PLANNING

• At the end of 1 month, patient will demonstrate stable weight with no sign of weakness and with increase appetite.

• At the end of 20-30min., patient body temperature will lower to 37 °C.

Impaired skin integrity:

At the end of 24 hours, patient demonstrates techniques to promote healing and displays timely wound healing.

Ineffective airway clearance:

At the end of 15-20 minutes, patient will be able to, expectorate secretions without assistance and improve airway clearance.

Acute Pain:

At the end of 20 mins., patients will report relief of pain and discomfort, display relaxed manner and able to sleep well.

Activity intolerance:

At the end of the day, patient will be able to participate in necessary/desired activities and reports increase in activity tolerance.

PLANNING

• Prioritize Problem/Diagnosis

• Formulate goals/desired outcomes

• Select nursing interventions

• Write nursing orders

PLANNING

• Is a deliberative, systematic phase of the nursing process that involves decision making and problem solving.

• In this phase, the nurse refers to the client's assessment data and diagnostic statements for :

  • direction in formulating client goals

  • designing the nursing interventions required to:

    • prevent

    • reduce or

    • eliminate the client health problems

NURSING INTERVENTIONS

• Is any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes.

  
  

  The product of the planning phase is Client Care Plan.

TYPES OF PLANNING

1. Initial Planning

   • The nurse who performs the admission assessment usually develops the initial comprehensive plan of care.

   • Should be initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital days.

2. Ongoing Planning

   • Is done by all nurses who work with the client.

   • Occurs at the beginning of the shift as the nurse plans the care to be given that day.

   
   

   • The nurse carries out the daily planning for the following purposes:

     • To determine whether the client's health status has changed.

     • To set priorities for the client's care during the shift.

     • To decide which problems to focus on during the shift.

     • To coordinate the nurse's activities so that more than one problem can be addressed at each client contact.

3. Discharge Planning

   • The process of anticipating and planning for needs after discharge

   • Is a crucial part of comprehensive health care and should be addressed in each client's care plan.

   • Effective discharge planning begins at the first contact of the patient to obtain information about the client's ongoing needs

DEVELOPING DISCHARGE PLAN

Informal Nursing Care Plan

• is a strategy for action that exist in the nurse's mind

Formal Nursing Care Plan

• is a written or computerized guide that organizes information about the client's care.

• It provides continuity of care

Standardize Care Plan

• is a formal plan that specifies the nursing care for groups of clients with common needs.(e.g. All clients with myocardial infarction)

Individualized Care Plan

• is tailored to meet the unique needs of the specific client.

FORMAT OF NURSING CARE PLAN

Guidelines for writing Nursing Care Plan

1. Date and sign the plan

2. Use category headings

3. Use standardized or approved medical or English symbols and key words rather than complete sentences to communicate your ideas.

   Ex. "Turn and reposition q2h" rather than

   "Turn and reposition the client every two hours."

4. Be specific.

5. Refer to procedure books or other sources of information rather than including all the steps on a written plan

6. Tailor the plan to the unique characteristics of the client by

   ensuring that the client's choices are included.

7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones.

8. Ensure that the plan contains interventions for ongoing assessment of

9. Include collaborative and coordination activities in the plan.

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

THE PLANNING PROCESS

1. Setting priorities

   • Is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions,

   • The nurse and the client should decide which nursing diagnosis requires attention first, which is second, and so forth..

   
   

   • Nurse can group then as:

     • Life-threatening problems

       (Loss of respiratory and cardiac functions)

     • Health-threatening problems

       (acute illness and decrease coping ability)

     • Low priority problems

       (arise from normal developmental needs)

2. Establishing client goals/Desired outcomes

   • The nurse and client set goals for each nursing diagnosis.

   • What the nurse hopes to achieve by implementing the nursing interventions.

     • GOAL (BROAD): Improved nutritional status

     • DESIRED OUTCOME (SPECIFIC): Gain 5 Ibs by April 25

4 components of goal/desired outcome statement

• Subject - client/patient

• Verb - action the client perform

• 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

• Criterion of desired performance

EXAMPLES OF ACTION VERBS

COMPONENTS OF GOALS/DESIRED OUTCOMES

2. Establishing client goal/Desired outcomes

   • Purposes of desired outcomes/goals

     • Provide direction for planning nursing interventions.

     • Serves as criteria for evaluating client progress

     • Enable the client and nurse to determine when the problem has been resolved

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

Characteristics of Outcome Criteria:

S - Specific

M - Measurable

A - Attainable

R - Realistic

T - Time-Framed

2. Establishing client goal/Desired outcomes

   Long-term and short-term goals

   • A short-term goal might be:

     • "Client will raise right arm to shoulder height by tomorrow" •

     • are useful for clients who require health core for a short period of time.

   • A long-term goal might be:

     • "Client will regain full use of arm in 6 weeks"

     • often used for clients who lived at home and have chronic health problems and in nursing homes.

       
       

3. Selecting nursing interventions and activities

   • Nursing interventions and activities - are actions that a nurse performs to achieve clients goals.

   • Specific interventions should focus on eliminating or reducing the etiology of the nursing diagnosis.

Types of nursing interventions

INDEPENDENT INTERVENTIONS - are those activities that nurses are licensed to initiate on the basis on their knowledge and skills.

They include:

• Physical core

• Ongoing assessment

• Emotional support and comfort

• Teaching Counseling

• Environmental management

• Making referrals

DEPENDENT INTERVENTIONS - are those activities carried out under the physician's orders or supervision, according to specified routines.

Physician's orders commonly include:

• Medications

• Intravenous therapy

• Diagnostic tests

• Treatments

• Diet

• Activity

COLLABORATIVE INTERVENTIONS - are those actions the nurse carries out in collaboration with other health team members, such as physical therapist, social workers, dietitians, and physicians.

4. Writing nursing orders

   • Components of the nursing orders

     • Date

     • Action verb

     • Content area

     • Time element

     • Signature