Key Terms- N210 Chapters 18-20 Unit 2

Front 1

Planning

Back 1

(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

Front 2

Priority setting

Back 2

the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions.

Front 3

High priority nursing diagnosis

Back 3

diagnoses that, if untreated, result in harm to the client or others. They can be either physiological or psychological

Front 4

Intermediate priority nursing diagnosis

Back 4

involve the non-emergent, non-life threatening needs of the client

Front 5

Low priority nursing diagnosis

Back 5

not always directly related to a specific illness or prognosis but affect the clients' future well-being.

Front 6

Initial planning

Back 6

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

Front 7

Ongoing Planning

Back 7

continuous updating of the clients' plan of care. as condition changes sometimes revise the initial plan of care and further individualize your interventions.

Front 8

Discharge panning

Back 8

involves critical anticipation and preparation for meeting the clients needs after discharge

Front 9

cognitive shift

Back 9

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.

Front 10

Goal

Back 10

is an aim, intent, or end. A broad statement that describes the desired change in a client's condition or behavior

Front 11

Expected outcomes

Back 11

measurable criteria to evaluate goal achievement, which you expect to occur in response to nursing care.

Front 12

Purpose of goals and expected outcomes

Back 12

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

Front 13

client-centered goal

Back 13

a specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function.

Front 14

short-term goal

Back 14

an objective behavior or response that you expect a client to achieve in a short time, usually less than a week

Front 15

Long-term goal

Back 15

an objective behavior or response that you expect a client to achieve over a longer period of time, usually several days, weeks, or months.

Front 16

nursing-sensitive client outcome

Back 16

an individual, family, or community state, behavior, or perception that is measurable along a continuum in response to a nursing intervention

Front 17

Guidelines for writing goals and expected outcomes

Back 17

client-centered, singular, observable, measurable, time-limited, mutual, and realistic

Front 18

Guidelines for writing goals- Client-centered

Back 18

write a goal to reflect client behavior, not to reflect nursing goals. ex. Client will ambulate in the hall 3 times a day

Front 19

Guidelines for writing goals- Singular

Back 19

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

Front 20

Guidelines for writing goals- Observable

Back 20

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

Front 21

Guidelines for Writing Goals- Measurable

Back 21

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

Front 22

Guidelines for Writing Goals- Time-limited

Back 22

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

Front 23

Guidelines for Writing Goals- Mutual Factors

Back 23

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

Front 24

Guidelines for Writing Goals- Realistic

Back 24

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.

Front 25

Independent Nursing Interventions

Back 25

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

Front 26

Dependent Nursing Interventions

Back 26

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

Front 27

Collaborative Interventions/interdependent interventions

Back 27

require the combined knowledge, skill, and expertise of multiple health care professionals.

Front 28

Selection of interventions

Back 28

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

Front 29

Nursing Care plan

Back 29

enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care.

Front 30

Student care plan

Back 30

useful for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care.

Front 31

Scientific Rationale

Back 31

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

Front 32

Institutional care plans

Back 32

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

Front 33

Critical Pathways

Back 33

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

Front 34

Consultation

Back 34

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.

Front 35

Implementation

Back 35

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

Front 36

nursing intervention

Back 36

any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes

Front 37

direct care interventions

Back 37

treatments performed through interactions with clients

Front 38

indirect care interventions

Back 38

treatments performed away from the client but on behalf of the client or group of clients

Front 39

Standing orders

Back 39

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.

Front 40

What should be done before implementation?

Back 40

reassessing the client, reviewing and revising the existing plan of care, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions

Front 41

Clinical Guideline

Back 41

a document that guides decisions and interventions for specific health care problems or conditions

Front 42

Reassessing the Client

Back 42

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.

Front 43

Reviewing and Revising the care Plan

Back 43

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.

Front 44

Preparing for Care

Back 44

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.

Front 45

Anticipate and Prevent Complications

Back 45

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

Front 46

Implementations Skills

Back 46

include: Cognitive skills, interpersonal skills, and pyschomotor skills.

Front 47

Cognitive Skills for Implementation

Back 47

involve the application of critical thinking in the nursing process. use good judgment and make sound clinical decisions. no intervention should be automatic.

Front 48

Interpersonal Skills for Implementation

Back 48

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.

Front 49

Direct Care

Back 49

Includes: Activities of Daily living, instrumental activities of daily living, physical care techniques, lifesaving measures, counseling, teaching, controlling adverse reactions, and preventive measures

Front 50

Activities of Daily Living-direct care

Back 50

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.

Front 51

Instrumental Activities of Daily Living-direct care

Back 51

skills such as shopping, preparing meals, writing checks, and taking medications. (occupational therapists are useful for training clients to adapt approaches with IADL)

Front 52

Physical Care Techniques-direct care

Back 52

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.

Front 53

Lifesaving measures- direct care

Back 53

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.

Front 54

Counseling-direct care

Back 54

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.

Front 55

Teaching-direct care

Back 55

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.

Front 56

Adverse reactions-direct care

Back 56

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.

Front 57

Preventive Measures-direct care

Back 57

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

Front 58

Indirect Care Measures

Back 58

Include communicating nursing interventions, and delegating, supervising, and evaluating the work of other staff members

Front 59

interdisciplinary care plan

Back 59

plans that represent the contributions of all disciplines caring for a client.

Front 60

Communicating Nursing interventions- indirect care

Back 60

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.

Front 61

Delegating, supervising, and evaluation of the work of other staff members

Back 61

Some care tasks may be delegated to other staff members, but the nurse is accountable for the care provided/not provided.

Front 62

Achieving goals

Back 62

Nursing care is implemented to meet client goals and outcomes

Front 63

Client adherence

Back 63

clients and families invest time in carrying out required treatments (another way to achieve goals)

Front 64

Evaluation

Back 64

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!

Front 65

Five Elements of the Evaluation Process

Back 65

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

Front 66

Evaluative Measures

Back 66

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

Front 67

Standard of Care

Back 67

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.

Front 68

Quality improvement (QI)/Performance improvement (PI)

Back 68

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

Front 69

Outcomes Management

Back 69

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)