Chapter 18

Planning Nursing Care

Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Establishing Priorities

 Ordering of nursing diagnoses or patient

problems uses determinations of urgency and/or
importance to establish a preferential order for
nursing interventions.
 Organization of a vision of desired outcomes.
 Classification of priorities:
 High—Emergent
 Intermediate—non-life-threatening
 Low—Affect patient’s future well-being

Copyright © 2017, Elsevier Inc. All Rights Reserved. 2

 Establishing Priorities (Cont.)

 The order of priorities changes as a patient’s

condition changes.
 Priority setting begins at a holistic level when
you identify and prioritize a patient’s main
diagnoses or problems.
 Patient-centered care requires you to know a
patient’s preferences, values, and expressed
needs.
 Ethical care is a part of priority setting.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 3

Priorities in Practice

Copyright © 2017, Elsevier Inc. All Rights Reserved. 4

 Case Study

 Fulmala is a first semester nursing student who

is assigned to Ms. Nadine Skyfall, a 35-year-old
American Indian patient diagnosed with severe
anemia secondary to a bleeding peptic ulcer.
Ms. Skyfall experiences pain because of the
ulcer and weakness and fatigue resulting from
the anemia.
 Fulmala develops Ms. Skyfall’s plan of care,
which addresses pain, weakness, fatigue,
nutrition, and patient safety.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 5

 Critical Thinking in Setting Goals
and Expected Outcomes
 Goal
 A broad statement that describes the desired change
in a patient’s condition, perceptions, or behavior
 An aim, intent, or end
 Expected outcome
 Measurable change that must be achieved to reach a
goal
 Many times, several must be met to meet a single
goal

Copyright © 2017, Elsevier Inc. All Rights Reserved. 6

Critical Thinking in Setting Goals
and Expected Outcomes (Cont.)

Copyright © 2017, Elsevier Inc. All Rights Reserved. 7

 Role of the Patient in Goal/Outcome
Setting
 Always partner with patients when setting their
individualized goals.
 Mutual goal setting includes the patient and
family (when appropriate) in prioritizing the goals
of care and developing a plan of action.
 Act as a patient advocate.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 8

 Setting Goals and
Expected Outcomes
 Patient-centered goal:
 A patient’s highest possible level of wellness and
independence in function, based on patient needs,
abilities, and resources
 Nursing-sensitive patient outcome
 A measurable patient, family, or community state,
behavior, or perception largely influenced by and
sensitive to nursing interventions
 Nursing Outcomes Classification (NOC)
 Links outcomes to NANDA-I nursing diagnoses

Copyright © 2017, Elsevier Inc. All Rights Reserved. 9

Writing Goals and Expected Outcomes

 Must be patient-centered
 Use SMART acronym
 Specific
 Measurable
 Attainable
 Realistic
 Timed

Copyright © 2017, Elsevier Inc. All Rights Reserved. 10

 Quick Quiz!

1. A patient is suffering from shortness of breath.

The correct goal statement would be written as:
A. the patient will be comfortable by the morning.
B. the patient will breath unlabored at 14 to 18
breaths per minute by the end of the shift.
C. the patient will not complain of breathing
problems within the next 8 hours.
D. the patient will have a respiratory rate of 14 to
18 breaths per minute.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 11

 Critical Thinking in
Planning Nursing Care
 Nursing interventions are treatments or actions
based on clinical judgment and knowledge that
nurses perform to enhance patient outcomes.
 Nurses need to:
 Know the scientific rationale for the intervention
 Possess the necessary psychomotor and
interpersonal skills
 Be able to function within a setting to use health care
resources effectively

Copyright © 2017, Elsevier Inc. All Rights Reserved. 12

 Types of Interventions

 Nurse-initiated
 Independent—Actions that a nurse initiates
 Health care provider initiated
 Dependent—Require an order from a physician or
other health care professional
 Collaborative
 Interdependent—Require combined knowledge, skill,
and expertise of multiple health care professionals

Copyright © 2017, Elsevier Inc. All Rights Reserved. 13

 Types of Interventions (Cont.)

 When preparing for physician-initiated or

collaborative interventions, do not automatically
implement the therapy, but determine whether it
is appropriate for the patient.
 The ability to recognize incorrect therapies is
particularly important when administering
medications or implementing procedures.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 14

 Case Study (Cont.)

