Potter and Perry: Chapter 14 Planning and Implementing Nursing Care p 179- 188
Planning Nursing Care
-after you identify a client’s diagnosis and strengths you begin planning nursing care
planning is a category of nursing behavior in which a nurse set client-centered goals, outlines expected outcomes, plans nursing interventions, and selects interventions that will resolve the client’s problems and achieve the goals and outcomes.
-requires critical thinking, applied through decision making and problem solving
-setting priorities is important and also collaborating with family and other health care members, review relevant literature
Figure 14-1: A model for priority setting
Establishing Priorities
priority setting is the ordering of nursing diagnoses or client problems, through the use of principles such as urgency or importance, to establish a preferential order for nursing actions
- rank diagnosis in order of importance and attend to most important needs first. Client must agree with ranking.
-e.g. a client has been diagnosed with acute pain, anxiety, deficient knowledge and impaired physical mobility (these has been put in prioritized order) before her scheduled operation in 5 hours. Treat pain to relieve anxiety, and then prepare client for surgery by giving client knowledge. Physical mobility needs to be addressed during all areas of care
- order of priorities may change as a clients condition changes
-three phases of priorities 1: initial- developing a preliminary plan 2: ongoing- continuous updating of plan of care and 3: discharge- anticipation and preparation for meeting clients needs after discharge
Critical Thinking in Establishing Goals and Expected Outcome
-once a nursing diagnosis has been established, you must decide the best approach to address the problem
Goals and Expected Outcomes are specific client behavior or physiological responses that you set to achieve through nursing diagnosis or collaborative problem resolution.
They provide a clear focus for the type of intervention necessary
-e.g. a client has been diagnosed with acute pain before surgery. Goal could be to improve pain control before surgery. Expected outcomes or measurable criteria are used to evaluate goal achievement. Expected outcome could be that client will rate pain on a scale of 0-10 at a 3 or less
-goals and expected outcomes serve two purposes. 1-to provide clear direction for the selection and use of nursing interventions, 2- provide focus for evaluating the effectiveness of the interventions
Goals of Care- a client-centered goal is a specific and measurable behavioral response that reflects a client’s highest possible level of wellness and independence in function. E.g. Client will perform self-care hygiene independently
-a goal is realistic and based on client’s needs and resources
-a goal involves only one behavior or response

short-term goal is an objective behavior or response that you can expect a client to achieve in a short time, usually less than a week.
long-term goal is an objective behavior or response that you can expect a client to achieve over a long period, usually over several days, weeks, or months.
-goal setting establishes the framework for the nursing care plan
Role of Client in Goal Setting- important to work closely with client in setting goals
-mutual goal setting includes clients, family
- clients need to be able to engage in problem solving and decision making to be able to participate in goal setting.
- unless you set goals mutually with the client, clients will not follow the plan
Figure 14-2 Critical thinking and the process of planning care.
Figure 14-3 From diagnosis to outcome.
Expected Outcomes- is a specific measurable change in a client’s status that you expect in response to nursing care. Expected outcomes provide a focus or direction for nursing care because they are the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of the client’s health problems.
-derived from both short- and long-term goals
-write expected outcomes sequentially, specifying time frames for each. Time frames provide progressive steps to recovery and assist in ordering nursing interventions. Time frames set limits for problem resolution.
Table 14-1 Examples of Goal Setting with Expected Outcomes
Table 14-2 Examples of NANDA International Nursing Diagnosis and Suggested NOC
Linkages
Nursing Outcomes Classification- the health care environment pays attention to measuring outcomes that are relevant to nursing interventions
-Nursing Outcomes Classification (NOC) has linked the outcomes to NANDA
International nursing diagnosis
nursing sensitive client outcome - and individual, family, or community state, behavior, or perception that is measurable along a continuum in response to a nursing intervention
-any given NANDA International nursing diagnosis, has multiple outcomes suggested in
NOC
Combining Goals and Outcome Statements- these can be referred to interchangeably. This is acceptable as long as the criteria for writing goals and outcomes are met. E.g. “Client will achieve pain control (goal) as evidenced by reporting pain acuity of lass that 3 on a pain scale (outcome) 0 to 10 within 24 hours”
Guidelines for Writing Goals and Expected Outcomes- seven guidelines
1.) Client-Centered Goal or Outcome: write a goal to reflect client behavior, not to reflect your goals or interventions. E.g. “Client will ambulate in the hall three

