Nursing process(Planning)

Planning Deliberate, systematic, problem-

solving phase of nursing process• Begins with first client contact• Continues until client (discharge)• Is multidisciplinary

Types of Planning

1 -Initial Planning

• Develops initial comprehensive plan of care

• Begun after initial assessment

2 -Ongoing Planning

• Done by all nurses • Individualization of initial care plan • At the beginning of a shift

Determine whether client's health status changed

Set priorities for client's care during shift Decide which problems to focus on Coordinate nurse's activities so that more

than one problem can be addressed at each client contact

3 -Discharge Planning

• Process of anticipating and planning for needs after discharge

• Addressed in each client's care plan• Begins at first client contact• Involves comprehensive and ongoing

assessment

Copyright © 2016, 2012, 2008Pearson Education, Inc.

All Rights ReservedKozier & Erb's Fundamentals of Nursing, Tenth EditionAudrey Berman | Shirlee Snyder | Geralyn Frandsen

Figure 13–1 Planning—the third phase of the nursing process. In this phase the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client's health problems.

Developing Nursing Care Plans

1- Informal nursing care plan A strategy for action that exists in

nurse's mind2- Formal nursing care plan

Written or computerized guide

3- Standardized care plan A formal plan that specifies actions for a

group of clients with common needs4- Individualized care plan

Tailored to meet the unique needs of a specific client

Standardized Approaches to Care Planning

• Standards of care Nursing actions for clients with similar medical

conditions Achievable rather than ideal nursing care Interventions for which nurses are accountable Usually, there are agency records that may be

referred to in client's care plan. Written from the perspective of the nurse's

responsibilities Do not contain medical interventions



Figure 13–4 A standardized care plan for the nursing diagnosis of Deficient Fluid Volume.

• Protocols Indicate actions commonly required for

a particular groups of clients May include both primary care

provider's orders and nursing interventions

Example: Protocol for admitting a client to the intensive care unit

• Policies and proceduresExample: Policy specifying the number of visitors a client may have

• Standing order Written document • Policies• Rules• Regulations• Orders regarding patient care

Gives the nurse authority to carry out specific actions under certain circumstances

Formats for Nursing Care Plans

• Student care plans Rationale• Evidence-based principle given as the

reason for selecting a particular nursing intervention

Concept maps• Visual tool in which ideas or data are

enclosed in circles or boxes with relationships indicated by lines or arrows

• Computerized care plans Create and store nursing care plans Can be accessed at a centrally located

terminal at nurses' station or in clients' rooms

Appropriate diagnoses selected from a menu suggested by the computer

Multidisciplinary (Collaborative) Care Plans

• known as critical pathways• Sequence care that must be given on

each day during projected length of stay for each condition

• Usually organized with a column for each day listing interventions and outcomes for that day

• Includes medical treatments to be performed by other providers

Guidelines for Writing Nursing Care Plans

1. Date and sign the plan2. Use category headings3. Use standardized/approved medical or

English symbols and key words rather than complete sentences to communicate your ideas unless agency policy dictates otherwise

4. Be specific

5. Refer to procedure books or other sources of information

6. Tailor the plan to the unique characteristics of the client by ensuring that the client's choices, such as preferences about the times of care and methods used, are included

7. Ensure that the nursing plan incorporates preventive and health maintenance aspects

8. Ensure that the plan contains ongoing assessment of the client

9. Include collaborative and coordination activities in the plan

10.Include plans for the client's discharge and home care needs

The Planning Process

• Consists of the following activities: Setting priorities Establishing client goals/desired

outcomes Selecting nursing interventions Writing individualized nursing

interventions on care plans

Setting Priorities

1- Establishing priorities sequence for nursing diagnoses and interventions

High priority (life-threatening) Medium priority (health-threatening) Low priority (developmental needs)

2- Factors to consider Client's health values and beliefs Client's priorities Resources available Urgency of the health problem Medical treatment plan

Establishing Client Goals/Desired Outcomes

• Goals Broad statements about the client's

status• Desired outcomes

More specific, observable criteria used to evaluate whether goals have been met



Table 13–2 Deriving Desired Outcomes from Nursing Diagnoses

Purpose of desired goals/outcomes

Provide direction for planning interventions

Serve as criteria for evaluating progress Enable the client and the nurse to

determine when the problem has been resolved

Help motivate the client and nurse by providing a sense of achievement

Short-term and long-term goals

By the end of the week or in over the course of many weeks(long)

Short-term goals useful for clients who:• Require health care for a short time• Are frustrated by long-term goals that

seem difficult to attain• Need the satisfaction of achieving a

short-term goal

Relationship of goals/desired outcomes

• to nursing diagnoses Goals derived from diagnostic label Diagnostic label contains the unhealthy

response (problem) Goal is opposite, healthy response How client will look or behave if health

response is achieved (observable, time-limited)

Achieving goal demonstrates resolution of the problem

Guidelines for writing goals/desired outcomes

Write in terms of client responses Must be realistic Ensure compatibility with therapies of

other professionals Derive from only one nursing diagnosis Use observable, measurable terms Make sure client considers goals

important

Selecting Nursing Interventions and Activities

• Actions nurse performs to achieve goals• Focus on eliminating or reducing

etiology of nursing diagnosis • Treat signs and symptoms and defining

characteristics• Interventions for risk nursing diagnoses

should focus on reducing client's risk factors

Types of nursing interventions

I. Independent interventionsActivities nurses are licensed to initiate (i.e., physical care, ongoing assessment)

II. Dependent interventionsActivities carried out under primary care provider's orders or supervision, or according to specified routines

III. Collaborative interventionsActions nurse carries out in collaboration with other health team members

Criteria for choosing nursing interventions

Safe and appropriate for the client's age, health, and condition

Achievable with the resources available Congruent with the client's values, beliefs,

and culture Congruent with other therapies Based on nursing knowledge and

experience or knowledge from relevant sciences

Within established standards of care

• Date when they are written• Verb

Action verb starts the interventions and must be precise.

• Conditions• Modifiers• Time element

How long or how often the nursing action is to occur

Delegating Implementation

• Delegation occurs during planning. Who is decided to do each task?

• Nurse is responsible for correct implementation of task delegated, analysis of data, and evaluation of outcome



Concept Map Ineffective Airway Clearance (Gas Exchange)