Nursing Intervention I 705:345
Nursing Care Plan - Clinical Reasoning Tool

Student: ____________________________________________________________
Client Initials: ____________________________________________
Date: __________________________________________

Assessment - Diagnostic Decision Making

Subjective Data (Verbal client reports)
Subjective cues can be verified only by personal experience. Such data is not measureable or observable; it can be obtained only from what the client tells you. Subjective data includes the client's thoughts, beliefs, feelings, sensations, and perception of self and health (e.g., pain, dizziness, nausea, sadness, and happiness).
Objective Cues (Direct observation, examination, obervational reports of others)
Objective data can be detected by someone other than the client. You will usually obtain by observing and examining the client. Examples of objective data include the following:

Pulse rate Skin color Urine output Skin turgor Results of diagnostic or X-rays Posture

Nursing Diagnosis: - (Actual/Potential Health Problem):

A statement of an actual or high-risk health problem that nurses can:

Legally identify and treat

Prevent or resolve primarily by independent nursing actions

A wellness nursing diagnosis is a clinical judgment about an individual, family, or community in transition from a specific level or wellness to a higher level of wellness.

Therapeutic Decision Making

Goals (Expected Client Outcomes)	Nursing Intervention
A goal is the desired outcome of a nursing intervention. On a care plan, the goals describe, in terms of observable client responses, what you hope to achieve by implementing the nursing orders. When developing goals, look at the problem and think what the alternative healthy response would be. To help describe the response in terms of specific behaviors, ask yourself the following: 1. If the problem is solved( or prevented), how will the client look or behave? What will I be able to see, hear, palpate, smell, or otherwise observe with my senses? 2. What must the client do to show that the goal is achieved? How well must he do it? Goals describe desired, or normal behaviors. Therefore, you can use any source that describes physiological, psychological, sociocultural, or spiritual norms to help you state the goals (e.g., physiology text, human growth and development text, hospital list of normal lab values). Every specific, measurable goal statement should contain a subject, an action verb, performance criteria, and a target time. A component for special conditions may be also necessary. Short-Term and Long-Term Goals Goals may be either short-term or long-term, depending on the length of time you think it will take for the client to achieve the specified behavior. Short-term goals identify outcomes that can be achieved within a few days or a few hours. Goals dealing with survival needs may even be stated in terms of minutes. For this reason, short-term goals are useful in acute-care settings, such as hospitals, where nurses often focus on the client's more immediate needs. Also, the client may be discharged before the nurse can evaluate progress toward long-term goals. Some examples of short-term goals follow:	Nursing interventions or nursing actions are the activities and behaviors performed to change Nursing actions may be something you do for the client or something you can help clients do for themselves. Independent interventions are those that the nurse prescribes and performs or delegates; they include physical care, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health-care professionals. Recall that nursing diagnoses are treated primarily by independent nursing interventions. Dependent interventions are prescribed by the physician and carried out by the nurse. Medical orders commonly include order for medications, intravenous therapy, diagnostic tests, treatments, diet, and activity. The nurse is responsible for explaining, assessing the need for, and administering the medical orders. Nursing orders may be written to individualize the medical order, based on the patient's status. Interdependent interventions are the actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians and physicians. Depending upon the type of patient problem, you will write nursing interventions for observation, prevention, treatment, and health promotion. *1. Observation.* This includes observations to determine whether a complication is developing, as well as observations of the client's responses to nursing, medical, and other therapies. Observation orders should be written for every problem: actual, high-risk, and possible nursing diagnoses and collaborative problems.
Examples: Voids within 6 hours after delivery of infant. States relief of pain within one hour after receiving p.o. oxycodone. Walks to end of hall and back, unassisted, by day 3 post-op. Short-term goals must usually be a accomplished before the client can achieve long-term goals, and they are often used to measure the client's progress toward long-term goals. Achieving several short-term goals also provides frequent reinforcement for the client, encouraging him to keep working on the problem. Long-term goals descibe changes in client outcomes over a longer period usually a week or more. The ideal long-term goal aims at restoring normal functioning in the problem area. When normal functioning cannot be restored, the long-term goal describes the maximum level of functioning that can be achieved given the client's health status and resources. Long-term goals are health care, rehabilitation centers, and other extended-care facilities. Some examples of long-term goals follow: Examples: After attending six weekly childbirth-education classes, will correctly demostrate abdominal and shallow chest breathing. By 12 weeks post-op, will have full range of motion of right shoulder. Within 3 months (12/24), will feed self using fork or spoon.	2. *Prevention.* Prevention orders prescribe the care needed to prevent complications or reduce risk factors. They are used mainly for high-risk nursing diagnoses and collaborative problems, but they can also be appropriate for actual nursing diagnoses. 3. *Treatment.* This includes teaching, referrals, physical, and other care needed to treat an existing problem. Treatment measures are appropriate for actual nursing diagnoses. 4. *Health Promotion:* When there are no health problems, the nurse helps the client to identify areas for improvement that will lead to a higher level of wellness. Health-promotion strategies encourage approach behaviors; that is, they help the client promote positive outcomes rather than avoid negative outcomes. Health promotion is not specific to any disease or problem, but aims to encourage activities that will actualize the client's general health potential.

