Exam 3: Chapters 14-17 Flashcards
Describe the purpose and benefits of outcome identification and planning.
- Primary purpose it to prioritze
- To identify and write expected patient outcomes
- To select evidence-based nursing interventions
- Communicate the plan of care
- *Don’t forget to communicate plan of care with patient and their family.**
Identify the 3 elements of comprehensive planning.
- Initial planning. Developed by the nurse who performs the admission nursing history and physical assessment.
- Ongoing planning. Carried out by any nurse who interacts with the patient. Any nurse who comes in contact with a PT is responsible to document that contact. CHIEF purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.
- Dishcarge planning. Carried out by the nurse who worked MOST CLOSELY WITH THE PT. Begins when the PT is admitted for treatment.
Discuss Maslow’s hierarchy of needs.
- Physiologic needs
- Safety needs
- Love and belonging
- Self-esteem
- Self-actualization
What 3 helpful guides can one utilize to prioritize patient problems?
- Maslow
- patient preference
- anticipation of future problems.
Describe how PT goals/expected outcomes and nursing orders are derived from nursing diagnoses.
It takes practice
Outcomes are derived from the problem statement of the nursing diagnosis.
For each nursing diagnosis at least one outcome should be written, that if achieved demonstrate a DIRECT resolution of the problem statement.
Nursing Outcome Classificiation (NOC)
What are short-term and long-term goals?
Long-term: more than 1 week
Short-term: Less than 1 week
What is a nursing intervention?
any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes.
Differentiate nurse-initiated interventions, physician-initiated interventions, and collaborative interventions.
Nurse-initiated: actions performed by a nurse without a doctors orders - cold packs for fever, feet up for low BP. These are actions performed by the nurse to monitor health status (dynamic) reduce risks, resolve, prevent, or manage a problem, facilitate independence and promote optimal sense of well being.
Physician-initiated: action inititated by a physician in response to a medical diagnosis but carried out by the nurse under doctor’s orders.
Collaborative: nurses may carry out treatments initiated by other providers such as pharmacists, respiratory therapists, or PA. Also PT, OT.
What is consultation?
a process in which two or more individuals with carrying degrees of experience and expertise discuss a problem and its solution, when it is discovered that more info is needed when developing a plan of care.
What is plan of nursing care (patient care plan)?
The written guide that directs efforts of the nursing team as nurses work with patients to meet their health goals. It specifies nursing diagnosis, outcomes, and interventions. Ensures that the nursing team works efficiently to deliver holistic, goal-oriented, individualized care to patients.
What is a kardex, computerized plan of nursing care, clinical pathway?
The plan of care is concisely written on folded card and placed in a central Kardex file where it is easily accessible. Teh plan is eventually placed in the patients health care record.
Describe common problems related to planning.
- failure to involve the patient in the planning process.
- insufficient data collection
- use of wrong data to develop nursing diagnosis
- outcomes state too broadly
- outcomes from poorly developed nursing dianosis
- failure to write nursing orders clearly
- written orders that do not resolve the problem
- failure to update the plan of care
what is implementing?
- the purpose is to assist the patient in achieving valued health outcomes: promote health, prevent illness and disease, restore health, facilitate coping with altered function.
- during this step- nursign actions “planned” are carried out
- best when pt has opportunities for self-care
- include patient and family
What are the advantages of having a standard classification of nursing interventions?
-standardized nomenclature
NIC and NOC outcomes
Discuss the nurse as coordinator
One of nursing’s major contributions is that Nurse’s are like a “coordinator” for patient care. Pts often feel like no one really knows what is going on with them etc. So the nurse makes rounds with all healthcare professionals and get results and lead pt through them. Nurse acts as a liaison.
