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comprehensive discharge plan

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should be developed for older adults and anyone who has complex needs, including self-care deficits.

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discharge plan

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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.

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planning

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based on nursing assessment data and identified nursing diagnoses

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Discharge planning

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often requires a multidisciplinary team, but initial and ongoing planning may not.

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Initial planning

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usually begun after the first patient contact, but there is no specified time for completion

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ongoing planning

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more or less continuous and is done as the need arises

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Comprehensive discharge

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should be done for patients who have a newly diagnosed chronic disease or have complex needs.

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Standardized care plans

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help promote consistency of care and ensure that 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

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standardized care plans and unit care plans

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Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis.

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unit standardized care plans

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more general and do not have goals for each patient. are kept on file in a central place on the unit and do not become a part of the care plan. describe minimal, not ideal, care.

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Individualizing the care plan

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means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patient's needs

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Transcribing orders

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is a part of developing and implementing the care plan but not of individualizing the plan

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Performing an assessment

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beginning step to developing a care plan.

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Assessment

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helps you to know the ways in which a standardized plan needs to be individualized.

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Outcome statements

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should have specific performance criteria and a target time

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Both critical pathways and standardized care plans

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are preplanned documents; they describe care common to all patients who have a certain condition (e.g., all patients who have a heart attack need some of the same interventions)

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NOC

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was developed for all specialty and practice areas

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Omaha System

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developed for community health nursing

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omaha system and NOC

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Both address health restoration and can be used for individuals, family, or groups (community). Both base goals on nursing diagnoses, although Omaha does not use the NANDA-I taxonomy.

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Short-term goals

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may be accomplished in hours or days

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long-term goals

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usually are achieved over weeks, months, or even years.

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standardized nursing care plans and individualized care plans

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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.

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Outcomes

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describe changes in the patient's health status in response to nursing, rather than medical, interventions

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Outcomes

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relate to patient behavior, not nursing behaviors

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Outcomes

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measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate.

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Performance criteria

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should be specific and measurable ex:"75% of each meal" is specific and measurable

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"Frequently"

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vague

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You cannot observe

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whether someone "understands."

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"Decreased"

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vague a numerical pain rating would be better

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goal for a collaborative problem

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always that the complication will not occur specific to the medical condition/treatment

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Both NANDA-I and NOC labels

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are stated as human responses

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NOC statements

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are neutral to allow for positive, negative, or no change in health status

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NANDA-I diagnoses

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describe both problem responses and positive responses (wellness labels).

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NANDA-I labels

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based on patterns of related cues

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NOC labels

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based on (linked to) NANDA-I labels.

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essential goal/outcome

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aimed at the problem response ex: Impaired Memory goal: Demonstrates use of techniques to help with memory loss

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Informal planning

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performed while doing other nursing process steps and is not written

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The end product of formal planning

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is a holistic plan of care that addresses the patient's unique problems and strengths

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Ongoing planning

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refers to changes made in the plan as you evaluate the patient's responses to care

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common error made when writing client outcomes

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includes the nurse expressing the client outcome as a nursing intervention

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Cognitive outcomes

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focused on knowledge effective address values, beliefs, and attitudes.

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successfully meeting an outcome,

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nurse should note the time and date that it was achieved in the client's plan of care.

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amend

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make minor changes in order to make it more accurate

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primary purpose of outcome identification and planning

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is to design a plan of care for (and with) the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations

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Questions to facilitate critical thinking during outcome identification and planning

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include those related to setting priorities, such as "Which problems require my immediate attention or that of the team?" and "Which problems are most important to the client?"

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Discharge planning

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best carried out by the nurse who worked most closely with the client and family.

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comprehensive discharge planning

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In acute care settings begins when the client is admitted for treatment.

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When setting priorities

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it is best to first meet the needs that the client believes are most important.

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Outcomes

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are derived from the problem statement of the nursing diagnosis

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each nursing diagnosis

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at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement.

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considerations in writing outcomes

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encourage the client and family to be involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability the goals will be achieved.

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measurable outcome

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subject (client or part of the client), verb (action to be performed), conditions (not always included), performance criteria (observable, measurable), and target time (to achieve the outcome).

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Common errors when writing client outcomes

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include expressing the outcome as a nursing intervention, using verbs that are not observable and measurable and writing vague outcomes ex: Client will be less anxious and fearful before and after surgery.

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nursing intervention

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any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated autonomous (independently performed).

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cause of the problem (etiology)

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suggests the nursing interventions

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selecting nursing interventions

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that specifically address factors that cause, or contribute to, the client's problem.

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Clinical pathways (critical pathways, CareMaps

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are tools used to communicate the standardized interdisciplinary plan of care for clients. The emphasis in case management is on clearly stating expected client outcomes and the specific times targeted to achieve these outcomes.

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If the plan is not achieved (not met)

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recommendations for revising the plan of care are included in the evaluative statement.

