Taylor - Fundamentals Of Nursing - Adn 1 Exam #3 Chapter 14- Outcome Identification And Planning

Front 1

During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to:

Back 1

•Establish priorities
•Identify and write expected patient outcomes
•Select evidence-based nursing interventions
•Communicate the plan of nursing care

Front 2

A patient outcome is

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an expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient’s health expectation.

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the phrase expected outcomes is used to refer to

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the specific, measurable criteria used to evaluate the extent to which a goal has been met.

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identification and planning allows nurses to:

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•Individualize care that maximizes outcome achievement
•Set priorities
•Facilitate communication among nursing personnel and their colleagues
•Promote continuity of high-quality, cost-effective care
•Coordinate care
•Evaluate the patient’s responses to nursing care
•Create a record that can be used for evaluation, research,reimbursement, and legal purposes
•Promote the nurse’s professional development

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The primary purpose of the outcome identification and planning step of the nursing process is to:

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design a plan of care for and with the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient’s health expectations,as identified in the patient outcomes.
Additionally, it specifies any routine nursing assistance the patient needs to meet basic human needs (e.g., assistance with hygiene or nutrition) and describes appropriate nursing responsibilities for fulfilling the collaborative and medical plan of care.

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Successful implementation of each step of the nursing process requires high-level skills in critical thinking. To plan healthcare correctly, the nurse must:

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•Be familiar with standards and agency policies for setting priorities, identifying and recording expected patientoutcomes, selecting evidence-based nursing interventions,and recording the plan of care •Remember that the goal of patient-centered care is to keept he patient and the patient’s interests and preferences central in every aspect of planning and outcome identification
•Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions?
•Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice
•Respect your clinical intuitions but before establishing priorities, identifying outcomes, and selecting nursing interventions be sure that research supports your plan
•Recognize personal biases and keep an open mind.

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Questions to facilitate critical thinking during planning and outcome identification include:

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•Setting priorities: Which problems require my immediate attention or that of the team? Which problems are my responsibility, and which should I refer to someone else?Which problems are most important to the patient?
•Identifying outcomes: What must I observe in the patient to demonstrate the resolution of the problems identified by the nursing diagnoses and general problem list? What is the time frame for accomplishing these outcomes? Do the outcomes need to be modified in light of the patient’s response (or lack of response) to the planned interventions?
•Selecting evidence-based nursing interventions: What do nursing science and my clinical experience suggest is the likelihood that this particular nursing intervention will help the patient realize his or her expected outcomes? How can I tailor my interventions to increase the likelihood of patient benefit? What is the worst thing that might happen with this intervention, how likely is it to happen, and what can I do to minimize the possibility of this harm?
•Communicating the plan of care: Does the plan of care adequately address the patient’s priorities today? If the plan of care is computerized or standardized, does it adequately address the specific needs of this particular patient? Can anyone reading the plan of care know how to intervene effectively with this patient?

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Comprehensive Planning:

In acute care settings, three basic stages of planning are critical to comprehensive nursing care:

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initial,
ongoing, and
discharge.

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Comprehensive Planning:

Initial Planning is developed by :

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the nurse who performs the admission nursing history and the physical assessment. This comprehensive plan addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care.

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Comprehensive Planning:

Ongoing Planning

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is carried out by any nurse who interacts with the patient. Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.
The nurse caring for the patient uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore,more effective. The work of ongoing planning includes:
stating nursing diagnoses more clearly (both the problem statement and the cause), developing new diagnoses,
making previously developed patient outcomes more realistic,
developing new outcomes as needed, and identifying nursing interventions that will best accomplish the patient goals.

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Comprehensive Planning:

Discharge Planning

Back 11

In acute care settings, comprehensive discharge planning begins when the patient is admitted for treatment.
Is best carried out by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources.
Ensures that the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carryout necessary self-care behaviors at home competently.

