CH 13 OUTCOME IDENTIFICATION AND
PLANNING
PLANNING
 The
process of prioritizing nursing diagnoses
and collaborative problems, identifying
measurable goals or outcomes, selecting
appropriate interventions, and documenting the
plan of care.
 The nurse consults with the client while
developing and revising the plan.
OUTCOME IDENTIFICATION AND PLANNING
A FORMAL PLAN OF CARE ALLOWS
THE NURSE TO:
Individualize care that maximizes outcome
achievement
 Set priorities
 Facilitate communication among nursing
personnel and colleagues
 Promote continuity of high-quality, cost-effective
care
 Coordinate care
 Evaluate patient response to nursing care
 Create a record used for evaluation, research,
reimbursement, and legal reasons
 Promote nurse’s professional development
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STANDARDS TO APPLY TO OUTCOME
IDENTIFICATION AND PLANNING
The Law
 National practice standards
 Specialty professional organizations
 The Joint Commission
 The Agency for Health Care Research and
Quality (AHRQ)
 Your employer

DERIVING PATIENT GOALS/OUTCOMES AND
NURSING ORDERS FROM NURSING DIAGNOSES
THREE ELEMENTS OF
COMPREHENSIVE PLANNING
Initial
 Ongoing
 Discharge

INITIAL PLANNING
Developed by the nurse who performs the
nursing history and physical assessment
 Addresses each problem listed in the prioritized
nursing diagnoses
 Identifies appropriate patient goals and related
nursing care

ONGOING PLANNING
Carried out by any nurse who interacts with patient
 Keeps the plan up to date
 States nursing diagnoses more clearly
 Develops new diagnoses
 Makes outcomes more realistic and develops new
outcomes as needed
 Identifies nursing interventions to accomplish
patient goals

DISCHARGE PLANNING
Carried out by the nurse who worked most
closely with the patient
 Begins when the patient is admitted for
treatment
 Uses teaching and counseling skills effectively
to ensure home care behaviors are performed
competently

QUESTION
Which one of the following nursing actions would most likely
occur during the ongoing planning stage of the
comprehensive care plan?
A. The nurse collects new data and uses them to update the
plan and resolve health problems.
B. The nurse uses teaching and counseling skills to help the
patient carry out self-care behaviors at home.
C. The nurse who performs the admission nursing history
develops a patient care plan.
D. The nurse consults standardized care plans to identify
nursing diagnoses, outcomes, and interventions.
ANSWER
Answer: A. The nurse collects new data and uses
them to update the plan and resolve health
problems.
Rationale:
In the ongoing planning stage, any nurse who
interacts with the patient updates the plan to
facilitate the resolution of health problems,
manage risk factors, and promote function.
Teaching and counseling are the key to discharge
planning.
The nurse performing the admission nursing
history consults standardized care plans during
initial planning to formulate the initial care plan.
PRIORITIZING NURSING DIAGNOSES
High priority—greatest threat to patient wellbeing
 Medium priority—nonthreatening diagnoses
 Low priority—diagnoses not specifically related
to current health problem

MASLOW’S HIERARCHY OF HUMAN NEEDS
Physiologic needs
 Safety needs
 Love and belonging needs
 Self-esteem needs
 Self-actualization needs

GENERAL GUIDELINES FOR SETTING PRIORITIES
1.
2.
3.
4.
Take care of immediate
lifethreatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on the
overall picture, the patient as a whole person,
and availability of time and resources.
NURSE IDENTIFIED PRIORITIES

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Composite of all patient’s strengths and health
concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.
QUESTION
Which of the following nursing diagnoses would
most likely be considered a high priority?
A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance
ANSWER
Answer: B. Impaired gas exchange
Rationale:
Impaired gas exchange poses a threat to the
patient’s well-being.
Disturbed personal identity and risk for
powerlessness are non–life-threatening and are
ranked as medium priorities.
Activity intolerance, if not specifically related to the
current health problem, is a low priority.
IDENTIFYING AND WRITING GOALS/OUTCOMES
Goals provide direction for planning
interventions
 Goals serve as criteria for evaluating the
effectiveness of nursing care
 Goals enable us to know when the problem has
been solved

STEPS FOR DERIVING OUTCOMES FROM
NURSING DIAGNOSIS



Look at the first clause of the nursing dx and
restate in a statement that describes
improvement, control or absence of the problem.
Diagnosis: Risk for infection r/t surgical wound
dehiscence secondary to abdominal obesity.
Outcome: The client will demonstrate no signs or
symptoms of infection AEB temperature below
100 degrees, no erythema or prurulent drainage
from wound bed by the end of the shift on _(date)___.
IDENTIFYING CLIENT-CENTERED OUTCOMES

State what the patient will do or experience at
the completion of care.
Give direction to the patient’s overall care.
Patient behaviors not nurse behaviors!

