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64 Cards in this Set
- Front
- Back
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What are the 4 basic steps to Planning? |
-Prioritize problems/ diagnoses
-Formulate goals/desired outcomes -Select nursing interventions -Write nursing interventions (Slide 31) |
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Define Planning
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-Deliberate, systematic, problem-solving phase of nursing process
(Slide 32 p. 215) |
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Who is involved in planning?
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It is multidisciplinary- all health care provider’s interacting with the client
(Slide 32 p. 215) |
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Who Decides on nursing interventions?
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-Nurse responsible, but input from client essential
(Slide 32) |
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When does nursing interventions Begin?
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-with first client contact and is an ongoing process
(Slide 32) |
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When does nursing interventions end?
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Continues until nurse-client relationship ends (discharge)
(Slide 32) |
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What is Initial Planning and when does it happen?
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-Develops initial comprehensive plan of care
-Begun after initial assessment (Slide 33)p.215 |
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What is Ongoing Planning, when does it happen, and who does it?
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-Done by all nurses who work with the client
-Individualization of initial care plan -Also occurs at the beginning of a shift (Slide 33)p.215 |
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What is Discharge Planning?
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-Process of anticipating and planning for needs after discharge
(Slide 34)p.215 |
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Where is Discharge Planning Addressed?
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- in each client’s care plan
(Slide 34)p.215 |
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When does Discharge Planning Begin?
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-at first client contact
(Slide 34)p.215 |
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What does Discharge Planning Involve?
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-comprehensive and ongoing assessment
(Slide 34)p.215 |
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What are the 4 types of care plans used for Developing Nursing Care Plans?
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-Informal
-formal -Standardized -Individualized (Slide 35)p.215 |
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Define Informal nursing care plan
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A strategy for action that exists in nurse’s mind
(Slide 35)p.215 |
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Define Formal nursing care plan
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Written or computerized guide
(Slide 35)p.215 |
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Define Standardized care plan
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A formal plan that specifies actions for a group of clients with common needs
(Slide 35)p.215 |
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Define Individualized care plan
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Tailored to meet the unique needs of a specific client
(Slide 35)p.215 |
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Describe the 6 components to Standards of Care
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-Describe nursing actions for clients with similar medical conditions
-Describe achievable rather than ideal nursing care -Define interventions for which nurses are accountable -Usually agency records that may be referred to in client’s care plan -Written from the perspective of the nurse’s responsibilities -Do not contain medical interventions (Slide 36)p.216 |
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What do Protocols Indicate?
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actions commonly required for a particular groups of clients
(Slide 37)p.217 |
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What may protocols include?
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May include both primary care provider’s orders and nursing interventions
Example: protocol for admitting a client to the intensive care unit (Slide 37)p.217 |
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What are Policies and Procedures?
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-Developed to govern handling of frequently occurring situations
-Cover situations pertinent to client care Example: policy specifying the number of visitors a client may have (Slide 38)p.217,218 |
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What is a Standing Order
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-Written document
---Policies ---Rules ---Regulations ---Orders regarding patient care -Gives the nurse authority to carry out specific actions under certain circumstances (Slide 39)p.219 |
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Why is Individualization of Standardized Care Plans done?
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Individualized to fit the unique needs of each client
(Slide 40)p.219 |
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When Individualization of Standardized Care Plan is done what does it Usually consist of?
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-Individual plan for unusual problems or problems needing special attention
-both pre-authored and nurse-created sections (Slide 40)p.219 |
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Why do we use Standardized care plans?
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-for predictable, commonly occurring problems
(Slide 40)p.219 |
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Name 4 Formats for Nursing Care Plans
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-Student care plans, rationales
-Concept maps -Computerized care plans -Multidisciplinary (collaborative) care plans ---Also called critical pathways (Slide 41)p.219 |
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The Planning Process Consists of what 4 activities?
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-Setting priorities
-Establishing client goals/desired outcomes -Selecting nursing interventions -Writing individualized nursing interventions on care plans (Slide 42)p.221 |
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In the planning process what is Setting Priorities?
