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Chapter: Medical Surgical Nursing: Critical Thinking,Ethical Decision Making, and the Nursing Process

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Planning - Using the Nursing Process

Once the nursing diagnoses have been identified, the planning component of the nursing process begins.

PLANNING

 

Once the nursing diagnoses have been identified, the planning component of the nursing process begins. This phase entails the following:

 

·           Assigning priorities to the nursing diagnoses and collabo-rative problems

 

·           Specifying expected outcomes

 

·           Specifying the immediate, intermediate, and long-term goals of nursing action

 

·           Identifying specific nursing interventions appropriate for attaining the outcomes

 

·           Identifying interdependent interventions

 

·           Documenting the nursing diagnoses, collaborative prob-lems, expected outcomes, nursing goals, and nursing in-terventions on the plan of nursing care

 

·           Communicating to appropriate personnel any assessment data that point to health needs that can best be met by other members of the health care team

 

Setting Priorities

 

Assigning priorities to the nursing diagnoses and collaborative problems is a joint effort by the nurse and the patient or family members. Any disagreement about priorities is resolved in a way that is mutually acceptable. Consideration must be given to the urgency of the problems, with the most critical problems receiv-ing the highest priority. Maslow’s hierarchy of needs provides a useful framework for prioritizing problems, with importance being given first to physical needs; once those lower-level needs are met, higher-level needs can be addressed.

 

Establishing Expected Outcomes

 

Expected outcomes of the nursing interventions are stated in terms of the patient’s behaviors and the time period in which they are to be achieved, as well as any special circumstances related to achiev-ing the outcome (Smith-Temple & Johnson, 2002). These out-comes must be realistic and measurable. The Nursing-Sensitive Outcomes Classification (NOC) (Chart 3-8) and standard out-come criteria for people with specific health problems estab-lished by health care agencies are resources for identifying appropriate expected outcomes. These outcomes can be associ-ated with nursing diagnoses and interventions and can be used when appropriate (Aquilino & Keenan, 2000). However, NOC may need to be adapted to establish realistic criteria for the spe-cific patient involved.


 

The expected outcomes that define the desired behavior of the patient will be used to measure to what extent progress toward resolving the problem has been made. The expected outcomes also serve as the basis for evaluating the effectiveness of the nurs-ing interventions and for deciding whether additional nursing care is needed or whether the plan of care needs to be revised.

 

Establishing Goals

 

After the priorities of the nursing diagnoses and expected out-comes have been established, the immediate, intermediate, and long-term goals and the nursing actions appropriate for attaining the goals are identified. The patient and his or her family are included in establishing goals for the nursing actions. Im-mediate goals are those that can be reached within a short pe-riod. Intermediate and long-term goals require a longer time to be achieved and usually involve preventing complications and other health problems and promoting self-care and rehabilita-tion. For example, goals for a patient with diabetes and a nurs-ing diagnosis of deficient knowledge related to the prescribed diet may be stated as follows:

 

Immediate goal: Demonstrates oral intake and tolerance of 1500-calorie diabetic diet spaced in three meals and one snack per day

 

Intermediate goal: Plans meals for 1 week based on diabetic exchange list

Long-term goal: Adheres to prescribed diabetic diet

 

Determining Nursing Actions

In planning appropriate nursing actions to achieve the desired goals and outcomes, the nurse, with input from the patient and significant others, identifies individualized interventions based on the patient’s circumstances and preferences that will address each outcome. Interventions should identify the activities needed and who will carry them out. Determination of interdiscipli-nary activities is made in collaboration with other health care providers as needed.

The nurse identifies and plans patient teaching and return demonstrations as needed to assist the patient in learning self-care activities to be performed. Planned interventions should be ethi-cal and appropriate to the patient’s culture, age, and gender. Standardized interventions, such as those found on institutional care plans or in the Nursing Interventions Classification (NIC) (Aquilino & Keenan, 2000; McCloskey & Bulechek, 2000) can be used. 

Chart 3-9 describes the NIC system and provides an ex-ample of an NIC system intervention. It is important to individ-ualize prewritten interventions to promote optimal effectiveness for each patient.

 

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