CHAPTER 18

Planning and Outcomes Identification in

Nursing Care

I. Introduction to Planning in Nursing

Planning is the third step of the nursing process, following:

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

Planning in nursing involves identifying patient problems and developing strategies to solve
them. It is an important step in the nursing process and requires more than everyday planning
because it focuses on making accurate clinical decisions for patient care

Fundamentals of Nursing 11E 202…

Planning nursing care requires:

 Critical thinking – analyzing patient data carefully

 Clinical judgment – making accurate care decisions
 Decision-making – choosing the best actions
 Prioritizing diagnoses – deciding which problems need attention first
 Setting outcomes – identifying goals for the patient
 Selecting interventions – choosing nursing actions to achieve goals

Overall, nursing planning is complex because nurses must use knowledge and judgment to create
an individualized, patient-centered care plan.

II. Clinical Judgment in Planning

Clinical judgment in planning involves using the six components of critical thinking to make
safe and effective clinical decisions

Fundamentals of Nursing 11E 202…

. Planning is not automatic—it requires thoughtful analysis of patient information and careful
decision-making.

During planning, clinical judgment includes:

• Reviewing assessment data – The nurse analyzes patient assessment findings to understand
the patient’s current health status and identify problems.
• Prioritizing nursing diagnoses – The nurse determines which patient problems are most
urgent and need immediate attention (for example, airway and safety issues before long-term
concerns).
• Generating solutions – The nurse develops possible strategies to address each identified
problem.
• Selecting interventions – The nurse chooses appropriate nursing actions based on evidence,
knowledge, patient condition, and available resources.
• Anticipating outcomes – The nurse predicts expected patient responses and sets measurable
goals to evaluate whether care is effective.

Planning must always be patient-centered and individualized. This means care plans are
created based on the patient’s unique needs, preferences, condition, and goals—not a routine or
standard plan for everyone

III. Factors Influencing Planning

According to the chapter framework (Fig. 18.2), planning is influenced by:

1️⃣ Knowledge Base

 Patient data and diagnoses

 Anatomy and physiology
 Pathophysiology
 Evidence-based interventions
 Growth and development
 Community resources
 Family dynamics
 Communication principles
2️⃣ Environment

 Time pressure
 Health care resources
 Task complexity
 Interruptions
 Staffing models

3️⃣ Experience

 Clinical experience
 Skill competence
 Recognition of changing patient conditions

4️⃣ Standards

 ANA Standards of Practice

 Clinical guidelines
 Agency policies
 Ethical standards

5️⃣ Attitudes

 Responsibility
 Discipline
 Creativity
 Perseverance

These factors shape how nurses prioritize and design care plans.

IVEstablishing Priorities
Definition:
Priority setting is the process of ordering nursing diagnoses or patient problems to determine the
correct sequence of nursing interventions.
Priorities:
• Change as patient conditions change – As the patient’s status improves or worsens, priorities
must be adjusted.
• Must be reassessed frequently – Ongoing assessment ensures the most urgent needs are
addressed.
• Are not based on task lists – Priorities are not determined by routine tasks or schedules.
• Are based on patient condition and safety – The patient’s current health status and safety
needs guide all priority decisions.

The chapter explains that nurses use structured frameworks to determine which patient problems
require attention first. Priority setting is based on urgency, patient safety, and clinical judgment
—not on routine tasks.

1️⃣ ABC Framework

The ABC approach is used to address immediate life-threatening conditions first:

• Airway – Ensure the airway is open and clear.

• Breathing – Assess and support oxygenation and ventilation.
• Circulation – Maintain adequate blood flow and cardiac function.

Problems affecting airway, breathing, or circulation are always high priority because they are
life-threatening. For example, if a patient develops chest pain and difficulty breathing (as in Mr.
Lawson’s case), this becomes an immediate priority.

2️⃣ Maslow’s Hierarchy of Needs

Maslow’s theory helps nurses prioritize based on human needs.

• Physiological needs (oxygen, circulation, nutrition, pain control)

• Safety needs

These basic survival needs take precedence over psychosocial or long-term concerns. However,
the chapter emphasizes that nurses must consider each patient’s unique situation and not focus
only on physical problems.

3️⃣ High, Intermediate, and Low Priority

The chapter categorizes nursing diagnoses into three levels:

Priority Level Description
Life-threatening or urgent problems (e.g., impaired gas exchange, severe pain,
High
safety risks).
Non-emergent but important problems that require timely intervention (e.g., risk
Intermediate
for infection).
Long-term, wellness, or health-promotion issues that do not require immediate
Low
action (e.g., anxiety about returning to work).

In Mr. Lawson’s case:

 Acute Pain was initially a high priority because it affected recovery and learning.
 Risk for Infection was intermediate unless signs of infection appeared.
 Anxiety became a lower priority unless it interfered with recovery or education.

