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NURSING PROCESS

NURSING PROCESS. Chapter 4 The Nursing Process: The Planning Step: Creating the Plan of Care. Reference.

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NURSING PROCESS

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  1. NURSING PROCESS Chapter 4 The Nursing Process: The Planning Step: Creating the Plan of Care

  2. Reference • Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process andnursing diagnosis: An interactive text for diagnostic reasoning(5th ed.). Philadelphia: F. A. Davis.

  3. Competencies for Chapter 4: The Planning Step • By the end of this unit the student will: • Describe the purpose of the planning step of the nursing process • Describe discharge planning • List 6 steps in creating the plan of care • Define goal and expected outcome • Describe 3 types of interventions

  4. Primary Purpose of the Planning Step: • The step where goals/outcomes are determined and interventions chosen • Planning step occurs once the diagnostic statement (diagnosis) is formulated • Begin to set priorities, establish goals, and determine interventions

  5. Initial planning • Developed by the nurse who performs the admission nursing history and the physical assessment • Nurse must rank the client needs in order of importance • Maslow’s Pyramid a helpful guideline

  6. Always Changing • Setting priorities is complex and dynamic • Client needs can change day-to day or minute- to-minute • Nurse’s responsibility to update plan of care to reflect those changes

  7. Steps in Creating the Plan of Care • Set priorities • Establish client goals • Identify desired outcomes • Select appropriate nursing interventions • Document Client Plan of Care • Validate the Client Plan of Care

  8. Setting Priorities • Maslow’s hierarchy of needs • Patient preference • Anticipation of future problems

  9. Goals/Outcomes • Goal – an aim or an end • Patient goal – expected patient outcome, an expected conclusion to a patient health problem • Expected outcomes – refers to the more specific, measurable criteria used to evaluate the extent to which a goal has been met.

  10. Establishing Client Goals Writing goals/outcomes • Goals– derived from the problem statement of the nursing diagnosis • short-term vs. Long-term goals • Guidelines for goal writing: subject, verb criteria, observable, measurable terms

  11. Identifying Desired Outcomes Components of client outcomes: • Specific • Realistic • Consider the clients circumstances and desires • Indicate a time frame • Provide measurable evaluation criteria “All outcomes should tell the reader specifically what the client is working on or doing” (Doenges& Moorhouse, 2008, p. 82)

  12. Selecting Appropriate Nursing Interventions • Nursing Intervention: • Any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes • Prescriptions for behaviors, treatment, or activities that assist the client to achieve expected outcomes • Individualizes client care • Must consider nursing standards and agency policy

  13. Types of Interventions • Nurse initiated • an autonomous action that a nurse executes to benefit the patient • Physician initiated • Initiated by the physician in response to a medical diagnosis but carried out by a nurse in response to a doctor’s order • Collaborative • carrying out treatments initiated by other providers ( such as pharmacists, therapies, dietician)

  14. Documenting Client Plan of Care • A formal plan of care: • Individualizes care • Set priorities • Enhances communication • Provides continuity of care • Promotes the nurse’s professional development • Assists with determination of staff needs • Serve as a teaching tool

  15. Validating Client Plan of Care Review plan to ensure: • Based on accepted nursing practice • Provides for safety of client • Diagnostic statements supported by data • Goals & outcomes are measurable • Demonstrates individualized care

  16. Chapter 4 Primary Purpose of the Planning Step: • To design a plan of care for and withthe patient that results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient’s health expectations

  17. Discharge Planning • Begins with the client enters the healthcare facility • Considers future needs especially the eventual discharge

  18. Summary • Set priorities • Establish client goals • Identify desired outcomes • Select appropriate nursing interventions • Document Client Plan of Care • Validate the Client Plan of Care • Begin discharge planning immediately • Use plan of care to provide individualized quality nursing care

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