NUR304 – Adult Health – Exam 2 Study Guide – Nursing Process: Planning Outcomes – Flashcards

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*Initial planning* begins with the first patient contact. It refers to the development of the initial comprehensive care plan, which should be written as soon as possible after the initial assessment. The nurse who performs the admission assessment has the benefit of personal contact (rather than relying completely on the written database), has the best information about the patient, and, ideally, is the one who should initiate the care plan. You may sometimes need to begin care planning even though the initial database is incomplete. For example, the patient may require emergency care before assessment is complete. Or another patient may need your immediate attention. In such situations, develop a preliminary plan with whatever information you have. You can complete and refine the plan when you are able to perform a more detailed assessment. *Ongoing planning* refers to changes made in the plan as you evaluate the patient's responses to care or as you obtain new data and make new nursing diagnoses. *Discharge planning* is the process of planning for self-care and continuity of care after the patient leaves a healthcare setting. Many patients are discharged despite ongoing need for nursing care and complex treatments. If appropriate services are not provided or if family members perform care incorrectly, the patient may experience delayed recovery or complications that require further treatment or hospital readmission. This means that nurses must prepare family members to perform tasks such as bathing, changing sterile dressings, and monitoring intravenously administered medications. If family members are not available or if skilled nursing care is needed, arrangements must be made for home healthcare or transfer to a skilled nursing or rehabilitation facility. Sometimes a case manager is assigned, but often staff nurses must plan and coordinate services.

Nurses use *individualized nursing care plans* to address nursing diagnoses unique to a particular client. These care plans refl ect the independent component of nursing practice, and therefore best demonstrate the nurse's critical thinking and clinical expertise. In addition to including goals and nursing orders that you write specifially for a patient, a complete individualized care plan may contain standardized single-problem care plans. *Standardized plans* focus on the common problems and interventions needed by most patients. They do not address unusual problems and may not meet a patient's individual needs. You should always adapt standardized plans by adding the necessary nursing diagnoses, goals/outcomes, and nursing orders not included in the standardized documents. *Expected outcomes* are derived directly from the nursing diagnosis. Therefore, they will be appropriate only if you identify the nursing diagnosis correctly. The problem clause (the clause at the left) of a nursing diagnosis describes the response or health status you wish to change. A desired outcome states the opposite of the problem and implies this response is what the interventions are intended to achieve. The NOC is a standardized vocabulary of more than 385 nursing-sensitive outcomes developed by a research team at the University of Iowa. In the NOC vocabulary, an *outcome* is "an individual, family, or community state, behavior, or perception that is measured along a continuum in response to nursing interventions" (Moorhead et al., 2008, p. 35). Thus, the NOC is versatile because it is appropriate for use in all specialty and practice areas. Each NOC outcome consists of an *outcome label, indicators,* and a *measurement scale.* The *outcome label* (usually referred to as "the outcome") is broadly stated (e.g., Decision Making, Mobility Level, Concentration). It is a neutral label (a variable), to allow for positive, negative, or no change in patient health status. The *indicators* are the observable behaviors and states you can use to evaluate patient status. For each outcome, NOC has a *5-point measurement scale* for describing patient status for each indicator.

*Short-term goals* are those you expect the patient to achieve within a few hours or days. They are important: ■ In situations in which the patient may be discharged before you can evaluate progress toward long-term goals (e.g., as in a day surgery). ■ SITUATIONS FOR USE ~ Acute care ~ Day surgery ~ Clinics ~ Focus on immediate needs ~ Students ■ For providing positive reinforcement to clients who are working toward long-term goals. ■ EXAMPLES ~ Describes pain as < 3 on a 1-10 scale within 30 min after receiving analgesic. ~ Limits food intake to 1,500 calories per day. *Long-term goals* are changes in health status that you wish to achieve over a longer period—perhaps a week, a month, or more. They describe the optimum level of functioning you expect the patient to achieve, given health status and available resources. Ideally, this is a return to normal functioning, but that is not always possible. ■ SITUATIONS FOR USE ~ Home healthcare ~ Extended-care facilities ~ Rehabilitation centers ~ Chronic illness ~ Conditions that are managed, not cured ■ EXAMPLES ~ Infant will double birth weight within 5 months. ~ Within 3 months after physical therapy treatments, will dress self except for buttons.

After assessment and diagnosis, the next step in individualized care planning is to formulate goals for improving or maintaining the patient's health status. *Goals* (also called expected outcomes, desired outcomes, or predicted outcomes) describe the changes in patient health status that you hope to achieve. *Nursing-sensitive outcomes* are those that can be influenced by nursing interventions. *Goals* are important for planning, implementation, and evaluation. Precise, descriptive, clearly stated goals / expected outcomes: ■ Provide a guide for selecting nursing interventions by describing what you wish to achieve. ■ Motivate the client and the nurse by providing a sense of achievement when the goals are met. This is especially important when the client must make difficult lifestyle changes. ■ Form the criteria you will use in the evaluation phase of the nursing process.

Each of the ANA standards includes a set of measurement criteria, called *competencies*, to help describe the standard. Criteria are measurable or observable characteristics, properties, attributes, or qualities. They describe the specific skills, knowledge, behaviors, and attitudes that are desired or expected. The patient goals and outcomes 5 are examples of criteria. As you learned there, these *criteria* should be concrete and specific enough to serve as guides for collecting evaluation data. In addition, they should be *reliable* and *valid*. A criterion is *reliable* if it yields consistent results; that is, the same results every time, regardless of who uses it. A criterion is *valid* if it is really measuring what it was intended to measure. For example, fever is often used as a criterion for concluding that a person has an infection. However, if used alone, it is not a valid indicator because (1) other conditions, such as dehydration, can cause a fever and (2) elevated temperature is not present in all infections. However, validity of that criterion is increased when you use additional criteria (e.g., elevated white blood cell count, presence of signs of infection such as redness and pus).

