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FUNDA > Nursing Process - Planning, Implementation, Evaluation > Flashcards

Nursing Process - Planning, Implementation, Evaluation Flashcards

1
Q

Write goals in observable or measurable terms whenever possible.

A

MEASURABLE

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2
Q

Problems that arise from normal developmental needs or that requires only minimal nursing support

A

Low priority problems

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3
Q

Includes adequacy of community-based resources

A

Resources

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4
Q

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

A

Goal partially met

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5
Q

It is realistic for the patient’s capabilities in the
time span you designate your goal.

A

ATTAINABLE AND REALISTIC

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6
Q

3 other factors that can also be considered when setting priorities

A
  1. THE PROBLEMS THE PATIENT FEELS ARE MOST IMPORTANT IF THIS PRIORITY DOES NOT INTERFERE
    WITH MEDICAL TREATMENT
  2. EFFECT OF POTENTIAL PROBLEMS
  3. COSTS, RESOURCES AVAILABLE, PERSONNEL, TIME NEEDED TO PLAN FOR AND TREAT EACH OF THE PATIENT’S IDENTIFIED PROBLEM
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7
Q

Completion of the implementing phase

A

DOCUMENTING NURSING ACTIVITIES

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8
Q

(Guidelines for Writing Goals)

T or F

Derive each goal from multiple nursing diagnosis

A

FALSE

Derive each goal from ONLY ONE nursing diagnosis.

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9
Q

3 types where nurses can group diagnoses

A
  1. High priority problems
  2. Medium priority problems
  3. Low priority problems
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10
Q

It is realistic for the nurse’s level of skill and experience.

A

ATTAINABLE AND REALISTIC

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11
Q

(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

A

Interdependent/Collaborative Interventions

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12
Q

________ will be more likely to carry out the care

A

Nurse

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13
Q

T or F

The nurse writes the chosen/planned nursing
interventions on the care plan.

A

True

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14
Q

It describes a change in the patient’s health status or functioning

A

Goal

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15
Q

4 PRINCIPLES IN IMPLEMENTATION OF NURSING CARE

A

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

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16
Q

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.

A

Patient’s behavior – body temperature will decrease
Criteria of performance – from 38.50C to 37.50C
Time – within 2 hours
Condition – after administering TSB

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17
Q

It is included in nursing care that which you hope to achieve with your patient.

A

ESTABLISHING CLIENT GOALS OR DESIRED
OUTCOMES

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18
Q

To be able to record client responses and/or changes in the client’s status, ________ data collection is necessary

A

continuing

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19
Q

What are the 7 things nurse should identify when planning nursing interventions?

A
  1. WHAT is TO BE DONE
  2. WHEN the ACTIVITY is to be done
  3. DURATION for EACH INTERVENTION
  4. any FOLLOW UP activity
  5. date interventions were selected
  6. SEQUENCE in which nursing activities are to be performed
  7. SIGNATURE of the NURSE writing the plan of care
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20
Q

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.

A

delegated

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21
Q

The nurse performs nursing interventions to resolve or reduce the identified nursing problem of the patient, with the patient, and for the patient.

A

Implementation

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22
Q

What does SMART means in writing goals?

A

S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time bounded

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23
Q

any treatment based on clinical judgment and knowledge that the nurse performs to enhance patient outcomes

A

Nursing Interventions

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24
Q

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.

A

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

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25
Q

_________ understanding and support of nursing goals will help to assure congruence with medical treatment

A

Physician

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26
Q

3 Types of Planning

A

Initial Planning
Ongoing Planning
Discharge Planning

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27
Q

Putting the nursing care plan into action to achieve
the expected outcome

A

Implementation

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28
Q

T or F

Clients may have several problems, but nurses can only deal with one diagnosis at a time.

A

False

nurses often deals with MORE THAN ONE diagnoses at a time

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29
Q

Includes patient’s changing ability

A

Patient variables

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30
Q

It is the designated time or date when the patient should be able to achieve the behavior

A

Time

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31
Q

Type of problems that are life-threatening problems, i.e. loss of respiratory or cardiac function

A

High priority problems

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32
Q

WHO, HOW AND WHEN OF
EVALUATION

A
  1. Recipient of care and care giver
  2. Terminal behavior demonstrated by the patient
  3. Conditions under which the behavior is expected to
    occur
  4. Criterion for determining acceptable performance
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33
Q

It is an observable activity that the patient will demonstrate

A

Patient’s behavior

34
Q

A planned, ongoing, purposeful activity

A

Evaluation

35
Q

What is the formula for writing a goal statement?

A

Patient’s behavior + Criteria of Performance + Time + Conditions (if needed) = GOAL STATEMENT

36
Q

(Guidelines for Writing Goals)

T or F

Write goals in terms of nurse activities

A

Write goals in terms of patient outcomes, NOT nurse
activities.

37
Q

activities the nurse plans and implement to help a patient achieve identified goal

A

Nursing Interventions

38
Q

T or F

Priorities cannot change even if client’s responses, problems, and therapies change.

