Nursing Process-Planning

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Planning

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is a category of nursing behavior in which client-centered goals and expected outcomes are established and nursing interventions are selected

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Priorities are classified how?

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high, intermediate, and low

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High priorities are what?

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occur in both the psychological and physiological dimensions, and the nurse should avoid classifying only physiological nursing diagnoses as high priority

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Intermediate priority involves what?

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nonemergent, non-life threatening needs of the client

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Low-priority nursing diagnoses are what?

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client needs that may not be directly related to a specific illness or prognosis but may affect the client's future wwll-being

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Examples of High Priority

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Risk for ineffective airway clearance related to abdominal incisional pain; Acute pain related to tissue trauma of surgical incision

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Examples of Intermediate Priority

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Ineffective peripheral tissue perfusion related to postoperative venous status and risk for thrombophlebitis

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Examples of Low Priority

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Deficient knowledge regarding postoperative home care related to inexperience; Risk for infection related to history of smoking for 20 years

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Goals and expected outcomes are what?

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specific statements of client behavior or physiological responses that a nurse sets to achieve problem resolution

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Example of goals for the nursing diagnosis, Impaired physical mobility related to acute pain

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"Client will achieve normal mobility" and Client will achieve pain control."

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The purpose for writing goals and expected outcomes are twofold:

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to provide direction for the selection and use of nursing interventions and to provide focus for evaluation of the effectiveness of the interventions

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Client-centered goal

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is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function

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Example of client-centered goal

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"Client will perform self-care hygiene independently," "Client will remain free of infection," "Client will accept body image alteration."

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A goal contains ___ behaviors or responses

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singular

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Goals should be what?

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realistic and based on client needs and resources

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Short-term goals are what?

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an objective that is expected to be achieved within a short time frame, usually less than a week

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Long-term goals are what?

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an objective that is expected to be achieved over a longer time frame, usually over weeks or months

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Expected Outcome

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is a specific measurable change in a client's status that is expected to occur in response to nursing care.

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Outcomes provide what?

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a focus for nursing care because they are the desired responses of a client's condition in the physiological, social, emotional, developmental, or spiritual dimensions

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The listing of the step-by-step expected outcomes gives the nurse what?

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practical guidance in planning interventions.

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Expected outcome statements should be written how?

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written sequentially, with time frames

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Often the terms ___ and ___ are used interchangeably in health care settings

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goals; outcomes

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Example of goals and expected outcomes for: Risk for ineffective airway clearance r/t abdominal incisional pain

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Goal: Client will maintain patent airway through postoperative period to discharge. Expected Outcome: Lungs will be clear to auscultation within 48 hours postoperatively; Client achieves incentive spirometer goal of 90% every 2 hours

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Seven guidelines for writing goals and expected outcomes

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1. Client-Centered 2. Singular Goal or Outcome 3. Observable 4. Measurable 5. Time-Limited 6. Mutual Factors 7. Realistic

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Outcomes and goals should reflect what?

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the client behavior and responses expected as a result of nursing interventions

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A common error occurs when the goals are written how?

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to reflect the nurse's goals or outcomes

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Client-centered means what?

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Client will or patient will

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Each goal and expected outcome statement should address what?

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only one behavior or response

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The nurse must be able to determine through ___ if change has taken place

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observation

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Observable changes can occur in what?

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physiological findings, the client's level of knowledge, perceptions or expressed feelings, and behavior.

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Example of measurable goals and expected outcomes

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"Body temperature will remain 98.6," and "Apical pulse will remain between 60 and 100 beats per minute."

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Common mistakes are made when the nurse uses vague qualifiers such as:

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normal, stable, acceptable, sufficient, small, medium, or large.

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Terms specifically describing what allow the nurse to evaluate whether outcomes are achieved.

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quality, quantity, frequency, length, or weight

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Time frames do what for the nurse?

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assist the nurse and client in determining the progress is being made at a reasonable rate.

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Time frames promote what?

