planning Flashcards
what is initial planning?
Begins with first client contact
Written as soon as possible after initial assessment
Development of the initial comprehensive care plan
what is ongoing planning?
Changes made in the plan as you evaluate the client’s responses to care
what is formal planning?
Formal planning is a conscious, deliberate activity involving decision making, critical thinking, and creativity”
what is informal planning?
Making mental notes or plans
what is discharge planning?
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
what is a nursing care plan?
The comprehensive nursing care plan is the central source of information needed to
Guide holistic, goal-oriented care ,
Address each client’s unique needs
why is a written nursing care plan important?
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
what information is contained in a comprehensive nursing care plan?
Basic needs and activities of daily living
Medical/multidisciplinary treatment
Nursing diagnoses and collaborative problems
Special discharge needs or teaching needs
what are unit standards of care
General guides; describe the care that nurses are expected to provide for all clients in defined situations
what are standardized nursing care plans
Detail nursing care for a particular nursing diagnosis; for all nursing diagnoses that commonly occur with a certain medical condition
what are critical pathways
Outcome-based, interdisciplinary plans that sequence client care based on case type
what is an individualized nursing care plan?
Used to address nursing diagnoses unique to a particular client
what is a computerized care plan?
Enter diagnosis or desired outcome
Computer generates list of suggested interventions
Choose appropriate interventions
Individualize by typing in own interventions as needed
process for writing an individualized care plan
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
what is critical pathway? and where is it used?
its an interdisciplinary plan used in managed care. Its more of a group effort.
what are clients goals?
Describe the changes in client health status you hope to achieve
what are nursing sensitive outcomes?
Those that can be influenced by nursing interventions
what are long-term goals
To be achieved over a longer period of time (week, month, or more)
what are short-term goals
To be achieved within a few hours or days
what are the components of a goal statement
Subject Action Performance criteria Target time Special conditions
how do goals relate to the nursing diagnosis?
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
what are non-essential goals
goals derive from the etiology
what are essential goals
goals derive from the problem
for every nursing diagnosis, you must state….
one goal that, if achieved, would demonstrate resolution or improvement of the problem
goals —-expected outcomes
interchangeable. what do you expect to happen from the nursing plans
what are your teaching objectives
Describe what the client is to learn
Describe the behaviors that will demonstrate learning
State whether learning is to be cognitive, psychomotor, or affective
for each nursing diagnosis you should ask yourself?
Is there at least one goal that, when met, would demonstrate problem resolution?
Are the predicted outcomes adequate to completely address the nursing diagnosis?
what to ask yourself about expected outcomes
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?
ask yourself, is each expected outcome?
Stated in positive terms?
Measurable or observable?
Given specific and concrete performance criteria?
other questions to ask about goals/outcomes?
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?
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
C.
Clients pressure ulcer will show presence of granulation tissue in 30 days
