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Fundamentals of Nursing, ch. 13 Planning
Terms in this set (27)
Clinical pathways, CareMaps
Case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay.
Interdependent nursing actions performed jointly by nurses and other members of the health care team.
Computerized plans of nursing care
Plans of patient care developed by computer software programs that enable the nurse to call up screens listing causes, goals, and related nursing interventions for nursing diagnoses and medical diagnoses.
Process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution.
Specified behavior; for example, the measurable criteria in a patient goal specifies how the patient must perform the desired behavior.
Systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care. May be in conjunction with a social worker.
Specific, measurable criteria used to evaluate whether the patient goal has been met.
An aim or an end.
Planning that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care.
Independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional and that result from their assessment of patient needs.
Any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated, and collaborative interventions.
Nursing interventions classification (NIC)
First comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions.
Presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention.
Includes stating nursing diagnoses more clearly (both the problem statement and the cause), developing new diagnoses, adjusting patient outcomes to be more realistic, developing new outcomes as needed, and identifying nursing interventions that will best accomplish the patient goals. Ie pressure ulcer.
Observation of the patient to demonstrate the resolution of the problems identified by the nursing diagnoses and general problem list, along with the time frame for accomplishing these outcomes.
Expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient's health expectation.
Dependent nursing actions, involving carrying out physician-prescribed orders.
Plan of nursing care
Written guide that directs the efforts of the nursing team as the nurses work with patients to meet health goals; it specifies nursing diagnoses, outcomes, and associated nursing interventions.
Standardized care plans
Prepared plan of care that identifies the nursing diagnoses, patient goals, and related nursing orders common to a specific population (e.g., normal neonates) or problem.
Identify and write expected patient outcomes
Select evidence-based nursing interventions
Communicate the plan of nursing care
Pose the greatest threat to a person's health or wellbeing.
Not specifically related to he current level or well-being are of low priority.
Six aims regarding quality care
Safe: avoiding injury
Effective: avoiding overuse and underuse
Patient-centered: responding to patient preferences, needs, and values
Timely: reducing waits and delays
Efficient: avoiding waste
Equitable: providing care that does not vary in quality to all recipients
Describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved.
Describe the person's ability to function in relation to the desired usual activities.
Focus on key factors that affect someone's ability to enjoy life and achieve personal goals.
S - specific
M - measurable
A - attainable
R - realistic
T - timebound
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