdepartmental collaboration (Doenges et al., 1997). In addition to collaboration, the planning of interdependent nursing interventions may also include consultation. Consultation is a method of soliciting help from a specialist in order to resolve nursing diagnoses. The need for consultation arises when an individual nurse identifies a problem that cannot be solved using own knowledge, skills, or resources. In the management of the client’s plan of care, nurses may consult with other health care personnel including health care practitioners, clinical nurse specialists, nutritionists, physical therapists, and social workers. Nurses frequently consult to verify assessment data or to obtain clinical advice: for example, discussing the effects of chemotherapy on a client’s self-esteem with an oncology clinical nurse specialist. Consultation can be informal or formal. An informal consultation may simply involve another health care practitioner’s ideas regarding a nursing problem. Some agencies have a formal protocol for the consultation of a health professional and may require that certain forms be completed. Steps in formal consultation reflect a logical sequence. and include: • Identifying the problem • Collecting all relevant data • Selecting a suitable consultant • Communicating unbiased data regarding the problem • Discussing recommendations with the consultant • Incorporating the recommendations into the client’s plan of care The consultation process often generates new approaches to the client’s individualized plan of care. Acquiring supplementary knowledge may help in ensuring that the best conceivable plan of care is being developed. In addition, nurses who have sought the help of a consultant are presented with an opportunity to learn from the recommendations for future situations. Dependent nursing interventions are those actions that require an order from another health care professional. An example of a dependent intervention is administration of a medication. Although this intervention requires specific nursing knowledge and responsibilities, it is not within the realm of legal nursing practice in many states to prescribe medications. The nurse may not order medications but, when administering them, the nurse is responsible for knowing the classification, the pharmacologic action, normal dosage, adverse effects, contraindications, and nursing implications of the drugs. Therefore, dependent nursing interventions must always be guided by appropriate knowledge and judgment. It should be noted that many state nurse practice acts sanction advanced practice registered nurses to prescribe medications. In those states, prescriptive authority is an independent intervention for nurses in advanced practice. Figure 8-1 illustrates the three categories of nursing interventions. All nursing interventions require critical thinking in making appropriate nursing judgments. Alfaro-LeFevre (1998) states that the development of critical reasoning skills by nurses is a progressive process that requires a dedication to examine common health problems, participate in diverse clinical experiences, and prepare for delivery of care in clinical settings. Given the emphasis on critical thinking in the planning step of the nursing process, the nurse does not automatically carry out a health care practitioner’s order without due consideration. All requested orders are given consideration for their appropriateness. An in-depth knowledge base is necessary to recognize an error and seek clarification. The use of rationales helps the nurse practice decision making and substantiate judgments. The rationales should accompany the nursing intervention or nursing order statement on the written plan of nursing care. A rationale is an explanation based on theories and scientific principles of natural and behavioral sciences and the humanities. EVALUATING CARE Evaluating care involves determining the client’s progress toward achievement of expected outcomes. Effective planning is essential if evaluation is to be effective. In other words, the planned outcomes are the yardsticks by which effectiveness of therapies are evaluated. If there is no stated expectation of care (i.e., client outcome), how can progress be measured? NURSING OUTCOMES CLASSIFICATION (NOC) Measuring outcomes in nursing began with Nightingale, who relied on mortality statistics as an indicator of quality of care for British soldiers in the Crimean War. Nightingale proved that the mortality rate for soldiers declined as a result of improved sanitation (Oermann & Huber, 1999). Recently, there has been increased emphasis by the nursing community on evaluating outcomes. Nurse researchers (Mass & Johnson, 1997) at the University of Iowa have developed classifications of client outcomes, the Nursing Outcomes Classification (NOC). The NOC provides a standardized language that can be used to measure the effects of nursing practice on client outcomes. Just as the North American Nursing Diagnosis Association (NANDA) and the Nursing Interventions Classifications (NIC) are continuing to develop standardized nursing language relative to diagnosis and intervention, NOC is striving toward a similar goal of standardized language for classifying nursing interventions. An outcome classification system can be used to enhance decision-making in clinical practice and research. Linking nursing interventions to improved client outcomes through scientific research is important. Nurse researchers who are observing, measuring, and studying client outcomes believe that outcomes indicate the quality or effectiveness of the nursing interventions provided. Porter-O’Grady (1999) states that nurses need to provide empirical evidence of the “insights and intuition of their practice. Strengthening the links between nursing interventions and client outcomes will benefit not only clients, but nursing as well. Having solid research evidence that documents the effectiveness of nursing care on client outcomes will influence political and financial decisions relative to nursing. “By measuring patient outcomes, nurses can answer two pivotal questions; Do our patients benefit from our care? And if so, how?” (Oermann & Huber, 1999, p. 41). The NOC taxonomy focuses on function, physiology, psychosocial aspects, health knowledge and behavior, and perceived self-health and family health. The NOC system, which defines over 190 client outcomes that are sensitive to nursing interventions, allows nurses to evaluate