PLANNING NURSING CARE. NURSING CARE PLAN.
lanning, the third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. Preceding this step is the collection of assessment data and the formulation of nursing diagnoses.
After a nurse thoroughly assesses a client and determines the client’s unique nursing diagnoses (or problems), a plan of action is developed with specific goals to resolve the nursing diagnoses or health problems of the client. Following the planning component, the nursing process continues with implementation of nursing interventions and evaluation of the client’s plan of care.
The four critical elements of planning include:
• Establishing priorities
• Setting goals and developing expected outcomes (outcome identification)
• Planning nursing interventions (with collaboration and consultation as needed)
The purpose, as well as the entire process, of the planning concept is illustrated with theory and examples. Strategies for effective planning of quality nursing care are described together with problems frequently encountered in this stage of the nursing process. The role of critical thinking in planning and outcome identification is emphasized.
PURPOSES OF OUTCOME IDENTIFICATION AND PLANNING
The American Nurses Association (1998), in its Standards of Clinical Nursing Practice, identifies outcome identification and planning as essential principles for ensuring the delivery of competent nursing care and outlines these components in terms of their significance within the nursing process. Although the overall purpose of a client’s plan of care should be to maintain or improve health at an optimal level, planning is a framework on which to base scientific nursing practice.
Therefore, the purposes of the planning component of the nursing process are to provide adequate direction to ensure quality nursing care for individual clients, to present a vehicle to improve staff communication, and to provide continuity in the delivery of individualized, quality nursing care to all clients.
The five steps of the nursing process are at the very core in using scientific reasoning for the delivery of individualized, quality nursing care in any setting (Doenges, Moorhouse, & Geissler, 1997). The ability to make appropriate decisions based on a strong knowledge base and problem-solving strategies is an expected behavior of the professional nurse.
More specifically, professional nurses are expected to think critically to process data and to make convincing, intelligent decisions concerning the planning, management, and evaluation of health care for their clients (Prechter, 1993). By combining the critical-thinking skills inherent in the nursing process with the client’s identified nursing diagnoses, the nurse can focus on resolving the client’s nursing diagnoses with greater proficiency.
The planning of nursing care occurs in three phases: initial, ongoing, and discharge. Each type of planning contributes to the coordination of the client’s comprehensive plan of care.
Initial planning involves development of beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Because of progressively shorter lengths of hospitalization, initial planning is important in addressing each prioritized problem, identifying appropriate client goals, and correlating nursing care to hasten resolution of the client’s problems.
Ongoing planning entails continuous updating of the client’s plan of care.
Every nurse who cares for the client is involved in ongoing planning. As new information about the client is gathered and evaluated, revisions may be formulated and the initial plan of care becomes further individualized to the client.
Discharge planning involves critical anticipation and planning for the client’s needs after discharge. Planning is sequential, dynamic, and future-oriented.
Planning includes establishing priorities, identifying goals and expected outcomes, developing nursing interventions, and documenting the client’s plan of care.
Appropriate guidelines are used to prioritize urgent needs. The client’s nursing diagnoses are determined and then ranked by mutual agreement of the nurse and client or significant others. The planning component continues with thorough examination of this prioritized list of nursing diagnoses and determination of the client’s goals and desired expected outcomes. After a clear picture is obtained regarding the diagnoses and goals, the nursing interventions can be planned to achieve the desired outcomes.
In the planning phase, the nurse organizes “thought processes for clinical decision making” (Doenges et al., 1997). To think critically is to examine an issue purposefully from a goal-directed perspective. Critical thinking “is based on principles of science and scientific method” (Alfaro-LeFevre, 1998). Therefore, critical thinking is a useful procedure in the development of objectives and in the formulation of a blueprint to achieve those objectives. The formulation of objectives is accomplished by using valid and reliable data previously gathered during the assessment component of the nursing process.
The establishment of priorities is the first element of planning. In establishing priorities, the nurse examines the client’s nursing diagnoses and ranks them in order of physiological or psychological importance. This method organizes a client’s nursing diagnoses into an operational format for the planning of nursing care. These diagnoses should be mutually ranked by the nurse and client or family and significant others. Involving the client in shared decision-making power helps motivate the client and gives the client a feeling of control, which inspires successful achievement of each goal (Doenges et al., 1997).
