funda lec planning and implementation

• Planning is an intentional, systematic phase of the nursing process that involves decision-making and problem-solving. In planning, the nurse refers to the cli-ent's assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems
• A nursing intervention is "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient / client outcomes"
• The end product of the planning phase is a client care plan.
• Initial Planning

  The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. This nurse has the benefit of seeing the client's body language and can also gather some intuitive kinds of information that are not available solely from the written database. Planning should be initiated as soon as possible after the initial assessment.
• Ongoing Planning

  All nurses who work with the client do ongoing plan-ning. As nurses obtain new information and evaluate the client's responses to care, they can individualize the initial care plan further. Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be given that day.
• Using ongoing assessment data, the nurse carries out daily planning for the following purposes:

  1. To determine whether the client's health status has changed
  2. To set priorities for the client's care during the shift
  3. To decide which problems to focus on during the shift
  4. To coordinate the nurse's activities so that more than one problem can be addressed at each client contact.
• Discharge planning, the process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive healthcare plan and should be addressed in each client's care plan. Because the average stay of clients in acute care hospitals has become shorter, people are sometimes discharged still needing care. Although many clients are discharged to other agencies
• Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client's ongoing needs.
• Developing Nursing Care Plans

  The end product of the planning phase of the nursing process is a formal or informal plan of care.
• An informal nursing care plan is a strategy for action that exists in the nurse's mind. For example, the nurse may think, Mrs. Phan is very tired. I will need to reinforce her teaching after she is rested."
• A formal nursing care plan is a written or computerized guide that organizes infor mation about the client's care. The most obvious benefit of a formal written care plan is that it provides for con. tinuity of care.
• A standardized care plan is a formal plan that speci fies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction).
• An individualized care plan is tailored to meet the unique needs of a specific client needs that are not addressed by the standardized plan.
• It is important for all caregivers to work toward the same outcomes and, if available, use approaches shown to be effective with a particular client.

  Nurses also use the formal care plan for direction about what needs to be documented in client progress notes and as a guide for delegating and assigning staff to care for clients. When nurses use the client's nursing diagnoses to develop goals and nursing interventions, the result is a holistic, individualized plan of care that will meet the client's unique needs.
• During the planning phase, the nurse must (a) decide which of the client's problems need individualized plans and which problems can be addressed by standardized plans and routine care, and (b) write individualized desired outcomes and nursing interventions for client problems that require nursing attention beyond preplanned, routine care.
• Plan of care


  The complete plan of care for a client is made up of several different documents
• Documents in a plan of care


  • Documents describing routine care needed to meet basic needs (e.g., bathing, nutrition)
  • Documents addressing the client's nursing diagnoses and collaborative problems
  • Documents specifying the nurse's responsibilities in carrying out the medical plan of care (e.g., keeping the client from eating or drinking before surgery; scheduling a laboratory test)
• Complete plan of care


  • Integrates dependent and independent nursing functions into a meaningful whole
  • Provides a central source of client information
• Standardized Approaches to Care Planning


  Most healthcare agencies have devised a variety of standardized plans for providing essential nursing care to specified groups of clients who have certain needs in common
• Specified groups of clients


  • All clients with pneumonia
• Standards of care, standardized care plans, protocols, policies, and procedures


  • Developed and accepted by the nursing staff
  • Ensure that minimally acceptable criteria are met
  • Promote efficient use of nurses time by removing the need to author common activities that are done repeatedly for many of the clients on a nursing unit
• Standards of care


  Describe nursing actions for clients with similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care
• Standards of care


  • Define the interventions for which nurses are held accountable
  • Do not contain medical interventions
• Standards of care


  Usually agency records and not part of the client's care plan, but they may be referred to in the plan
• A nurse might write "See unit standards of care for cardiac catheterization"
• Standards of care may or may not be organized according to problems or nursing diagnoses
• Standards of care are written from the perspective of the nurse's responsibilities
• Standardized care plans:

  • Are kept with the client's individualized care plan on the nursing unit. When the client is discharged, they become part of the permanent medical record.
  • Provide detailed interventions and contain additions or deletions from the standards of care of the agency.
  • Typically are written in the nursing process format:Problem -> Goals / Desired Outcomes ->Nursing Interventions -> Evaluation.
  • Frequently include checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions
• Like standards of care and standardized care plans, protocols are predeveloped to indicate the actions commonly required for a particular group of clients. For example, an agency may have a protocol for admitting a client to the intensive care unit or for caring for a client receiving continuous epidural analgesia. Protocols may include both the primary care provider's orders and nursing interventions. Depending on the agency, protocols may or may not be included in the client's permanent record.
• Policies and procedures are developed to govern the handling of frequently occurring situations. For example, a hospital may have a policy specifying the number of visitors a client may have. Some policies and procedures re similar to protocols and specify what is to be done, tor example, in the case of cardiac arrest. If a policy covers a citation pertinent to client care, it is usually noted on the care plan (e.S, "Make social service referral according to Policy Manual"). Policies are institutional records and do not become a part of the care plan or permanent record.
• Standing order


  A written document about policies, rules, regulations, or orders regarding client care
• Standing orders


  • Give nurses the authority to carry out specific actions under certain circumstances, often when a primary care provider is not immediately available
  • In a hospital critical care unit, a common example is the administration of emergency antiarrhythmic medications when a client's cardiac monitoring pattern changes
  • In a home care setting, a primary care provider may write a standing order for the nurse to obtain blood tests for a client who has been on a certain therapy for a prescribed amount of time
• Student Care Plans

  Because student care plans are a learning activity as well as a plan of care, they may be lengthier and more detailed than care plans used by working nurses. To help students learn to write care plans, educators may require that more of the plan be original work. They may also modify the plan by adding "Rationale" after the nursing interven-tions.
• A rationale is the evidence-based principle given as the reason for selecting a particular nursing intervention. Students may also be required to cite supporting literature for their stated rationale. For an example of a Nursing Care Plan
• Concept maps are creative endeavors. They can take many different forms and encompass various categories of data, according to the creator's interpretation of the dient or health condition.
• Computerized Care Plans

  Computers are increasingly being used to create and store nursing care plans. The computer can generate both standardized and individualized care plans. Nurses access the client's stored care plan from a centrally located terminal at the nurses' station or from terminals in client rooms.
• Multidisciplinary (Collaborative)

  Care Plans

  A multidisciplinary care plan is a standardized plan that outlines the care required for clients with common, predictable usually medical conditions.
• also referred to as collaborative care plans and critical path-ways, sequence the care that must be given on each day during the projected length of stay for the specific type of condition.
• multidisciplinary care plan can specify outcomes and nursing interventions to address client problems (includ-ing nursing diagnoses). However, it includes medical treatments to be performed by other healthcare providers as well.
• 1. Date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning.

  The nurse's signature demonstrates accountability to the client and to the nursing profession, since the effectiveness of nursing actions can be evaluated.