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69 Cards in this Set

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(the third step of the nursing process) a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions
Priority setting
the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions.
High priority nursing diagnosis
diagnoses that, if untreated, result in harm to the client or others. They can be either physiological or psychological
Intermediate priority nursing diagnosis
involve the non-emergent, non-life threatening needs of the client
Low priority nursing diagnosis
not always directly related to a specific illness or prognosis but affect the clients' future well-being.
Initial planning
development of preliminary plan of care following admission assessment and initial selection of nursing diagnoses. Important in addressing nursing dx and collaborative problems to hasten problem resolution
Ongoing Planning
continuous updating of the clients' plan of care. as condition changes sometimes revise the initial plan of care and further individualize your interventions.
Discharge panning
involves critical anticipation and preparation for meeting the clients needs after discharge
cognitive shift
shifts in attention from one client to another during the conduct of the nursing process. shift of attention occurs in response to client needs changing, new procedures being ordered, or environmental processes interacting.
is an aim, intent, or end. A broad statement that describes the desired change in a client's condition or behavior
Expected outcomes
measurable criteria to evaluate goal achievement, which you expect to occur in response to nursing care.
Purpose of goals and expected outcomes
provide specific statements of client behavior or physiological responses that you set to achieve nursing diagnosis or collaborative problem resolution. Provide a clear focus for the type of interventions necessary
client-centered goal
a specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function.
short-term goal
an objective behavior or response that you expect a client to achieve in a short time, usually less than a week
Long-term goal
an objective behavior or response that you expect a client to achieve over a longer period of time, usually several days, weeks, or months.
nursing-sensitive client outcome
an individual, family, or community state, behavior, or perception that is measurable along a continuum in response to a nursing intervention
Guidelines for writing goals and expected outcomes
client-centered, singular, observable, measurable, time-limited, mutual, and realistic
Guidelines for writing goals- Client-centered
write a goal to reflect client behavior, not to reflect nursing goals. ex. Client will ambulate in the hall 3 times a day
Guidelines for writing goals- Singular
be precise in evaluating a client response to a nursing action, each goal/outcome addresses only one behavior or response. Ex. lungs will be clear to auscultation by 8/22
Guidelines for writing goals- Observable
need to be able to observe if a change takes place in a clients status. occur in physiological findings and the clients knowledge, perceptions, and behavior. Observe by assessment or asking client directly. Ex. client will be able to self-administer insulin
Guidelines for Writing Goals- Measurable
set goals/outcomes that set standards against which to measure the client's response to nursing care, do not use vague qualifiers but use terms that describe quantity, quality, frequency, length or weight allow you to evaluate precisely
Guidelines for Writing Goals- Time-limited
each goal/income should indicate when you expect the response to occur which assist in determining if client is making progress, and they promote accountability in the delivery and management of nursing care
Guidelines for Writing Goals- Mutual Factors
mutually set goals to ensure client and nurse agree on the direction and time limits of care which will increase the client's motivation and cooperation
Guidelines for Writing Goals- Realistic
set goals that client is able to reach, but realistic goals provide hope which increases motivation and cooperation. be aware of limitations, and client ability.
Independent Nursing Interventions
actions that are initiated by the nurse, and do not require direction or an order form another health care professional. These pertain to ADL's, health education, health promotion, and counseling
Dependent Nursing Interventions
actions that require an order from a physician or another health care professional, which are based on treatment/management of medical diagnosis. You intervene by carrying out the orders
Collaborative Interventions/interdependent interventions
require the combined knowledge, skill, and expertise of multiple health care professionals.
Selection of interventions
consider six important factors: characteristics of the nursing dx; goals and expected outcomes; evidence base for the interventions; feasibility of the intervention; acceptability to the client; and your own competency
Nursing Care plan
enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care.
Student care plan
useful for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care.
Scientific Rationale
the reason that you chose a specific nursing action, based on supporting evidence. Needs to include a reference, document the source from the scientific literature
Institutional care plans
Does not have a scientific rationale, as it is assumed that the nurses know the rationales for recommended interventions, and the focus will differ by setting and evolving client situation
Critical Pathways
multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition
a process in which you seek the expertise of a specialist, such as your nursing instructor, to identify ways to handle problems in client management or the planning and implementation of therapies.
begins after the nurse develops a plan of care, the nurse initiates interventions that are most likely to achieve the goals, and expected outcomes needed to support or improve the clients health status
nursing intervention
any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes
direct care interventions
treatments performed through interactions with clients
indirect care interventions
treatments performed away from the client but on behalf of the client or group of clients
Standing orders
a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific clients with identified clinical problems. give the nurse legal protection to intervene appropriately in the client's best interest.
What should be done before implementation?
reassessing the client, reviewing and revising the existing plan of care, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions
Clinical Guideline
a document that guides decisions and interventions for specific health care problems or conditions
Reassessing the Client
assessment should be a continuous process that occurs each time you interact with the client. It helps you decide if the proposed nursing action is still appropriate.
