Nursing Care Plan Essentials

Goal of Outcome Identification and Planning

• Establishing priorities is a key component.
• Identifying and writing expected patient outcomes is essential.
• Selecting evidence-based nursing interventions is necessary.
• Communicating the nursing plan of care ensures coordinated efforts.

A Formal Care Plan Allows Nurses To

• Individualize care to maximize outcome achievement.
• Set priorities to address the most critical needs.
• Facilitate communication among nursing personnel and colleagues.
• Promote continuity of high-quality, cost-effective care.
• Coordinate care to ensure a comprehensive approach.
• Evaluate patient response to nursing care to adjust interventions as needed.
• Create a record used for evaluation, research, reimbursement, and legal reasons.
• Promote nurse's professional development through reflection and learning.

Clinical Reasoning for Outcome Identification and Planning

• Be familiar with standards and agency policies for setting priorities, identifying/recording expected patient outcomes, selecting nursing interventions, and recording the care plan.
• Center practice on the patient, keeping their interests/preferences central.
• Maintain focus on the "big picture" to align daily interventions with discharge goals.
• Trust clinical experience and judgment, but seek help when needed and value collaborative practice.
• Base decisions on research to support the plan and to respect clinical intuitions before establishing priorities, identifying outcomes, and selecting nursing interventions.
• Recognize personal biases and maintain an open mind.

Standards for Outcome Identification and Planning

• Legal standards
• Guidelines from specialty professional organizations
• The Joint Commission standards
• Agency for Healthcare Research and Quality guidelines
• Employer policies

Three Elements of Comprehensive Planning

• Initial planning
• Ongoing planning
• Discharge planning

Initial Planning

• Initial planning is developed by the nurse performing the nursing history and physical assessment.
• It addresses each problem listed in the prioritized problem list.
• It identifies appropriate patient goals and related nursing care.

Ongoing Planning

• Ongoing planning is carried out by any nurse who interacts with the patient.
• Keep the plan up to date managing risk factors and promotes function.
• Problem statements are stated more clearly.
• New problem statements are developed.
• Outcomes are made more realistic and new outcomes are developed as needed.
• Identifies nursing interventions to accomplish patient goals.

Discharge Planning

• Discharge planning is carried out by the nurse who worked most closely with the patient.
• Begins when the patient is admitted for treatment.
• Teaching and counseling skills are used effectively to ensure competent performance of home care behaviors.

Deriving Patient Goals/Outcomes

• The first part of the nursing diagnosis involves identifying the unhealthy response and what should change.
• The goals/outcomes desired for change can be suggested.
• The second part of the nursing diagnosis involves identifying factors causing the undesirable response and preventing desired change.
• Suggests nursing interventions.

Establishing Priorities

• Maslow's hierarchy of human needs is considered.
• Patient preference guides care decisions.
• Anticipation of future problems informs the plan.
• Critical thinking/clinical reasoning and judgment is applied.

Maslow's Hierarchy of Human Needs

• Physiologic needs are the most basic.
• Safety needs are followed by love and belonging needs.
• Self-esteem needs are next.
• Self-actualization needs are at the top.

Clinical Reasoning and Establishing Priorities

• Determine which problems need immediate attention.
• Discern which problems fall under the nurse's responsibility.
• Use standard plans when appropriate.
• Ensure all problems are addressed for safe hospital stay and timely discharge, including those not covered by standard plans.
• Assess if changes in the patient's health status change the priority of nursing diagnoses.
• Evaluate if changes in the patient's response to health/care plan impacts nursing diagnoses that can be realistically addressed.
• Determine if relationships among diagnoses require one to be addressed before another can be resolved.
• Evaluate if several patient problems be dealt with together.

Identifying Outcomes

• Outcomes should be derived from nursing diagnoses/problems.
• Establishing long-term versus short-term outcomes.
• Outcomes should be patient-centered.
• Cognitive, psychomotor, and affective outcomes should used.
• Identifying clinical functional, and quality of life outcomes.
• Culturally appropriate outcomes should being identified.
• Outcomes should be supportive of the total treatment plan.

Categories of Outcomes

• Cognitive outcomes show increases in patient knowledge or intellectual behaviors.
• Psychomotor outcomes describe the patient's achievement of new skills.
• Affective outcomes exhibit changes in patient values, beliefs, and attitudes.

Clinical, Functional, and Quality-of-Life Outcomes

• Clinical outcomes describe the expected status of health issues at certain points in time and address whether problems are resolved.
• Functional outcomes describe the person's ability to function in relation to desired activities.
• Quality-of-life outcomes focus on key factors affecting someone's ability to enjoy life and achieve personal goals.

Parts of a Measurable Outcome

• Subject
• Verb
• Conditions
• Performance criteria
• Target time

Types of Nursing Interventions

• Nurse-initiated: autonomous action that a nurse executes to benefit the patient in a predictable way.
• Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor's orders.
• Collaborative: treatments initiated by other providers and carried out by a nurse.

Nurse-Initiated Interventions

• Actions include monitoring health status, reducing risks, resolving problems, and promoting independence.
• Aim to promote physical, psychological, and spiritual well-being.
• Giving patients information needed to make informed decisions and be independent.

Structured Care Methodologies

• Procedure: set of how-to action steps.
• Standard of care: description of acceptable level of patient care.
• Algorithm: set of steps used to make a decision.
• Clinical practice guideline: statement outlining appropriate practice for clinical condition or procedure.

Formats of Care Plans

• Computerized
• Concept map
• Change of shift reports
• Multidisciplinary (collaborative)
• Student

Six Aims to Be Met by Health Care Systems

• Safe: avoiding injury
• Effective: avoiding overuse and underuse
• Patient-centered: responding to patient preferences, needs, and values
• Timely: reducing waits and delays
• Efficient: avoiding waste
• Equitable: providing care that does not vary in quality

Joint Commission National Patient Safety Goals

• Identify patients correctly.
• Improve staff communication.
• Use medicines safely and alarms.
• Prevent infection.
• Identify patient safety risks.
• Prevent mistakes in surgery.

Explore key aspects of nursing care plans, including outcome identification, discharge planning, professional development, and patient-centered outcomes. Understand the difference between short-term and long-term goals and the importance of prioritization.