N400 Nursing Process

Front 1

Describe the essential
aspects of the planning
phase of the nursing
process

Back 1

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

Front 2

Nursing goal

Back 2

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.

Front 3

Short term goal

Back 3

Focused on the immediate
needs of the patient.
Most goals are short term.
We only see patients for
usually maximum 3 days/48 hrs.

Front 4

Long term goal

Back 4

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.

Front 5

Self care goal

Back 5

"What the client will do"
specific and measurable behavior
or response

Front 6

Dependent care goal

Back 6

"What others (family/s.o./
friends/nurses) will do. Often
because the client is unable
to participate.

Front 7

Identify criteria that
helps the nurse and
client set priorities

Back 7

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.

Front 8

High priority

Back 8

Protects clients basic needs of
safety, adequate oxygenation,
and comfort

Front 9

Intermediate/medium
priority

Back 9

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

Front 10

Low priority

Back 10

May not be directly related to a
specific illness or prognosis
but may affect the clients
future well-being

Front 11

Describe how to prioritize
Orem's universal,
developmental, and self
care requisites

HIGH

Back 11

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

Front 12

INTERMEDIATE

Back 12

Intermediate priority:
Universal self-care
requisites – associated with
life processes and maintenance
of the integrity of human
structure and function.

Front 13

LOW

Back 13

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.

Front 14

Describe the relationship
of goals to the nursing
diagnosis

Back 14

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.

Front 15

Differentiate between
goals and outcome
criteria

Back 15

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.

Front 16

Goals

Back 16

Goal = aim of a maneuver or
operation. Detailed, specific
statement describes the method
thru which the outcome will
be achieved.

Front 17

State the purpose of
expected (projected) outcomes
and the rationale for the
outcomes being stated in
measurable terms (evaluation
criteria)

Back 17

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

Front 18

Give an exp. of an expected
outcome to include:
achievement of self care
requisite

Back 18

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

Front 19

Define planning in regards
to nursing process

Back 19

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.

Front 20

Purpose for expected
pt outcomes with specific
criteria

Back 20

1. Provide direction for
individualized nursing
interventions.
2. Set standards for determining
the effectiveness of the
interventions (pt teaching,
making them independent)

Front 21

Client centered

Back 21

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.

Front 22

Singular factors

Back 22

One behavior at a time.
Specific.
exp. Turn q 2h and prn

Front 23

Observable factors

Back 23

Rn or family observe to notice
if a change happens.
exp. Pt ate food on own without
assist.

Front 24

Measurable

Back 24

standard measure of response

Front 25

Time limited

Back 25

when expected behavior should
occur

Front 26

Mutual factors

Back 26

shared, goals/outcomes client
and RN agree to

Front 27

Realistic

Back 27

Attainable, shared
goals/outcomes client
and RN agree to

Front 28

Types of interventions

Back 28

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

Front 29

Benefit of nursing
care plan

Back 29

Sets priorities, interventions,
legitimizes nurses, focused,
date when active and resolved.