chapter 18 planning nursing care so after a nurse identifies the patient's diagnosis and their collaborative problems the nurse will begin to plan the planning step of the nursing process planning for us involves setting priorities based on patient diagnoses and collaborative problems we identify patient-centered goals as well as expected outcomes and we will prescribe nursing interventions that are appropriate for each of the diagnoses the most important thing when we're planning this care is that it is individualized for the patient and the patient remains the center of the care plan based on the patient's own unique needs the nursing diagnoses will direct the selection of the interventions as well as goals and the outcomes that we hope the patient can achieve planning requires critical thinking that is applied through each of the deliberate decision making as well as problem solving areas we also have to communicate with our patients family and the health care team and we know that any plan of care is dynamic and it changes as our patients needs change priority setting is when we order the nursing diagnoses or the patient problems to establish a preferential order for our interventions problem focus diagnoses and problems usually take priority over wellness potential risk and other health promotion problems short-term acute patient needs and problems will be are typically our priority over long term or chronic needs priority setting is not the ordering of a list of care tasks but it is the organization of the desired outcomes for our patient priority setting is not a matter of numbering the nursing diagnoses based on severity or physiologic importance this kind of numbering system does not always reflect the actual patient changes clinically as a nurse we need to establish priorities related to the patient's ongoing clinical importance when a nurse classifies they classify patients priorities as either high intermediate or low nursing diagnosis that if are untreated can result in harm to a patient or to others have high priorities airway circulation breathing safety and pain we prioritize our nursing diagnosis because we consider immediate needs based on airway breathing circulation higher highest priority can also be determined by using maslow's hierarchy of needs in that the physiologic needs are necessary for the occurrence of life so many factors in the healthcare environment will affect the nurses ability to set priorities as a nurse we have a plan of action that helps us effectively manage our time avoid unnecessary interruptions and avoid helping others when this could potentially jeopardize our patients priority of care so when reading this why isn't anemia and the peptic ulcer part of our nursing care plan it is because our care plans do not directly address any medical diagnoses the planning process involves application of the nurse's knowledge knowledge about the patient clinical experiences practice standards and critical thinking attitudes the planning process is dynamic and it changes as the patient's needs change as a nurse we apply critical thinking after identifying the patient's nursing diagnosis or collaborative problems goals and expected outcomes are specific statements of a patient behavior or physiologic response that the nurse and the patient have selected to resolve a nursing diagnosis or a collaborative plan the goal serves two purposes it sets a clear direction for selection and use of nursing interventions and it sets specific measures so we can evaluate the effectiveness of the patient meeting the goal a goal is actually a broad statement that can describe a desired change in the patient's condition perception or behavior each goal is time limited so that every member of the team has a common timeline to help resolve the problem the time frame will depend on the type of problem etiology condition of the patient as well as the treatment setting there are short-term and long-term goals a short-term goal is an objective behavior or a reason a short-term goal is an objective behavior or a response that the nurse expects the patient to achieve in a short time you usually less than a week in an acute care setting a short term goal may be a shift goal it's just set first few hours a long term goal is some objective behavior or response that the nurse expects the patient to achieve usually over several days weeks or months and it may be seen as a discharge goal in the acute care setting patient-centered care includes the involvement of the patient and their family as appropriate this care always collaborate with the patients during the goal setting process the mutual goal setting helps the nurse prioritize the goals of care and develop the realistic and relevant plan for the patient unless the goals are mutually set and include a clear plan of action the patient may not participate patients need to have an understanding and see the value of the therapy that is provided by nursing even though they are oftentimes totally dependent on the nurse the nurse will play a vital role in the interprofessional collaboration especially when we communicate patients needs to all the healthcare team we will clarify priorities and we collaborate to ensure a continuum of patient-centered care when the interprofessional collaboration functions well outcomes are improvements in patient care improvements in health care satisfaction it controls costs it will reduce the clinical errors and improvements in patient safety will be seen an expected outcome is a measurable change whether it's a behavior a physical state or perception that must be achieved by the patient to reach the goal in health care often times the terms goal and outcomes are interchanged an outcome measurement is a priority within health care institutions however the way that electronic health records label goals and outcomes it use i'm sorry they're categories that nurses use to complete our care plans can sometimes be confusing so we need to think of a goal as an ultimate outcome and expected outcomes as the major measurable changes that a patient achieves to reach the goal a patient-centered goal will reflect the patient's highest possible level of wellness and independence with functioning it is