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Fundamentals > Ch 16: Outcomes identification and planning > Flashcards

Ch 16: Outcomes identification and planning Flashcards

1
Q

What does outcome identification and planning include between people and who

 What 4 things can you do during outcome identification and planning

  • Establish
  • identifies/write
  • select
  • communicate
A

How come identification in planning includes a partnership between patients and families

4 things you can do during out come at identification and planning

  • establish priorities
  • identify and write expected outcomes
  • Select evidence based interventions
  • Communicate nursing care plan
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2
Q

How do you define a goal

what is a patient outcome defined as 

Goal = =

What is the difference between an expected outcome and a goal and what does an expected outcome measure

A

A goal is an aim or end

Patient outcome is an expected conclusion to health problem/expectation

Call = objective = outcome

Expected outcome is specific and measurable v goal: broad
-expected outcomes measure the extent to which a goal has been met


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3
Q

What is informal planning

Why is it important to include family as much as possible

A

Informal planning is a problem that comes along with patient treatment as we treat other problems that we must address 1st and then go back to the original problem

Including family allows to identify and I’ll come and start planning

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4
Q

What is a formal care plan allow the nurse to do

  • personal
  • set
  • facilitate
  • promote
  • what is done with care
  • response
  • record/reimbursement
  • promote
A

 formal care planning allows:

  • individualized care to maximize outcome achievement
  • Set priorities
  • facilitate communication among professionals
  • promote high-quality cost effective care -coordinate care
  • evaluate response to nursing care -create record for eval, research, reimbursement
  • promote professional development
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5
Q

What is the ultimate primary purpose of alchemy identification planning
-what does it allow

How do we see the patient and what are nursing care plans designed to incorporate

What does nursing planning help do

A

Ultimate primary purpose of outcome identification planning is to:
-design a care plan within for the patient (individualize)
• care plan allows to implement, prevent, reduce, resolve health problems

Nurses see patients holistically

Nursing care plans designed to incorporate independent, dependent, collaborative responsibilities

Nursing planning helps:

  • promote wellness,
  • prevent disease/illness
  • promote recovery
  • **facilitate coping with altered functioning
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6
Q

What does successful implementation of each step require a high level of skill in

When does discharge planning begin

A

To successfully implement each step of the nursing process you must have a high level of skill in critical thinking/reasoning

Discharge planning begins from the moment the patient steps into the hospital (You see patient)

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7
Q

How can you plan healthcare correctly (what must you do)

What is the big picture focus:

A

To correctly plan healthcare
• be familiar with standards/agency policies for setting priorities
• ID and record patient outcomes select evidenced based nursing interventions record planning (talk to me)

• remember goal of patient centered care is to keep patient interest and preference central

Big picture focus:
-What are discharge goals for the patient and How should this direct shift interventions

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8
Q

Defined the clinical reasoning used during Outcome identification and planning

What do you want to trust and ask for

What is there to value

What is there to respect

Recognize and keep what?

A

Trust clinical experience/judgment be willing to ask for help when more qualifications and experience are needed

VALUE COLLABORATIVE PRACTICE 

Respect your clinical intuition before establishing priorities, outcomes and selecting interventions be sure that the research supports your plan
-Ask yourself why

Recognize personal bias and keep an open mind

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9
Q

What are questions that facility (produce) clinical reasoning
- What do you do when identifying outcomes and planning

A
  1. Setting priorities: what problems require my IMMEDIATE attention/or teams
  2. Identifying outcomes: what must I observe in patient to demonstrate resolution of problem identified by nursing diagnosis
  3. Selecting EBP nursing interventions: what Intervention backed by science will help my patient get to the expected outcomes
  4. Communicating plan of care: does care address the patient’s priority today
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10
Q

Give the three elements of comprehensive planning

A
  1. Initial
  2. On going
  3. Discharge
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11
Q

What does the initial planning phase begin with (how)

WHO develops the initial planning

What is addressed

What does the initial planning phase identify

A

Initial planning phase begins with nursing history and physical assessment

 A nurse who performs nursing history and physical assessment develops initial planning

