1. CH 13 outcome identification and planning

2. Planning
The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care.
The nurse consults with the client while developing and revising the plan.

3. Outcome Identification and Planning

4. A Formal Plan of Care 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

5. Standards to Apply to Outcome Identification and Planning
The Law
National practice standards
Specialty professional organizations
The Joint Commission
The Agency for Health Care Research and Quality (AHRQ)
Your employer

6. Deriving Patient Goals/Outcomes and Nursing Orders from Nursing Diagnoses

7. Three Elements of Comprehensive Planning
Initial
Ongoing
Discharge

8. Initial Planning
Developed by the nurse who performs the nursing history and physical assessment
Addresses each problem listed in the prioritized nursing diagnoses
Identifies appropriate patient goals and related nursing care

9. Ongoing Planning Carried out by any nurse who interacts with patient
Keeps the plan up to date
States nursing diagnoses more clearly
Develops new diagnoses
Makes outcomes more realistic and develops new outcomes as needed
Identifies nursing interventions to accomplish patient goals

10. 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 home care behaviors are performed competently

11. Question
Which one of the following nursing actions 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 nursing diagnoses, outcomes, and interventions.

12. Answer
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.

13. Prioritizing Nursing Diagnoses
High priority—greatest threat to patient well-being
Medium priority—nonthreatening diagnoses
Low priority—diagnoses not specifically related to current health problem

14. Maslow’s Hierarchy of Human Needs
Physiologic needs
Safety needs
Love and belonging needs
Self-esteem needs
Self-actualization needs

15. General Guidelines for Setting Priorities
Take care of immediate life-threatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

16. Nurse Identified Priorities
Composite of all patient’s strengths and health concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.

17. Question
Which of the following nursing diagnoses would most likely be considered a high priority?
A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance

18. Answer 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.

19. Identifying and writing Goals/Outcomes
Goals provide direction for planning interventions
Goals serve as criteria for evaluating the effectiveness of nursing care
Goals enable us to know when the problem has been solved

20. Steps for deriving outcomes from Nursing Diagnosis
Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem.
Diagnosis: Risk for infection r/t surgical wound dehiscence secondary to abdominal obesity.
Outcome: The client will demonstrate no signs or symptoms of infection AEB temperature below 100 degrees, no erythema or prurulent drainage from wound bed by the end of the shift on _(date)___.

21. Identifying Client-centered Outcomes
State what the patient will do or experience at the completion of care.
Give direction to the patient’s overall care.
Patient behaviors not nurse behaviors!
“The patient will…”

22. Components of Outcomes
Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the actions?
Performance criteria: what specific behaviors/assessments/findings will indicate positive achievement of this goal?
Target time: by when is the person expected to be able to perform the actions?
Our directions state G T T (goal, tool, time)

23. The Nursing Process (cont.)
GOALS MUST BE REALISTIC (in terms of the client’s potential for achieving them & the nurse’s ability to help the client achieve them.)
--sometimes we can’t fix the patient’s problem, or we can only accomplish a small step in the process instead of the whole goal. Be realistic about what you can do.
GOALS SERVE AS GUIDES IN SELECTING NURSING INTERVENTIONS.
GOALS ARE ALWAYS STATED BEGINNING WITH “CLIENT WILL”
ie: By Sept. 17, client’s lungs will remain clear to auscultation
By Sept. 18, client will eat one high fiber food with each meal
By Sept. 17, client’s skin will remain intact

24. Long-Term vs. Short-Term Outcomes
Long-term—requires a longer period to be achieved and may be used as discharge goals
May be used with chronic health problems
May take weeks/months to accomplish
Short-term—may be accomplished in a specified period of time
Students will write goals for their care for the shift
Nurses typically write shift goals, as short hospital stays demand fast resolution of problems
Short-term goals can be a few days to a week

25. 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
Physical—describes physical attributes that resolve the health problem

26. Question Which one of the following outcomes is an affective outcome?
A. By 6/09/11, the patient will correctly demonstrate the procedure for washing her newborn baby.
B. By 6/09/11, the patient will list three benefits of eating a healthy diet.
C. By 6/09/11, the patient will use a walker to ambulate the hallway.
D. By 6/09/11, the patient will verbalize valuing his health enough to stop smoking.

27. Answer
Answer: D. By 6/09/11, 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 B are psychomotor outcomes (learning a new skill) and Answer C is a cognitive outcome (increase in patient knowledge).