realistic and it is based on the patient's needs abilities and resources the patient center goal is a so an associated outcome these will reflect the patient's behavior not the nurse's goal this will become important to measure the patient's outcomes that are influenced by the nursing care a nursing sensitive patient outcome is a measurable outcome for the patient and it is measured on a continuum that is in response to specific nursing interventions um a valuable resource for selecting patient goals and outcomes is the nursing outcomes classification this links all the outcomes to the nanda one or nanda international nursing diagnoses the resource is an option that can be used when selecting goals or outcomes for nurses patients for each diagnosis there are multiple evidence-based goals the outcomes have labels for describing the focus of the nursing care and include indicators which are expected outcomes that can be used to help evaluate success the indicators for each nursing outcome classification will allow for measurement on any point on a five point likert scale when writing a patient goal it has to use the acronym smart so the goal is specific for that patient it is measurable so it has to be something that can be measured for example a pain scale using 0 to 10 and the patient's pain starts at a seven and now we want to reduce it to a four that is measurable it has to be something that can be attained so the patient has to be able to reach that it has to be realistic okay so not everything that we or every goal that we determine is realistic for every patient even if the patients may present the same so it has to be realistic for that specific patient and each goal or outcome is has a time frame and that time frame is when we will actually evaluate that goal a patient is suffering from shortness of breath the correct goal statement would be written as the patient will be comfortable by the morning the patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift the patient will not complain of breathing problems within the next eight hours the patient will have a respiratory rate of 14 to 18 breaths per minute so when looking for the correct goal statement remember to look back at the prior slide and look at smart the answer for this is b during the planning the nurse makes clinical decisions by choosing nursing interventions that are most appropriate for the patient's diagnosis and collaborative problems the actual implementation of these interventions occurs during the fourth step of the nursing process which is the implementation step a nursing intervention is any treatment or action that is based on clinical judgment and knowledge that nurses can perform to help patients reach their goals during planning the nurse will select the interventions that is designed to help patients move from their present level of health to the level described in the goal and measured by the expected outcomes nurse initiated interventions are independent nursing interventions that a nurse initiates in response to a nursing diagnosis this means the nurse does not need supervision directions or a prescribing order from anyone direct care measures are treatments or procedures that are performed through interaction with the patient this is when the nurse is actually physically assisting the patient indirect care measures are treatments or procedures that are performed away from the patient but on behalf of the patient so you may need to call the prescriber and have the medication change that's an indirect care measure um health care provider initiated interventions these are dependent nursing interventions because these require an order from the provider there are other are other health provider interventions or interdependent interventions these are therapies that require combined knowledge skill and expertise of various providers what are the guidelines used for writing goals and expected outcomes when the nurse chooses interventions the nurse considers six different factors the desired patient outcomes the characteristic of the nursing diagnosis the research-based knowledge or the science for the nursing intervention the actual feasibility or cost for doing the intervention the acceptability to the patient so will the patient be willing to do it and the nurse's competency as a nurse we realize that our desired patient outcomes these are outcomes that serve as criteria against where i'm judging efficacy of the intervention so were they efficient were they effective the nursing outcomes classification these outcomes are linked to nanda nursing diagnoses the nursing outcomes classification are also linked to nursing interventions classification these resources are used to help develop our nursing care plans so when we looking at a nursing diagnosis we want to choose interventions that will alter the etiology or the related two factor or the cause of the diagnosis when an etiology factor cannot change direct the interventions toward treating the signs and symptoms for a risk diagnosis we would direct the interventions at maybe altering or eliminating the risk factors when we're thinking about research base and interventions we need to know the research evidence for the intervention what is the science that is backing this there should always be research evidence to support the nursing intervention this will indicate the effectiveness when the research is not available we want to make sure that we're using the scientific principles or we can consult a legal i mean excuse me a clinical expert for feasibility we need to make sure that a specific intervention has potential to interact with other interventions we need to know and be involved in the patient's total plan of care we need to always consider the patient's cost and with consideration of costs we need to think about the time that's going to be needed to implement these interventions for acceptability of the patient we need to make sure that if possible we offer that patient a choice of interventions so that way they have feel like they have some something to gain in their nursing care plan this will promote an informed choice giving patients about giving patients information related to each intervention and how they would be