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Standardized care plans are:

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prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.
They can provide an excellent basis for the initial plan if the nurse individualizes them.

Front 13

Prioritizing patient problems :


Maslow’s hierarchy of human needs

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Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following hierarchy:
1.Physiologic needs
2.Safety needs
3.Love and belonging needs
4.Self-esteem needs
5.Self-actualization needs

Front 14

Prioritizing patient problems :

Patient Preference

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It is best to first meet the needs the patient thinks are most important, if this order does not interfere with other vital therapies.

Front 15

Outcomes are derived from:

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the problem statement of the nursing diagnosis. For each nursing diagnosis in the plan of care, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement.

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Problem Statement of Nursing Diagnosis: Pain Related Patient Goal/Outcome can be :

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Within 8 hours, patient will report pain is absent or diminished.

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Problem Statement of Nursing Diagnosis:

Imbalanced Nutrition: More Than Body Requirements


Related Patient Goal/Outcome can be :

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By 12/6/12, patient will reach target weight of 122 lb.

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Problem Statement of Nursing Diagnosis:

Impaired Physical mobility

Related Patient Goal/Outcome can be :

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Before discharge, patient will ambulate length of hallway independently.

Front 19

Outcomes might be either:

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long term or short term.
Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes. They also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular patient.

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Determining Patient Centered Outcomes

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Nurses need to be realistic and consider:

•Patient’s health state & overall prognosis
•Expected length of stay
•Growth and development
•Patient values and cultural considerations
•Other planned therapies for the patient
•Available human, material, and financial resources
•Risks, benefits, and current scientific evidence
•Changes in status that indicate you need to modify usual expected outcomes

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Outcomes might be categorized according to the type of change they describe for the patient. The three are:

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cognitive,
psychomotor, and
affective.

Front 22

Outcomes might be categorized according to the type of change they describe for the patient.

Cognitive changes

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Cognitive outcomes describe increases in patient knowledge or intellectual behaviors
—for example: “Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge.”

Front 23

Outcomes might be categorized according to the type of change they describe for the patient.

Psychomotor Changes

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Psychomotor outcomes describe the patient’s achievement of new skills
—for example, “By 6/12/12, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer.”

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Outcomes might be categorized according to the type of change they describe for the patient.

Affective changes

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Affective outcomes describe changes in patient values, beliefs, and attitudes.
Difficult both to write and to evaluate, affective outcomes might be critical to the resolution of a complex patient problem
—for example, “By 6/12/12, the patient wil lverbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.”
In this example, even if the patient intellectually grasps the reasons for taking care of her leg and can competently redress her ulcer,unless she is motivated to take care of herself, her knowledge and skills will not result in healthy outcomes.

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For Outcomes to be measurable, they should have the following:

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•SUBJECT: the patient or some part of the patient
•VERB: indicates the action the patient will perform
•CONDITIONS: specifies the particular circumstances in or by which the outcome is to be achieved. Not every outcome specifies conditions.
•PERFORMANCE CRITERIA: describe in observable, measurable terms the expected patient behavior or other manifestation
•TARGET TIME: specifies when the patient is expected to be able to achieve the outcome

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VERBS helpful in writing measurable outcomes include:

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Define
Prepare
Identify
Design
List
Verbalize
Describe
Choose
Explain
Select
Apply
Demonstrate

Front 27

In writing measurable outcomes, Target time or time criterion may be:

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a realistic, actual date or other statement indicating time, such as:
before discharge,
after viewing film,
whenever observed.

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examples of properly constructed measurable outcomes:

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•During the next 24-hour period, the patient’s fluid intake will total at least 2,000 mL.
•At the next visit, 12/23/12, the patient will correctly demonstrate relaxation exercises.

It might be helpful to include special conditions when writing an outcome if this information is important for other nurses (e.g., “Before discharge, the patient will ambulate independently the length of hallway and back, using a Philadelphia collar to support cervical vertebrae”).

