Module 7 Flashcards
Outcome Identification is essentially..
a goal
Steps of Outcome Identification / Planning
- Establish priorities
- ID and write expected patient outcomes
- Select EBP nursing interventions
- Communicate care plan
What things does a formal care plan allow the nurse to do?
Individualize Care
Facilitate Communication
Set Priorities
Give high quality care
Have coordinated care
Evaluate patient response
Create a record
Promote professional development
To Clinically Reason in the Planning (Outcome ID stage) you must…
Be familiar with policies
Keep patient at the center
Keep the “big picture” in mind
Trust clinical judgment, but do not fear asking for help
Trust your intuitions
Recognize biases and keep an open mind
What standards must be applied to planning and outcome ID?
The Law
National Practice Standards
Specialty Professional Organization
Joint Commission
AHRQ
Employer Standards
3 Elements/Types of Comprehensive Planning
Initial
Ongoing
Discharge
Initial Planning
Done by nurse who does health history and phys assessment on admission
Comes up with priority problems and identifies appropriate patient goals and related nursing care - puts nursing plan together to achieve goals
Ongoing Planning
Non-admission nurses continue care plan and might add something to the diagnosis, keep it up to date, manage risks, promote function, and state the diagnosis and new diagnosis more clearly
Makes outcomes realistic and develops new ones as needed
ID’s nursing interventions to accomplish goals
Discharge Planning
Carried out by nurse working closely with patient
Begins on admission and teaches/counsels them in effective skills and knowledge to ensure home care behaviors are done competently
Prioritizing Nursing Diagnoses
High Priority > Medium > Low
Greatest threat to well being > non threatening diagnosis > diagnoses not specifically related to current health problem
Keep maslows in mind while prioritizing
Maslow’s Hierarchy Levels
Physiologic Needs > Safety > Love and Belonging > Self-Esteem > Self-Actualization
When clinically reasoning and establishing priorities, what things should be kept in mind?
What problems need immediate attention
What is my responsibility and what to refer to others
Which problem can use standard plans
Which problems don’t have protocols or standard plans but need addressing
Has the health status changed?
Have changes in patient changed ability of the diagnosis to address the problem?
Are there diagnoses relationships that have a hierarchy of which to work on first?
Can several problems be dealt with at once?
Long-Term Outcomes
require longer periods to be achieved
Maybe used as discharge goals
Short Term Outcomes
may be accomplished in a specified time period
The parts of a measurable outcome can be determined by using ____
S M A R T
What does SMART stand for
Specific
Measurable
Attainable
Relevant
Time
Decker Care Plan Outlines Include
Nursing Diagnosis
Long Term Goal
2 Short Term Goals
2 Evidence Based Interventions
IOM
Institute of Medicine
They have stated 6 goals to be met by healthcare systems to reach quality of care
6 IOM Goals Regarding Quality of Care
Safe Care
Effective Care
Patient Centered Care
Timely Care
Efficient Care
Equitable Care
Categories of Outcome Goals
Cognitive
Psychomotor
Affective
Cognitive Outcome
Described increases in patient knowledge or intellectual behaviors
Psychomotor Outcomes
Described patient’s achievement of new skills
Affective Outcomes
Described changes in patient values, beliefs, and attitudes
3 Types of Outcomes
Clinical
Functional
Quality of Life
Clinical Outcome
describe the expected status of health issues at certain points in time, after treatment is complete.
They address whether the problems are resolved or to what degree they are improved
Functional Outcomes
describes the person’s ability to function in relation to the desired usual activities
Quality of Life Outcomes
Focus on key factors that affect someone’s ability to enjoy life and achieve personal goals
Common Errors when writing patient outcomes?
Expressing patient outcome as a nursing intervention
Using verbs that are not observable or measurable
Including more than 1 patient behavior/manifestation in short term outcomes
Writing vague outcomes
Types of Nursing Interventions
Nurse Initiated
Physician Initiated
Collaborative
Nurse Initiated Intervention
Actions performed by the nurse without a physician’s order
Physician Initiated Intervention
Action initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders
Collaborative Intervention
treatments initiated by other providers and carried out by a nurse
Under a nursing intervention, include…
explanation of rationale with evidence based reasoning
Actions commonly performed in nurse-initiated interventions
Monitoring health status
reducing risks
resolve, prevent, manage problems
Facilitate independence with assistance
Promote optimum sense of phys, psych, spirit well being
Structured Care Methodologies
These can help make nursing care plans for specific situations:
Procedure
Standards of Care
Algorithm
Clinical Practice Guidelines
Procedure
Set of how to action steps
Standards of Care
Description of acceptable level of patient care
Algorithm
set of steps used to make a decision
Clinical Practice Guideline
statement outlining appropriate practice for clinical condition or procedure
Types of Institutional Plans of Care
Computerized Plans of Care
Concept Map Plans of Care
Change of Shift Reports
Multidisciplinary (collaborative) Plans of Care
Student Plans of Care
NIC and NOC
Nursing Intervention/Outcomes Classification
What are the benefits of using NIC/NOC standardized languages?
Demonstrate impact nurses have
Defines knowledge base for nursing
Facilitates selection of approp interventions
Facilitates communication of nursing treatments to others
Enables research to examine effectiveness and cost of care
assists educators in developing curricula
Facilitates teaching of clinical decision making
assists administrators in planning
promotes development and use of nursing info systems
communicates nature of nursing in the public
Purpose of the Implementation Stage of the Nursing process
Helps patients achieve valued health outcomes
promotes health and prevents illness
restores health
facilitates coping with altered fxning
Aims for Nursing Outcome Classification Research
ID, Label, Validate, Classify Nursing Sensitive Patient outcomes and indicators
Evaluate validity and usefulness of classification
Define and test measurement procedures for outcomes and indicators
Implementing involves…
carrying out the plan
continued data collection and plan modification
documentation of care
How is clinical reasoning used with implementing
Reassesses when change in status that may need new interventions occurs
Helps find research to support best interventions
Monitors the patients responses to intervention so you can modify when needed
Alfaros Rule
Alfaro’s Rule
Assess, Reassess, Revise, and Record
*do these things when implementing care plans
Types of Nursing Interventions
Those providing direct and indirect care
Those aimed at individuals, family, and community
Those for nurse-initiated and other provider-initiated treatments
How do you implement guidelines into the nursing care plan implementation?