When an individual client has more than one diagnosis, the nurse and client need to establish priorities to identify which nursing diagnosis will be addressed initially in the plan of care (Carpenito, 1999). By communicating this decision-making process to other members of the health care team, the nurse encourages an orderly approach to the achievement of optimal health for each client.
Various guidelines are used in the establishment of priorities for determining which nursing diagnosis will be addressed initially. The client’s basic needs, safety, and desires, as well as anticipation of future diagnoses must be considered. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life-threatening diagnosis be given more urgency than a non–life threatening diagnosis. Once the basic physiological needs (e.g., respiration, nutrition, hydration, elimination) are met to some degree, the nurse may consider needs on the next level of the hierarchy (e.g., safe environment, stable living condition) and so on up the hierarchy until all the client’s nursing diagnoses have been prioritized.
Following table illustrates this process
A useful guide for the beginning nursing student would be to examine each nursing diagnosis, determine its level of need, and rank the need in order of priority.
Another consideration in the designation of priorities is client preferences. If at all possible, the client should always be involved in the decision-making process of establishing priorities. If the nurse and the client do not mutually set priorities, there may be a contradictory course of direction and motivation, which may lead to noncompliance and nonresolution of the client’s nursing diagnoses. The client must participate in the identification of priorities so that the nature of the problem, as well as the client’s values, are reflected in the selected course of action.
An additional point regarding the establishment of priorities is the anticipation of future diagnoses. Nursing diagnoses of low and moderate priorities often involve the prevention of anticipated potential or risk diagnoses. Although potential nursing diagnoses may not be a current threat to the client, their seriousness may require that the nurse consider the development of nursing interventions directed toward prevention of the problem. For example, a client in the Postanesthesia Care Unit may have a high-priority nursing diagnosis of Ineffective Breathing Pattern related to the anesthesia and sedative drugs. Despite the fact that the client currently has no problem in this area, this diagnosis is indeed the basis for the Postanesthesia Care Unit protocol of monitoring the client closely.
Establishing priorities does not mean that one diagnosis must be totally resolved before giving attention to another diagnosis. Nursing interventions for several diagnoses may be carried out simultaneously. However, at times, it is crucial that the nurse and client correctly identify the order of priority of the client’s nursing diagnoses so that maximum effort can be directed toward resolution of the most urgent diagnosis.
Following table illustrates this process:
ESTABLISHING GOALS AND EXPECTED OUTCOMES
After assessing the client, formulating nursing diagnoses, and establishing priorities, the nurse sets goals and identifies and establishes expected outcomes for each nursing diagnosis. The purposes of setting goals and expected outcomes are to provide guidelines for individualized nursing interventions and to establish evaluation criteria to measure the effectiveness of the nursing care plan.
A goal is an aim, an intent, or an end. A goal is a broad or globally written statement describing the intended or desired change in the client’s behavior, response, or outcome. An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved. It includes aspects such as direct nursing care and client teaching.
Written goals need to be constructed clearly. Clear, precise terminology improves the chances that goals will be achieved. When goals are clearly written, their establishment provides direction for the nursing plan of care and for determination of effectiveness in the evaluation of nursing interventions. A guideline is provided for the desired change in the client, and the client has a clear idea of the direction to be taken for achieving resolution of each nursing diagnosis. Goals establish appropriate evaluation criteria to measure the effectiveness of planned nursing interventions for the resolution of the client’s individual nursing diagnoses.
Goals should be established to meet the immediate, as well as long-term prevention and rehabilitation, needs of the client.
A short-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a few hours or days.
A long-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis over a longer period of time, usually over weeks or months (Alfaro-LeFevre, 1997). See the accompanying display for examples of short-term and long-term goals.
Another consideration is the accuracy in identifying the etiology of the problem. If the etiology of the problem is incorrectly identified, the client may meet the short-term goal but the problem will not be resolved. Thus, it is important to correctly identify the etiology of the problem.
Setting long-term goals is important in successful discharge planning. It assists in coordinating all health care team members to accomplish the same overall purpose, that is, client discharge. Coordination promotes continuity of care into settings such as restorative care or home health (see the accompanying display).
