Nurse's Pocket Guide

from the diagnostic statement and are what the client hopes to
achieve. They serve as the guidelines to evaluate progress toward
resolution of needs/problems, providing impetus for revising
the plan as appropriate. In this book, outcomes are stated in
general terms to permit the practitioner to individualize them
by adding timelines and other data according to specific client
circumstances. Outcome terminology needs to be concise, realistic,
measurable, and stated in words the client can understand,
because they indicate what the client is expected to do or
accomplish. Beginning the outcome statement with an action
verb provides measurable direction, for example, “Verbalizes
relationship between diabetes mellitus and circulatory changes
in feet within 2 days” or “Correctly performs procedure of home
glucose monitoring within 48 hours.”
Interventions are the activities taken to achieve the desired
outcomes and, because they are communicated to others, they
must be clearly stated. A solid nursing knowledge base is vital to
this process because the rationale for interventions needs to be
sound and feasible with the intention of providing effective,
individualized care. The actions may be independent or collaborative
and may encompass specific orders from nursing, medicine,
and other disciplines. Written interventions that guide
ongoing client care need to be dated and signed. To facilitate the
planning process, specific nursing priorities have been identified
in this text to provide a general ranking of interventions. This
ranking would be altered according to individual client situations.
The seasoned practitioner may choose to use these as
broad-based interventions. The student or beginning practitioner
may need to develop a more detailed plan of care by
including the appropriate interventions listed under each nursing
priority. It is important to remember that because each
client usually has a perception of individual needs or problems
he or she faces and an expectation of what could be done about
the situation, the plan of care must be congruent with the
client’s reality or it will fail. In short, the nurse needs to plan care
with the client, because both are accountable for that care and
for achieving the desired outcomes.
The plan of care is the end product of the nursing process and
documents client care in areas of accountability, quality assurance,
and liability. Therefore, the plan of care is a permanent
part of the client’s healthcare record. The format for recording
the plan of care is determined by agency policy and may be
handwritten, standardized forms or clinical pathways, or computer-generated
documentation. Before implementing the plan
of care, it should be reviewed to ensure that:
• It is based on accepted nursing practice, reflecting knowledge
of scientific principles, nursing standards of care, and
agency policies.
APPLICATION OF THE NURSING PROCESS 15