3.3 Outcomes & Treatment Planning

From Nursing Diagnosis to Nursing Care Plan

Planning is the second step of the nursing process — Assessment, Diagnosis, Planning, Implementation, Evaluation, or ADPIE — and on the PMH-BC exam it is tested as the bridge between what the nurse found in assessment (Domain I) and what the nurse will do in implementation (Domain III). A nursing diagnosis, per NANDA International (NANDA-I) taxonomy, is written in a three-part format: Problem related to Etiology as evidenced by Signs and symptoms. For example: "Risk for Suicide related to hopelessness and recent loss of employment as evidenced by verbalized plan and access to a firearm." Common psychiatric nursing diagnoses include Risk for Suicide, Risk for Self-Directed or Other-Directed Violence, Disturbed Thought Process, Ineffective Coping, Social Isolation, and Anxiety.

Writing SMART Goals

Every outcome written into the plan should meet the SMART standard:

A poorly written outcome such as "patient will feel less depressed" fails nearly every SMART criterion: it cannot be measured or verified and carries no deadline. A correctly written outcome such as "patient will verbalize two coping strategies for managing depressive thoughts by discharge" is specific, measurable, and time-bound. Both short-term goals, achievable within the current shift or admission, and long-term goals, achievable over weeks to months and often carried into outpatient care, belong in the plan.

Prioritizing Competing Problems

Psychiatric patients frequently present with multiple simultaneous nursing diagnoses. The exam tests prioritization heavily, and the governing framework is Maslow's hierarchy of needs, applied through a safety-first lens:

1. Physiological needs and immediate safety — airway, breathing, circulation, and in psychiatric care, imminent risk of suicide, homicide, or self-harm always takes priority over every other need, including comfort, insight-building, or long-term goals.
2. Safety and security — freedom from harm in the environment, such as fall risk, elopement risk, and medication safety.
3. Love and belonging — social isolation, family conflict.
4. Esteem — self-image and a sense of competence and worth.
5. Self-actualization — reaching full personal potential, the top of the recovery journey described in Section 3.2.

A useful exam heuristic: when a stem lists several valid nursing diagnoses and asks which to address first, choose the option describing a direct threat to life or physical safety over one describing emotional, social, or self-esteem needs, even if the "softer" need feels more pressing to the patient in the moment.

Interdisciplinary Treatment Planning

The RN does not create the treatment plan alone. PMH-BC planning content emphasizes coordination with the full interdisciplinary team: the psychiatrist or psychiatric-mental health nurse practitioner (diagnosis and prescribing), social worker (discharge planning, benefits, family work), psychologist (formal testing, individual therapy), occupational therapist (activities of daily living, coping-skill groups), case manager (community resource coordination), and, increasingly, peer support specialists (lived-experience support). The RN's unique contribution is the 24-hour bedside and unit perspective — direct observation of the patient's response to the milieu, medications, and interventions across the day — brought to interdisciplinary treatment team meetings and used to revise the plan.

Building In Available Support Systems

Finally, the written plan should explicitly name the support systems identified in Section 3.2 rather than leaving them implied: a specific family member who will attend discharge teaching, a specific outpatient therapist's name and first appointment date, a specific peer-support meeting the patient has agreed to attend. Concrete, named resources are far more likely to be used after discharge than a generic instruction to "follow up with outpatient services," and continuity of support systems is one of the strongest protective factors against relapse and readmission.

Documenting and Reviewing the Plan

The written treatment plan is a legal and clinical document, not an internal nursing note. Accreditation standards, such as those from the Joint Commission, require that an individualized treatment plan be initiated shortly after admission, typically reviewed and updated within the first 72 hours and then at regular intervals throughout the stay, and revised whenever the patient's condition or goals change significantly. Best practice involves the patient directly in reviewing the written plan and, whenever feasible, obtaining the patient's signature or documented verbal agreement to the goals, which reinforces the shared decision-making and client-centered principles introduced in Section 3.2. A plan that is written once at admission and never revisited fails both the accreditation standard and the clinical purpose of planning, because it cannot reflect the patient's progress, new information from the interdisciplinary team, or a change in level-of-care needs. Regular review is also where the nurse builds in the outcome-evaluation criteria that will be used later, in Chapter 6, to determine whether each SMART goal was actually met.