Module 03: Fundamental Nursing Process (Part 02) Flashcards
Under the nursing process, this transpires after identifying a patient’s nursing diagnoses & collaborative problems.
Planning
What does planning under the nursing process include?
(1) Prioritizes the diagnoses.
(2) Sets patient-centered goals & expected outcomes.
According to Ackley and Ludwig, 2014, what is planning?
The nurse collaborates with a patient & family (as appropriate) & the rest of the health care team to determine the urgency of the identified problems & prioritizes patient needs.
What should nurses consider when planning?
(1) Planning requires critical thinking.
(2) Individualize a plan of care for a patient’s unique needs.
(3) Communicating closely with patients, families & health care team.
This is the act of ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.
Priority Setting
Why are priorities important?
Priorities helps to anticipate & sequence nursing interventions.
How do you set priorities?
Set priorities by selecting mutually agreed- on priorities with a patient on the basis of urgency of patient’s problems, safety, nature of treatment & the
relationship among the diagnoses.
How does a nurse classify priorities?
(1) High
(2) Intermediate
(3) Low importance
This considers nursing diagnosis of high priority.
Maslow’s Hierarchy of Needs
When can you say that the situation is high priority?
It is high priority nursing diagnosis when it drives priorities by selecting mutually agreed- on priorities with a patient on the basis of urgency of patient’s problems, safety, nature of treatment & the
relationship among the diagnoses. (Acute Pain)
When can you say that the situation is intermediate priority?
When it involves non-emergent, none life-threatening needs of patients. (Risk for Infection)
When can you say that the situation is low priority?
When it is not always directly related to specific illness or prognosis (Anxiety)
How do you set priorities in the clinical nursing practice?
(1) Assess the patient
(2) Identify the problem
(3) Prioritize problems
(4) Identify desired outcomes
(5) Identify interventions for achieving outcomes
(6) Prioritize interventions
(7) Deliver patient care
(8) Evaluate interventions
What are the factors that affect priority setting in the clinical nursing practice?
(1) Experience and expertise of nurse
(2) Patient acuity
(3) Availability of resources
(4) Interruptions from care providers
(5) Nurse-patient relationship
(6) Ward organization
(7) Priority setting strategies and frameworks
(8) Philosophies and models of care
What are the questions that you need to ask when setting goals and expected outcomes?
(1) What do I plan to achieve?
(2) How will I know when I have achieved what I want?
This describes a desired change in a patient’s condition, perceptions, or behavior.
Goal
This is the measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal.
Expected Outcome
This is the patient’s highest possible level of wellness & independence in function.
Patient-centered goal
What constitutes patient-centered goal?
(1) Mission and values aligned with patient goals
(2) Care is collaborative, coordinated, and accessible.
(3) Physical comfort and emotional well-being are top priorities
(4) Patient and family viewpoints respected and values
(5) Patient and family always included in decisions
(6) Family welcome in care setting
(7) Full transparency and fast delivery of information
Is this a goal statement or an outcome statement, “Patient will ambulate independently in 3 days”.
Goal statement
Is this a goal statement or an outcome statement, “Patient ambulates in the hall 3 times a day by 4/22.”
Outcome Statement
What does SMART mean?
(1) Specific
(2) Measurable
(3) Attainable
(4) Realistic
(5) Timed
Under SMART, in this each goal & outcome addresses only one behavior, perception, or physiological response.
Specific
Why is the statement “Patient will administer a self-injection
and demonstrate infection control measures.” wrong?
The statement uses two approaches namely administer and demonstrate. Hence, the statement should be - Patient will administer a self-injection and demonstrate infection control measures.
The nurse should word each goal separately.
(a) “Patient will administer a self-injection by discharge”.
(b) “Patient will demonstrate infection control measures at home”.
Under SMART, in this the goals and the expected outcomes are the standards against which to measure or observe a patient’s response.
Measurable
What is another condition for a measurable outcome?
Goals & expected outcomes are the standards against which to measure or observe a patient’s response.
Example: “Apical pulse will remain between 60 and 100 beats/min”.
Under SMART, in this, a goal & an outcome likely are attainable when mutually set with the patient.
Example: Distance to walk; topics to learn about medications.
Attainable
In this, the goals and expected outcomes that a patient is able to realistically reach.
Example: Patient who experienced stroke. “Assuming self-care with bathing”.
Initial goal: “Patient will wash hands & face in 72 hours.
Realistic
Under SMART, the goal and outcome is time limited so health care team has a common time frame for problem resolution.
Example: Patient will achieve pain relief by day of discharge.
