Chapter 8: Planning

Introduction to Planning in the Nursing Process

  • Planning is the third step of the nursing process.

  • Involves the following actions:

    • Prioritization of patient nursing diagnoses

    • Determination of short- and long-term goals

    • Identification of outcome indicators

    • Listing of nursing interventions for patient-centered care.

  • Each action requires careful consideration of assessment data and understanding the relationship among nursing diagnoses, goals, and evidence-based interventions.

LO 8.1: The Planning Process

  • Critical decisions regarding the patient are made during the planning step of the nursing process.

  • Process includes:

    • Prioritizing each hypothesis and nursing diagnosis.

    • Establishing goals in collaboration with the patient.

    • Identifying urgent goals based on patient capabilities.

    • Selecting interventions for the individualized plan of care.

  • Urgent goals are prioritized based on:

    • Severity of symptoms

    • Patient preferences.

  • After addressing emergent needs, less critical needs follow.

  • The nurse’s ability to prioritize is essential for realistic outcome criteria and interventions.

Patient Involvement in the Planning Process

  • Patients should be included in the planning process for the following reasons:

    1. Awareness of identified needs.

    2. Acceptance of realistic and measurable goals.

    3. Embrace interventions for achieving agreed-on goals.

  • Involving patients improves goal attainment and cooperation with interventions.

  • Patient empowerment and control play a significant role in achieving care goals.

LO 8.2: Prioritizing Care

  • Setting priorities is the first step in the planning process.

  • The nurse is responsible for:

    • Monitoring patient responses.

    • Making decisions leading to a plan of care.

    • Implementing interventions, including interdisciplinary collaboration.

  • Nurses are increasingly accountable for patient care outcomes.

  • Contemporary challenges include increasing patient comorbidities and complexity of patient needs.

Ethical, Legal, and Professional Practice Standards

  • Standards of care are met by prudent nursing process performance.

  • The planning step is critical for guiding patient care to acceptable outcomes.

  • Legal requirements include adherence to nursing knowledge and competency.*

  • Oversight by state boards of nursing is mandated for adherence to standards of care.

LO 8.3: Use of Maslow's Hierarchy of Needs

  • Maslow’s hierarchy organizes needs from urgent to less urgent:

    • Physiologic needs must be met before higher needs.

  • Example: Nursing diagnosis of Nausea is prioritized over Impaired Socialization, as resolving nausea may enhance social interactions.

Table 8.1: Maslow's Hierarchy of Needs Applied to Patient Data

  • Level of Needs & Examples of Data:

    • Physiologic: Airway patency, breathing, circulation, oxygen level, nutrition, hydration, body temperature, infection, pain level.

    • Safety and Security: Physical safety (falls, drug side effects), psychological security (knowledge of routines, fear of isolation).

    • Love and Belonging: Compassion from healthcare providers, information from family, support systems.

    • Self-esteem: Changes in body image, changes in self-concept, pride in abilities.

    • Self-actualization: Motivation, autonomy, goal attainment, problem-solving abilities.

Life-Threatening Concerns Versus Routine Care

  • Identify life-threatening concerns quickly.

  • Use ABCs of life support (Airway, Breathing, Circulation) as a guiding tool.

  • In urgent situations, nursing process steps may occur rapidly.

  • Example: In respiratory arrest, the primary goal is restoring breathing.

  • After stabilization, further assessment to identify less urgent goals ensues.

Joint Patient-Nurse Priority Setting

  • Conflicting priorities may arise between nurse and patient beliefs.

  • Example scenarios:

    • Difficulty finding time to exercise due to a work schedule.

    • Cultural dietary practices affecting health changes.

  • Identifying realistic, acceptable goals requires collaboration.

LO 8.4: Goal Development

  • Goals are broad statements that outline the aims of nursing care.

  • They represent short- or long-term objectives determined during planning.

  • Effective goals share characteristics:

    • Mutually acceptable to nurse, patient, family.

    • Appropriate relative to medical/nursing diagnoses.

    • Realistic considering patient capabilities and resources.

    • Specific for clear understanding.

    • Measurable for evaluation.

  • Collaboration involves discussions about current conditions and desired progress.

    Detailed Goal Characteristics

Realistic Goals

  • Consider the patient's mental, physical, and spiritual condition when setting goals.

  • Barriers may arise from conditions like pain, depression, or economic factors.

Patient-Centered Goals

  • Written specifically for the patient, reflecting actual patient activities rather than nursing actions.

Measurable Goals

  • Specific with numeric evaluations to determine success. Example: “The patient’s morning blood pressure will be between 120 and 140 mm Hg systolic.”

Table 8.3: Measurable Verbs for Writing Goals and Outcomes

  • Example verbs include: Administer, Ambulate, Cough, Demonstrate, Walk, etc.

Time-Limited Goals

  • It's critical to include an evaluation time frame in goal statements.

  • The frequency of goal evaluations varies based on intervention, condition, and setting.

  • New goals may be set based on evaluations or continuation of existing ones.

LO 8.6: Outcome Identification and Goal Attainment

  • Outcome identification was added in 1991 as part of the nursing process.

  • Involves listing observable behaviors that signify goal attainment.

  • Nursing outcomes taxonomies include:

    • Nursing Outcomes Classification (NOC).

    • Clinical Care Classification System (CCC).

    • International Classification for Nursing Practice (ICNP).

  • Example of a measurable goal statement:

    • Nursing Diagnosis: Hyperthermia

    • Goal: Patient's temperature to return to 98.2° to 98.6° F within 48 hours. Evaluation through vital signs tracking.

LO 8.7: Care Plan Development

  • Care plans provide individualized patient-centered approaches.

  • Documentation formats vary by health care agency, including electronic formats.

  • Key elements in care plans:

    1. Key assessment data

    2. Nursing diagnoses

    3. Goals

    4. Interventions

    5. Evaluation of outcomes.

  • Conceptual Care Maps (CCM) can help organize information effectively for students.

Types of Interventions

  1. Independent Interventions: Nurse-initiated actions.

  2. Dependent Interventions: Require healthcare provider orders, like administering medications.

  3. Collaborative Interventions: Involve cooperation with other professionals to accomplish patient needs.

Conclusion on Planning Throughout Patient Care

  • Care planning is continuous, starting from patient interactions to when care is no longer required.

  • Preadmission teaching is crucial for patient preparation.

  • Nursing plays a key role during transitions from hospital to home, with a focused approach to discharge planning to avoid readmissions.

Summary of Learning Outcomes

  • LO 8.1: Articulate nursing actions during planning including prioritization and outcome identification.

  • LO 8.2: Identify measures for prioritizing patient care using Maslow's hierarchy and ABCs of life support.

  • LO 8.3: Recognize the importance of goal development and goal characteristics.

  • LO 8.4: Link outcome identification with goal attainment.

  • LO 8.5: Differentiate formats for developing patient-centered care plans.

  • LO 8.6: Explain types of interventions in nursing practice.

  • LO 8.7: Discuss the significance of continuous planning in patient care.