Chapter 18 Flashcards
Planning nursing care involves:
1-Setting priorities based on patient diagnoses and collaborative problems
2-Identifying patient-centered goals and expected outcomes
3-Prescribing nursing interventions appropriate for each diagnosis
is the ordering of nursing
diagnoses or patient problems to establish a preferential order for nurs-
in interventions. Generally, problem-focused diagnoses and problems
take priority over wellness, possible risk, and health promotion prob
lems.
Priority setting
Methods for prioritizing
importance
High (maslow hierarchy of needs)
Intermediate
Low
Goals are categorized in:
short term goal
Long term goal
How do you nurses choose the correct interventions for each client?
desired patient outcomes,
characteristics of the nursing diagnosis
research base knowledge for the intervention,
feasi-
bility for doing the intervention, acceptability to the patient,
your own competency
6-What is the difference between independent and dependent nursing interventions?
Dependent: Require an ordis from a
health care promidey. Interuentions are based on á physician’s or nurse proclitioner’s chaices
independent nursing inter.
ventions that a nurse initiates in response to a nursing diagnosis with.
out supervision, direction, or orders from others. Examples include
positioning patients to prevent pressure injury formation, initiating
early mobility protocols, offering counseling for coping, or instructing
patients in side effects of medications.
Nurse-initiated interventions are
autonomous actions based on scientific rationale.
Types of interventions
Nurse-initiated
Health care provider-initiated
Other provider-initated
8-What is an expected outcome?
Patient remaining afebrile without wound drainage and with wound edges healing
Match the elements for correct identification of outcome statements
with the SMART acronym terms below.
- Specific
- Measurable
- Attainable
- Realistic
- Timed
a. Mutually set an outcome that a patient able le agrees to meet. b. Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources. C. Be sure an outcome addresses only one patient behavior or response. d. Include when an outcome is to be met. e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status.
1c 2e 3a 4b 5d
A nursing student is providing a hand-off report to the RN
assuming her patient’s care. She explains, “I ambulated him twice
during the shift; he tolerated walking to end of hall each time and
back with no shortness of breath. Heart rate was 88 and regular
after exercise. The patient said he slept better last night after
closed his door and gave him a chance to have some uninter.
rupted sleep. I changed the dressing over his intravenous (IV)
site and started a new bag of D,½NS. Which intervention is a
dependent intervention?
1. Providing hand-off report at change of shift
2. Enhancing the patient’s sleep hygiene
3. Administering IV fluids
4. Taking vital signs
3
A nursing student is providing a hand-off report to a registered
nurse (RN) who is assuming her patient’s care at the end of the clin-
ical day. The student states, “The patient had a good day. His intra-
venous (IV) fuid is infusing at 124 mL/hr with Ds½NS infusing in
left forearm. The IV site is intact, and no complaints of tenderness.
I ambulated him twice during the shift; he tolerated walking to the
visitors lounge and back with no shortness of breath, respirations
14, heart rate 88 after exercise. He uses his walker without diffi-
culty, gait normal. The patient ate ¾ of his dinner with no gastroin-
testinal complaints. For the goal of improving the patients activity
tolerance, which expected outcomes were shared in the hand-off?
(Select all that apply.)
1. IV site not tender
2. Uses walker to walk
3. Walked to visitors lounge
4. No shortness of breath
5. Tolerated dinner meal
3
4
Which of the following factors should be considered when choos-
ing an intervention for a patient’s plan of care? (Select all that apply)
1. The specific patient outcome against which to judge effective.
ness of interventions
2. The timing of care activities routinely conducted on the care
unit
3. The scientific evidence available in support of an intervention
4. The amount of time required for implementation in consider-
ation of patient’s condition
5. The patient’s values and beliefs regarding the intervention
1
3
4
5
A nurse assesses a 78-year-old patient who weighs 108.9 kg
(240 lb) and is partially immobilized because of a stroke. The
nurse turns the patient and finds that the skin over the sacrum is
very red and the patient does not feel sensation in the area. The
patient has had fecal incontinence on and off for the past 2 days.
The nurse identifies the nursing diagnosis of Risk for Impaired
Skin Integrity. Which of the following outcomes is appropriate
for the patient?
1. Patient will be turned every 2 hours within 24 hours.
2. Patient will have normal formed stool within 48 hours.
3. Patient’s ability to turn self in bed improves.
4. Erythema of skin will be mild to none within 48 hours.
4
An 82-year-old patient who resides in a nursing home has the
following three nursing diagnoses: Risk for Fall, Impaired Physi-
cal Mobility related to pain, and Imbalanced Nutrition: Less Than
Body Requirements related to reduced ability to feed self. The nurs-
ing staff identified several goals of care. Match the goals on the left
with the appropriate outcome statements on the right.
Goals
1–Patient will ambulate independently in 3 days
2–Patient will be injury free for 1 months
3–Patient will achieve 5pounds weight gain in 1 months
4–Patient will achieve pain relief by discharges
Outcomes a. Patient expresses fewer non- verbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 calories daily. C. Patient walks 20 feet using a walker in 24 hours. d. Patient identifies barriers to remove in the home within 1 week.
1c
2d
3b
4a
