Lesson 1, Topic 1
In Progress

Planning

May 1, 2021

During the planning phase of the nursing process, priorities of care are established and nursing interventions are chosen to best address the nursing diagnosis. This information is typically communicated through the care plan so that all health care personnel directly involved in care of the patient can follow the same plan, resulting in continuity of care. The nurse must work with the patient and significant others in choosing appropriate interventions and in considering evidenced-based practice guidelines. The plan of care should be comprised of standardized languages or recognized terminology to document and effectively communicate the plan.

Priority Setting

The nurse in today’s busy health care facility is caring for many patients with complex problems and is challenged daily to use time and effort wisely. Priorities must be established to provide care for each patient.

Once nursing diagnoses have been identified, the registered nurse must prioritize the diagnoses according to the patient’s current health status. The framework most often used to guide the prioritization is Maslow’s hierarchy of needs. This structure is based on the principle that lower-level needs must be met before higher-level needs can be satisfied. The physiologic needs are more vital than the safety and security needs, and the safety and security needs are more critical than the love and belonging needs. Review Maslow’s hierarchy in Figure 1-8. Life-threatening and health-threatening problems are ranked before other types of problems. Actual problems often are ranked before risk problems, unless the risk problems, if they were to develop, are life threatening. For example, risk for ineffective airway clearance might be prioritized higher than an actual problem of constipation. With use of Maslow’s hierarchy, the nurse can determine whether the actual or risk for nursing diagnosis has the highest priority. The nurse must also take into consideration the patient’s thoughts and feelings regarding prioritization of problems. If patients are not active participants in the plan of care, they are not likely to be driven to work towards meeting the agreed-upon goals.

Time factors and severity of illness are important considerations in the determination of what problems to address initially. The patient who is admitted to the emergency department with a possible heart attack (myocardial infarction) is not ready at that time to contemplate dietary instructions to reach a goal of reducing cholesterol.

Priorities change as the patient progresses through time in a health care facility. As some problems are resolved, the approach to other problems opens up. Consider the following scenario and how the concerns of nursing change during one patient’s hospital stay.

A 28-year-old woman admitted for an abdominal hysterectomy may have the preoperative diagnosis of fear or anxiety. Acute pain is an important nursing diagnosis in the first few days after surgery. As the pain is controlled, imbalanced nutrition: less than body requirements and risk for constipation are managed. When the patient approaches discharge, teaching about wound care and activity restrictions becomes the focus for nursing diagnoses. Because of the loss of reproductive ability, self-esteem problems have to be confirmed or ruled out as possible nursing diagnoses for this patient. Note how the nursing diagnoses changed, but the medical procedure did not.

Selecting Nursing Interventions

Nursing interventions are those activities that promote the achievement of the desired patient outcome. Interventions include activities that the nurse selects, in partnership with the patient, to resolve a nursing diagnosis, monitor for the development of a risk problem, or carry out physician orders. Nursing interventions are classified as physician prescribed or nurse prescribed.

Physician-prescribed interventions are those actions ordered by a physician for a nurse or other health care professional to perform. Remember that physician orders are not orders for nurses but are prescriptive instructions for patients (Carpenito, 2013). Although the physician has given the order, nursing judgment must still be used. The LPN/LVN must follow orders when administering medications, performing wound care, and ordering diagnostic tests. Assessing, teaching, and validating the safety of physician orders are important nursing responsibilities. In this text, the term “health care provider” has been used to encompass those health care professionals who have prescriptive authority, such as physicians, advanced practice nurses, and physician’s assistants. The term “physician-prescribed interventions” applies to these individuals.

Nurse-prescribed interventions are any actions that a nurse is legally able to order or begin independently. Nurses write interventions for themselves or other nursing staff (Carpenito, 2013). Examples of independent nursing interventions are providing a back massage, turning a patient every 2 hours, and monitoring for complications. When determining appropriate nursing interventions, the nurse should consider the contributing, etiologic, and related factors; risk factors; the patient-centered goal or desired patient outcome; and the nursing diagnosis label itself. Nursing interventions are focused on any or all of these areas.

Nursing interventions often are aimed at reducing or eliminating the causative factor. For example, for the nursing diagnosis anxiety, related to lack of knowledge about hospital procedures, an appropriate nursing intervention is to teach the patient about typical routines and procedures. Providing information addresses any knowledge deficit, which helps to reduce the fear of the unknown, thereby reducing anxiety.

The patient outcome is also considered when selecting nursing interventions. For example, when the patient outcome statement says, “The patient will plan a week’s menu for an 1800-calorie diabetic diet within 1 week’s time,” the interventions are selected to increase the patient’s knowledge about planning for a diabetic diet.

