Nursing Process: Planning

Question 1

Third step of the nursing process

Answer 1

Planning

Question 2

4 Main Purposes of Plan of Care

Answer 2

1. Promotes communication among caregivers to promote continuity of care.
2. Directs care and documentation.
3. Creates a record that can later be used for evaluation, research, and legal reason.
4. Provides documentation of health care needs for insurance reimbursement purposes.

Question 3

ACTIVITIES OF THE PLANNING PHASE

Answer 3

→ Attending to urgent priorities.
→ Clarifying expected outcomes.
→ Deciding which problems must be prescribed.
→ Determining individualized nursing interventions.
→ Making sure the plan is adequately recorded.

Question 4

TRUE OR FALSE?

Focus on what MUST be achieved before what’s NICE to do.

Answer 4

TRUE

Question 5

Deciding which problem must be recorded is influenced by your understanding of:

Answer 5

✓ The whole picture of all the problems present
✓ The person’s overall health status and expected discharge outcomes.
✓ The expected length of contact with the patient.
✓ Focus on what MUST be achieved before what’s NICE to do.
✓ The patient’s perception of priorities
✓ Whether there are standard plans that apply, are there critical pathways? Guidelines? Protocols?

Question 6

“Always check policies and procedures for recording the plan, as they are designed to help ____ ______ and protect ___ ____ ______.”

Answer 6

“Always check policies and procedures for recording the plan, as they are designed to help your patient and protect you from legal liability.”

Question 7

BASIC PRINCIPLES: ATTENDING TO URGENT PRIORITIES.

Answer 7

1. Choose a method of assigning priorities and use it consistently.
2. Maslow’s hierarchy of needs.
3. Problems usually present in a cluster

Question 8

TRUE OR FALSE?

Study the relationships among the problems to determine major priorities.

Answer 8

TRUE

Question 9

TRUE OR FALSE?

Assign high priority to problems that does not contribute to other problems.

Answer 9

FALSE

Assign high priority to problems that contribute to other problems.

Question 10

It serves the purpose of ordering the delivery of nursing care so that the more important or life-
threatening problems are treated before less critical problems are treated.

Answer 10

Setting Priorities

Question 10

TRUE OR FALSE?

Consider state laws, hospital policy statements, and outcome criteria established for the particular setting.

Answer 10

TRUE

Question 11

TRUE OR FALSE?

Do not consider the effect of potential problems when setting priorities.

Answer 11

FALSE

Consider the effect of potential problems when setting priorities.

Question 12

TRUE OR FALSE?

Consider costs, resources available, personnel and time needed to plan and treat each of the patient’s identified problems.

Answer 12

TRUE

Question 13

TRUE OR FALSE?

Focus on the problems the patient feel are less important if this priority does not interfere with medical treatment.

Answer 13

FALSE

Focus on the problems the patient feel are MOST important if this priority does not interfere with medical treatment.

Question 14

TRUE OR FALSE?

It is okay not to consider the patient’s culture, values, and beliefs when setting priorities.

Answer 14

FALSE

Consider the patient’s culture, values, and beliefs when setting priorities.

Question 15

TRUE OR FALSE?

Maslow’s hierarchy of basic need cannot guide the selection of high- priority problems.

Answer 15

FALSE

Maslow’s hierarchy of basic need can guide the selection of high- priority problems.

Question 16

CLARIFYING OR ESTABLISHING OUTCOMES (RESULTS)

Answer 16

→ Patient outcome
→ The desired result of nursing care
→ That which one hopes to achieve with the patient and which is designed to prevent, remedy or lessen the problem identified in the nursing diagnosis.

Question 17

OUTCOME IDENTIFICATION

Answer 17

The nurse identifies expected outcomes individualized to the patients.

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.

Question 18

refer to the INTENT.

Answer 18

Goals and Objectives

Question 19

refers to results.

Answer 19

Outcomes

Question 20

What you intend to do.

Answer 20

Goals and Objectives

Question 21

What you expect the patient to be able to do

Answer 21

Outcomes

Question 22

Describes what will be observed in the patient after care is done to show the benefits of nursing care.

Answer 22

Expected Outcomes

Question 23

3 MAIN PURPOSES OF EXPECTED OUTCOMES

Answer 23

1. They are the “measuring sticks.” For the plan of care.
2. They direct interventions.
3. They are motivating factors.

Question 24

At a basic level, determining outcomes requires you to simply “________ ___ _______” or state what you expect to observe in the patient after you perform an intervention.