During initial planning each problem listen in the prioritized nursing diagnosis are addressed

Initial planning phase identifies goals and related nursing care



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12
Q

Describe ongoing planning

By why and what do they do? 
 Aka? 
What is done to diagnosis
What is done to outcomes
What is identified
A

Carried out by ANY Nurse who interacts with patients
-Keeps plan up-to-date, manages risk factors, promote function

Aka new problems

Makes modifications if diagnosis is unclear or adjusts to new data
+ makes NEW Diagnosis

Makes outcomes more realistic and develops new outcomes

Identifies nursing interventions to accomplish patient goals

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13
Q

Describe discharge planning

When does discharge planning begin

How do you ensure home care behaviors are performed competently
-what is the key to planning

A

Begins: when patient is admitted

Carried out by nurse who worked MOST CLOSELY with patient (case manager)

Uses teaching and counseling to ensure home care behaviors are performed competently
-education = key to planning

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14
Q

What is a standardized care plan and what can be used as and how are they modified

A

Standardize care plans are prepared (set) plans that can be used as a baseline and customize to the patient and their needs

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15
Q

What are the priorities of nursing diagnoses and define them (3)

What is another term for low priority
What is not needed for low priority

A

High priority diag: greatest threat to patient will being

Medium priority diag : NONTHREATENING diagnoses

Low priority diag: diagnosis NOT SPECIFICALLY REATED TO CURRENT HEALTH PROBLEM

  •   risk of (Potential problem)
  • no immediate intervention
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16
Q

What priorities are greater than psychosocial

what is the exception

A

Physiologic priorities> psychosocial needs

Unless patient’s safety is being threatened like suicide
-if you won’t have a patient, it is the highest priority!

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17
Q

What are ways to establish priorities among nursing diagnosis

What are 3 helpful guides to help prioritize patient problems

A

Develop a prioritized list of nursing diagnoses to help set priorities

 3 helpful guides to prioritize patient problems:

  1. Maslow‘s HON
  2. Patient preference
  3. anticipation of future problems
    + physiological v psychosocial
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18
Q

Describe Maslow’s hierarchy of needs in reference to the most important to the least important of need classification

A 
MOST
1. Physiologic needs
2. safety needs 🦺
3. ♥️ and belonging needs
4. self-esteem 
5. self actualization
LEAST
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19
Q

What do you meet when considering patient preferences as part of a guide to Prioritize patient needs
-when are they dressed


Define anticipation of future problems

A

Patient preferences:
-meet patient needs at that time That patient thinks are the most important
-ADDRESSED 1st
🚫you can cause problems by not addressing those patient needs

Anticipation of future problems:
Considering the potential effects of different nursing actions

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20
Q

What are 4 questions you ask yourself to prioritize patient care

A

Q1. What problems need immediate attention/which can wait

Q2. What problems are your responsibility what can you refer to someone else
-work within your scope

Q3. What problems can be dealt with by using standard plans

  1. What problems are not covered by protocol standards but must be addressed to ensure safe hospital state and timely discharge
21
Q

What changes as a patient’s health status changes

What changes come about in response patient’s response to health/illness (condition)

What do you do if there’s a relationship among diagnoses

What can we do if patient has multiple nursing diagnoses that are related

A

As a patient health status changes our priorities change or become influenced by change

If patients have a change in response to health and illness there is a change in a nursing diagnosis

If there is a relationship among diagnoses One maybe worked on before another

If patient has multiple related diagnosis they can be treated together



22
Q

What are outcomes derived from give an example

What do problems usually reflect (2)
-what do problem directly demonstrate

What is the minimum number of outcomes per diagnosis

What language is used for diagnosis

A

Outcomes derived from problem statements
I.e: (P): pain,  (O) within eight hours patient will say pain is diminished

Problems usually Reflect that the objective (cool) has been achieved or demonstrates direct resolution of problem statement

Minimum 1 Outcome per diagnosis
use standardize language

23
Q

Long-term goals(Outcomes):