“The patient will…”


COMPONENTS OF OUTCOMES

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Subject: who is the person expected to achieve the
outcome?
Verb: what actions must the person take to achieve the
outcome?
Condition: under what circumstances is the person to
perform the actions?
Performance criteria: what specific
behaviors/assessments/findings will indicate positive
achievement of this goal?
Target time: by when is the person expected to be able to
perform the actions?
Our directions state G T T (goal, tool, time)
THE NURSING PROCESS (CONT.)
GOALS MUST BE REALISTIC (in terms of the client’s potential for
achieving them & the nurse’s ability to help the client achieve
them.)
--sometimes we can’t fix the patient’s problem, or we can
only accomplish a small step in the process instead of the
whole goal. Be realistic about what you can do.
GOALS SERVE AS GUIDES IN SELECTING NURSING
INTERVENTIONS.
GOALS ARE ALWAYS STATED BEGINNING WITH “CLIENT WILL”
ie: By Sept. 17, client’s lungs will remain clear to auscultation
By Sept. 18, client will eat one high fiber food with each meal
By Sept. 17, client’s skin will remain intact
LONG-TERM VS. SHORT-TERM OUTCOMES

Long-term—requires a longer period to be achieved
and may be used as discharge goals
May be used with chronic health problems
 May take weeks/months to accomplish


Short-term—may be accomplished in a specified
period of time
Students will write goals for their care for the shift
 Nurses typically write shift goals, as short hospital stays
demand fast resolution of problems
 Short-term goals can be a few days to a week

CATEGORIES OF OUTCOMES
Cognitive—describes increases in patient
knowledge or intellectual behaviors
 Psychomotor—describes patient’s achievement
of new skills
 Affective—describes changes in patient values,
beliefs, and attitudes
 Physical—describes physical attributes that
resolve the health problem

QUESTION
Which one of the following outcomes is an
affective outcome?
A. By 6/09/11, the patient will correctly
demonstrate the procedure for washing her
newborn baby.
B. By 6/09/11, the patient will list three benefits
of eating a healthy diet.
C. By 6/09/11, the patient will use a walker to
ambulate the hallway.
D. By 6/09/11, the patient will verbalize valuing
his health enough to stop smoking.
ANSWER
Answer: D. By 6/09/11, the patient will verbalize
valuing his health enough to stop smoking.
Rationale:
An affective outcome describes changes in patient
values, beliefs, and attitudes.
Answers A and B are psychomotor outcomes
(learning a new skill) and Answer C is a cognitive
outcome (increase in patient knowledge).
THE NURSING OUTCOMES CLASSIFICATION
(NOC)
A taxonomy of nursing language for describing
outcomes of nursing intervention has been
developed
 Over 385 outcomes identified in 7 domains —
classes within these domains specify categories.
 Each is given a 4 digit identifier for computer ID
and coding
 Both texts include NOC outcomes within each
section.

NOW WHAT?
Nursing interventions are the things the nurse
does to accomplish the goal.
 They focus on eliminating or reducing the
etiology of the problem, the 2nd clause of the
diagnostic statement.

 Correct
identification of the etiologies is essential
 Interventions for “risk for” diagnoses focus on
reducing or eliminating the risk
TYPES OF NURSING INTERVENTIONS
Nurse-initiated—actions performed by a nurse
without a physician’s order
 Physician-initiated—actions initiated by a
physician in response to a medical diagnosis
but carried out by a nurse under doctor’s
orders
 Collaborative—treatments initiated by other
providers and carried out by a nurse

ACTIONS PERFORMED IN NURSE-INITIATED
INTERVENTIONS (ALFARO, 2002)
Monitor health status.
 Reduce risks.
 Resolve, prevent, or manage a problem.
 Facilitate independence or assist with ADLs.
 Promote optimum sense of physical,
psychological, and spiritual well-being.