Answer 24

“reverse the problem”

Question 25

Describe the benefits expected to be seen at a certain point in time after the plan has been implemented.

Answer 25

LONG TERM OUTCOME-

Question 26

State what you expect to observe in the patient when the problems are resolved or controlled.

Answer 26

PROBLEM OUTCOMES

Question 26

Describe early expected benefits of nursing interventions.

Answer 26

SHORT TERM OUTCOME-

Question 27

State the benefit you expect to observe in the patient after an intervention is performed.

Answer 27

INTERVENTION OUTCOMES-

Question 28

Outcome may relate to problems or interventions. What are they?

Answer 28

TRUE PROBLEM OUTCOMES INTERVENTION OUTCOMES

Question 29

Outcomes describe the specific benefits you expect to see in the patient after care has been given.

Answer 29

TRUE SHORT TERM OUTCOME LONG TERM OUTCOMES

Question 30

COMPONENTS OF OUTCOME STATEMENTS

Answer 30

→ Subject → Verb → Condition → Performance criteria → Target time.

Question 31

Changes in attitude, feelings, or values.

Answer 31

Affective domain

Question 32

Dealing with acquired knowledge or intellectual skills.

Answer 32

Cognitive domain

Question 32

Dealing with developing motor skills.

Answer 32

Psychomotor domain

Question 33

What actions must the person take to achieve the outcome?

Answer 33

VERB

Question 34

Who is the person expected to achieve the outcome.

Answer 34

SUBJECT

Question 35

Under what circumstances is the person to perform the actions?

Answer 35

CONDITION

Question 36

How well is the person to perform the actions?

Answer 36

PERFORMANCE CRITERIA

Question 36

By when is the person expected to be able to perform the actions?

Answer 36

TARGET TIME

Question 37

An observable activity to the patient will demonstrate at some time in the future showing improvement in the problem area.

Answer 37

Patient Behavior

Question 38

Not all outcomes will have______.

Answer 38

conditions

Question 39

TRUE OR FALSE? Specific aides which will facilitate the patient performing a behavior at the level in the criteria and within specified time frame.

Answer 39

TRUE

Question 40

TRUE OR FALSE? Specific aids that will help the patient perform a behavior at the level specified in the criteria portion of the outcome statement.

Answer 40

TRUE

Question 41

A stated level or standard for the patient behavior stated in the outcome.

Answer 41

PERFORMANCE CRITERIA

Question 42

It specifies a realistic improvement in functioning in the problem area by stated time and will be used to determine whether the outcome was satisfactorily achieved.

Answer 42

PERFORMANCE CRITERIA

Question 43

A time or date to clarify how long it would realistically take for the patient to reach the level of functioning stated in the criteria part of the outcome.

Answer 43

TIME FRAME

Question 44

A designated time or date when the patient should be able to achieve the behavior.

Answer 44

TIME FRAME

Question 45

It clarifies and individualizes the outcome based on the patient’s ability and a realistic expectation for the level of functioning in the future.

Answer 45

PERFORMANCE CRITERIA

Question 46

TYPES OF TIME FRAME

Answer 46

A. INTERMEDIATE OUTCOMES B. LONG TERM OR FINAL OUTCOMES C. DISCHARGE OUTCOMES.

Question 47

It identifies behavior a patient can achieve quickly. A. INTERMEDIATE OUTCOMES B. LONG TERM OR FINAL OUTCOMES C. DISCHARGE OUTCOMES.

Answer 47

A. INTERMEDIATE OUTCOMES

Question 48

It gives direction for the nursing care over time. A. INTERMEDIATE OUTCOMES B. LONG TERM OR FINAL OUTCOMES C. DISCHARGE OUTCOMES.

Answer 48

B. LONG TERM OR FINAL OUTCOMES

Question 49

It appears in the end of the critical pathways used with the hospitalized patient.

Answer 49

C. DISCHARGE OUTCOMES.

Question 50

It tries to identify the maximum level of functioning possible for a patient with a particular nursing diagnosis. A. INTERMEDIATE OUTCOMES B. LONG TERM OR FINAL OUTCOMES C. DISCHARGE OUTCOMES.

