05.04 Nursing Process – Plan

When we talk about the planning phase of the nursing process, there's one thing I want you guys to realize before we really get rolling into this, and that is that I get how annoying care plans can be in nursing school. What a lot of us think is that the minute we get out of nursing school, we're never going to do a care plan again. We're all excited. We throw them all away.

But I want you guys to realize is that this nursing process and plans of care are things that we use throughout our entire career. What I see a lot of times happen with nurses is is they start here. They're all excited just to throw care plans away. Then they progress, and they realize, whoa, being a nurse is really hard. Then what happens is they start thinking like a nurse, and they start developing care plans in their brain without ever writing them down. It all just starts to become second nature.

I want you to realize that, yes, you might not be writing official nursing care plans as you go into the field. As you start to think like a nurse, as you start to take care of more patients, you'll begin to develop plans of care right inside your brain, because this all starts to become second nature.

The planning part of the nursing process, this is the third phase of the nursing process, ADPIE, right? Planning is the third phase of the nursing process. This really develops for us what we plan to do. It's what we want to do before we do it. We're choosing our interventions, and we're prioritizing them. Here's all the things we need to do for our patient, and here's the most important. Here's the second important. We're picking all these things that we think need to be done for this patient, and then we start to prioritize.

Now, there's a few different types of care planning or ways that we can plan care for our patient. First of all, we need to base them on the immediate concerns, what's most important for our patient. What are the emergent and urgent needs for our patient, and what are the plans that we can use? Then you start to have to be flexible as different needs arise for these patients as we start implementing this stuff.

Now, you also can plan your care based on the goals for the patient. What is the patient’s short-term goals versus what are their long-term goals? Maybe they need to walk today, but we're hoping to get them home in a week or in three weeks.

One of the best ways to set goals are what are called smart goals. Now, I'm sure you've heard of this, but I'll just reiterate it here real quick. Smart goals are specific, they're measurable, they're achievable, they're relevant, and they're time oriented. Now, handwriting is horrible, but goals need to be set in this order.

For example, if we have a patient who just had a stroke yesterday, and we say, "Hey, we're going to be walking tomorrow," well, that's not really achievable for that patient. Or if we say patient will walk once a day, well, that's not fully measurable, because we should say we'll walk 150 steps each day. We really got to make sure we're specific, measurable, achievable, relevant, and time-oriented to have a really good goal for our patient.

Our care planning needs to also be based around the plans of care for our patient. We can develop care plans based on the patient's stay, and it's followed by the whole team, by the PT, RNs, providers, physician team, surgery, RT. Everybody will start to follow these care plans to help the patient. It really starts to be based on multiple aspects of need. What does PT need for this patient? What does RT need for this patient? What does the nursing staff, what does the medical staff need for this patient?

Then we also need to base our care plans on discharge planning, care plans developed for the patient at admission and throughout their stay. We're really working on trying to get them home, identifying resources they're going to need when they go home from the time they come in, because our goal isn't to keep patients in the hospital. It's to get patients home. We really need to start working through discharge planning as we begin taking care of patients.

Care plans are also going to be based on diagnosis. We're going to base it on medical diagnosis and on the nursing diagnosis. Nurses will provide care based on what the medical diagnosis is that the patients have. Care will then also be based on the prognosis for the patient.

Really what happens here, so let's say the patient has a wound, so here's ... they got this big stage 4 pressure ulcer here on their butt. Now, following medical orders and caring for that pressure wound would be basing our care around a medical diagnosis. Then care can also be planned around the nursing diagnosis. We identified primary diagnosis, so then care will also be planned around the nursing diagnosis. The nurse identifies the needs, the risk for this patient. We plan it around our immediate needs, our urgent needs, and we start to really take care of our patient based on what we see them having and what we think they might need, so for example, turning our patient every two hours to prevent further skin breakdown. That's going to be based on our nursing plan. It's going to be based on nursing diagnosis and how we can keep that patient well and make sure they don't have any further skin breakdown.

Now, when you're making your plans of care, you really can base it on Maslow's Hierarchy of Needs. If you haven't watched those lessons, make sure you watch them. But Maslow's Hierarchy of Needs shows us what needs our patients has with our most urgent and most important needs down here at the bottom. As we're doing this, we can plan our care for our single patient based on Maslow's Hierarchy of Needs. Then we can base our care also on having multiple patients, so the person in room 1 has more urgent needs than the person in room 3.

We really start to plan it around single patients where we take care of their most emergent needs first. Then we take care of their less emergent needs next. Then we also plan our care around our different where over in bed 3, they're very stable. They just need some food. In bed 1, they just fell out of the bed. They're not safe. We got to get them safe.

We really plan our care based on physiologic needs, ABCs, safety, both physical and infection safety, love and belonging, esteem, and self-actualization. We really got to be efficient when we're planning our care. That's one of the hardest things as a nurse is having all these things to do and then planning our care in a way that we can be efficient. As we just talked about there, plan it around your emergent needs first, your urgent needs, and then your non-urgent needs, all this other stuff that needs to be taken care of.

Another really important thing, and we'll talk about this in other lessons, but another really important thing is clustering care. What does that mean? That means instead of going in the room every time something needs to be done, we try to batch all that together, go into the patient's room once, and take care of everything that we can at that time.

One way you can do this is in a lot of hospitals and a lot of facilities, you're allowed to give a medicine 30 minutes before or 30 minutes after it's due. You could give your 10:00 and your 11:00 meds both at 10:30. You could bring all your 11:00 meds in there at 10:30, all your 10:00 meds in there at 10:30. Rather than having these two trips, you can go in there one time to save yourself time. Your time is very valuable. Your time is very critical as a nurse, so try to be as careful as you can with your time. You can also batch together your bed bath, your changing the linens, and your peri care all at the same time on this patient.

Then make sure you're delegating. Understand delegation. Watch our lessons on that. Make sure that you're using your time as wisely as you can and delegating those tasks that either you don't need to do or you simply can't do. Try to be as efficient as you can with your time.

What nursing concepts relate to this? First of all, professionalism, understanding your role as a nurse, understanding how to use your time, and then clinical judgment. How do I get things done as a nurse? Who do I see as a nurse? This is one of the most important things to understand. As you're planning care, you really have to use a high level of clinical judgment.
Let's talk about some of the key points. Planning, nursing care plans are based on what is found in assessment and what that assessment tells us. It's based on our data and our analysis of it. We start to look at, okay, what are we going to do. What are we actually going to do with all that stuff that we've gathered?

Now, you've got to identify urgency, so you don't want to address these low-level needs on Maslow's. We're not worried about self-actualization right now if the patient has an urgent ABC need. All right, and so we really address those physiological needs as fast as we can. Then we work our way up Maslow's Hierarchy of Needs.

Then we really have to consider the diagnosis. We use both the nursing diagnosis and the medical diagnosis to help us plan our care around what we've identified our patient has.

Then we cluster care. Your time is very important. Your time is very critical as a nurse. Make sure you're using your time as efficiently as you can, clustering care and delegating as possible.
All right, guys. That's a breakdown of the planning phase of the nursing process. I hope that helps. Make sure you check out all the other resources in this lesson. As always, happy nursing.