Chapter 17: Outcome Identification and Planning - Nursing

Chapter 17 Outcome Identification and Planning Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Goal of Outcome Identification and Planning Step Establish priorities Identify and write expected patient outcomes Select evidence-based nursing interventions Comm...

Chapter 17 Outcome Identification and Planning Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Goal of Outcome Identification and Planning Step Establish priorities Identify and write expected patient outcomes Select evidence-based nursing interventions Communicate the nursing plan of care Copyright © 2023 Wolters Kluwer All Rights Reserved Outcome Identification and Planning Copyright © 2023 Wolters Kluwer All Rights Reserved A Formal Care Plan Allows the Nurse to:  Individualize care that maximizes outcome achievement  Set priorities  Facilitate communication among nursing personnel and colleagues  Promote continuity of high-quality, cost-effective care  Coordinate care  Evaluate patient response to nursing care  Create a record used for evaluation, research, reimbursement, and legal reasons  Promote nurse’s professional development Copyright © 2023 Wolters Kluwer All Rights Reserved Outcome Identification, Planning, and Clinical Reasoning #1 Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the care plan Remember that the goal of thoughtful, patient- centered practice is to keep the patient and the patient’s interests and preferences central in every aspect of planning and outcome identification Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions? Copyright © 2023 Wolters Kluwer All Rights Reserved Outcome Identification, Planning, and Clinical Reasoning #2 Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan Recognize your personal biases and keep an open mind Copyright © 2023 Wolters Kluwer All Rights Reserved Standards to Apply to Outcome Identification and Planning The law Specialty professional organizations The Joint Commission The Agency for Healthcare Research and Quality (AHRQ) Your employer Copyright © 2023 Wolters Kluwer All Rights Reserved Three Elements of Comprehensive Planning Initial Ongoing Discharge Copyright © 2023 Wolters Kluwer All Rights Reserved Initial Planning Developed by the nurse who performs the nursing history and physical assessment Addresses each problem listed in the prioritized problem list Identifies appropriate patient goals and related nursing care Copyright © 2023 Wolters Kluwer All Rights Reserved Ongoing Planning Carried out by any nurse who interacts with patient Keeps the plan up to date, manages risk factors, promotes function States problem statements more clearly Develops new problem statements Makes outcomes more realistic and develops new outcomes as needed Identifies nursing interventions to accomplish patient goals Copyright © 2023 Wolters Kluwer All Rights Reserved Discharge Planning Carried out by the nurse who worked most closely with the patient Begins when the patient is admitted for treatment Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently Copyright © 2023 Wolters Kluwer All Rights Reserved Question #1 Which nursing action would most likely occur during the ongoing planning stage of the comprehensive care plan? A. The nurse collects new data and uses them to update the plan and resolve health problems B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home C. The nurse who performs the admission nursing history develops a patient care plan D. The nurse consults standardized care plans to identify patient problems, outcomes, and interventions Copyright © 2023 Wolters Kluwer All Rights Reserved Answer to Question #1 Answer: A. The nurse collects new data and uses them to update the plan and resolve health problems Rationale: In the ongoing planning stage, any nurse who interacts with the patient updates the plan to facilitate the resolution of health problems, manage risk factors, and promote function. Teaching and counseling are the key to discharge planning. The nurse performing the admission nursing history consults standardized care plans during initial planning to formulate the initial care plan. Copyright © 2023 Wolters Kluwer All Rights Reserved Deriving Patient Goals/Outcomes and Nursing Orders From Nursing Diagnoses Copyright © 2023 Wolters Kluwer All Rights Reserved Establishing Priorities Maslow’s hierarchy of human needs Patient preference Anticipation of future problems Critical thinking/clinical reasoning and judgment Copyright © 2023 Wolters Kluwer All Rights Reserved Maslow’s Hierarchy of Human Needs Physiologic needs Safety needs Love and belonging needs Self-esteem needs Self-actualization needs Copyright © 2023 Wolters Kluwer All Rights Reserved Clinical Reasoning and Establishing Priorities #1 What problems need immediate attention and which ones can wait? Which problems are the responsibility of the nurse and which need to be referred to someone else? Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)? Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge? Copyright © 2023 Wolters Kluwer All Rights Reserved Clinical Reasoning and Establishing Priorities #2 Have changes in the patient’s health status influenced the priority of nursing diagnoses/problems? Have changes in the way the patient is responding to health and illness or the care plan affected those nursing diagnoses/problems that can be realistically addressed? Are there relationships among diagnoses/problems that require that one be worked on before another can be resolved? Can several patient problems be dealt with together? Copyright © 2023 Wolters Kluwer All Rights Reserved Question #2 Which patient problem would most likely be considered a high priority? A. Disturbed personal identity B. Impaired gas exchange C. Risk for powerlessness D. Activity intolerance Copyright © 2023 Wolters Kluwer All Rights Reserved Answer to Question #2 Answer: B. Impaired gas exchange Rationale: Impaired gas exchange poses a threat to the patient’s well-being. Disturbed personal identity and risk for powerlessness are non–life-threatening and are ranked as medium priorities. Activity intolerance, if not specifically related to the current health problem, is a low priority. Copyright © 2023 Wolters Kluwer All Rights Reserved Identifying Outcomes Deriving outcomes from nursing diagnoses/problems Establishing long-term versus short-term outcomes Determining patient-centered outcomes Using cognitive, psychomotor, and affective outcomes Identifying clinical, functional, and quality of life outcomes Identifying culturally appropriate outcomes Identifying outcomes supportive of the total treatment plan Copyright © 2023 Wolters Kluwer All Rights Reserved Categories of Outcomes Cognitive: describes increases in patient knowledge or intellectual behaviors Psychomotor: describes patient’s achievement of new skills Affective: describes changes in patient values, beliefs, and attitudes Copyright © 2023 Wolters Kluwer All Rights Reserved Clinical, Functional, and Quality-of-Life Outcomes Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved Functional outcomes describe the person’s ability to function in relation to the desired usual activities Quality-of-life outcomes focus on key factors that affect someone’s ability to enjoy life and achieve personal goals Copyright © 2023 Wolters Kluwer All Rights Reserved Question #3 Which outcome is an affective outcome? A. By 6/09/19, the patient will correctly demonstrate the procedure for washing her newborn baby B. By 6/09/19, the patient will list three benefits of eating a healthy diet C. By 6/09/19, the patient will use a walker to ambulate the hallway D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking Copyright © 2023 Wolters Kluwer All Rights Reserved Answer to Question #3 Answer: D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking Rationale: An affective outcome describes changes in patient values, beliefs, and attitudes. Answers A and C are psychomotor outcomes (learning a new skill) and Answer B is a cognitive outcome (increase in patient knowledge). Copyright © 2023 Wolters Kluwer All Rights Reserved Parts of a Measurable Outcome Subject Verb Conditions Performance criteria Target time Copyright © 2023 Wolters Kluwer All Rights Reserved Question #4 Tell whether the following statement is true or false. A collaborative intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician’s order. A. True B. False Copyright © 2023 Wolters Kluwer All Rights Reserved Answer to Question #4 Answer: B. False Rationale: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis, but carried out by a nurse in response to a physician’s order. Copyright © 2023 Wolters Kluwer All Rights Reserved Common Errors in Writing Patient Outcomes Expressing patient outcome as nursing intervention Using verbs that are not observable or measurable Including more than one patient behavior or manifestation in short-term outcomes Writing vague outcomes Copyright © 2023 Wolters Kluwer All Rights Reserved IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care 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 to all recipients Copyright © 2023 Wolters Kluwer All Rights Reserved Joint Commission National Patient Safety Goals Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery Copyright © 2023 Wolters Kluwer All Rights Reserved Types of Nursing Interventions Nurse-initiated: autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes 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 Copyright © 2023 Wolters Kluwer All Rights Reserved Actions Performed in Nurse-Initiated Interventions (Alfaro, 2020) Monitor health status Reduce risks Resolve, prevent, or manage a problem Promote independence with ADLs Promote optimum sense of physical, psychological, and spiritual well-being Give patients information needed to make informed decisions and be independent Copyright © 2023 Wolters Kluwer All Rights Reserved 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 Copyright © 2023 Wolters Kluwer All Rights Reserved Question #5 Tell whether the following statement is true or false. A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort. A. True B. False Copyright © 2023 Wolters Kluwer All Rights Reserved Answer to Question #5 Answer: A. True Rationale: A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort. Copyright © 2023 Wolters Kluwer All Rights Reserved Formats of Care Plans Computerized care plans Concept map care plans Change of shift reports Multidisciplinary (collaborative) care plans Student care plans Copyright © 2023 Wolters Kluwer All Rights Reserved