Answer 50

B. LONG TERM OR FINAL OUTCOMES

Question 51

It identifies the behavior the patient is expected to achieve to be safely discharged from the institution. A. INTERMEDIATE OUTCOMES B. LONG TERM OR FINAL OUTCOMES C. DISCHARGE OUTCOMES.

Answer 51

C. DISCHARGE OUTCOMES.

Question 52

TRUE OR FALSE? Keep outcome long.

Answer 52

FALSE Keep outcome short.

Question 53

TRUE OR FALSE? Make outcome specific.

Answer 53

TRUE

Question 54

TRUE OR FALSE? Whenever possible, the outcome is important and valued by the patient and family only

Answer 54

FALSE Whenever possible, the outcome is important and valued by the patient, family, the nurse and the physician.

Question 55

TRUE OR FALSE? The outcome is an observable or immeasurable patient behavior.

Answer 55

FALSE The outcome is an observable or measurable patient behavior.

Question 56

TRUE OR FALSE? The outcome is congruent with and supportive of other therapies.

Answer 56

TRUE

Question 57

TRUE OR FALSE? For an actual nursing diagnosis, the outcome is a patient behavior that demonstrates reduction or alleviation of the problem.

Answer 57

TRUE

Question 58

TRUE OR FALSE? The outcome is a realistic for the patient’s capabilities in the time span you designate in your outcome.

Answer 58

TRUE

Question 59

TRUE OR FALSE? For at risk medical diagnosis, the outcome is a patient behavior that demonstrates the maintenance of the current status of health or functioning.

Answer 59

FALSE For at risk NURSING diagnosis, the outcome is a patient behavior that demonstrates the maintenance of the current status of health or functioning.

Question 60

TRUE OR FALSE? Derive each outcome from only one nursing diagnosis.

Answer 60

TRUE

Question 61

TRUE OR FALSE? The outcome can be unrealitic for the nurse’s level of skill, experience and time/ workload.

Answer 61

FALSE The outcome realistic for the nurse’s level of skill, experience and time/ workload.

Question 62

TRUE OR FALSE? Designate a specific time for the achievement of each outcome.

Answer 62

TRUE

Question 63

TRUE OR FALSE? Write outcomes in terms of nursing actions behavior, patient behavior.

Answer 63

FALSE Write outcomes in terms of patient behavior, not nursing actions.

Question 64

3 BASIC STEPS TO DETERMINING WHICH PROBLEMS MUST BE RECORDED

Answer 64

1. Create a problem list. 2. Decide which problem must be managed in order to achieve the overall outcomes of care 3. Determine what documentation will guide how to teach problem will be managed.

Question 65

PLANNING – BEGIN BY PRIORITIZING CLIENT PROBLEMS

Answer 65

→ Prioritize list of client’s nursing diagnoses using Maslow. → Rank as high, intermediate or low. → Client specific → Priorities can change.

Question 66

TYPES OF PLANNING

Answer 66

→ Initial → Ongoing → Discharge

Question 67

Admission A. Initial B. Ongoing C. Discharge

Answer 67

A. Initial

Question 68

Confinement A. Initial B. Ongoing C. Discharge

Answer 68

B. Ongoing

Question 69

Before discharge A. Initial B. Ongoing C. Discharge

Answer 69

C. Discharge

Question 70

PLANNING – TYPES OF GOALS

Answer 70

→ Short term goals → Long term goals

Question 71

GOALS ARE PATIENT CENTERED AND SMART

Answer 71

o S - Specific o M – measurable o A – attainable o R – relevant o T – time bound

Question 72

INTERVENTIONS – 3 TYPES

Answer 72

→ INDEPENDENT (Nurse initiated) → DEPENDENT (Physician initiated) → COLLABORATIVE

Question 73

Any action the nurse can initiate without direct supervision.

Answer 73

INDEPENDENT (Nurse initiated)

Question 74

Nursing action requiring MD orders.

Answer 74

DEPENDENT (Physician initiated)

Question 75

Nursing actions performed jointly with other health care team members.

Answer 75

COLLABORATIVE

Question 76

OTHER FACTORS IN PRIORITIZING:

Answer 76

→ Client’s health status and belief. → Client’s priorities → Available resources → Urgency of the health problem → Medical treatment plan.