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PLANNING
prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting interventions and writing nursing interventions
Multidisciplinary planning
involves all healthcare providers interacting with the client and includes the client and family to the fullest extent possible in every step
Student care plan
are used as a learning activities and are longer and more detailed than those used by working nurses
INITIAL PLANNING
is usually performed by the nurse who completes the admission assessment. This type of planning results in the initial comprehensive care of plan
ONGOING PLANNING
Is done by all nurses who work with the client
Individualization of the initial plan occurs as new information is obtained and the client’s response to care is evaluated
Also occurs at the beginning of a shift as nurses plan care to be given for the shift
DISCHARGE PLANNING
Is the process of anticipating and planning for needs after discharge
Effective discharge planning begins at the first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs
Informal nursing care plan
Inferring and hypothesis
Formal nursing care plan
written or computerized care plan
Standardized Care Plan
are preprinted guides for nursing care of a client who has a need that arise frequently in the agency
written from the perspective of what care the client can expect
Protocols
preprinted and indicate the actions commonly required for a particular group of patients
include both physician’s order and nursing intervention
Policies and Procedures
developed yo govern the handling of frequently occurring situations
policy
covers a situation pertinent to client care
Individualized Care plan
customize to fit the unique needs of each client
Rationale
Evidence based principle given as the reason for selecting a particular nursing intervention
Concept maps
visual tools for information
Computerized care plan
appropriate diagnosis selected from menu suggested computer
Guideline when writing nursing care plan
Date and sign the plan
Use category headings
Use standardized/approved medical or English symbols and key words
Be specific
Refer to procedure book or other sources
Tailor the plan to the unique characteristics of the client
ensure that the nursing care plan incorporates preventive and health maintenance aspects
Ensure that the plan contains interventions for ongoing assessment
Include collaborative and coordination activities in the plan
Include plans for the client’s discharge and home care needs
PRIORITY SETTING
Is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions
LIFE THREATENING PROBLEMS
High priority
Such as loss of respiratory or cardiac function
HEALTH THREATENING PROBLEMS
medium priority
Such as acute illness and decreased coping abilities, are considered medium priority
Developmental need
Low priority
Problem that arises from ___________ needs or only requires minimal nursing support
FACTORS THAT MUST BE CONSIDERED WHEN PRIORITY SETTING
The client’s values and beliefs
The client’s priorities
Resources available to the nurse and client
Urgency of the health problem
Medical treatment plan
NURSING OUTCOMES CLASSIFICATION ( NOC)
Standardized or common nursing language is required in all phases if nursing data are to be included in computerized databases that are analyzed and used in nursing practice
It is a taxonomy for describing client outcomes that respond to nursing interventions
Each NOC is assigned a four digit identifier, NOC outcome is similar to goal in traditional language
GOAL/DESIRED OUTCOMES
describe in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing intervention
Provide directions for planning nursing interventions
Serve as a criteria for evaluating client progress
Usually has the following components; subject (the client), verb (specifies action that the client is expected to perform), condition or modifier and criterion of describe performance
GUIDELINES FOR WRITING GOALS/DESIRED OUTCOMES
Write goals/outcomes in terms of client responses, not nurse activities
Be sure that goals/desired outcomes are realistic
Ensure that goals/ outcomes are compatible with the therapies of other professionals
Make sure that each goal/desired outcome is derived from only one nursing diagnosis
Use observable, measurable terms for goal/desired outcomes
Make sure the client considers the goals/desired outcomes important and values them
NURSING INTERVENTIONS
Actions a nurse performs to achieve client goals/desired outcomes
They should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the second clause of the diagnostic statement
Intervention for risk diagnoses should focus on measures to reduce the client’s risk factors which are also found in the second clause
Criteria to follow in nursing intervention
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
Based on nursing knowledge and experience or knowledge from relevant sciences
INDEPENDENT INTERVENTIONS
those activities that nurses are licensed to initiate on the basis of their knowledge and skills
DEPENDENT INTERVENTIONS
Activities carried out under the primary care provider’s orders or supervision or according to specified routines
COLLABORATIVE INTERVENTIONS
Actions that nurse carries out in collaboration with other health team members.
Nurse must choose interventions that are most likely to achieve the goal/desired outcome
The nurse must consider the risks and benefits of each intervention which requires nursing knowledge and experience