28. The Nursing Outcomes Classification (NOC)
A taxonomy of nursing language for describing outcomes of nursing intervention has been developed
Over 385 outcomes identified in 7 domains —classes within these domains specify categories.
Each is given a 4 digit identifier for computer ID and coding
Both texts include NOC outcomes within each section.

29. Now what?
Nursing interventions are the things the nurse does to accomplish the goal.
They focus on eliminating or reducing the etiology of the problem, the 2nd clause of the diagnostic statement.
Correct identification of the etiologies is essential
Interventions for “risk for” diagnoses focus on reducing or eliminating the risk

30. Types of Nursing Interventions
Nurse-initiated—actions performed by a nurse without a physician’s order
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

31. Actions Performed in Nurse-Initiated Interventions (Alfaro, 2002)
Monitor health status.
Reduce risks.
Resolve, prevent, or manage a problem.
Facilitate independence or assist with ADLs.
Promote optimum sense of physical, psychological, and spiritual well-being.

32. Question 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

33. Answer
Answer: B. False
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.

34. Selecting Nursing Interventions
Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking.
The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects.
Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.

35. Interventions
Nursing interventions require intellectual, interpersonal and technical skills.
Intellectual skills required of the nurse include: problem identification, and problem solving, critical thinking, and the ability to make sound judgments.
A strong theoretical background is necessary for these intellectual skills
All actions (interventions) planned for the client must be based on scientific principles and rationale.
Students will document a rationale for each intervention and cite it using APA format

36. Relationship of interventions to the problem
The focus of interventions:
Observations
Prevention
Treatments
Health promotion
Format of interventions on the care plan:
Action verb, conditions and modifiers, time frame

37. The Nursing Interventions classification (NIC)
NIC taxonomy developed in 1992
Standardized language to describe nursing interventions
542 approved interventions
Included throughout both texts and discussed again in CH 15

38. Benefits of Using NIC/NOC Standardized Language
Demonstrate the impact that nurses have on the system of healthcare delivery.
Define the knowledge base for nursing curricula and practice.
Facilitate the selection of appropriate nursing intervention.
Enable researchers to examine the effectiveness and cost of nursing care.
Assist educators to develop curricula that better articulates with clinical practice.

39. Benefits of Using NIC/NOC Standardized Language (cont.)
Facilitate the teaching of clinical decision making to novice nurses.
Assist administrators in planning more effectively for staff and equipment needs.
Promote the development and use of nursing information systems.
Communicate the nature of nursing to the public.

40. Communicating and recording—How patient care activities are generated
Direct orders
Standing orders
Standards of care
Protocols
Policies and procedures

41. Types of Institutional Plans of Care
Kardex plans of care
Computerized plans of care
Case management plans of care
Clinical pathways, care maps
Concept map care plan
Student plans of care

43. Your student care plans
Done post care—not ideal
Usually 15% of your course grade
Instructors grade on your thought process—if you wrote a certain diagnosis that was not relevant, based on your assessment, points are deducted.
We use APA format. Do it exactly and get all the points.
We also grade on spelling/grammar as a point of professionalism

44. Your care plan will contain….
A nursing diagnosis, stated in NANDA terminology
A short term goal for the care for your shift
It must be measurable and timed
“The patient will…”
Interventions that start with an action verb. (Don’t include, “The nurse will…,” as that is understood.
Rationales that are the science behind your action. Use Taylor—it’s good. Other texts are acceptable as well.
They must be direct quotes, enclosed by quotation marks, and cited in APA style.

45. A revision of some sort if the goal was not met or partially met.
An evaluation of whether or not the goal was met (we haven’t talked about evaluation yet)
A revision of some sort if the goal was not met or partially met.
And—depending on the course—you may have to write 1, 2, or 3 diagnoses and work them all through.
Also included--
a complete patient assessment, using our assessment form. You’ll be writing one this term for Funds 1.
A page with all your patient’s medications
Sound like a lot of work? It is, but we all went through this. It will teach you how to think like a nurse!

46. Problems Related to Outcome Identification and Planning
Failure to involve patient
Insufficient data collection
Nursing diagnoses developed from inaccurate or insufficient data
Outcomes stated too broadly
Outcomes derived from poorly developed nursing diagnoses
Failure to write nursing order clearly
Nursing orders that do not solve problems
Failure to update the plan of care

47. Workbook exercises Work in groups of 2-3 to answer the following:
Matching exercises A & B, p
Short answers #8 and #9 only.
You can look up the answers when you are finished!
Answer the quiz (handout) questions by using your text as a reference.