Nursing Process and Care Planning

Nursing Process and Care Planning: Key Concepts from Lecture

Nursing Process Overview

• Steps: Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation

• Clinical Judgment Model: generating solutions, taking action, evaluating

• Scope of practice: nurses use orders; nurse-initiated interventions are allowed within scope; physician-initiated vs collaborative interventions involve different authorships

• Emphasis on patient- and family-centered care; involve patient and family in planning and decisions

Etiology and Nursing Diagnoses

• Distinguish between medical diagnoses and nursing diagnoses; etiology is what causes the nursing problem, not the medical diagnosis itself

• Always relate etiologies to nursing diagnosis first; avoid selecting a medical diagnosis as the etiology

• Example case discussion: postoperative respiratory risk can be influenced by pain and limited movement, which affect deep breathing and mobility

• Illustrative statement: postoperative pain can be an etiology for impaired breathing/mobility, increasing risk for pneumonia if not addressed

• Dysphagia case study (Ms. X): etiology described as decreased chewing muscle strength and facial paralysis secondary to CVA (stroke)

• Signs/symptoms that support dysphagia: coughing with liquids, pocketing of food, reports of choking

• Possible nursing diagnosis choices in the case: impaired mobility, self-care deficit, or risk for impaired skin integrity; etiology should support the chosen problem without naming a medical diagnosis

• Etiology framing for case: describe nonmedical factors leading to the nursing problem (e.g., malnutrition, caregiver support, mobility issues) and link back to the problem while avoiding a medical diagnosis label

Data Types in Assessment: Subjective vs Objective

• Subjective data: what the patient says (e.g., dizziness, pain description, perception of symptoms)

• Objective data: observable/measurable findings (e.g., heart rate, breath sounds, mobility status)

• Examples from discussion: heart rate and breath sounds are objective; patient reports of respiratory problems are subjective

• A cue to a nursing diagnosis: data that align with a problem (e.g., shortness of breath on walking a few steps may cue an respiratory/functional problem)

Goals, Outcomes, and Prioritization

• Singular/focused goals: goals should target one outcome at a time

  • Example of singular-focused goal: "Patient will cough" (as opposed to combining multiple targets like diet adherence and weight loss)

• Other example outcomes discussed: mix of multiple targets (not singular) should be avoided when a single outcome is more precise

• Outcomes should be SMART: Specific, Measurable, Attainable, Realistic, Time-based

  • SMART = ext{Specific}, ext{Measurable}, ext{Attainable}, ext{Realistic}, ext{Time-based}

• Time frames for outcomes:

  • Short-term outcomes: typically <
    1 week

  • Long-term outcomes: commonly > 1 week (e.g., months) for chronic conditions

• Types of outcomes by domain:

  • Psychomotor (action-oriented): patient demonstrates a skill

  • Cognitive: patient understands and can verbalize knowledge (teach-back)

  • Affective: coping, attitudes, and feelings

  • Physiological: measurable physiological parameters (e.g., oxygen saturation, weight)

• Example outcome structure (case study):

  • Short-term: patient will ambulate 30 feet with no shortness of breath by end of shift

  • Physiological: O2 saturation maintained > 92% during present shift

  • Functional: patient will perform activities of daily living with supervision or independently as appropriate

• Documentation note: each outcome should derive from a specific problem and be evaluable with a time frame

Case Study: Dysphagia (Ms. X)

• Problem: impaired swallowing due to CVA (stroke) with associated dysphagia

• Etiology: decreased muscle strength for chewing and facial paralysis secondary to CVA

• Objective data supporting the case: left facial droop, left leg flaccidity, left hand weakness

• Potential nursing diagnoses to consider: impaired mobility, self-care deficit, or risk for impaired skin integrity

• Proposed outcome: "Ms. X will swallow liquids freely by Sunday" with evidence: no aspiration, no coughing, no pocketing of food for liquids at meals

• Interventions to address dysphagia (examples):

