Chapter 18: Planning Nursing Care

Question 1

Careful planning involves

Answer 1

seeing the relationships among a patient’s problems, recognizing that certain problems take precedence over others, and proceeding with a safe an efficient approach to care.

Question 2

Planning involves:

Answer 2

1. setting priorities
2. identifying patient-centered goals and expected outcomes
3. prescribing individualized nursing interventions
4. critical thinking
5. deliberate decision making
6. problem solving
7. communication and ongoing consultation

Question 3

Priority Setting

Answer 3

placing a nursing diagnosis in an order that considers urgency and/or importance to establish preferential treatment for nursing actions

Question 4

Priority Setting helps you

Answer 4

anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems

Question 5

Priorities are mutually agreed upon with your patient based on:

Answer 5

1. urgency of the problem
2. the patient’s safety and desires
3. the nature of the treatment indicated
4. the relationship among the diagnoses

Question 6

Classification of Priorities: Dynamic

Answer 6

1. High Importance
2. Intermediate Importance
3. Low Importance

Question 7

High Importance

Answer 7

Think Maslow!

Airway status, Ciruclation, Safety (physiological and psychological) and pain.

Question 8

Intermediate Importance

Answer 8

• non-emergent/nonlife-threatening [but necessary] needs.
• impaired mobility
• risk for infection

Question 9

Low importance

Answer 9

usually dealing with long-term health care needs

Question 10

With priority setting, be sure to remember:

Answer 10

1. always assign priorities on the basis of good nursing judgement
2. order of the priorities changes with patient’s condition
3. appropriate ordering of priorities ensures you meet a patient’s needs in a timely and effective way.
4. involve patients in priority setting whenever possible

Question 11

What are environmental factors that may affect priority setting (cognitive shifts)?

Answer 11

1. the organization of the nursing unit
2. staffing levels
3. interruptions from other care providers
4. available resources (material and clinical specialists)
5. policies and procedures
6. access to supplies

Question 12

Once a nursing diagnosis has been identified for your patient, ask yourself:

Answer 12

1. What is the best approach to address and resolve each problems?
2. What do I plan to achieve?

Question 13

Goal

Answer 13

broad statement that describes a desired change in a patients condition or behavior.
ex. “patient expresses understanding of postoperative risks”

Question 14

Expected outcome

Answer 14

a measurable criterion to evaluate goal achievement
ex. “patient identifies 3 S&S of wound infection” or “patient will demonstrate correct use of the incentive spirometer”

Question 15

Short-term goal

Answer 15

objective behavior or response that you expect a patient to achieve in a short time
usually less than a week .

Question 16

Long-term goal

Answer 16

objective behavior or response that you expect a patient to achieve over a longer period
usually over several days, weeks or months

Question 17

to participate in goal setting the patient must be/have:

Answer 17

• alert
• some degree of independence in completing ADL’s
• problem solving ability
• decision making ability

Question 18

Outcomes need to meet intellectual standards by being

Answer 18

(S)pecific/Singular
(M)easureable
(A)ttainable
(R)ealistic
(T)imed

Question 19

Seven Guidelines for Writing Goals & Expected Outcomes

Answer 19

1. Patient-Centered
2. Singular Goal or Outcome
3. Measurable
4. Attainable
5. Realistic
6. Time-limited
7. Observable

Question 20

Expected outcome

Answer 20

is a specific measureable change in a patient’s status that you expect to occur in response to nursing care.

Question 21

Nursing-Sensitive Patient Outcome

Answer 21

measureable patient, family, or community state, behavior or perception largely influenced by and sensitive to nursing interventions.

Question 22

Nursing interventions

Answer 22

• treatments or actions based on clinical judgement and knowledge that nurses perform to meet patient outcomes.
• individualized to each patient.

Question 23

Choosing nursing interventions involves competency in three areas:

Answer 23

1. knowing the scientific rationale for the intervention
2. possessing the necessary psychomotor and interpersonal skills.
3. being able to function using the available health care resources effectively

Question 24

What are the three categories of nursing interventions?

Answer 24

1. independent
2. dependent
3. collaborative interventions

Question 25

Independent Interventions

Answer 25

• initiated by nursing
• do not require an order from another professional
• based on scientific rationale

Question 26

Dependent Interventions

Answer 26

• actions that require an order from a physician or other health care provider
• advanced practice nurses may write dependent nursing interventions

Question 27

Collaborative Interventions

Answer 27

Interdependent

-therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

Question 28

When preparing dependent or collaborative interventions,

Answer 28

do not automatically implement the therapy but determine whether it is appropriate for the patient.

Question 29

Six Factors when Choosing Interventions:

Answer 29

1. desired patient outcomes: nursing outcomes classification
2. characteristics of the nursing diagnosis: address the r/t and AEB factors
3. Researched based
4. feasibility of the interventions
5. acceptability to the patient
6. capability of the nurse

Question 30

Nursing Care Plans include:

Answer 30

1. nursing diagnosis
2. goals and/or expected outcomes
3. specific nursing interventions
4. evaluation of the findings/results

Question 31

Plans of care may be recorded in

Answer 31

• kardex
• standardized care plans (written)
• computerized care plans: electronic health records

Question 32

Nursing Plans of Care:

Answer 32

• reduce the risk for incomplete, incorrect, or inaccurate care.
• details specific supplies/equipment necessary to use
• makes it easy to continue care from one nurse to another
• includes details on discharge planning

Question 33

Planning care for patient in community based setting are designed to:

Answer 33

• educate the patient/family about the necessary care techniques and precautions
• teach the patient/family how to integrate care within family activities
• guide the patient/family on how to assume a greater percentage of care over time
• evaluate the expected outcomes

Question 34

Standard practice for all off-going nurses to on-coming shift.

Answer 34

-discusses plans of care and overall progress.
nurses collaborate and
-share important information that ensure the continuity of care.

Question 35

Report is given in

Answer 35

SBAR format

Question 36

SBAR

Answer 36

Situation: pts brief c/o or reason for hospitalization
Background: brief hx
Assessment: pertinent data including labs, radiographs, tests
Recommendation: what was left undone, how to continue care

Question 37

Walking Rounds or Bedside Report

Answer 37

• allows pts to be involved in decision-making and confirm information
• allows the off-going nurse to “talk-up” her peer
• allows the on-coming nurse to ask questions and clarify any miss-communication

Question 38

Concept Maps

Answer 38

• visual representation of all of the pts nursing diagnoses
• diagram of interventions related to each nursing diagnosis
• visualizes how interventions may apply to more than one diagnosis.
• provides a holistic view of your patients health care needs

Question 39

Consultation

Answer 39

Process by which you seek the expertise of a specialist to identify ways to handle problems in patient management or the planning and implementation of therapies.

Question 40

Slide 30 ?

Answer 40

Nursing instructor
Physicians
Clinical educators
Physical therapists
Nutritionists
Social workers
Pharmacists

Question 41

When to consult

Answer 41

When you identify a problem that you are unable to solve using personal knowledge, skills, and resources.

Question 42

Six Steps to Consultation

Answer 42

1. Identify the general problem area
2. Direct the consultation to the right professional
3. Provide the consultant with relevant information about the problem
4. Do not prejudice or influence consultants. Avoid bias!
5. Be available to discuss the consultant’s findings and recommendations
6. Incorporate the consultant’s recommendations into the care plan