Planninng Nursing Care

Planning is the third step of Nursing process

1. Planning Nursing Care
A National Workshop on Nursing Process: A
Framework of Quality Nursing Care
TeerthankarMahavir University, Moradabad,
Uttar Pradesh
15-16March 2019
Prof. Dr.Smriti Arora
Amity College of Nursing
Amity University Haryana
[email protected], 9810840372

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Objectives
Types of planning
Establishing priorities
Setting goals and expected outcomes
Interventions –types and selection
Systems for planning nursing care

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Types of Planning
Initial
Ongoing
Discharge

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Types of Planning
1-Initial Planning
• Develop initial comprehensive plan
of care
• Begun after initial assessment, at
admission

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Planning
1.Involves setting priorities
2.Identifying patient centred goals and
expected outcomes, and
3.Prescribing individualized nursing
interventions

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Establishing Priorities
Rank Ordering of nursing diagnoses or
patient problems ,
using determinations of urgency and/or
importance to establish a preferential order
for nursing actions.
Helps to anticipate and sequence nursing
interventions

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Establishing Priorities (cont’d)
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.

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Priority ?
Maslow’s hierarchy
ABC

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Classification of priorities:
➢High
➢Intermediate
➢Low
High priority : emergent action
➢Impaired gas exchange
➢Decreased cardiac output

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Classification of Priority
Intermediate priority
➢Non emergent, non life threatening needs
e.g. -
➢Knowledge deficit
➢Impaired physical mobility
Low priority diagnoses
➢Focus on patient’s future well being
e.g. -Patient’s concern about prognosis of surgery,
sexual functioning

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Setting Goals and Expected
Outcomes
Set goals for each nursing diagnosis
There can be several EO for one goal
Goal
➢A broad statement that describes the desired
change in a patient’s condition or behavior
➢An aim, intent, or end
Expected outcome
➢Measurable criteria to evaluate goal achievement

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Goals of Care-types
Patient-centered goal:
A specific and measurable behavior or
response that reflects a patient’s highest
possible level of wellness and independence
in function
Short-term goal:
An objective behavior or response expected
within hours to a week
Long-term goal:
An objective behavior or response expected
within days, weeks, or months

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How to set Goals of Care ?
Always partner with patients when setting
their individualized goals.
For patients to participate in goal setting, they
need to be alert and must have some degree of
independence in completing activities of daily
living, problem solving, and decision making.
Patients need to understand and see the value
of nursing therapies, even though they are often
totally dependent on you as the nurse.

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Expected Outcomes
An objective criterion for goal achievement
A specific,measurablechange in a patient’s
status that you expect in response to nursing
care
It directs nursing care
It determines when a specific, patient-
centered goal has been met
Are written sequentially, with time frames
Usually, several are developed for each
nursing diagnosis and goal.

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Nursing Outcomes Classification
The Iowa Intervention Project published the Nursing
Outcomes Classification (NOC) and linked the
outcomes to NANDA International nursing diagnoses.
NOC outcomes provide a common nursing language
for continuity of care and measuring the success
/impact of nursing interventions.

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Example –NANDA and NOC linkage
Nursing
diagnosis
Suggested NOC
outcome
Outcome
indicators
Activity intolerance Activity tolerance
Self care status
Oxygen saturation with
activity
Pulse rate with activity
RR with activity
Bathes self
Dresses self
Prepare food and fluid
for eating

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Seven Guidelines for Writing Goals
1. Patient centred
2. Singular goal or outcome
3. Observable
4. Measurable
5. Time limited
6. Mutual factors
7. Realistic

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1. Patient centred
Goals and outcome must reflect patient
behaviours and responses as a result of
nursing intervention
Goal –patient will ambulate independently in
3 days
Outcome –patient will ambulate in hall 3
times a day by 22 . 04. 19

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2. Singular goal or outcome
Each goal should address only one behaviour
Incorrect
➢Patient will administer a self injection and
demonstrate infection control measures
Correct
➢Patient will prepare medication dose correctly
➢Patient uses medical asepsis when preparing
injection site

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3. Observable
Observe physiological findings, knowledge ,
behaviour
Example
➢Patient prepares insulin dosage correctly by
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➢Lungs will be clear on auscultation by …..

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4. Measurable
Do not use vague terms –normal, stable
Be objective
Body temperature will remain 98.6 degree F
Pulse will be within 60-100 beats per minute

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5. Time limited
To determine if patient’s progress is at a
reasonable rate
patient will ambulate in hall 3 times a day by
22 . 04. 19

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6. Mutual factors
Agreed by patient and nurse
Increases motivation and cooperation

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7. Realistic
Feasible
Assess available resources-staff, time, cost
Check the potential of patient

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Example

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NI are treatments or actions based on clinical
judgment and knowledge that nurses perform to
meet patient outcomes.
For choosing suitable NI, 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
Nursing Interventions

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Types of Interventions
Nurse initiated
➢Independent—Actions that a nurse initiates
Physician 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

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Nursing interventions
Nurse initiated
➢Elevating an edematouslimb
➢Changing position
Physician initiated
➢Administering medications
➢Implementing invasive procedure –IV infusion ,
diagnostic tests
Collaborative interventions
➢Referral to counsellors , physiotherapists

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Errors in writing NI

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Selection of Interventions
Six factors to consider:
•Characteristics of nursing diagnosis
•Goals and expected outcomes
•Evidence base for interventions
•Feasibility of the interventions
•Acceptability to the patient
•Nurse’s competency

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Selection of Interventions
1. Characteristics of nursing diagnosis
Interventions should address the etiological
factor or sign and symptoms
➢ND -Knowledge deficit related to surgical
recovery
➢NI –provide information R/T recovery procedures

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Nursing interventions
2. Expected outcomes
EO –Pt. will be able to perform urinary catheter
care by discharge
NI –Observe patient perform UCC
3. Research base –high quality care
4. Feasibility-time, money, human resources
5. Acceptability to patient –cultural values
6. Capability of nurse –competent

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Clarifying an Order
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.

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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.

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Systems for Planning Nursing Care
The plan of care can take several forms
➢Standardized care plans
➢Computerized plans
➢Interdisciplinary plans -Contributions from all
disciplines involved in patient care.
➢Concept maps
➢Critical pathways

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Change of Shift
A critical time, when nurses collaborateand share
important information that ensures the continuity of
care for a patient and prevents errors or delays in
providing nursing interventions
Change-of-shift report: Communicates information
from offgoing to oncoming patient care personnel =
“Nurse handoff”
Focus your reports on the nursing care, treatments,
and expected outcomes documented in the care
plans.

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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.
Themain purpose of critical pathways is to
deliver timely care at each phase of the care
process for a specific type of patient.

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Concept Maps
Provide a visually graphic way to show the
relationship between patients’ nursing diagnoses and
interventions
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

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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.

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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.

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