Plano de cuidados de enfermagem como estratégia de ensino

Plano de cuidados de ensino.
Exibições: 23,539 Comentários: 1.
Atualmente estou trabalhando no meu primeiro plano de ensino. Espero que eu esteja no caminho certo. É o que eu tenho até agora.
Por favor, ajude e me diga se estou fazendo isso corretamente. Obrigado.
Status do Código: Código Completo.
Alergias: sem alergias conhecidas.
Status do Código: Código Completo.
Alergias: sem alergias conhecidas.
Álcool / tabaco / outras drogas: bebidas não-fumantes ocasionalmente. Não uso de drogas ilegais.
História cirúrgica passada: sem cirurgias passadas.
História social: solteira e vive com a família; não fumante; bebe ocasionalmente.
Neuro: Alerta e orientado para pessoa, lugar, comportamento adequado para a idade. Não c / o de tonturas, dor de cabeça, perda de memória, perda de consciência. Não observou paralisia. Os alunos são reativos à luz e iguais. Sem visão ou perda de audição, Discurso claro.
Cardíaca: freqüência cardíaca regular e ritmo. Pulsos periféricos palpáveis ​​nas extremidades superior e inferior. Não foi observado nenhum edema.
Respiratório: Pulmões claros. Não observou falta de ar. Saturação de oxigênio 99% no ar ambiente. Reenchimento capilar inferior a 3 segundos.
GI: Abdomen não distendido, não tierno, sons intestinais ativos em todos os 4 quadrantes. Não há náuseas ou vômitos. Nenhuma queixa de constipação ou diarréia, frequência normal.
GU: Não há incontinência urinária, urgência ou alterações na produção de urina.
MU: dor no joelho esquerdo com descanso e movimento. Inchaço observado no joelho esquerdo. Escala de movimento normal para extremidades superiores R / L e extremidade inferior direita.
Risco de lesão relacionada à falta de conhecimento de exercícios pós-operatórios relacionados a nenhuma exposição prévia.
2. Depois de ensinar, o Paciente listará três benefícios de exercícios pós-operatórios contínuos em casa.
3. O paciente relacionará suas opiniões sobre por que os exercícios são importantes para continuar fazendo após a alta. Nível na realização dos exercícios pós-op.
Os exercícios demonstrados são:
Bombas de tornozelo: bombeando o pé para a frente e para trás.
Gluteus aperta: apertando e segurando seu glúteo por 3 segundos e soltando.
Músculos quádruplos: apertando o músculo da coxa e empurrando para trás no joelho contra a cama mantendo esta posição por 3 segundos e soltando.
Quads de arco curto: pegando uma toalha e rolando na coxa e levantando o pé diretamente da cama ao mesmo tempo, não levante a coxa do rolo e segure esta posição por 3 segundos.
Slides de calcanhar & quot; tomando o fundo do calcanhar e deslizando-o em direção ao seu glúteo e dobrando o joelho ao mesmo tempo.
Levantamento de perna direta: levando a perna afetada e levante lentamente a perna de 8 a 12 polegadas do chão.
Pt declarará verbalmente três medidas:
1. Ao exercer a perna afetada, isso aumentará o fluxo sanguíneo para o músculo eo osso para ajudar na recuperação.
2. O exercício manterá minhas articulações móveis.
3. O exercício também manterá o tônus ​​muscular no joelho afetado.
visão geral: uma sinopse sobre o que será ensinado no (s) objetivo (s) do curso: o (s) objetivo (s) ou desfecho (s) que você deseja que seu aluno alcance como resultado da lição que você planeja objetivos: a informação mais específica que o aprendiz sairá do curso sabendo que vai atingir os objetivos que você determinou. conteúdo: um jogo por jogo do conteúdo específico que será ensinado e na sequência que acontecerá. seu conteúdo deve abordar e cobrir todos os objetivos. Esta parte do plano de aula escrito é apresentada em um formato de estrutura de tópicos. procedimentos e materiais: como todos os itens acima serão alcançados, ou seja, documentos de palestra, demonstração, discussão, etc., que podem ser usados ​​e os recursos que podem ser necessários para que a lição seja bem-sucedida e essencial para ensinar seu plano de aula estão listados e podem incluir demonstrações, áudio-visuais, folhetos, experiências, histórias, jogos e outros itens criativos. avaliação: determinar se você atendeu os objetivos do plano de ensino. Isso pode ser feito através de uma demonstração de retorno, breve post teste, breve pergunta e retorno resposta sessão com o cliente para verificar que eles entendem a informação corretamente ou uma tarefa que o participante precisa executar. como você pode ver, segue muito os passos de um plano de cuidados. no entanto, o próprio plano de ensino se torna uma intervenção de enfermagem de um diagnóstico de enfermagem. O diagnóstico de enfermagem que você está escolhendo é:
O paciente já estava ferido no acidente do scooter e teve que operar? A falta de conhecimento de exercícios pós-operatórios relacionados a nenhuma exposição prévia não soa como um fator de risco para uma lesão física; Este diagnóstico tem a ver com possíveis lesões físicas para o corpo. Não faz sentido que não saber como fazer exercícios pós-operatórios será uma causa de ferimento físico para alguém. Como você pode explicar isso? uma vez que você está se concentrando no ensino, um diagnóstico melhor seria conhecimento deficiente, exercícios pós-operatórios relacionados à falta de informação aeb paciente afirmando para a enfermeira antes da alta "não lembro de todos os exercícios e devo continuar em casa ? & quot; ou o seu plano de ensino pode ser incluído junto com outras intervenções de enfermagem para avaliação, cuidado e gerenciamento de mobilidade física comprometida relacionada ao comprometimento musculoesquelético secundário a artrite, trauma físico e cirurgia aeb [sinais e sintomas do movimento limitado do joelho]. Existem 4 tipos de intervenções de enfermagem e seu plano de ensino seria educado para o paciente:
avaliar / monitorar / avaliar / observar (para avaliar a condição do paciente, cuidar / executar / fornecer / auxiliar (realizar atendimento ao paciente efetivo) ensinar / educar / instruir / supervisionar (educar o paciente ou cuidador) gerenciar / consultar / contato / notificar (gerenciar os cuidados em nome do paciente ou cuidador)
2. Depois de ensinar, o paciente listará três benefícios de continuar exercícios pós-operatórios em casa.
3. O paciente relacionará suas opiniões sobre por que os exercícios são importantes para continuar fazendo após a alta. nível na realização dos exercícios pós-op.
Os exercícios demonstrados são:
bombas de tornozelo: bombeando o pé para frente e para trás.
aperto de glúteo: apertando e segurando seu glúteo por 3 segundos e soltando.
quad músculos: apertando o músculo da coxa e empurrando para trás no joelho contra a cama mantendo esta posição por 3 segundos, em seguida, soltando.
quads de arco curto: pegando uma toalha e rolando na coxa e levantando o pé diretamente da cama ao mesmo tempo, não levante a coxa e role esta posição por 3 segundos.
lâminas de calcanhar & quot; tomando o fundo do calcanhar e deslizando-o em direção ao seu glúteo e dobrando o joelho ao mesmo tempo.
aumento direto da perna: levando a perna afetada e levantar lentamente a perna de 8 a 12 polegadas do chão.
Pt declarará verbalmente três medidas:
1. Ao exercer a perna afetada, isso aumentará o fluxo sanguíneo para o músculo eo osso para ajudar na recuperação.
2. O exercício manterá minhas articulações móveis.
3. O exercício também manterá o tônus ​​muscular no joelho afetado.
estilo de aprendizagem: este é outro item de avaliação. pergunte como ele aprende melhor: veja procedimentos e materiais acima.

Plano de cuidados de enfermagem como estratégia de ensino
PLANEANDO CUIDADO DE ENFERMAGEM. PLANO DE CUIDADO DE ENFERMAGEM.
O terceiro passo do processo de enfermagem inclui a formulação de diretrizes que estabelecem o curso proposto de ação de enfermagem na resolução de diagnósticos de enfermagem e o desenvolvimento do plano de atendimento do cliente. Preceder este passo é a coleta de dados de avaliação e a formulação de diagnósticos de enfermagem.
Depois que uma enfermeira avalia completamente um cliente e determina os diagnósticos de enfermagem exclusivos (ou problemas) do cliente, um plano de ação é desenvolvido com metas específicas para resolver os diagnósticos de enfermagem ou problemas de saúde do cliente. Seguindo o componente de planejamento, o processo de enfermagem continua com a implementação de intervenções de enfermagem e avaliação do plano de atendimento do cliente.
Os quatro elementos críticos do planejamento incluem:
• Definir metas e desenvolver os resultados esperados (identificação do resultado)
• Planejamento de intervenções de enfermagem (com colaboração e consulta conforme necessário)
O objetivo, assim como todo o processo, do conceito de planejamento é ilustrado com teoria e exemplos. As estratégias para o planejamento efetivo de cuidados de enfermagem de qualidade são descritas juntamente com os problemas freqüentemente encontrados nesta etapa do processo de enfermagem. O papel do pensamento crítico no planejamento e identificação de resultados é enfatizado.
OBJECTIVOS DE IDENTIFICAÇÃO DE RESULTADOS E PLANEJAMENTO.
A Associação Americana de Enfermeiros (1998), em sua Norma de Prática de Enfermagem Clínica, identifica a identificação e o planejamento de resultados como princípios essenciais para assegurar o atendimento de enfermagem competente e descreve esses componentes em termos de sua significância no processo de enfermagem. Embora o objetivo geral do plano de atendimento de um cliente deve ser manter ou melhorar a saúde em um nível ótimo, o planejamento é um quadro para basear a prática científica de enfermagem.
Portanto, os propósitos do componente de planejamento do processo de enfermagem são fornecer orientação adequada para assegurar cuidados de enfermagem de qualidade para clientes individuais, apresentar um veículo para melhorar a comunicação da equipe e assegurar a continuidade na entrega de cuidados de enfermagem de qualidade individualizados para todos clientes.
