CH 5 Nursing Process: Planning Outcomes – Flashcards

A. Long-Term Goal B. Short-Term Goal C. Short-Term Goal D. Short-Term Goal

B. Omaha System

B. Wellness goal Rationale: This is a wellness goal because the patient response is maintenance of the current healthy status of his weight

A. Initial. Done for the purpose of identifying patient problems and developing the care plan B. Ongoing. Revising and individualizing the client's plan of care as new data are obtained C. Discharge. Planning for the client's healthcare needs upon leaving the institution or transitioning to another level of care D. Formal. A conscious, deliberate activity involving decision making, critical thinking, and creativity E. Informal. Making mental notes or plans

True

False

True

True

process outcomes

problem

critical pathways

realistic

1) Written for a specific medical diagnosis or treatment 3) A description of minimal level of care a patient is expected to receive Rationale: Unit standards describe the minimal level of care the nurses are expected to achieve. They are not kept in the patient's chart but are kept in a file on the unit. Protocols are written to cover specific medical diagnoses and treatments. Unit standards are not organized according to nursing diagnoses.

2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication Rationale: Outcome criteria should be stated with specific measurement criteria; the pain outcome is the most specific and measurable or observable. "Use incentive spirometer" should specify how long and how often. "Increase the distance" should say how much he should increase the difference and what the baseline distance is. "Verbalize side effects" should specify by what date the patient is expected to do this.

2) Activities of daily living Rationale: NOC outcomes are broad neutral labels, not goal statements; the physical activity and strength outcomes are specific goals because they use the word increase, implying a target behavior. The adaptive equipment outcome includes the word appropriate, implying a judgment of the quality of the behavior—not a neutral statement. Goals state what the desired status will be. NOC outcomes provide only the topic to be evaluated.

3) Specifies patient outcomes and interventions for each day, or other period of time Rationale: A critical pathway specifies patient outcomes and interventions for each day, and in some situations (such as labor and delivery) for each hour. Critical pathways do include medical orders, so that statement is not true of critical pathways. Critical pathways are standardized, not individualized, so this is not true of critical pathways. Both critical pathways and standardized care plans are preprinted documents for a particular diagnosis or condition, so that statement cannot be used to differentiate them.

3) Target time Rationale: The goal does not have a target time. Its action verb is "will walk." Its special conditions are "with the help of one person."

2) Airways clear to auscultation Rationale: For every nursing diagnosis, it is essential to have one goal that, if achieved, would show resolution of the problem. If the airways were clear to auscultation, that would show resolution of Ineffective Airway Clearance. Effective cough, reduced pain, and splinting of incision would help to resolve the problem, but they are aimed at the etiology side of the diagnostic statement. Even if pain is reduced, for example, the airways still might not be clear.

3) Individualized patient care plan Rationale: Individualized, or nursing diagnosis, care plans address nursing diagnoses unique to a particular client. They reflect the independent component of nursing practice and include goals and nursing orders written specifically for a patient. A Kardex contains essential client data that either do not change or that are used and updated often. It includes ADLs and other basic care needs. It does not address a client's individual problems. A critical pathway is a standardized plan that specifies patient outcomes and broad interventions for all patients with a particular condition (e.g., myocardial infarction, sepsis). A standardized (model) patient care plan describes the nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical diagnosis. They do not describe care for a particular patient.

1) Integrated plan of care (IPOC) 2) Critical pathway Rationale: IPOCs are standardized plans that function as care plans as well as documentation forms. Many critical pathways are designed as IPOCs, and may function as documentation forms; however, not all critical pathways are IPOCs. Individualized care plans are not designed to be used as documentation forms. Although some standardized care plans provide writing space in which to individualize nursing orders and patient goals, they do not provide a place to document care and patient responses to care.

1) Make a working problem list with problems in priority order. Rationale: Writing an individualized plan of care follows in natural sequence from the assessment and diagnosis phases of the nursing process. In those phases, the nurse has already developed and prioritized a list of the patient's problems and strengths. The nurse must start with this list and then decide which problems can be managed with standardized plans or critical pathways. Then the nurse individualizes the standardized plan(s) as needed. After that, the nurse enters the medical orders in the appropriate documents and writes ADLs and basic care needs in special sections of the care plan or Kardex. Finally, the nurse develops individualized (nursing diagnosis) care plans to address problems not covered by the standardized documents.

2) An older adult who has had a stroke affecting the left side of his body and lives alone Rationale: A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits, especially when they live alone and have no support within the home. The other patients do not have the complex needs of the older adult patient who has had a stroke that affects body function.

