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Planning in the Nursing Process
- Prioritize problems/ diagnoses
- Formulate goals/ desired outcomes
- Select nrsing interventions
- Write nursing interventions
What is Planning?
A deliberative, systematic phase of the nursing process that involves decision making and problem solving. The nurse refers to the client's assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problem.
When does Planning happen?
- Begins with the first client contact and continues until the nurse-client relationship ends (discharged).
- Its Multidisciplinary (all health care providers interacting with the client)
Types of Planning and definition?
- Initial Planning: The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. Planning should be initiated as soon as possible after the initial assessment.
- Ongoing Planning: Done by all nurses who work with the client. As nurses obtain new information and evaluate the client's responses to care, they can individualize the initial care plan further. Purposes; to determine whether the client's health status has changed, set priorities for the client's care during the shift, decide which problems to focus on during the shift, coordinate the nurse's activities so that more than one problem can be addressed at each client contact.
- Discharge Planning: The process of anticipating and planning for needs after discharge. Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client's ongoing needs.
What is a Standardized Care Plan?
A formal plan that specifies the nursing care for groups of clients with common needs.
Standards of Care
Standardized care plans, protocols, policies, and procedures are developed and acceptable standards are ment and promote efficient use of nurses' time by removing the need to author common activities that are done over and over for many of the clients on a nursing unit.
How are Standardized care plans become Individualized care plans?
- Standardized care plans for are for predictable, commonly occurring problems
- Idividual plan for unusual problems or problems needing special attention
- standard care plan can be initiated then a patient condition changes which creates an individual care plan
An _____ _____ plan is tailored to meed the unique needs of a specific client- needs that are not addressed by the standardized plan.
What are Protocols in the standards of care and standardized care plans?
Are preprinted to indicate the actions commonly required for a particular group of clients. Example; an agency may have a protocol for admitting a client to the intensive care unit or for caring for a client receiving continuous epidural analgesia.
_____ and _____ aredeveloped to govern the handling of frequently occurring situations. Example; a hospital may have a policy specifying the number of visitors a client may have
Policies and Procedures
What are the Guidelines for Care Plans?
- Date and sign the plan
- Use category headings
- Use standardized/approved medical or English symbols and key words
- Be specific
- Refer to procedure book or other sources rather than including steps
- Tailor the plan to the client
- Incorporate prevention and health maintenance
- Include interventions for ongoing assessment
- include collaborative and coordination activities include discharge plans and home care
In the Planning Process, nurses engages in what activities?
- Setting priorities: The process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
- Establishing client goals/desired outcomes: In terms of obervable client responses, what the nurse hopes to achieve by implementing the nursing interventions. nurse and client set goals
- Selecting nursing interventions: Are the actions that a nurse performs to achieve client goals.
- Writing individualized nursing interventions on care plans: Nursing interventions on the care plan are dated when they are written and reviewed regularly at intervals that depentd on the individual's needs.
What is an example of Short Term and Long Term Goals?
Short-term goals might be "Client will raise right arm to height by Friday." A long-term goal might be "Client will regain full use of right arm in 6 weeks."
What is the relationship of desired goals and Nursing diagnoses?
- Goals derived from the client's nursing diagnostic label
- Diagnostic labelcontains the unhealthy resopnse (problem)
- Must write the desired outcome/outcomes that demonstrates resolution of the problem.
What are the types of Nursing Intervention?
- Independent Interventions: are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.
- Dependent Interventions: are activities carried out under the physician's orders or supervision, or according to specified routines.
- Collaborative Interventions: are actions the nurse carries out in collaboration with other health team members
Nursing Interventions and Activites
- Actions nurse performs to achieve goals/desired outcomes
- Focus on eliminating or reducing etiology of nursing diagnosis
- Treat signs and symptoms and defining characteristics
What are the Criteria for chossing interventions?
- Sage and appropriate for the client's age, health, and condition
- Achievable with the resources available
- Congruent with the client's values, beliefs, and culture
- Congruent with other therapies
- Based on nursing knowledge and experience or knowledge from relevant sciences
- Within established standards of care and cite your sources of evidence