Planning Nursing Care
Planning Nursing Practiced is a cornerstone of professional practice, ensuring patients receive individualized, goal-oriented, and evidence-based care. This process involves prioritizing care, setting achievable goals, and collaborating with interdisciplinary teams to address patient needs holistically. To develop a successful nursing care plan, critical thinking is vital in identifying priorities, establishing goals, and determining expected outcomes.
- Establishing Priorities.
- Critical Thinking in Setting Goals and Expected Outcomes.
- Critical Thinking in Planning Nursing Care.
- Systems for Planning Nursing Care.
- Consulting with Other Health Care Professionals.
By the end of this section, you should know about:
Let’s take a closer look at them.
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Establishing Priorities in Planning Nursing Care
Initial Nursing Assessment and Diagnosis
Tonya made a comprehensive assessment of Mr. Lawson’s condition and identified three significant nursing diagnoses to meet his immediate and ongoing needs The first diagnosis was Chronic Pain, which was caused by depression which came during his circumcision surgery. The second is the readiness for increased knowledge, which reflects the need for education and the readiness to give up. Lastly, Tonya noted the risk of infection due to the presence of a surgical wound, requiring vigilance and appropriate preventive measures.
Planning Nursing Care
Based on the nursing diagnosis, Tonya developed a comprehensive care plan to guide Mr. Lawson’s treatment while he was hospitalized. His main objective was to ensure a smooth transition for Mr Lawson as he prepared to return home. To this end, Tonya worked closely with Mr. Lawson and his wife, incorporating their ideas into the care plan. She also consulted with other health care providers, including home health care, to ensure comprehensive care.
Tonya applied evidence-based practice principles by formulating the PICOT question: Does the use of visual aids affect a patient’s ability to learn the principles of infection prevention during treatment? compare the standard repair manuals? This approach allowed her to design interventions that met Mr Lawson’s specific needs, while addressing the relationship between his health concerns and addressing the most important issues of the former.
Collaborative Care and Prioritization
Nurses collaborate with other healthcare professionals to set patient-centered goals and determine interventions based on diagnosis. In Mr. Lawson’s case, Tonya used nursing assessment to guide her practice, ensuring that her intervention was consistent with the overall treatment plan established by the health care team.
Establishing Priorities in Planning Nursing Care
Prioritization is important for more diagnosed and needed patients. Tonya prioritized Mr. Lawson’s care by dealing with the most urgent matters first. Initially, Acute Pain was paramount because effective pain management is essential to learning and preparing for discharge. Once Mr. Lawson’s pain was managed, Tonya focused on Readiness for Enhanced Knowledge to prepare him to return home. Although the risk of infection was high, it was considered to be of intermediate importance.
Nurses classify priorities into three categories
High Priority: Life-threatening or immediate concerns, such as airway management, circulation, or severe pain.
Intermediate Priority: Non-life-threatening but still urgent concerns, such as infection prevention.
Low Priority: Long-term issues, such as anxiety about future work.
Changing Priorities in Planning Nursing Care
As Mr. Lawson’s condition improved, Tonya adjusted her focus accordingly. Initially, pain relief took precedence. Once his pain decreased, the focus shifted to discharge education and infection prevention. This dynamic approach ensured that his evolving needs were met effectively.
Tonya planned specific interventions to address Mr. Lawson’s priorities. For Acute Pain, she administered analgesics, repositioned him for comfort, and taught relaxation techniques. The sequence of these interventions was flexible and adjusted based on his immediate needs. For example, if Mr. Lawson experienced severe pain, administering analgesics would take priority over other interventions.
Patient involvement in prioritizing care was essential to align the care plan with Mr. Lawson’s preferences and concerns. However, Tonya balanced his input with professional judgment to ensure safe and effective care.
Factors Affecting Prioritization
Several factors influenced Tonya’s prioritization decisions, including the healthcare environment, clinical changes in Mr. Lawson’s condition, and his specific needs. Staffing, workflows, and resource availability played a role in shaping the care plan. Additionally, Tonya remained adaptable, reassessing his condition frequently to provide timely and appropriate care.
Effective care for Mr. Lawson required strong collaboration within the healthcare team. Tonya worked closely with nursing assistive personnel (NAP) to communicate the care plan and ensure that priorities were aligned at the start of each shift. This teamwork ensured that all aspects of Mr. Lawson’s care were addressed efficiently and effectively.
Goal: A broad statement that describes what the nurse aims to achieve in the care of a patient. Goals are typically long-term, general statements that provide direction for care. They are often patient-centered and aim at improving health outcomes.
