NURSING PROCESS- PLANNING PHASE

Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for the patient that might lead to selection of Nursing Interventions appropriate to the goals set. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient can have access to the plan of care & follow the Nursing Interventions.

 STEPS IN THE PLANNING PHASE

ESTABLISHING PRIORITIES

After the Nursing Diagnoses & Collaborative problems are identified, the Nurse must determine the urgency of the Identified Problems. Diagnoses of the highest priority require immediate Intervention & lowest priority can be intervened at a later time.

When setting Priorities, the Nurse should first Intervene for Life threatening problems as CAB- Circulation (C), Airway (A), Breathing (B). Physical needs should be met next & then the psychosocial needs of the client should be Addressed.

It is also helpful to determine the patient’s perception of what is important. When patient’s priorities are not congruent with the actual situation, the nurse should give explanation to make the client understand the need for setting priorities & it is more efficient to patient’s priority need before moving to other priorities

ESTABLISHING GOALS

The patient-specific goals and the attainment of such assist in ensuring a positive outcome.

For each of the medical issues, the nurse must assign a simple, achievable and measurable goal for a positive outcome for the patient.

Generally, these are short-term goals, although longer-term goals may be outlined depending on the condition.

There may be a single goal or several goals all working towards the improvement of a common condition.

There must be a way of tracking the outcome outlined within the plan.

The goals could be extremely basic such as moving from the bed to a chair a certain amount of time each day.

They could be more complex and longer-term such as gaining a specific amount of weight through eating a planned amount of food that needs to be measured daily

Goals should be S-M-A-R-T

• S- Specific:
  • Well defined, clear, and unambiguous
  • Goals that are specific have a significantly greater chance of being accomplished.
  • To make a goal specific, the five “W” questions must be considered: -Who: Who is involved in this goal?- What: What do I want to accomplish?- Where: Where is this goal to be achieved?- When: When do I want to achieve this goal?- Why: Why do I want to achieve this goal?
• M-Measurable:
  • Criteria for measuring progress.
  • If there are no criteria, it is not possible to determine the progress whether the goal is reached.
  • To make a goal measurable, ask
  • How many/much?
  • How is the goal reached?
  • What is the indicator to measure the progress?
• A- Achievable:
  • Achievable and attainable.
  • This will help to figure out ways to realize that goal and work towards it. The achievability of the goal should be defined well enough to actually achieve it. For an Achievable goal ask the following Questions
  • Is there resources and capabilities to achieve the goal? If not, what is missing?
  • Have others done it successfully before?
• R-Realistic
  • The goal should be realistically achieved given the available resources and time.
  • Goals are likely to be realistic, if it can be accomplished. For a realistic Goal ask the Following questions
  • Is the goal realistic and within reach?
  • Is the goal reachable, given the time and resources?
  • Is it possible to commit to achieving the goal?
• T-Timely
  • Must be time-bound in that it has a start and finish date. If the goal is not time-constrained, there will be no sense of urgency and, therefore, less motivation to achieve the goal.
  • Does the goal have a deadline?
  • By when the goal will be achieved?

EXPECTED OUTCOMES

The purposes of outcome identification and planning are to provide direction to ensure quality nursing care, to improve communication within the health care system, and to provide continuity of care. An outcome statement for a client with a problem-oriented diagnosis should describe the expected client status (behavior or function) when a nursing diagnosis has been resolved and the modification of the condition that places the client at risk. The outcome statement when a client has a wellness diagnosis should be a statement of the enhancement of a client’s positive adaptation.

Expected outcome statements include

(1) the subject, or client;

(2) a task statement, the hoped-for client behavior or function;

(3) the criteria by which the nurse will determine whether the expected outcome is met, usually the absence of the defining characteristics for the nursing diagnosis;

(4) the conditions, or qualifying statements or conditions for meeting the expected outcome and

(5) the time frame within which that outcome is expected to be reached.

