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29 Cards in this Set

  • Front
  • Back
Describe the essential
aspects of the planning
phase of the nursing
process
The planning phase involves
the following activities:
a. setting priorities
b. establishing goals
(objective)
c. establishing oucome
criteria
d. writing a plan of action
(nursing orders)
e. developing a nursing care
plan
Nursing goal
Goals are stated in terms of
anticipated client outcomes
not in terms of nursing
activities. Can be short term
or long term. Objective,
measurable, and realistic,
with an established time
period for achievement of the
outcome.
Short term goal
Focused on the immediate
needs of the patient.
Most goals are short term.
We only see patients for
usually maximum 3 days/48 hrs.
Long term goal
Usually achieved over a couple
of weeks, months, years. What
happens when the patient
leaves or is discharged.
Nurse educates on long term
goal when d/c.
Self care goal
"What the client will do"
specific and measurable behavior
or response
Dependent care goal
"What others (family/s.o./
friends/nurses) will do. Often
because the client is unable
to participate.
Identify criteria that
helps the nurse and
client set priorities
Each problem that has been
identified in dx is assigned
a rating - high, medium, low.
This is a nursing judgement,
but it must also include the
client's view on urgency.
High priority
Protects clients basic needs of
safety, adequate oxygenation,
and comfort
Intermediate/medium
priority
Non-emergent, non-life
threatening needs of the client
Low priority
May not be directly related to a
specific illness or prognosis
but may affect the clients
future well-being
Describe how to prioritize
Orem's universal,
developmental, and self
care requisites

HIGH
High priority: Development
self-care requisites –
associated with human
developmental process and
conditions and events that
occur during various stages of
the life cycle as well as
with events that may adversely
affect development
INTERMEDIATE
Intermediate priority:
Universal self-care
requisites – associated with
life processes and maintenance
of the integrity of human
structure and function.
LOW
Low-priority: Health
deviation self-care requisites
– associated with genetic and
constitutional defects and
human structural and
functional deviations and
their effects, as well as with
medical diagnostic and
treatment measures prescribed
by physicians.
Describe the relationship
of goals to the nursing
diagnosis
Client goals are derived from
the first clause of the
nursing dx, i.e., from the
problem statement, and they
form the basis of evaluation
criteria. The second clause
of the nursing dx guides the
actions of the nurse, i.e.,
the nursing goals.
Differentiate between
goals and outcome
criteria
Outcome = the end to which a
design tents or which a person
aims to reach or accomplish.
A broad or globally written
statement describing the
intended or desired change in
the clients' behavior,
response, or outcome.
Realistic, Murually desired
by the client and nurse, and
attainable within a defined
time period.
Goals
Goal = aim of a maneuver or
operation. Detailed, specific
statement describes the method
thru which the outcome will
be achieved.
State the purpose of
expected (projected) outcomes
and the rationale for the
outcomes being stated in
measurable terms (evaluation
criteria)
An expected outcome is a
specific measurable change in
a client’s status that is
expected to occur in response
to nursing care. Goals and
expected outcomes are written
to give nurse a standard
against which to measure the
client’s response to nursing
care. A goal or an outcome
that is stated in measurable
terms allows the nurse to
objectively quantify changes
in the client’s status
Give an exp. of an expected
outcome to include:
achievement of self care
requisite
Nursing dx: risk for
ineffective airway clearance
related to abd incision pn.
Goals: client will maintain
patent airway through post op
period to d/c
Expected outcome: lungs will
be clear to auscultation
within 48 hours postoperatively
Define planning in regards
to nursing process
Category of nursing behaviors
in which client centered
expected outcomes and criteria
are established and nursing
interventions are selected
to achieve the goals of care.
Purpose for expected
pt outcomes with specific
criteria
1. Provide direction for
individualized nursing
interventions.
2. Set standards for determining
the effectiveness of the
interventions (pt teaching,
making them independent)
Client centered
Specific and measurable
behavior that reflects the
most that the client can do
(highest level).
exp. Pt will walk 10 min without
assist up hall b.i.d.
Singular factors
One behavior at a time.
Specific.
exp. Turn q 2h and prn
Observable factors
Rn or family observe to notice
if a change happens.
exp. Pt ate food on own without
assist.
Measurable
standard measure of response
Time limited
when expected behavior should
occur
Mutual factors
shared, goals/outcomes client
and RN agree to
Realistic
Attainable, shared
goals/outcomes client
and RN agree to
Types of interventions
Independent - nurse initiated
intervention, scope of practice
assessment, teaching
Dependent - physician initiated
giving meds
Collaborative - PT, OT,
dietician, can call and get
others to help
Benefit of nursing
care plan
Sets priorities, interventions,
legitimizes nurses, focused,
date when active and resolved.