Planning: The step in the nursing process where the nurse sets priorities, establishes patient goals, and determines the interventions needed to achieve those goals. Planning involves organizing care to ensure it is systematic, effective, and focused on the patient’s needs.
Patient-Centered Goal: A goal that is specifically tailored to the patient’s individual needs, preferences, and values. This type of goal focuses on what is important to the patient and aligns with their personal health priorities.
Critical Thinking in Setting Goals and Expected Outcomes
As nursing students or professionals who plan care, they must use critical thinking to set clear, realistic and measurable goals. Goals are broad statements describing desired improvements in patient health, while expected outcomes are specific, measurable and time-bound indicators of progress toward those goals.
For example, in a patient like Mr. Lawson whose diagnosis is Risk for Infection, the goal should be to ensure that the patient remains “infection free.” Commonly anticipated outcomes may include persistence of fever, lack of wound drainage, and observed healing of the wound drains within a certain time frame.
Setting goals against each other is important to ensure patient-centered care. Goals should be developed jointly by the nurse, patient, and, if appropriate, their family. This approach promotes patient involvement and control over the care process. To participate effectively, patients must be alert, motivated, and autonomous enough to contribute to care-related decisions.
Patient role in goal setting
For example, Tonya works to establish a shared goal with Mr. Lawson and his wife to increase Mr. Lawson’s understanding of postoperative risks. Together they agree to watch an educational DVD on infection control, and Tonya gives clear instructions on activity limitations after surgery.
Selecting Goals and Expected Outcomes
Nurses use the SMART framework to select goals that reflect the patient’s highest potential level of wellness. These goals consider the patient’s individual needs, abilities, and available resources. SMART goals are:
Specific: Focused on a singular behavior or outcome, such as “Patient will ambulate independently in 3 days.”
Measurable: The goal must include criteria for evaluation, like “Patient ambulates in the hall 3 times a day by 4/22.”
Attainable: Goals must be achievable given the patient’s condition and available resources.
Realistic: Goals must align with the patient’s current abilities and limitations. For instance, a stroke patient may realistically aim to “wash hands and face independently within 72 hours.”
Timed: A time frame ensures coordinated efforts and tracks progress effectively.
Outcome Classification (NOC)
The Nursing Outcomes Classification (NOC) links nursing diagnoses to specific, measurable outcomes, allowing nurses to evaluate their interventions more precisely. For Mr. Lawson’s Acute Pain, the NOC outcome might be “pain control” or “pain relief,” with measurable outcomes such as a reduced pain rating or improved mobility levels.
Writing Goals and Expected Outcomes in Planning Nursing Care
Writing effective goals and outcomes is vital for guiding nursing care and evaluating progress. Goals provide direction, while expected outcomes define measurable benchmarks. For example, with a diagnosis of Risk for Infection, achieving the goal of being infection-free might involve meeting outcomes such as wound healing, remaining afebrile, and no signs of drainage.
Interventions
Interventions are the actionable steps nurses take to achieve the goals and outcomes. These actions must be evidence-based, patient-specific, and focused on resolving the identified issues.
For example, Tonya provides Mr. Lawson with educational interventions, including an infection control DVD, and consults the surgeon to ensure accurate, relevant information. By tailoring her interventions to Mr. Lawson’s specific needs and involving his family, Tonya ensures that the care plan is both effective and achievable.
Dependent Nursing Interventions: Nursing actions that require a healthcare provider’s order or a prescription before they can be implemented. For example, administering medication or performing a procedure that requires a physician’s authorization.
Expected Outcome: The anticipated or predicted result of nursing interventions, based on specific, measurable criteria. It is the outcome that nurses aim to achieve through their planned interventions, often related to a patient’s health improvement or recovery.
Nursing Outcomes Classification (NOC): A standardized system for measuring and classifying patient outcomes that are sensitive to nursing interventions. It includes a range of outcomes related to patient health status, satisfaction, and well-being, helping nurses assess the effectiveness of care.
Critical Thinking in Planning Nursing Care
Nurse interventions are intentional actions taken by nurses to achieve patient goals and improve health outcomes. These interventions are of three main types. Nurse-initiated interventions are independent actions that nurses can take without mandate from other health professionals. Examples include teaching patients, assisting with activities of daily living, positioning or pain management with techniques such as breathing exercises. Health care provider initiating intervention requires physician or other provider orders, such as medication administration, wound care, or procedures such as catheterization Collaborative approaches involve teamwork and communication with other professionals do it, such as consulting with a physical therapist or working with a discharge coordinator to ensure the flow of care on.
