nursing process (test 3) – Flashcards

During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to: establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care

Is to design a plan of care for and with the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patients health expectations, as identified in the patient outcomes

1. the law- your states nurse practice act outlines the scope of nursing practice. Your state board of nursing also outlines what you are and are not allowed to do. 2. national practice standards such as those of the American Nurses Association 3. specialty processional organizations- such as the American Association of Critical Care Nurses or Emergency Nurses Association, which develop standards for specialty practice. 4. the joint commission- this powerful accrediting body has developed detailed standards that must be followed to keep accreditation 5. the agency for health care research and quality (AHRQ)- this organization develops, reviews, and updates clinical guidelines to aid healthcare providers to prevent, diagnose, and manage clinical conditions 6. your employer- each facility usually develops its own unique set of standards that reflect how nursing care should be given in specific situations

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1. initial planning- is developed by the nurse who performs the admission nursing history and physical assessment. This comprehensive plan addresses each problem listed in the prioritized nursing diagnosis and identifies appropriate patient goals and the related nursing care. 2. ongoing planning- is carried out by any nurse who interacts with the patient. Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function. 3. discharge planning- is best by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources

1. Maslow's Hierarchy of Human Needs- basic human needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following: 1. Physiologic needs 2. Safety needs 3. Love and belonging needs 4. Self-esteem 5. Self-actualization needs. EX: a geriatric patient who is incontinent of urine and sitting in a wet disposable brief will be unable to participate fully in a music therapy diversional activity until the more basic need is met. 2. patient preference- it is best to first meet the needs the patient thinks are most important, if this order does not interfere with other vital therapies. EX: a woman is admitted to an orthopedic unit with a fractured pelvis and multiple lacerations after an automobile accident, the morning after she refuses to take an assisted bath until she finds out who is taking care of her 15 month old twins. 3. anticipation of future problems- nurses must tap their knowledge base to consider the potiental effects of different nursing actions. Assigning low priority to a diagnosis that the patient wants to ignore but that can result in hrmful future consequences for the patient might be nursing negligence. EX: an obese patient with multiple sclerosis and greatly decreased limbs strength who spends most of her day in bed may see no value in diet modification and position changes, a nurse would assign high priority to this diagnosis and would change the plan of care regardless of the patients desire to

It is important because the patient that is suffering from a life threatening sickness would need to be tended to before the person with self-esteem problems

Long term outcomes require a longer period to be achieved than short-term outcomes do. They also may be used as discharge goals in which case they are more broadly written

1. Cognitive outcomes- describe increase in patient knowledge or intellectual behaviors EX: within 1 day after teaching, the patient will list three benefits of continuing to apply moist compressions to leg ulcer after discharge 2. Psychomotor outcomes- describes the patients achievement of new skills EX: by 6/12/12 the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer 3. Affective outcome- describe changes in patient values, beliefs, and attitudes. Difficult both to write and to evaluate, affective outcomes might be critical to the resolution of a complex patient problem, EX: by 6/12/12 the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer

Measurable outcomes should have the following: 1. subject- the patient or some part of the patient 2. verb- indicates the action the patient will perform 3. conditions- specifies the particular circumstance in or by which the outcome is to be achieved. Not every outcome specifies a condition 4. performance criteria- describe in observable, measurable, term the expected patient behavior or manifestation 5. target time- specifies when the patient is expected to be able to achieve the outcome. Verbs helpful in writing measurable outcomes include: define, prepare, list identify, design, verbalize, choose, describe, explain, select, supply, and demonstrate Common errors when writing patient outcomes include the following (272): 1. expressing the patient outcome as a nursing intervention 2. using verbs that are not observable and measurable 3. including more than one patient behavior/manifestation in short-term outcomes 4. writing outcomes that are so vague that other nurses are unsure of the goal of nursing care

1. Nurse-initiated interventions- is an autonomous action based on scientific rational that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes. Nursing interventions are actions performed by the nurse to: 1. monitor health status 2. Reduce risks 3. Resolve, prevent, or manage a problem 4. Facilitate independence or assist with activities of daily living 5. Promote optimal sense of physical, psychological, and spiritual well-being 2. Physician-initiated intervention- is initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a doctor's orders 3. Collaborative interventions- nurses also carry out treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants

1. Procedure- a set of how to action steps for performing a clinical activity or task 2. Standard of care- a description of an acceptable level of patient care or professional practice 3. Algorithm- a set of steps that approximates the decision process of an expert clinical and is used to make a decision; these clinical rules are typically embedded in a branching flow chart 4. Clinical practice guidelines- a statement or series of statements outlining appropriate practice for a clinical condition or procedure