After the goal is established, the expected outcomes can be identified based on the goal. Given the client’s unique situation and resources, expected outcomes are constructed to be:
• Mutually desired by the client and nurse
• Attainable within a defined time period
These desired outcomes are the measurable steps toward achieving the previously established goals (Doenges et al., 1997). Because nursing care is based on a holistic approach, expected outcomes may be written in the spiritual, emotional, physiological, developmental, and social dimensions. An expected outcome depicts measurable behavioral change or evidence of change in the client when the goal has been met. Several expected outcomes may be required for each goal. Expected outcomes are used in the evaluation process by providing a standard for comparison to determine if the client successfully accomplished the goals.
In the construction of both goals and expected outcome objectives, essential components include: subject, task statement, criteria, the conditions (if necessary), and time frame (Doenges et al., 1997). When goals and outcomes are written clearly, the nurse can select nursing interventions to ensure that the client’s baseline data are thoroughly assessed, individual client needs are identified, and appropriate approaches are used in the plan of care. Usually, each nursing diagnosis has one global goal and several expected outcomes. In writing the goal statement, the nurse considers the nursing diagnosis for the formulation of a suitable client behavior that illustrates reduction or alleviation of the nursing diagnosis.
These concepts are demonstrated in the Nursing Process Highlight.
Each component of an appropriately written goal is discussed in the following paragraphs. For clarity of each concept, examples are provided with related discussion. The examples are designed with the intent of developing skills in the construction of goals.
The component to be considered initially in writing a goal is the subject. The subject identifies the person who will perform the desired behavior or meet the goal. In a client-centered plan of nursing care, the client is the person who needs to achieve a desired change in behavior. See the accompanying display for an application of the subject component.
The next component in writing goals is the task statement or the action verb. This component describes what the client (or subject) will do to obtain an expected change in behavior. The task statement enables the evaluator to determine achievement of observable behavior. When the actual behavior is stated as a task statement that can be clearly and directly measured, the nurse can determine whether the client is demonstrating achievement of the goal.
Only one task statement should be used for each goal. It is clearer to write separate goals than to try to accurately measure a combination of tasks.
See the accompanying display for an application of the task statement.
The next essential component is the criteria of a goal.
Criteria are standards used to evaluate whether the behavior demonstrated indicates accomplishment of the goal. Criteria may be written in a variety of ways.
Criteria may include:
• A time limit
• Amount of activity
• Important characteristics of accurate performance
• Description of the performance to be followed
The nurse should specify the precise performance to be considered acceptable in accomplishment of the goal. It is not always possible to specify a criterion with as much detail as one would like; however, the nurse should continue to communicate precise criteria as explicitly as possible. To provide better direction to the client, the nurse considers how well the client, family member, or significant other should perform the task.
See the accompanying display for an application of criteria.
The next component to be included in writing proper goals is the conditions under which the client should perform or demonstrate mastery of the task. Although this component is optional in terms of writing goals, conditions may provide clarity and assist the client in demonstrating the expected behavior. The conditions may include the experiences that the client is expected to have before performing the task.
See the accompanying display for an application of conditions.
The last component to be included in writing goals appropriately is the time frame in which the client should perform or demonstrate mastery of the task.
PROBLEMS FREQUENTLY ENCOUNTERED IN PLANNING
Nursing students, as beginners in the use of the nursing process, often fall into some common pitfalls when applying the steps to practice. These pitfalls are described with the intent of providing a clear direction for the use of this process and proposing suggestions for avoiding these common errors.
In regard to writing goals, the errors frequently observed in this component involve improper format.
Format errors include goals that are nurse-centered instead of client-centered, unrealistic, negative rather than positive, generically copied from a reference and not individualized to the client, unmeasurable, nonspecific, nonbehavioral, vague, wordy, and without a time frame.
Another challenge in the development of goals and expected outcomes is the establishment of appropriate time frames for accomplishment of the intended results.
Although this component may be difficult at first to master, nursing students should practice writing goals that are realistic and include appropriate time frames using available literature and resources to gain expertise. It is preferable for a goal to include an excessively short, rather than an excessively long, time frame, because the goal is brought to attention in the evaluation process more frequently. By inserting the time frame “daily” for specific goals, the expected outcome will be brought up frequently for evaluation. Through a process of building on continued professional growth and experience, students and beginning nurses will become more adept and realistic in applying the nursing process to client situations.
Finally, novices as well as experienced nurses tend to make decisions for clients in a paternalistic fashion by deciding what is best for the client without input from the client. To correct this problem, the nurse must establish a trusting nurse-client relationship that promotes mutual understanding and caring. The nurse should encourage clients to make their own decisions regarding health care.
