Nursing Intro Ch18 - Planning Nursing Care
|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|
|Goal||An aim, intent, or end in a client's condition or behavior|
|Client-centered goal||Specific and measurable behavior or response that reflects a client's highest possible level of wellness|
|Short-term goal||Objective behavior that you expect the client wilt achieve in a short time|
|Long-term goal||Objective behavior that is expected over a long period|
|Expected outcome||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|
|Collaborative interventions||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||Nursing interventions|
|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||No|
|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|