SELECTION OF NURSING INTERVENTIONS

After outcomes are identified, Nursing Interventions are Selected

A Nursing Intervention is any treatment based on Clinical Judgement & Knowledge, that a Nurse performs to enhance patient outcomes

Nursing Interventions include both direct or indirect care, Nurse-initiated treatments resulting from Nursing Diagnoses

When Choosing Interventions the Nurse should consider the following

1.Desired Patient Outcomes

2.Etiology of the Nursing Diagnoses

3.Clinical practice Guidelines developed from evidence-based summaries

4.Specific Principles from Behavioral & Biologic Sciences

5.Feasibility of Successfully Implementing the Intervention

6.Acceptability to the client

7.Capability of the Nurse

The Final Selection of Interventions should also include the client’s choices when possible. The client or the family members often have more information about measures that were successful or unsuccessful in the past. Significant time & effort are save by asking the client’s opinion.

CLASSIFICATION OF NURSING INTERVENTIONS

• Independent Nursing Interventions: Independent nursing interventions are those sanctioned by professional nurse practice acts. They do not require direction or an order from another health care professional.
• Interdependent Nursing Interventions: Interdependent nursing interventions are actions that are implemented in a collaboration or consultation with other health care professionals.
• Dependent Nursing Interventions: Dependent nursing interventions are those that require an order from other health care professionals

PROTOCOLS & STANDING ORDERS

• Protocols:
  • A protocol is a series of standing orders or procedures that should be followed under certain specific conditions.
  • They define what interventions are permissible and under what circumstances the nurse is allowed to implement the measures. Health care agencies or individual health care practitioners frequently have standing orders or protocols for client preparation for diagnostic tests or for immediate interventions in life-threatening circumstances.
  • These protocols prevent needless duplication of writing the same orders repeatedly for different clients and often save valuable time in critical situations.
• Standing Orders:
  • A standing order is a standardized intervention written, approved, and signed by a health care practitioner that is kept on file within health care agencies to be used in predictable situations or in circumstances requiring immediate attention.
  • Nurses can implement standing orders in these situations after they have assessed the client and identified the primary or emerging problem.
  • For example, nurses in an ambulatory clinic or home health care agency may have standing orders for administering certain medications or ordering laboratory tests when indicated, or a health care practitioner may establish standing orders on an inpatient unit that specify certain medications that can be administered for common complaints such as headache.

TYPES OF NURSING CARE PLAN

• Student Oriented Care Plans: 
  • Student-oriented care plans are detailed documents used for teaching.
  • Student Nurses practice & learn Nursing process by collecting Assessment data, Identifying Nursing diagnoses & selecting patient outcomes & Interventions with rationales are selected and all are recorded on specific forms.
• Standardized Care Plans:
  • Standardized care plans are preplanned and preprinted guidelines for the nursing care of client groups with common needs
  • These Nursing Care plans may be used in practice as guides for routine Nursing care and as a basis for developing Individualized care plans.
• Institutional Care Plans:
  • Institutional nursing care plans are documents used by individual hospitals and agencies that are usually a part of the medical record.
• Computerized Care Plans:
  • Computerized care plans are standardized plans created and stored in the computers.

WRITING NURSING CARE PLAN

• Write the Date & Sign the Plan:
  • The date the plan is written is essential for evaluation, review, and future planning.
  • The nurse’s signature demonstrates accountability.
• Write Specific Nursing Interventions:
  • Nursing interventions should be specific and clearly stated, indicating what the nurse is expected to do.
  • It should provide directions for carrying out the planned Interventions.
• Begin with an "Action verb":
  • Action verb starts the intervention and must be precise.
  • Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity.
  • For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.”
• Follow Institutional Policy:
  • The client’s Nursing Care Plan is documented according to hospital policy and becomes part of the client’s permanent medical record which may be reviewed by the oncoming nurse.
  • Use only abbreviations accepted by the institution.