 Fulmala develops Ms. Skyfall’s plan of care,

including writing the goals and expected
outcomes.
 Fulmala knows that the guidelines for writing
goals and expected outcomes include that they
be measurable, time-limited, observable, and
realistic.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 15

 Selection of Interventions

 Six factors to consider:

Desired patient outcomes
Characteristics of the nursing diagnosis
Research-based knowledge
for the intervention
Feasibility of the interventions
Acceptability to the patient
Nurse’s competency

Copyright © 2017, Elsevier Inc. All Rights Reserved. 16

 Nursing Interventions Classification
(NIC)
 The Iowa Intervention Project developed a set of
nursing interventions that provides a level of
standardization to enhance communication of
nursing care across health care settings and to
compare outcomes.
 The NIC model includes three levels—domains,
classes, and interventions—for ease of use.
 NIC interventions are linked with NANDA
International nursing diagnoses.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 17

 Case Study (Cont.)

 Fulmala knows that _________________

interventions require an order from a physician
or another health care professional.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 18

 Systems for Planning Nursing Care

 Nursing care plan = Nursing diagnoses, goals

and expected outcomes, and nursing
interventions, and a section for evaluation
findings so any nurse is able to quickly identify a
patient’s clinical needs and situation
 Reduces the risk for incomplete, incorrect, or
inaccurate care
 Changes as the patient’s problems and status change
 Interdisciplinary care plan = Contributions from
all disciplines involved in patient care

Copyright © 2017, Elsevier Inc. All Rights Reserved. 19

 Hand-Off Reporting

 A critical time, when nurses collaborate and

share important information that ensures the
continuity of care for a patient and prevents
errors or delays in providing nursing
interventions
 Transferring essential information from one
nurse to the next during transitions in care
 Ask questions, clarify, and confirm important
details about a patient’s progress and continuing
care needs
Copyright © 2017, Elsevier Inc. All Rights Reserved. 20
 Student Care Plans

 A student care plan

 Helps you apply knowledge gained from the nursing
and medical literature and the classroom to a practice
situation
 Is more elaborate than a care plan used in a hospital
or community agency because its purpose is to teach
the process of planning care
 Planning care for patients in community-based
settings involves
 Educating the patient/family about care
 Guiding them to assume more of the care over time
Copyright © 2017, Elsevier Inc. All Rights Reserved. 21
 Critical Pathways

 Critical pathways are patient care plans that

provide the multidisciplinary health care team
with activities and tasks to be put into practice
sequentially.
 The main purpose of critical pathways is to
deliver timely care at each phase of the care
process for a specific type of patient.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 22

 Concept Maps

 Visual representation of all of a patient’s nursing

diagnoses that allows you to diagram
interventions for each
 Group and categorize nursing concepts to give
you a holistic view of your patient’s health care
needs and help you make better clinical
decisions in planning care
 Help you learn the interrelationships among
nursing diagnoses to create a unique meaning
and organization of information
Copyright © 2017, Elsevier Inc. All Rights Reserved. 23
 Case Study (Cont.)

 Fumala writes down several independent

nursing interventions that she is developing for
Ms. Skyfall.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 24

 Quick Quiz!

2. When caring for a patient who has multiple

health problems and related medical diagnoses,
nurses can best perform nursing diagnoses and
nursing interventions by developing a:
A. critical pathway.
B. nursing care plan.
C. concept map.
D. diagnostic label.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 25

 Consulting Other Health Care
Professionals
 Planning involves consultation with members of
the health care team.
 Consultation is a process by which you seek the
expertise of a specialist such as your nursing
instructor, a physician, or a clinical nurse
educator to identify ways to handle problems in
patient management or in planning and
implementation of therapies.
 Consultation occurs at any step in the nursing
process, most often during planning and
implementation.
Copyright © 2017, Elsevier Inc. All Rights Reserved. 26
 When and How to Consult

 When: The exact problem remains unclear

How: Begin with your understanding of the patient’s
clinical problem.
Direct the consultation to the right professional.
Provide the consultant with relevant information about
the problem area: summary, methods used to date, and
outcomes
Do not influence consultants.
Be available to discuss the consultant’s findings.
Incorporate the suggestions.
Copyright © 2017, Elsevier Inc. All Rights Reserved. 27
 Case Study (Cont.)

 Fumala’s clinical coordinator tells her to

coordinate with a nutritionist to develop a meal
plan for Ms. Skyfall.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 28

 Quick Quiz!

3. Consultation occurs most often during which

phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation

Copyright © 2017, Elsevier Inc. All Rights Reserved. 29