Chapter 2
Thoughtful practice
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Setting priorities
Assigning priorities to the nursing diagnoses and collabora-
tive problems is a joint effort by the nurse and the patient or
family members. Any disagreement about priorities is resolved
in a way that is mutually acceptable. Consideration must be
given to the urgency of the problems, with the most critical
problems receiving the highest priority. Maslow’s hierarchy of
needs (Chapter 1) provides a useful framework for prioritising
problems, with importance being given first to physical needs;
once those lower-level needs are met, higher-level needs can
be addressed.
Establishing expected outcomes
Clinical governance is a system through which organisations
are accountable for continuously improving the quality of their
services and safeguarding high standards of care, by creating
an environment in which clinical excellence will flourish.
Evidence of clinical governance is obtained using patient
outcome measures collected through audits.
The International Council of Nurses (ICN, 2009) defines
nursing sensitive patient outcomes as:
... the end results of nursing interventions and are indicators of
problem resolution or progress toward problem or symptom reso-
lution. The ICNP® defines a nursing outcome as the measure or
status of a nursing diagnosis at points in time after a nursing inter-
vention, while nursing-sensitive outcomes are defined as changes in
health status upon which nursing care has had a direct influence.
Variables affecting patient outcomes include diagnosis, socio-
economic factors, family support, age and gender, and the quality of
care provided by other professionals and support workers.
Indicators of nurse-sensitive outcomes include patient
falls, pressure areas, urinary tract infections, nosocomial
infections, fluid management, patient satisfaction, and length
of stay.
Expected outcomes of the nursing interventions are stated
in terms of the patient’s behaviours and the time period in
which they are to be achieved, as well as any special circum-
stances related to achieving the outcome.
These outcomes must be realistic and measurable.
The outcomes are used to measure to what extent progress
towards resolving the problem has been made. The outcomes
also serve as the basis for evaluating the effectiveness of the
nursing interventions and for deciding whether additional
nursing care is needed or whether the plan of care needs to be
revised (White, et al., 2011).
Establishing goals
After the priorities of the nursing diagnoses and expected
outcomes have been established, the immediate, medium-term,
and long-term goals and the nursing actions appropriate for
attaining the goals are identified. The patient and his or
her family are included in establishing goals for the nursing
actions. Immediate goals are those that can be reached within
a short period. Medium-term and long-term goals require a
longer time to be achieved and usually involve preventing
complications and other health problems and promoting self-
care and rehabilitation. For example, goals for a patient with
diabetes and a nursing diagnosis of
deficient knowledge related to
the prescribed diet
may be stated as follows:
Immediate goal
: Demonstrates oral intake and tolerance
of 6300 kJ diabetic diet spaced in three meals and one
snack per day
Medium-term goal
: Plans meals for 1 week based on diabetic
exchange list
Long-term goal
: Adheres to recommended diabetic diet.
Determining nursing actions
In planning appropriate nursing actions to achieve the desired
goals and outcomes, the nurse, with input from the patient
and significant others, identifies individualised interventions
based on the patient’s circumstances and preferences that
will address each outcome. Interventions should identify the
activities needed and the people who will carry them out.
Determination of interdisciplinary activities is made in collab-
oration with other healthcare providers as needed.
The nurse identifies and plans imparting knowledge through
patient
teaching
and demonstrations as needed to assist the
patient in learning self-care activities to be performed. Planned
interventions should be ethical and appropriate to the patient’s
culture, age, and gender and decided upon in consultation
with the patient/family and relevant members of the multi
disciplinary healthcare team.
Implementation
The
implementation
phase of the nursing process involves
carrying out the proposed plan of nursing care. Implementation
includes direct or indirect execution of the planned interven-
tions. It is focused on resolving the patient’s nursing diagnoses
and collaborative problems and achieving expected outcomes,
thus meeting the patient’s health needs. The nurse assumes
responsibility for the implementation although performance
of interventions, however, may be carried out by the patient
and the family, other members of the nursing team, or other
members of the healthcare team as appropriate. The nurse
coordinates the activities of all those involved in implemen-
tation so that the schedule of activities facilitates the patient’s
recovery. The plan of nursing care or critical pathway serves as
the basis for implementation:
•
The immediate, medium, and long-term goals are used as
a focus for the implementation of the designated nursing
interventions.
•
While implementing nursing care, the nurse continually
assesses the patient and his or her response to the nursing
care.
•
Revisions are made in the plan of care as the patient’s
condition, problems, and responses change and when
reassignment of priorities is required.
Examples of nursing interventions are assisting with hygiene
care; promoting physical and psychological comfort; support-
ing respiratory and elimination functions; facilitating the
ingestion of food, fluids, and nutrients; managing the patient’s
immediate surroundings; providing health teaching; promoting
a therapeutic relationship; and carrying out a variety of thera-
peutic nursing activities.
Judgement, critical thinking and good decision-making
skills are essential in the selection of appropriate scientifically
and ethically based nursing interventions. All nursing inter-
ventions are person-focused and outcome-directed and are
implemented with compassion, confidence, and a willingness
to accept and understand the patient’s responses.
Although many nursing actions are independent, others
are interdependent, such as carrying out prescribed treat-
ments, administering therapies, and collaborating with other
healthcare team members to accomplish specific expected