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accountability in the delivery of nursing care

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Mutually set goals and expected outcomes ensures what?

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that the client and nurse agree in the direction and time limits of care

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Mutual goal setting can what?

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increase the client's motivation and cooperation

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When establishing realistic goals, the nurse , through assessment, must know what?

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the resources of the health care facitily, family, and client; the client's physiological, emotional, cognitive, and sociocultural potential; and the economic cost and resources available to reach expected outcomes in a timely manner

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Nursing interventions

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are any treatment or action, based upon clinical judgment and knowledge, that nurses perform to enhance clients' outcomes

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Nursing interventions are designed to do what?

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to assist the client in moving from the present level of health to that which is described in the goal and measured by the expected outcomes

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To initiate the intervention the nurse must be competent in three areas:

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1. knowing the scientific rationale for the intervention, 2. Possessing the necessary psychomotor and interpersonal skills, and 3. being able to function within a particular setting to use the available health care resources effectively

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3 categories of nursing interventions

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Nurse-initiated, Physician-initiated, and collaborative

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Nurse-initiated intervention

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are the independent response of the nurse to the client's health care needs and nursing diagnosis

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Nurse-initiated intervention are ___ actions based on scientific rationale that is expected to benefit the client in a predicted way related to the nursing diagnosis and client-centered goal

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autonomous

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Nurse-initiated interventions do not require what?

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no supervision or directions from others

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Physician-initiated interventions

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are based on a physician's response to treat or manage a medical diagnosis

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Examples of physician-initiated interventions

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Administering a medication, implementing and invasive procedure, changing a dressing, and preparing a client for diagnostic tests.

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Collaborative interventions

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are therapies that require the knowledge, skill, and expertise of multiple health care professionals.

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When encountering physician-initiated or collaborative interventions, the nurse does not what?

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automatically implement the therapy but must determine whether it is appropriate for the client

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When choosing interventions, a nurse deliberates about six important factors, what are they?

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1. characteristics of the nursing diagnosis, 2. expected outcomes, 3. research base for the intervention, 4. feasibility of the intervention, 5. acceptability to the client, and 6. competencies of the nurse

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A nursing care plan is a ___ for clinical care

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guide

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A written care plan is what?

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designed to direct clinical care and to decrease the risk of incomplete, incorrect, or inaccurate care.

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The care plan can ___ and ___ resources used to deliver nursing care.

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identify; coordinate

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The nursing care plan enchances the continuity of nursing care by doing what?

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listing specific nursing actions necessary to achieve the goals and outcomes of care.

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The student care plan is what?

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essential for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care

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The common format used in written student nursing care plans is what?

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columnar plan that includes assessment, goals, nursing interventions, supporting scientific rationales, and outcome criteria

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Kardex

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is a trade name for a card-filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care.

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Critical pathways does what?

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allows staff from all disciplines, such as medicine, nursing, pharmacy, and social work, to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type

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A critical pathway ensures what?

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better continuity of care because it maps out clearly the responsibility of each health care discipline

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Concept Map

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is a tool that assists learners in developing a self-appraisal of their own individual thinking process

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Basically, a concept map is what?

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it is a diagram of client problems and interventions that shows their relationships to one another

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The use of a concept map promotes what?

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critical thinking and helps student nurses to organize complex client data, process complex relationships, and achieve a holistic view of a client's situation

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Consultation

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is a process in which the expertise of a specialist is sought to identify ways to handle problems in client management or the planning and implementation of therapies

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When is a Consultation appropritate?

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the nurse has identified a problem that cannot be solved using personal knowledge, skill, and resources.

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Steps in how to consult (6)

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1. Identify the general problem areas. 2. Consult should ne directed to the correct professional. 3. Provide the consultant with pertinent assessment information 4. Should not bias the consultant. 5. The nurse requesting consultation should be available to discuss findings and recommendation. 6. The nurse incorporates the consultant's recommendations into the plan of care