expected to perce participate we want to think about the patient's values beliefs and their culture to ensure that we are doing a patient-centered approach and the capability or competency the nurse has to have knowledge of scientific rationale for the intervention the nurse has to have the necessary psychosocial and psychomotor skills to complete the intervention and they have to be able to function within the specific setting to effectively use the healthcare resources just as with standardized nursing outcomes classification there's also a set of nursing interventions classification that are standardized to help enhance communication of nursing care throughout all the actual care settings the nursing interventions classification model includes three different domains classes and the interventions seven domains are the highest level and they use broad terms to organize the more specific classes and the interventions the second level of the model addresses 30 different classes or groups of related intervention and the third level of the model includes 565 different interventions defined as a treatment based on the clinical judgment and the knowledge that the nurse has the interventions can be used with various um different 248 classifications of diagno diagnoses each intervention will then include a variety of activities that the nurse can choose from and that a nurse will commonly use within the plan of care the intervention classification can be a valuable resource for selecting appropriate interventions and activities for the patient this is ongoing it's evolving and it is practice oriented this classification system is comprehensive it includes independent and collaborative interventions however it does remain the nurse's decision to determine the interventions and activities that will best suit the patient's individualized needs so what type of interventions will require an order from a provider dependent nursing interventions these are actions that require an order from a health care provider systems exist for developing and communicating the nurses plan of care to other nursing professionals and health care providers good planning ensures safety and quality of nursing care the nursing care plan includes nursing diagnoses goals expected outcomes individualized interventions and a section for evaluation of findings the nursing care plan will promote continuity of care and better communication student care plans will help the nursing student learn problem solving the nursing process skills of written communication and organizational skills for nursing care most important it will help the student apply the knowledge gained from specific scientific literature and the classroom to a practice situation usually students will write a care plan for each nursing diagnosis using a table format with columns for assessment findings goals outcomes interventions and then we have the rationale to support interventions and then we will have a column for evaluation of outcomes part of planning is transferring information from one individual to the next a nurse to nurse when we transition in care a handoff report is real time this offers the nurse that's accepting the care of the patient an opportunity to ask questions this will help clarify and confirm important details about the patient's care plan their progress and any kind of needs a quality handoff information this will enable the nurse to recognize and understand changes in the patient's status and to anticipate risks to promote patient safety a concept map is a visual representation of all the patients nursing diagnoses that allows the nurse to diagram interventions for each the concept map makes a patient's diagnosis more meaningful because it shows the cognitive connections that are made between the diagnoses and the interventions using a concept map has been shown to approve improve nursing self-reflection and nursing critical thinking the math will show relationships within the nursing process and concept maps will group and categorize nursing concepts to provide a holistic view of the patient's care needs an e-r-a-s incorporates evidence-based practice and includes a comprehensive projective plan for the patient's journey through the surgical process beginning with pre-op screening through pro-stop care for example an eras will set time frames for when patients are to progress with mobility advance in diets receive specific types of medications and have therapies such as maybe an iv or fully discontinued a pathway is a clinical management tool that will provide a road map for best practices based on clinicians expertise and clinical guidelines that are shaped by health professionals so what are some examples of an independent nursing interventions that may be used here remember that independent nursing interventions don't require an order from a health provider specific examples of independent nursing interventions may include position patient positioning and patient education 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 critical pathway nursing care plan concept map diagnostic label the answer is c as noted prior concept maps will help a nurse organize nursing interventions for a patient that has multiple problems a consultation is necessary if the nurse needs to seek procedural assistance or clinical expertise for a specific problem to ensure that our patient receives the necessary interventions during the consultation the nurse will seek expertise of a specialist maybe it might be a nursing instructor a provider or a clinical nurse specialist to help identify ways or methods to handle specific problems when managing patients or planning and implementing therapies would working with a nutritionist be considered a collaborative intervention recall that collaborative interventions or interdependent interventions are therapies that require the combined knowledge skill and expertise of multiple health care consultation occurs most often during which phase of the nursing process assessment diagnosis planning evaluation the answer is c when a nurse is unsure of how to proceed in the planning process they should seek out another colleague's knowledge and experience to assist in planning interventions for the patient