Nursing Process - Planning, Implementation, Evaluation Flashcards
Write goals in observable or measurable terms whenever possible.
MEASURABLE
Problems that arise from normal developmental needs or that requires only minimal nursing support
Low priority problems
Includes adequacy of community-based resources
Resources
It is when either the short term goal was achieved but the long term goal was not, or the desired outcome was only PARTIALLY attained
Goal partially met
It is realistic for the patient’s capabilities in the
time span you designate your goal.
ATTAINABLE AND REALISTIC
3 other factors that can also be considered when setting priorities
- THE PROBLEMS THE PATIENT FEELS ARE MOST IMPORTANT IF THIS PRIORITY DOES NOT INTERFERE
WITH MEDICAL TREATMENT - EFFECT OF POTENTIAL PROBLEMS
- COSTS, RESOURCES AVAILABLE, PERSONNEL, TIME NEEDED TO PLAN FOR AND TREAT EACH OF THE PATIENT’S IDENTIFIED PROBLEM
Completion of the implementing phase
DOCUMENTING NURSING ACTIVITIES
(Guidelines for Writing Goals)
T or F
Derive each goal from multiple nursing diagnosis
FALSE
Derive each goal from ONLY ONE nursing diagnosis.
3 types where nurses can group diagnoses
- High priority problems
- Medium priority problems
- Low priority problems
It is realistic for the nurse’s level of skill and experience.
ATTAINABLE AND REALISTIC
(Type of Nursing Interventions)
actions that the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dieticians, and physicians; those performed jointly by nurses and other members of the health care team
Interdependent/Collaborative Interventions
________ will be more likely to carry out the care
Nurse
T or F
The nurse writes the chosen/planned nursing
interventions on the care plan.
True
It describes a change in the patient’s health status or functioning
Goal
4 PRINCIPLES IN IMPLEMENTATION OF NURSING CARE
a. maintaining the individuality of man
b. consideration for the patient’s safety, comfort and privacy
c. considering economy of time, effort and materials
d. neatness of the finished product
Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION
Goal:
Body temperature will decrease from 38.50C to 37.50C within 2 hours after administering TSB.
Patient’s behavior – body temperature will decrease
Criteria of performance – from 38.50C to 37.50C
Time – within 2 hours
Condition – after administering TSB
It is included in nursing care that which you hope to achieve with your patient.
ESTABLISHING CLIENT GOALS OR DESIRED
OUTCOMES
To be able to record client responses and/or changes in the client’s status, ________ data collection is necessary
continuing
What are the 7 things nurse should identify when planning nursing interventions?
- WHAT is TO BE DONE
- WHEN the ACTIVITY is to be done
- DURATION for EACH INTERVENTION
- any FOLLOW UP activity
- date interventions were selected
- SEQUENCE in which nursing activities are to be performed
- SIGNATURE of the NURSE writing the plan of care
If care has been ________ to other health care personnel, the nurse responsible for the client’s overall care must ensure that the activities have been implemented according to the care plan.
delegated
The nurse performs nursing interventions to resolve or reduce the identified nursing problem of the patient, with the patient, and for the patient.
Implementation
What does SMART means in writing goals?
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time bounded
any treatment based on clinical judgment and knowledge that the nurse performs to enhance patient outcomes
Nursing Interventions
Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION
Goal:
Verbalization of decreased pain from a scale of 2 to 1 (where 3=severe, 2=moderate, 1=mild, 0=no pain) within the shift.
Patient’s behavior – verbalization of decreased pain
Criteria of performance – from a scale of 2 to 1 (where 3 = severe, 2 = moderate, 1 = mild, 0 = no pain)
Time – within the shift
Condition – not stated
_________ understanding and support of nursing goals will help to assure congruence with medical treatment
Physician
3 Types of Planning
Initial Planning
Ongoing Planning
Discharge Planning
Putting the nursing care plan into action to achieve
the expected outcome
Implementation
T or F
Clients may have several problems, but nurses can only deal with one diagnosis at a time.
False
nurses often deals with MORE THAN ONE diagnoses at a time
Includes patient’s changing ability
Patient variables
It is the designated time or date when the patient should be able to achieve the behavior
Time
Type of problems that are life-threatening problems, i.e. loss of respiratory or cardiac function
High priority problems
WHO, HOW AND WHEN OF
EVALUATION
- Recipient of care and care giver
- Terminal behavior demonstrated by the patient
- Conditions under which the behavior is expected to
occur - Criterion for determining acceptable performance
It is an observable activity that the patient will demonstrate
Patient’s behavior
A planned, ongoing, purposeful activity
Evaluation
What is the formula for writing a goal statement?
Patient’s behavior + Criteria of Performance + Time + Conditions (if needed) = GOAL STATEMENT
(Guidelines for Writing Goals)
T or F
Write goals in terms of nurse activities
Write goals in terms of patient outcomes, NOT nurse
activities.
activities the nurse plans and implement to help a patient achieve identified goal
Nursing Interventions
T or F
Priorities cannot change even if client’s responses, problems, and therapies change.