Timed
This type of intervention can be executed solely by the nurse and require no doctor’s order.
Independent intervention
What are some examples of independent intervention?
(1) Positioning patients
(2) Instructing patients in side effects of medications
(3) Providing skin care
This type of intervention cannot be executed solely by the nurse and require doctor’s order.
Dependent interventions
What are some examples of dependent intervention?
(1) Medication administration
(2) Inserting FC and IV
(3) Preparing patient for diagnostic test
This type of intervention cannot be done solely by the nurse and entails work from different healthcare professionals like respiratory therapist and nutritionists.
Collaborative interdependent
What are some examples of collaborative interdependent intervention?
(1) Consultation with respiratory therapist
(2) Consultation with Dietician
(3) Physical Therapy
What should nurses do under planning?
(1) Establish a plan of care that
prioritizes the diagnoses & establishes nursing interventions, patient-centered
goals, & expected outcomes.
(2) Plan individualize plan of care for a patient’s unique needs.
What do outcomes provide?
Outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses.
This approach in the nursing process begins after you develop a plan of care.
Implementation
What does implementation include?
Direct and indirect care measures
What should implementation be?
Patient-centered
These are preprinted document containing orders for routine therapies, monitoring guidelines, and/or diagnostic procedures.
Standing Orders
(Example: Order specifying certain medication. (Cardizem,
Cordarone)
What are the purpose of nursing interventions classifications?
(1) Standardizing the nomenclature
(2) Expanding nursing knowledge about connections among nursing diagnoses, treatments, & outcomes.
(3) Developing NIC language into software of health care information systems.
(4) Teaching decision making to students; defining & classifying N.I.
(5) Expanding nursing knowledge about connections among nursing diagnoses, treatments, & outcomes.
(6) Determining the cost of services provided by nurses.
(7) Standardizing a clear & consistent language to communicate the unique functions of nursing.
(8) Linking with the classification systems of other health care providers.
Explain the implementation process?
(1) Reassessing a patient
(2) Reviewing and revising the existent care plan
(3) Preparing for implementation
(4) Anticipating and preventing complications
(5) Implementation skills (cognitive, interpersonal, and psychomotor)
This type of care includes activities of daily living like ambulation, dressing and eating.
Direct Care
This includes, shopping, preparing meals, and taking medications.
Instrumental ADL’s
What are examples of direct care?
(1) Physical care techniques e.g turning & positioning, administering medications
(2) Lifesaving measure e.g CPR, administering “E” drugs
(3) Counseling
(4) Teaching
(5) Controlling for adverse reactions
What are examples of indirect care?
(1) Communicating N.I
(2) Delegating, supervising & evaluating the work of other staff members
What should nurses consider under implementation?
(1) The implementation of
nursing skills requires additional K, nursing skills & personnel resources.
(2) Know the purpose of each intervention.
This is the final step of the nursing process.
Evaluation
Under the nursing process, this pertains to the expected outcomes established during
planning are the standards whether goals have been met.
Evaluation
According to She-Yuan et al. 2013, what are the indicators of evaluation?
(1) Examine the results according to clinical data
(2) Compare achieved effect with goals and expected outcomes
(3) Recognize errors
(4) Understand patient situation, participate self-reflection and correct errors
What are the steps in evaluating outcomes of care?
(1) Examine the outcome criteria to identify the exact desired patient behavior or response.
(2) Evaluate patient’s actual behavior or response
(3) Compare established outcome criteria with the actual behavior or response
(4) Judge the degree of agreement between outcome and actual behavior
What are the components of a care plan revision?
(1) Discontinuing a care plan
(2) Modifying a care plan
(3) reassessment
(4) Redefining diagnoses
(5) Goals and expected outcomes (time frame)
(6) Interventions
This is the minimum level of care accepted to ensure high quality of patient care.
Standard of care
In this, the nurse collaborates and evaluates effectiveness of interventions as well as documents results.
Standards of Evaluation
What are the two components of evaluation?
(1) Examination of condition
(2) Judgement
This occurs when the desired goals and expected outcomes are met.
Positive evaluation
These are assessment skills use to collect data for determining
if outcomes are met.
Evaluative measures
This allows all members of the health care team to know whether or not a patient is
progressing.
Documentation of evaluative
findings
What happens do the nursing diagnosis after evaluation?
A patient’s nursing diagnoses, priorities, and interventions sometimes change as a result of
evaluation.
What are the two factors examined by evaluation?
Evaluation examines two factors:
appropriateness of the interventions & the correct
application of the intervention.