As cinco etapas do processo de enfermagem são fundamentais no uso do raciocínio científico para a entrega de cuidados de enfermagem de qualidade individualizados em qualquer ambiente (Doenges, Moorhouse e Geissler, 1997). A capacidade de tomar decisões apropriadas com base em uma sólida base de conhecimento e estratégias de resolução de problemas é um comportamento esperado da enfermeira profissional.
Mais especificamente, espera-se que as enfermeiras profissionais pensem criticamente para processar dados e tomar decisões convincentes e inteligentes sobre planejamento, gerenciamento e avaliação de cuidados de saúde para seus clientes (Prechter, 1993). Ao combinar as habilidades de pensamento crítico inerentes ao processo de enfermagem com os diagnósticos de enfermagem identificados pelo cliente, a enfermeira pode se concentrar em resolver os diagnósticos de enfermagem do cliente com maior proficiência.
O planejamento do atendimento de enfermagem ocorre em três fases: inicial, contínua e alta. Cada tipo de planejamento contribui para a coordenação do plano abrangente de atendimento do cliente.
O planejamento inicial envolve o desenvolvimento do início do atendimento pela enfermeira que realiza a avaliação de admissão e reúne os dados abrangentes de avaliação de admissão. Devido a períodos de hospitalização cada vez menores, o planejamento inicial é importante para abordar cada problema priorizado, identificando os objetivos adequados do cliente e correlacionando os cuidados de enfermagem para acelerar a resolução dos problemas do cliente.
O planejamento contínuo implica uma atualização contínua do plano de atendimento do cliente.
Toda enfermeira que cuida do cliente está envolvida no planejamento contínuo. À medida que novas informações sobre o cliente são reunidas e avaliadas, as revisões podem ser formuladas e o plano inicial de cuidados torna-se mais individualizado para o cliente.
O planejamento de descarga envolve antecipação crítica e planejamento para as necessidades do cliente após a alta. O planejamento é sequencial, dinâmico e orientado para o futuro.
O planejamento inclui estabelecer prioridades, identificar metas e resultados esperados, desenvolver intervenções de enfermagem e documentar o plano de atendimento do cliente.
As diretrizes apropriadas são usadas para priorizar necessidades urgentes. Os diagnósticos de enfermagem do cliente são determinados e, em seguida, classificados por acordo mútuo da enfermeira e do cliente ou outros significativos. O componente de planejamento continua com um exame minucioso desta lista priorizada de diagnósticos de enfermagem e determinação dos objetivos do cliente e resultados desejados desejados. Depois de obter uma imagem clara sobre os diagnósticos e metas, as intervenções de enfermagem podem ser planejadas para alcançar os resultados desejados.
Na fase de planejamento, a enfermeira organiza "processos de pensamento para a tomada de decisões clínicas" (Doenges et al., 1997). Pensar criticamente é examinar uma questão propositadamente a partir de uma perspectiva orientada por objetivos. O pensamento crítico "baseia-se em princípios de ciência e método científico" (Alfaro-LeFevre, 1998). Portanto, o pensamento crítico é um procedimento útil no desenvolvimento de objetivos e na formulação de um plano para atingir esses objetivos. A formulação de objetivos é realizada usando dados válidos e confiáveis ​​previamente reunidos durante o processo de avaliação do processo de enfermagem.
O estabelecimento de prioridades é o primeiro elemento de planejamento. Ao estabelecer prioridades, a enfermeira examina os diagnósticos de enfermagem do cliente e classifica-os em ordem de importância fisiológica ou psicológica. Este método organiza os diagnósticos de enfermagem de um cliente em um formato operacional para o planejamento dos cuidados de enfermagem. Esses diagnósticos devem ser classificados mutuamente pela enfermeira e cliente ou família e outros significativos. O envolvimento do cliente no poder de decisão compartilhado ajuda a motivar o cliente e dá ao cliente um sentimento de controle, o que inspira a realização bem-sucedida de cada objetivo (Doenges et al., 1997).
Quando um cliente individual possui mais de um diagnóstico, a enfermeira e o cliente precisam estabelecer prioridades para identificar qual diagnóstico de enfermagem será abordado inicialmente no plano de atendimento (Carpenito, 1999). Ao comunicar este processo de tomada de decisão a outros membros da equipe de cuidados de saúde, a enfermeira encoraja uma abordagem ordenada para a obtenção de uma saúde ideal para cada cliente.
Várias diretrizes são usadas no estabelecimento de prioridades para determinar qual diagnóstico de enfermagem será abordado inicialmente. As necessidades básicas, a segurança e os desejos do cliente, bem como a antecipação de diagnósticos futuros devem ser consideradas. Um dos métodos mais comuns de seleção de prioridades é a consideração da hierarquia de necessidades de Maslow, que requer que um diagnóstico com risco de vida seja mais urgente do que um diagnóstico que não seja fatal. Uma vez que as necessidades fisiológicas básicas (por exemplo, respiração, nutrição, hidratação, eliminação) são atendidas até certo ponto, a enfermeira pode considerar as necessidades no próximo nível da hierarquia (por exemplo, ambiente seguro, condição de vida estável) e assim por diante a hierarquia até que todos os diagnósticos de enfermagem do cliente tenham sido priorizados.
A tabela a seguir ilustra esse processo.
Um guia útil para o estudante de enfermagem inicial seria examinar cada diagnóstico de enfermagem, determinar seu nível de necessidade e classificar a necessidade em ordem de prioridade.
Outra consideração na designação de prioridades é a preferência do cliente. Se for possível, o cliente deve sempre estar envolvido no processo de tomada de decisão de estabelecer prioridades. Se a enfermeira e o cliente não estabelecem prioridades, pode haver um curso e uma motivação contraditórios, o que pode levar ao descumprimento e à não resolução dos diagnósticos de enfermagem do cliente. O cliente deve participar na identificação de prioridades para que a natureza do problema, bem como os valores do cliente, sejam refletidos no curso de ação selecionado.
Um ponto adicional em relação ao estabelecimento de prioridades é a antecipação de diagnósticos futuros. Os diagnósticos de enfermagem de prioridades baixas e moderadas geralmente envolvem a prevenção do potencial antecipado ou diagnósticos de risco. Embora os possíveis diagnósticos de enfermagem possam não ser uma ameaça atual para o cliente, sua seriedade pode exigir que a enfermeira considere o desenvolvimento de intervenções de enfermagem direcionadas para a prevenção do problema. Por exemplo, um cliente na Unidade de Cuidados Pós-Intensidade pode ter um diagnóstico de enfermagem de alta prioridade de Padrão de Respiração Ineficaz relacionado à anestesia e medicamentos sedativos. Apesar do fato de que o cliente atualmente não tem problema nessa área, esse diagnóstico é, de fato, a base do protocolo da Unidade de Cuidados de Pós-Intensidade de monitorar o cliente de perto.
Estabelecer prioridades não significa que um diagnóstico deve ser totalmente resolvido antes de dar atenção a outro diagnóstico. As intervenções de enfermagem para diversos diagnósticos podem ser realizadas simultaneamente. No entanto, às vezes, é crucial que a enfermeira e o cliente identifiquem corretamente a ordem de prioridade dos diagnósticos de enfermagem do cliente para que o máximo esforço possa ser direcionado para a resolução do diagnóstico mais urgente.
A tabela seguinte ilustra esse processo:
ESTABELECENDO METAS E RESULTADOS ESPERADOS.
Depois de avaliar o cliente, formular diagnósticos de enfermagem e estabelecer prioridades, a enfermeira define metas e identifica e estabelece resultados esperados para cada diagnóstico de enfermagem. Os objetivos de estabelecer metas e resultados esperados são fornecer diretrizes para intervenções de enfermagem individualizadas e estabelecer critérios de avaliação para medir a eficácia do plano de cuidados de enfermagem.
Um objetivo é um objetivo, uma intenção ou um fim. Um objetivo é uma declaração ampla ou globalmente escrita descrevendo a mudança pretendida ou desejada no comportamento, resposta ou resultado do cliente. Um resultado esperado é uma declaração detalhada e específica que descreve os métodos através dos quais o objetivo será alcançado. Inclui aspectos como atendimento direto de enfermagem e ensino de clientes.
Os objetivos escritos precisam ser construídos de forma clara. Uma terminologia clara e precisa melhora as chances de que os objetivos sejam alcançados. Quando os objetivos são claramente escritos, seu estabelecimento fornece orientação para o plano de cuidados de enfermagem e para determinação da eficácia na avaliação de intervenções de enfermagem. Uma diretriz é fornecida para a mudança desejada no cliente, e o cliente tem uma idéia clara da direção a ser tomada para alcançar a resolução de cada diagnóstico de enfermagem. Os objetivos estabelecem critérios de avaliação adequados para medir a eficácia das intervenções de enfermagem planejadas para a resolução dos diagnósticos individuais de enfermagem do cliente.
Os objetivos devem ser estabelecidos para atender às necessidades imediatas, preventivas e de reabilitação a longo prazo, das necessidades do cliente.
Um objetivo a curto prazo é uma declaração escrita em formato objetivo demonstrando uma expectativa a ser alcançada na resolução do diagnóstico de enfermagem em um curto período de tempo, geralmente em poucas horas ou dias.
Um objetivo a longo prazo é uma declaração escrita em formato objetivo demonstrando uma expectativa a ser alcançada na resolução do diagnóstico de enfermagem por um longo período de tempo, geralmente durante semanas ou meses (Alfaro-LeFevre, 1997). Veja a exibição que acompanha para obter exemplos de metas de curto prazo e longo prazo.