Failure to involve the patient in the planning process, insufficient data collection, use inaccurate or insufficient data to develop nursing diagnosis, outcomes that are stated to broadly, outcomes that are derived from poorly developed nursing diagnosis, failure to write nursing orders clearly, written nursing orders that do not resolve the problem, and failure to update the plan of care

1. Nursing Outcomes Classification (NOC)- used to describe the patient outcomes that are responsive to nursing interventions. The current classification lists 358 outcomes with definitions, indicators, measurement scales, and supporting references. The outcomes may be used for individuals, families, and communities 2. Nursing Intervention Classification (NIC)- the first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties, greatly facilitated the work of identifying appropriate interventions

In 1992, McCloskey and Bulechek published Nursing Interventions Classification (NIC), a report of research to construct a taxonomy of nursing interventions. Advantages of having a standard classification of nursing interventions include the following: 1. Helps demonstrate the impact that nurses have on the system of healthcare delivery. 2. Standardizes and defines the knowledge base for nursing curricula and practice. 3. Facilitates the appropriate selection of a nursing intervention. 4. Facilitates communication of nursing treatments to other nurses and other providers. 5. Enables researchers to examine the effectiveness and cost of nursing care. 6. Assists educators to develop curricula that better articulate with clinical practice. 7. Facilitates the teaching of clinical decision making to novice nurses. 8. Assists administrators in planning more effectively for staff and equipment needs. 9. Promotes the development of a reimbursement system for nursing services. 10. Facilitates the development and use of nursing information systems. 11. Communicate the nature of nursing to the public

1. Identify, label, validate, and classify nursing-sensitive patient outcomes and indicators. 2. Evaluate the validity and usefulness of the classification in clinical field-testing. 3. Define and test measurement procedures for the outcomes and indicators.

are independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another healthcare professional. Nurses are legally accountable for their assessments and their nursing responses.

are dependent nursing actions, involve carrying out physician-prescribed orders. State Nurse Practice Acts specify from whom nurses can receive orders. Nurses are still accountable for dependent orders they implement and are thus responsible for the clarification of any questionable order.

are interdependent nursing actions, are those performed jointly by nurses and other members of the healthcare team. Because nurses are increasingly respected as professional colleagues with unique patient knowledge, they are increasingly involved in collaborative ventures with the healthcare team.

Are written plans that detail the nursing activities to be executed in specific situations.

That empower the nurse to initiate actions that ordinarily require the order or supervision of a physician

Yes they should

1). When implementing nursing care, remember to act in partnership with the patient/family. 2). Before implementing any nursing actions, reassess the patient to determine whether the action is still needed. 3). Approach the patient competently. Know how to perform the nursing action, why the action is being performed, and potential adverse responses. Have all equipment and supplies ready. 4). Approach the patient caringly. Explain the nursing action using language the patient understands. Communicate genuine concern for what the patient is experiencing. 5). Modify nursing interventions according to the patient's (1) Developmental and psychsocial background, (2) ability and willingness to participate in the plan of care, and (3) responses to previous nursing measures and progress toward goal/outcome achievement. 6). Check to make sure that the nursing interventions selected are consistent with standards of care and within legal and ethical guides to practice. 7). Always question that the nursing intervention selected is the best of all possible alternatives. Consult colleagues and the nursing and related literature to see if other approaches might be more successful. Evaluate the effectiveness of the intervention selected, noting any factors that positively or negatively influenced the outcome. 8). Develop a repertoire of skilled nursing interventions. The more options one can choose from, the greater the likelihood of success

1. Patient Variables: Ideally, the patient is primary in determining how nursing interventions are implemented. Successful nurses modify their nursing actions according to the patients (1) changing ability and willingness to participate in the plan of care and (2) previous responses to nursing interventions and progress toward goal/outcome achievement. Other important patient variables are developmental stage and psychosocial background. 2. Nurse Variables: Nurse Variables that influence the implementation of the plan of care include levels of expertise, creativity (ability to match patient needs with specific nursing strategies), willingness to provide care, and available time. 3. Resources: The most elaborately designed plan of care cannot be fully effective without adequate staff. 4. Current Standards of Care: All nursing actions for implementing the plan of care must be consistent with standards of practice. All nurses are responsible for learning the standards that dictate practice in their specialty. Failure to practice according to these standards may result in a charge of negligence. 5. Research Findings: Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice. Reading professional nursing journals and attending continuing education workshops and conferences are excellent ways to learn about new nursing strategies that have proved effective. 6. Ethical and Legal Guides to Practice: To practice good nursing, it is important to be knowledgeable about the laws and regulations that affect healthcare and the ethical dimensions of clinical practice. Each nurse is responsible for becoming sensitive to the ethical and legal dimensions of practice, and moral and legal accountability are inherent to the practice of professional nursing

