Planning Types what do you want achieve to Make : - Time sequenced planning thrubut : Initial starts when you meet : Ongoing : Discharge : . . statements actual risk for · , will walk to end Wellness of the hall long > - document can implement well-being : short term- compliance wimmediate feedback Goalsare SMART Goals S comprehensive multidisciplinary (critical) Pt teaching . * · nursing-sensitive electronic · a ways to Legal implications . written · . starts when the pt arrives Formats · Eval plan resources Devise . written a Her shift pt wlpt whoever works the will you do this? andhow , term 31/day W/ April by walker 8 pt Outcomes + . Teaching goals > - cognitive do Standards of learning they understand ? · · Reasoning · relevance learning address how they're looking Demotions+ feelings Types independent by by : A the nurse : dependent depth the provider The entire healthcare team intment breadth precision learning Intervention significance clarity accuracy affective psychomotor : logic Observation monitor pt : . prevention prevent complications ........................................... : Implementation putting treatment Reducation as the nurse Are these barriers to make sure you can Never delegate Teaching Evaluation ready treating the health promotion interventions in place Are you : is the to do this ? learning ? : lack of edu . improving biggest Is the no problem or a maintenace keeping level intervention A pt ready to do this? . support system , etc . explain what you did and why ? Assessment Advanced interventions Collaboration Unstable pt . Planning recordeverythingA * · change · · progress pt progress "now . eval. can be · Assessment pt responses Recommendation 1 : : audit nursing · structure eval . 3 Compare pt outcomes / desired outcomes evaluative statement . Relate 5 no nursing interventionsto outoe a involved for all harm eval ...... . outcome eval . nursing diagnosis care plan . , , , elimination , nutrition hydration · med orders tests scheb . , , , etc prescribed treatments outcomes nursing interventions Addendum care Plans used for · daily clin care plans pt will get modified version . written , Predictable conditions · profile . instructions needs to meet basic responsibilities plan for pt . s identified Unit standards of care standardized "preprinted care plans · common · : collaborative problems pathway . ruh pts total + nursing di agnoses multidisciplinary · pt & & nursing Standardized · includes I care discharge planning special teaching needs : . prob . · · critical ↳ , , outcomes nursing orders for a single nursing diagnosis comprehensive plan of care plan of care for a pt age admitting diagnoses support system demographics other data , : and or name draw conclusions . Write the 4 . . . . . . . . . . . . . · where you see change interventions Review the desired outcomes/indicators . process . --- . Collect the eval. data 2 · peer review beneficence best nonmaleficence do You need to redo or Process ongoing reliability Terms · n test results standard validity criteria Sitchuation ackground , . · How do I measure this ? · . nursingdiagnose.progress ............. if this is plan of care ? · identify pt pt condition changes in pt . the was SBAR of shift ., Evaluation ........... successful Reports Oral Vitals behavior · specific by to nurses groups rather an indiv defined situations I contain medical orders No · care for . only Model Care Plans kept wlpts active care plan nurses are held accountable in the not · stored · easu Care deviations from the unit for the Planning . list all 3 detailed instructions · referencing process format addendum care plans can be added Guide * Kardex protocol Guidelines for synthsize data + problems I determine which problems 2 date . . 3 addressed " now . . individualize model care plans 4 6 # can be 7 . to the plan remaining nursing diagnoses 8 problems . 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