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:
Awareness of identified needs.
Acceptance of realistic and measurable goals.
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:
Key assessment data
Nursing diagnoses
Goals
Interventions
Evaluation of outcomes.
Conceptual Care Maps (CCM) can help organize information effectively for students.
Types of Interventions
Independent Interventions: Nurse-initiated actions.
Dependent Interventions: Require healthcare provider orders, like administering medications.
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.