Front 29

Common errors when writing patient outcomes include:
•Expressing the patient outcome as a nursing intervention.

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Incorrect: “Offer Mr. Myer 60 mL fluid every 2 hours while awake.”

Correct: “Mr. Myer will drink 60 mL fluid every 2 hours while awake, beginning 2/24/12.”

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Common errors when writing patient outcomes include:
•Using verbs that are not observable and measurable.

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Incorrect: “Mrs. Gaston will know how to bathe her new-born.”

Correct: “After attending the infant care class, Mrs. Gaston will correctly demonstrate the procedure for bathing her newborn.”

Verbs to be avoided when writing goals include:
“know,”
“understand,”
“learn,” and
“become aware.”
These verbs are too general and cannot be measured.

Front 31

Verbs to be avoided when writing goals include

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“know,”
“understand,”
“learn,” and
“become aware.”
These verbs are too general and cannot be measured.

Front 32

Common errors when writing patient outcomes include:
Including more than one patient behavior/manifestation in short-term outcomes.

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.Incorrect: “Patient will list dangers of smoking and stop smoking.”

Correct: “By next meeting, 3/11/12, the patient will:
(1) identify three dangers of smoking and

2) describe a plan he is willing to try to stop smoking.

By 6/20/12, the patient will report that he no longer smokes.”

Front 33

Common errors when writing patient outcomes include:
Writing outcomes that are so vague that other nurses are unsure of the goal of nursing care.

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Incorrect: “Patient will cope better.”

Correct: “After teaching, 10/20/12, the patient will:
(1) describe two new coping strategies he is willing to try and
(2) demonstrate decreased incidence of previously observed ineffective coping behaviors (chain smoking,withdrawal behavior, heavy alcohol consumption).”

Front 34

A nursing intervention is:

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any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes .
There are 3 types of intrerventions:
nurse-initiated,
physician-initiated, and
collaborative interventions..

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A nurse-initiated intervention is:

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an autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes.

Front 36

Nursing interventions are actions performed by the nurse to:

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1.Monitor health status
2.Reduce risks
3.Resolve, prevent, or manage a problem
4.Facilitate independence or assist with activities of daily living
5.Promote optimal sense of physical, psychological, and spiritual well-being .

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Nurse-initiated interventions do not require:

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a physician’s(or other team member’s) order.

Front 38

Nurse-initiated interventions, like patient goals, are derived from:

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the nursing diagnosis.

The PROBLEM statement of the diagnosis suggests the patient GOALS,

The cause of the problem (ETIOLOGY) that suggests the nursing INTERVENTIONS .

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The Nursing Outcomes Classification (NOC) presents

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the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing interventions.

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Identifying and Selecting Appropriate Nurse-Initiated Interventions:

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After writing the patient outcomes, the nurse IDENTIFIES various nursing interventions to help the patient ACHIEVE the outcomes.

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The Nursing Intervention Classification (NIC) is:

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the first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties.
It greatly facilitates the work of identifying appropriate interventions.

Front 42

Nursing interventions should be:

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•Appropriate in terms of the nursing diagnosis and related patient outcomes, safe and efficient.
•Consistent with research findings and standards of care
•Realistic in terms of the abilities, time, and resources available to the nurse and patient.
•Compatible with the patient’s values, beliefs, and cultural and psychosocial background.
•Valued, whenever possible, by the patient and family.
•Compatible with other planned therapies.

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nurses need to answer four key questions if they want to determine if individualized evidence-based interventions will achieve desired outcomes and what the risks involved will be:

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1.What can be done to prevent or minimize the risks or causes of this problem?
2.What can be done to manage the problem?
3.How can I tailor interventions to meet expected outcomes?
4.How likely are we to get desired versus adverse responses to the interventions, and what can we do to reduce the risks and increase the likelihood of beneficial responses?

Front 44

Each nursing intervention should include:

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•Date
•Verb: Action to be performed
•Subject: Who is to do it
•Descriptive phrase: How, when, where, how often, how long, or how much.