client status over time. PLAN OF CARE The plan of care is a written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health. Nursing care plans usually include components such as assessment, nursing diagnoses, goals and expected outcomes, nursing interventions, and evaluations. The nurse begins the nursing care plan on the day of admission and continually updates and individualizes the client’s plan of care until discharge. The plan of care directs the efforts of the entire health care team regarding each client. This plan promotes the health care team’s delivery of quality, holistic, individualized, and goal-oriented care to the client. Attention to a comprehensive assessment of the entire person allows for a holistic approach. Individualization is enhanced by continous reviewing and updating of the plan of care. A carefully formulated written plan of care prioritizes problems and addresses short- and long-term needs of the client. JCAHO standards state that each client will be assessed and reassessed according to the health care facility policy (JCAHO, 2000). The written plan of care authenticates activeities of assessment by maintaining written records and providing evidence of nursing interventions, the client’s response to nursing interventions, and changes in the client’s condition. Although plans of care differ in various institutions from handwritten to computerized forms, they all have the same basic elements in common. The plan of care is realistically designed and customized to each individual client’s health status and is the final result of the planning component of the nursing process. The nursing plan of care documents health care needs, coordinates nursing care, promotes continuity of care, encourages communication within the health care team, and promotes quality nursing care. There are several types of care plans. These different types include student-oriented, standardized, institutional, and computerized care plans. The student-oriented care plan promotes learning of problem-solving skills, the nursing process, verbal and written communication skills, and organizational skills. This comprehensive care plan has great depth for teaching the process of planning care. Educational programs vary, but usually the student-oriented care plan begins with assessment and proceeds in a sequential manner until it concludes with the plan of care evaluation. The standardized care plan is a preplanned, preprinted guide for the nursing care of client groups with common needs. This type of care plan generally follows the nursing process format (i.e., problem, goals, nursing orders, and evaluation). The nurse may use standardized care plans when a client has predictable, commonly occurring problems. Individualization may be accomplished by the inclusion of additional handwritten notes on unusual problems. Institutional nursing care plans are concise documents that become a part of the client’s medical record after discharge. The Kardex nursing care plan is an example of this type of care plan and is frequently used. The institutional nursing care plan may simply include the problem, goal, and nursing action. In addition, the Kardex nursing care plan may be expanded to include assessment, nursing diagnosis, goal, implementation, and evaluation.
Computers are used for creating and storing nursing care plans and can generate both standardized and individualized nursing care plans. The nurse selects appropriate diagnoses from a menu suggested by the computer, which then lists possible goals and nursing interventions. The nurse has the option of reading the client’s plan of care from the computer screen or printing out an updated working copy. Figure 8-3 presents an example of a computerized nursing care plan. STRATEGIES FOR EFFECTIVE CARE PLANNING In planning quality nursing care for each client, thenurse assumes responsibility for the coordination of totalnursing care. The nurse coordinates the participation of various health care team members to implement theirrecommendations into the delivery of quality nursingcare. Critical thinking assists the nurse in establishing collaborativerelationships with other members of the healthcare team and managing complex nursing systems. An important strategy for effective planning is clearcommunication of the client’s plan of care to otherhealth care personnel.The nurse must always communicate the plan of care in clear, precise terms. Avoid using vague terminology such as improved, adequate, and normal. Another strategy for effective planning is to establish a realistic nursing plan of care because this will avoid setting a goal that is too difficult or impossible to achieve. If a goal is too ambitious or is unattainable, the client and nurse may become discouraged or apathetic about the resolution of nursing diagnoses. In addition, goals should be measurable. Quantitative terms assist in the determination of measurement. Finally, the goals should be futureoriented. Because a goal is an aim or a desired achievement, goals should be written in future tense format. Once appropriate nursing diagnoses are individualized to the client, the plan of care has a stable framework on which an optimum level of wellness for the client can be reached. Although some clients may not achieve complete resolution of all nursing diagnoses, the nursing plan of care that is individualized can improve health to the client’s optimal level. K E Y C ONCEPTS • The outcome identification and planning component of the nursing process is a sequential, orderly method of using problem-solving skills and critical thinking to formulate a nursing plan of care to resolve nursing diagnoses. • The planning component of the nursing process includes establishing priorities, setting goals, developing expected outcomes, selecting nursing interventions, and documenting the plan of care. • The purposes of outcome identification and planning are to provide direction for nursing care, to improve staff communication, and to provide continuity of nursing care. • The establishment of priorities may be guided by such factors as endangerment of well-being, Maslow’s hierarchy of needs, client preferences, and anticipation of future diagnoses. • Setting goals and expected outcomes provides guidelines for directing nursing interventions and establishes evaluation criteria by deciding on goals that illustrate a desired change in the client’s behavior. • Goals and expected outcome objectives include the components of