  • how long
  • what can long-term goals be used as

S short term outcomes:
When is it accomplished
Give an example


A

Long-term goals:

  • Last longer than 1 week
  • maybe used as discharge goals

Short term outcomes:
-accomplish in a specific time frame (days/hours)
I.E no signs of infection

24
Q

What is the first thing you should do to determine patient centered outcomes

What are things to keep into consideration when developing patient centered outcomes
-status/overall
-stay
-G & D
- Considerations
X changes indicating what
A 
For outcomes:
#1 is ask patient to describe 2 to 3major goals they would like to achieve

Consideration for patient centered outcomes:

  • patient health status and overall prognosis
  • expected length of stay
  • growth and development values
  • cultural considerations (preferences) -incorporate in outcomes other therapies (do not duplicate)
  • available human material, financial resources, risks, benefits, current scientific evidence (EBP)
  • ***Changes in status that indicate the need to modify usual outcomes
  • “patient changes so we change”
25
Q

What is one of the most important considerations in writing outcomes and why

A

What are most important considerations in writing outcomes is encourage family involvement (or patient) to explore will help patient chief goals

26
Q 
What are the IOM‘s six aims to meet by healthcare system regarding quality of care (highest)
-avoid
-How old are used
-how is care centered
-What do we want to reduce
-Avoid what due to high cost
-What must not very
A

IOM 6 Aims for higher quality of care

  1. Safe: avoid injury
  2. Effective: avoid over/underuse
  3. Patient centered: respond to patients preferences, needs , values
  4. Timely: reduce weights and delays
  5. Efficient: avoid waste due to high costs
  6. Equitable: provide care of that does not vary (two equally)
27
Q

What are outcomes classified by


Give the 3 categories of patient outcomes and describe them

A

Outcomes: classified by type of change needed by patient

3 outcomes:

  1. Cognitive: describes increase in knowledge or intellect( shows learning)
    - verbal!
    - “ listing “ 
  2. Psycho motor: describes (demonstrates) patient achievement of new skill

Effective: dealing with patients values, beliefs, attitudes (emotions)
3.

28
Q

What do clinical outcomes identify
-what does it describe

Describe functional outcomes

Describe quality of life outcomes

A

Clinical outcomes identified status of health issue at certain points in time (post treatment)
-Describes whether problems are resolved or if improvement

Functional outcomes: the ability to function (do) certain activities (desired)

Quality of life outcomes:
-Focus on key factors that affect quality of life



29
Q

What does the American nurses association standard practice direct

What should the outcome support

A

ANA standard directs: practicing  in a manner congruent to culture and diversity including The principles

Outcome should support overall treatment

30
Q

What must MEASURABLE OUTCOMES contain (components)

A
  • Subject:
  • Verb: the ACTION Performed by patient
  • Condition: the circumstance in/by which the outcome is achieved

• performance criteria
-expected patient behavior or observable manifestations

31
Q

What must patient outcomes and goals be?

(what was planning Be? )

A

Patient outcomes and goals must be SMART

S-specific (how)
M measurable (number)
A Attainable (reasonable)
R realistic/result oriented*
T Time framed (date and time) 
32
Q

What are a few errors in writing patient outcomes

-writing
-non-verbs
-more than one
-Excess


A
  1. writing outcome as nursing intervention
  2. Using non-observable/measurable verbs
    - I.E: patient will know

 3. more than one behavior in short term outcome

  1. Vague outcomes
33
Q

Using verbs what do you want to avoid

A

Avoid using verbs that are non-measurable
-🚫 miserable =🚫use 

What are verbs you do not use in patient outcomes

  • Know
  • understand
  • learn
  • become aware
34
Q

What is the nursing intervention classification (NIC) definition of nursing interventions

What interventions are used

What are two specific categories used during nursing interventions and give examples of each

A

Nursing interventions:
-treatment based on clinical judgment and knowledge that a nurse performed to enhance patient outcomes

