Chapter 5

Nursing Process

Planning Outcomes

Formal Planning

Informal Planning

Initial Planning

* Begins with first pt. contact.

* Written as soon as possible after the intial assessment.

*Develop a preliminary plan with whatever infromation you have.

All nursing process steps are over lapping and interdependent.

develop a plan of care with realsitic goals and effective nursing orders. You must have accurate, complete assessment data and corretly idnetified and prioritized nursing diagnosis.

The goals then suggest nursing inteventions.

*Which are written as nursing orders in the planning interventions phase.

* Plan of care is carried out in the implementation pahse.

* The evaluation step of the goals.desired outcomes serve as criteria for evaluating whether the nursing care has been effective.

Discharge Planning

Discharge Planning begins at assessment

* Physical condition and functional and self-care limitation.

*Emotional stability and ability to learn.

* Financial resources.

*Family or other caregiver available.

*Environment, both home and and community.

Ongoing Planning

Written Discharge Plans

Discharge Planning Requires Collaboration

Comprehensive Nursing Care Plan

(also called patient care plans)

*A document; the control source of information needed to guide holistic goal-oriented care to address each pt's unique needs.

*Specifies dependent,interdependent, and independent nursing fucntions necessary for care of a specific pt. and usually uses both standardized and individual appraoches to care.

Why is a written Nursing Care Plan Important?

• Ensuring that care is complete.
• Providing continuity of care.
• Promoting efficient use of nursing efforts.
• Providing a guide for assessment and charting.
• Meeting the requirement of accrediting agency.
  

Comprehensive Care Plan continues

4 different

Kinds of Care

• Basic needs and ADL's.
• Medical diagnosis and collaborative. problems.
• Special Discharge needs/teaching needs.
  

Preprinted Standardized

Plans

• A comprehensive care paln usually includes one or more preprinted, standardized documents.
• Standardized plans save nurisng time, promotes cosnsitency of care and help ensure that nurses do not overlook improtant interventions.
  

Protocols

(Specific therapeutic action usually required for a clinical problem unique to a subgroup of pts's)

Unit Standards of Care

The care that nurses are expected to provide for all pt's in defined situations.

Describe the minimum level of care the nurses are expected to acheive given the instuition resources and the cleint population.

Standardized Nursing Care Plans

(Model)

Critical Pathways

• Used in managed care systems.
• Are outcome-based,interdisciplinary plans that seq. pt. care according to case types.
• Specify predicted patient outcomes and broad intervention for each day, or in some situations, for each hour.
  

Special Discharge Teaching Plans

Process for Writing Individual Nursing Care Plan

• Make a working problem list.
• Decide which problem can me managed with standardized care plans/critical pathways.
• Individualized the standardized plan as needed.
• Transcribe medical orders o apporiate documents.
• Write ADL's and basic care needs in special sections of the kardex care plan or computer.
• Develop individual care plans for problems not addressed by stand documents.

Process for Writing Individualized Nursing Care Plan

2nd part(cont'd)

Planning Cleint Goals/Outcomes

Goals (expected outcomes,desired out comes, or predicted outcomes). Describe the chges in pt. helath status you hope to acheive.

Nursing Sensitive Outcomes: Those that can be influenced by nursing interventions

Log Term Goals

To be acheived over a longer period of time (week, month, more)

Short Term Goals

To be acheived within a few hours or days.

eg. Free of pain within hours painfree from the rest of hospital stay,

What are the Components of A Goal Statement

• Subject: Always the Patient.
• action: What you want patient to do.
• Performance criteria: How, waht, where criteria.
• Target time: Performance behaviour should be acheived.
• Special Conditions:
  

Essential

vs.

Non-Essential Goals

• Essential/patient goals- Flow from the problem side of the nursing disgnsosi because the problem side describes the unhealthy response that you intend to change.
• Non-essential goal derive from the etiology.

The Rule

For every nursing diagnosis, you must state one goal that, if acheived, would demosntrate resolution or improvement of the problems

Goals for Actual, Risk, and Possible Nursing Diagnosis

How do Goals Relate To Nursing Diagnosis

• Exptected outcomes are dreived directly form the nursing diagnosis.
• The problem statmeent of a nursing diagnosis describes the response or health status that you wish to change.
• A desired outcome states the opposite if the problme and implies that this repsosne is what the interventions are intended to acheive.
  

Goal for

Collborative

Problems

• Primary intervention are medical and, if there is obstruction, probably surgical.
• All goals on a nursing care plan should be nursing-sensitive goals.
• Collbaorative goals are appropriate on multidisciplinary care plans and critical pathways.
  

How do I use standardized

Terminolgy for Outcomes

How do I write Goals for Wellness Diagnosis

Outcomes for Special Teaching Plans

Teaching objectives

Describe what the patient is to learn and the observable behaviours that will demonstrate learning, and they should state whether learning is to be cognitive, psychomtor, or affective.

Reflecting Critically about Expected outcomes/Goals

For each nursing diagnosis:

1. Is there at least one goal that, when met, would demonstrate problem resolution; that is does at least one goal flow from the problem cause.
2. Are the predicted outcomes adequate to completely address the nursing disgnsosis.
   

Reflecting Critically about Expected outcomes/Goals

(cont'd)

For each expected outcome:

1. Is the outcome appropriate for the nursing disgnosis.
2. Is each outcome derived from only one nursing diagnosis.
3. Does each outcome describe only one pt. response or behaviour.

Reflecting Critically about Expected outcomes/Goals

(cont'd)

For each expected outcome:

1. Is the outcome stated as a patient behaviour, not a nurse activity.
2. Is the outcome stated in positive terms?
3. Is the outcome measurable or observable?
   

Reflecting Critically about Expected outcomes/Goals

(cont'd)

For each expected outcomes:

1. Are the performance criteria specific abd concrete.
2. Does each goal include all the necessary parts?
3. Is the expected outcome realsitic and acheivable by this patient: given the avaialble resources
   

Reflecting Critically about Expected outcomes/Goals

(cont'd)

For each expected outcomes:

1. Does the outcome conflict with the medical or other collaborative treatment plan?
2. Does the pt. family, or community value the outcome?

Reflecting Critically about Expected outcomes/Goals

(cont'd)

For each expected outcomes:

1. Does the patient family, or community value the outcome.
2. Does the goal conflict with any religious/cultural values?