subject, task statement, criteria, conditions, and time frame. • Two common problems frequently encountered in planning in regard to goals are the improper format and unrealistic and nonmeasurable qualities of this component. • In planning nursing care, the nurse uses an expansive scientific knowledge base and critical thinking to select independent, interdependent, and dependent nursing interventions guided by local and federal standards of care. • The plan of care documents health care needs, coordinates nursing care, promotes continuity of care, encourages communication within the health care team, and promotes quality nursing care. • Strategies for effective care planning include communication of the client’s plan of care within the health care team, establishment of a realistic plan of care, and formulation of measurable and future-oriented goals. C R I T I C A L T H I N K I N G AC T I V I T I E S 1. Decide whether the following statements are client-centered and place a mark in front of all client-centered goals. _____ 1. The nursing assistant will ambulate client in the hall three times a day by Saturday. _____ 2. Will teach the client to plan a low-fat diet for 24 hours. _____ 3. The client will describe two purposes of a low-fat diet by Wednesday. _____ 4. Will encourage the client to walk the entire length of hallway two times a day by Thursday. 2. Decide whether the following statements have action verbs for their task assignment and place a mark in front of all goals with action verbs. _____ 1. The client will know five reasons for proper nutrition. _____ 2. The client will be able to state where diabetic injection equipment may be purchased after discharge. _____ 3. The client will explain the purpose of maintaining asepsis in daily dressing changes by Wednesday. _____ 4. The client will understand how to change dressings on abdomen. 3. Indicate whether the following statements have criteria and place a mark in front of all goals with criteria. _____ 1. The client will describe two purposes of the low-salt diet by Friday. _____ 2. The client will know the cause of low blood sugar. _____ 3. The client will understand the importance of returning for follow-up visits to the health care practitioner. _____ 4. The client will demonstrate crutch walking the entire length of the hallway twice a day. 4. Decide whether the following statements have conditions and place a mark in front of all goals with conditions. _____ 1. The client will describe two purposes of the low-salt diet by Friday. _____ 2. The client will know the cause of low blood sugar. _____ 3. The client will understand the importance of returning for follow-up visits to the health care practitioner. _____ 4. The client will demonstrate crutch walking. 5. Decide whether the following statements have time frames and place a mark in front of all goals with time frames. _____ 1. The client will describe two purposes of the low-salt diet by Friday. _____ 2. The client will know the cause of low blood sugar. _____ 3. The client will understand the importance of returning for follow-up visits to the health care practitioner. _____ 4. The client will demonstrate crutch walking. CHAPTER 8 Outcome Identification and Planning 145 MULT I P L E C H O I C E Q U E S T I ONS 6. The plan of nursing care includes: a. Client assessment data, medical treatment regime and rationales, and diagnostic test results and significance b. Doctor’s orders, demographic data, and medication administration and rationales c. Collected documentation of all team members providing care for your client d. Client’s nursing diagnoses, goals and expected outcome objectives, and nursing interventions 7. When establishing priorities of a client’s plan of nursing care, the nurse should rank the highest priorities to life-threatening diagnoses and the lowest priorities to: a. Safety-related needs b. The client’s social, love, and belonging needs c. Needs of family members and friends who are involved in plan of care d. Needs of client regarding referral agencies 8. What is the main purpose of the expected outcome? a. To describe the education plans to be taught to the client b. To describe the behavior the client is expected to achieve as a result of nursing interventions c. To provide a standard for evaluating the quality of health care delivered to the client during the hospital stay d. To make sure that the client’s treatment does not extend beyond the time allowed under the diagnosis- related group system 9. What are the essential components of an expected outcome? a. Nursing diagnosis, interventions, and expected client behavior b. Target date, nursing action, measurement criteria, and desired client behavior c. Nursing action, client behavior, target date, and conditions under which the behavior occurs d. Client behavior, measurement criteria, conditions under which the behavior occurs, and target date 10. Which guideline is most appropriate when developing nursing interventions? a. Choose actions that a nurse can perform without leaving the unit or consulting with medical staff. b. Make intervention statements specific to ensure continuity of care. c. Write interventions in general terms to allow maximum flexibility and creativity in delivering nursing care. d. Make sure that nursing care activities receive priority over other aspects of the treatment regime. What are the three phases in planning nursing care?The planning occurs in three phases: initial, ongoing, and discharge. Initial planning involves the development of a preliminary plan of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data.
What is the purpose of planning in nursing?In nursing, planning helps to ensure that clients or patients will receive the nursing services they want and need and that these services are delivered by satisfied nursing workers. Planning should be based on objectives that should be framed in terms of making a product or providing a service for the community.
What is the planning part of a nursing care plan?A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales. These components are elaborated below: Client health assessment, medical results, and diagnostic reports are the first steps to be able to design a care plan.
Which action should the nurse perform during the planning phase of the nursing process?Which action should the nurse perform during the planning phase of the nursing process? Identify measurable goals or outcomes.
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