QUESTION
Tell whether the following statement is true or
false.
A collaborative intervention is an intervention
initiated by a physician in response to a
medical diagnosis but carried out by a nurse in
response to a physician’s order.
A. True
B. False
ANSWER
Answer: B. False
A physician-initiated intervention is an
intervention initiated by a physician in response
to a medical diagnosis, but carried out by a
nurse in response to a physician’s order.
SELECTING NURSING
INTERVENTIONS
 Planning the measures that the client and
nurse will use to accomplish identified goals
involves critical thinking.
 The nurse selects strategies based on the
knowledge that certain nursing actions produce
desired effects.
 Nursing interventions must be safe, within the
legal scope of nursing practice, and compatible
with medical orders.
INTERVENTIONS
Nursing interventions require intellectual, interpersonal
and technical skills.
 Intellectual skills required of the nurse include: problem
identification, and problem solving, critical thinking, and
the ability to make sound judgments.
A strong theoretical background is necessary for these
intellectual skills
All actions (interventions) planned for the client must be
based on scientific principles and rationale.


Students will document a rationale for each intervention and cite
it using APA format
RELATIONSHIP OF INTERVENTIONS TO THE
PROBLEM

The focus of interventions:
 Observations
 Prevention
 Treatments
 Health

promotion
Format of interventions on the care plan:
 Action
verb, conditions and modifiers, time frame
THE NURSING INTERVENTIONS CLASSIFICATION
(NIC)
NIC taxonomy developed in 1992
 Standardized language to describe nursing
interventions
 542 approved interventions
 Included throughout both texts and discussed
again in CH 15

BENEFITS OF USING NIC/NOC STANDARDIZED
LANGUAGE
Demonstrate the impact that nurses have on the
system of healthcare delivery.
 Define the knowledge base for nursing curricula
and practice.
 Facilitate the selection of appropriate nursing
intervention.
 Enable researchers to examine the effectiveness
and cost of nursing care.
 Assist educators to develop curricula that better
articulates with clinical practice.

BENEFITS OF USING NIC/NOC STANDARDIZED
LANGUAGE (CONT.)
Facilitate the teaching of clinical decision
making to novice nurses.
 Assist administrators in planning more
effectively for staff and equipment needs.
 Promote the development and use of nursing
information systems.
 Communicate the nature of nursing to the
public.

COMMUNICATING AND RECORDING—HOW
PATIENT CARE ACTIVITIES ARE GENERATED
Direct orders
 Standing orders
 Standards of care
 Protocols
 Policies and procedures
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TYPES OF INSTITUTIONAL PLANS OF CARE
Kardex plans of care
 Computerized plans of care
 Case management plans of care
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 Clinical
pathways, care maps
Concept map care plan
 Student plans of care
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YOUR STUDENT CARE PLANS
Done post care—not ideal
 Usually 15% of your course grade
 Instructors grade on your thought process—if you
wrote a certain diagnosis that was not relevant,
based on your assessment, points are deducted.
 We use APA format. Do it exactly and get all the
points.
 We also grade on spelling/grammar as a point of
professionalism

YOUR CARE PLAN WILL CONTAIN….
A nursing diagnosis, stated in NANDA terminology
 A short term goal for the care for your shift

It must be measurable and timed
 “The patient will…”

Interventions that start with an action verb. (Don’t
include, “The nurse will…,” as that is understood.
 Rationales that are the science behind your
action. Use Taylor—it’s good. Other texts are
acceptable as well.


They must be direct quotes, enclosed by quotation
marks, and cited in APA style.
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An evaluation of whether or not the goal was met (we
haven’t talked about evaluation yet)
A revision of some sort if the goal was not met or
partially met.
And—depending on the course—you may have to write 1,
2, or 3 diagnoses and work them all through.
Also included-
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a complete patient assessment, using our assessment form.
You’ll be writing one this term for Funds 1.
A page with all your patient’s medications
Sound like a lot of work? It is, but we all went through
this. It will teach you how to think like a nurse!
PROBLEMS RELATED TO OUTCOME
IDENTIFICATION AND PLANNING
Failure to involve patient
 Insufficient data collection
 Nursing diagnoses developed from inaccurate
or insufficient data
 Outcomes stated too broadly
 Outcomes derived from poorly developed
nursing diagnoses
 Failure to write nursing order clearly
 Nursing orders that do not solve problems
 Failure to update the plan of care

WORKBOOK EXERCISES

Work in groups of 2-3 to answer the following:
 Matching
exercises A & B, p. 74-75.
 Short answers #8 and #9 only.
 You can look up the answers when you are finished!

Answer the quiz (handout) questions by using
your text as a reference.