Nursing Process: Step 3-Planning
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Nursing Process: Step 3-Planning. BY RENI PRIMA GUSTY, SK.p,M.Kes. POKOK BAHASAN . Mendiskusikan pentingnya memprioritas diagnosa keperawatan Mendiskusikan Intervensi perencanaan yang berfokus pada klien yang dibuat perawat dan kolaborasi tim kesehatan lainnya

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Nursing process step 3 planning

Nursing Process: Step 3-Planning

BY

RENI PRIMA GUSTY, SK.p,M.Kes


Pokok bahasan

POKOK BAHASAN

  • Mendiskusikan pentingnya memprioritas diagnosa keperawatan

  • Mendiskusikan Intervensi perencanaan yang berfokus pada klien yang dibuat perawat dan kolaborasi tim kesehatan lainnya

  • Mediskusikan peran mandiri & kolaborasi perawat dalam intervensi.

  • Mendiskusikan peran perawa dalam kaitan dengan tidakan penceahan terjadinya eror intervensi yang dilakukan sendiri maupun team kesehatan

  • Mendemonstrasikan kemampuan menulis tujuan dan kriteria hasil pada contoh kasus


Definition

Definition

  • According to (Potter, Perry, Ross-Kerr & Wood, 2006), planning “involves establishing client goals and expected outcomes and selecting nursing interventions” (p.198).


Planning

Planning

Determine desired outcomes and plan specific nursing interventions to achieve them

This is done with the patient (and family/whanau as appropriate)

Objective

Outcome

Goal

Of or relating to a goal or aim

Something that follows from an action; result; consequence

The aim or object towards which an endeavour is directed


Planning1

Planning

  • It is third stage of the nursing process.

  • Interventions are selected to solve the client’s health needs and to attain goals and outcomes.

  • Decision-making and problem solving skills are required


Planning2

Planning

  • Planning require:

    • review of the literature

    • collaborates with client, family and other health team members


Planning3

Planning

Effective planning depends on the quality and comprehensiveness of the assessment

  • Determine the problems

  • Establish the risks and priorities- How ill are they?

  • Can they breath adequately (safe airway?)

  • Are they in pain? (physical/ psychological)

  • Can they maintain a safe environment? If not why not? (Drugs, drink, mental or psychological problem?)

  • Non-compliance with medical advice


Priorities

Priorities

  • Priorities are required to help the nurse determine nursing interventions when a client has a number of problems.

  • Because often clients have a number of problems, the client and nurse can decide urgency of the problem, nature of treatment and relationship between diagnoses.


General guidelines for setting priorities

General Guidelines for Setting Priorities

  • Take care of immediate life-threatening issues.

  • Safety issues.

  • Patient-identified issues.

  • Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.


Nurse identified priorities

Nurse Identified Priorities

  • Composite of all patient’s strengths and health concerns.

  • Moral and ethical issues.

  • Time, resources, and setting.

  • Hierarchy of needs.

  • Interdisciplinary planning.


Priorities1

Priorities

  • Priorities may be high, intermediate or low. Depends on the urgency of the situation.

  • High priority if untreated could be harmful to the client Ex: Decreased cardiac output would be high priority

  • Intermediate would be considered non urgent, non life-threatening. Ex. sore throat

  • Low priority may not be connected to the direct illness or prognosis but may affect the individual’s future well-being. Ex. dressing change in the ambulatory setting.

    (See Priority Setting Potter et al., 2006 p.199)


Client goals

Client Goals

  • Broad statements that represent the health state/level of self care for the client

  • Should be realistic and based on the client’s needs

  • Should also aim to prevent and rehabilitate the client

  • Develop collaboratively between client and nurse

  • Note:if the client is cognitively or physically impaired, the healthcare team works on behalf of the client


Client goals1

Client Goals

  • Client Goals can be short or long term goals

  • Short-Term Goal- objective is to be attained within a short time i.e.: a week

    • Ex: client will achieve comfort within 24 hours post surgery

      Long-Term Goal- achieve over a longer period of time i.e: weeks or months.

    • Ex: client will follow post-op activity restriction for 1 month


Short term goals

Short-Term Goals

  • Outcomes achievable in a few days or 1 week

  • Developed form the problem portion of the diagnostic statement

  • Client-centered

  • Measurable

  • Realistic

  • Accompanied by a target date


Long term goals

Long-Term Goals

  • Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems


Expected outcomes

Expected Outcomes

  • Expected Outcomes are developed on the basis of the nursing diagnoses and client goals.

  • Also known as evaluative criteria

  • Desired behaviours or responses that the nurse and where applicable, the client expect to occur as a result of the interventions taken by the nurse

  • Enable the nurse and client evaluate whether the pan of care has been successful in meeting the goal(s)


Nursing process step 3 planning

Outcomes need to be:

S pecific What will happen?

M easurable How will you know it has happened?

A chievable Can it happen?

R ealistic Is it realistic to expect it to happen?

T imeframed When will it happen?


