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3.5 Generating Solutions

After assessment and hypotheses generation, the nurse considers what desirable outcomes would be realistic for a patient. The Outcomes Identification Standard of Practice by the American Nurses Association states, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[1] Review the competencies for the Outcomes Identification Standard of Practice for registered nurses in the following box.

ANA’s Outcomes Identification Competencies[2]

The registered nurse:

  • Engages with the health care consumer, interprofessional team, and others to identify expected outcomes.
  • Collaborates with the health care consumer to define expected outcomes integrating the health care consumer’s culture, values, and ethical considerations.
  • Formulates expected outcomes derived from assessments and diagnoses.
  • Integrates evidence and best practices to identify expected outcomes.
  • Develops expected outcomes that facilitate coordination of care.
  • Identifies a time frame for the attainment of expected outcomes.
  • Documents expected outcomes as measurable goals.
  • Identifies the actual outcomes in relation to expected outcomes, safety, and quality standards.
  • Modifies expected outcomes based on the evaluation of the status of the health care consumer and situation.

An outcome is a “measurable behavior demonstrated by the patient who is responsive to nursing interventions.”[3] Outcome identification includes setting short-term and long-term goals and then creating specific expected outcome statements for each. Outcome statements are always patient-centered. They should be developed collaboratively with the patient and significant others who will care for the patient after discharge. Outcomes are individualized to meet the patient’s unique needs, values, and cultural beliefs. Outcome statements should be directed at resolving the defining characteristics for each nursing diagnosis/hypothesis.

Read more about how to use Motivational Interviewing techniques in setting individualized goals and expected outcomes with a patient in Chapter 4.4.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic:

  • Specific
  • Measurable
  • Attainable/Action-oriented
  • Relevant/Realistic
  • Time frame

See Figure 3.5[4] for an image of the SMART components of outcome statements.

 

Image showing a breakdown of SMART goal acronym
Figure 3.5 SMART Components

The Planning Standard of Practice by the American Nurses Association states, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”[5]

Review the competencies for the Planning Standard of Practice for registered nurses in the following box.

ANA’s Planning Competencies[6]

The registered nurse:

  • Develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team.
  • Designs innovative nursing practices that can be incorporated into the plan.
  • Prioritizes elements of the plan based on the assessment of the health care consumer’s level of safety needs to include risks, benefits, and alternatives.
  • Establishes the plan priorities with the health care consumer, family, significant others, and interprofessional team.
  • Advocates for compassionate, responsible, and appropriate use of interventions to minimize unwarranted or unwanted treatment, health care consumer suffering, or both.
  • Includes strategies designed to address each of the identified diagnoses, health challenges, issues, or opportunities. These strategies may include, but are not limited to, maintaining health and wellness; promotion of comfort; promotion of wholeness, growth, and development; promotion and restoration of health and wellness; prevention of illness, injury, disease, complications, and trauma; facilitation of healing; alleviation of suffering; supportive care; and mitigation of environmental or occupational risks.
  • Incorporates an implementation pathway that describes an overall timeline, steps, and milestones.
  • Provides for the coordination and continuity of care.
  • Identifies cost and economic implications of the plan.
  • Develops a plan that reflects compliance with current statutes, rules, regulations, and standards.
  • Modifies the plan according to the ongoing assessment of the health care consumer’s response and other outcome indicators.
  • Documents the plan using standardized language or recognized terminology.
  • Actively contributes at all levels in the development and continuous improvement of systems that support the planning process.

As always, consult a current, evidence-based nursing care planning resource as well as the healthcare team when planning nursing interventions individualized to each patient’s needs. You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan regarding mental health care?” There are several sources that can be used to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient health record.

The nurse also needs to consider the actions of the healthcare team. For example, knowledge of potential prescriber orders may influence medication planning. The patient may need a consultation with a counselor or dietitian, for example. Working with the interdisciplinary team is necessary when developing a plan of care. The patient may be at risk for certain complications of a given illness or therapeutic regimen. For example, a nurse needs to be aware that a patient starting an antidepressant medication may be at higher risk for suicidal ideation for the first two to three weeks. The nurse will then plan risk reduction strategies to keep the patient free of self-harm (the outcome).

Case Study

Recall the patient in the previous chapter, a 32-year-old male diagnosed with Major Depressive Disorder. The nurse used the cues to create these four nursing hypotheses/diagnoses:

  • Risk for Suicide as manifested by reported desire to die
  • Hopelessness related to social isolation
  • Imbalanced Nutrition: Less than Body Requirements related to insufficient dietary intake
  • Self-Neglect related to insufficient personal hygiene

The nurse established the top priority as Risk for Suicide and immediately screened for suicidal ideation and a plan using the Patient Safety Screener.

The nurse then identified the following SMART expected outcome: The patient will remain free from self-harm self during the hospitalization stay.