Choosing the Right Interventions
Selecting appropriate interventions requires careful consideration of a variety of factors. Patient-preferred outcomes are paramount, and interventions are designed to directly contribute to specific, measurable goals. The symptoms in the nursing diagnosis guide intervention, addressing the factors contributing to the patient’s condition or managing the symptoms if the cause cannot be changed Evaluation and evidence play an important role, ensure that practices are effective and appropriate for the patient’s needs. Feasibility is another key factor, which incorporates practical considerations such as resource availability, deadlines, and comprehensive care planning. The patient must also be accepting of the interventions, respecting their cultural, emotional, and personal preferences, and ensuring agreement with the care plan. Finally, the qualifications of the nurse are important because interventions must be designed with the necessary skills and clinical knowledge.
Nursing Interventions Classification (NIC)
The nursing practice classification (NIC) chart organizes nursing practice into broad areas, specific units, and standard practices. This standardized framework encourages improvement and clear communication in care planning, enables nurses to select interventions based on specific patient needs, link interventions to relevant nursing assessments, and provide practices a based-on analysis they can be adapted implement NIC system has three levels: domains, which are physical security concerns etc. The highest levels and; categories, which are specific categories within each area, such as pain relief under the promotion of physical pleasure; and interventions, which consist of a wide range of behaviors tailored to the patient’s circumstances.
Planning Interventions in Planning Nursing Care
The planning process for nursing interventions is guided by evidence-based practices, clinical judgment, and patient-centered care principles. Interdisciplinary collaboration is often essential to ensure interventions align with the patient’s goals, values, and available resources. By combining research and teamwork, nurses can provide interventions that meet individual patient needs effectively and holistically.
Nursing Interventions Classification (NIC): A comprehensive system that categorizes and defines nursing interventions. It includes actions nurses can take to improve patient outcomes and is used to guide practice and measure nursing care interventions across various settings.
Systems for Planning Nursing Care
A nursing care plan is an important tool in healthcare, designed to guide patient care in a systematic, comprehensive, and personalized manner. It is a dynamic document that adapts to changes in the patient’s condition, allowing nurses to monitor progress and adjust interventions to meet evolving need’s role.
Assessment
The first step in planning nursing care is gathering detailed information about the patient’s health. This includes the patient’s medical history including past and present conditions and surgeries, and current medical diagnoses such as symptoms, physical examination results, laboratory findings with emotional, psychological and social impact a it is on health and includes psychosocial factors Under consideration. For example, Mr. Lawson, 62, worries about the patient’s own recovery and return to work after surgery.
Nursing Diagnosis
From the assessment, the nurse identifies actual or potential health issues using standardized nursing terminologies like NANDA, NOC, or NIC. This step ensures clarity and consistency in care planning. For instance, Mr. Lawson’s nursing diagnosis is Anxiety, related to uncertainty about resuming work after surgery.
Goals and Expected Outcomes (Planning)
Based on the nursing diagnosis, nurses establish specific, measurable goals that describe desired patient outcomes by discharge. Goals reflect improvements in the patient’s condition resulting from planned interventions. For Mr. Lawson, a goal is that he will demonstrate understanding of activity restrictions and accept the necessity of full recovery before returning to work.
Interventions
Interventions are evidence-based actions taken by nurses to achieve the expected outcomes. They focus on minimizing risks and promoting health. For Mr. Lawson, interventions might include:
Anxiety reduction through calm and reassuring communication.
Collaboration with healthcare providers to address wound healing and activity restrictions.
Emotional support by encouraging his wife’s involvement in his care.
Evaluation in Planning Nursing Care
Evaluation is a critical step where nurses assess the effectiveness of interventions and the patient’s progress toward goals. If outcomes are unmet, adjustments are made to the care plan. In Mr. Lawson’s case, demonstrating reduced anxiety and an improved understanding of recovery needs indicates the success of the nursing interventions.
Hand-Off Reporting
The nursing care plan also serves as a guide for hand-off reporting during transitions of care, such as shift changes. This ensures essential information about the patient’s progress and care requirements is communicated effectively, preventing lapses in care continuity.
Student Care Plans
For nursing students, care plans act as educational tools to develop problem-solving, communication, and organizational skills. These plans often include more detailed formats to help students apply theoretical knowledge in clinical settings, fostering a deeper understanding of care planning.
Community-Based Care Plans
In community settings, care plans extend to family and environmental assessments. Nurses work with patients and their families to manage care independently, focusing on education, skill-building, and resource coordination to ensure ongoing support after discharge.
