Chapter 17

Outcome Identification and

Planning

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Goal of Outcome Identification
and Planning Step

 Establish priorities
 Identify and write expected patient outcomes
 Select evidence-based nursing interventions
 Communicate the nursing plan of care

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Outcome Identification and Planning

Copyright © 2023 Wolters Kluwer • All Rights Reserved

A Formal Care Plan 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

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Outcome Identification, Planning, and
Clinical Reasoning #1

 Be familiar with standards and agency policies for

setting priorities, identifying and recording expected
patient outcomes, selecting evidence-based nursing
interventions, and recording the care plan
 Remember that the goal of thoughtful, patient-
centered practice is to keep the patient and the
patient’s interests and preferences central in every
aspect of planning and outcome identification
 Keep the “big picture” in focus: What are the
discharge goals for this patient, and how should this
direct each shift’s interventions?

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Outcome Identification, Planning, and
Clinical Reasoning #2

 Trust clinical experience and judgment but be willing

to ask for help when the situation demands more
than your qualifications and experience can provide;
value collaborative practice
 Respect your clinical intuitions, but before
establishing priorities, identifying outcomes, and
selecting nursing interventions, be sure that
research supports your plan
 Recognize your personal biases and keep an open
mind

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Standards to Apply to Outcome
Identification and Planning

 The law
 Specialty professional organizations
 The Joint Commission
 The Agency for Healthcare Research and Quality
(AHRQ)
 Your employer

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Three Elements of
Comprehensive Planning

 Initial
 Ongoing
 Discharge

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Initial Planning

 Developed by the nurse who performs the nursing

history and physical assessment
 Addresses each problem listed in the prioritized
problem list
 Identifies appropriate patient goals and related
nursing care

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Ongoing Planning

 Carried out by any nurse who interacts with patient

 Keeps the plan up to date, manages risk factors,
promotes function
 States problem statements more clearly
 Develops new problem statements
 Makes outcomes more realistic and develops new
outcomes as needed
 Identifies nursing interventions to accomplish
patient goals

Copyright © 2023 Wolters Kluwer • All Rights Reserved

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 that home care behaviors are performed
competently

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Question #1

Which nursing action 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 patient
problems, outcomes, and interventions

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Answer to Question #1

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.

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Deriving Patient Goals/Outcomes and
Nursing Orders From Nursing Diagnoses

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Establishing Priorities

 Maslow’s hierarchy of human needs

 Patient preference
 Anticipation of future problems
 Critical thinking/clinical reasoning and judgment

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Maslow’s Hierarchy of Human Needs

 Physiologic needs
 Safety needs
 Love and belonging needs
 Self-esteem needs
 Self-actualization needs

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Clinical Reasoning and Establishing
Priorities #1

 What problems need immediate attention and which

ones can wait?
 Which problems are the responsibility of the nurse
and which need to be referred to someone else?
 Which problems can be dealt with by using standard
plans (e.g., critical paths, standards of care)?
 Which problems are not covered by protocols or
standard plans but must be addressed to ensure a
safe hospital stay and timely discharge?

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Clinical Reasoning and Establishing
Priorities #2

 Have changes in the patient’s health status

influenced the priority of nursing
diagnoses/problems?
 Have changes in the way the patient is responding
to health and illness or the care plan affected those
nursing diagnoses/problems that can be realistically
addressed?
 Are there relationships among diagnoses/problems
that require that one be worked on before another
can be resolved?
 Can several patient problems be dealt with
together?

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Question #2

Which patient problem would most likely be

considered a high priority?
A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Answer to Question #2

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.

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Identifying Outcomes

 Deriving outcomes from nursing diagnoses/problems

 Establishing long-term versus short-term outcomes
 Determining patient-centered outcomes
 Using cognitive, psychomotor, and affective
outcomes
 Identifying clinical, functional, and quality of life
outcomes
 Identifying culturally appropriate outcomes
 Identifying outcomes supportive of the total
treatment plan

Copyright © 2023 Wolters Kluwer • All Rights Reserved

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

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Clinical, Functional, and Quality-of-Life
Outcomes

 Clinical outcomes describe the expected status of

health issues at certain points in time, after
treatment is complete. They address whether the
problems are resolved or to what degree they are
improved
 Functional outcomes describe the person’s ability to
function in relation to the desired usual activities
 Quality-of-life outcomes focus on key factors that
affect someone’s ability to enjoy life and achieve
personal goals

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Question #3

Which outcome is an affective outcome?

A. By 6/09/19, the patient will correctly demonstrate
the procedure for washing her newborn baby
B. By 6/09/19, the patient will list three benefits of
eating a healthy diet
C. By 6/09/19, the patient will use a walker to
ambulate the hallway
D. By 6/09/19, the patient will verbalize valuing his
health enough to stop smoking

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Answer to Question #3

Answer: D. By 6/09/19, 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 C
are psychomotor outcomes (learning a new skill) and
Answer B is a cognitive outcome (increase in patient
knowledge).

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Parts of a Measurable Outcome

 Subject
 Verb
 Conditions
 Performance criteria
 Target time

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Question #4

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

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Answer to Question #4

Answer: B. False

Rationale: 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.

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Common Errors in Writing
Patient Outcomes

 Expressing patient outcome as nursing intervention

 Using verbs that are not observable or measurable
 Including more than one patient behavior or
manifestation in short-term outcomes
 Writing vague outcomes

Copyright © 2023 Wolters Kluwer • All Rights Reserved

IOM’s Six Aims to Be Met by Health Care
Systems Regarding Quality of Care

 Safe: avoiding injury

 Effective: avoiding overuse and underuse
 Patient-centered: responding to patient preferences,
needs, and values
 Timely: reducing waits and delays
 Efficient: avoiding waste
 Equitable: providing care that does not vary in
quality to all recipients

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Joint Commission National Patient Safety
Goals

 Identify patients correctly

 Improve staff communication
 Use medicines safely
 Use alarms safely
 Prevent infection
 Identify patient safety risks
 Prevent mistakes in surgery

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Types of Nursing Interventions

 Nurse-initiated: autonomous action based on

scientific rationale that a nurse executes to benefit
the patient in a predictable way related to the
nursing diagnosis and projected outcomes
 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

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Actions Performed in Nurse-Initiated
Interventions (Alfaro, 2020)

 Monitor health status

 Reduce risks
 Resolve, prevent, or manage a problem
 Promote independence with ADLs
 Promote optimum sense of physical, psychological,
and spiritual well-being
 Give patients information needed to make informed
decisions and be independent

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Structured Care Methodologies

 Procedure: set of how-to action steps

 Standard of care: description of acceptable level of
patient care
 Algorithm: set of steps used to make a decision
 Clinical practice guideline: statement outlining
appropriate practice for clinical condition or
procedure

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Question #5

Tell whether the following statement is true or false.

A protocol prescribes specific therapeutic interventions
for a clinical problem unique to a subgroup of patients
within the cohort.
A. True
B. False

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Answer to Question #5

Answer: A. True

Rationale: A protocol prescribes specific therapeutic

interventions for a clinical problem unique to a
subgroup of patients within the cohort.

Copyright © 2023 Wolters Kluwer • All Rights Reserved

Formats of Care Plans

 Computerized care plans

 Concept map care plans
 Change of shift reports
 Multidisciplinary (collaborative) care plans
 Student care plans

Copyright © 2023 Wolters Kluwer • All Rights Reserved