PLANNING NURSING INTERVENTIONS
Once the goals have been mutually agreed on by the nurse and client, the nurse should use a decision-making process to select appropriate nursing interventions.
A nursing intervention is an action performed by a nurse that helps the client to achieve the results specified by the goals and expected outcome. These terms are based on scientific principles and knowledge from behavioral and physical sciences. Usually, several nursing interventions are developed for each of the goals identified for the client (Sparks & Taylor, 1993). It is important to identify as many nursing interventions as possible so that if one proves to be unsuitable, others are readily available.
The interventions are prioritized according to the order in which they will be implemented. With the inclusion of scientific problem solving and critical thinking, the delivery of quality, individualized nursing care is greatly enhanced. Through critical thinking, sound conclusions are reached in the selection of nursing interventions to prevent, reduce, or eliminate the nursing diagnoses or problems. The nurse studies the entire issue thoroughly in the planning component of the nursing process by examining the assessment data and nursing diagnoses, analyzing the client’s goals and expected outcomes, and selecting which nursing interventions should be used from a multitude of possibilities to ensure the delivery of quality nursing care for each client.
Several factors can assist the nurse in selecting nursing interventions. Just as the client’s goals can be derived from the nursing diagnosis, the nursing interventions can be developed from the etiology of each nursing diagnosis. The effective nurse plans interventions that are directed toward the cause of the client’s nursing diagnosis or problem. For example, for a client with angina who may have the nursing diagnosis of Pain related to myocardial ischemia, an appropriate nursing intervention would be to help the client conserve energy (i.e., bedrest).
The nurse may use various guidelines in selecting appropriate nursing interventions. These guidelines include the individual nurse practice acts, state boards of nursing standards, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for nursing care. Other determining factors of appropriate nursing interventions include whether an action is realistic in terms of the abilities of the client and nurse, and if it is compatible with available resources, the client’s values and beliefs, and other therapies planned for the client.
In determining which nursing interventions to use, the nurse should critically consider the consequences and the risks of each intervention. After considering these factors, the nurse selects those that are most likely to be effective with the minimum of risk.
This table applies the guidelines for selection of appropriate nursing interventions for a specific nursing diagnosis.
After setting the goals and planning the appropriate nursing interventions, the nurse writes nursing orders to communicate the exact nursing interventions that are to be implemented for the client. A nursing order is a statement written by the nurse that is within the realm of nursing practice to plan and initiate. These statements specify direction and individualize the client’s plan of care. For example, a health care practitioner’s order to force fluids must be specified in the nursing order as the number of milliliters per hour or per shift (e.g., 100 ml/h or Day shift = 800 ml; Evening shift = 800 ml; Night shift = 400 ml).
Ensuring that nursing orders are well written requires several essential elements. These elements include: the nursing order date, action verb, detailed description, time frame, and signature (Wilkinson, 1998).
See the accompanying display for a summary of the elements of a nursing order.
The type of nursing order written is determined by the client problem. The nurse is responsible for writing nursing orders that involve health promotion, observation, prevention, and treatment (Wilkinson, 1998).
This table gives examples of types of nursing orders.
CATEGORIES OF NURSING INTERVENTIONS
Nursing interventions are classified according to three categories: independent, interdependent, and dependent.
Independent nursing interventions are nursing actions initiated by the nurse that do not require direction or an order from another health care professional.These interventions are sanctioned by professional nurse practice acts derived from licensure laws. In many states, the nurse practice acts allow independent nursing interventions regarding activities of daily living, health education, health promotion, and counseling. An example of an independent nursing intervention is the nurse’s action to elevate a client’s edematous extremity.
Interdependent nursing interventions are those actions that are implemented in a collaborative manner by the nurse with other health care professionals.
Collaboration is a partnership in which all parties are valued for their contribution. Collaboration is used to gather data, plan, implement, evaluate, and gain objectivity by examining another’s viewpoint. Interdependent nursing interventions allow the client’s nursing diagnoses to be resolved on the basis of recommendations of an interdisciplinary health care team approach. 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)
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.
PLAN OF CARE
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
twice a day.
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:
a. 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
a. 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?
a. 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
a. 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
a. 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
Implementation, 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:
• Ongoing assessment
• 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)
• Available resources
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.
Delegation of Tasks
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
• Who will do it
• 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
• Discharge planning
• 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.