  • Ensure liquids are thickened as ordered; reduce risk of aspiration

  • Sit patient upright (90 degrees) while eating

  • Avoid straws; use appropriate cup to slow flow

  • Use small bites and appropriate pacing; consider chin-tuck swallow technique as ordered by speech therapy

  • Coordinate with speech-language pathology for swallow studies and proper diet/testing

• Note: ensure rationales support interventions (e.g., thickened liquids reduce aspiration risk; upright seating improves airway protection)

Planning Stage: Purpose and Process

• Goals of planning stage:

  • Establish core priorities and order of problems

  • Identify expected outcomes that are specific and measurable

  • Select evidence-based nursing interventions

  • Communicate the care plan with patient, family, and the healthcare team (providers, PT/OT, SLP, etc.)

• How planning works in practice:

  • Electronic health record (EHR) auto-populates interventions; tailor to patient

  • Individualize care plans to patient-specific needs and circumstances

• Foundation concepts to support planning:

  • Maslow's hierarchy of needs (physiological needs first)

  • Priority frameworks: ABCs (Airway, Breathing, Circulation); urgent vs nonurgent; invasive vs noninvasive

  • Scope of practice: what nurses can do independently vs what requires orders or collaboration

• Delegation and collaboration:

  • Determine what can be delegated and what requires provider orders

  • Collaboration with physical therapy, occupational therapy, speech therapy, and others to address mobility, self-care, and safety needs

• Communication and documentation:

  • Use SBAR (Situation, Background, Assessment, Recommendation) for handoffs

  • Document plan and patient progress; ensure plan is visible to all care team

• Medication safety and MAR:

  • Five rights: ext{Patient}, ext{Dose}, ext{Route}, ext{Time}, ext{Documentation}

  • Compare MAR to provider orders first; bedside verification before administration

  • Do not pour pills out of packaging until in the room; verify patient identity and right medication

• Inpatient pharmacology concerns:

  • IV meds require careful consideration of drug interactions and potential need for separate IV lines

  • Always check contraindications and potential interactions before administration

• Real-world planning considerations:

  • Always involve patient and family preferences; respect privacy and comfort levels

  • Prepare for discharge planning early (e.g., heart failure patients require teaching on daily weights, sodium restriction, medications)

  • Consider community resources and case management for post-discharge support

• Practical example: discharge planning for heart failure

  • Daily weights to monitor fluid status

  • Education on medications and low-sodium diet

  • Arranging follow-up appointments and home support; explore readmission risk and strategies to prevent readmission

• Standardized care plans and protocols:

  • Some conditions have standardized care plans (e.g., total joint replacements; heparin protocols with PTT-based titration; sliding-scale insulin)

  • Standardized plans must be adapted to the individual patient

• Care planning resources:

  • LivingCare Advisor resources for problem-based care plans with goals and interventions

  • UpToDate handouts and drug information through library access

  • The book itself as a resource for rationales and interventions

Medication Safety and Administration Details

• Five rights of medication administration: ext{Patient}, ext{Dose}, ext{Route}, ext{Time}, ext{Documentation}

• MAR checks:

  • Always compare MAR to the doctor's order first, then verify with the patient and the medication at the bedside

• In-room administration:

  • Do not remove medication from packaging until you are in the patient’s room

• IV medications and interactions:

  • Be aware of potential drug interactions and separate IV lines if necessary

• Documentation and accountability:

  • If it’s not documented, it wasn’t done

• Example incident:

  • Infiltration risk requiring assessment, warm compresses, elevation, and provider notification if the IV site is compromised

Interventions: What Nurses Do

• Types of interventions:

  • Direct care: actions performed directly for the patient (e.g., turning, suctioning, performing ROM)

  • Indirect care: actions performed to support the patient by interacting with the care team (e.g., participating in planning meetings, advocating for patient resources)

• Physician-initiated vs collaborative interventions:

  • Physician-initiated: orders written by the provider; nurses execute these orders

  • Collaborative: interventions requiring multiple disciplines (PT/OT/SLP) to support mobility and safety

• Protocols, standing orders, and care bundles:

  • Stroke protocol: coordinated diagnostic and treatment steps within a time window

