Reference:
- Lecturer (Tuiza)
Planning involves designing nursing activities. It is required to prevent, reduce, or eliminate a client’s health problems through an intentional, systematic process of decision-making and problem-solving. It utilizes the client’s assessment data and diagnostic statements for direction in formulating client goals and designing nursing interventions.
Nursing Care Plan
The end product of this phase is a Nursing Care Plan (NCP). NCPs may be standardized (used for specific populations with predictable, common problems) and/or individualized (tailored to unique needs).
| Type of Planning | Description |
|---|---|
| Initial Planning | Admission assessment that develops the initial comprehensive plan of care that is initiated as soon as possible. |
| Ongoing Planning | Occurs at the beginning of every shift for determining required care for a nurse’s shift. It determines: - Changes in health status - Set priorities and decide problems to focus on - Coordinate the nurse’s activities |
| Discharge Planning | The anticipation and planning for client needs after discharge. Effective discharge planning begins at first client contact. |
Creating NCPs
An NCP should contain aspects of restoration of health, prevention of disease, and maintenance of health. On-going assessment is also outlined for continual use of the care plan.
- Date and sign the plan. This is done for evaluation, review, and future planning. Accountability is expressed with a signature.
- Category headings are used to compartmentalize the pertinent entries for each phase of the nursing process.
- Use standardized, approved medical notation. This keeps the plan succinct yet meaningful between members of the healthcare team.
- Nurses may refer to procedure books rather than outline procedures within the plan itself, e.g., “See unit procedure book for tracheostomy care.”
- Be specific. The details of an intervention (e.g., duration, time) is outlined comprehensively to assure proper compliance between shifts.
- Individualize. Care is not always a stenciled activity. Client choices and preferences are considered when planning care.
- Multidisciplinary Coverage: collaborative interventions should be used, adhering to the holistic aspect of care. Referrals to dietitians, occupational therapists, physicians, etc. are included in the care plan.
- Discharge Planning: plans for discharge and home care needs should be included in the care plan.
Planning Process
- Priority Setting: the assignment of problems as high, medium, or low priority.
| Priority Level | Cases, Examples |
|---|---|
| High | Life-threatening; impaired cardiopulmonary function - Altered respiratory status (r/t secretions, pain, fatigue) - Alteration in fluid volume (fluid loss r/t fever, diaphoresis) |
| Medium | Health-threatening; acute illness and decreased coping ability - Anxiety (r/t difficulty breathing) - Concerns over work and parenting roles |
| Low | Normal developmental needs; requires minimal nursing support - Impaired nutritional status (r/t anorexia, nausea, increased metabolism) - Self-care deficit (r/t weakness) |
- Establishing Client Goals/Desired Outcomes: goals are broad statements, while desired outcomes are specific, measurable statements. Here are some examples:
| Diagnosis | Goal | Desired Outcomes |
|---|---|---|
| Alteration in mobility | - Improved mobility - Ability to bear weight on affected leg | - Ambulate with crutches by the end of the week - Stand without assistance by the end of the month |
| Altered respiratory status related to poor cough effort, secondary to incision pain and fear of damaging sutures | - Effective airway clearance | - Clear lungs upon auscultation during the entire postoperative period. - No skin pallor or cyanosis by 12 hours postoperation. - Demonstrate good cough effort within 24 hours postoperation. |
Timespan
Goals can be generally considered as short-term (within days or even hours), or long-term (within weeks or months).
- Selecting Nursing Interventions:
- Independent interventions are those activities which nurses are able to initiate on the basis of their knowledge and skills.
- Dependent interventions are those carried out under the orders of a licensed physician.
- Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, and dietitians.
- Writing Individualized Nursing Interventions: written interventions follow the verb-condition/modifier-time element format. For example:
- Measure and record (verb) ankle circumference (condition/modifier) daily at 0900 (time element)
- Apply (verb) spiral bandage firmly (condition/modifier) to left lower leg.
- Assist (verb) client with tub bath (condition/modifier) daily at 0700 (time element)
Delegation
The planned care may be delegated to those qualified, with supervision. It is the task of the delegator to determine the most appropriate and qualified delegees for the task. Certified nursing assistants (CNAs) and unlicensed assistive personnel (UAPs) are generally allowed to aid in positioning, feeding, recording of intake and output, ambulating, and vital signs (but not interpretation) and bathing. The following are never delegated:
- Unstable clients: newly admitted patients, those returning from procedures, those post-operative, those with unstable vital signs, unstable blood sugar, and unstable neurological status
- Evaluation: interpreting data, lab values, pain, and vital signs are all tasks of the nurse
- Assessment: initial, first, primary assessment of the patient
- Teaching: initial, first, primary education of the patient