define formal planning
concious, deliberate activity involving decision making, critical thinking, and creativity.
Define informal planning
making mental notes or plans
initial planning
1. begins with the first pt contact.
2. is documented asap after initial assessment
3. includes development of the initial comprehensive care plan
ongoing planning
causes changes to be made in the plan as you evaluate the clients responses to care or obtain new data
discharge planning
1. planning for self-care and continuity of care after client leaves healthcare setting
2. begins with initial assessment
3. needed by all clients
4. requires collaboration
The comprehensive nursing plan of care is the central source of information needed to
1. guide holistic, goal-oriented care
2. address each clients unique needs
Why is a written nursing plan of care important?
1. ensures care is complete
2. provides continuity of care
3. promotes efficient use of nursing efforts
4. provides a guide for assessing and charting
5. meets requirements of accrediting agencies.
Identify patients who need a comprehensive, formal discharge plan.
a pt who
1. has a personal characteristic that interferes with self-care ex. learning disability, poor mobility
2. disease or treatment characteristics;coexisting illness ex terminal illness, major surgery
3. social of family factors ex inadequate service
What information is contained in a comprehensive nursing plan of care?
1. basic needs and activities of daily living
2. medical/multidisciplinary treatment
3. nursing concepts and collaborative problems
4. special discharge needs or teaching methods
what are the types of preprinted, standardized plans
1. Unit standards of care
2. standardized nursing care plans
3. critical pathways
4. integrated plans of care
Unit standards of care
general guides that describe the care that nurses are expected to provide for all clients in defined situations
standardized nursing care plans
detailed nursing care for a particular nursing diagnosis; for all nursing diagnoses that commonly occur with a certain medical condition.
critical pathways
outcome-based, interdisciplinary plans that sequence client care based on case type
integrated plans of care
standardized plans designed to be both care plan and documentation form
what is an Individualized nursing care plan
used to address nursing diagnoses unique to a particular client
What is a special discharge or teaching plan?
May use standardized plan for discharge planning and teaching or include as teaching in a nursing diagnosis care plan
computerized care plan
1. enter diagnosis or desired outcome
2. computer generates list of suggested interventions
3. choose appropriate interventions
4. individualize by typing in own interventions as needed
process for writing an individualized nursing care plan
1. make a working problem list
2. decide which problems can be managed with standardized care plans or critical pathways
3. individualize the standardized plan as needed
4. transcribe medical orders to appropriate documents
planning client goals/outcomes
goals- describe the changes in client health status you hope to achieve
outcome- can be influenced by nursing interventions
short term goals
to be achieved within a few hours or days
long term goals
to be achieved over a longer period of time
what are the components of a goal statement?
1. subject
2. action
3. performance criteria
4. target time
5. special condition
how do goals relate to nursing diagnosis?
1. expected outcomes derive directly from the nursing diagnosis
2. problem statement describes the response/health status to be changed
3. desired outcome states the opposite of the problem response
essential versus nonessential goals
non- derive from the etiology
essential-derive from the problem
what is an outcome label?
: This is a broadly stated neutral label (a variable), to allow for positive, negative, or no change in patient health status.
indicators
The observable behaviors and states you can use to evaluate patient status.
measurement scale
For each outcome, NOC has a five-point measurement scale for describing patient status for each indicator. As a rule, 1 is least desirable and 5 is most desirable. In your initial assessment, you assign the number that represents the patient's present hea
How to write goals for groups?
1. NOC outcomes can be used for all settings
2. THE CLINICAL CARE CLASSIFICATION SYSTEM
3. The omaha system
Goals for wellness diagnoses
Describe behaviors/responses that
1. demonstrate health maintenance or
2. achievement of an even higher level of health
teaching objectives
1. describe what the client is to learn
2. describe the behaviors that will demonstrate learning
3. state whether learning is to be cognitive, psychomotor, or affective
What to reflect critically about for expected outcomes/goals?
for each nursing diagnosis-
1. is there one goal that, when met, would demonstrate problem resolution?
2. are the predicted outcomes adequate to completely address the nursing diagnosis?
3. appropriate for the nursing diagnosis?
4. derived from only one n