Fundamentals of Nursing Chapter 18 – Flashcards
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Planning involves:
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Prioritizing the diagnoses, setting patient-centered goals and expected outcomes, prescribing individualized nursing interventions.
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Nurses establish priorities in relation to importance and time. Briefly explain the following.
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a. If untreated, result in harm to the patient or others. b. Involve non emergent, nonthreatening needs of the patient. c. Are not always directly related to a specific illness or prognosis.
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Identify some factors withing the health care environment that affect the ability to set priorities.
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a. Model for delivering care b. Nursing unit's workflow routine c. Staffing levels d. Interruptions e. Available resources f. Policies and procedures g. Supply access
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Goal
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A broad statement that describes a desired change in a patient's condition or behavior
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Patient-centered goal
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Specific and measurable behavior or responses that reflects a patient's highest possible level of wellness.
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Short-term goal
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Objective behavior that you expect the patient will achieve in a short time.
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Long-term goal
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Objective behavior that is expected over a long period
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Expected outcome
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A measurable criterion to evaluate goal achievement.
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Nursing-sensitive patient outcome
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An individual, family, or community state, behavior, or perception that is measurable in response to a nursing intervention.
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The SMART approach for writing goals and outcomes statement stands for.
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Specific, Measurable, Attainable, Realistic, Timed.
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Briefly explain the guidelines to follow when writing goals and expected outcomes. (Singular goal or outcome)
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A singular goal or outcome is precise in evaluating a patient response to a nursing action; each goal and outcome should address only one behavior, perception, or physiologic response.
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Briefly explain the guidelines to follow when writing goals and expected outcomes. (Measurable)
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Terms describing quality, quantity, frequency, length, or weight allow the nurse to evaluate outcomes precisely.
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Briefly explain the guidelines to follow when writing goals and expected outcomes. (Attainable)
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For a patient's health to improve he or she must be able to attain the outcomes of care that are set; mutually set attainable goals and outcomes.
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Briefly explain the guidelines to follow when writing goals and expected outcomes. (Realistic)
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A realistic goal or outcome is one that a patient is able to achieve.
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Briefly explain the guidelines to follow when writing goals and expected outcomes. (Timed)
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A time-limited outcome is one that a patient is able to achieve.
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Independent nursing intervention
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Independent nursing interventions are nurse-initiated interventions that do not require direction or an order from another health care professional.
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Dependent nursing intervention
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Dependent nursing interventions are physician-initiated interventions that require an order from a physician or other health care professional.
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Collaborative interventions
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Collaborative interventions are interdependent nursing interventions that require the combined knowledge, skill, and expertise or multiple care professionals.
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Identify the six factors the nurse uses to select nursing interventions for a specific patient.
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a. Desired patient outcomes b. Characteristics of the nursing diagnosis. c. Research base knowledge for the intervention d. Feasibility for doing the intervention e. Acceptability to the patient f. Your own competency
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Define the purposes of the nursing care plan.
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The nursing care plan should direct clinical nursing care and decrease the risk of incomplete, incorrect, or inaccurate care. It identifies and coordinates resources for delivering care. It lists the interventions needed to achieve the goals of care.
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Student care plans.
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Student care plans are useful for learning problem-solving techniques, nursing process, skills of written communication, and organizational skills needed for nursing care.
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Interdisciplinary care plans
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The interdisciplinary care plan is designed to improve the coordination of all patients therapies and communication among all disciplines.
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Explain the process of "nursing handoffs" as a practice of communication information at the end of the shift.
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In a "nursing handoff", nurses collaborate and share information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions.
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Consultation is a process in which:
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Consultation is a process in which the nurse seeks the expertise of a specialist to identify ways to handle problems in patient management or the planning and implementation of therapies.
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List the six steps of the nurse's role when seeking consultation:
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a. identify the general problem area b. Direct the consultation to the right professional c. Provide the consultant with relevant information about the problem area. d. Do not prejudice or influence the consultants. e. Be available to discuss the findings and recommendations f. Incorporate the recommendations into the plan of care.
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The following statement appears on the nursing care plan for an immunosuppressed patient: "The patient will remain free from infection throughout hospitalization." This statement is an example of a(n): 1. Long-term goal 2. Short-term goal 3. Nursing diagnosis 4. Expected outcome
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Answer: 2. Short-term goal Rationale: An objective behavior or response that you expect a patient to achieve in a short times, usually less than 1 week.
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The following statements appear on a nursing care plan for a patient after a mastectomy: "Incision site approximated; absence of drainage or prolonged erythema at incision site; and patient remains afebrile." These statements are examples of: 1. Long-term goals 2. Short-term goals 3. Nursing goals 4. Expected outcomes
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Answer: 4. Expected outcomes Rationale: The measurable change in a patient's condition that you expect to occur in response to the nursing care.
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The planning step of the nursing process includes which of the following activities? 1. Assessing and diagnosing 2. Evaluating goal achievement 3. Setting goals and selecting interventions 4. Performing nursing actions and documenting them
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Answer: 3. Setting goals and selecting interventions Rationale: The nurse sets patient-centered goals and expected outcomes and plans nursing interventions.