Outra consideração é a precisão na identificação da etiologia do problema. Se a etiologia do problema for incorretamente identificada, o cliente poderá atingir o objetivo de curto prazo, mas o problema não será resolvido. Assim, é importante identificar corretamente a etiologia do problema.
Definir metas de longo prazo é importante no planejamento de alta de sucesso. Ele auxilia na coordenação de todos os membros da equipe de cuidados de saúde para atingir o mesmo objetivo geral, ou seja, a alta do cliente. A coordenação promove a continuidade do atendimento em contextos como o cuidado restaurador ou a saúde doméstica (ver a exibição que acompanha).
Depois que o objetivo for estabelecido, os resultados esperados podem ser identificados com base no objetivo. Dada a situação e os recursos exclusivos do cliente, os resultados esperados são construídos para serem:
• Mútuos desejados pelo cliente e pela enfermeira.
• Alcançável dentro de um período de tempo definido.
Esses resultados desejados são os passos mensuráveis ​​para alcançar os objetivos previamente estabelecidos (Doenges et al., 1997). Como os cuidados de enfermagem são baseados em uma abordagem holística, os resultados esperados podem ser escritos nas dimensões espiritual, emocional, fisiológica, de desenvolvimento e social. Um resultado esperado mostra mudanças comportamentais mensuráveis ​​ou evidências de mudança no cliente quando o objetivo foi atingido. Podem ser necessários vários resultados esperados para cada objetivo. Os resultados esperados são usados ​​no processo de avaliação, fornecendo um padrão de comparação para determinar se o cliente conseguiu com sucesso os objetivos.
Na construção de objetivos e objetivos de resultados esperados, os componentes essenciais incluem: assunto, declaração de tarefa, critérios, condições (se necessário) e cronograma (Doenges et al., 1997). Quando os objetivos e os resultados são escritos claramente, a enfermeira pode selecionar intervenções de enfermagem para garantir que os dados de base do cliente sejam cuidadosamente avaliados, as necessidades individuais do cliente são identificadas e as abordagens apropriadas são usadas no plano de cuidados. Normalmente, cada diagnóstico de enfermagem tem um objetivo global e vários resultados esperados. Ao escrever a declaração de metas, a enfermeira considera o diagnóstico de enfermagem para a formulação de um comportamento adequado do cliente que ilustra redução ou alívio do diagnóstico de enfermagem.
Esses conceitos são demonstrados no Destaque do Processo de Enfermagem.
Cada componente de um objetivo apropriadamente escrito é discutido nos seguintes parágrafos. Para maior clareza de cada conceito, os exemplos são fornecidos com discussão relacionada. Os exemplos são projetados com a intenção de desenvolver habilidades na construção de objetivos.
O componente a ser considerado inicialmente na escrita de um objetivo é o assunto. O sujeito identifica a pessoa que irá realizar o comportamento desejado ou atingir o objetivo. Em um plano centrado no cliente de cuidados de enfermagem, o cliente é a pessoa que precisa alcançar uma mudança de comportamento desejada. Veja a exibição que acompanha para uma aplicação do componente sujeito.
O próximo componente em objetivos de escrita é a declaração de tarefa ou o verbo de ação. Este componente descreve o que o cliente (ou assunto) fará para obter uma mudança de comportamento esperada. A declaração de tarefa permite ao avaliador determinar a realização de comportamentos observáveis. Quando o comportamento real é declarado como uma declaração de tarefa que pode ser medida clara e diretamente, a enfermeira pode determinar se o cliente está demonstrando a realização do objetivo.
Apenas uma declaração de tarefa deve ser usada para cada objetivo. É mais claro escrever metas separadas do que tentar medir com precisão uma combinação de tarefas.
Veja a exibição de acompanhamento para uma aplicação da declaração de tarefas.
O próximo componente essencial é o critério de um objetivo.
Os critérios são padrões utilizados para avaliar se o comportamento demonstrado indica realização do objetivo. Os critérios podem ser escritos de várias maneiras.
Os critérios podem incluir:
• Quantidade de atividade.
• Características importantes de desempenho preciso.
• Descrição do desempenho a seguir.
A enfermeira deve especificar o desempenho preciso para ser considerado aceitável na realização do objetivo. Nem sempre é possível especificar um critério com o máximo de detalhes que alguém gostaria; no entanto, a enfermeira deve continuar a comunicar critérios precisos o mais explicitamente possível. Para fornecer uma melhor direção ao cliente, a enfermeira considera o quão bem o cliente, o membro da família ou outro significativo deve realizar a tarefa.
Veja a exibição de acompanhamento para uma aplicação de critérios.
O próximo componente a ser incluído na escrita de objetivos adequados é as condições em que o cliente deve executar ou demonstrar o domínio da tarefa. Embora este componente seja opcional em termos de metas de escrita, as condições podem fornecer clareza e ajudar o cliente a demonstrar o comportamento esperado. As condições podem incluir as experiências que o cliente deve ter antes de executar a tarefa.
Veja a exibição acompanhada para uma aplicação de condições.
O último componente a ser incluído nos objetivos de escrita adequadamente é o período em que o cliente deve executar ou demonstrar o domínio da tarefa.
PROBLEMAS FREQUENTEMENTE ENCONTRADOS NO PLANEJAMENTO.
Os estudantes de enfermagem, como iniciantes no uso do processo de enfermagem, muitas vezes caem em armadilhas comuns ao aplicar os passos para a prática. Estas armadilhas são descritas com a intenção de fornecer uma direção clara para o uso desse processo e propor sugestões para evitar esses erros comuns.
Em relação aos objetivos de escrita, os erros freqüentemente observados neste componente envolvem formato impróprio.
Os erros de formato incluem metas centradas na enfermagem, em vez de centradas no cliente, não realistas, negativas e positivas, genericamente copiadas de uma referência e não individualizadas para o cliente, não são mensuráveis, inespecíficas, não comportamentais, vagas, verbosas e sem um período de tempo.
Outro desafio no desenvolvimento de objetivos e resultados esperados é o estabelecimento de prazos apropriados para a realização dos resultados pretendidos.
Embora este componente possa ser difícil em primeiro lugar dominar, os estudantes de enfermagem devem praticar metas de escrita que sejam realistas e incluem cronogramas apropriados usando literatura e recursos disponíveis para obter experiência. É preferível que uma meta inclua um período de tempo excessivamente curto, em vez de excessivamente longo, porque o objetivo é levado a atenção no processo de avaliação com mais freqüência. Ao inserir o cronograma "diariamente" para objetivos específicos, o resultado esperado será gerado com freqüência para avaliação. Através de um processo de crescimento profissional contínuo e experiência, os alunos e enfermeiros iniciantes tornar-se-ão mais adeptos e realistas na aplicação do processo de enfermagem às situações do cliente.
Finalmente, novatos e enfermeiras experientes tendem a tomar decisões para os clientes de forma paternalista, decidindo o que é melhor para o cliente sem a contribuição do cliente. Para corrigir este problema, a enfermeira deve estabelecer um relacionamento confiável entre enfermeiro e cliente que promova a compreensão e o cuidado mútuos. A enfermeira deve encorajar os clientes a tomar suas próprias decisões em relação aos cuidados de saúde.
PLANEANDO INTERVENÇÕES DE ENFERMAGEM.
Uma vez que os objetivos tenham sido mutuamente acordados pela enfermeira e cliente, a enfermeira deve usar um processo de tomada de decisão para selecionar intervenções de enfermagem adequadas.
Uma intervenção de enfermagem é uma ação realizada por uma enfermeira que ajuda o cliente a alcançar os resultados especificados pelas metas e resultados esperados. Estes termos são baseados em princípios científicos e conhecimentos de ciências comportamentais e físicas. Normalmente, várias intervenções de enfermagem são desenvolvidas para cada um dos objetivos identificados para o cliente (Sparks & Taylor, 1993). É importante identificar tantas intervenções de enfermagem quanto possível, de modo que, se alguém se revelar inadequado, outros estão prontamente disponíveis.
As intervenções são priorizadas de acordo com a ordem em que serão implementadas. Com a inclusão da resolução de problemas científicos e do pensamento crítico, a prestação de cuidados de enfermagem de qualidade e individualizados é grandemente aprimorada. Através do pensamento crítico, são alcançadas conclusões sólidas na seleção de intervenções de enfermagem para prevenir, reduzir ou eliminar os diagnósticos ou problemas de enfermagem. A enfermeira estuda toda a questão minuciosamente no componente de planejamento do processo de enfermagem, examinando os dados de avaliação e os diagnósticos de enfermagem, analisando os objetivos do cliente e os resultados esperados, e selecionando quais intervenções de enfermagem devem ser usadas a partir de inúmeras possibilidades para garantir a entrega de Cuidados de enfermagem de qualidade para cada cliente.
Vários fatores podem ajudar a enfermeira na seleção de intervenções de enfermagem. Assim como os objetivos do cliente podem ser derivados do diagnóstico de enfermagem, as intervenções de enfermagem podem ser desenvolvidas a partir da etiologia de cada diagnóstico de enfermagem. A enfermeira eficaz planeja intervenções direcionadas para a causa do diagnóstico ou problema de enfermagem do cliente. Por exemplo, para um cliente com angina que pode ter o diagnóstico de dor de Dor relacionado à isquemia miocárdica, uma intervenção de enfermagem apropriada seria ajudar o consumidor a economizar energia (ou seja, repouso em cama).
A enfermeira pode usar várias diretrizes na seleção de intervenções de enfermagem adequadas. Essas diretrizes incluem os atos de prática de enfermeiros individuais, os padrões estaduais de enfermagem e as normas da Joint Commission on Accreditation of Organizações de Saúde (JCAHO) para cuidados de enfermagem. Outros fatores determinantes de intervenções de enfermagem adequadas incluem se uma ação é realista em termos de habilidades do cliente e da enfermeira, e se for compatível com os recursos disponíveis, os valores e crenças do cliente e outras terapias planejadas para o cliente.