The professional nurse is responsible for care planning, and cannot delegate it. However, you should be aware that some healthcare facilities list care planning in their job description for licensed practical or vocational nurses. Certainly LPNs can provide valuable input for RNs who are planning the care. Box 5-1 lists American Nurses Association (ANA) and Canadian Nurses Association (CNA) standards that specifi cally identify planning as the role of the registered nurse. Planning can be *formal* or *informal.* *Formal planning* "is a conscious, deliberate activity involving decision making, critical thinking, and creativity" (Wilkinson, 2007, p. 262). During the planning phases of the nursing process, you will work with the patient and family to derive desired outcomes from identified patient problems (e.g., nursing diagnoses) and then to identify nursing interventions to help achieve those outcomes. The end product of formal planning is a holistic plan of care that addresses the patient's unique problems and strengths. Not all plans are written. Nurses do *informal planning* while performing other nursing process steps. For example, while performing neurovascular checks for Ben Ivanos, you might discover that he is not obtaining adequate pain relief. Reflect on this situation. What would you do? Any response in that scenario would require some mental planning. For example, you might make a mental note (plan) to notify the physician and obtain a prescription for an increase in the analgesic dose.

You will probably need a comprehensive, formal discharge plan if the patient is an older adult (NSW Department of Health, 2007; Walker, Hogstel, & Curry, 2007) or has one or more of the following: ■ Difficulty learning or a memory deficit ■ A terminal illness ■ A complicated major surgery ■ No family or signifi cant others to help provide care ■ A complex treatment regimen or multiple medications to continue at home ■ Self-care defi cits (e.g., dressing, feeding, bathing, toileting) ■ Incontinence ■ An illness with an expected long period of recovery ■ Inadequate financial resources ■ A newly diagnosed or multiple chronic health problems (e.g., diabetes, chronic pain) ■ Emotional or mental illness ■ Inadequate services available in the community ■ Poor mobility ■ Preexisting wound ■ Malnutrition The percentage of older adults in hospitals is quite high, and they tend to have complex needs when discharged. Therefore, when an older adult is hospitalized, it is especially important to start discharge planning at the initial admission assessment. This means that assessment of functional abilities, cognition, vision, hearing, social support, and psychological well-being must be a part of the initial assessment so that you can identify needed services at discharge. A comprehensive discharge process for older adults should help to achieve the following objectives: ■ Maintain functional ability. ■ Lengthen the time between rehospitalizations. ■ Involve all concerned parties in decision-making. ■ Improve interagency communication (e.g., hospital to nursing home). ■ Emphasize client and family involvement and interdisciplinary collaboration (Walker, Hogstel, & Curry, 2007).

A well-written comprehensive care plan benefits the patient and the healthcare institution by: 1. Ensuring that Care is Complete. 2. Providing Continuity of Care. 3. Promoting Efficient Use of Nursing Efforts. 4. Providing a Guide for Assessments and Charting. 5. Meeting the Requirements of Accrediting Agencies.

The comprehensive nursing care plan (also called patient care pl

Regardless of their format, comprehensive care plans include directions for four different kinds of care and include both medical and nursing interventions: 1. Basic needs and activities of daily living (ADLs). Whatever the patient's diagnoses, nurses need to know what routine assistance the patient needs with hygiene, nutrition, elimination, and so on. 2. Medical/multidisciplinary treatment. Nurses need to know the medical orders for each patient (e.g., prescriptions for intravenous fl uids and medications) and the nursing activities necessary for carrying out those orders. 3. Nursing diagnoses and collaborative problems. This section may be referred to as the nursing diagnosis care plan. It contains goals and nursing orders for the patient's nursing diagnoses and collaborative problems. 4. Special discharge needs or teaching needs. Finally, the plan should contain instructions for formal discharge planning and special teaching if they are needed. For example, the client may need to be taught how to self-administer injections or follow a prescribed diet.

Writing an individualized nursing care plan follows in natural sequence from the assessment and diagnosis phases of the nursing process: 1. Make a Working Problem List. 2. Decide which problems can be managed with standardized care plans or critical pathways. 3. Individualize the standardized plan as needed. 4. Transcribe medical orders to appropriate documents. 5. Write ADLs and basic care needs in special sections of the Kardex, care plan, or computer. 6. Develop individualized care plans for problems not addressed by standardized documents.

After writing the expected outcomes for a client, use the full-spectrum nursing model to help you evaluate their quality. For each nursing diagnosis: 1. Is there at least one goal that, when met, would demonstrate problem resolution? 2. Do the predicted outcomes completely address the nursing diagnosis? For each expected outcome: 3. Is the outcome appropriate for the nursing diagnosis? 4. Is each outcome derived from only one nursing diagnosis? 5. Does each outcome describe only one patient response or behavior? 6. Is the outcome stated as a patient behavior, not a nurse activity? 7. Is the outcome stated in positive terms? 8. Is the outcome measurable or observable? 9. Are the performance criteria specific and concrete? 10. Does each goal include all the necessary parts? 11. Is the expected outcome realistic and achievable by this patient, given the available resources? 12. Does the outcome confl ict with the medical or other collaborative treatment plan? 13. Does the patient, family, or community value the outcome? 14. Does the goal conflict with any religious or cultural values?

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