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-Establishing a preferential sequence for addressing nursing diagnoses and interventions
(Slide 43)p.221 |
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What are the 3 priority levels name and define?
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-High priority (life-threatening)
-Medium priority (health-threatening) -Low priority (developmental needs) (Slide 43)p.221 |
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What 5 Factors need to be considered about the client When Setting Priorities?
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-Client’s health values and beliefs
-Client’s priorities -Resources available to nurse and client -Urgency of the health problem -Medical treatment plan (Slide 44)p.221 |
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What are Goals?
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- broad statements about the client’s status
(Slide 45)p.222,223 |
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What are Desired Outcomes?
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- more specific (than goals), observable criteria used to evaluate whether goals have been met
(Slide 45)p.222,223 |
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What is the Purpose of Desired Goals/ Outcomes?
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-Provide direction for planning interventions
-Serve as criteria for evaluating progress -Enable the client and the nurse to determine when the problem has been resolved -Help motivate the client and nurse by providing a sense of achievement (Slide 46)p.224 |
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What is the Relationship of Desired Goals/ Outcomes to Nursing Diagnosis?
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-Goals and desired outcomes are derived from diagnostic label
-Diagnostic label contains the unhealthy response (problem) -Goal is opposite, healthy response -How client will look or behave if health response is achieved (observable, time limited) -Achieving goal demonstrates resolution of the problem (Slide 47)p.224 |
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What are the Components of Goal/Desired Outcome Statements?
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-Subject
-Verb -Condition or modifier -Criterion of desired performance (Slide 48)p.225 |
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What are 6 Guidelines for Writing Goals/Desired Outcomes
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-Write in terms of client responses
-Must be realistic -Ensure compatibility with therapies of other professionals -Derive from only one nursing diagnosis -Use observable, measurable terms -Make sure client considers goals important (Slide 49)p.225-227 |
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Define Nursing Interventions and Activities
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Actions nurse performs to achieve goals
(Slide 50)p.227 |
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What does Nursing Interventions and Activities Focus on?
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-eliminating or reducing etiology of nursing diagnosis
-Treat signs and symptoms and defining characteristics -Interventions for risk nursing diagnoses should focus on reducing client’s risk factors (Slide 50)p.227 |
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What are the 3 Types of Nursing Interventions?
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-Independent interventions
-Dependent interventions -Collaborative interventions (Slide 51)p.227 |
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Define Independent interventions
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-Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
(Slide 51)p.227 |
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Define Dependent interventions
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-Activities carried out under primary care provider’s orders or supervision, or according to specified routines
(Slide 51)p.227 |
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Define Collaborative interventions
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-Actions nurse carries out in collaboration with other health team members
-Reflect overlapping responsibilities of health care team (Slide 51)p.227 |
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What are the 6 Criteria for Choosing Appropriate Interventions?
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-Safe and appropriate for the client’s age, health, and condition
-Achievable with the resources available -Congruent with the client’s values, beliefs, and culture -Congruent with other therapies -Based on nursing knowledge and experience or knowledge from relevant sciences -Within established standards of care (Slide 52)p.228 |
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Basic things to remember when Writing Individualized Nursing Interventions?
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-Date when they are written
-Verb--Action verb starts the interventions and must be precise -Conditions -Modifiers -Time element--How long or how often the nursing action is to occur (Slide 53)p.228 |
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When is Delegating Implementation done?
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-Delegation occurs during planning
-Who does each task is decided (Slide 54)p.229 |
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Who is responsible for delegation tasks?
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-Nurse is responsible for correct implementation of task delegated, analysis of data, and evaluation of outcome
(Slide 54)p.229 |
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The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following?
A. Hospital policies B. Standardized care plans C. Orthopedic protocols D. Standards of care |
*A. Correct. Policy and procedure documents provide data about how certain situations are handled. Note: Even hospital policies are not absolute. Each situation must be analyzed and responded to individually.