Para determinar quais intervenções de enfermagem devem ser utilizadas, a enfermeira deve considerar criticamente as conseqüências e os riscos de cada intervenção. Depois de considerar esses fatores, a enfermeira seleciona aqueles que são mais prováveis ​​de serem eficazes com o mínimo de risco.
Esta tabela aplica as diretrizes para seleção de intervenções de enfermagem adequadas para um diagnóstico específico de enfermagem.
Depois de definir as metas e planejar as intervenções de enfermagem adequadas, a enfermeira escreve ordens de enfermagem para comunicar as intervenções exatas de enfermagem a serem implementadas para o cliente. Uma ordem de enfermagem é uma declaração escrita pela enfermeira que está dentro do campo da prática de enfermagem para planejar e iniciar. Essas declarações especificam direção e individualizam o plano de atendimento do cliente. Por exemplo, a ordem do profissional de saúde para forçar fluidos deve ser especificada na ordem de enfermagem como o número de mililitros por hora ou por turno (por exemplo, 100 ml / h ou Dia = 800 ml; Turno noturno = 800 ml; Turno noturno = 400 ml).
Assegurar que as ordens de enfermagem estão bem escritas exigem vários elementos essenciais. Esses elementos incluem: a data do pedido de enfermagem, o verbo de ação, a descrição detalhada, o prazo e a assinatura (Wilkinson, 1998).
Veja a exibição que acompanha para um resumo dos elementos de uma ordem de enfermagem.
O tipo de pedido de enfermagem escrito é determinado pelo problema do cliente. A enfermeira é responsável por escrever ordens de enfermagem que envolvam promoção, observação, prevenção e tratamento de saúde (Wilkinson, 1998).
Esta tabela fornece exemplos de tipos de pedidos de enfermagem.
CATEGORIAS DE INTERVENÇÕES DE ENFERMAGEM.
As intervenções de enfermagem são classificadas de acordo com três categorias: independente, interdependente e dependente.
As intervenções independentes de enfermagem são ações de enfermagem iniciadas pela enfermeira que não requerem direção ou ordem de outro profissional de saúde. Essas intervenções são sancionadas por atos de prática de enfermeiros profissionais derivados de leis de licenciamento. Em muitos estados, os atos de prática de enfermagem permitem intervenções de enfermagem independentes sobre atividades de vida diária, educação em saúde, promoção de saúde e aconselhamento. Um exemplo de uma intervenção de enfermagem independente é a ação da enfermeira para elevar a extremidade edematosa de um cliente.
As intervenções de enfermagem interdependentes são aquelas ações que são implementadas de forma colaborativa pela enfermeira com outros profissionais de saúde.
A colaboração é uma parceria em que todas as partes são valorizadas pela contribuição. A colaboração é usada para coletar dados, planejar, implementar, avaliar e obter objetividade examinando o ponto de vista de outro. As intervenções interdependentes de enfermagem permitem que os diagnósticos de enfermagem do cliente sejam resolvidos com base em recomendações de uma abordagem interdisciplinar da equipe de cuidados de saúde. For example, a client care conference or a discharge planning committee uses an interdisciplinary approach that includes health care members such as a nursing supervisor, a home health care nurse, a dietitian, a social worker, a physical therapist, and occasionally a physician.
The nurse assumes the responsibility of being both the primary coordinator of the client’s plan of nursing care and intermediary of interdepartmental collaboration ( Doenges et al., 1997).
In addition to collaboration, the planning of interdependent nursing interventions may also include consultation.
Consultation is a method of soliciting help from a specialist in order to resolve nursing diagnoses. The need for consultation arises when an individual nurse identifies a problem that cannot be solved using own knowledge, skills, or resources. In the management of the client’s plan of care, nurses may consult with other health care personnel including health care practitioners, clinical nurse specialists, nutritionists, physical therapists, and social workers. Nurses frequently consult to verify assessment data or to obtain clinical advice: for example, discussing the effects of chemotherapy on a client’s self-esteem with an oncology clinical nurse specialist.
Consultation can be informal or formal. An informal consultation may simply involve another health care practitioner’s ideas regarding a nursing problem. Some agencies have a formal protocol for the consultation of a health professional and may require that certain forms be completed. Steps in formal consultation reflect a logical sequence. and include:
• Identifying the problem.
• Collecting all relevant data.
• Selecting a suitable consultant.
• Communicating unbiased data regarding the problem.
• Discussing recommendations with the consultant.
• Incorporating the recommendations into the client’s plan of care.
The consultation process often generates new approaches to the client’s individualized plan of care.
Acquiring supplementary knowledge may help in ensuring that the best conceivable plan of care is being developed. In addition, nurses who have sought the help of a consultant are presented with an opportunity to learn from the recommendations for future situations.
Dependent nursing interventions are those actions that require an order from another health care professional.
An example of a dependent intervention is administration of a medication. Although this intervention requires specific nursing knowledge and responsibilities, it is not within the realm of legal nursing practice in many states to prescribe medications. The nurse may not order medications but, when administering them, the nurse is responsible for knowing the classification, the pharmacologic action, normal dosage, adverse effects, contraindications, and nursing implications of the drugs. Therefore, dependent nursing interventions must always be guided by appropriate knowledge and judgment. It should be noted that many state nurse practice acts sanction advanced practice registered nurses to prescribe medications. In those states, prescriptive authority is an independent intervention for nurses in advanced practice.
Figure 8-1 illustrates the three categories of nursing interventions.
All nursing interventions require critical thinking in making appropriate nursing judgments. Alfaro - LeFevre (1998) states that the development of critical reasoning skills by nurses is a progressive process that requires a dedication to examine common health problems, participate in diverse clinical experiences, and prepare for delivery of care in clinical settings. Given the emphasis on critical thinking in the planning step of the nursing process, the nurse does not automatically carry out a health care practitioner’s order without due consideration. All requested orders are given consideration for their appropriateness.
An in-depth knowledge base is necessary to recognize an error and seek clarification. The use of rationales helps the nurse practice decision making and substantiate judgments. The rationales should accompany the nursing intervention or nursing order statement on the written plan of nursing care. A rationale is an explanation based on theories and scientific principles of natural and behavioral sciences and the humanities.
Evaluating care involves determining the client’s progress toward achievement of expected outcomes.
Effective planning is essential if evaluation is to be effective. In other words, the planned outcomes are the yardsticks by which effectiveness of therapies are evaluated. If there is no stated expectation of care (i. e., client outcome), how can progress be measured?
NURSING OUTCOMES CLASSIFICATION (NOC)
Measuring outcomes in nursing began with Nightingale, who relied on mortality statistics as an indicator of quality of care for British soldiers in the Crimean War. Nightingale proved that the mortality rate for soldiers declined as a result of improved sanitation ( Oermann & Huber, 1999). Recently, there has been increased emphasis by the nursing community on evaluating outcomes. Nurse researchers (Mass & Johnson, 1997) at the University of Iowa have developed classifications of client outcomes, the Nursing Outcomes Classification (NOC). The NOC provides a standardized language that can be used to measure the effects of nursing practice on client outcomes. Just as the North American Nursing Diagnosis Association (NANDA) and the Nursing Interventions Classifications (NIC) are continuing to develop standardized nursing language relative to diagnosis and intervention, NOC is striving toward a similar goal of standardized language for classifying nursing interventions.
An outcome classification system can be used to enhance decision-making in clinical practice and research.
Linking nursing interventions to improved client outcomes through scientific research is important. Nurse researchers who are observing, measuring, and studying client outcomes believe that outcomes indicate the quality or effectiveness of the nursing interventions provided.
Porter-O’Grady (1999) states that nurses need to provide empirical evidence of the “insights and intuition of their practice. Strengthening the links between nursing interventions and client outcomes will benefit not only clients, but nursing as well. Having solid research evidence that documents the effectiveness of nursing care on client outcomes will influence political and financial decisions relative to nursing. “By measuring patient outcomes, nurses can answer two pivotal questions; Do our patients benefit from our care? And if so, how?” ( Oermann & Huber, 1999, p. 41). The NOC taxonomy focuses on function, physiology, psychosocial aspects, health knowledge and behavior, and perceived self-health and family health. The NOC system, which defines over 190 client outcomes that are sensitive to nursing interventions, allows nurses to evaluate client status over time.
The plan of care is a written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health. Nursing care plans usually include components such as assessment, nursing diagnoses, goals and expected outcomes, nursing interventions, and evaluations. The nurse begins the nursing care plan on the day of admission and continually updates and individualizes the client’s plan of care until discharge.
The plan of care directs the efforts of the entire health care team regarding each client. This plan promotes the health care team’s delivery of quality, holistic, individualized, and goal-oriented care to the client. Attention to a comprehensive assessment of the entire person allows for a holistic approach. Individualization is enhanced by continous reviewing and updating of the plan of care. A carefully formulated written plan of care prioritizes problems and addresses short - and long-term needs of the client. JCAHO standards state that each client will be assessed and reassessed according to the health care facility policy (JCAHO, 2000). The written plan of care authenticates activeities of assessment by maintaining written records and providing evidence of nursing interventions, the client’s response to nursing interventions, and changes in the client’s condition.
Although plans of care differ in various institutions from handwritten to computerized forms, they all have the same basic elements in common. The plan of care is realistically designed and customized to each individual client’s health status and is the final result of the planning component of the nursing process. The nursing plan of care documents health care needs, coordinates nursing care, promotes continuity of care, encourages communication within the health care team, and promotes quality nursing care.
There are several types of care plans. These different types include student-oriented, standardized, institutional, and computerized care plans. The student-oriented care plan promotes learning of problem-solving skills, the nursing process, verbal and written communication skills, and organizational skills. This comprehensive care plan has great depth for teaching the process of planning care. Educational programs vary, but usually the student-oriented care plan begins with assessment and proceeds in a sequential manner until it concludes with the plan of care evaluation.
