Planning involves three subsets: setting priorities, writing expected outcomes, and establishing target dates. Planning sets the stage for writing nursing actions by establishing where we are going with our plan of care. Planning further assists in the final phase of evaluation by defining the standard against which we will measure progress.
Setting Priorities
With the sicker, quicker problem discussed earlier, you are going to find yourself in the situation of having identified many more problems than can possibly be resolved in a 1- to 3-day hospitalization (today’s average length of stay). In the long-term care facilities, such as home health, rehabilitation, and nursing homes, long-range problem solving is possible, but setting priorities of care is still necessary.
Several methods of assigning priorities are available. Some nurses assign priorities based on the life threat posed by a problem. For example, Ineffective Airway Clearance would pose more of a threat to life than the diagnosis Risk for Impaired Skin Integrity. Some nurses base their prioritization on Maslow’s Hierarchy of Needs. In this instance, physiologic needs would require attention before social needs. One way to establish priorities is to simply ask the patient which problem he or she would like to pay attention to first. Another way to establish priorities is to analyze the relationships between problems. For example, a patient has been admitted with a medical diagnosis of headaches and possible brain tumor. The patient exhibits the defining characteristics of both Pain and Anxiety. In this instance, we might want to implement nursing actions to reduce anxiety, knowing that if the anxiety is not reduced, pain control actions will not be successful. Once priorities have been established, you are ready to establish expected outcomes.
Expected Outcomes
Outcomes, goals, and objectives are terms that are frequently used interchangeably because all indicate the end point we will use to measure the effectiveness of our plan of care.
Several guidelines for writing clinically useful expected outcomes:
- Expected outcomes are clearly stated in terms of patient behavior or observable assessment factors.
- Expected outcomes are realistic, achievable, safe, and acceptable from the patient’s viewpoint.
- Expected outcomes are written in specific, concrete terms depicting patient action.
- Expected outcomes are directly observable by use of at least one of the five senses.
- Expected outcomes are patient centered rather than nurse centered.
Establishing Target Dates
Writing a target date at the end of the expected outcome statement facilitates the plan of care in several ways:
- Assists in “pacing” the care plan. Pacing helps keep the focus on the patient’s progress.
- Serves to motivate both patients and nurses toward accomplishing the expected outcome.
- Helps patient and nurse see accomplishments.
- Alerts nurse when to evaluate care plan.
Target dates can be realistically established by paying attention to the usual progress and prognosis connected with the patient’s medical and nursing diagnoses. Additional review of the data collected during the initial assessment helps indicate individual factors to be considered in establishing the date. For example, one of the previous expected outcomes was stated as “Accurately return-demonstrates self-administration of insulin by 9/11.”
The progress or prognosis according to the patient’s medical and nursing diagnosis will not be highly significant. The primary factor will be whether diabetes mellitus is a new diagnosis for the patient or is a recurring problem for a patient who has had diabetes mellitus for several years.
For the newly diagnosed patient, we would probably want our deadline day to be 5 to 7 days from the date of learning the diagnosis. For the recurring problem, we might establish the target date to be 2 to 3 days from the date of diagnosis. The difference is, of course, the patient’s knowledge base.
Now look at an example related to the progress issue. Mr. X is a 19-year-old college student who was admitted early this morning with a medical diagnosis of acute appendicitis. He has just returned from surgery following an appendectomy. One of the nursing diagnoses for Mr. X would, in all probability, be Pain. The expected outcome could be “Will have decrease in number of requests for analgesics by [date].” In reviewing the general progress of a young patient with this medical and nursing diagnosis, we know that generally analgesic requirements start decreasing within 48 to 72 hours. Therefore, we would want to establish our target date as 2 to 3 days following the day of surgery. This would result in the objective reading (assume date of surgery was 11/1): “Will have decrease in number of requests for analgesics by 11/3.”
To further emphasize the target date, it is suggested that the date be underlined, highlighted by using a different-colored pen, or circled to make it stand out. Pinpointing the date in such a manner emphasizes that evaluation of progress toward achievement of the expected outcome should be made on that date. In assigning the dates, be sure not to schedule all the diagnoses and expected outcomes for evaluation on the same date. Such scheduling would require a total revision of the plan of care, which could contribute to not keeping the plan of care current. Being able to revise single portions of the plan of care facilitates use and updating of the plan. Remember that the target date does not mean the expected outcome must be totally achieved by that time; instead, the target date signifies the evaluation date.
Once expected outcomes have been written, you are then ready to focus on the next phase—implementation. As previously indicated, the title supported by this book for this section is “Nursing Actions.”
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