VI. Outcomes Identification

After prioritizing diagnoses, nurses identify expected outcomes.

Definition:

An outcome is the effect a health care service or intervention has on the health status of a patient

Outcomes serve two purposes:

1. Guide selection of nursing interventions

2. Provide criteria for evaluation

VII. Characteristics of Expected Outcomes

Expected outcomes must be:

 Specific
 Measurable
 Observable
 Relevant
 Time-limited

They should reflect patient behavior or physiological response.

VIII. SMART Model for Writing Outcomes
The SMART method helps nurses write clear and effective patient outcomes.

S – Specific
Focus on one clear patient behavior or response.

M – Measurable
The outcome must be observable or quantifiable.

A – Attainable
The goal should be achievable with patient involvement and participation.

R – Realistic
It must be within the patient’s physical, emotional, and cognitive abilities.

T – Timed
Include a clear deadline or time frame for achievement.

Outcome:
Patient will correctly describe three signs of infection by the end of today.

 Specific: Describe three signs of infection

 Measurable: Three signs (clear number)
 Attainable: Achievable after teaching
 Realistic: Appropriate for patient’s condition
 Timed: By the end of today

Example:
Patient will report pain level of 3 or less on a 0–10 scale within 24 hours.

 Specific: Pain level

 Measurable: 3 or less on scale
 Attainable: Achievable with treatment
 Realistic: Appropriate for condition
 Timed: Within 24 hours**

IX. Nurse-Sensitive Outcomes

Defined as measurable patient behaviors or perceptions influenced by nursing interventions

Examples include:

 Pressure injury rates

 Falls
 Patient satisfaction
 Pain control

These demonstrate nursing quality and accountability.

X. Nursing Outcomes Classification (NOC)

NOC links:

 Nursing diagnoses
 Standardized outcomes
 Outcome indicators

It uses a five-point Likert scale for measurement

NOC improves:

 Consistency
 Evaluation
 Documentation
 Evidence-based practice

Example

Nursing Diagnosis: Acute Pain

NOC Outcome: Pain Control

Outcome Indicators:
• Pain intensity level
• Ability to rest
• Facial expression of discomfort

Measurement:
Rated on a 1–5 scale
(1 = severe pain / poor control, 5 = no pain / excellent control)
Example 2 – Nursing Outcomes Classification (NOC)

Nursing Diagnosis: Impaired Skin Integrity

NOC Outcome: Tissue Integrity: Skin and Mucous Membranes

Outcome Indicators:
• Wound size
• Skin redness
• Presence of drainage
• Skin temperature

Measurement:
Each indicator is rated on a 1–5 Likert scale
(1 = severely impaired, 5 = normal / healed)

XI. Planning Nursing Interventions

After identifying outcomes, nurses select interventions.

Definition:

Nursing interventions are treatments or actions based on clinical judgment and knowledge that
nurses perform to achieve patient outcomes

Interventions must be:

 Evidence-based
 Feasible
 Acceptable to patient
 Within nurse competency

XII. Types of Nursing Interventions

1️⃣ Independent (Nurse-Initiated)

 Do not require provider order

 Based on nursing knowledge
 Example:
Repositioning a patient every 2 hours to prevent pressure injuries.
(Planned and performed by the nurse independently.)

2️⃣ Dependent (Provider-Initiated)

 Require medical order

 Nurse carries out therapy

Example:
Administering a prescribed antibiotic for infection.
(The nurse gives the medication as ordered.)

3️⃣ Interdependent (Collaborative)

 Require cooperation with other disciplines

 Example:
 Working with a physical therapist to assist a patient with postoperative mobility
exercises.
 (The nurse and therapist collaborate to improve mobility.)

XIII. Nursing Interventions Classification

(NIC)
Nursing Interventions Classification (NIC)

NIC provides standardized language for describing nursing interventions. It helps nurses clearly
communicate the care they provide across different settings.

NIC is organized into three levels:

• Domains – Broad areas of nursing practice (e.g., physiological, behavioral, safety).

• Classes – Groups of related interventions within each domain (e.g., Physical Comfort
Promotion).
• Specific Interventions – Individual nursing actions (e.g., Pain Management, Wound Care,
Positioning).
Example

Domain: Physiological: Basic

Class: Physical Comfort Promotion
Intervention: Pain Management

Benefits of NIC

• Improves communication among health care providers

• Promotes consistency in care
• Supports standardized documentation
• Enhances evidence-based practice

XIV. Nursing Care Plans

A nursing care plan includes:

1. Nursing diagnoses
2. Expected outcomes
3. Interventions
4. Evaluation findings

Care plans:

 Promote continuity
 Improve communication
 Reduce errors
 Coordinate resources

Interprofessional care plans integrate multiple disciplines.