B. Standardized care plans are written for groups of clients with similar medical or nursing diagnoses. They generally do not address questions such as hospital routines and nonmedical client needs. C. Orthopedic protocols would address elements specifically associated with the surgery. D. Standards of care are written for groups of clients with similar medical or nursing diagnoses. They usually do not address hospital routine or nonmedical client needs. |
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The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when aroused. The client’s pain is 2 on a scale of 0 to 10; vital signs are within preoperative range; extremities are warm with good pulses but very dry skin. The client declines oral fluids due to nausea and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element would likely be high priority for the current care plan?
A. Pain B. Nausea C. Constipation D. Potential for wound infection |
A. The client’s pain level is not extreme considering his recent surgery, and pain intervention can be assumed to be effective.
*B. Correct. A more detailed assessment data and consultation with the client would be needed to confirm the priority. Postoperative nausea that inhibits oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. C. Although the constipation is probably bordering abnormal, nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. D. Wound infection can occur but there are no data to indicate that this requires a change in the current plan. |
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The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and a surgical incision. Which of the following represents a properly stated outcome/goal? The client will:
A. Turn in bed q2h. B. Report the importance of applying lotion to skin daily. C. Have healthy intact skin during hospitalization. D. Use a pressure-reducing mattress |
A. Turning in bed is an intervention that may result in achieving the goal, but the goal or outcome should state the opposite of the nursing diagnosis stem.
B. The goal or outcome should state the opposite of the nursing diagnosis stem. Applying lotion is an intervention that may help in achieving the goal. *C. Correct. The goal or outcome should state the opposite of the nursing diagnosis stem; healthy intact skin is the opposite of impaired skin integrity. D. The goal or outcome should state the opposite of the nursing diagnosis stem. Using a pressure-reducing mattress is an intervention that may result in achieving the goal. |
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The care plan includes a nursing intervention “4/2/11 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted?
A. Action verb B. Content C. Time D. None |
A. Incorrect. In the sentence, “measure” is an action verb.
B. Incorrect. Content is not missing. *C. Correct. Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done “routinely” or at specific intervals (e.g., q4h). However, critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings. D. Incorrect. A time element was missing. |
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Which of the activities is a part of the planning outcomes phase of the nursing process?
A. Formulating a nursing diagnosis B. Analyzing client data C. Developing client goals D. Carrying out a nursing order |
Answer: C
Rationale: The nurse analyzes data and formulates diagnoses in the diagnosis stage. The nurse carries out nursing orders in the interventions stage. |
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When should discharge planning begin for a patient?
A. On admission B. The day before discharge C. 24 hours after admission D. The morning of discharge |
Answer: A
Rationale: Because most patients are in the hospital for only a short time, it is essential to begin discharge planning on admission and continue it until the patient leaves the agency. As a rule, discharge is not the end of the illness episode for the patient, but the transition to another phase of it. Research shows that discharge planning can reduce complications and readmissions (Dedhia, P., 2009). (Schneider et al., 1993). |
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After collecting data and formulating the nursing diagnoses, what is the next step for the nurse?
A. Plan the client’s care. B. Carry out the nursing orders. C. Implement the medical plan. D. Evaluate the client’s progress |
Answer: A
Rationale: The next step is to plan the client’s care. The stages of the nursing process, in order, are: assessment, diagnosis, planning, implementation, and evaluation. |
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Ideally, who should write the initial plan of care? The nurse who:
A. Performs the initial assessment B. Is in charge of the unit C. Has the most education D. Has the most experience |
Answer: A
Rationale: The nurse who interviews the client has the advantage of personal contact and is best prepared for planning the client’s care. |
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Who is responsible for ongoing planning?
A. The admitting nurse B. The nurse who wrote the initial care plan C. Any nurse caring for the patient D. The nurse in charge of the unit |
Answer: C
Rationale: Ongoing planning is done as new information is obtained and as the patient’s responses to care are evaluated. A patient usually has two or three different nurses caring for him in a 24-hour period. The care plan should be changed as soon as new interventions are required. It might be several days before the admitting nurse or the charge nurse care for the patient again. The person who makes the ongoing assessment is in the best position to alter the care plan. |
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This goal appears on a care plan: “Client will name four basic food groups, giving at least two examples of foods in each group.” Which category of skills does this goal address?
