Learning Objectives
By the end of this section, you will be able to:
- Describe the development and prioritization of nursing hypotheses
- Explain how the nurse generates solutions to address patient needs and achieve care goals
- Identify appropriate nursing actions based on specific patient situations
After assessing and analyzing cues, the nurse proceeds to the next steps in the CJMM, which are prioritizing hypotheses and generating solutions. The nurse uses the specific patient assessment findings (cues), in combination with their foundational clinical knowledge, to develop hypotheses, or educated guesses, about the patient’s condition. As more cues are assessed and more information about the patient is obtained, the nurse can refine their initial hypothesis, determine its accuracy, and generate specific solutions and interventions for the patient.
Once the solutions and interventions are determined, the nurse can take action. Taking action involves implementing appropriate nursing interventions in an effort to achieve desired patient outcomes. The nurse uses a combination of clinical judgment and critical thinking skills to determine which nursing interventions are the priority actions and implements them accordingly.
Prioritizing Hypotheses
A hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored. No one can draw conclusions without first noticing and then prioritizing cues. Paying close attention to the patient, environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. Be mindful of your five primary senses: the things you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns to be able to take appropriate action quickly, especially in emergency situations.
Remember the example involving Mr. Silva, who recently underwent knee replacement surgery. After assessing him, the nurse finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues as signs of infection and then develops a hypothesis that the incision has become infected. The nurse also notices that an order has been placed to transition Mr. Silva from NPO status to a regular diet, which involves informing the patient and may involve contacting the dietary services department. The nurse prioritizes the incision findings because, left untreated, the infection could become more severe and eventually life-threatening. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. After the antibiotics have been ordered, the nurse moves onto changing Mr. Silva’s diet. This is an example of prioritizing hypotheses in nursing practice.
Generating Solutions
Based on prioritized hypotheses, nurses must use clinical judgment and knowledge to determine both actual problems that the patient is currently experiencing and potential problems that the patient may experience in the future. This involves looking at the comprehensive patient history and significant findings and thinking of the best and worst possible outcomes. The best outcome indicates progress toward recovery. In contrast, the worst outcome will reveal patient deterioration and decompensation. The nurse must always be thinking two steps ahead. Most people do this type of thinking in everyday life and probably do not even realize it. Think back to the last time you took a road trip. Did you just hit the open roads without any thought to the destination or plan to get there? Successful travelers put some serious planning into the trip to ensure the best possible outcome. The same example can be related to nursing practice. Before initiating interventions, the nurse must first establish specific patient goals (outcomes).
Thinking back to the example about Mr. Silva, the nurse decides that the provider should be made aware of the abnormal incision site findings. The nurse alerts the provider and anticipates that the provider will order antibiotics. The nurse also determines that it would be beneficial to change the patient’s dressing to ensure that the site is left clean, dry, and intact to prevent worsening infection.
Outcomes or Goals
A desired result or goal after implementation of the patient’s individualized plan of care is called an outcome. Identified outcomes may be long-term goals or short-term goals, but they should always follow the SMART goal format (Figure 4.3). The nurse considers five factors related to outcome identification:
- specific measurements to determine success of outcomes
- measurability of desired outcomes
- attainability of the outcome based on outlined timeline and available resources
- relevance of the outcomes for the specific patient with their unique qualities and need
- timeline that is appropriate for the desired outcomes
Realistic Outcomes
The nurse will determine if the outcome identified is realistic, meaning reasonable and attainable for this specific patient. For example, patients who experience minor surgical procedures typically begin to move very soon after surgery and possibly walk within a day of (or even the same day as) the procedure. However, this is not realistic for all patients. Think about a patient who has been prescribed physical therapy to gain muscle coordination and strength training after surgery. After one session of therapy, it is realistic and attainable to expect the patient to walk a few steps in the room with assistance. It is not realistic or attainable to expect that the patient will walk 500 ft (150 m) to the nurse’s station and back without assistance. Although common sense can help with outcome identification, a strong use of critical thinking is also warranted.
Expected Time Frame for Completion
Just as with any goal or expectation, a time frame for completion must be set. Having a set time frame enables the nurse to implement the interventions and, at the end of the period, evaluate the interventions’ effectiveness. The nurse and health-care team should collaborate to set the time frame with the patient’s input when possible. There are two types of outcome identification regarding time frames: short-term and long-term.
