Outcome Identification And Planning. (ch 14) Flashcards
Goal
Aim or an end
Outcome Identification and Planning
- Establish priorities.
- Identify and write expected patient outcomes.
- Select evidence-based nursing interventions.
- Communicate the plan of nursing care.
Patient outcomes
An expected conclusion to a patient health problem, or in the event of the wellness diagnosis- an expected conclusion you patient’s health expectations.
Expected outcomes
Measurable criteria used to evaluate the extent to which a goal has been met.
Initial planning
Developed by the nurse who performs the admission nursing history and physical assessment.
Addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care.
Standardized care plans
Prepared plans of care that identify the nursing diagnosis, outcomes, and related nursing interventions common to a specific population/health problem
Ongoing planning
Keeps the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.
Carried out by the nurse who interacts with the patient.
Discharge planning
Begins when the patient is admitted for treatment.
Nurse uses teaching and counseling skills effectively to help the patient/family carry out self care behaviors at home competently
Establishing priorities
High: life threatening
Medium: non life threatening
Low: not specifically related to the current health problems.
Maslow’s Hierarchy of Needs
- Physiologic needs
- Safety needs
- Love and belonging
- Self esteem needs
- Self actualization needs
Nursing Outcomes classification
Describes the patient outcomes that are responsive to nursing interventions.
Nursing intervention
Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes
Nursing intervention classification. NIC
List of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions.
Consultation
Two or more individuals with varying degrees of experience and expertise discuss problems and solutions - often proves helpful
Plan of nursing care
Written guide that directs the efforts of the nursing team as nurses work with patients to meet their health goals.
Specifies nursing diagnoses, outcomes, and associated nursing interventions.
Kardex care plan
Nursing care plan that specifies the nursing diagnosis or health problems and related outcomes of nursing interventions.
Stored in a central Kardex file and eventually placed in patients record.
Benefits of : Computerized plans of care
Ready access to large knowledge base, improved record keeping, documentation by all healthcare team with printouts for the patient’s record and for change of shift reports.
Clinical pathways. aka CareMaps
Tools used in case management to communicate the standardized, interdisciplinary plan of care for patients.
Clearly states expected patient outcomes and the specific reasonable times
Formal plan of care allows nurses to:
individualize care that maximizes outcome achievement
set priorities
facilitate communication among nursing personnel and their colleagues
promote continuity of high quality, cost effective care
coordinate care
evaluate the patient’s responses to nursing care
create a record that can be used for evaluation, research, reimbursement, and legal purposes
promote the nurse’s professional development
informal planning
link between identifying a patient’s strength or problem and providing an appropriate nursing response
Nursing’s broad aims
promote wellness
prevent disease and illness
promote recovery
facilitate coping with altered functioning
In acute care, three basic stages of planning
initial, ongoing, discharge
Outcomes are derived from?
problem statement of nursing diagnosis
Following factors should be considered when selecting outcomes:
type of health concern nursing or medical diagnoses and health problems patient characteristics patient resources patient preferences patient capacities treatment potential
Institute of Medicine in its report “Crossing the Quality Chasm” highlights six aims to be met by healthcare system with regard to quality of care
safe effective patient centered timely efficient equitable
Cognitive outcomes
describe increases in patient knowledge or intellectual behaviors
Psychomotor outcomes
describe the patient’s achievement of new skills
Affective outcomes
describe changes in the patient’s beliefs, values, and attitude
To be measurable, outcomes should have the following
subject, verb, conditions, performance criteria, target time
Nurse-initiated intervention
an autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes
Nursing interventions are actions preformed by the nurse to:
monitor health status
reduce risk
resolve, prevent, or manage a problem
facilitate independence or assist with activities of daily living
promote optimal sense of physical, psychological, and spiritual well being
Nursing-initiated interventions do not need a physician’s order. TRUE OR FALSE
TRUE
Each nursing intervention should include
Date, verb, subject, descriptive phase
Evaluative statements include?
a statement about achievement of the desired outcome and list actual patient behavior as evidence supporting the statement
Nursing care related to basic human need
the plan should concisely communicate to caregivers the data about the patient’s usual health habits and patterns obtained during the nursing history, that are needed to direct daily care
Nursing care related to nursing diagnosis
the plan contains outcomes and nursing interventions for every nursing diagnosis, as well as a place to note the patient’s responses to care
Nursing care related to the medical and interdisciplinary plan of care
the plan of care also records current medical orders for diagnostic studies and treatment and specified related nursing care
Concept map care plan
diagram of patient problems and interventions. ideas about the patient problems and treatments are the concepts that are diagrammed