False
Priorities changes
(Guidelines for Writing Goals)
T or F
Whenever possible, the goal is important and valued by
the patient and the nurses.
False
Goal is valued by patient, nurses, AND the physician
Includes the financial resources of the patient
Resources
Type of problems that are health- threatening problems, i.e. acute illness and decreased coping ability because they may result in delayed development or cause destructive physical or emotional
change
Medium priority problems
Identify outcomes in patient’s status or behavior that can be achieved fairly quickly in a matter of hours or days
Short term goals
Includes laws and regulations that affect health care and the ethical dimensions of clinical practice
Ethical and legal guides to practice
Includes adequate staff, equipment and supplies
Resources
(Type of Nursing Interventions)
includes physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, making referrals to other health care professionals
Dependent/Physician-Initiated Interventions
It is when the client’s response is THE SAME as the desired outcome
Goal met
(Type of Nursing Interventions)
those activities that nurses are licensed to initiate on the basis of their knowledge and skills
Independent/Nurse-Initiated Interventions
T or F
Nursing interventions on the care plan should be dated when they are written and reviewed regularly at intervals that depend on the nurse’ needs.
False
depend on the individual’s needs
Includes progress towards goal
Patient variables
It is the circumstances, if important, under which the behavior will be performed
Condition
_______ will be more motivated to reach the goal
Patient
All goals include a time at which point the patient is to be evaluated for goal achievement.
TIME BOUNDED
What is the Planning Process?
- Setting priorities
- Establishing client goals/ desired outcomes
- Selecting nursing interventions/ planning nursing interventions
- Writing individualized nursing interventions on care plans
(Type of Nursing Interventions)
involves carrying out actions that nurses initiate without the direction or supervision of another health care professional and that the result from their assessment of patient needs
Independent/Nurse-Initiated Interventions
Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION
Goal:
Will not manifest any sign of infection during hospitalization
Patient’s behavior – will not manifest
Criteria of performance – any sign of infection
Time – during hospitalization
Condition – not stated
Goals should be _____?
SMART
2 parts of Evaluation statement
conclusion and supporting data
Doing phase of the nursing process
Implementation
Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION
Goal:
Before discharge, the patient will ambulate length of hallway independently
Patient’s behavior – will ambulate length of hallway
Criteria of performance (how) – independently
Time (when) – before discharge
Condition – not stated
(Guidelines for Writing Goals)
T or F
It is okay to keep the goal long.
FALSE
Keep the goal SHORT.
Identify the conclusion and supporting data
Evaluative Statement:
Goal partially met: Patient refused to ambulate in the
morning but walked to the bathroom once in the
afternoon w/ the assistance of one nurse
Conclusion: Goal partially met
Supporting data: Patient refused to ambulate in the
morning but walked to the bathroom once in the
afternoon w/ the assistance of one nurse
T or F
Goals should be measurable, but you are allowed to use terms such as good, normal, adequate, and
improve, increase.
False
(Guidelines for Writing Goals)
T or F
The goal is congruent with and supportive of other therapies. (Nursing goals for the patient contradict or interfere with the work of other professionals caring for the patient).
FALSE
Nursing goals do not contradict or interfere with work of other professionals.
ASPECTS OF THE NURSE’S ROLE IN IMPLEMENTATION OF CARE
- Care aspects
- Curative
- Protective
- Teaching
- Patient advocate
How long does a goal needs for it to be considered a long term goal?
usually more than a week
Includes level of expertise, creativity, willingness to provide care, and available time
Nurse variables
(Type of Nursing Interventions)
reflect the overlapping responsibilities of and collegial
relationships between health personnel
Interdependent/Collaborative Interventions
Give direction for nursing care over time, usually more than a week.
Long term goals
5 purpose of implementation
- Assist patient in achieving desired health goals
- Promote health
- Prevent illness
- Restore health
- Facilitate coping with altered health function
4 VARIABLES THAT INFLUENCE GOAL OUTCOME
ACHIEVEMENTS
- Patient Variables
- Nurse Variables
- Resources
- Ethical and Legal guides to practice
3 Components of Nursing Intervention
- PDx (Diagnostics)
- PTx (Theapeutic)
- PEd (Education of Health Teaching)
What does ABC means in Setting Priorities?
Airway, Breathing, Circulation
Determining the client’s response to nursing interventions using the goals of care as criteria
Evaluation
What are the 3 guides for setting priorities?
- Maslow’s Hierarchy
of Needs - ABC’s of Life
- Life Preservation
(Type of Nursing Interventions)
involves carrying out nurse prescribed interventions
Independent/Nurse-Initiated Interventions
This helps safeguard the client, for example, from receiving a duplicate dose of the drug.
immediately DOCUMENTING/recording certain nursing interventions
The goal statement is a patient behavior that demonstrates reduction of the problem identified in the nursing diagnosis.
SPECIFIC
Includes previous responses to nursing interventions
Patient variables
It is the level at which the patient will perform the
behavior (how well? how long? how far?
how much?)
Criteria of performance
Includes willingness to participate in the plan of care
Patient variables