1). Lack of family support. 2). Lack of understanding about the benefits of compliance 3). Low value attached to outcomes or related interventions. 4). Adverse physical or emotional effects of treatment (such as pain and fatigue) 5). Inability to afford treatment 6). Limited access to treatment

1. Beyond patient visits: You will find help in many forms, not just in face-to-face visits. You will find help on the Internet, on the telephone, from many sources, by many routes, in the form you want it. 2. Individualization: You will be known and respected as an individual. Your choices and preferences will be sought and honored. The usual system of care will meet most of your needs. When your needs are special, the care will adapt to meet you on your own terms. 3. Control: The care system will take control only if and when you freely give permission. 4. Information: You can know what you wish to know, when you wish to know it. Your medical record is yours to keep, to read, and to understand. The rule is: "Nothing about you without you." 5. Science: You will have care based on the best available scientific knowledge. The system promises you excellence as its standard. Your care will not vary illogically from doctor to doctor or from place to place. The system will promise you all the care that can help you, and will help you avoid care that cannot help you. 6. Safety: Errors in care will not harm you. You will be safe in the care system. 7. Transparency: Your care will be confidential, but the care system will not keep secrets from you. You can know whatever you wish to know about the care that affects you and your loves ones. 8. Anticipation: Your care will anticipate your needs and will help you find the help you need. You will experience proactive help, not just reactions, to help you restore and maintain your health. 9. Value: Your care will not waste your time or money. You will benefit from constant innovations, which will increase the value of care to you. 10. Cooperation: Those who provide care will cooperate and coordinate their work fully with each other and with you. The walls between professions and institutions will crumble, so that your experiences will become seamless. You will never feel lost

1. Terminate: Plan of care when each expected outcome is achieved. 2. Modify: Plan of care if there are difficulties achieving the outcomes. 3. Continue: Plan of care if more time is needed to achieve the outcomes.

When evaluation reveals that the patient has made little or no progress toward outcome achievement, the nurse needs to reevaluate each preceding step of the nursing process to try to identify the contributing factors pointing to problems with the plan of care. New assessment data might need to be collected, diagnoses may be added or altered, outcomes might need to be modified or rewritten, nursing orders may be changed, or evaluation may be targeted more frequently. When the nurse has identified the factors contributing to the outcomes not being achieved, the evaluative statement can be used to suggest the necessary revision in the plan of care: 1). Delete or modify the nursing diagnosis. 2). Make the outcomes statement more realistic. 3). Increase the complexity of the outcome statement. 5). Change the nursing intervention. If a patient did not meet the specified outcome, many courses of action are then available to the nurse. Possible revisions to any plan of care include the following: 1). Delete or modify the nursing diagnosis: This might not be a problem or concern for the resident. Evaluate and validate data pointing to the nursing diagnosis. 2). Make the outcome statement more realistic: Carefully determine the resident's need for activities and ability or desire to participate in activities. 3). Adjust time criteria in outcome statement: Reevaluate after 3 weeks; resident may need more time to adjust to being institutionalized and more encouragement. 4). Change nursing interventions: Make a special effort to familiarize yourself with the resident's interest, and match these with available programs and activities.

1. Cognitive Outcomes: Cognitive outcomes involve increases in patient knowledge. These outcomes may be evaluated simply by asking patients to repeat information or, at a higher level of performance, by asking patients to apply the new knowledge to their everyday situations. For example, asking patients to describe new dietary restrictions is different from asking them to plan a weekly menu compatible with these restrictions. 2. Psychomotor Outcomes: Psychomotor outcomes describe the patient's achievement of new skills; they are evaluated by asking the patient to demonstrate the new skill. Affective Outcomes: Affective outcomes pertain to changes in patient values, beliefs, and attitudes and are more complex to evaluate. Observation of patient behavior and conservation can determine whether affective outcomes have been achieved. 3. Physiologic Outcomes: In the final type of outcome statement, physiologic outcomes, physical changes in the patient are the targeted outcome. To evaluate achievement to this type of outcome, the nurse uses physical assessment skills to collect relevant data and compares these with previous patient data

1. Criteria - are measurable qualities, attributes, or characteristics that specify skills, knowledge, or health states. 2.Standards - are the levels of performance accepted and expected by the nursing staff or other health team members. They are established by authority, custom, or consent. *The goal is to design and deliver nursing care that evidence supports as likely to produce the expected patient outcomes

The nurse collects evaluative data to determine whether or not the patient has met the desired outcomes. Whereas the nurse collects data in the nursing assessment to identify patient health problems, the data collected in the evaluation step are used to determine whether the identified health problems have been or are being resolved through outcome achievement

Before the nurse can make a judgment about the patient's achievement of outcomes, it is necessary to study and interpret the data collected. Just as clusters of data are interpreted before the nurse identifies and validates a nursing diagnosis, so too does evaluative data need to be interpreted. For example: a patient who is expected to walk the length of the hall-way with support of a walker asks to be taken back to her room because she feels weak. The nurse must gather more data and then determine if this is a one-time incident linked to medications or a temporary metabolic imbalance, or if it signals a consistent inability to achieve this behavior. Interpreting evaluative data requires critical thinking and is a skill that must be practiced.

