DIAGNOSTIC, OUTCOME IDENTIFICATION, PLANNING Flashcards
The nurse analyzes the strength and weaknesses of the patient, the patient’s family, the nursing personnel, the health care facility and available resources
outcome identification
In this phase, the nurse develops outcomes for the patient to achieve showing an optimum or improved level of functioning in the problem areas identified in the nursing diagnoses
outcome identification
The resulting outcomes and plan of nursing care are designed to help patients and their families
make informed decisions about their health and health care
maintain their current level of health and functioning if they identified as being at risk for developing problems
avoid injury or disease
Outcome identification formula
outcome identification=setting priorities +establishing outcomes
ordering the delivery of nursing care so that more important or life threatening problems are treated before the less critical problems are treated
setting priorities
What are the classifications of setting priorities?
high
middle
low
What are the guidelines for setting priorities?
-Maslow’s Hierarchy of meeds
-focus on the problems the patient feels are most important
-consider the patient’s culture, values, and beliefs when setting priorities
-consider the effect of potential problems when setting priorities
consider cost resources available, personnel, and time needed to plan for and established for each of the patient’s identified problem
-consider state laws, hospital policy statement, and outcome criteria established for the particular setting
is a measurable, expected client goal to be achieved at some specified time in the future
an outcome
the desired result of nursing care; that which you hope to achieve with your patient and which is designed to prevent, remedy, or lessen the problem identified in the nursing diagnosis
patient outcome
Why is outcome identification needed?
-guidance in the selection of nursing interventions
-gives standard against which to compare the patient’s hourly, daily, weekly, monthly, yearly, and lifelong efforts to maintain and improve health functioning
-gives a sense of where this particular patient started from and where the individual and nurse hope to end up
-criteria used to evaluate the success of nursing intervention
-it helps motivate the nurse, the patient, and the family to continue their efforts
What are the components of an outcome statement?
Outcome Statement= patient behavior (verb) + criteria of performance + conditions or modifier + time frame
it can be seen, heard, felt, or measured by the nurse or reported by the patient
patient behavior
For risk nursing diagnosis, the outcome should not deal with the etiology but address
lessening or elimination of the problem
it is a stated level or standard for the patient behavior stated in the outcome
criterion of performance
it clarifies and individualizes the outcome based on the patient’s abilities and realistic expectations for the level of functioning in the future
criterion of performance
the level at which the patient will perform the behavior
criterion of acceptable performance
can be thought as specific aids that will help the patient perform a behavior at the level specified in the criteria portion of the outcome statement
condition
the circumstances, if necessary, under which the behavior is performed
conditions
What are the different types of time frame?
Intermediate outcomes
Long-term or Final Outcomes
Discharge outcomes
health promotion or wellness outcomes
identify behavior a patient can achieve fairly quizkly
intermediate outcomes
under intermediate outcome is
progressive intermediate outcome
give directions for nursing care over time
long-term or final outcomes
this can be though of as an eventual destination
long term or final outcomes
what are the considerations of long term or final outcomes?
prognosis of the patient health problems
resources available
strength and weaknesses of the patient function
nursing care abilities of the personnel
often appear at the end in critical pathways used with hospitalized patients
discharge outcomes
these outcomes identify the behavior the patient is expected to achieve to be safely discharged from the institution
discharge outcomes
What are the examples of health promotion or wellness outcome
physical well-being
psychosocial well-being
balance of life roles:personal, family career
are specific activities that the nurse plans and implement to help a patient achieve identified outcome
nursing interventions
nursing interventions is also called
nursing actions
nursing strategies
nursing treatment plan
nursing orders
What are the four types of nursing interventions?
Environmental Management
Physician-Initiated and Ordered Interventions
Nurse-Initiated and Physician-ordered interventions
Nurse-initiated and Ordered Intervention
Example is intravenous fluid
Physician Initiated and Ordered Intervention
What are the independent nursing interventions?
health teaching and health promotion
health counseling to help patients make informed choices
referrals to other nurses or health care professionals
what are specific nursing treatments
ambulating
repositioning
suctioning
cleaning
dressing wound
ROM exercises
optimum nutrition
What are the 6 domains
Physiological Basic
Physiological Comex
Behvaioral Ir Behavior
Safety
Family
Health Care system
Carrying out the planned nursing interventions
Implementation
Statement of the client response (NANDA label)
Problem
Factors contributing to or probable cause of the reponse
Etiology
Defining characteristics manifested by the client
Signs and symptoms
How to avoid error in diagnostic reasoning
-Verify
-Build a good knowledge on what is normal
-Have a working knowledge on what is normal
-Consult resources
-base diagnosis on patterns
-improve critical thinking dkills
A process of determining the relatedness of facts and deteemining whether any patterns are present
Analyzing data
Is generally acceptable measure, rule, model or pattern
Standard or norm
Words that have been added to some NANDA labels
Qualifiers
Inadequate amount, quantity,or degree not sufficient incomplete
Deficient
Made worse, weakened, damaged, reduced, Deteriorated
Impaired
Lesser in size, amount or degree
Decreased
Not producing the desired effect
Ineffective
To make vulnerable to threat
Compromised
It is a condition that necessitates intervention
Health problem
is a deliberative, systematic phase of the nursing process that involves decision making and problem solving
Planning
What is the end product of planning phase?
Client care plan
What are the types of planning?
Initial
Ongoing
Discharge
the process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive health care plan and should be addressed in each client’s care plan
Discharge planning
strategy for action that exists in the nurse’s mind
Informal nursing care plan
is a written or computerized guide that organizes information about the client’s care. The most obvious benefit of a formal written care plan is that it provides for continuity of care.
Formal nursing care plan
is a formal plan that specifies the nursing care for groups of clients with common needs
Standardized care plan
is tailored to meet the unique needs of a specific client—needs that are not addressed by the standardized plan
Individualized care plan
describe nursing actions for clients with similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care.
Standards of care
are developed to govern the handling of frequently occurring situations
Policies and procedures
is a written document about policies, rules, regulations, or orders regarding client care.
Standing order
Care of plan is organized jnto four sections, what are these?
Problem/nursing diagnoses
Goals or desired outcomes
Nursing interventions
Evaluation
is the evidence-based principle given as the reason for selecting a particular nursing intervention.
Rationale
is a visual tool in which ideas or data are enclosed in circles or boxes of some shape, and relationships between these are indicated by connecting lines or arrows
Concept map
What are the components of goal or desired outcome statements?
Subject
Verb
Conditions or modifiers
Cruterion of desired performance
Freedom from injury, illness, and disease
Physical well-being
Strong self-esteem and social support system
Psychosocial well-being
Personal, family care
Balance of life roles
4 areas in reviewing the Care Plan
Safety
Appropriateness
Effectiveness
Individualized nursing care
4 areas of reviewing the care plan
Safety
Appropriateness
Effectiveness
Individualized nursing care
Are instructions for specific individualized activities the nurse performs to help the client meet established health care goals
Nursing orders