  • Heparin protocol: anticoagulation management with PTT-based titration

  • Sliding-scale insulin: insulin dosing based on blood glucose levels per order

• Considerations when selecting interventions:

  • Address the actual nursing diagnosis/problem first; actual problems take priority over risk diagnoses

  • Consider the probability of adverse outcomes and weigh risks vs benefits

  • Ensure feasibility and patient capability; assess for barriers such as pain, transportation, finances, or health literacy

• Documentation in implementation:

  • Document what you actually did, not just that you did something

  • Use real-time documentation when possible, but if not feasible, keep contemporaneous notes

• Patient safety during interventions:

  • Ensure proper equipment and patient environment

  • Check for contraindications and potential interactions (especially with medications and IVs)

  • Prepare for unexpected outcomes and have contingency plans

Implementation and Communication Tools

• SBAR: Situation, Background, Assessment, Recommendation

• Shift handoffs and group planning meetings to ensure continuity of care

• Use of whiteboards and room boards to communicate plan and patient goals to staff and family

Evaluation of Care: How to Know if Outcomes Are Met

• Ongoing evaluation is essential; compare current data to expected outcomes

• Types of outcomes to evaluate:

  • Psychomotor: motor/skill performance

  • Cognitive: knowledge retention and understanding (teach-back)

  • Affective: emotional and coping responses

  • Physiological: vital signs, labs, functional status

• Decision rules after evaluation:

  • If outcomes are met: terminate the plan and discharge or move to a new problem

  • If partially met: revise the plan, adjust interventions or time frame

  • If not met: modify the plan and possibly extend time frame

• Common evaluation pitfalls:

  • Inaccurate or outdated data leading to poor problem identification

  • Vague diagnoses or goals not aligned with the problem

  • Inadequate or incomplete documentation

• Case example for Ms. X (dysphagia):

  • Outcome: swallow liquids freely by Sunday; evidenced by no aspiration and no coughing; if coughing persists or pocketing occurs, revise goal or extend time frame

Documentation, Communication, and Resources

• Documentation is critical for legal and clinical accountability; everything done must be documented

• Resources for care planning and evidence-based interventions:

  • Care plan templates and resources in LivingCare Advisor

  • UpToDate drug handouts and patient education sheets via library access

  • Course book as a reference for rationales and intervention ideas

• Self-care project expectations:

  • Include problem, etiology, objective and subjective data, expected outcomes, and three nursing interventions with rationales

  • Determine whether outcomes were met, partially met, or not met; indicate continuation, modification, or termination of interventions

• Practice exam and remediation (ATI):

  • Practice exams A and B; focused review for missed questions; remediation; then take a quiz

  • Benchmarks toward NCLEX-style questions; benchmarks vary by level in the handbook

  • Emphasis on applying knowledge to scenarios, not memorizing definitions

Ethical, Philosophical, and Practical Implications

• Ethical considerations:

  • Respect patient autonomy and involve family when appropriate

  • Consider cultural differences and ensure care plans are congruent with the patient’s culture and values

• Practical implications:

  • Early discharge planning improves outcomes and reduces readmissions; 30-day readmission penalties affect hospital reimbursement

  • Daily weights for heart failure patients help detect fluid overload early

  • Collaboration with social work and case management to address transportation, finances, and access to care

• Real-world challenges:

  • Pressure from staffing and time constraints can affect quality of care; must still document care and adhere to standards

  • The risk of nonadherence due to education gaps, affordability, or access; address root causes and advocate for patient needs

Quick Reference: Formulas, Thresholds, and Key Lists

• Five rights of medication administration:

  • \text{Patient},\; \text{Dose},\; \text{Route},\; \text{Time},\; \text{Documentation}

• Oxygen saturation goal examples:

  • \text{O}_2 \text{ sat} > 92\% (example threshold mentioned)

• SMART goals:

  • SMART = {Specific,\; Measurable,\; Attainable,\; Realistic,\; Time-based}

• Short-term vs long-term outcomes:

  • Short-term: typically less than or equal to 1 week

  • Long-term: commonly greater than 1 week (e.g., months for chronic conditions)

