Critical Thinking- Planning


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.
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

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.
Goal (broad): improved nutritional status
Desired outcome: (specific): gain 2 kg by April 25
Objective will be:
Improved nutritional status as evidenced by weight gain of 2 kg by April 25
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.
The expected outcome serves as a criteria to evaluate the effectiveness of nursing activities and resolution of the nursing problems.
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 (address only one goal or outcome)
Be sure to provide precise method to evaluate client response to a nursing action.
Develop outcomes that are observable:
Observation helps to determine whether the change has taken place or not.
Eg: client achieves clear lung sounds.
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.
Time limited
Clearly state the time frame:
The time frame for each goal and expected outcome indicates when the expected outcome should occur.
Time frame also promotes accountability in the delivery and management of nursing care.
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.
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
Independent 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 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.
A standing order is a document containing orders for the conduct of routine therapies. monitoring guidelines, and/ or diagnostic procedures for specific clients with identified clinical problems.
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



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item Critical Thinking- Planning
Critical Thinking- Planning
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