Concept Maps
Concept maps are visual tools that organize and relate nursing diagnoses, illustrating how different issues are interlinked. They provide clarity in understanding complex cases and help plan interventions that address multiple aspects of a patient’s health effectively. The nursing care plan is essential for ensuring patient-centered care, fostering collaboration, and adapting to dynamic healthcare needs, ultimately contributing to improved patient outcomes and continuity of care.
Nursing Care Plan: A written or electronic plan that outlines the patient’s health problems, goals, nursing interventions, and expected outcomes. It is a tool for guiding nursing practice and ensures that care is organized, comprehensive, and personalized.
Consulting with Other Health Care Professionals
Effective collaboration with other health professionals is an important part of nursing practice in the planning and implementation phase of patient care This collaborative process allows nurses to seek expert input to improve and manage patient outcomes challenges beyond their expertise. Nurses are often faced with situations where their own knowledge, skills, or resources are insufficient, the consultation process. This process can involve a variety of health professionals such as nurse educators, clinical specialists, physicians, physical therapists, nutritionists, social workers, and others.
The SBAR Approach
The SBAR (situation, background, assessment, recommendation) approach is a structured approach often used by nurses in consultation, especially when the situation is urgent or critical. SBAR helps nurses communicate important information clearly, concisely, to ensure effective decision making. The first part, the “situation,” focuses on describing what is happening at the time. A “background” follows, providing context or pertinent medical history that can help understand the condition. In the “assessment” phase, the nurse shares her assessment of the problem, and the “recommendation” phase includes recommendations for next actions or requests for specific advice.
Collaboration is important in situations when the patient’s condition is unclear or uncertain, when the nurse is faced with a complex procedure that has not been addressed before, requiring the use of specialized equipment or resources Interprofessional cooperation is also important as more healthcare professionals are needed to meet the full range of patient needs. Nurses should seek consultation when they need clarification on a patient’s condition, or when their current approach is not yielding the desired results. This process helps expand the nurse’s knowledge, provides additional skills, and contributes to finding solutions to complex care issues.
Tips for Making Phone Consultations
When making phone consultations with other healthcare providers, it is important for nurses to be well-prepared. They should ensure they have all the relevant patient information, such as medical records and medication details, before making the call. Nurses should also conduct a personal assessment of the patient to provide firsthand information that will guide the consultant. Additionally, the nurse should be mindful of including the patient’s perspective, addressing not only the clinical aspects but also the social and cultural context of the situation. It is crucial to be clear about the issue, providing a concise diagnosis or explanation of the patient’s condition along with a summary of the actions taken so far. Nurses should avoid introducing personal bias and focus on presenting the problem factually. Lastly, they should remain open to the consultant’s recommendations and keep the focus on resolving the issue.
How to Consult
The consultation process itself involves several key steps. The nurse begins by assessing the problem and identifying the general issue at hand. Once the problem is understood, the nurse should direct the consultation to the appropriate healthcare professional, such as a physician, physical therapist, or social worker, depending on the issue. The nurse must then provide all relevant information to the consultant, including medical history, interventions already attempted, and the outcomes of those interventions. It is important to avoid influencing the consultant’s perspective by presenting the facts clearly without leading the consultant toward a specific solution. After the consultation, the nurse should ensure follow-up, discussing the consultant’s findings and recommendations to integrate them into the care plan. After implementing the consultant’s advice, the nurse should continue to monitor the results and provide feedback to the consultant, which enhances the collaboration process and improves future care planning.
Application of Consultation in Teamwork
In cases like Mr. Lawson’s anxiety regarding returning to work, consultation with healthcare professionals such as a social worker, psychologist, or occupational therapist can be essential for addressing complex issues. Teamwork plays a crucial role in such situations, as different perspectives contribute to more effective solutions and interventions. Nurses must collaborate with the entire healthcare team to develop a comprehensive care plan that addresses not only the patient’s physical health but also their psychological and social needs. This holistic approach ensures that all aspects of the patient’s well-being are considered and attended to during their recovery process.
Collaborative Interventions: These are actions that require the input or assistance of other healthcare professionals (such as doctors, physical therapists, or social workers) in the management of a patient’s care. Collaborative interventions are those in which nurses work together with other team members to achieve the patient’s health goals.
Consultation: A process where a nurse seeks advice or expertise from other healthcare professionals to help solve a patient care problem. It typically involves sharing information and brainstorming solutions to a clinical issue.