Sample outcome statements

Sample outcome statements

  • Wound will show 50% granulation within 2 weeks

  • Wound will show evidence of epithelialisation within 3 weeks

  • Comfort will be maintained during episode of care, as stated by patient

  • Oedema will be reduced within 3 weeks with the use of compression bandaging

  • Exudate will be contained and strike through prevented until infection resolved


Expected outcomes1

Expected Outcomes

  • Client Centered -reflect client behavior & response

  • Singular - address only one behavior or specify one outcome

  • Measurable to the extent possible-the desired outcome can be determined or not

  • Client specific-where possible the degree of proficiency required for the outcome to be considered achieved by the client is stated

  • Time limited- where appropriate, the time frame for an expected response should be included

  • Mutual- where possible, the client should be in agreement with the outcomes to ensure a greater chance of being successful

  • Realistic -must be attainable


Examples of expected outcomes

Examples of Expected Outcomes

  • Client will explain reasons for activity restriction by day of discharge.

  • Client will sit up in chair 20 minutes without abnormal heart rate by day 2.

  • See handout for examples of verbs to help formulate client outcomes (p.4)


Goals and expected outcomes

Goals and Expected Outcomes

  • Critical thinking is required

  • Nursing knowledge coupled with experience will help the nurse determine the ‘goal’

  • A client centered goal is specific and able to be measured and reflects the person’s highest level of wellness.

  • Goal needs to lead to prevention.


Nursing interventions

Nursing Interventions

  • Nursing interventions are decided after goals and expected outcomes are confirmed.

  • Assist the client to move form his/her present state of health to that which is identified in the goal and outcomes.


Interventions should

Interventions should:

  • Monitor, prevent & manage health problems/concerns & risk factors

  • Promote optimum function, independence & sense of wellbeing

  • Achieve expected outcomes


Interventions

Interventions

  • Direct interventions: actions performed through interaction with clients.

  • Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.


Selecting nursing interventions

Selecting Nursing Interventions

  • Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking.

  • Nursing interventions are directed at eliminating the etiologies.


Selecting an intervention

Selecting an intervention

  • The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects.

  • Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.


Communicating the plan

Communicating The Plan

  • The nurse shares the plan of care with nursing team members, the client, and client’s family.

  • The plan is a permanent part of the record.


Types of planned client focused interventions

Types of Planned Client Focused Interventions

  • Nurse-Initiated Interventions

  • Physician-Initiated Interventions

  • Collaborative Interventions


Nurse initiated interventions

Nurse-Initiated Interventions

  • Nurse-Initiated Interventions – are the independent response of the nurse to the client’s health care requirements. They are automatic reactions based on scientific rationale that are expected to benefit the client

  • No order required from the physician

  • Ex. Interventions to increase person’s knowledge of nutrition- Discuss Canada’s food guide


Physician initiated interventions

Physician-Initiated Interventions

  • Physician-Initiated Interventions-interventions based on physician’s response to treat the client.

  • Nurses carry out physician’s orders

  • Requires expertise in technological nursing knowledge and nursing responsibility

  • Ex. Give a medication or change a dressing


Collaborative interventions

Collaborative Interventions

  • Collaborative Interventions-therapies that require the knowledge and skills of a number of professionals to provide care to a client.

  • Ex. Client with a stroke-requires multiple interventions from nursing, physiotherapy etc.


Client interventions

Client Interventions

  • Client Interventions- are interventions carried out by the client to meet his/her goals and expected outcomes.

  • Also remember that client interventions are not mirror nursing interventions

  • Ex: Client attends the fitness program three times per week


Writing interventions

Writing Interventions

  • Interventions must be written in the following format: verb-noun-modifier

  • Ex: Administer Tylenol 325 mg po for temperature > than 38.5

  • Note: Interventions are action verbs


Independent and interdependent role of the nurse

A nurse thinks clearly and does not select interventions randomly

Nurse considers a number of factors such as: characteristics of the nursing diagnosis, expected outcomes, nursing knowledge, feasibility of the intervention, acceptability to the client, and nursing competencies.

Collaboration with the client, family and other members of the health team is necessary

Review previous clinical experiences and priorities to select the best nursing interventions

Independent and Interdependent Role of the Nurse


Prevention of intervention errors

Nurse initiated, physician initiated and collaborative interventions require the nurse to us critical thinking and decision making.

Nurse must decide if the interventions are appropriate for the client

Important to recognize errors such as a physician’s order, incorrect therapy, etc.

Prevention of Intervention Errors


Nursing process step 3 planning

And Always on the Move

Assess

Evaluate

Diagnose

Implement

Plan


Summary

Summary

  • Prioritization of nursing diagnosis

  • Discussion on the types of planned client focused interventions

  • Discussion on the independent and interdependent role of the nurse in relation to interventions directed by other health care professionals.

  • Discussion on the role of the nurse as it relates to the prevention of intervention errors

  • Demonstrate ability to write short and long term goals and expected client outcomes based on simulated client situations


Nursing process step 3 planning

Thank you

Thank you


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