The nursing diagnosis label itself may also direct the interventions. If the nursing diagnosis label is acute pain, interventions to relieve acute pain are selected.

A variety of sources list nursing interventions. Nursing textbooks, periodicals, and care planning books are helpful sources of information. The Nursing Interventions Classification (NIC) may be another helpful source for nursing interventions and activities. (The NIC is discussed subsequently in this chapter.) Nursing colleagues and previous experience in nursing care are also good sources of ideas for interventions, as are patient suggestions regarding care. In addition, nursing conferences held to plan patient care often provide an environment for the development of creative approaches to patient care.

Writing Nursing Interventions

Because nursing interventions offered in textbooks and care planning resources are often broad general statements that indicate an activity to be performed, these nursing interventions need to be converted to more specific instructional statements. Suggested interventions for constipation may include increase dietary bulk, increase activity, and encourage fluids.

This information is helpful because it prescribes a direction for care, but the information provided is lacking in specific details. The nurse must determine specific information regarding interventions so that any person following the direction of the care plan can carry out interventions without question. For care planning purposes, the nurse must be able to change the guiding general statement about the nursing intervention to a more specific statement. Nursing interventions have to be written to reduce the likelihood of misinterpretation. Details are provided to convey the intended meaning. Written nursing interventions should include the subject (the nurse is assumed unless stated otherwise), action verb, and qualifying details. Consider the following interventions:

•Ambulate the patient three times a day at 0900, 1400, and 1900.
•Ambulate the patient 30 feet three times a day at 0900, 1400, and 1900.

The correctly written nursing intervention is the second one because it contains the subject (the nurse is assumed), the action verb (ambulate), and the qualifying details (30 feet three times a day). This intervention is specific and easily interpreted by any health care professional following the care plan.

A properly written nursing intervention is specific for the problem, realistic for the patient, compatible with the medical plan of care, and based on scientific, evidenced-based principles. The following examples illustrate appropriate conversion of general nursing interventions into specific nursing interventions:

•Add four servings of fruits and vegetables of patient’s choice to daily menu, one extra serving per meal and one snack.
•Turn the patient every 2 hours with the assistance of two personnel and the lift sheet.
•Offer water and juices up to 2000 mL per day according to the following schedule: 7 to 3 shift, 1200 mL; 3 to 11 shift, 600 mL; 11 to 7 shift, 200 mL.

Communicating the Nursing Care Plan

After completing the initial assessment, analyzing the data, writing the nursing diagnoses, selecting outcomes, and selecting appropriate nursing interventions (which are then made more specific with written nursing interventions), the nurse has the responsibility to communicate the detailed plan of care for the patient. The written nursing care plan is the tangible product of the nursing process (Table 5-4). (Refer to Chapter 3 for additional information on charting and documentation.)

Because the nursing staff constantly changes (nurses work different shifts and have days off), written guidelines are important for continuity of patient care. Continuity increases patient trust in the nursing staff and promotes outcome achievement.

Nursing care plans may be specifically written for a patient, or the nurse may use a standardized care plan for a patient. The nurse must individualize each care plan to the patient, even with use of standardized care plans. Individually prepared care plans are the most time consuming but often provide care that is best matched to the specific patient’s needs and situation. An individualized plan of care takes into consideration pertinent patient characteristics such as age, culture, and medical diagnosis.

Standardized nursing care plans are appropriate for patient populations with routine, expected care requirements. Women who have had a vaginal delivery or a cesarean delivery are ideal patient populations for standardized care plans. Many standardized care plans include blank spaces that the nurse fills in to individualize to some degree.

Linear Care Plans versus Concept Maps

Among nursing faculty, a range of different expectations often exists for the care planning process. Formats for the written nursing care plan vary from school to school. Components that are common in an educational setting are NANDA-I diagnostic labels, patient-centered goals and desired patient outcomes, and nursing interventions and orders.

Nursing faculty may require students to submit the care plan in a four-column or five-column format that is referred to as a linear style. With this system, rationale is often necessary to explain why the intervention is needed or how the intervention will work. This encourages the student to use critical thinking skills and evidence-based practice for supporting the nursing interventions chosen.

Other nursing faculty may prefer the care plan to be represented as a concept map. A concept map, with use of different shapes and connecting lines to show relationships, provides a visual representation of the care plan (Berman et al., 2008). With concept mapping, the student may put the nursing diagnosis into a rectangular shape in the middle of the page; interventions are in circles that branch off from the nursing diagnosis, and outcomes are placed into a triangle. The student should follow the specific guidelines of the nursing program for topics to be included on a concept map and its organization.