The standardized care plan is a preplanned, preprinted guide for the nursing care of client groups with common needs. This type of care plan generally follows the nursing process format (i. e., problem, goals, nursing orders, and evaluation). The nurse may use standardized care plans when a client has predictable, commonly occurring problems. Individualization may be accomplished by the inclusion of additional handwritten notes on unusual problems.
Institutional nursing care plans are concise documents that become a part of the client’s medical record after discharge. The Kardex nursing care plan is an example of this type of care plan and is frequently used. The institutional nursing care plan may simply include the problem, goal, and nursing action. In addition, the Kardex nursing care plan may be expanded to include assessment, nursing diagnosis, goal, implementation, and evaluation.
Figure 8-2 provides an example of an institutional care plan.
Computers are used for creating and storing nursing care plans and can generate both standardized and individualized nursing care plans. The nurse selects appropriate diagnoses from a menu suggested by the computer, which then lists possible goals and nursing interventions. The nurse has the option of reading the.
client’s plan of care from the computer screen or printing out an updated working copy.
Figure 8-3 presents an example of a computerized nursing care plan.
STRATEGIES FOR EFFECTIVE CARE PLANNING.
In planning quality nursing care for each client, the nurse assumes responsibility for the coordination of total nursing care. The nurse coordinates the participation of various health care team members to implement their recommendations into the delivery of quality nursing care. Critical thinking assists the nurse in establishing collaborative relationships with other members of the health care team and managing complex nursing systems.
An important strategy for effective planning is clear communication of the client’s plan of care to other health care personnel. The nurse must always communicate the plan of care in clear, precise terms. Avoid using vague terminology such as improved, adequate, and normal.
Another strategy for effective planning is to establish a realistic nursing plan of care because this will avoid setting a goal that is too difficult or impossible to achieve. If a goal is too ambitious or is unattainable, the client and nurse may become discouraged or apathetic about the resolution of nursing diagnoses. In addition, goals should be measurable. Quantitative terms assist in the determination of measurement. Finally, the goals should be futureoriented . Because a goal is an aim or a desired achievement, goals should be written in future tense format. Once appropriate nursing diagnoses are individualized.
to the client, the plan of care has a stable framework on which an optimum level of wellness for the client can be reached. Although some clients may not achieve complete resolution of all nursing diagnoses, the nursing plan of care that is individualized can improve health to the client’s optimal level .
K E Y C ONCEPTS.
• The outcome identification and planning component of the nursing process is a sequential, orderly method of using problem-solving skills and critical thinking to formulate a nursing plan of care to resolve nursing diagnoses.
• The planning component of the nursing process includes establishing priorities, setting goals, developing expected outcomes, selecting nursing interventions, and documenting the plan of care.
• The purposes of outcome identification and planning are to provide direction for nursing care, to improve staff communication, and to provide continuity of nursing care.
• The establishment of priorities may be guided by such factors as endangerment of well-being, Maslow’s hierarchy of needs, client preferences, and anticipation of future diagnoses.
• Setting goals and expected outcomes provides guidelines for directing nursing interventions and establishes evaluation criteria by deciding on goals that illustrate a desired change in the client’s behavior.
• Goals and expected outcome objectives include the components of subject, task statement, criteria, conditions, and time frame.
• Two common problems frequently encountered in planning in regard to goals are the improper format and unrealistic and nonmeasurable qualities of this.
• In planning nursing care, the nurse uses an expansive scientific knowledge base and critical thinking to select independent, interdependent, and dependent nursing interventions guided by local and federal standards of care.
• The plan of care documents health care needs, coordinates nursing care, promotes continuity of care, encourages communication within the health care team, and promotes quality nursing care.
• Strategies for effective care planning include communication of the client’s plan of care within the health care team, establishment of a realistic plan of care, and.
formulation of measurable and future-oriented goals.
C R I T I C A L T H I N K I N G AC T I V I T I E S.
1. Decide whether the following statements are.
client-centered and place a mark in front of all.
_____ 1. The nursing assistant will ambulate.
client in the hall three times a day by.
_____ 2. Will teach the client to plan a low-fat.
diet for 24 hours.
_____ 3. The client will describe two purposes of.
a low-fat diet by Wednesday.
_____ 4. Will encourage the client to walk the.
entire length of hallway two times a day.
2. Decide whether the following statements have.
action verbs for their task assignment and place a.
mark in front of all goals with action verbs.
_____ 1. The client will know five reasons for.
_____ 2. The client will be able to state where.
diabetic injection equipment may be.
purchased after discharge.
_____ 3. The client will explain the purpose of.
maintaining asepsis in daily dressing.
changes by Wednesday.
_____ 4. The client will understand how to.
change dressings on abdomen.
3. Indicate whether the following statements have.
criteria and place a mark in front of all goals with.
_____ 1. The client will describe two purposes of.
the low-salt diet by Friday.
_____ 2. The client will know the cause of low.
_____ 3. The client will understand the importance.
of returning for follow-up visits to.
the health care practitioner.
_____ 4. The client will demonstrate crutch.
walking the entire length of the hallway.
4. Decide whether the following statements have conditions.
and place a mark in front of all goals with.
_____ 1. The client will describe two purposes of.
the low-salt diet by Friday.
_____ 2. The client will know the cause of low.
_____ 3. The client will understand the importance.
of returning for follow-up visits to.
the health care practitioner.
_____ 4. The client will demonstrate crutch.
5. Decide whether the following statements have time.
frames and place a mark in front of all goals with.
_____ 1. The client will describe two purposes of.
the low-salt diet by Friday.
_____ 2. The client will know the cause of low.
_____ 3. The client will understand the importance.
of returning for follow-up visits to.
the health care practitioner.
_____ 4. The client will demonstrate crutch.
CHAPTER 8 Outcome Identification and Planning 145.
MULT I P L E C H O I C E Q U E S T I ONS.
6. The plan of nursing care includes:
uma. Client assessment data, medical treatment.
regime and rationales, and diagnostic test results.
b. Doctor’s orders, demographic data, and medication.
administration and rationales.
c. Collected documentation of all team members.
providing care for your client.
d. Client’s nursing diagnoses, goals and expected.
outcome objectives, and nursing interventions.
7. When establishing priorities of a client’s plan of.
nursing care, the nurse should rank the highest.
priorities to life-threatening diagnoses and the lowest.
uma. Safety-related needs.
b. The client’s social, love, and belonging needs.
c . Needs of family members and friends who are.
involved in plan of care.
d. Needs of client regarding referral agencies.
8. What is the main purpose of the expected outcome?
uma. To describe the education plans to be taught to.
b. To describe the behavior the client is expected to.
achieve as a result of nursing interventions.
c. To provide a standard for evaluating the quality.
of health care delivered to the client during the.
d. To make sure that the client’s treatment does not.
extend beyond the time allowed under the diagnosis-
related group system.
9. What are the essential components of an expected.
uma. Nursing diagnosis, interventions, and expected.
b. Target date, nursing action, measurement criteria,
and desired client behavior.
c. Nursing action, client behavior, target date, and.
conditions under which the behavior occurs.
d. Client behavior, measurement criteria, conditions.
under which the behavior occurs, and target.
10. Which guideline is most appropriate when developing.
uma. Choose actions that a nurse can perform without.
leaving the unit or consulting with medical staff.
b. Make intervention statements specific to ensure.
continuity of care.
c. Write interventions in general terms to allow.
maximum flexibility and creativity in delivering.
d. Make sure that nursing care activities receive priority.
over other aspects of the treatment regime.
IMPLEMENTING NURSING CARE.
I mplementation , the fourth step in the nursing process, involves the execution of the nursing plan of care derived during the planning phase of the nursing process. It involves completion of nursing activities to accomplish predetermined goals and to make progress toward achievement of specific outcomes. The execution of the implementation phase of the nursing process, as with the other phases of the process, requires a broad base of clinical knowledge, careful planning, critical thinking and analysis, and judgment on the part of the nurse.
This chapter discusses the purposes of implementation, the specific skills associated with effectively implementing the nursing plan of care, and the activities involved in this process. Although identified as the fourth step of the nursing process, the implementation phase begins with assessment and continually interacts with the other steps in the process to reflect the changing needs of the client and the response of the nurse to those needs.
PURPOSES OF IMPLEMENTATION.
Implementation is directed toward a fulfillment of client needs that results in health promotion, prevention of illness, illness management, or health restoration in a variety of settings including acute care, home health care, ambulatory clinics, or extended care facilities.
It also involves the delegation of tasks to staff members and assistive personnel and documentation of the specific activities executed by the nurse and the client’s response to these activities.
The American Nursing Association (1998), in its Standards of Clinical Nursing Practice , describes the standards applicable to implementation in terms of both a standard of care and standards of professional performance.
Adherence to these standards requires that the nurse have a current knowledge base, be proficient with technical and communication skills, and use sound judgment in determining safe and efficient use of personnel and materials.
REQUIREMENTS FOR EFFECTIVE IMPLEMENTATION.
The implementation phase of the nursing process requires cognitive (intellectual), psychomotor (technical), and interpersonal skills. These skills serve as competencies through which effective nursing care can be delivered and are used either in conjunction with each other or individually as required by the client and the specific needs of the situation.
Cognitive skills enable nurses to make appropriate observations, understand the rationale for the activities performed, and appreciate the differences among individuals and how they influence nursing care. Critical thinking is an important element within the cognitive domain because it helps nurses to analyze data, organize observations, and apply prior knowledge and experiences to current client situations.
Proficiency with psychomotor skills is necessary to safely and effectively perform nursing activities. Nurses must be able to handle medical equipment with a high degree of competency and to perform skills such as administering medications and assisting clients with mobility needs (e. g., positioning and ambulating).
