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what diagnoses are the highest priority?

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Nursing diagnoses that, if untreated, result in harm to a patient or others (e.g., those related to airway status, circulation, safety, and pain) have the highest priorities

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classification of priorities:

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-High—Emergent -Intermediate—non-life-threatening -Low—Affect patient's future well-being

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Fulmala is a first semester nursing student who is assigned to Ms. Nadine Skyfall, a 35-year-old American Indian patient diagnosed with severe anemia secondary to a bleeding peptic ulcer. Ms. Skyfall experiences pain because of the ulcer and weakness and fatigue resulting from the anemia. Fulmala develops Ms. Skyfall's plan of care, which addresses pain, weakness, fatigue, nutrition, and patient safety.

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Nursing care plans do not directly address the medical diagnosis

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A broad statement that describes the desired change in a patient's condition, perceptions, or behavior An aim, intent, or end

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goal

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reflects a patient's specific behavior, not your own goals or interventions. It is important to select and measure patient outcomes that are influenced by nursing care.

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A patient-centered goal or outcome

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represents predicted resolution of a diagnosis or problem, evidence of progress toward resolution, progress toward improved health status, or continued maintenance of good health or function

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patient goal

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A measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

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Nursing-sensitive patient outcome

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is a resource that can be used in selecting goals and outcomes for your patients. links outcomes to NANDA-I nursing diagnoses

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nursing outcomes classification

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when writing goals and expected outcomes what should u do?

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Must be patient-centered Use SMART acronym -Specific -Measurable -Attainable -Realistic -Timed

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is an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting, you often set goals for over a course of just a few hours.

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short term goal

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

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long- term goal

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. A patient is suffering from shortness of breath. The correct goal statement would be written as: A. the patient will be comfortable by the morning. B. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. the patient will not complain of breathing problems within the next 8 hours. D. the patient will have a respiratory rate of 14 to 18 breaths per minute.

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Answer: B

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are treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes

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nursing interventions

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require no order and no supervision or direction from others. they are autonomous actions based on scientific rationale. Such interventions benefit a patient in a predicted way related to nursing diagnoses and patient goals

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Nurse-initiated interventions independent

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require specific nursing responsibilities and technical nursing knowledge. These interventions are based on the health care provider's response to treat or manage a medical diagnosis. Each of these interventions requires nursing responsibilities and technical nursing knowledge.

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Health care provider-initiated interventions dependent

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Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals

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collaborative

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When preparing for physician-initiated or collaborative interventions what do you do?

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do not automatically implement the therapy, but determine whether it is appropriate for the patient.

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Fulmala develops Ms. Skyfall's plan of care, including writing the goals and expected outcomes. Fulmala knows that the guidelines for writing goals and expected outcomes include that they be measurable, time-limited, observable, and realistic. What are the rest of the seven guidelines for writing goals and expected outcomes

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The seven guidelines for writing goals and expected outcomes are patient-centered, singular goals or outcomes; they are observable, measurable, and time-limited with mutual factors, and they are realistic

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6 factors to consider when selecting an intervention

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-Desired patient outcomes -Characteristics of the nursing diagnosis -Research-based knowledge for the intervention -Feasibility of the interventions -Acceptability to the patient -Nurse's competency

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Correctly written nursing interventions include

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actions, frequency, quantity, method, and the person to perform them.

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Fulmala knows that _________________ interventions require an order from a physician or another health care professional What type of interventions require an order from a physician or other health care professional?

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Dependent nursing interventions are actions that require an order from a physician or other health care professional

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The plan gives all nurses a central document that outlines a patient's what??

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diagnoses/problems, the plan of care for each diagnosis/problem, and the outcomes for monitoring and evaluating patient progress.

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focuses on patient priorities and improves the coordination of all patient therapies and communication among all disciplines.

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interdisciplinary care plan

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nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions.

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hands off reporting

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are useful for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care. The plan also helps you to apply theory you learned. Most commonly, a column format is used.

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student care plan

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A five-column format includes :

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(1) assessment data relevant to corresponding diagnosis, (2) goals/outcomes identified for the patient, (3) implementation of the plan of care, (4) a scientific rationale (the reason that you chose a specific nursing action, based on supporting evidence), and (5) a section to evaluate your care. In the implementation section, you select interventions appropriate for the patient.

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The following questions help you design a plan:

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-What is the intervention, and is it evidence based? -When should each intervention be implemented? -How should the intervention be performed for this specific patient? -Who should be involved in each aspect of intervention?

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For care plans in community-based settings, you design a plan to:

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(1) educate the patient/family about necessary care techniques and precautions, (2) teach the patient/family how to integrate care within family activities, and (3) guide the patient/family on how to assume a greater percentage of care over time. Finally, the plan includes nurses' and the patient's/family's evaluation of expected outcomes.

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are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially.

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critical pathways defines transition points in patient progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficiently as poble.

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what is the main purpose of critical pathways?

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to deliver timely care at each phase of the care process for a specific type of patient.

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Fumala writes down several independent nursing interventions that she is developing for Ms. Skyfall.

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Independent nursing interventions do not require an order from another health care professional. Examples of independent nursing interventions include patient positioning and education

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When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a: A. critical pathway. B. nursing care plan. C. concept map. D. diagnostic label.

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Answer: C Rationale: As noted above, concept maps help the nurse organize nursing interventions for a patient with multiple problems.

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is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies

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Consultation

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at what step does consultation take place

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can occur during any but mainly during planning and implementation

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occurs when you identify a problem that you are unable to solve using personal knowledge, skills, and resources.

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Consultation

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When and How to Consult

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When: The exact problem remains unclear How: Begin with your understanding of the patient's clinical problem. Direct the consultation to the right professional. Provide the consultant with relevant information about the problem area: summary, methods used to date, and outcomes Do not influence consultants. Be available to discuss the consultant's findings. Incorporate the suggestions.

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Fumala's clinical coordinator tells her to coordinate with a nutritionist to develop a meal plan for Ms. Skyfall. Would Fumala's working with a nutritionist be considered a collaborative intervention?

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Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals

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Consultation occurs most often during which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation

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Answer: C Rationale: When a nurse is unsure of how to proceed in the planning process, he or she will seek out another colleague's knowledge and experience to assist in planning interventions for the patient.

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