Act in partnership with patient
Before implementing, reassess if action still needed
Approach patient competently and caringly
Modify interventions according to patient factors
check that interventions are consistent with standard of care and in legal/ethical guides of practice
Question if intervention is the best one to use
Develop repertoire of skilled nursing interventions
How to implement the care plan
Determine patients new or cont need for assistance
promote self care (teaching, counseling, advocacy)
assist patient to achieve valued outcomes
reassess and review care plan
clarify prerequisite nursing competencies
organize resources
anticipate unexpected situations
prevent errors and omissions
assist patients to meet outcomes
What to keep in mind when reassessing the patient and reviewing the care plan
Be sure each nursing intervention has scientific rationale
Be sure each intervention is consistent with professional standards
Be sure the actions are safe for the patient and individualized to their preferences
Clarify questionable orders
Variables Influencing Outcome Achievement
Patient Variables
Nurse Variables
Health Care System Variables
Patient Variables that may influence outcome achievement
development stage
psychosocial background and culture
Nursing Variables that may influence outcome achievement
Resources
Current Standards of Care
Research Findings
Ethical and legal guides to practice
Common Reasons for Patient Noncompliance
Lack of Family Support
Lack of Understanding Benefits
Low perceived value
Adverse physical/emotional effects
Inability to afford
Limited Access
When a patient is noncompliant..
we should investigate the why (they may not want to say they cannot afford it)
Five Rights of Delegation
Right Task
Right Circumstances
Right Person
Right Direction of Communication
Right Supervision and Evaluation
Checklist for organizing STUDENT clinical responsibilities
Patient Profile and name they are to be addressed by
Patient chief complain and reason for admission
Routine assistance to meet basic human needs
Priorities for nursing care and special daily events
Special teaching, counseling, or advocacy needs
Special family needs
Evaluation step of the nursing process involves..
the nurse and patient measuring how well achievement of outcomes has occurred
Nurse ID factors contributing to ability to achieve outcomes, and when needed, modified care plan
Purpose of evaluation is to allow the patients achievement of expected outcomes to direct future nurse patient interactions
Possible Actions based on the patients response to the are plan
Termination
Modifications
Continuation
5 Elements of Evaluation
ID Evaluative Criteria
Collect Data to see if criteria are met
Interpret and Summarize findings
Document Judgment
Terminating, Continuing, or Modifying Care Plan
Criteria
Measurable qualities that specify skills, knowledge, or health status
they describe acceptable level of performance by stating expected behaviors of nurse or patient
Standards
level of performance accepted and expected by the nursing stage
established by authority, custom, or consent
Difference between Criteria and Standards
Criteria are measurable while standards are what we expect
4 Types of Patient Outcomes
Cognitive - increased knowledge
Psychomotor - achieve new skills
Affective - changes in value, belief, attitude
Physiologic - physical change
How to evaluate cognitive outcomes?
ask patient to repeat info or apply new knowledge
How to evaluate psychomotor outcomes
ask patient to demonstrate new skills
How to evaluate affective outcomes
observing patient behavior and conversation
How to evaluate physiologic outcomes
using physical assessment skill to collect and compare data
When doing evaluating statements…
describe how well the outcome was met and list patient date or behavior to support this decisions
When describing evaluation statements on short term goals we use…
Met, Partially Met, Not Met
When describing evaluation statements on long term goals we use…
the word “ongoing”
When describing evaluation statements on nursing interventions we use…
the word “done”
What things can be done in revision of the care plan?
Deletion or Modification depending on how goals turned out
Make outcome statements more realistic
Increase complexity of outcome statement
Adjust time criteria in outcome statement
Change the nursing intervention
How to ensure adequacy of evaluation in your nursing process?
Evaluate patient achievements of desired outcomes
Review how the process is used
Revise care plan as necessary
Participate in quality assurance programs
IOM’s 10 Rules to Redesign and Improve Care
- Care based on cont healing relationships
- Patient based customization
- Patient is source of control
- Shared knowledge and free info flow
- EBP decision making
- safety as priority
- the need for transparency
- anticipation of patient’s needs
- continuous decrease in waste
- cooperation among clinicians
4 Steps to Improving Nursing Process Performance
- Discover a Problem
- Plan a strategy via indicators
- Implement change
- assess change and/or plan a new strat if outcomes not met
How to improve professional performance among nurses?
Peer Review
Quality Assurance Programs
Structure Evaluations
Process Evaluation
Outcome Improvement
Nursing Audit
Concurrent and Retrospective Evaluation
QSEN
Quality and Safety Education for nurses
The purpose of this initiative is to prep nurses with info, skills, and attitudes needed to continuously improve quality and safety of health care systems
Elements of a Healthy Work Environment
Skilled communication
True collaboration
effective decision making
appropriate staffing
meaningful recognition
authentic leadership
7 Critical Conversations to have About the Health care System
Broken Rules
Mistakes
Lack of Support
Incompetence
Poor Teamwork
Disrespect
Micromanagement
Which of the 7 critical conversations to have about health care impact and put patient care at risk the most?
Poor Teamwork
Disrespect
Micromanagement
