Mrs Nidhina Paul Lecturer YNC Planning Planning is

Mrs. Nidhina Paul Lecturer YNC

Planning • Planning is to formulate the way to manage the problem. • The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.

Types of planning • Initial planning • Ongoing planning • Discharge planning

Initial Planning • Done by the nurse who perform admission assessment in order to prioritize problems, identify goals and correlate nursing care to resolve the problems.

Ongoing planning • Involves continuous updating of the client’s plan of care. Every nurse who cares for the client is involved in ongoing planning.

Purposes: 1. To determine whether the client’s health status has changed 2. To set priorities for the client’s care during the shift 3. To decide which problems to focus on during the shift 4. To coordinate the nurse’s activities so that more than one problem can be addressed at each client contact

Discharge planning • Involves anticipation and planning for the client’s needs after discharge.

Process • Setting priorities • Formulate goals/desired outcomes ØShort Term goal (to resolve in few hours or days) ØLong Term goal (to resolve over weeks or months) • Prioritizing the problems/nursing diagnosis • Select nursing interventions • Write nursing interventions

1. Setting priorities A process of establishing a preferential sequence for addressing nursing diagnosis and intervention. *High Priority- life- threatening *Medium Priority- delayed development or causes physical and emotional changes *Low Priority-arises from normal developmental needs or that requires minimal nursing support • Ex. Loss of cardiac function, Loss of respiratory function, Acute illness, Decreased coping ability • Often use HIERARCHY OF NEEDS of Abraham Maslow

Principles of setting priorities: Priority ratings will be influenced by the following • Clients own perception of priorities • Overall treatment plan(if a person goes for physio therapy- to eat earlier than usual) • Overall health status of the client(newly diagnosed diabetic pt- knowledge deficit is given high priority where as the same is given low priority for critically ill)

• Presence of the potential pbm. Eg, Assisting the patient to mobilize during the imm postop day takes priority over patient’s desire to mobilize on his own. • Nursing students should choose a method of assigning priority rating and use it consistently to become systematic and comprehensive. ( according to gordan’s / maslow’s) • Problems that are contributing factors to other problems should be treated first. ( Joint pain – reduced mobility, resolve the problem of pain first to improve mobility)

2)Establishing client goals/expected outcomes. A goal is broad statements about the effects of nursing interventions, desired outcome, or change in a client behavior. Expected outcomes/objective/outcome criterion/predicted outcome is more specific, measurable criteria used to evaluate whether the goal has been met.

Components of Expected Outcome Statement a. Subject is a client, or any part of the client, or some attribute of the client. For example: client's pulse or urinary output. b. Verb denotes an action the client is to perform, e. g. what the client is to do, learn, or experience. It denotes directly observable behaviors, e. g. administer, demonstrate, show, walk and so on.

Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. Example: - Walks with the help of a walker (how). - After attending two group diabetes classes, lists signs and symptoms of D. M (when) - When (at home), maintains weight at existing level (where). - Discusses four food groups and recommended daily servings

Criterion of desired performance: standards by which a performance is evaluated or the level at which the client will performed the specified behavior. Criteria may specify time or speed, accuracy, distance, and quality, examples: Weighs 65 Kg by April (time). Lists five out of six signs of diabetes mellitus (accuracy). Walks one block per day (time and distance). Administers insulin using a septic technique (quality).

Characteristics Of Well Stated Goals/ Expected Outcomes A well stated expected outcome is: • Derived primarily from the first clause of the nursing diagnosis. • Possible to achieve. • Stated in terms of client responses rather than nursing activities. • Statement of one specific client behavior. • Specific and concrete. • Appraisable or measurable. • Valued by the client and family.

• Goals are patient-centered and S Specific M Measurable A Attainable R Relevant T Time Bound

Examples of Goal Setting with Expected Outcomes for Mr. Jacobs NURSING DIAGNOSES GOALS EXPECTED OUTCOMES Acute pain related to incisional trauma Mr. Jacobs achieves pain • Mr. Jacobs reports pain relief by at a level 3 or below by day of discharge. • Mr. Jacobs moves and turns freely in bed within 24 hours. • Mr. Jacobs shows less grimacing during movement in 24 hours.

NURSING DIAGNOSES GOALS EXPECTED OUTCOMES Anxiety related to uncertainty over course of recovery Mr. Jacobs expresses • Mr. Jacobs acceptance of discusses surgical health status by day outcomes with of discharge. surgeon in 24 hours. • Mr. Jacobs shares concerns with wife before discharge. • Mr. Jacobs describes effects surgery will have on recovery.

Interventions to identify when planning for comprehensive patient care • Performing nsg assessment to determine the status of existing problem or to identify a new problem. • Performing client education or teaching for the client to gain knowledge. • Counselling the client to make decisions

• Consulting / referring to other health care professional to obtain appropriate directions. • Performing specific interventions to reduce / resolve problem • Assisting client to perform activities by themselves. • Nurses role: assessing, teaching, counseling, consulting when providing patient care.

Selecting nursing strategies. (intervention) • Nursing interventions are defined as any direct care treatment that a nurse performs on behalf of a client. These treatments include nurse-initiated treatments resulting from nursing diagnosis, physician treatments resulting from medical diagnosis and performance of the daily essential functions for the client who cannot do these. • Interventions should be: • -Consistent with the established plan of care. • -Are implemented in safe and appropriate manner • -Are documented

Types Of Nursing Strategies • Independent Interventions • Dependent Interventions • Collaborative Interventions

• Independent Interventions: are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals.