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concept map care plan

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diagram of client problems and interventions. The nurse's ideas about client problems and treatments that are diagrammed. used to organize client data, analyze relationships in the data, and enable the nurse to take a holistic view of the client's situation

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Nursing interventions

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They include information that answers the questions who, what, where, when, and how.

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Two client behaviors

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is an error ex: drawing up insulin and identifying four signs and symptoms.

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client-centered measurable outcomes

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a target time is required. not a flexible time frame target time specifies when the client is expected to be able to achieve it.

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Resources for identifying appropriate expected outcomes

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Nursing-Sensitive Outcomes Classification (NOC) and standard outcome criteria established by health care agencies for people with specific health problems.

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intermediate priority

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one that involves the non-emergent, non-life-threatening needs of the client.

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low priority

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not directly related to a specific illness or prognosis ex: nurse is working with a client who is being prepared for a diagnostic test this afternoon and tells the nurse that she wants to have her hair shampooed

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Preparing a client for a diagnostic test

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example of a physician-initiated intervention

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collaborative intervention.

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ex: Notifying a nutritionist of a client's dietary preferences

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does not include frequecy (how frequently)

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ex: "Nurse will apply warm, wet soaks to the patient's leg while awake"

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method

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ex: applying warm, wet soaks to the patient's leg while awake

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quantity

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ex:warm, wet soaks

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qualification

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the person who will perform the action is the designation of "the nurse."

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Critical pathways

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allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type ex: client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy.

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Kardex

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card-filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care

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computerized care plan

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standardized care plan on the computer

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standardized care plan

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prewritten plan created for a specific nursing diagnosis or clinical problem. The nurse individualizes the care plan for the client's needs.

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Consultation

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appropriate when the nurse has identified a problem that cannot be solved using personal knowledge, skills, and resources, or when the exact problem remains unclear.

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A consultant

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objectively entering a situation can more clearly assess and identify the exact nature of the problem. The whole problem is not turned over to them. they is not there to take over the problem but is there to assist the nurse in resolving it. The person requesting for one usually identifies the problem area. The nurse should not bias them with subjective and emotional conclusions about the client and problem.

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achievable realistic goals

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increases the client's motivation. The nurse also takes available resources into consideration in order to set realistic goals.

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Being observable

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being able to determine if change has taken place is a must

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measurable goal

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written so the nurse has a standard to evaluate the client's response to nursing care.

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Being client-centered

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should reflect the client's behavior and responses expected as a result of nursing interventions.

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Level 2, Domain 2 (Physiological: Complex).

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Interventions to maintain or restore tissue integrity

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Level 2, Domain 1 (Physiological: Basic)

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Maintaining regular bowel elimination

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Level 2, Domain 5 (Family)

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Promoting the health of the family

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Level 2, Domain 1 (Physiological: Basic).

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Managing restricted body movement

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nursing care plan that is usually included in the student's care plan, but not in the client's record

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scientific rationales

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concept map

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diagram of client problems and interventions that shows their relationship to one another. promotes critical thinking and helps nurses to organize complex client data, process complex relationships, and achieve a holistic view of the client's situation. highly individualized

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client-centered goal

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specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function, ex: "The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit"

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evaluating understanding

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ex: goal of, "Client will understand purpose of coughing and deep breathing within 4 hours of returning to room" outcome is Client will cough and deep breathe every 1 hour while awake without staff prompting

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Clients

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are not always appropriately prepared to set and plan goals without professional help

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If a client or significant other is not able to participate in goal development

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you assume responsibility until the client is able to participate

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Outcomes and goals

answer

reflect the client's behavior and responses expected as a result of nursing interventions. ex: Client will consume at least 75% of each meal

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Write a goal

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to reflect client behavior, not to reflect your goals or interventions.

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Each goal and outcome

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addresses only one behavior or response ex: client will walk to the shower daily

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goals should be singular in focus

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because nurse will find it difficult to modify the plan of care if the goals are not met Singularity allows you to decide if there is a need to modify the plan of care because only one response is considered.

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You observe outcomes

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by directly asking clients about their condition or by using assessment skills.

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vague qualifiers

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normal," "acceptable," or "stable"

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Nurse Practice Act

answer

defines the legal scope of nursing practice Each state within the United States has developed it

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Each physician-initiated intervention

answer

requires specific nursing responsibilities and technical nursing knowledge

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nursing care plan

answer

enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care

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Psychomotor interventions

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include activities such as positioning, inserting, and applying.

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educational interventions.

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Demonstrating, teaching, and observing a return demonstration

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nursing intervention

answer

treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/patient outcomes.

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The most basic domain of the seven domains of Nursing Intervention Classifications

answer

physiologic: basic.

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The qualifier

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description of the parameter (framework;guideline) for achieving the outcome

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Nursing-Sensitive Outcomes Classification system organizes outcomes

answer

according to categories, classes, labels, outcome indicators, and measurement activities for outcomes.

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Nursing-Sensitive Outcomes Classification

answer

computerized information system

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