planning

Question 1

what is initial planning?

Answer 1

Begins with first client contact

Written as soon as possible after initial assessment

Development of the initial comprehensive care plan

Question 2

what is ongoing planning?

Answer 2

Changes made in the plan as you evaluate the client’s responses to care

Question 3

what is formal planning?

Answer 3

Formal planning is a conscious, deliberate activity involving decision making, critical thinking, and creativity”

Question 4

what is informal planning?

Answer 4

Making mental notes or plans

Question 5

what is discharge planning?

Answer 5

Planning for self-care and continuity of care after client leaves health-care setting

Begins with initial assessment

All clients need discharge planning

Requires collaboration

Question 6

what is a nursing care plan?

Answer 6

The comprehensive nursing care plan is the central source of information needed to
Guide holistic, goal-oriented care ,
Address each client’s unique needs

Question 7

why is a written nursing care plan important?

Answer 7

Ensures care is complete
Provides continuity of care
Promotes efficient use of nursing efforts
Provides a guide for assessing and charting
Meets requirements of accrediting agencies

Question 8

what information is contained in a comprehensive nursing care plan?

Answer 8

Basic needs and activities of daily living
Medical/multidisciplinary treatment
Nursing diagnoses and collaborative problems
Special discharge needs or teaching needs

Question 9

what are unit standards of care

Answer 9

General guides; describe the care that nurses are expected to provide for all clients in defined situations

Question 10

what are standardized nursing care plans

Answer 10

Detail nursing care for a particular nursing diagnosis; for all nursing diagnoses that commonly occur with a certain medical condition

Question 11

what are critical pathways

Answer 11

Outcome-based, interdisciplinary plans that sequence client care based on case type

Question 12

what is an individualized nursing care plan?

Answer 12

Used to address nursing diagnoses unique to a particular client

Question 13

what is a computerized care plan?

Answer 13

Enter diagnosis or desired outcome

Computer generates list of suggested interventions

Choose appropriate interventions

Individualize by typing in own interventions as needed

Question 14

process for writing an individualized care plan

Answer 14

Make a working problem list

Decide which problems can be managed with standardized care plans or critical pathways

Individualize the standardized plan as needed
Transcribe medical orders to appropriate
documents

Question 15

what is critical pathway? and where is it used?

Answer 15

its an interdisciplinary plan used in managed care. Its more of a group effort.

Question 16

what are clients goals?

Answer 16

Describe the changes in client health status you hope to achieve

Question 17

what are nursing sensitive outcomes?

Answer 17

Those that can be influenced by nursing interventions

Question 18

what are long-term goals

Answer 18

To be achieved over a longer period of time (week, month, or more)

Question 19

what are short-term goals

Answer 19

To be achieved within a few hours or days

Question 20

what are the components of a goal statement

Answer 20

Subject 
Action
Performance criteria 
Target time
Special conditions

Question 21

how do goals relate to the nursing diagnosis?

Answer 21

Expected outcomes derive directly from the nursing diagnosis

Problem statement describes the response/health status to be changed

Desired outcome states the opposite of the problem response

Question 22

what are non-essential goals

Answer 22

goals derive from the etiology

Question 23

what are essential goals

Answer 23

goals derive from the problem

Question 24

for every nursing diagnosis, you must state….

Answer 24

one goal that, if achieved, would demonstrate resolution or improvement of the problem

Question 25

goals —-expected outcomes

Answer 25

interchangeable. what do you expect to happen from the nursing plans

Question 26

what are your teaching objectives

Answer 26

Describe what the client is to learn

Describe the behaviors that will demonstrate learning

State whether learning is to be cognitive, psychomotor, or affective

Question 27

for each nursing diagnosis you should ask yourself?

Answer 27

Is there at least one goal that, when met, would demonstrate problem resolution?

Are the predicted outcomes adequate to completely address the nursing diagnosis?

Question 28

what to ask yourself about expected outcomes

Answer 28

Appropriate for the nursing diagnosis?

Derived from only one nursing diagnosis?

Descriptive of only one client response/behavior?

Stated as a client behavior, not a nurse activity?

Question 29

ask yourself, is each expected outcome?

Answer 29

Stated in positive terms?

Measurable or observable?

Given specific and concrete performance criteria?

Question 30

other questions to ask about goals/outcomes?

Answer 30

Does each goal/outcome include all the necessary parts?

Is each outcome/goal realistic and achievable?

Does it not conflict with the medical or other collaborative treatment plan?

Does the client, family, or community value the outcome?

Does the goal conflict with any religious or cultural values?

Question 31

Identify the long-term goal

A. Client’s pulse oxygenation level will be greater than 92% on room air by tomorrow

B. Client will administer his own insulin using correct technique by discharge

C. Client’s pressure ulcer will show presence of granulation tissue in 30 days

D. Client’s urine output will be 400 mL per 8 hour shift within 72 hours

Answer 31

C.

Clients pressure ulcer will show presence of granulation tissue in 30 days