Learning outcomes for Chapter 8, Yoost – Flashcards

During planning, the professional nurse prioritizes the patient's nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care.

Maslow's hierarchy of needs and the ABCs of life support in the health care setting are helpful resources in prioritizing care. Collaboration with patients while developing goals can decrease the incidence of conflicting priorities.

Care planning begins when a patient and nurse first interact and continues until the patient no 115longer requires care. It takes place at a variety of times and places. It can include preadmission, acute care, home care, and discharge planning. Seamless communication throughout a patient's care ensures continuity of treatment and improved patient outcomes.

Goals need to be patient centered, realistic, and measurable. Using measurable verbs and time limits when writing goals assists the nurse in evaluation of patient goal attainment.

Independent interventions are nurse initiated, and dependent nursing interventions require an order from a patient's health care provider. Collaborative interventions require cooperation among a few or many members of the interdisciplinary health care team.

Outcome identification, added by ANA in 1991 as a specific aspect of the nursing process, involves listing observable behaviors or items that indicate attainment of a goal.

Each health care facility or agency has its own electronic health record or form on which patient care plans are formulated and documented. In some agencies and specialty units, standardized care plans, which must be individualized for each patient, are available to guide nurses in the planning process. The conceptual care map (CCM) is a format for nursing students to use when developing patient care plans. It helps students to accurately collect, analyze, and synthesize patient data that are used to identify appropriate nursing diagnoses, goals, and interventions.

Repositioning a patient in bed, performing oral hygiene, and providing emotional support through active listening are examples of other independent nursing interventions.

(1) the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label), (2) the etiology or underlying cause (i.e., related to [r/t]), and (3) signs and symptoms (i.e., as evidenced by [AEB] or as manifested by [AMB]). the acronym PES (problem, etiology, symptoms) is used to remind nursing students of how to structure an actual nursing diagnosis statement.

A risk nursing diagnostic statement contains: (1)the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors). A health-promotion nursing diagnostic statement contains: (1) the nursing diagnostic label and (2) defining characteristics. It always begins with the words Readiness for Enhanced.

3 The health-promotion nursing diagnosis is based on the desire expressed by the patient or family for a change in lifestyle that will improve the patient's health. The actual nursing diagnosis addresses the patient's current need or health problem. The risk nursing diagnosis addresses the chance of complications or potential risks in a patient due to the current health problem. The actual nursing diagnosis addresses the response of the patient to the current need or life process.

It describes a person's readiness to enhance specific health behaviors for well-being.

The third part of the nursing diagnostic statement is the defining characteristic of the nursing diagnosis; in this actual nursing diagnosis, "grimacing" is the defining characteristic. Defining characteristics are clusters of related data that are signs or symptoms of an actual or health-promotion nursing diagnosis. In this case, the patient's grimace is the sign or objective data. "Severe pain" is the diagnosis label, which is the first part of the statement. The phrase "Related to" introduces the second part of the nursing diagnostic statement. This section comprises related factors, which is the underlying problem. In this case, the related factor is "femur fracture."

2 Priorities are helpful to anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems. The patient has impaired gas exchange and therefore, is assigned a high priority level. This is because if left untreated, impaired gas exchange may become life threatening. A low-level priority focuses on the patient's long-term health care needs. Very low priority is not a consideration in health care. Intermediate priority involves non-emergent, nonlife-threatening needs of the patient.

The nurse formulates a diagnosis statement by analyzing and clustering related assessment data. The nurse obtains patient data from medical records as well as from the patient and the family members to formulate an accurate diagnosis statement. The nurse obtains the past medical problems of the patient in a clinical interview. The nurse collects subjective as well as objective patient data during the assessment to formulate a diagnosis statement.

2 An example of a nursing-sensitive outcome is one that is influenced and sensitive to nursing interventions. Such is the case with "reduction in pain severity." "Patient will achieve pain relief by discharge" is a goal. "Patient will be free of a surgical wound infection by discharge" is a medical outcome. "Patient will describe purpose of pain medicine by discharge" is an outcome for a knowledge problem but not for the diagnosis of acute pain.

4 The patient may develop constipation due to limited physical mobility. decreased mobility affects bowel movements. The patient may develop bleeding only if there is an injury or a clotting abnormality. The patient is likely to develop an infection in the presence of a wound or surgical incision. The patient may experience isolation and loneliness if the patient has been isolated to prevent caregivers and family from being infected.

