Online Companion: Nursing Fundamentals: Caring & Clinical Decision Making

Summary
Chapter 13: Outcome Identification and Planning

Outcome identification and planning are essential components of the nursing process. The purposes of outcome identification and planning are to provide direction to ensure quality nursing care, to improve communication within the health care system, and to provide continuity of care. An outcome statement for a client with a problem-oriented diagnosis should describe the expected client status (behavior or function) when a nursing diagnosis has been resolved and the modification of the condition that places the client at risk. The outcome statement when a client has a wellness diagnosis should be a statement of the enhancement of a client’s positive adaptation.

Expected outcomes are part of the planning process. Nursing-sensitive client outcomes are those that reflect the direct influence of nursing interventions. The four elements of outcome identification and planning are (1) establishing diagnosis priorities, (2) developing expected client outcomes and establishing outcome criteria, (3) planning nursing strategies, and (4) writing the nursing care plan and nursing orders. The nursing care plan includes the diagnosis, outcome statements, nursing interventions, and evaluation criteria for determining whether outcomes have been met. Ideally, the nurse and client should be planning for the discharge of the hospitalized client as soon as possible after admission. Developing expected outcomes and writing a nursing care plan require critical (problem-solving) thinking.

The four types of care plans are student-oriented, standardized, institutional, and computerized. Student-oriented care plans are detailed documents used for teaching. Standardized care plans are preplanned and preprinted guidelines for the nursing care of client groups with common needs. Institutional nursing care plans are documents used by individual hospitals and agencies that are usually a part of the medical record. They may be individualized. Computerized care plans are standardized plans created and stored in the computers. They also may be individualized.

When determining priorities, the nurse should consider the client’s basic needs and safety first, along with anticipated nursing diagnoses, based on the client’s situation. Determining priorities also requires involvement by the client, family members, and significant others. Priorities are not constant. They change with changes in the client’s condition and responses.

Expected outcome statements include (1) the subject, or client; (2) a task statement, the hoped-for client behavior or function; (3) the criteria by which the nurse will determine whether the expected outcome is met, usually the absence of the defining characteristics for the nursing diagnosis; (4) the conditions, or qualifying statements or conditions for meeting the expected outcome, such as “in a wheelchair” or “while on a soft diet;” and (5) the time frame within which that outcome is expected to be reached.

Each expected outcome statement should address only one nursing diagnosis. A single nursing diagnosis may require more than one expected outcome. Short-term expected outcomes focus on the etiology of a problem and cover a short period of time, within hours or days. Long-term expected outcomes focus on the problem and cover a longer time frame. Expected outcomes should be constructed to be realistic, mutually desired by the client and nurse, and attainable within a defined time period.

A nursing intervention is an action performed by a nurse that helps the client achieve the results specified by the expected outcome. More than one intervention may be needed for each outcome. Interventions are prioritized according to the order in which they will be implemented. Interventions should (1) address the “etiology” component of the nursing diagnosis, (2) be based on clinical guidelines and standards for nursing care when available, (3) be compatible with the client’s abilities and value system, and (4) pose minimal risk.

A nursing order is a statement written by the nurse that is within the realm of nursing practice to plan and initiate. The elements of nursing orders are (1) the date; (2) an action verb stating the nurse’s action; (3) a detailed description of what, when, where, and how the nurse will act; (4) a description of when, how often, and how long the nursing action is in effect; and (5) a signature implying legal and ethical accountability.

Nursing interventions are classified as independent, interdependent, and dependent. Independent nursing interventions are those sanctioned by professional nurse practice acts. They do not require direction or an order from another health care professional. Interdependent nursing interventions are actions that are implemented in a collaboration or consultation with other health care professionals. Dependent nursing interventions are those that require an order from other health care professionals. All nursing interventions require critical thinking. All nursing interventions should be accompanied by appropriate rationale or scientific explanations.

Evaluation of care involves tracking the client’s progress toward achievement of expected outcomes. Nursing researchers at the University of Iowa have developed the Nursing Outcomes Classification (NOC), focusing on function, physiology, psychosocial aspects, health knowledge and behavior, perceived self-health, and family health.