A

False

Priorities changes

39
Q

(Guidelines for Writing Goals)

T or F

Whenever possible, the goal is important and valued by
the patient and the nurses.

A

False

Goal is valued by patient, nurses, AND the physician

40
Q

Includes the financial resources of the patient

A

Resources

41
Q

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

A

Medium priority problems

42
Q

Identify outcomes in patient’s status or behavior that can be achieved fairly quickly in a matter of hours or days

A

Short term goals

43
Q

Includes laws and regulations that affect health care and the ethical dimensions of clinical practice

A

Ethical and legal guides to practice

44
Q

Includes adequate staff, equipment and supplies

A

Resources

45
Q

(Type of Nursing Interventions)

includes physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, making referrals to other health care professionals

A

Dependent/Physician-Initiated Interventions

46
Q

It is when the client’s response is THE SAME as the desired outcome

A

Goal met

47
Q

(Type of Nursing Interventions)

those activities that nurses are licensed to initiate on the basis of their knowledge and skills

A

Independent/Nurse-Initiated Interventions

48
Q

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.

A

False

depend on the individual’s needs

49
Q

Includes progress towards goal

A

Patient variables

50
Q

It is the circumstances, if important, under which the behavior will be performed

A

Condition

51
Q

_______ will be more motivated to reach the goal

A

Patient

52
Q

All goals include a time at which point the patient is to be evaluated for goal achievement.

A

TIME BOUNDED

53
Q

What is the Planning Process?

A
  1. Setting priorities
  2. Establishing client goals/ desired outcomes
  3. Selecting nursing interventions/ planning nursing interventions
  4. Writing individualized nursing interventions on care plans
54
Q

(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

A

Independent/Nurse-Initiated Interventions

55
Q

Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION

Goal:
Will not manifest any sign of infection during hospitalization

A

Patient’s behavior – will not manifest
Criteria of performance – any sign of infection
Time – during hospitalization
Condition – not stated

56
Q

Goals should be _____?

A

SMART

57
Q

2 parts of Evaluation statement

A

conclusion and supporting data

58
Q

Doing phase of the nursing process

A

Implementation

59
Q

Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION

Goal:
Before discharge, the patient will ambulate length of hallway independently

A

Patient’s behavior – will ambulate length of hallway
Criteria of performance (how) – independently
Time (when) – before discharge
Condition – not stated

60
Q

(Guidelines for Writing Goals)

T or F

It is okay to keep the goal long.

A

FALSE

Keep the goal SHORT.

61
Q

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

A

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

62
Q

T or F

Goals should be measurable, but you are allowed to use terms such as good, normal, adequate, and
improve, increase.

A

False

63
Q

(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).

A

FALSE

Nursing goals do not contradict or interfere with work of other professionals.

64
Q

ASPECTS OF THE NURSE’S ROLE IN IMPLEMENTATION OF CARE

A
  1. Care aspects
  2. Curative
  3. Protective
  4. Teaching
  5. Patient advocate
65
Q

How long does a goal needs for it to be considered a long term goal?

A

usually more than a week

66
Q

Includes level of expertise, creativity, willingness to provide care, and available time

A

Nurse variables

67
Q

(Type of Nursing Interventions)

reflect the overlapping responsibilities of and collegial
relationships between health personnel

A

Interdependent/Collaborative Interventions

68
Q

Give direction for nursing care over time, usually more than a week.

A

Long term goals

69
Q

5 purpose of implementation

A
  1. Assist patient in achieving desired health goals
  2. Promote health
  3. Prevent illness
  4. Restore health
  5. Facilitate coping with altered health function
70
Q

4 VARIABLES THAT INFLUENCE GOAL OUTCOME
ACHIEVEMENTS

A
  1. Patient Variables
  2. Nurse Variables
  3. Resources
  4. Ethical and Legal guides to practice
71
Q

3 Components of Nursing Intervention

A
  1. PDx (Diagnostics)
  2. PTx (Theapeutic)
  3. PEd (Education of Health Teaching)
72
Q

What does ABC means in Setting Priorities?

A

Airway, Breathing, Circulation

73
Q

Determining the client’s response to nursing interventions using the goals of care as criteria

A

Evaluation

74
Q

What are the 3 guides for setting priorities?

A
  1. Maslow’s Hierarchy
    of Needs
  2. ABC’s of Life
  3. Life Preservation
75
Q

(Type of Nursing Interventions)

involves carrying out nurse prescribed interventions

A

Independent/Nurse-Initiated Interventions

76
Q

This helps safeguard the client, for example, from receiving a duplicate dose of the drug.

A

immediately DOCUMENTING/recording certain nursing interventions

77
Q

The goal statement is a patient behavior that demonstrates reduction of the problem identified in the nursing diagnosis.

A

SPECIFIC

78
Q

Includes previous responses to nursing interventions

A

Patient variables

79
Q

It is the level at which the patient will perform the
behavior (how well? how long? how far?
how much?)

A

Criteria of performance

80
Q

Includes willingness to participate in the plan of care

A

Patient variables

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