The use of interpersonal skills involves communication with clients and families as well as with other health care professionals. The nurse-client relationship is established through the use of therapeutic communication that helps ensure a beneficial outcome for the client’s health status. Interaction between members of the health care team promotes collaboration and enhances holistic care of the client.
Nursing implementation activities include:
• Establishment of priorities.
• Allocation of resources.
• Initiation of nursing interventions.
• Documentation of interventions and client response.
These activities are interactive and each is discussed in further detail.
The nursing plan of care is based on the initial assessment data collected by the nurse and the nursing diagnoses derived from those data. Because a client’s condition can change rapidly, or new data may become available through interaction with the client, ongoing assessment is necessary to validate the relevance of proposed interventions. Goals, expected outcomes, and interventions may need to be altered as new data are collected or progress toward outcomes is evaluated.
Although a focused assessment should be completed during the initial interaction with the client, continuous observations during the implementation process allow for adaptations to be made to better individualize care.
It is not unusual for nursing diagnoses to change or to be resolved in a short period of time. For example, the nursing care plan for Mrs. Cline, a preoperative client, might include an intervention to teach her about the use of a patient-controlled analgesia (PCA) pump. As the use of this equipment is being demonstrated, the nurse observes that Mrs. Cline is unable to depress the button easily with the fingers of her right hand. Mrs. Cline informs the nurse that she forgot to mention that her joints swell occasionally and she has very little strength in her hand during these times. This information is essential for both developing a nursing diagnosis concerning Mrs. Cline’s impaired physical mobility and determining appropriate teaching methods for use of the PCA pump.
Ongoing assessment demands attention to verbal and nonverbal cues from the client and requires knowledge of expected responses to specific interventions. If nurses observe that responses are different from those expected, this assessment data can lead to a change in expected outcomes and accompanying interventions.
Ongoing assessment is of equal importance in home health care or extended care settings when contact with skilled health care providers might occur less frequently and the length of time that the care is required varies (see the accompanying display). The nurse’s assessment and clinical judgment often determine whether the client needs continued care or referral to other health care providers.
Establishment of Priorities.
Following ongoing assessment and review of the problem list, priorities are determined for implementation of care. Priorities are based on:
• Which problems are deemed most important by the nurse, the client, and family or significant others.
• Activities previously scheduled by other departments (e. g., surgery, diagnostic testing)
The change-of-shift report can also be a valuable tool in determining priorities. A client’s condition and variables in the clinical setting can change quickly and frequently—especially in acute care settings—requiring that the nurse exercise strong clinical judgment and maintain flexibility in organizing care. For example, the nursing care plan for Mr. Jenkins, who had hip replacement surgery, might reflect a priority nursing diagnosis of Impaired Physical Mobility with interventions focused toward learning to ambulate. When the nurse listens to Mr. Jenkins’ breath sounds on a particular morning, it is noted that his breathing is more labored and crackles can be auscultated in the lung bases. This assessment is noted on the change-of-shift report, and the priorities of interventions change to focus on this new development.
Time management is important whether the nurse is caring for one client or a group of clients. It is helpful to make a list of tasks that need to be accomplished throughout the day and to create a worksheet outlining a target time for these activities. Those activities with specified times for completion should be scheduled first. For example, medications usually allow a narrow time frame for administration and must be scheduled at specific times on the worksheet. An example of a worksheet that outlines a plan for activities is shown in Table 9-1.
The time allotted for activities depends on the complexity of the task and the amount of assistance required by the client. An example of a worksheet for a group of clients is presented in Table 9-2.
Allocation of Resources.
Before implementing the nursing plan of care, the nurse reviews proposed interventions to determine the level of knowledge and the types of skills required for safe and effective implementation. The assessment provides data for determining if an activity can be performed independently by the client, can be completed with assistance from family, or requires assistance of health care personnel.
The registered nurse is legally responsible for all nursing care given. Whereas some interventions are complex and require the knowledge and skills of a registered nurse, other interventions are relatively simple and can be delegated to assistive personnel. Delegation is the process of transferring a selected nursing task in a situation to an individual who is competent to perform that specific task. It must be remembered that, although some activities can be assigned to other health care personnel, the registered nurse remains accountable for appropriate delegation and supervision of care provided by these individuals. In general, registered nurses are authorized by law to both provide nursing care to clients directly and supervise and instruct others to deliver this care. Further, the registered nurse is empowered to delegate selected tasks to either licensed or unlicensed nursing personnel (see Figure 9-1).
Decisions about delegation are guided by the needs of the client, the number and type of available personnel, and the nursing management system of the unit or agency. In performing delegated tasks, nursing students must either determine if the intervention is one that they have performed with supervision and can safely accomplish independently or is one for which assistance is needed.
The first consideration in determining the most appropriate nursing personnel to administer care is client safety. Nurse practice acts dictate to some extent which tasks can be legally delegated. For example, administration of blood or blood products is not an act that can be legally delegated to licensed practical nurses or unlicensed assistive personnel in most states.
Other activities, such as assisting clients with activities of daily living (ADL, those activities performed by a person usually on a daily basis), ordering supplies, or transcribing orders, can often be safely delegated to other personnel.
If delegation of a particular activity is legally allowed, the nurse should validate the knowledge and skill level of personnel before delegation. If uncertain about the level of competence of an individual to perform an activity, the nurse should not delegate the task even though it might be legally performed by that level of personnel.
The registered nurse is held accountable to delegate only such care that can safely be done by the other individual and would be performed with the same level of competency and respect for state laws and regulations as would be evident in the nurse’s performance of this care.
Types of Management Systems.
Wise use of resources dictates that tasks be assigned to the most cost-effective level of personnel who can safely and proficiently perform the activity. The nursing management system often determines the numbers and types of personnel available. Changes in health care delivery in recent years have resulted in an increasing emphasis on cost containment and have subsequently created several unique management models. The redesign of the workplace in many health care agencies has included cross-training of employees, with nurses frequently assuming responsibilities formerly assigned to other health care providers. For example, nurses might draw blood for laboratory tests, perform electrocardiograms, or administer respiratory treatments, as care is focused around the client rather than the various departments in the agency. Nurses in community health settings have traditionally exercised a variety of roles in their practice.
As health care delivery continues to evolve in this country, a variety of innovative approaches will emerge to better meet the needs of clients. The most common management systems currently used include functional nursing, team nursing, primary nursing, total client care, modular nursing, and case management.
The functional nursing approach divides care into tasks to be completed and uses various levels of personnel depending on the complexity of the assignment. Each member of the staff performs his or her assigned task for each client. For example, one nurse may assess each client and document findings and another may give all medications and treatments. Another nurse may be assigned to complete client teaching or discharge planning (process that enables the client to resume self-care activities before leaving the health care environment).
One nursing assistant might serve all trays and collect intake and output records for each client while another is responsible for giving baths or making beds.
The advantage of this system is that a large number of clients can be cared for by a relatively small number of personnel. In addition, it allows the use of less skilled (and less expensive) personnel for some tasks and allows personnel to be used in areas for which they have special knowledge or skill. However, this system can also result in fragmented and depersonalized care and may invite omissions in care because no one person is responsible for the total care of the client.
The team nursing approach uses a variety of personnel (professional, technical, and unlicensed assistants) in the delivery of nursing care. The registered nurse is leader of the team and is responsible for supervision of the team, as well as planning and evaluating the results of caregiving activities. This management system uses professional nurses for skilled observations and interventions and provision of direct care to acutely ill clients, while licensed practical nurses care for less acutely ill clients, and nursing assistants are responsible for serving trays, making beds, and assisting the nurses with other tasks. This management system is frequently used because it is cost-effective and provides more individualized care than the functional approach.
In the primary nursing management system, the professional nurse assumes full responsibility for total client care for a small number of clients. Although care may be delegated to nurse associates for shifts when the primary nurse is not in attendance, the primary nurse maintains responsibility for total client care 24 hours a day (see Figure 9-2).
The primary nurse sets health care goals with the client and plans care to meet those goals.
The principal advantage of this approach is the continuity of care inherent in the system. Primary nursing is most effective with a total staff of registered nurses, which makes this system expensive to maintain.
Total Client Care and Modular Nursing.
Total client care and modular nursing are variations of primary nursing. Although these systems imply that one nurse is responsible for all the care administered to a client, responsibility for the client actually changes from shift to shift with the assigned caregiver. This system uses both registered nurses and licensed practical nurses; the registered nurses are assigned to more complex client situations. A unit manager or charge nurse typically coordinates activities on the unit. Modular nursing attempts to assign caregivers to a small segment or “module” of a nursing unit, ensuring that clients are cared for by the same personnel on a regular basis.
In the case management system, the nurse assumes responsibility for planning, implementing, coordinating, and evaluating care for a given client, regardless of the client’s location at any given time. This approach is often used when care is complex and a number of health care team members are involved in providing care. Generally, a case management plan, or critical pathway, is developed (based on the norm or typical course of the condition), and the nurse evaluates the progress of the client in relation to what is expected, investigating and following up on any variance in the time required or the amount of improvement noted.
Although the case load for the individual nurse might be smaller (thus making this approach expensive), continuity of care and collaboration are enhanced.
After reviewing the client’s current condition, verifying priorities, and examining resources, the nurse should be ready to initiate nursing interventions. A nursing intervention is an action performed by the nurse that help the client to achieve the results specified by the goals and expected outcomes.
All interventions must conform to standards of care. Nurses should understand the reason for any intervention, the expected effect, and any potential problems that may result. Understanding the reason for a nursing intervention is the hallmark of a professional nurse, in that the nurse is using logic and/or scientific reasoning as the basis of practice.
Nursing interventions are a blend of science (rational acts) and art (intuitive actions). It is important for novice nurses to identify the rationale (the fundamental principle) of all interventions in order to implement theory-based practice. Prior to implementation, it is necessary to determine exactly:
• What is to be done.