• Dependent Interventions: are those activities carried out under the physician‘s order or supervision, or according to specific routines.

• Collaborative Interventions: are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians

Writing Nursing Orders • After choosing the appropriate nursing interventions, the nurse writes them on the care plan as nursing orders. • Nursing orders are instructions for the specific activities the nurse performs to help the client meet established health care goals

• A complete well-written nursing order is composed of five components: - • Date: Nursing orders are dated when they are written and reviewed regularly at intervals that depend on the individual‘s needs. • Specific action verb, such as instruct, place, supervise, and observe. Sometimes a modifier, such as actively, softly, firmly helps clarify the verb.

• Content area: The content is the where and what of the order. • Time element: The time element answers when, how long, or how often the nursing action is to occur. • Signature: the signature of the nurse prescribing the order show‘s the nurses accountability and has legal significance.

Developing nursing care plans. The nursing care plan is a written guide that organized information about clients care into a meaningful whole. Purposes of a Written Care Plan To provide direction for individualizes care of the client. To provide for continuity of care.

To provide direction about what needs to be documented on the client's progress notes. To serve as a guide for assigning staff to care for the client. To serve as a guide for reimbursement from medical insurance companies.

Format of Nursing Care Plan Although formats differ from agency to agency, the plan is organized into four columns or categories: 1) nursing diagnosis, 2) goals and outcome, 3) nursing orders, and 4) evaluation.

Guidelines for Writing Nursing Care Plans • Date and sign the plan. • Use the category headings ―Nursing Diagnosis, ‖ ―Goals/ outcome criteria, ‖ ―Nursing orders‖and―Evaluation‖ and include a date for the evaluation of each goal. • Refer to procedure books or other sources of information rather than including all the steps on a written plan.

• Tailor the plan to the unique characteristics of the client by ensuring that the client‘s choices, such as preferences about the time of care and the methods used, are included. This reinforces the client‘s individuality and sense of control. • Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative. • Ensure that the plan contains orders for ongoing assessment of the client.

• Include collaborative and coordination activities in the plan. • Include plans for the client‘s discharge and home care needs.

Types of Nursing Care Plans • Student Nursing Care Plans • Each school of nursing has a care plan format adopted by or developed by the faculty for student use. Because student plans are used as learning tools, they are usually more comprehensive and detailed than the care plans utilized by graduate staff nurses.

• Individually Developed Nursing Care Plans Individual care plans are intended to focus on the specific needs of the person and are to be updated as the person’s condition changes. • Advantages: The advantages of individually developed nursing care plans include their specificity to a particular person. They contain only the pertinent nursing diagnoses, outcomes and interventions.

• Disadvantages: The primary disadvantage of this is the time-consuming aspect of the development process. • Also, as is true with other formats for care plans, the individually developed nursing care plan may not accurately reflect the person‘s current problems if it has not been updated.

Standardized Nursing Care Plans: • Printed care plans, known as standardized care plans, are developed commercially or by an individual health care facility. • They direct nursing care for people with specific medical diagnoses (e. g. myocardial infarction) with certain nursing diagnoses such as pain or anxiety, or who are undergoing special procedures such as cardiac catheterization. • These care plans are typed, preprinted, duplicated, and made available to the appropriate units in the health care facility.

• The format is designed to leave space for the nurse to individualize the care plan by filling in specific related factors associated with nursing diagnosis, adding deadlines to the outcomes, and clarifying the interventions with additional details. • For example, the interventions could be individualized by adding frequencies, amounts, times, and the client‘s preferences.

• Advantages: • Reduced amount of writing needed to record routine nursing interventions and help to the staff by highlighting necessary interventions • These are usually developed by a group of nurses who use their collective expertise and experience to produce a well researched tool. • Particularly helpful to nurses who may be asked to work in an unfamiliar area.

• Disadvantages: • Nurses may use these care plans without individualizing them for a particular person. • Many of the nursing diagnoses, outcomes, and interventions may not be applicable. • These may tend to be long

Teaching plans • Teaching plans are a specialized form of nursing care plans. • Individually developed teaching plans may be hand written or computer generated for individuals with complex teaching needs.

Case management care plans • Case management is a method of delivering care that has evolved from the emphasis on decreasing the length of stay in hospitals and the focus on achieving timely client outcomes.

Computerized Nursing Care Plans • Many software vendors have developed computerized nursing care plans and critical paths. Computerized plans of care generated from assessment data entered into a computer about a specific client. The plan is written by experts in the area and the content is similar to that of standardized plan of care. Once the plan is on the computer screen, the nurse has opportunity to customize it for the client

Criteria for choosing nursing intervention • Safe and appropriate for the individuals age, health, and condition. • Achievable with the resources available. • Congruent with the clients values, beliefs and culture. • Congruent with otherapies.

• Be realistic when choosing interventions- consider limitations/preferences of the client, developmental age of the client, within the capability of the nurse, congruent with otherapies, provide under safe therapeutic environment, utilize appropriate resources. • Know the rationale for actions(utilize scientific rationale). • Create opportunity for teaching and learning whenever possible(eg, teach reason for intervention) • Consult other professionals (eg, dietician) when indicated

• Based on nursing knowledge and experience or knowledge from relevant sciences. i, e based on rationale. • Within established standards of care as determined by state laws, professional associations, and the policies of institutions