MODULE 4 NURSING PLANNING

• prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting interventions and writing nursing interventions

involves all healthcare providers interacting with the client and includes the client and family to the fullest extent possible in every step

are used as a learning activities and are longer and more detailed than those used by working nurses

is usually performed by the nurse who completes the admission assessment. This type of planning results in the initial comprehensive care of plan

• Is done by all nurses who work with the client

• Individualization of the initial plan occurs as new information is obtained and the client’s response to care is evaluated

• Also occurs at the beginning of a shift as nurses plan care to be given for the shift

• Is the process of anticipating and planning for needs after discharge

• Effective discharge planning begins at the first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs

Inferring and hypothesis

• written or computerized care plan

• are preprinted guides for nursing care of a client who has a need that arise frequently in the agency

• written from the perspective of what care the client can expect

• preprinted and indicate the actions commonly required for a particular group of patients

• include both physician’s order and nursing intervention

• developed yo govern the handling of frequently occurring situations

• covers a situation pertinent to client care

• customize to fit the unique needs of each client

Evidence based principle given as the reason for selecting a particular nursing intervention

visual tools for information

• appropriate diagnosis selected from menu suggested computer

1. Date and sign the plan

2. Use category headings

3. Use standardized/approved medical or English symbols and key words

4. Be specific

5. Refer to procedure book or other sources

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

7. ensure that the nursing care plan incorporates preventive and health maintenance aspects

8. Ensure that the plan contains interventions for ongoing assessment

9. Include collaborative and coordination activities in the plan

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

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

• High priority

• Such as loss of respiratory or cardiac function

• medium priority

• Such as acute illness and decreased coping abilities, are considered medium priority

• Low priority

• Problem that arises from ___________ needs or only requires minimal nursing support

1. The client’s values and beliefs

2. The client’s priorities

3. Resources available to the nurse and client

4. Urgency of the health problem

5. Medical treatment plan

• Standardized or common nursing language is required in all phases if nursing data are to be included in computerized databases that are analyzed and used in nursing practice

• It is a taxonomy for describing client outcomes that respond to nursing interventions

• Each NOC is assigned a four digit identifier, NOC outcome is similar to goal in traditional language

• describe in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing intervention

• Provide directions for planning nursing interventions

• Serve as a criteria for evaluating client progress

• Usually has the following components; subject (the client), verb (specifies action that the client is expected to perform), condition or modifier and criterion of describe performance

1. Write goals/outcomes in terms of client responses, not nurse activities

2. Be sure that goals/desired outcomes are realistic

3. Ensure that goals/ outcomes are compatible with the therapies of other professionals

4. Make sure that each goal/desired outcome is derived from only one nursing diagnosis

5. Use observable, measurable terms for goal/desired outcomes

6. Make sure the client considers the goals/desired outcomes important and values them

• Actions a nurse performs to achieve client goals/desired outcomes

• They should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the second clause of the diagnostic statement

• Intervention for risk diagnoses should focus on measures to reduce the client’s risk factors which are also found in the second clause

1. Safe and appropriate for the client’s age, health and condition

2. Achievable with the resources available

3. Congruent with the client’s values, beliefs and culture

4. Congruent with other therapies

5. Based on nursing knowledge and experience or knowledge from relevant sciences

6. Based on nursing knowledge and experience or knowledge from relevant sciences

• those activities that nurses are licensed to initiate on the basis of their knowledge and skills

• Activities carried out under the primary care provider’s orders or supervision or according to specified routines

• Actions that nurse carries out in collaboration with other health team members.

• Nurse must choose interventions that are most likely to achieve the goal/desired outcome

• The nurse must consider the risks and benefits of each intervention which requires nursing knowledge and experience