• Example discharge considerations for heart failure:

  • Daily weights, low-sodium diet, medications, home monitoring, and arranging follow-up care

Final Takeaways

• Always connect the nursing diagnosis to nonmedical etiologies and patient-centered goals

• Prioritize actual conditions over risks; plan using SMART, singular-focused outcomes

• Use a structured planning process that includes patient/family input, evidence-based interventions, and clear communication

• Evaluate iteratively, documenting outcomes as met, partially met, or not met, and adjust the plan accordingly

• Leverage available resources (care plan templates, UpToDate, ATI practice/remediation) to support evidence-based practice

Ch17…Nursing Process: Planning/Goal Setting

Explain the relationship of planning to assessment and nursing diagnosis.

• The planning stage follows assessment and nursing diagnosis, where core priorities and the order of problems are established based on the identified nursing diagnoses.

• Accurate assessment data (subjective and objective) informs the development of nursing diagnoses, which in turn guides the formulation of specific patient goals and interventions during planning.

• Etiologies, which describe the cause of the nursing problem (not the medical diagnosis), are directly related to the nursing diagnosis and form the basis for targeted planning.

Discuss the criteria used in priority setting.

• Maslow's hierarchy of needs: Physiological needs (e.g., airway, breathing, circulation) typically take precedence.

• Priority frameworks: Use ABCs (Airway, Breathing, Circulation) as a foundational guide; consider urgent versus nonurgent issues; weigh invasive versus noninvasive approaches.

• Scope of practice: Prioritize interventions that nurses can perform independently versus those requiring orders or collaboration.

• Actual vs. Risk Diagnoses: Actual problems generally take priority over risk diagnoses.

Describe goal/ expected outcome setting. Utilize SMART goals and Outcomes

• Goals and Outcomes: Statements that describe the desired changes in patient condition or behavior.

• Singular/focused goals: Each goal should target one outcome at a time (e.g., "Patient will cough" rather than combining multiple targets).

• Outcomes should be SMART (Specific, Measurable, Attainable, Realistic, Time-based): SMART = \text{Specific}, \text{Measurable}, \text{Attainable}, \text{Realistic}, \text{Time-based}

• Time frames for outcomes:

  • Short-term outcomes: Typically less than or equal to 1 week.

  • Long-term outcomes: Commonly greater than 1 week (e.g., months) for chronic conditions.

• Types of outcomes by domain:

  • Psychomotor (action-oriented): Patient demonstrates a skill.

  • Cognitive: Patient understands and can verbalize knowledge (e.g., teach-back).

  • Affective: Involve coping, attitudes, and feelings.

  • Physiological: Measurable physiological parameters (e.g., oxygen saturation, weight).

Discuss the differences between nurse-initiated, physician-initiated, and collaborative interventions.

• Nurse-initiated interventions: Actions performed by nurses within their scope of practice without physician orders (e.g., turning a patient, providing comfort measures, patient education on self-care).

• Physician-initiated interventions: Orders written by the healthcare provider; nurses execute these orders (e.g., medication administration, specific treatments, diagnostic tests).

• Collaborative interventions: Interventions requiring multiple disciplines (e.g., physical therapy, occupational therapy, speech-language pathology) to support patient needs such as mobility, self-care, or safety.

Describe the role that communication plays in planning patient-centered care.

• Communication is essential to ensure patient and family involvement in planning and decisions, maintaining patient- and family-centered care.

• It facilitates the sharing of the care plan with the entire healthcare team (providers, PT/OT, SLP, etc.) to ensure coordinated care.

• SBAR (Situation, Background, Assessment, Recommendation) is used for shift handoffs to ensure continuity of care and effective communication of the plan.

• Whiteboards and room boards are used to communicate plans and patient goals to staff and family.

Discuss the process of selecting nursing interventions.

• Identify evidence-based interventions: Select actions supported by research or best practices.

• Address the actual nursing diagnosis/problem first: Prioritize interventions for actual problems over risk diagnoses.

• Consider probability of adverse outcomes: Weigh risks vs. benefits of each intervention.