After the data have been collected and interpreted to determine patient outcome achievement, the nurse makes and documents a judgment summarizing the findings. This is termed the evaluative statement. The two-part evaluative statement includes a decision about how well the outcome was met, along with patient data or behaviors that support this decision. The nurse has three decision options for how outcomes have been met: met, partially met, not met

When the patient outcomes were developed, a time frame was established for determining whether the specified changes have been achieved. At the designated time, the nurse, in collaboration with the patient, the family, and other members of the nursing team, evaluates the patient's attainment of the outcome. If outcomes are developed in observable and measurable terms, the task of collecting data for evaluation is clear-cut. Examples of three types of time criteria follow: 1). By 7/8/12, the patient will walk the length of the hallway with support of a walker. 2). Beginning 7/8/12, the patient will demonstrate a weight loss of 3 lb per month until target weight (135 lb) is achieved (6/8/12, weight: 151 lb). 3). Before discharge, parents will correctly demonstrate chest physiotherapy procedures for patient. It is important for nurses to evaluate patient outcome achievement as early as possible. Celebrating outcome attainment with the patient usually helps encourage the patient and lead to further outcome achievement. When failure to meet designated outcomes is detected early, the plan of care can be modified to remedy the failure

After the data have been collected and interpreted to determine patient outcome achievement, the nurse makes and documents a judgment summarizing the findings. This is termed the evaluative statement. The two-part evaluative statement includes a decision about how well the outcome was met, along with patient data or behaviors that support this decision. The nurse has three decision options for how outcomes have been met: met, partially met, or not met. The nurse signs and dates the evaluative statement. Alternatively, the nurse follows the documentation guidelines for evaluating outcome achievement specified in the institution's computerized documentation systems.

the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization, is an important mechanism nurses can use to improve their professional performance. This can be done formally or informally by inviting a peer you respect to give you feedback on nursing skills you are trying to develop

Specially designed programs that promote excellence in nursing. These range from small programs conducted by nurses on a small nursing unit to those developed for an entire institution, state, province, or country. Quality-assurance programs enable nursing to be accountable to society for the quality of nursing care. Such programs are also a response to the public mandate for professional accountability. They ensure survival of the profession, encourage nursing's fidelity to its moral and ethical responsibilities, and assist nursing to comply with other external pressures

or audit focuses on the environment in which care is provided. Standards describe physical facilities and equipment; organizational characteristics, policies, and procedures; fiscal resources; and personnel resources

is the nature and sequence of activities carried out by nurses implementing the nursing process. Criteria make explicit acceptable levels of performance for nursing actions related to patient assessment, diagnosis, planning, implementation, and evaluation

Focuses on measurable changes in the health status of the patient or the end results of nursing care. Whereas the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in patient health status

The commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes. Its internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than individuals, and has no end points.

is a method of evaluating nursing care that involves reviewing patient records to assess the outcomes of nursing care or the process by which these outcomes were achieved. Successful nursing audits depend on careful nursing documentation

is conducted by using direct observation of nursing care, patient interviews, and chart review determines whether the specified evaluative criteria are met

may use postdischarge questionnaires, patient interviews( by telephone or face to face), or chart review(nursing audit) to collect data. The type of retrospective audit most familiar to nurses working in hospitals is the Joint Commission retrospective chart review. This accrediting body initially required hospitals to conduct a certain number of audits per year

1. Focus on organizational mission. 2. Continuous improvement. 3. Customer orientation. 4. Leadership commitment 5. Empowerment 6. Collaborative/crossing boundaries 7. Focus on process 8. Focus on data and statistical thinking

Nursing actions are far too valuable and costly resources to be haphazardly implemented. Evaluation that is carefully planned and executed can direct and redirect these actions to maximize the patient's benefit. This is the outcome and challenge of nursing evaluation. Criteria that might be helpful in determining the adequacy of the evaluation step of the nursing process include the following: 1. Evaluation of the patient's achievement of desired outcomes. 2. Review of how the process is used and revision of the plan of care, if necessary. 3. Participation in quality-assurance programs.