Nursing Process: Outcomes, Planning, and Implementation

Nursing Diagnoses, Outcomes, and Planning

• Diagnose and organize care around how data supports PES (Problem, Etiology, Symptoms):
  • Example: Inadequate fluid volume related to prolonged vomiting as evidenced by tachycardia and poor skin turgor.
  • Evidence of risk factors and etiology can include infection evidenced by cancer, recent surgery, etc.
  • Readiness for health promotion or coping can be evidenced by patient expressing desire to enhance social support and spiritual resources.
• Documentation and resources
  • A document listing commonly used diagnoses can help students see how diagnoses are formulated (to be posted on Blackboard).
  • Questions about nursing diagnoses can be addressed as needed.

Outcome Identification and Planning

• Goals and planning steps
  • Establish priorities.
  • Write expected outcomes.
  • Select nursing interventions.
  • Finalize the nursing care plan and communicate with family, patient, and other care providers.
• Formal care plan in the electronic health record (EHR)
  • Updated daily by every nurse.
  • Personalizes care based on patient preferences and needs.
  • Helps communicate plan of care to other nurses and prevent memory gaps.
  • Supports continuity of care, coordination, evaluation of response, and legal documentation; promotes professional accountability.
• Using clinical reasoning in setting outcomes
  • Know agency policies and standards of care for setting priorities, patient outcomes, interventions, and care plans.
  • Be thoughtful, open-minded, and maintain a bigger-picture focus while staying aligned with discharge goals.
• Scope of practice and standards of care
  • Scope of practice defines what a nurse can do based on license and without requiring specific orders.
  • Do not perform activities outside your scope; consult others when needed.
  • Apply standards and legal requirements to ensure safe, appropriate care.

Planning: Elements and Process

• Three elements of planning
  • Initial step occurs during admission data collection and problem learning to start the plan of care.
  • Revisit and update the plan at every patient contact and by every nurse who sees the patient.
  • Use shift data to modify and adjust goals; include discharge planning to ensure everything comes together for the patient’s home or next setting.
• Discharge planning
  • Discharge teaching should be integrated; explain what happened, how goals were met, and what to do at home.

From Nursing Diagnosis to Outcomes

• How outcomes relate to the diagnosis
  • Use the problem statement to suggest outcomes.
  • Use the etiology (causes) to suggest interventions.
• Prioritization framework
  • Maslow’s hierarchy of needs (basic needs must be met before higher-level needs can be addressed): air, food, fluids, body temperature, safety, etc.
  • Consider patient preferences and anticipated outcomes based on diagnosis and nursing knowledge.
• Four questions to establish priority
  • Which problems require immediate attention?
  • Which responsibilities fall under the nurse vs. scope of practice?
  • Which problems can be addressed with standard plans or protocols?
  • Which problems require individual, safety-focused attention beyond protocols?
• Timing and sequencing
  • Assess whether health status has changed since last contact.
  • Determine if responses to interventions have changed.
  • Identify whether relationships among problems require addressing one issue before another.
  • Decide if several problems can be grouped and addressed together.

Outcomes: Types and Structure

• Long-term vs short-term outcomes
  • Short-term goals are usually achieved within days to weeks; often linked to immediate problem resolution.
  • Long-term goals may extend beyond discharge and are broader to accommodate individual patient circumstances.
• Outcome categories
  • Cognitive: knowledge or intellectual changes (e.g., understanding relationship between carbs and blood sugar).
  • Psychomotor: demonstration of a skill (e.g., proper insulin administration or monitoring techniques).
  • Affective (effective): changes in attitudes, beliefs, or emotions (e.g., increased confidence in managing condition).
  • Clinical: health status changes or resolution of the presenting problem.
  • Functional: level of functioning in daily activities.
  • Quality of life: patient-reported wellbeing and life satisfaction.
• Example: diabetes education case
  • Cognitive: patient verbalizes understanding of the relationship between carbohydrates and blood sugar.
  • Psychomotor: patient demonstrates correct self-administration of insulin.
  • Affective: patient expresses increased confidence in managing diabetes.
  • Clinical: blood glucose kept within target range; adherence to monitoring and diet plans.
  • Functional: patient performs self-care tasks (glucose monitoring, insulin administration, meal planning).
  • Quality of life: patient reports improved energy and ability to participate in daily activities.
• Outcome components (to be explicit and measurable)
  • Subject: the patient.
  • Verb: action the patient will perform (observable).
  • Circumstances: conditions under which the outcome will occur.
  • Performance criteria: observable, measurable behavior.
  • Target time: when the outcome should be achieved.
  • Example: The patient will drink 60{
    m \,mL} of fluid every 2{
    m \,h} while awake by the date of discharge.
• Verbs to use and avoid
  • Use observable/measurable verbs: define, prepare, identify, verbalize, explain, demonstrate, etc.
  • Avoid non-observable verbs: know, understand, learn, become aware, etc.
  • Avoid multi-behavior outcomes in a single statement; split into separate outcomes when necessary.
  • Avoid vague outcomes like "the patient will cope better" without specifying what, how, and how it will be measured.

SMART and Target Time Framework

• SMART goals (commonly used in patient outcomes)
  • Specific, Measurable, Achievable/Attainable, Realistic (relevant), Time-bound (timely).
  • Example: During the next 21 period (e.g., 21 days or 21 shifts), the patient’s fluid intake will total at least 2000 \,\text{mL} per day.
  • Example: The patient will correctly demonstrate relaxation exercises during the next session.
• Time-bound criteria
  • Define a target time for achieving each outcome (e.g., by discharge, within 2 weeks, by the next shift, etc.).

Common Errors in Writing Outcomes

• Making outcomes an action for the nurse (e.g., "Mister Meyer will offer 60 mL of fluid every 2 hours" is a nursing intervention, not an outcome).
• Using non-observable verbs (e.g., know, understand, learn).
• Combining multiple patient behaviors into one outcome.
• Writing vague outcomes (e.g., "the patient will cope better").

Quality and Safety Aims in Healthcare

• Institute of Medicine (IOM) aims for quality of care
  • Safe, effective, patient-centered, timely, efficient, and equitable care.
• Joint Commission safety goals (high-level guidance for hospitals)
  • Identify patients correctly, improve staff communications, use alarms, prevent infection, identify patient safety risks, and prevent mistakes.
• These aims guide how goals and planning should be framed, but ensure they are tailored to each patient’s plan of care and discharge goals.

Implementing: From Plan to Action

• Implementing the plan of care
  • Continues data collection and monitors the patient’s response.
  • Modify the plan as needed based on patient response and shifting priorities.
  • Document actions and rationale for interventions.
• Scope of practice in implementation
  • Ensure you stay within your licensed scope; seek supervision or orders for tasks outside scope.
• Taxonomy and care coordination
  • Use the taxonomy and clinical reasoning to perform interventions safely and effectively.
  • Coordinate with other services as needed to optimize patient outcomes.
• Rationale for implementation
  • Implementing the plan aims to: promote health, prevent disease, restore health, and facilitate coping with altered functioning.
• Pre- and post-implementation assessment
  • Assess patient before performing interventions to tailor actions.
  • Reassess after interventions to determine effectiveness and guide modifications.