• How it is to be done.
• When it should be done.
• How long it should be done.
Interventions are determined by and directed toward the cause of the problem or factors contributing to the nursing diagnosis and may vary for clients with similar nursing diagnoses depending on realistic expected outcomes for the individual. Consideration should be given to client preferences, the developmental level of the client, and availability of resources. In addition, the health care practitioner’s orders often have an impact on nursing interventions by imposing restrictions on factors such as diet or activity.
Types of Nursing Interventions.
Nursing interventions are written as orders in the care plan and may be nurse-initiated, health care practitioner-initiated, or derived from collaboration with other health care professionals. These interventions can also be categorized as independent, dependent, or interdependent, depending on the authority required for initiation of the activity.
Interventions can be implemented on the basis of standing orders or protocols. A standing order is a standardized intervention written, approved, and signed by a health care practitioner that is kept on file within health care agencies to be used in predictable situations or in circumstances requiring immediate attention. Nurses can implement standing orders in these situations after they have assessed the client and identified the primary or emerging problem. For example, nurses in an ambulatory clinic or home health care agency may have standing orders for administering certain medications or ordering laboratory tests when indicated, or a health care practitioner may establish standing orders on an inpatient unit that specify certain medications that can be administered for common complaints such as headache. Table 9-3 provides an example of standing orders used for client preparation for a barium enema.
A protocol is a series of standing orders or procedures that should be followed under certain specific conditions.
They define what interventions are permissible and under what circumstances the nurse is allowed to implement the measures. Health care agencies or individual health care practitioners frequently have standing orders or protocols for client preparation for diagnostic tests or for immediate interventions in life-threatening circumstances.
These protocols prevent needless duplication of writing the same orders repeatedly for different clients and often save valuable time in critical situations.
Nursing Interventions Classification.
The Iowa Intervention Project has developed a taxonomy of nursing interventions that includes both direct and indirect activities directed toward health promotion and illness management (Iowa Intervention Project, 1993).
This taxonomy, the Nursing Interventions Classification (NIC), is a standardized language system that describes nursing interventions performed in all practice settings.
“NIC offers a standardized language that communicates the nature and worth of the work we do. Without it, nursing will remain in jeopardy” ( Eganhouse , Comi - McCloskey, & Bulecheck , 1996). NIC is a method for linking nursing interventions to diagnoses and client outcomes (McCloskey, Bulechek , & Eoyang , 1999).
The format for each intervention is as follows: label name, definition, a list of activities that a nurse performs to carry out the intervention, and a list of background readings (McCloskey & Bulechek , 1996) (See Table 9-4).
NIC offers standardized language for research on nursing interventions and is a promising tool for determining reimbursement for nursing services.
Nursing Intervention Activities.
Nursing interventions include:
• Assisting with ADL.
• Delivering skilled therapeutic interventions.
• Monitoring and surveillance of response to care.
• Supervising and coordinating nursing personnel.
Implementing nursing interventions requires that consideration be given to client rights, nursing ethics, and the legal implications associated with providing care. Clients have the right to refuse any intervention.
However, the nurse must explain the rationale for the intervention and possible consequences associated with refusing treatment. If the intervention refused was health care practitioner-initiated, the health care practitioner should be informed of the refusal of care. Ethical standards require that clients be afforded privacy and confidentiality. Matters related to a client’s condition and care should be discussed only with individuals directly involved with the client’s care, and any discussion should be held in a location where information cannot be overheard by visitors or bystanders. From a legal standpoint, the nurse must ensure that the authority for prescribing any intervention has been satisfied and that applicable standards of care are maintained during implementation of all nursing interventions.
Activities of Daily Living.
Clients frequently need assistance with ADL such as bathing, grooming, ambulating, eating, and eliminating.
The goal for most clients is to return to self-care or to regain as much autonomy as possible. The nurse’s role is to determine the extent of assistance needed and to provide support for ADL while at the same time fostering independence. Ongoing assessment is important for determining the appropriate balance between ensuring safety and promoting independence. For example, maintaining personal grooming is important for purposes of hygiene and comfort as well as for promoting self-esteem.
The nurse must always provide privacy when assisting clients with personal hygiene. If these tasks are assigned to other personnel, adequate supervision is imperative to ensure compliance with these principles.
Therapeutic nursing interventions are those measures directed toward resolution of a current problem and include activities such as administration of medications and treatments, performing skilled procedures, and providing physical and psychological comfort. Written orders must be verified before implementing interventions requiring prescriptive authority. Reassessment of the client is also needed to determine if the intervention remains appropriate. In addition, a nurse must also understand the rationale, expected effects, and possible complications that could result from any intervention.
Monitoring and Surveillance.
Observation of the client’s response to treatment is an integral part of implementation of any intervention.
Monitoring and surveillance of the client’s progress or lack of progress are essential in determining the effectiveness of the plan of care and for detection of potential complications. Specific interventions require specific monitoring activities; however, typical monitoring activities include observations such as vital signs measurement, cardiac monitoring, and recording of intake and output.
A key element in health promotion and illness management is the counseling of clients to help them modify their behaviors in response to potential health risks and actual health alterations. As part of this teaching process, nurses must also discuss the rationales for the interventions that are included in the nursing plan of care.
Numerous opportunities arise every day for informal teaching related to client care. For example, teaching clients about the medications they are taking and possible side effects should occur routinely as medications are administered. Similarly, as nurses perform assessment activities, the sharing of observations with the client can be informative in terms of what characteristics are desirable and what observations are sources of concern.
This knowledge can be valuable to a client when self-monitoring.
Effective teaching requires insight into the client’s knowledge base and readiness to learn. Realistic teaching goals and learning outcomes should be set on the basis of these factors. It is also desirable to include the family or significant others in teaching plans. A suitable learning environment should be created that is nonthreatening and allows active participation by the client.
Nurses should be careful to use terminology easily understood by the client. It is important that learning outcomes are validated to be sure that clients can safely and effectively care for themselves on discharge.
Preparation for discharge begins at the time of admission to a health care facility. As the average length of stay in acute care settings continues to decrease, early discharge planning becomes imperative. Expected outcomes dictate the type of planning required and the interventions necessary to attain the desired outcomes.
Interventions directed toward discharge planning include activities such as teaching and consultation with other agencies (e. g., home health, rehabilitation facilities, nursing homes, social services) concerning followup care. Teaching related to any changes in diet, medications, or lifestyle must be implemented; any barriers or problems in the home environment must be resolved before discharge. Some agencies employ personnel with the primary responsibility of teaching or discharge planning for groups of clients; however, the nurse who is caring for the individual client is also responsible for ensuring that all appropriate interventions have been implemented before discharge.
Supervision and Coordination of Personnel.
The management style and type of facility, as well as the needs of the client, determine the scope of interventions associated with supervision and coordination of client care. In a health care facility in which nurses are assigned clients within a total client care management system, responsibilities for supervision might be minimal, whereas facilities that use a variety of ancillary personnel for certain client activities might require a large percentage of time devoted to supervision of care. In home health care, for example, the primary role of the professional nurse might be supervision of personnel who provide assistance with ADL. Although a nurse might delegate certain tasks to other personnel, it is still the nurse’s responsibility to ensure that the task was completed according to standards of care and to note the response of the client in order to evaluate progress toward expected outcomes.
Regardless of management style or type of facility, coordination of client activities among various health care providers remains the nurse’s responsibility. For example, in acute care settings, the nurse needs to coordinate client activities around the schedule of diagnostic tests or physical therapy. Scheduling of procedures, therapy, treatments, and medications for a number of clients often requires considerable organizational skills, creativity, and resourcefulness.
An important step to assure the delivery of quality care is evaluation of nursing interventions. One approach to determining the efficacy of nursing interventions is by evaluating clients’ achievement of expected outcomes.
The Nursing Intervention Classification (NIC), previously described in this chapter, provides a systematic method for linking nursing activities to client outcomes. When treatment can be shown to directly improve client outcomes, both nursing and health care consumers benefit.
Another taxonomy , the Nursing Outcomes Classification (NOC) has been specifically designed to evaluate nursing interventions. NOC provides a common language for measuring client responses to nursing interventions.
Documentation of Interventions.
Communication concerning implementation of interventions must be provided through written documentation and should also be verbally conveyed when responsibility of the client’s care is transferred to another nurse.
The nurse is legally required to record all interventions and observations related to the client’s response to treatment.
This not only provides a legal record but also allows valuable communication with other health care team members for continuity of care and for evaluating progress toward expected outcomes. In addition, written documentation provides data necessary for reimbursement for services and tracking of indicators for continuous quality improvement.
The recording of information can be in the form of either checklists , flow sheets, or narrative summaries. A complete description must be provided if there are any deviations from the norm or if any changes have occurred.
Verbal interaction among health care providers is also essential for communicating current information about clients. Nurses who delegate the delivery of client care to assistive personnel must be careful to elicit their feedback related to activities completed and the client’s response to any interventions. In addition, assistive personnel should be alerted as to what additional data are meaningful, and these data should be conveyed to the nurse responsible for the client’s care. For example, if a nursing assistant observes that Mrs. Robbins, hospitalized with a deep vein thrombosis of the left leg, is having difficulty swallowing and has eaten very little, this information should be reported to the nurse. This is especially important if the behavior is a new occurrence and not a part of the established problem list, because the nurse might not otherwise seek this information.
Communication between nurses generally occurs at the change of shift, when the responsibility for care changes from one nurse to another. Nursing students must communicate relevant information to the nurse responsible for their clients when they leave the unit. Information that should be shared in the verbal report includes:
• Activities completed and those remaining to be completed.
• Status of current relevant problems.
• Any abnormalities or changes in assessment.