B, C, D The nurse must assess the patient's religious practices and prepare an individualized nursing diagnosis. This will prevent interventions that conflict with the patient's religious practice. Some cultural food practices may affect the health of the patient, so the nurse must consider the impact of culture on the patient's health. The nurse must write individualized nursing diagnostic statements that address the highest-priority needs of the patient. The nurse must assess each individual, regardless of age, to obtain accurate nursing diagnoses. Assumptions based solely on age may be impersonal and not accurate. The nurse need not consult the health care provider for accuracy of the diagnosis. The nurse must consult the North American Nursing Diagnosis Association International (NANDA-I) list of approved nursing diagnostic statements to ensure accurate use of diagnosis labels.

Examples of medical treatments requiring a physician order include urinary catheterization, 24-hour urine collection, dressing changes, incision irrigation, intubation, and placement of a nasogastric tube. The nurse collects data and gathers supplies and necessary information to carry out these interventions. Nurses must use sound clinical judgment to perform interventions and should seek clarification as needed. For example, if a patient has been ordered to ambulate four times daily, but a recent ultrasound confirms the presence of a deep vein thrombosis in the patient's left leg, the nurse would contact the physician about the ultrasound results to obtain updated orders before ambulating the patient.

A, B Don't wait. Begin at admission. Family will help a lot if they're decent.

1 Collecting objective and subjective patient data to formulate a nursing diagnosis is evidence-based practice. This process ensures that the nurse will be able to understand the patient's condition accurately and plan effective nursing interventions. The nurse will make mistakes when using only personal experiences to analyze the assessment data. This is because the nurse will not understand the patient's concerns. The nurse needs to cluster data that are related and similar to formulate a diagnosis, not use multiple diagnosis labels within the actual diagnosis.

1 Measurable goals must be specific, with numerical parameters, and include measurable verbs. Weight loss following dialysis is normal and expected. Breathing normally is not measurable and is subjective. Losing weight is not a specific, measurable goal. Normal blood pressure is measurable but should be specific to this patient's parameters, with defined systolic and diastolic measurements listed in the goal.

Potential response to a health problem

surgical removal of the gallbladder

A, B, D Using a calm approach with patients helps reduce their anxiety and encourages them to share their feelings or concerns. Once the patient's pain is reduced, the patient feels better and can attend to and discuss issues causing anxiety. The nurse can help the patient reduce fear and anxiety by working with the physician to provide factual medical information to the patient. A close family member provides support and helps the patient overcome stress and should be allowed to participate in discussions.

B C D When the patient and the family are involved in the planning process for nursing care, they become aware of the patient's needs. This enables the nurse to prioritize the care depending on the severity of the symptoms and the patient's preference. The patient and the family can identify and mutually agree to the interventions to achieve measurable and realistic outcomes. Involvement of the patient and the family increases their sense of ownership toward the outcomes and they become active participants in the nursing interventions. The nurse accepts input from the patient and the family, and they mutually agree on the goals for the patient. The primary health care provider may contribute to nursing care plans but is not involved in the actual work of creating a nursing care plan.

B, C, D, E While planning care for the patient, some resources will be reviewed for proper planning to achieve effective outcomes. The resources include nursing literature, standard protocols, procedure manuals, and nursing interventions classification. A consent form is not a resource that has to be reviewed while planning care. Moreover, a consent form is not required for routine care.

According to NANDA I diagnoses, related factors come in four categories: situational, maturational, treatment-related, and pathophysiological. A related factor is identified from the patient's assessment data. The related factor is associated with a patient's actual response to the health problem. It can be changed by using specific nursing interventions.

A, C, D, E When a nurse makes a diagnosis, it is important to be accurate, to be aware of related factors pertinent to the diagnosis, to plan interventions suited for treating the diagnosed condition, and to be aware of the defining characteristics of the diagnosis. These things are essential for effectively planning the treatment. An accurate nursing diagnosis helps the nurse formulate the appropriate outcome goals for the patient. The defining characteristics are essential components of a nursing diagnosis, and give direction to the interventions planned. A medical diagnosis is not carried out by a nurse; rather, it is carried out by the primary healthcare provider.

4 The nurse uses the NIC to determine the interventions that will help the patient meet the outcome goals. Each NIC includes interventions that the nurses perform, which may be on behalf of the patients, independent and collaborative interventions, and direct and indirect care. Maslow's hierarchy of needs is useful in determining the priority of patient needs. The nurse applies this to prioritize the nursing diagnoses. Gordon's functional health patterns represent a method of organizing the patient's assessment data. The NOC is taxonomy for describing patient outcomes from the nursing interventions.

The patient's goals need to be mutually set with family members who will care for him or her. A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Stating that the goals of care will always be long term is not accurate; goals will be short term and long term, depending on the patient's condition. Stating that the patient's goals need to be mutually set is true for any health care setting. Stating that expected outcomes need to address what can be influenced by interventions is an error; the outcomes allow you to direct your evaluation of care.

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