Goals (Expected Client Outcomes)

Nursing Intervention

A goal is the desired outcome of a nursing intervention. On a care plan, the goals describe, in terms of observable client responses, what you hope to achieve by implementing the nursing orders. When developing goals, look at the problem and think what the alternative healthy response would be. To help describe the response in terms of specific behaviors, ask yourself the following:
1. If the problem is solved( or prevented), how will the client look or behave? What will I be able to see, hear, palpate, smell, or otherwise observe with my senses?
2. What must the client do to show that the goal is achieved? How well must he do it?
Goals describe desired, or normal behaviors. Therefore, you can use any source that describes physiological, psychological, sociocultural, or spiritual norms to help you state the goals (e.g., physiology text, human growth and development text, hospital list of normal lab values). Every specific, measurable goal statement should contain a subject, an action verb, performance criteria, and a target time. A component for special conditions may be also necessary.

Short-Term and Long-Term Goals
Goals may be either short-term or long-term, depending on the length of time you think it will take for the client to achieve the specified behavior.

Short-term goals identify outcomes that can be achieved within a few days or a few hours. Goals dealing with survival needs may even be stated in terms of minutes. For this reason, short-term goals are useful in acute-care settings, such as hospitals, where nurses often focus on the client's more immediate needs. Also, the client may be discharged before the nurse can evaluate progress toward long-term goals. Some examples of short-term goals follow:

Nursing interventions or nursing actions are the activities and behaviors performed to change Nursing actions may be something you do for the client or something you can help clients do for themselves.
Independent interventions are those that the nurse prescribes and performs or delegates; they include physical care, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health-care professionals. Recall that nursing diagnoses are treated primarily by independent nursing interventions.
Dependent interventions are prescribed by the physician and carried out by the nurse. Medical orders commonly include order for medications, intravenous therapy, diagnostic tests, treatments, diet, and activity. The nurse is responsible for explaining, assessing the need for, and administering the medical orders. Nursing orders may be written to individualize the medical order, based on the patient's status.
Interdependent interventions are the actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians and physicians. Depending upon the type of patient problem, you will write nursing interventions for observation, prevention, treatment, and health promotion.

1. Observation. This includes observations to determine whether a complication is developing, as well as observations of the client's responses to nursing, medical, and other therapies. Observation orders should be written for every problem: actual, high-risk, and possible nursing diagnoses and collaborative problems.

Examples:

Voids within 6 hours after delivery of infant.
States relief of pain within one hour after receiving p.o. oxycodone.
Walks to end of hall and back, unassisted, by day 3 post-op.

Short-term goals must usually be a accomplished before the client can achieve long-term goals, and they are often used to measure the client's progress toward long-term goals. Achieving several short-term goals also provides frequent reinforcement for the client, encouraging him to keep working on the problem.
Long-term goals descibe changes in client outcomes over a longer period usually a week or more. The ideal long-term goal aims at restoring normal functioning in the problem area. When normal functioning cannot be restored, the long-term goal describes the maximum level of functioning that can be achieved given the client's health status and resources. Long-term goals are health care, rehabilitation centers, and other extended-care facilities. Some examples of long-term goals follow:

Examples:

After attending six weekly childbirth-education classes, will correctly demostrate abdominal and shallow chest breathing. By 12 weeks post-op, will have full range of motion of right shoulder. Within 3 months (12/24), will feed self using fork or spoon.

