Selecting Nursing Interventions
Nursing interventions, also called nursing orders or nursing actions, are activities that will most likely produce the desired outcomes (short-term or long-term). Sometimes, the client and nursing staff set specific target dates for achieving certain goals, checking them off as they are completed. Nursing orders may include such things as further assessment, client teaching, or referral.
Generally, specific nursing interventions are selected because scientific research has demonstrated that these actions are effective. That is, the interventions are based on the scientific rationale or reason for using them.
Consider again the client with the medical diagnosis of pneumonia described.Follow her nursing care through the next steps of the nursing process. Her nursing diagnosis was “Ineffective Airway Clearance related to the physiologic effects of pneumonia as evidenced by increased sputum, cough, abnormal breath sounds, tachypnea, and dyspnea.” You want to help the client to experience less difficulty breathing. An expected outcome could be “Within 24 hours, the client will state that breathing is easier.” To achieve this outcome, you would select nursing interventions such as the following examples:
• Offering fluids frequently
• Positioning the woman with the head of the bed elevated for optimum breathing
• Teaching the woman deep-breathing exercises
• Monitoring vital signs frequently
• Encouraging correct use of the incentive spirometer
• Administering oxygen as ordered by the physician
• Ensuring that Respiratory Therapy is administering nebulizer treatments as ordered
Writing a Nursing Care Plan
The nursing care plan is the formal guideline for directing the nursing staff to provide client care. The entire nursing team usually formulates the nursing care plan at a meeting called a nursing care conference or team conference (Fig. 35-3). One or two nurses may create the care plan. Ideally, plans for client care are written to provide instructions and guidelines for the total healthcare team to use for direction and communication.
The nursing care plan usually includes nursing diagnoses or client problems (according to priorities), expected outcomes (short- and long-term objectives or goals), and nursing orders (activities nurses carry out to help the client achieve goals). Nurses develop the care plan shortly after a client is admitted to the facility. However, the plan is an ever-changing guide, which is updated regularly as the client’s condition changes.
FIGURE 35-3 • The nursing team often holds a nursing care conference to develop a nursing care plan for a client with complex healthcare needs.
Consequently, some parts of the recorded care plan may be written in pencil. Because each healthcare facility develops its own format according to the particular health needs of its clients, the content and the structure of the written nursing care plan vary. Be sure to familiarize yourself with the format used in your facility.
The written care plan is kept in several ways. Sometimes plans are written on some type of general information system (i.e., a basic Kardex-type handwritten or computergenerated file). More commonly, many healthcare facilities that have computerized medical information systems often keep the nursing care plan as part of a client’s computerized health record. The healthcare trend is to utilize electronic versions. Changes to the care plan are entered along with other pertinent client data. For convenience, you may either scroll the computer monitor for the care plan or print out an individualized care plan each time you care for the client.
Regardless of the manner in which the care plan is kept, it becomes part of the client’s permanent health record. Documentation of a nursing care plan is a requirement of agencies such as the Joint Commission, nursing home regulators, and Medicare. Personnel from such organizations review health records during site visits to the facility. If a nursing care plan does not exist within 12 to 24 hours of the client’s admission, the healthcare facility will be cited for noncompliance. Penalties can be severe.
The ideal nursing care plan is individualized for each client. Many facilities, however, use a standardized nursing care plan and incorporate the usual and expected outcomes for a particular type of nursing care problem or nursing diagnosis. These standardized care plans allow for additions or substitutions so that the care plan can be individualized to the specific client. The standardized care plan is efficient and a welcome aid when you must work with many clients.
Key Concept Planning is the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals. Remember the following steps involved in planning:
• Setting priorities
• Establishing expected outcomes
• Selecting nursing interventions
• Writing a nursing care plan
KEY POINTS
• Nursing diagnosis is a statement about the client’s actual or potential health concerns that can be managed through independent nursing interventions.
• Medical diagnosis is concerned with the disease process. Nursing diagnosis is concerned with the person and how the disease affects his or her functioning.
• Nursing diagnosis helps identify nursing priorities and goals to maintain quality and continuity of care.
• Nursing diagnosis is stated in terms of a problem (a statement approved by NANDA-I), its etiology, and signs and symptoms.
• After establishing the nursing diagnosis, planning nursing care begins. Priorities, expected outcomes, and nursing interventions are selected; a nursing care plan is written.