• Ensure feasibility and patient capability: Assess for barriers such as pain, transportation, finances, or health literacy.

• Individualize care plans: Tailor interventions to patient-specific needs and circumstances, even when using electronic health record (EHR) auto-populated interventions.

Describe the purposes of a written nursing care plan.

• Establish core priorities and the order of patient problems.

• Identify specific and measurable expected outcomes for the patient.

• Select evidence-based nursing interventions to address the problems.

• Communicate the care plan effectively with the patient, family, and the entire interdisciplinary healthcare team, ensuring continuity and coordination of care.

• Serve as a legal and clinical record of patient care, outlining what was planned and executed.

Ch18…Nursing Process: Implementing

Explain the relationship of implementation to the nursing diagnostic process.

• Implementation is the action phase where the nursing interventions, determined during the planning stage based on identified nursing diagnoses, are carried out.

• It directly translates the goals and outcomes derived from the nursing diagnoses into concrete patient care activities, effectively addressing the identified problems.

Describe the association between critical thinking and selecting nursing interventions.

• Critical thinking is crucial for selecting appropriate interventions by continuously assessing patient needs, weighing the risks and benefits of potential actions, and evaluating the feasibility of interventions based on patient capabilities and resources.

• Nurses must think critically to adapt standardized interventions to individual patient situations, ensuring the most effective and safe care.

Identify preparatory activities to use before implementation.

• Compare MAR to provider orders first: Verify medication details against the physician's orders.

• Bedside verification: Verify patient identity and the right medication at the bedside before administration.

• In-room administration: Do not remove medication from packaging until in the patient’s room.

• Ensure proper equipment and patient environment: Gather all necessary supplies and ensure the environment is safe and conducive to the intervention.

• Check for contraindications and potential interactions: Especially important for medications and IVs.

• Prepare for unexpected outcomes: Have contingency plans in place.

Discuss steps used to revise a plan of care before performing implementation.

• Before full implementation of a care plan, especially standardized ones, it's crucial to individualize it to the patient's specific needs and circumstances.

• This involves reviewing the planned interventions in light of the patient's current condition, preferences, and any new assessment data, making modifications as necessary to ensure the plan remains relevant and effective.

Describe and compare direct and indirect nursing interventions.

• Direct care: Actions performed directly for the patient (e.g., turning a patient, suctioning, performing range of motion exercises, administering medication, performing wound care).

• Indirect care: Actions performed to support the patient by interacting with the care team or managing the environment (e.g., participating in planning meetings, advocating for patient resources, documenting care, collaborating with other disciplines, ensuring equipment availability).

Select appropriate interventions for an assigned patient.

• When selecting interventions, first address actual nursing diagnoses/problems, which take priority over risk diagnoses.

• Consider the probability of adverse outcomes and weigh risks versus benefits.

• Assess feasibility and patient capability, looking for barriers such as pain, transportation, finances, or health literacy that might hinder successful implementation.

• For a patient with dysphagia (Ms. X), appropriate interventions include: ensuring liquids are thickened, sitting the patient upright (90 degrees) while eating, avoiding straws, using small bites and appropriate pacing, and coordinating with speech-language pathology for swallow studies and specific diet/testing.

Explain why reassessment after a nursing intervention is important.

• Reassessment after a nursing intervention is vital for ongoing evaluation, allowing the nurse to compare current patient data to expected outcomes and immediately identify if the intervention has had the desired effect, no effect, or an adverse effect.

• This continuous reassessment informs whether the intervention should be continued, modified, or discontinued, ensuring patient safety and the effectiveness of care.

Ch19…Nursing Process: Evaluating

Discuss the relationship between nursing process and evaluation.

• Evaluation is the final, continuous step of the nursing process, wherein the effectiveness of the entire plan of care, from assessment to implementation, is critically reviewed.

• It closes the loop of the nursing process, determining if patient goals and outcomes established during planning were achieved, thereby informing whether the plan should be terminated, revised, or modified.

Identify the five elements of the evaluation process.

While not explicitly listed as