A. Affective B. Cognitive C. Psychomotor D. Spiritual |
Answer: B
Rationale: This goal focuses on thinking and learning—an intellectual skill. Affective skills are concerned with feelings/emotions. Psychomotor skills are concerned with doing, with body movement or processes. “Spiritual” is not one of the defined domains for behavioral learner objectives. |
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This goal appears on a care plan: “Will ambulate with a walker by 5/1.” What is wrong
with the goal? It has no: A. Client behavior. B. Target time. C. Special conditions. D. Performance criteria. |
Answer: D
Rationale: This goal has no performance criteria. It should state how far or how long the client is to ambulate. “Will ambulate” is the client behavior. “5/1” is the target time. “with a walker” is the special condition, or assistance, the client needs in order to ambulate. |
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What is wrong with this outcome criterion? “Client will be able to climb one flight of stairs without shortness of breath.”
A. No target time if given. B. It is not measurable. C. Behavioral terms are not used. D. It is too general (nonspecific). |
Answer: A
Rationale: There is no target time in this goal. The outcome criterion is measurable; it is stated behaviorally; and it is specific, not general. |
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“Patient will establish normal bowel elimination pattern within new month.” What is this an example of?
A. Nursing diagnosis B. Nursing order C. Short-term goal D. Long-term goal |
Answer: D
Rationale: This is a long-term goal. Long-term goals describe changes in client outcomes over a longer period—usually a week or more. The ideal long-term goal aims at restoring normal functioning in the problem area. A diagnosis is a statement of a patient problem and the etiology of the problem. A nursing order contains directions for the nurse’s activities. Short-term goals should be achievable in a matter of hours or days (usually 2 weeks or even less). |
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Which of the following is a client goal?
A. Turn every 2 hours B. Chest congestion C. Temperature 100o F D. No dyspnea on exertion |
Answer: D
Rationale: “No dyspnea on exertion” is a client goal. “Turn every 2 hours” is a nursing order. “Chest congestion” is client data, as is “Temperature 100o F.” As a goal, that should say “Temperature will be less than 100o F.” |
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The following statement appears on a care plan: “After the first teaching session the
client will correctly demonstrate use of the glucose meter.” What is this statement an example of? A. Short-term goal B. Long-term goal C. Nursing order D. Nursing diagnosis |
Answer: A
Rationale: This is a short-term goal. It describes desired client behaviors, achievable in a few minutes or hours. Long-term goals usually extend over several days, weeks, or longer. Nursing orders describe nurse, not client, activities. A nursing diagnosis describes a problem and its etiology. |
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Which predicted outcome is correctly written?
A. The client will be adequately hydrated. B. The client will lose 5 lbs within 2 weeks. C. The nurse will provide emotional support. D. The client will walk better. |
Answer: B
Rationale: “The client will lose 5 lbs within 2 weeks” has all the necessary components, and it is observable. “Adequately hydrated” is not observable, and the outcome has no target time. “The nurse will provide emotional support” directs nurse, not client, activities; so it is a nursing order. “The client will walk better” has no target time and is not specific or measurable; “better” could be interpreted differently by different nurses. |
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The following statement appears on a care plan: “Client will name four basic food
groups, giving at least two examples of foods in each group.” What does this statement represent? A A. Nursing diagnosis B. Collaborative order C. Client goal D. Nursing order |
Answer: C
Rationale: The statement is a client goal; it states a desired, observable client behavior. A nursing diagnosis states a problem and its etiology. A collaborative order would direct nurse rather than client activities, as would a nursing order. |
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Which of these is a specific, measurable predicted outcome?
A. Has daily bowel movement beginning on 10/21 B. Understands diabetic diet by dismissal C. Regains optimum state of health by 10/21 D. Achieves good post-op recovery by day 7 |
Answer: A
Rationale: The specific, measurable predicted outcome is, “Has daily bowel movement beginning on 10/21.” “Understands” is not observable; “states understanding” or “demonstrates understanding, as evidenced by. . .” would be observable. “Optimum state of health” could mean many different things to many people. “Good” recovery is not measurable and is open to many Interpretations. |