3) Get patient input when making the plan. Rationale: It is most important to get patient input. The discharge plan may be developed in a timely manner and involve the family and a multidisciplinary team, but if the patient does not agree with the plan, it will not be successful.

4) Help ensure that important interventions are not overlooked Rationale: Standardized care plans help promote consistency of care and ensure important interventions are not forgotten. They are not likely to apply to every patient on a unit because they are usually single-problem plans or are used with a particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day.

4) Provide detailed nursing interventions Rationale: They both provide detailed nursing interventions, although the individualized care plan is more specific to the patient's needs and reflects critical thinking, whereas standardized plans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group.

In the planning phases, the nurse chooses outcomes/goals based on assessments and nursing diagnoses, chooses nursing interventions, and writes the plan of care.

Initial planning is done for the purpose of identifying patient problems and creating the care plan. Ongoing planning allows you to revise and individualize the patient's care plan as new data are obtained. Discharge planning is done to evaluate the patient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hospital or other healthcare agency.

The comprehensive care plan also contains information about the medical/multidisciplinary plan of care, information about care related to nursing diagnoses and collaborative problems, and information regarding special teaching and/or discharge planning needs.

Critical pathways focus on care for a particular medical diagnosis or DRG; they are organized on a time line to meet recommended lengths of stay; instructions for nursing interventions are usually less specific/detailed.

Computerized and standardized care plans may cause you to lose some creativity, intuition, insight, or caring because it is tempting, when you are busy, to accept the "easy answer" provided by the computer and not go further to think about the unique needs of this particular patient.

A process for creating such a care plan should include the following steps: Perform a comprehensive patient assessment. Make and prioritize a working problem list. Decide which problems can be managed with standardized care plans or critical pathways. Individualize the standardized plan as needed. Mark off any instructions that do not apply to the patient; add or adapt nursing orders as appropriate. Transcribe medical orders to appropriate documents. Write ADLs and basic care needs in special sections of the Kardex, care plan, or computer. Develop individualized care plans for problems not addressed by standardized documents. Write outcomes and nursing orders for each nursing diagnosis not addressed by standardized documents.

They are all short term.

Subject: client (assumed) Action verb: will walk Performance criterion: to the doorway Target time: by 12/13/15 Special conditions: with the help of one person

Subject: client Action verb: (will be able to) identify Performance criterion: foods to avoid on a low-fat diet Target time: by 3/1/15 Special conditions: after two teaching sessions

Subject: bowel movements (client is assumed) Action verb: will be (note that this is not an action verb) Performance criterion: soft and formed, and of his usual frequency Target time: ("at all times" is assumed if goal is for a potential problem; if for actual constipation, a date or time should be written) Special conditions: none

Subject: lung sounds (client is assumed) Action verb: are (Note that "are" is assumed, not stated. "Are" is not an action verb. This is acceptable because we are describing what the lungs are to do, rather than what the patient is to do.) Performance criterion: clear Target time: at all times Special conditions: to auscultation

Pain Control Behavior Pain Level

Pain Control Behavior Recognizes causal factors Uses non-analgesic relief measures Uses analgesics appropriately Reports pain controlled Pain Level Oral/facial expressions of pain Change in respiratory rate, heart rate, blood pressure Restlessness

Pain Control Behavior Rationale: It has higher numbers than Pain Level.

Which standardized classification system was designed specifically for community health nursing?

Clinical Care Classification (CCC), also called Saba or Georgetown

NOC

Questions to ask include the following: For each nursing diagnosis: Is there at least one goal that, when met, would demonstrate problem resolution? That is, does at least one goal flow from the problem clause? For each nursing diagnosis: Are the predicted outcomes adequate to completely address the nursing diagnosis? For each expected outcome: Is the outcome appropriate for the nursing diagnosis? Is each outcome derived from only one nursing diagnosis? Does each outcome describe only one patient response or behavior? Is the outcome stated as a patient behavior, not a nurse activity? Is the outcome stated in positive, rather than negative, terms? Is the outcome measurable or observable? Are the performance criteria specific and concrete? Avoid words such as normal, sufficient, enough, more, less, adequate, increased. Does each goal include all the necessary parts? Is the expected outcome realistic and achievable by this patient, given the available resources? Does the outcome conflict with the medical or other collaborative treatment plan? Does the patient, family, or community value the outcome? Does the goal conflict with any religious or cultural values?