PLANNING
Meaning
Planning begins with the first client contact and continues
until the nurse- client relationship ends, usually when the client is
discharged from the health care agency.
STEPS IN PLANNING
1.
Setting priority
2. Establishing patient goals
3. Identifying desired outcome
4. Selecting appropriate nursing
interventions
5. The patient plan of care
6. Discharge planning
7. Documenting the plan of care
8. Validating the plan of care
TYPES OF PLANNING
1. Initial planning
2. Ongoing planning
3. Discharge planning
Initial planning
The nurse who performs the admission assessment usually develops
the initial comprehensive plan of care.
The nurse has the benefit of the clients body language as
well as some intuitive kinds of information that are not available solely from
the written database.
Ongoing planning
Ongoing planning is done by all nurses who work with the
client.
As nurses obtain new
information and evaluate the clients responses to care, they can
individualize the initial care plan further.
Discharge planning
Is the process of anticipating
and planning for needs after
discharge, is a crucial part of comprehensive health care and should be
addressed in each clients care plan.
Eg: shorter stay, long term care facilities etc
Establishing priorities
Is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
The nurse and the client begin planning by deciding which
nursing diagnosis requires attention
first, which second, and so on.
Grouping priorities
High priority: Life threatening problems, such as
loss of respiratory or cardiac function, are designated as high priority
Medium priority: Health threatening problems, such as
acute illness and decreased coping ability, are assigned medium priority
because they may result in delayed development or cause destructive physical or
emotional changes.
Low priority
low priority problem is one that arises from normal
developmental needs or that requires only minimal nursing support.
Setting priorities for patient care;
In Maslow's hierarchy physiologic
needs such as air, food and water
are basic to life and receive higher
priority than the need for security and activity.
Thus, nursing diagnoses such as ineffective airway clearance
and impaired gas exchange would take priority over nursing diagnoses such as
anxiety or ineffective coping.
Factors influencing priority
assignment
1. Clients health values and beliefs:
Values concerning health may be more important to the nurse
than to the client
Eg: client may believe being home for the children to be more
urgent than a health problem
2. Clients priorities:
Involving the client in prioritizing and care planning
enhances cooperation.
Eg: an elderly client may not regard turning and
repositioning in the bed as important, preferring to be undisturbed.
3. Resources available to the nurse and client:
If money, equipment, or personnel are scarce in a health care
agency, then a problem may be given a lower priority than usual.
Eg: a client who is unemployed may defer a dental treatment.
4. Urgency of the health problem
Regardless of the framework used, life threatening situations
require that the nurse assign them a high priority.
Fug: client may be anxious about child care, but her ineffective
airway clearance has higher priority.
5. Medical treatment plan.
The priorities for treatment health problems must be
consistent with treatment by other health professionals.
Eg: a high priority for the client might be to become
ambulatory, however if the primary care regimens calls for extended bed rest,
then the ambulation must assume lower priority in the nursing care plan
Establishing goals and expected
outcomes
Expected outcomes/desired outcomes
An expected outcome is the specific step by step objective
that leads to attainment of the goals and resolution of the etiology and
nursing diagnoses.
An outcome is a measurable change of the clients status in
response to the nursing care.
These desired outcomes are the measurable steps toward
achieving the patient goals that were established earlier.
An expected outcome are the derived measurable responses of a
clients condition including
responses in a physiological, social, emotional, developmental
and situational dimensions.
The expected outcomes are derived from short term and long
term goals, determines when a specific, client centered goals has been met.
Example:
Goal (broad): improved nutritional status
Desired outcome: (specific): gain 2 kg by April 25
Objective will be:
Expected outcomes have several functions/ purposes:
They provide the direction for selecting the nursing
activities.
They include observable clients behavior and measurable
criteria for each goal.
They also provide a projected time span for goal attainment,
and an opportunity to state any additional resources, that may be required to
achieve goals, including additional equipment, personnel or knowledge.
Guidelines for writing goals and expected outcomes:
1. Client centered
2. Singular
3. Observable
4. Measurable
5. Time limited
6. Mutual
7. Realistic factor
Client centered:
Focuses on the client.
Outcomes and goals should be reflect the client behavior and responses expected
as a result of nursing interventions.
Correct statement: client ambulates in the hall three
times in a day.
Error: ambulate the client in the hall
three times in a day.
Singular
Singular (address only one goal or outcome)
Be sure to provide precise method to evaluate client response
to a nursing action.
Observable
Develop outcomes that are observable:
Observation helps to determine whether the change has taken
place or not.
Eg: client achieves clear lung sounds.
Measurable
Write outcome that can be measured:
Goals and expected outcomes are written to provide a standard
against which the clients response to the nursing care is measured.
A goal or outcome that is stated in measurable terms allows
the nurse to objectively quantify the changes in patients health status.
Avoid vague quantifiers such as normal, stable.
Clearly state the time
frame:
Time frame also promotes accountability in the delivery and
management of nursing care.
Mutual
Consult with the client:
Mutual setting and expected outcomes ensures that the client
and care giver agree on the direction and time limits of care.
Mutual goal setting can increase the clients motivation and
cooperation.
Realistic Factor
Set goals and expected outcomes that can be achievable.
It gives a sense of accomplishment.
While establishing realistic goals thorough assessment, nurse
must know resources of the health care facility, family and client.
