Nurse established "high" priority...
If untreated, result in harm to the client or others
Nurse established "Intermediate" priority...
Involve nonemergent, non-threatening needs of the client
Nurse established "Low" priority...
Are not always directly related to a specific illness or prognosis
An aim, intent, or end in a client's condition or behavior
Specific and measurable behavior or response that reflects a client's highest possible level of wellness
Objective behavior that you expect the client wilt achieve in a short time
Objective behavior that is expected over a long period
Specific measurable change in a client's status that you expect to occur
Nursing-sensitive client outcome
An individual, family, or community state, behavior, or perception that is measurable in response to a nursing intervention
There are seven guidelines to follow when writing goals and expected outcomes. List them:
Client centered, Singular goal/outcome, Observable, Measureable, Timelimited, Mutual, Realistic
Describe the guideline for Client-centered goal
Outcomes and goals reflect the client's behavior and responses expected as a result of nursing interventions
Describe the guideline for singular goals/outcomes
Precise in evaluating a client response to a nursing action; addresses only one behavior or response per goal
Describe the guideline for observable goals
Be able to observe if a change takes place in a client's status
Describe the guideline for measurable goals
Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely
Describe the guideline for time-limited goals
Indicates when you expect the response to occur
Describe the guideline for mutual goals
Ensure that the client and nurse agree on the direction and time limits of care
Describe the guideline for realistic goals
A goal that a client is able to reach
What are the three categories of interventions
Independent, Dependent, Collarborative
Independent nursing interventions
Nurse-initiated interventions that do not require direction or an order from another health care professional
Dependent nursing interventions
Physician-initiated interventions that require an order for a physician or other health care professional
Interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple care professionals
What are the six factors that nurses use to select nursing interventions for a specific client
1. characteristics of the nursing diagnosis
2. goals and expected outcomes
3. evidence-based interventions
4. feasibility of the interventions
5. acceptability to the client
6. your own competency
Define the purpose of the nursing care plan
Direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care; identifies and coordinates resources for delivering care; lists the interventions needed to achieve the goals of care
Describe a Student care plan
Useful for learning the problem-solving technique, nursing process, skills of written communication, and organizational skills needed for nursing care
Describe a Institutional care plan
Are part of the client's legal record and differ by setting and the evolving client situation
Describe a Computerized care plan
Format is standardized plans, which the nurses are able to individualize for a specific client
Describe Critical Pathways
Multidisciplinary treatment plans that outline treatments or interventions clients need to have; most are based on medical diagnoses rather then nursing
What are the Nine Steps in preparing for concept mapping
1. Gather the clinical assessment data base from the client's medical record.
2. Review all of the information about the client's problems, treatments, and medication in the literature.
3. Review any standardized care plans, critical pathways, protocols, or client education material.
4. First, develop a skeleton diagram of the client's chief medical diagnosis and patterns of assessment data. Identify and group the related patterns.
5. Review your assessment patterns and identify nursing diagnoses.
6. When planning, analyze relationships among the nursing diagnoses.
7. List the nursing interventions to attain the outcomes for each nursing diagnosis.
8. Use the map to write down the responses to each nursing activity.
9. Revise, take notes, and add or delete nursing interventions.
Consultation is a process in which
Is a process in which you seek the expertise of a specialist to identify ways to handle problems in client management or the planning and implementation of therapies
List six responsibilities of the nurse when seeking consultation
1. identify the general problem area
2. direct the consultation to the right professional
3. provide the consultant with relevant information about the problem area
4. do not prejudice or influence the consultants
5. be available to discuss the findings and recommendations
6. incorporate the recommendations into the plan of care
During planning the nurse should
Determine client goals, set priorities, develop expected outcomes of nursing care, and develop a nursing care plan.
Priorities help you to anticipate and sequence nursing interventions when a client has
Multiple nursing diagnoses and collaborative problems
Multiple factors in the nursing care environment influence
A nurse's ability to set priorities
Goals and expected outcomes provide clear direction for the selection and use of
Goals and expected outcomes provide focus for
Evaluation of the effectiveness of the interventions.
In setting goals the time frame depends on
The nature of the problem, etiology, overall condition of the client, and treatment setting
Do nurse-initiated interventions require supervision or direction from others
The Nursing Interventions Classification taxonomy
Provides a standardization to assist nurses in selecting suitable interventions for clients' problems
Correctly written nursing interventions include
Actions, frequency, quantity, method, and the person to perform them