Nurses use both independent and collaborative interventions

Use of physiologic and psychologic
Physiologic:
-Hypo glycemic treatment

Psychological
-Decreasing anxiety




35
Q

What are the major focuses of nursing interventions

ACTUAL DIAG

-contributing factors
-promoting + (decreasing)
-Monitor
-
To rule out/Confirm

A

Major focus of nursing interventions:

  • Reduce/eliminate contributing factors of diagnosis
  • promote higher level of wellness ⬇️ problem
  • Monitor and eval status
  • collect additional data to rule out/confirm diag
  • eval response
36
Q

 What are major focuses of interventions for at risk diagnosis

A
  • we want to decrease or eliminate contributing risk factors
  • prevent potential problems
  • Monitor and eval patient status
37
Q

What are types of nursing interventions

I
Nurse
Physician
collaborative

A

Nurse initiated: INDEPENDENT
- Select appropriate, individualize(to patients ability) , record in record

Physician initiated: initiated by physician in response to medical diagnosis but carried out by nurse

Collaborative: treatment by OTHER providers carried out by a nurse

38
Q



What are 3 actions done in nursing interventions

A

1. Resolve, prevent, manage problem

  1. Facility Independence or assist with ADL
    - Promote optimum sense of physical, psychological, spiritual well-being
39
Q

What are six factors to consider when choosing interventions

what is our goal
What do we want to consider
What do we want to be
What must patient due to intervention
What is there to determine about the nurse

A

For interventions Consider:

  • desired patient outcome
  • character of nursing diagnosis
  • be feasible
  • patient must accept to do intervention
  • capability of nurse to do intervention
  • ?
40
Q

Describe the following structured care methodologies used in nursing care

 procedure
standard of care
algorithm
clinical practice guidelines

A

 procedure: set of how to do action

Standard of care: acceptable level of patient care

Algorithm: set of steps TO MAKE A DECISION
-gives no provider flexibility

Clinical practice guidelines: statement with appropriate practice for clinical condition or procedure

41
Q

Define consulting

Who can consult

What is an ethicists

A

Consulting: process in which two are more people with varying degrees of experience discuss a topic, and suggest solutions for problem

Consultations may be done by anyone including social workers, pastoral, caregiver

Ethicist: evaluate case and make suggestions on practices

42
Q

What are evaluative strategies defined by

When are patient outcomes meaningless and what must you do when evaluating the patient outcomes

Give the ratings of patient outcomes

A

Evaluative strategies defined by well written outcomes

Patient outcomes are meaningless if the Nurse does not evaluate progress towards achievement

Met, Partially met, not meant

43
Q

What does a care plan equal

What are a few factors in the world written care plan

A

Care plans = guide to meeting goals

Factors in a well written care plan:

  • have effective philosophy of nursing and advance nursing aims
  • prepared BY BURSE
  • Clearly identifies nursing assistance the patient needs and nursing collaborative responsibilities
  • directs the nursing assessment priorities*
44
Q

What does documentation usually specify

A

Documentation usually specifies nursing diagnosis and outcomes + any associated nursing interventions needed to achieve goals

45
Q

Describe the following plans of care

Computerized

Concept maps

Change of shift report “ hand off”

Multidisciplinary (collaborative) care plan

A

Computerized :
-EHR

Concept maps:
-DIAGRAMS to reflect problem, interventions and I’ll come

Change of shift report “ hand off”
-Giving critical information to other nurse

Multidisciplinary (collaborative) care plan
-helps communication with others about patient status

46
Q

What are a few problems Recognized when developing nation care plans

A

•Not involving patient
•insufficient data
•Inaccurate data outcomes or too broad •outcomes derived from poorly development diagnosis
-bad diagnosis = bad outcomes
• failure to write nursing orders clearly •nursing orders that are not resolve the problem
•failure to update

47
Q

What are the benefits of using NIC (nursing intervention classification

A
  • Demonstrate impact of nurses and healthcare delivery
  • define The knowledge base for nursing curriculum
  • standardize language facility selection of appropriate nursing interventions
  • facility communication
  • enable researchers to examine effectiveness and cost
48
Q

What does the NIC (nursing intervention classification) equal?

A

NIC = universal standardized language to communicate 

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