Goals
Long term goals - indicate the overall direction or
end result of care and may very well not be achieved before discharge.
Short term goals - are most specific guides for care
and must usually be met before discharge or transfer to a less acute level of
care, supervision or support.
Planning the nursing care:
After establishing goals and expected outcomes select the
appropriate nursing interventions or actions.
Selecting appropriate
nursing intervention
Nursing
interventions like nursing diagnosis are key element of the knowledge of
nursing, in fact the scientific body of knowledge of nursing intervention like
that of nursing diagnosis continues to grow as research supports the connection
between the action and outcomes.
To select the interventions the nurse must be competent in
three areas.
Have knowledge of scientific rationale for the
interventions.
Possess the necessary psychomotor
and interpersonal skills to perform the interventions.
Be able to function within a particular setting to use
available health care resources.
Types of interventions:
1.
Independent interventions- Nurse initiated
2.
Dependent interventions- Physician initiated
3.
Collaborative interventions
Nurse initiated: Are those interventions a nurse can
independently initiate to manage the clients health care needs.
This type of interventions are based on the scientific
principles. Eg:
·
Physical
care
·
Ongoing
assessment
·
Emotional
support and comfort
·
Teaching
\counseling
·
Making
referrals to other health care professionals
Dependent interventions:
Physician initiated. Are based on the physicians response to
the medical diagnosis.
The nurse follows the physicians written or verbal
prescriptions. Eg:
·
Administering
the medications.
·
Implementing
an invasive procedures
·
Changing
the dressing
·
Preparing
the client for diagnostic procedure.
Collaborative
interventions:
Are the therapies that requires the combined knowledge, skill
and expertise of multiple health care professionals. Eg:
Such as physical therapists, social workers, dietitians and
physicians.
Selection of
interventions:
Selection depends on the 6 main factors
1. Characteristics of nursing diagnosis
2. Goals and expected outcomes
3. Evidence base
4. Feasibility of the intervention
5. Acceptability to the patient
60 Capability of the
nurse
Selection of
interventions:
l . Characteristics of nursing
diagnosis
Interventions should alter the etiological factor or signs
and symptoms associated with diagnosis.
Eg: acute pain related to incisional trauma
·
Interventions
·
Positioning
·
Turning
·
Analgesic
Goals and expected outcomes
State outcomes in terms used to evaluate the effect of an
intervention.
Eg: patient will perform urinary catheter care by discharge-
Observation of the outcome: observation of the patient
performing catheter care
Evidence base
Research evidence in support of a nursing intervention will
indicate the effectiveness of using the intervention with certain types of
patients.
Fug: research articles, evidence based practice guidelines
that describe use of evidences
Hand washing, suctioning without using NS, back massage with
oil
Feasibility of the
intervention
A specific intervention has the potential to interact with
other interventions
Fug: if you plan to get a patient up into a chair 3 times a
day, will there be staff to assist with the transfer?
Acceptability to the
patient
A treatment plan needs to be acceptable to the patient and
family and match the patients goals health care values, and culture.
Help a patient to know how to participate in health education,
how to understand if bp reduced or not after medications?
Capability of the nurse
Be prepared to carry out the intervention.
Be able to function within the specific setting , use of
health care resources.
Eg. Experienced and confident nurses approach in attending a
patient in causality with road traffic accident
Protocol
Protocol is a written plan specifying the procedures to be
followed during an assessment or when providing treatment for a specific
condition or nursing care problem.
Example: Nurses on a general medical unit will follow a
protocol to provide wound care.
The
established protocol explains the conditions that nurses are permitted to
treat, such as controlled hypertension, and the recommended treatment plan,
including the therapies the nurse is permitted to administer, such as diet
counseling, stress management, and prescriptions of antihypertensives.
Standing order
·
Standing
order is a written document about policies, rules, regulations or orders
regarding client care.
·
Standing
orders give nurses the authority to carryout specific action under circumstances
in the absence of supervision of a physician.
The orders direct the conduct of client care in various
clinical settings.
Standing orders are approved and signed by the physician in
charge of care before their implementation.
They are commonly found in critical care settings and other
specialized practice settings where client need can change rapidly and require
immediate attention.
Standing orders are also common in the community health
setting, in which the nurse encounters situations that do not permit immediate
contact with a physician.
Thus protocols and standing orders give you the legal
protection to intervene appropriately in the clients best interest.
Before implementing any therapy, including those included in
protocols and standing orders, nurse must use sound judgment in determining
whether the intervention is correct and appropriate.
Nursing responsibility is equally great for all types of
interventions.
Writing the nursing
care plan
Writing the nursing care plan is an initial step in planning.
After assessing and diagnosing the patient, nurse assigns a priority to each
nursing diagnosis.
The nursing diagnosis with the highest priority is the
beginning point for the nursing care plan.
Planning care can save valuable time when the goals of care,
patient's outcomes and nursing interventions to achieve them are clearly
identified and recorded for all to see.
The plan of care is written to:
•
Provide
continuity of care
•
Enhance
communication
•
Assist
with unit staffing needs
•
Document
the nursing process
•
Serve
as a teaching tool
•
Coordinate
care among discipline
•
Mastery
of the skills of planning care
•
Formula
for Writing Goals/Outcomes
COMMENTS