Nursing Plan of Care Flashcards
A four column nursing plan contains what four columns?
Nursing diagnoses
Goals/Desired outcomes
Nursing interventions
Evaluation
A three-column nursing plan contain what three columns?
Nursing Diagnoses
Goals/desired outcomes
Nursing interventions
A five-column nursing plan contains what five columns?
Assessment Nursing diagnoses Goals/desired outcomes Nursing interventions Evaluation
Concept map
Enhances clinical reasoning by showing how individual steps of the nursing process relate to each other in a logical pattern.
Serves as a visual guide of clinical data to help prioritize client needs
Standardized plan
Identifies nursing care needed for groups of clients with common health problems
Clinical pathway
Standardized, evidence-based, multidisciplinary plan that outlines the expected care required for clients with common, predictable health problems.
Low priority problems
Problems that can be resolved easily with minimal interventions and do not cause significant dysfunction.
Medium priority problems
Problems that may cause unhealthy physical or emotional consequences but are not life threatening
High priority problems
Life-threatening problems of airway breathing and circulation, or conditions that have a potential to become life threatening within a short amount of time
Urgency Factor: Non-acute
A delay in providing these interventions would not negatively impact client outcomes
Urgency Factor: Acute
A low potential for the client’s condition to become life threatening exists. Interventions are usually scheduled during the shift when time constraints of higher priorities are completed
Urgency Factor: Critical
Considered medium-high urgency. The nurse needs to respond quickly to a high priority physical or psychological problem within a short period of time because of the potential for the client’s condition to become life threatening if the intervention is delayed.
Urgency Factor: Imminent Death
Highest urgency level.
Interventions address airway obstruction, absence of breathing, or ineffective cardiac functioning.
Immediate intervention is needed to save the client’s life.
Prioritizing by time constraints
Some interventions have time restraints. i.e. providing an antibiotic at the right time so that peak and trough drug levels are correctly measured
Triage: Emergent or immediate
The client has a life-threatening issue that needs immediate intervention
Triage: Urgent or delayed
The client has a serious health problem. However, delaying treatment would not cause a life-threatening situation
Triage: Non-urgent or minor
The client has a health issue that does not require immediate care. The client can ambulate and is in no acute distress.
Prioritizing care Ranking activities: Priority 1 or Must Do
Activities that take priority over any other interventions, such as suctioning secretions from a blocked endotracheal tube
Prioritizing care Ranking activities: Priority 2 or Should Do
Activities that should be done, but are not essential, such as putting more paper towels next to the sink in the room of a client with a wound infection
Prioritizing care Ranking activities: Priority 3 or Nice to Do
Actions can be done when there is available time, such as washing a client’s hair
Factors to consider when prioritizing care: Ethics
The ethical principles of justice and fairness are used when prioritizing care
Factors to consider when prioritizing care: Safety
Nurses protect clients and provide a safe environment by following the approach “to do no harm”
Factors to consider when prioritizing care: Availability of resources
If resources are insufficient or absent, reprioritization may be needed.
Factors to consider when prioritizing care: Time management
Nurses determine the amount of time needed to complete an intervention and the urgency in which to complete it.
Factors to consider when prioritizing care: Multiple clients
Nurses determine which interventions are priorities for assigned clients and then set the priority for completion
Factors to consider when prioritizing care: PT preferences
Nurses take the pts needs and desires into consideration when prioritizing care.
Factors to consider when prioritizing care: Change in pt condition
Nurses must be aware of which pts health statuses have changed in order to reprioritize care actions.
Factors to consider when prioritizing care: The unexpected
Things do not always go as planned and must reprioritize interventions as necessary to meet the most urgent client needs
Factors to consider when prioritizing care: Nurse self-care
A short time away from pt care is beneficial to break up the intensity of the work environment and relieve stress
Factors to consider when prioritizing care: Delegation
Delegation helps complete more priority interventions. Taks evaluation needs to be performed after completion.
