|
|
Online Companion: Fundamentals of Nursing Standards and Practice 2E
The focus of Chapter 8 is the third step of the nursing process: outcome identification and planning. Planning has four critical elements: establishing priorities, setting goals and identifying outcomes, planning nursing interventions and documenting. The American Nurses' Association's Standards of Clinical Nursing Practice identifies this step as essential to providing competent nursing care. The purposes of planning within the nursing process are to provide direction for quality care of clients, to improve staff communication and to provide continuity in the delivery of quality nursing care to clients.The planning step requires the nurse to think critically to develop objectives for care and to formulate a blueprint to achieve those objectives. Critical thinking is to reach conclusions about which nursing interventions will prevent or reduce nursing diagnoses or problems. Critical thinking is emphasized in the planning step; physician's orders for care are considered carefully to determine their appropriateness for the individual client. The three phases of planning nursing care are initial planning, ongoing planning, and discharge planning. Initial planning begins with admission assessment' ongoing assessment occurs as more information about the client is gathered and evaluated. In the ongoing phase, revisions may be made to further individualize the plan of care for the client. The third phase, discharge planning, anticipates the client's needs after discharge. Establishing priorities is a primary element in planning. The nurse ranks the client's nursing diagnoses in order of physiological or psychological importance. Maslow's hierarchy of needs is a common method that nurses use to select priorities. This hierarchy places basic physiologic needs at the top of the priority list; the need for a safe environment and psychosocial comfort are at the next lower level. The nurse should involve the client and family in decision-making about the relative importance of the problems. The clinical situation often requires that several nursing diagnoses be worked on simultaneously; potential or risk nursing diagnoses may be of high priority. The use of priorities guides the nurse to direct maximum effort toward the most urgent client problems. The nurse sets goals to provide guidelines for nursing interventions and to establish evaluation criteria to measure effectiveness of the care plan. Short-term goals state an expectation for problem resolution within a few hours or days. Long-term goals express an expectation for improvement in a nursing diagnosis over a period of weeks or months. Expected outcome statements are the measurable steps toward achieving the goals. These statements are written to be realistic and attainable within a defined time period and agreed upon by the client and nurse. The expected outcomes depict the measurable behavior change in the client that can be observed when the goal is met. The outcomes are used as the standard for comparison during the evaluation step. Typically, each nursing diagnosis has one global goal and several expected outcomes. Goals and expected outcomes are carefully constructed to include: subject, task statement, criteria, the conditions and the time frame. For example, "The client will have palpable peripheral pulses in 1 week." is a clearly written goal. Some common pitfalls that nurses encounter when writing goals involve formatting, in which goals are nurse-centered or unrealistic or not individualized, not measurable or without a time frame. Developing an appropriate time frame for a goal to be met requires clinical experience. The authors suggest using a "daily" time frame so that the outcome will be evaluated frequently. Failure to get input from the client in goal-setting is another common problem encountered in the planning step. Once the goals have been set and
agreed upon, the nurse decides which interventions will be selected for the
client. The nurse uses critical thinking skills and various guidelines to select
the most appropriate interventions. These guidelines may include individual
state nurse practice acts, state boards of nursing standards, the Joint Commission
on Accreditation of Health Care Organizations (JCAHO) standards of care.
|