• Results of treatments (i. e., client response)
• Diagnostic tests scheduled or completed (and results)
All communication—written and/or verbal—must be objective, descriptive, and complete. The communication includes observations rather than opinions and is stated or written so that an accurate picture of the client is conveyed. For example, if it is noted that a client is less alert today than yesterday, the behavior that led to that conclusion should be documented. This observation can be objectively and descriptively communicated by the statement: “Does not respond unless firmly touched; quickly returns to sleep.” This description results in a more complete picture of the client than simply stating: “Less alert today.” Thorough and detailed communication of implementation activities is fundamental to ensuring that client care and progress toward goals can be adequately evaluated.
• The implementation step of the nursing process is directed toward meeting client needs and results in health promotion, prevention of illness, illness management, or health restoration and also involves delegation of nursing care activities to assistive personnel and documentation of the implementation activities performed.
• Implementation requires cognitive, psychomotor, and intellectual skills to accomplish goals and make progress toward expected outcomes.
• Implementation activities include ongoing assessment, establishment of priorities, allocation of resources, initiation of specific nursing interventions, and documentation of interventions and client responses.
• Ongoing assessment is necessary for determining effectiveness of interventions and for detection of new problems.
• Changing variables in clients and the environment demand clinical judgment and flexibility in organizing care.
• Time management skills are essential in implementing client care.
• The nurse maintains responsibility for care delegated to other health care personnel.
• The most common management systems currently used include functional nursing, team nursing, primary nursing, total client care, modular nursing, and case management.
• Interventions can be nurse-initiated, health care practitioner-initiated, or collaborative in origin, and thus are considered dependent, independent, or interdependent.
• Nursing Interventions Classification (NIC) is a system for sorting, labeling, and describing nursing interventions.
• Nursing interventions include assisting with activities of daily living, skilled therapeutic interventions, monitoring and surveillance of response to care, teaching, discharge planning, and supervision and coordination of nursing personnel.
• Communication concerning interventions should be provided verbally and in writing.

Nursing care plan as a teaching strategy.
The intervention and goal sessions follow the same class format. After each nurse has answered the posttest, the instructor again clarifies the criteria that support the correct response. More questions and examples were brought back to each class by the participants. The game concept allowed the participants to feel more at ease making mistakes. The Purpose of the Written Care Plan Care plans provide direction for individualized care of the client. Care plans help teach documentation.
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Teaching/learning care plan?
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* Pt will be able to explain the purpose of digoxin.
* Pt will be able to recognize s/s of digoxin toxicity and when to contact their doctor/healthcare provider.
* Pt will be able to take their own pulse.
* Teach how to take pulse (tell pt to contact their doctor/healthcare provider before taking medication if pulse is <60bpm or >100bpm)
* Review s/s of digoxin toxicity (first signs are usually abdominal pain, anorexia, N&V, visual disturbances (yellowish tint to vision or halos around lights), bradycardia or other arrhythmias; weakness, confusion, dizziness; advise pt to notify doctor/healthcare provider immediately if these or sx of CHF occur. Inform that these sx can be mistaken for the cold/flu)
* Drug safety (avoid taking w/ meals bc meals can decrease absorption; avoid concurrent use of OTCs & herbals without first consulting your doctor; avoid antacids/antidiarrheals w/in 2 hours of digoxin)
* Review fall prevention strategies (adequate lighting, keeping areas free of throw rugs, cords or wires) - digoxin has been associated with increased falls in the elderly, and the patient in this scenario is an 84-y. o. woman.
* lecture on s/s of digoxin toxicity, drug safety & fall prevention strategies (maybe give handouts?)
* demo/return demo with pulse.
* return demonstration with pulse.
* pt will be able to explain the purpose of digoxin - you have no interventions that include teaching the purpose of this drug in your content outline so you can't legitimately have this as a goal.
* pt will be able to recognize s/s of digoxin toxicity and when to contact their doctor/healthcare provider.
* pt will be able to take their own pulse.
* teach how the this drug works on the heart to correct the heart failure.
teach how to take pulse (tell pt to contact their doctor/healthcare provider before taking medication if pulse is <60bpm or >100bpm) - also teach when to take the pulse; mention why this is important.
* review s/s of digoxin toxicity (first signs are usually abdominal pain, anorexia, n&v, visual disturbances (yellowish tint to vision or halos around lights), bradycardia or other arrhythmias; weakness, confusion, dizziness; advise pt to notify doctor/healthcare provider immediately if these or sx of chf occur. inform that these sx can be mistaken for the cold/flu)
* drug safety (avoid taking w/ meals bc meals can decrease absorption; avoid concurrent use of otcs & herbals without first consulting your doctor; avoid antacids/antidiarrheals w/in 2 hours of digoxin)
* review fall prevention strategies (adequate lighting, keeping areas free of throw rugs, cords or wires) - digoxin has been associated with increased falls in the elderly, and the patient in this scenario is an 84-y. o. woman.
* lecture on s/s of digoxin toxicity, drug safety & fall prevention strategies (maybe give handouts?)
* demo/return demo with pulse.
* return demonstration with pulse.
overview : a synopsis about what is going to be taught in the course goal(s): the aim(s) or outcome(s) that you want your learner to achieve as a result of the lesson you plan objectives : the more specific information that the learner will come away from the course knowing that will achieve the goal(s) you have determined. content : a play-by-play of the specific content that is going to be taught and in the sequence it will happen. your content should address and cover all the objectives. this part of the written lesson plan is presented in an outline format. procedures and materials: how all the above will be achieved, i. e. lecture, demonstration, discussion, etc. materials that can be used and resources that can be needed for the lesson to be successful and essential to teaching your lesson plan are listed and may include demonstrations, audio-visuals, handouts, experiments, stories, game playing and any number of other creative items. evaluation: determining if you met the goals of the teaching plan. this can be done through a return demonstration, short post test, short question and return answer session with the client to verify they understand the information correctly or a task the participant needs to perform. if you look at it, it has some of the elements of a care plan (goals, interventions, execution and evaluation). what is different is that you actually lay out how a list of how you are going to do the teaching, kind of like a nursing procedure is laid out step-by-step for you.
* Pt will be able to explain the purpose of digoxin.
* Pt will be able to recognize s/s of digoxin toxicity and when to contact their doctor/healthcare provider.
* Pt will be able to take their own pulse.
[FONT=Arial Narrow]And for the 'psychomotor' domain: At the next office visit, the client will demonstrate the ability to correctly assess his/her pulse.

What Is A Nursing Care Plan and Why is it Needed?
In nursing school, there is probably no more hated class assignment than the nursing care plan. They’re assigned for every type of class, for intensive care patients, in mental health, and even for community care. Nursing students stay up all night preparing patient-specific care plans for the next day’s clinical, but why is this agony inducing tool still used so universally?
The Purpose of the Written Care Plan.
Care plans provide direction for individualized care of the client. A care plan flows from each patient’s unique list of diagnoses and should be organized by the individual’s specific needs. Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds. Care plans help teach documentation . The care plan should specifically outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. They serve as a guide for assigning staff to care for the client. There may be aspects of the patient’s care that need to be assigned to team members with specific skills. Care plans serve as a guide for reimbursement. Medicare and Medicaid originally set the plan in action, and other third-party insurers followed suit. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented.
The purpose of students creating care plans is to assist them in pulling information from many different scientific disciplines as they learn to think critically and use the nursing process to problem solve. As a nursing student writes more plans, the skills for thinking and processing information like a professional nurse become more effectively ingrained in their practice.
The exact format for a nursing care plan varies slightly from place to place. They are generally organized by four categories: nursing diagnoses or problem list; goals and outcome criteria; nursing orders; and evaluation.
As defined by the the North American Nursing Diagnosis Organization-International (NANDA-I), nursing diagnoses are clinical judgments about actual or potential individual, family or community experiences or responses to health problems or life processes. A nursing diagnosis is used to define the right plan of care for the client and drives interventions and patient outcomes.
Nursing diagnoses also provide a standard nomenclature for use in the Electronic Medical Record (EMR), allowing for clear communication among care team members and the collection of data for continuous improvement in patient care.
Nursing diagnoses differ from medical diagnoses. A medical diagnosis — which refers to a disease process — is made by a physician and will be a condition that only a doctor can treat. In contrast, a nursing diagnosis describes a client’s physical, sociocultural, psychologic and spiritual response to an illness or potential health problem. For as long as a disease is present, the medical diagnosis never changes, but a nursing diagnosis evolves as the client’s responses change.
The goal as established in a nursing care plan — in terms of observable client responses — is what the nurse hopes to achieve by implementing nursing orders. It is a desired outcome or change in the client’s condition. The terms goal and outcome are often used interchangeably, but in some nursing literature, a goal is thought of as a more general statement while the outcome is more specific. For example, a goal might be that a patient’s nutritional status will improve overall, while the outcome would be that the patient will gain five pounds by a certain date.
Nursing orders are instructions for the specific activities that will perform to help the patient achieve the health care goal. How detailed the order is depends on the health personnel who will carry out the order. Nursing orders will all contain:
The date An action verb like “monitor,” “instruct,” “palpate,” or something equally descriptive A content area that is the where and the what of the order, for example, placing a “spiral bandage on the left leg from ankle to just below the knee” A time element will define how long or how often the nursing action will occur The signature of the prescribing nurse, since orders are legal documents.
Finally, in the evaluation , the client’s health care professionals will determine the progress towards the goal achievement and the effectiveness of the nursing care plan. The evaluation is extremely important because it determines if the nursing interventions should be terminated, continued or changed.
To help students learn and apply their knowledge, educators often add one more category to care plans. The rationale is the scientific reason for selecting a specific nursing action. Students may be required to cite supporting literature for their plan and rationale.
Care plans teach nursing students how to think critically, how to care for patients on a more personal level, not as a disease or diagnosis. They help teach how to prioritize care and interventions. They are a necessary evil of nursing school, tried and true for teaching future nurses not to care, but how to provide care that will improve the client’s health status.
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