Short-Term Goals
A short-term goal has a time frame of days to a week; some are even within the assigned shift. Most short-term goals are intended to be achieved before the patient is discharged. This allows the health-care team to evaluate the effectiveness of a newly prescribed treatment, medication, or specific intervention. For example, a patient with an indwelling Foley catheter may have identified the following goal or outcome: “The patient will void (urinate) within two hours after removal of the Foley catheter.” This outcome allows the health-care team to ensure the patient regains bladder function. Another example of a short-term goal is for a patient who has been recently diagnosed with diabetes. This patient might identify the following outcome: “The patient will demonstrate how to check their own blood sugar using the return demonstration method before discharge.” Achieving this goal ensures the patient will be able to self-monitor their blood sugar upon discharge.
Long-Term Goals
A long-term goal generally has a time frame that lasts longer than a few days: it can be several weeks or even months. Long-term goals often involve ongoing activities or interventions, long after the patient has been discharged. Examples of long-term goals include wound care; medication protocols; and cardiac, respiratory, or physical rehabilitation. Long-term goals often are set to improve quality of life.
Generating Solutions to Achieve Goals
In the CJMM, generating solutions serves as a pivotal stage in the nursing process. This is where nurses translate their prioritized hypotheses into actionable interventions aimed at achieving patient-centered goals and outcomes. In combination with an understanding of the patient's health status, the nurse uses their clinical expertise and evidence-based practice guidelines to formulate tailored solutions. While generating solutions, the nurse must consider the physiological, psychological, sociocultural, and environmental factors influencing the patient's well-being, ensuring that interventions are not only clinically effective but also aligned with the patient's values, preferences, and individualized care needs. Whether administering pharmacological treatments, implementing therapeutic interventions, or facilitating health promotion strategies, nurses can use a variety of interventions to address patient care goals. As the nurse moves through the steps of the CJMM to make clinical decisions, they are also continuously checking in to reevaluate the plan of care. As the nurse assesses and cares for a patient, they can determine whether their actions have satisfied the goals of care.
Taking Action
Thinking back to Mr. Silva, the care team, including the nurse, has developed a plan of care to address Mr. Silva’s postsurgical needs. This plan includes interventions for pain management, mobilization exercises to regain knee function, and wound care to prevent infection. The team is confident that the plan can achieve Mr. Silva’s desired outcomes, which include effective pain control, improved mobility, and wound healing without complications (Cleveland Clinic, 2023).
However, the team also knows that simply having a plan is not enough; it needs to be implemented effectively in a patient-centered way. The implementation phase in nursing includes several key areas of emphasis: actively putting the plan into action and gauging the patient's response to the interventions. For example, in this stage of the CJMM, the nurse would implement specific actions to address the incision site findings, such as administering antibiotics as prescribed and changing the dressing.
Patient-Specific Interventions
For Mr. Silva, putting the plan into action begins with the nurse administering prescribed pain medication; this intervention should help to manage postoperative pain and facilitate early mobilization. The nurse also coordinates with the physical therapy team to initiate mobilization exercises and ensure the exercises align with Mr. Silva’s pain management plan. This interprofessional coordination is crucial to balance pain control with the need for early movement to prevent complications such as blood clots or stiffness in the knee.
In addition to these interventions, the nurse plays a pivotal role in wound care. This includes regularly changing dressings, monitoring the surgical site for signs of infection, and educating Mr. Silva on how to care for his wound. Effective implementation also requires all members of the health-care team to continuously evaluate the effectiveness of each intervention. Health care is a dynamic process, and Mr. Silva’s evolving needs and responses should guide the implementation of his care plan. This same sentiment can be applied to care for all patients, regardless of their condition or the care setting. All interventions should be tailored specifically to the patient, ensuring that the care provided is optimized for the patient’s needs and goals.
Gauging Patient Response
Gauging the patient’s response to interventions is a critical aspect of the implementation, or taking action, phase. It involves observing and interpreting how the patient reacts to the care plan, both physically and emotionally. This process is essential for ensuring that interventions are effective and align with the patient’s needs and comfort levels. Nurses assess responses through various means, including direct feedback from the patient, clinical observations, and monitoring vital signs or other relevant health indicators. This ongoing assessment allows the nurse to make timely adjustments to the care plan, ensuring it remains responsive and patient-centered.
In Mr. Silva's case, the nurse would closely monitor his responses to pain medication and physiotherapy. This might include observing changes in his pain levels, mobility, and overall comfort during and after mobilization exercises. If Mr. Silva reports increased pain or discomfort, the care team may need to reassess the approach to pain management or the intensity of the exercises. Similarly, the nurse would observe the healing of Mr. Silva's surgical wound, being alert to any signs of infection or poor healing so the team can make necessary adjustments to the wound care regimen. This careful monitoring ensures that Mr. Silva’s recovery stays on track and that any concerns are addressed promptly.