Planning NUR 102 PDF

Planning NUR 102  Planning Third step of the Nursing Process, begins with the first client contact and continues until discharge. Nurse formulate goals to help the client with their problems based on assessment data and diagnostic statements Expected outcomes are identified Int...

Planning NUR 102  Planning Third step of the Nursing Process, begins with the first client contact and continues until discharge. Nurse formulate goals to help the client with their problems based on assessment data and diagnostic statements Expected outcomes are identified Interventions (nursing orders) are selected to aid the client reach these goals. The product of this phase is a client care plan.  TYPES OF PLANNING Initial Planning:3  Initiated on admission after initial assessment  The nurse conduct the admission assessment develop initial comprehensive plan of care Ongoing planning:  Done by all nurses who work with the client  Individualization of initial plan  Occur at the beginning of the shift as the nurse plan the given care at that day  The nurse carries out daily planning (ongoing planning) for the following Purposes: ♣To determine whether the client’s health status has changed ♣To set priorities for the clients care during the shift. ♣To decide which problems to focus on during the shift ♣To coordinate the nurse’s activities 4  Discharge Planning Process of anticipating and planning for needs after discharge Clients usually discharged still needing care Begins at first client contact and Involves comprehensive and ongoing assessment to obtain information about the client ongoing needs 5  DEVELOPING NURSING CARE PLANS 6 Informal nursing care plan: is strategy for action that exists in nursing mind e.g. the nurse may think “Mr. (x) is tired. I will need to reinforce his teaching after he is rested” Formal nursing care plan: is a written or computerized guide that organizes information about the client’s care. Benefit of this type is that it provides for continuity of care.  Formal nursing care plan 7 Standardized care plan: is formal plan that specifies nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction) Individualized care plan: is tailored to meet the unique needs of specific client - needs that are not addressed by the standardized care plan 8  Documents included in a complete 9 plan of care Problem list Kardex cards for client profile, basic need…etc Special discharge plan Special teaching plan Policies and procedures Protocols Standards of care Individualized NCP.  Standardized Approaches to Care Planning 10 Standards of care -Nursing actions for clients with similar medical conditions -Achievable rather than ideal nursing care -Usually, there are agency records that may be referred to in client care plan -Don’t contain medical interventions -Nurse might write “see unit standards of care for cardiac catheterization”  Standardized Approaches to Care Planning 11 Protocol -Indicate actions commonly required for a particular group of clients -May Include primary care provider’s orders and nursing interventions -Example: protocol for admitting a client to the ICU -Protocol for administering magnesium sulfate to a client with preeclampsia  Standardized Approaches to Care Planning 12  Policies and Procedures -Govern the handling of frequently occurring situation -Example: a hospital may have a policy specifying the number of the visitors the client can have  Standing order -Written documents about policies, rules, regulations, or orders regarding client care. -It gives the nurses the authority to carry out specific actions under certain circumstances, often when physician is not immediately available. -Example: In ICU: administration of emergency anti arrhythmic medication. -Home care setting: obtaining blood tests for a client who has been on a certain therapy for a prescribed amount of time.  Formats for Nursing Care Plans 13 Care plan formats differ according to health agency:  It might be organized in 4 columns (one for diagnosis, one for goals\desired outcomes, one for nursing intervention, the last for evaluation)  Or organized in 3 columns ( one for diagnosis, one for goals and evaluation, the third for intervention)  Or organized in 5 column (assessment Formats for Nursing Care Plans 14 Student care plans: detailed, handwritten, column for rationale of interventions, citation for literatures used. Concept maps ( mind map ): may containing of boxes or circles that connected by arrows or lines, it’s a tool for student learning of a disease. Computerized care plans: created and stored NCP, it can be standardized and individualized Multidisciplinary (collaborative) care plans Also called critical pathway: standardized plan, sequence the care that must be given on each day. Listing the interventions and the outcomes on that day. 15 Example of Pathophysiology Concept Map 16 17  Guidelines for Writing Nursing Care Plans: 18  Date and sign the plan  Date: for evaluation, review, and future planning  Signature: demonstrate accountability to the client and to the nursing profession.  Use category headings: “ Nursing Diagnosis”, “goals/Desired outcomes”,…etc  Use standardized medical or English symbols+ key words rather than complete  Be specific: expected timing (e.g., dressing q shift vs q 12h)  Refer to procedure books or other source of information: do not include all the steps (e.g., see unit procedure book for tracheostomy care)  Tailor the plan to unique characteristics of the client by ensuring that the clients choices, such as preferences about the times of care and methods included  Ensure that the nursing plan incorporates preventive and health maintenance aspect as well as restorative one (active assist in ROM: prevent joint contracture & maintain muscle strength)  Ensure that the plan contains intervention for ongoing assessment of client( e.g., inspect wound q 8 hrs)  Include collaborative activities (nutritionist, physiotherapist)  Include plans for the clients discharge+ home care needs(social workers, specific agencies; also, teaching….) 19 The Planning Process 20  1. Setting Priorities 21 Is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions High priority (life-threatening as loss of respiratory or cardiac function) Medium priority (health-threatening such as acute illnesses ) Low priority (developmental needs) Nurses use Maslow’s hierarchy of needs when setting priorities (physiologic needs are basic to life)  Factors to Consider When Setting Priorities 23 Client’s health values and beliefs Client’s priorities Resources available to the nurse and client Urgency of the health problem Medical treatment plan 2. Establishing Client 24 Goals/ Desired Outcomes Goals/desired outcome: describe, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions ( Expected outcome, outcome criterion, objective, predicted outcomes are other interchangeable names)  25 Some differentiate between goal and outcome as follows: Goal ( broad statement about the client status): e.g. to maintain fluid volume balance Desired outcome (more specific, observable criteria used to evaluate whether the goals have been met): drink 3L of fluids by the end of the day *When goals are stated broadly, the care plan must include both goals and desired outcomes. Some time they are combined (e.g. improved nutritional status as evidenced by weight gain of 5 kg by April 25) *E.g. (2): Nsg Dx: Impaired physical mobility Goal (broad): improved mobility Desired outcome (specific): ambulate with crutches by end of the week  Types of Goals  Short term goals: 26 - useful for clients who require health care for a short time - For patient who are frustrated by long-term goals - Acute care settings where the nurse spent most of there time on client immediate need  E.g., “ client will raise right arm to shoulder height by Friday” short-term goal  Long-term goals: used for clients who live at home and have chronic health problems, and rehabilitations centers  E.g., “client will regain full use of right arm in 6wks”  Goals are patient-centered and SMART Specific Measurable Attainable Relevant Time Bound Pt will walk 50 ft after the physical therapy. Pt will eat 75% of meal Pt will be OOB 2-4hrs Pt will maintain HR