Front 45

Well-written nursing interventions accomplish the following:

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•Assist the patient to meet specific outcomes that are related directly to one outcome
•Clearly and concisely describe the nursing action to be performed (answer the questions: who,
what,
where,
when, and
how)
•Are dated when written and when the plan of care is reviewed
•Are signed by the nurse prescribing the order or intervention
•Use only those abbreviations accepted in the institution(these are usually found in the agency’s policy manual
•Refer the nurse to the agency’s procedure manual or other literature for the steps of routine, lengthy procedures.

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Comprehensive nursing interventions specify:

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what observations (assessments) need to be made and how often,
what nursing interventions need to be done and when they must be done, and
what teaching, counseling,and advocacy needs patients and families have.

Many sets of nursing interventions are inadequate because they fail to indicate the ongoing assessment priority needs for a specific problem or goal.

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A physician-initiated intervention is:

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an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a doctor’s order.

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Nurses who question the appropriateness of physician-initiated interventions are:

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legally responsible to seek clarification of the order with responsible parties.
Under no circumstances should a nurse implement a questionable intervention, even at the urging of a physician or other professional.

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Structured Care Methodologies:

•Procedure:

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A set of how-to action steps for performing a clinical activity or task.

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Structured Care Methodologies:
Standard of care:

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A description of an acceptable level of patient care or professional practice.

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Structured Care Methodologies:
Algorithm:

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A set of steps that approximates the decision process of an expert clinician and is used to make a decision; these clinical rules are typically embedded in a branching flow chart

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Structured Care Methodologies:
Clinical practice guideline:

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A statement or series of statements outlining appropriate practice for a clinical condition or procedure

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Consultation is:

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a process in which two or more individuals with varying degrees of experience and expertise discuss a problem and its solution.

Front 54

The plan of nursing care(patient care plan) is:

Back 54

the written guide that directs the efforts of the nursing team as nurses work with patients to meet their health goals.
It specifies:
nursing diagnoses,
outcomes, and
associated nursing interventions.
It ensure that the nursing team works efficiently to deliver holistic, goal-oriented, individualized care to patients

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The plans of care, regardless of their format, communicate directions for three different types of nursing care:

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nursing care related to basic human needs, nursing care related to nursing diagnoses, and nursing care related to the medical and interdisciplinary plan of care.

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NURSING CARE RELATED TO BASIC HUMAN NEEDS:

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The plan should concisely communicate to caregivers the data about the patient’s usual health habits and patterns,obtained during the nursing history, that are needed to direct daily care.

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NURSING CARE RELATED TO NURSING DIAGNOSES:

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The plan contains outcomes and nursing interventions for every nursing diagnosis, as well as a place to note the patient’s responses to care. This section is the heart of the nursing care plan because it represents the independent component of nursing practice.

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NURSING CARE RELATED TO THE MEDICAL AND NTERDISCIPLINARY PLAN OF CARE:

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The plan of care records current medical orders for diagnostic studies and treatment and specified related nursing care.

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Kardex care plan:

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trade name for a care plan documentation system that encompasses:
(1) prescriptions for nursing care related to activities of daily living;
(2) nursing diagnoses and related patient goals and nursing orders; and
(3) the nursing care related to diagnostic measures and the medical regimen.

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Computerized plans of nursing care:

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plans of patient care developed by computer software programs that enable the nurse to call up screens listing causes, goals, and related nursing interventions for nursing diagnoses and medical diagnoses.

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Clinical pathway/critical path/Care Map:

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case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients;
care guidelines and outcomes are specified for each day of the patient’s stay.

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concept map care plan is:

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a diagram of patient problems and interventions.
Your ideas about patient problems and treatments are the “concepts” that are diagrammed.
These maps are used to organize patient data, analyze relationships in the data, and enable you to take a holistic view of the patient’s situation.