Nursing Process: Planning Outcomes

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Planning

Formal = conscious, deliberate activity involving decision making, critical thinking and creativity

Informal = making mental notes or plans

Initial Planning

Begins when you first meet them

Document ASAP after initial assessment

Includes the development of a care plan

Ongoing Planning

Causes changes to be in the the care plan

Evaluates client's responses to care

Discharge Planning

Planning for self-care and continuity of care after client leaves a healthcare setting

Have to teach the patient and make sure they do it back

Begins with initial assessment = Planning starts as soon as they get admitted

Needed by all clients

Need to know about where they are going, who they are with and will they be taken care of

Requires collaboration

Collaboration is ideally done with patient involvement to ensure achievement of desired outcomes

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Nursing Care Plans

The central source of information needed to:

Guide holistic, goal-oriented care

Address each client's unique needs

Why is a written Nursing Care Plan Important?

Ensuring that care is complete

Specific written directions less likely to be overlooked by busy caregivers

Provides continuity of care

This helps ensure that when an effective intervention is found, all caregivers will use the same approach with the patient.

Promotes efficient use of nursing efforts

Specific, written instructions help to ensure that nurses do not waste time on ineffective approaches.

Provides a guide for assessing and charting

Nursing orders and goals/expected outcomes on the care plan can help you plan your activities and ensure nothing is omitted from your documentation.

Meets requirements of accrediting agencies

The Joint Commission and professional standards review organizations (PSROs) require a patient-specific plan of care.

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Information in a Comprehensive Nursing Care Plan

Basic Needs and Activities of Daily Living

Includes routine assistance that the patient needs with hygiene, nutrition, elimination and so forth, regardless of the nursing diagnosis

Medical/Multidisciplinary Treatment

Need to know the medical orders for each patient and the nursing activities necessary for carrying out these order

Nursing Diagnosis + Collaborative Problems

The nursing care plan = Contains goals and nursing orders for the patient's nursing diagnosis and collaborative problems

Special Discharge needs or teaching needs

Contains instructions for formal discharge planning and special teaching if they are needed

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Preprinted, Standardized Plans

Unit Standards of Care = "To do list"

Describes the care that nurses are expected to provide for all clients in defined situations

Describes minimal level of care

Not organized according to diagnoses

Standardized Nursing Care Plans

More detailed interventions

Organized by nursing diagnosis

Include specific goals and orders

Part of the comprehensive care plan and permanent record

Ideal rather than minimal care

Allows you to incorporate other care plans

Checklists, blank lines, empty spaces for individualized goals and interventions

Critical Pathway

Outcome based and care based on case type

Minimal standard of care to meet recommended length of stay for patients with certain conditions

Used for my frequent case types or situations with predictable outcomes

Emphasize medical problems and interventions

Do not provide a way to judge nursing effectiveness

Integrated plans of care

Standardized plans = The care plan + Documentation form

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Individualized Nursing Care Plan

Used to address nursing diagnoses unique to a client

Special Discharge or Teaching Plan

May use standardized plan for discharge and teaching or include it as teaching in a nursing diagnosis care plan

Goals may also be called expected/desired/ predicted outcomes

Computerized Care Plan

Enter diagnosis/desired outcome

Computer has a list of suggested interventions - choose appropriate interventions

Individualize by typing in interventions as needed

Process for writing Individualized Nursing Care Plan

Make a working problem list

Decide which problems can be managed with standardized care plans or critical pathways

Individualize as needed

Transcribe medical orders to appropriate documents

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Planning Client Goals/ Outcomes

Goals: Changes in the client's health status you hope to achieve

Outcomes:

What happens

Should be measurable

Did they meet the outcome or no

Nursing-Sensitive Outcomes: Those that can be influenced by nursing interventions

Short-Term and Long-Term

Long-term = Goals achieved over a longer period (week, month or more)

Short-term = Goals achieved within a few hours or days

Components of a Goal Statement

Subject:

The subject is understood to be the client, but it can also be a function or part of the client.

Action:

Use an action verb to indicate the action the client will perform: what the client will learn, do, or say.

Performance criteria:

These need to be written in concrete, observable terms because they indicate what you need to measure in order to evaluate outcomes. Performance criteria specify: (a) how, what, when, or where something is to be done; (b) amount, quality, accuracy, speed, distance, and so forth.

Target time:

This is the realistic date or time by which the performance/behavior should be achieved.

Special conditions:

These describe the amount of assistance or resources needed or the experiences/treatments the client should have to perform the behavior.

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Goals and the Nursing Diagnosis

Outcomes derived from the diagnosis

Problem statement describes the response/health status to be changed

Desired outcome states the opposite of the problem response

For every diagnosis you must state one goal that, if achieved, would demonstrate resolution or improvement of the problem

Essential vs. Nonessential Goals

Nonessential from etiology

Essential from the problem

*If an expected outcome is not deemed appropriate for the nursing diagnosis, a new nursing diagnosis should be written

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Standardized Terminology for Outcomes

ANA approved several standardized vocabularies for describing client outcomes

Components of NOC Outcome

Outcome label

Indicators

Measurement Scale

Writing Goals for Groups

NOC outcomes

Can be used for both individuals and groups

Home and community health nurses are especially likely to write goals for aggregates (groups), such as families, and communities.

Emphasize health promotion, health maintenance, and disease prevention outcomes.

Clinical Care Classification (CCC)

Developed by Virginia Saba for use in home health nursing.

Form goals by adding modifiers to the nursing diagnoses.

This system has four nursing diagnoses that are clearly for family units: Family Coping Impairment, Compromised Family Coping, Disabled Family Coping, and Family Processes Alteration.

Omaha System

Developed specifically for community health nursing and each nursing diagnosis must be labeled as individual, family, or group

You can write aggregate outcomes by specifying a family or group diagnosis and then creating a goal from it, by using terms in a Problem Rating Scale for Outcomes.

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Goals for Wellness Diagnosis

Describe behaviors/response that:

Demonstrate health maintenance OR

Achievement of an higher level of health

If the client, family, or community values a care plan goal, it is more likely to be effective. If your goals conflict with the patient’s you may need to explore the patient’s thinking and try to find a compromise or alternative approach.

Does the goal conflict with any religious or cultural values? If a patient is “noncompliant,” the reason may be that he or she is complying with his or her cultural beliefs rather than the caregiver’s plan of care.

Teaching Objective

Describe what the client is to learn

Describe the behaviors that will demonstrate learning

State whether learning is cognitive, psychomotor or affective

*Always need to communicate with the patient

*Can address the issues as long as the patient is proactive

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Reflecting Critically About Expected Outcomes/Goals

For each nursing diagnosis:

Did at least one goal demonstrate problem resolution

Are the predicted outcomes adequate

Is each expected outcome:

Appropriate for the nursing diagnosis

Derived from only one diagnosis

Descriptive of only one client response/behavior

Stated as a client behavior and not a nurse activity

In positive terms

Measurable or observable

Given specific and concrete performance

Including all the necessary parts

Realistic and achievable

Not in conflict with out treatment plans

Valued by the client,family or community

Conflicting with any religious or cultural values