Reviewing and Revising the care Plan
Care plans have to modified to reflect the patients most current status. Revise data in assessment column to reflect current status. Revise the nursing diagnosis as needed. Revise specific interventions that correspond to each new diagnosis or goal. Determine the method of evaluation for determining achieved outcomes.
Preparing for Care
Make sure needed equipment is available, in working order, and safe for client. make sure the personnel needed for action are available. Make sure that the environment is safe and conducive to the implementation of therapies. Be sure the client is as physically and psychologically comfortable as possible.
Anticipate and Prevent Complications
Be alert for and recognize risks, adapt choice of interventions to the situation, evaluate the relative benefit of the treatment versus the risk, and then initiate risk preventive measures
Implementations Skills
include: Cognitive skills, interpersonal skills, and pyschomotor skills.
Cognitive Skills for Implementation
involve the application of critical thinking in the nursing process. use good judgment and make sound clinical decisions. no intervention should be automatic.
Interpersonal Skills for Implementation
Developing a trusting relationship, expressing a level of caring, communicating clearly with client and family. Good skills are critical for keeping clients informed, providing individualized teaching, and effectively supporting clients with challenging emotional needs.
Direct Care
Includes: Activities of Daily living, instrumental activities of daily living, physical care techniques, lifesaving measures, counseling, teaching, controlling adverse reactions, and preventive measures
Activities of Daily Living-direct care
activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, brushing teeth and grooming. Assistance with ADL may be partial or complete.
Instrumental Activities of Daily Living-direct care
skills such as shopping, preparing meals, writing checks, and taking medications. (occupational therapists are useful for training clients to adapt approaches with IADL)
Physical Care Techniques-direct care
include turning and positioning; performing invasive procedures/ administering medication, and providing comfort measures. often involve protecting you and client from injury, using proper infection control practices, staying organized and following applicable practice guidelines.
Lifesaving measures- direct care
a physical care technique that you use when a client's physiological or psychological state is threatening, and the purpose is to restore equilibrium. Include: administering emergency medications, instituting CPR, intervening to protect a confused or violent client, and obtaining immediate counseling from a crisis center for severely anxious clients.
Counseling-direct care
a direct care method that helps the client use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships. Involves emotional, intellectual, spiritual, and psychological support, and can foster cognitive, behavioral, developmental, experiental, and emotional growth in clients.
Teaching-direct care
usually closely aligned with counseling, but is focused on the intellectual growth or the acquisition of new knowledge or psycho-motor skills. Correct principles, procedures, techniques of health care are taught, and clients are informed of health status. include topics such as medication administration scheduled, activity restrictions, health promotion activities, and knowledge about disease and related complications.
Adverse reactions-direct care
a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. Nursing actions must know how to reduce or counteract adverse reactions. Must be able to recognize signs and symptoms of an adverse reaction and intervene in a timely manner.
Preventive Measures-direct care
promote health and prevent illness to avoid the need for acute or rehabilitative health care. Includes assessment and promotion of client's health potential, application of prescribed measures, health teaching, and identification of risk factors for illness and/or trauma
Indirect Care Measures
Include communicating nursing interventions, and delegating, supervising, and evaluating the work of other staff members
interdisciplinary care plan
plans that represent the contributions of all disciplines caring for a client.
Communicating Nursing interventions- indirect care
any intervention you provide must be communicated in a written and/or oral format. The information written in a medical records about interventions/and need for them will allow other personnel to know what is being done for the client. Verbally communicating also allows others to know what is being done and what still needs to be done. Communication helps reduce duplication of services, prevents delays in care, and helps tasks to get completed.
Delegating, supervising, and evaluation of the work of other staff members
Some care tasks may be delegated to other staff members, but the nurse is accountable for the care provided/not provided.
Achieving goals
Nursing care is implemented to meet client goals and outcomes
Client adherence
clients and families invest time in carrying out required treatments (another way to achieve goals)
An ongoing process that occurs anytime you have contact with a client. Involves two components: an examination of condition or situation and then a judgement as to whether change has occurred. You conduct evaluative measure to see if outcomes/goals are met, not if nursing interventions were completed!
Five Elements of the Evaluation Process
Identifying evaluative criteria and standards; collecting data to determine whether the criteria or standards are met; interpreting and summarizing findings; documenting findings and any clinical judgments; and terminating, continuing, or revising the care plan
Evaluative Measures
assessment skills and techniques (auscultation, observation, discussion, and inspection) are actually the same as the assessment but performed at the point of care when you make decisions about the client's status and progress
Standard of Care
the minimum level of care accepted to ensure high quality of care to clients, and define the types of therapies typically administered to clients with defined problems.
Quality improvement (QI)/Performance improvement (PI)
describe an approach to the continuous study and improvement of the processes of providing health care services to meet the needs or clients and others
Outcomes Management
managing the individual clinical outcomes of clients as a result of prescribed treatments (used to conduct a formal measurement of system-level performance and effectiveness ex. # of hospital re-admissions, infection rates, # of missed appointments)