Sample Nursing Actions for Risk for Suicide

Nursing Action

The nurse will…

 Rationale
Use an evidence-based process to conduct a suicide risk assessment. Patients with suicidal ideation vary widely in their risk for a suicide attempt depending on whether they have a plan, intent, and past history of attempts. In-depth assessment of patients who screen positive for suicide risk must be completed to determine how to appropriately treat them.[7]
Document and communicate the patient’s overall level of risk for suicide with the treatment team and the plan for mitigating their risk for suicide. All interprofessional health care team members who might come in contact with a patient at risk for suicide must be aware of the level of risk and the mitigation plans to reduce that risk. This information should be explicitly documented in the patient’s record.[8]
Perform an environmental risk assessment and remove features that could be used to attempt suicide. The Veteran’s Health Administration showed that use of a Mental Health Environment of Care Checklist to facilitate a thorough, systematic environmental assessment reduced the rate of suicide from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions.[9]
Administer prescribed treatment and collaboratively manage psychiatric symptoms that may be contributing to the patient’s suicidal ideation or behavior. Symptoms of the disorder may require treatment with antidepressant, antipsychotic, or antianxiety medications. A systematic review has shown a significant effect for cognitive behavioral therapy in reducing suicidal behavior.[10]
Express desire to help the patient and validate the client’s experience of psychological pain while maintaining a safe environment for the client. The nurse must reconcile their goal of preventing suicide with recognition of the patient’s goal to alleviate their psychological pain.[11]
Develop a positive therapeutic relationship with the patient; do not make promises that may not be kept. Spend at least 5 minutes per shift with the patient to discuss feelings and thoughts. Nurses connect suicidal patients with humanity by guiding the patient, encouraging effective coping strategies, and helping them connect appropriately with others.[12]
Determine the patient’s need for supervision and assign a room near the nursing station as necessary. Close assignment increases ease of observation and availability for a rapid response in the event of a suicide attempt.[13]
Search the newly hospitalized patient and the client’s personal belongings for weapons or potential weapons and hoarded medications during the admission process and remove dangerous items. Patients with suicidal ideation may bring the means with them. This action is necessary to maintain a hazard-free environment and patient safety.[14]
Limit access to windows and exits unless locked and shatterproof, as appropriate. Ensure exits are secure. Suicidal behavior may include attempts to jump out of windows or escape to find other means of suicide.[15]
Place the patient in the least restrictive, safe, and monitored environment that allows for the necessary level of observation. Assess suicidal risk at least daily and more frequently as warranted. Close observation of the patient is necessary for safety as long as the intent remains high. Suicide risk should be assessed at frequent intervals to adjust suicide precautions and ensure restrictions continue to be appropriate.[16]
Consider strategies to decrease isolation and opportunity to act on harmful thoughts (e.g., use of a sitter). Patients have reported feeling safe and having their hope restored in response to close observation.[17]
Create a safety plan with the patient, encouraging the patient to inform a staff member if self-harm ideation occurs. Discussing thoughts of suicide and self-harm with a trusted person can provide relief for the patient. A safety plan gets the subject out in the open and places some of the responsibility for safety with the patient.[18]
Explain suicide precautions and relevant safety issues to the patient and family (purpose, duration, behavioral expectations, and behavioral consequences). Suicide precautions may be viewed as restrictive. Patients have reported the loss of privacy as distressing.[19] Explaining the reasoning for safety precautions helps the patient understand why they are being used even though they may feel restrictive and distressing. When patients and family members understand the reasoning for the precautions, they are more likely to comply.
Verify the patient has taken medications as ordered (e.g., conduct mouth checks after medication administration). The patient may attempt to hoard medications for a later suicide attempt.[20]
Maintain increased surveillance of the patient whenever the use of an antidepressant has been initiated or the dose increased. Antidepressant medications take anywhere from 2 to 6 weeks to achieve full efficacy. During that period, the patient’s energy level may increase although the depression has not yet lifted, which increases the potential for suicide.[21]
Involve the patient in treatment planning and self-care management of psychiatric disorders. Self-care management promotes feelings of self-efficacy. The more patients participate in their own care, the less powerless and hopeless they feel.[22]
Assess the patient’s skin, if necessary, for any self-inflicted injury once per shift. Some patients do not inform the staff of injurious behaviors and may be hiding a contraband item.
Assist the patent in identifying a network of supportive persons and resources (e.g., family, clergy, care providers). Social support and positive events were found to have a protective effect against suicidal ideation.[23]
Document patient behavior in detail to support involuntary admission if actively suicidal. Read more about involuntary admissions in the “Patient Rights” section of the “Legal and Ethical Considerations” chapter. Involuntary inpatient admissions serve to keep the client safe from harm. Involuntary outpatient commitment is also available in many states and can improve treatment, reduce the likelihood of hospital readmission, and reduce episodes of violent behavior in persons with severe psychiatric illnesses.[24]
Involve the family in discharge planning (e.g., illness/medication teaching, recognition of increasing suicidal risk, patient’s plan for dealing with recurring suicidal thoughts, and community resources). Family members must learn how to respond to cues early, support the treatment regimen, and encourage the patient to initiate an emergency plan.[25] When family members are aware of cues, treatments, and emergency plans, patients are less likely to act on thoughts of suicide or self-harm.
Before discharge from the hospital, ensure the patient has a safety plan to use after discharge, including a supply of prescribed medications and a plan for outpatient follow-up. Ensure they understand the plan or have a caregiver able and willing to follow the plan, as well as the ability to access outpatient treatment. Patients may have difficulty concentrating on the plan for follow-up. They may need assistance from others to ensure prescriptions are filled, appointments are attended, and transportation is available to appointments.[26]
In the event of a patient’s suicide, refer the family to a support group for survivors of suicide. Psychoeducational support group participants found relief in sharing their bereavement with others.[27]
  1. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  2. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  3. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵
  4. “SMART-goals.png” by Dungdm93 is licensed under CC BY-SA 4.0 ↵
  5. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  6. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  7. DeAngelis, T. (2019). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10), 38. https://www.apa.org/monitor/2019/11/ce-corner-relationships ↵
  8. DeAngelis, T. (2019). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10), 38. https://www.apa.org/monitor/2019/11/ce-corner-relationships ↵
  9. DeAngelis, T. (2019). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10), 38. https://www.apa.org/monitor/2019/11/ce-corner-relationships ↵
  10. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  11. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  12. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  13. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  14. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  15. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  16. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  17. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  18. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  19. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  20. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  21. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  22. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  23. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  24. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  25. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  26. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
  27. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
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