2. Prevention. Prevention orders prescribe the care needed to prevent complications or reduce risk factors. They are used mainly for high-risk nursing diagnoses and collaborative problems, but they can also be appropriate for actual nursing diagnoses.

3. Treatment. This includes teaching, referrals, physical, and other care needed to treat an existing problem. Treatment measures are appropriate for actual nursing diagnoses.

4. Health Promotion: When there are no health problems, the nurse helps the client to identify areas for improvement that will lead to a higher level of wellness. Health-promotion strategies encourage approach behaviors; that is, they help the client promote positive outcomes rather than avoid negative outcomes. Health promotion is not specific to any disease or problem, but aims to encourage activities that will actualize the client's general health potential.

Rationale (cite references)	Evaluation of Client Response	Revision of Plan
The scientific principles which support the selection of a particular nursing action as a mechanism to assist in meeting the patient-centered objectives. (Reference citation for each rationale listed is required). The rationale for action should clearly relate why a particular nursing action should assist in meeting a patient-centered objective. The rationale for action should be reflective of current nursing theory, or research. The rationale for action should be reflective of physical, psychlogical, or social scientific priniciples. The rationale must explain why you are doing.	Outcome evaluation focuses on the client's health status and satisfaction with the results of care. Outcomes are evaluated by comparing clients' changes or responses to their health goals. Evaluation is a planned, ongoing, deliberate activity in which the nurse, client, significant others, and other health-care professionals determine 1. the extent of client goal achievement, and 2. the effectiveness of the nursing care plan. Three possible conclusions about outcome achieve- 1. Goal met The desired client response occured, and the actual outcome is congruent with the predicted 2. Goal partially met Some, but not all, predicted outcomes were achieved, or The predicted outcome is achieved only part of the time 3. Goal not met The desired client response did not occur by the target time, or The actual outcome does not match the predicted outcome	Revise plan if the problem still exists, but nursing interventions need revision. Changes in the client's condition and the status of her goal achievement (form the outcome evaluation) determine whether, but not how, the care plan should be revised. After finishing the outcome evaluation, you should examine the nursing care plan to see if it needs modification. You will probably modify the care plan if (1) the client's condition changes or (2) if the health goals were not met. You should obtain client imput for modifying the plan, just as you did developing it.

Rationale (cite references)

Evaluation of Client Response

Revision of Plan

The scientific principles which support the selection of a particular nursing action as a mechanism to assist in meeting the patient-centered objectives.

(Reference citation for each rationale listed is required).

The rationale for action should clearly relate why a particular nursing action should assist in meeting a patient-centered objective.

The rationale for action should be reflective of current nursing theory, or research.

The rationale for action should be reflective of physical, psychlogical, or social scientific priniciples.

The rationale must explain why you are doing.

Outcome evaluation focuses on the client's health status and satisfaction with the results of care. Outcomes are evaluated by comparing clients' changes or responses to their health goals.

Evaluation is a planned, ongoing, deliberate activity in which the nurse, client, significant others, and other health-care professionals determine

1. the extent of client goal achievement, and
2. the effectiveness of the nursing care plan.

Three possible conclusions about outcome achieve-

1. Goal met

The desired client response occured, and the actual outcome is congruent with the predicted

2. Goal partially met

Some, but not all, predicted outcomes were achieved, or The predicted outcome is achieved only part of the time

3. Goal not met

The desired client response did not occur by the target time, or The actual outcome does not match the predicted outcome

Revise plan if the problem still exists, but nursing interventions need revision.

Changes in the client's condition and the status of her goal achievement (form the outcome evaluation) determine whether, but not how, the care plan should be revised. After finishing the outcome evaluation, you should examine the nursing care plan to see if it needs modification. You will probably modify the care plan if (1) the client's condition changes or (2) if the health goals were not met. You should obtain client imput for modifying the plan, just as you did developing it.

Ethical Decision Making

Assessment Dilemma or Conflict (if present) Resolution

Identify 2 or 3 ethical principles that may influence the care provided to the client

State actual or potential dilemma or conflict

If actual conflict or dilemma, state how it was resolved.
If potential, state how it could have been resolved.