Planning client outcomes Flashcards
what are the two types of planning
formal and informal
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 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 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 comprehensive nursing care plan
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 so 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 is contained in the 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 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 nursing 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 are client goals
Describe the changes in client health status you hope to achieve
what are client 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 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
derive from the etiology
what are essential 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.
what is standardized terminology for outcomes
ANA has approved several standardized vocabularies for describing client outcomes
what are 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
