Textbook of Medical-Surgical Nursing 3e

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Chapter 2   Thoughtful practice

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