Chapter 18 Flashcards
The ordering of nursing diagnosis or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions
Priority Setting
Classify patient priorities as
High, intermediate, or low importance
High priorities for nursing care plan
those related to airway status, circulation, safety, and pain.
Intermediate priority nursing care plan
risk of infection,
Low-priority nursing care plan
affect a patients future well-being Long term care health needs
A nursing “Goal”
is a broad statement that describes a desired change in a patients condition, perceptions or behavior.
Knowledge
- patients database and selected nursing diagnoses
- anatomy & physiology
- psychology
- pathophysiology
- normal growth & development
- evidence-based nursing interventions
- role of other health care disciplines
- community resources
- family dynamics
- teaching/learning process
- delegation principles
- priority-setting principles
Standards
- ANA scope of nursing practice
- specialty standards of practice
- patient-centered goa bhyuiebnmopw2azcdeyls and outcomes
- intellectual standards
- agency’s policies and procedures
Atitudes
- creativity
- responsibility
- perseverance
- discipline
Experience
- previous patient care experience
- personal experience in organizing activities
A patient-centered goal
reflects a patients highest possible level of wellness and independence in function.
A correct goal statement
“patient will ambulate independently in 3 days”
A correct outcome statement
“patient ambulates in the hall 3 times a day by 4/22”
Nursing-sensitive patient outcome
is a measurable patient, family or community state, behavior or perception largely influenced by nursing interventions
Examples of nursing-sensitive outcomes
reduction in pain frequency and severity, incidence of pressure ulcers, and incidence of falls.
NOC termonology for the nursing diagnosis of “acute Pain”
“pain control” or “pain releif”
SMART goals
S-specific M-measurable A-attainable R-realistic T-timed
Specific goal
-word each goal separately
By doing this each single goal can either be accomplished or still working towards and determine when the patient achieves each outcome.
Measure goal
- set goals that are numbered and able to be measured.
- I.e. terms describing quality, quantity, frequency, length, or weight.
Words to not use in a measurable goal
Normal, acceptable, or stable
Attainable
-Patient and nurse should agree on the goal
Realistic
-set goals and outcomes that the patient is able to obtain.
Timed
-each goal and outcome has a specific time limit
Short-term goal
objective behavior or response expected to achieve in usually less than a week
Long-term goal
objective behavior or response expected to achieve over a longer period. several days, weeks or months.
When does the implementation of these goals occur
During the implementation phase of the nursing process
3 types of interventions
- independent nursing interventions
- health care provider initiated interventions (dependent)
- collaborative interventions
Independent Nursing Interventions
Actions that a nurse initiates without supervision or direction from others. No order required
Ex-
-positioning pt to prevent pressure ulcer formation
-educating pt about medication side effects
-Providing skin care to an ostomy site
Dependent nursing interventions
Actions that require an order from a health care provider.
-Advance practice nurses who work under collaborative agreements with physicians or who are licensed independently by state practice acts are also able to write dependent interventions.
Ex-
-administer the medication
-implementing an invasive procedure (foley catheter, starting IV
-preparing a patient for diagnostic tests.
Collaborative interventions
Therapies that require the combined knowledge, skill and expertise of multiple health care providers.
Six important factors when choosing interventions
- desired patient outcome
- characteristics of the nursing diagnosis
- research based knowledge for the intervention
- feasibility for doing the intervention
- acceptability to the patient
- your own compentcy
Student Care Plan
- Assessment data relevant to corresponding diagnosis
- goals/outcomes identified for the patient
- implementation for the plan of care
- A scientific rationale
- a section to evaluate your care
SBAR
Situation
Background
Assessment
Recommendation
First step in making a consultation
assess the situation and identify the general problem
