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is a conscious, deliberate activity involving decision making, critical thinking, and creativity. Discuss with family and patient to derive otucomes and then identify nursing interventions to achieve outcomes. THe end product of formal planning is a holistic plan of care.
it is done while performing other nursing process steps. Mental planning
Describe relationship of assessment and nursing diagnosis to planning patient care
To develope a plan of care with realistic goals and effective nursing orders, you must have accurate, complete assessment data and correctly identified and prioritized nursing diagnoses. THe goals/desired outcomesflow logically from tne nursing diagnoses. By stating what is to be achieved, thagoals then suggest nursing inteventions (which are written as nursing orders in the planning interventinos phase). THe plan of care is carried out in the implementation phase. In the evaluation step , the goals/desired outcomes sever as criteria for evaluating whether the nursing care has been effective.
is done for the purpose of identifying patient problems and creating the care plan.
llows you to revise and individualize the patient's care plan as new data are obtained.
is done to evaluate the patient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hospital or other healthcare agency.
Policies and prodedures
similar to ruels andregulations. when a situation occurs frequently or requres a consistant response regardless of who handles it, management developes a policy to govern who it is to be handeled.
cover specific actions usually requires for a clinical problem unique to a subgroup of patients.
Standardazied( model) nursing care plans
- detail the nursing car that is ususally needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical condition. It:
- provide more detailed interventions. they mad add to or delete from unit stndards of care
- Are organized by nursing diagnosis and include specific patient goals and nursing orders
- Are a part of the patient's comphrehensive car plan and become a part of the permanet record
- Describe ideal rather than minimum nursing care
- Allow you to incorporate addendum care plans
- Include checklists, blanklines, orempty spcaes so that you can individualized goals and interventions.
are often used in managed care systems. they are otcomes-based, interdisciplinary plans that swquence patient care according to case type. They specify predicted patient otucomes and broad interventions for each day. or in some situations, for each hour. They describe the minimal standard of care required to meet the recommended lenght of stay for patients with aparticular condition or diagnosis-related group.
also called expceted outcomes, desired otucomes, or predicted outcomes, desribe the changes in patien thealthstatus that you hope to achieve.
Describe the preocess of creating client-centered goals and idnetifying expceted outcomes
- Must include both goals and expceted outcomes on the care plan becuase a broad goal does not provide enough guidence for evaluating patient reponses to care. Cobine goal and specific expected outcome into a signel statement by writting, "as evidenced by" ex. Constipation will be relieved as evidenced by soft formed bowle movement within 24 hours.
- THe goal have to be presice,descrpitive, clearly sated.
- Set Short-term goals and long-term goals
- Must have subject(client or part of the client), action verb(ex on pg.93) and performance criteria - concrete, observable, msearurable in order to evaluate otcomes it specify how, what, when , or where something is to be done, Amount, quality, accuracy, speed, distance. Target time - The realistic date or time "when" part of the performance criterion. Special condition - amount of assistance or resources needed or the experices/treatments the client should have to perfrom the behavior.
- To evaluate the quality of written expected outcomes go to page 99 14 guides.
Direct and Indirect nursing interventions
- Direct-care interventions: is one performed through interaction with the client. Acticities include phisical care, emotional support, and patient teaching
- Inidrect-care intervention: performed away from the client but on hbehalf of a client or gropu of clients. Activities include advocacy, managing the environment, consluting with other members of the healthcare team, and making referrals.
are actions, based on clinical judgment and nursing knowledge, thatnurses perform to achieve client otucomes. INterventions are also refered to as nursing actions, measures, strategies, and activities.
HOw to select nursing interventions
- 1. Review the nursing diagnosis. Nursing orders should flow from the etiology and sometimes from the problem side of the diagnosis.
- 2. Review the desired patient outcomes. Outcomes suggest nursing strategies that are specific to the individual patient.
- 3. Identify several interventions/actions that might achieve the desired outcomes for the nursing diagnosis.
- 4. Choose the best interventions for this patient—those expected to be most effective in helping to achieve client goals.
- 5. Individualize the standardized interventions to meet the unique needs of the patient.
- you will perform or delegate planned interventions that is, carry out the care plan.
- It ends when you document the nursing actions in the chart; it evolves into evaluationas you document the resultingclient responses.
- It is doing, delegating, and documenting.
means working with patients and other caregiver to plan, make decisions, or perform interventions.
Different aspects in the process of implementing the plan fo care.
- It is important to orgonize your work bfore implementing care to insure efficiency. In today's work environment, nurses have heavy workloads and cannot afford to waste time. Making good use of time helps the nurse to prevent errors and to provide the best possible care for patients.
- The following preparations should be made before implementing care:
- ● Establish feedback points.
- ● Check your knowledge/skill to see if you are qualified to perform the intervention.
- ● Organize/prepare supplies and equipment.
- ● Prepare the patient (e.g., assure that the intervention is still needed, check for readiness, tell the patient what she will experience and what she is expected to do, and provide privacy).
Deligation of nursing implementation
- is the process of directing another poerson to perform a task or activity, it is a transfer of authority or responsibility. The person deligating retains accountability ofr the outcome of the activity.
- These are the "five rights" of delegation:
- ● Right task
- ● Right circumstance (patient)
- ● Right person (personnel)
- ● Right direction/communication
- ● Right supervision
- is the process of directing, guiding, and influencing the performance of the delegated task. when you delegate tasks to a NAP or LPN you or another RN must be availabe to answer question and provide hlelp if necessary.YOu are responsible for providing supervision and evaluationg the outcomes.
- Supervisory activities should include the following:
- ● Monitor the person's work to be sure it complies with agency policies and procedures and standards of practice.
- ● Intervene, if necessary. Perhaps demonstrate caregiving activities.
- ● Obtain and provide feedback from the worker.
- ● Give positive, as well as negative, feedback often.
- ● If the NAP's performance was not acceptable, communicate privately with the NAP.
- ● Evaluate client outcomes.
- ● Ask the client for input after the care is given.
- ● Ensure proper documentation.
Ways in which the nurse can assist the client in achieving goasl and outcomes
- The following actions promote client participation:
- ● Assess the client's knowledge about her illness and the treatments, and provide the necessary information
- ● Assess the client's supports and resources
- ● Be sensitive to the client's cultural, spiritual, and other needs and viewpoints.
- ● Realize and accept that some attitudes cannot be changed.
- ● Determine the client's main concerns.
- ● Determine the client's priorities.
- ● Help the client to set realistic goals.
- Invlove the pateint as much as possible in goal setting, becuase goal achievement is more likely if the clint believes the goals are importantand realistic.
Evaluation the final step of Nursing process
- it is planned, ongoing, systematic activity in which you will make judgments about:
- the client's progress toward desired health otcomes
- the effectiveness of the nursing care plna
- the quality of nursing care inth healcare seting