times a day” is correct. “Ambulate client in the hall three times a day” is incorrect.
2.) Singular Goal or Outcome: be precise, each goal and outcome addresses only one behavior or response.
3.) Observable Goal or Outcome: you need to be able to see whether a change in a client’s status occurs. Changes in physiological findings and in the client’s knowledge, perceptions and behavior are observable. You observe outcomes by directly asking questions about their condition and by using assessment skills.
E.g. using the statement “will appear” which is not observable.
4.) Measurable Goal or Outcome: you will learn to write goals and expected outcomes that set standards against which to measure the client’s response to nursing care. E.g. “body temperature will remain 98.6 degrees F”
5.) Time-Limited Goal or Outcome: the time frame for each goal and expected outcome indicates when you expect the response to occur. Time frames assist in determining progress towards goals and outcomes.
6.) Mutual Goals or Outcomes: mutually set goals ensure that the client and nurse agree on the direction and time limits of care. It also increases motivation and cooperation with the client.
7.) Realistic Goal or Outcome: set goals that are reachable. Provides client with a sense of hope that increases motivation and cooperation.
Types of Intervention
-three types, some patients need all three, some two.
-nurse-initiated interventions are independent nursing interventions : do not require orders form other health care professionals. E.g. instructing clients in side effects of medications, or directing a client to splint an incision during coughing.
-physician-initiated interventions are dependent nursing interventions : these are actions that require orders or directions form physicians or other health care professionals.
Aimed at treating a medical diagnosis. E.g. administering a medication, changing a dressing.
- interdependent nursing interventions are collaborative interventions : therapies that require the combined knowledge, skill, and expertise of a number of health care professionals. E.g. introducing a social worker into your clients care plan
Selection of Interventions
-interventions are not selected randomly. A client diagnosed with anxiety may require a variety or interventions. When choosing interventions consider 6 factors. (1) the nursing diagnosis, (2) goals and expected outcomes, (3) the evidence based (e.g., research or proven practice guidelines), (4) feasibility, (5) acceptability to the client, and (6) your own competence
Nursing Interventions Classification
-set of nursing interventions that provide a level of standardization, which enhances communication of nursing care across all health care setting and enables health care professionals to compare outcomes. Includes three levels: domain, classes and interventions. See all related tables and boxes in text

Table 14-3 Frequent Errors in writing Nursing Interventions
Box 14-1 Choosing Nursing Interventions
Table 14-4 Nursing Interventions Classifications (NIC) Taxonomy ** IMPORTANT **
Box 14-2 Examples of Interventions for Physical Comfort Promotion
Box 14-3 Example of Interventions and Associated Nursing Activities
Planning Nursing Care
-nurse is responsible for developing a written plan of care for clients
-a written nursing care plan includes nursing diagnosis; goals, expected outcomes, or both; and specific nursing interventions so that any nurse is able to quickly identify a clients clinical needs and situation. This ensures continuity of care and coordination by health care workers.
- written care plans are exchanged during report at change of shift reports
Institutional Care Plans
-become a part of a client’s legal medical record
- many hospitals use written Kardex nursing care plan. Kardex card-filing system allows for quick reference to needs of client for certain aspects of nursing care. Kardex system varies by agency and focuses on planned interventions to meet the needs of the client and family and to prepare client for discharge from the hospital.
Box 14-3 Example of Interventions and Associated Nursing Activities
Computerized Care Plans
-majority of health care facilities now have some type of electronic health record (EHR) and documentation system
-software is available for nursing care programs
Care Plans for Community-Based Settings
-e.g. clinics community centers, or client’s homes involves using the same principles of nursing practice
-however in these settings you need to complete a more comprehensive community, home and family assessment, because the client or family unit must be able to provide the majority of health care independently
Critical Pathways
critical pathways are multidisciplinary treatment plans that outline treatments or interventions that clients may require for treatment of a condition.
-usually based on medical rather than nursing diagnoses, but also incorporate nursing diagnoses and interventions.
-it maps out day to day or even hour-to-hour, the recommended interventions and expected outcomes

-e.g. a pathway for a surgical procedure such as bowel resection will recommend a dayby-day basis the client’s activities, procedures, and discharge planning activities.
-ensures better continuity of care
-nurses use them to monitor a patient’s progress
-some forms of documentation are eliminated (nursing care plan, flow sheets, and nurses notes) because all the pertinent components are included in the pathway.
Box 14-4 Nursing Care Plan