Unit 8 Flashcards
Goals of outcome identification and planning step?
- Establish priorities
- Identify and write expected patient outcomes.
- Select evidence-based nursing interventions
- Communicate the plan of care
A Formal Plan of Care Allows the Nurse to:
- Individualize care
- Set priorities
- Facilitate communication among nursing personnel
- Promote continuity of high-quality, cost-effective care
Coordinate care - Evaluate patient response to nursing care
- Create a record used for evaluation, research, reimbursement, and legal reasons
- Promote nurse’s professional development
Three Elements of Comprehensive Planning
- Initial
- Ongoing
- Discharge
Comprehensive Planning: Initial
When does initial planning begin?
On admission after history and PE
Comprehensive Planning: Ongoing
Who does it and what is done?
- Completed by the nurse that care for client
- Review current diagnoses
- Identify new diagnoses
- Adjust and develop new outcomes
- Adjust and develop new interventions
Comprehensive Planning: Discharge
When does it begin and what is the main focus?
- Acute care begins on admission
2. Focuses on teaching and planning to allow client and family to carry out health and self care activities
Establishing Priorities
What questions should you ask yourself?
- What problems need immediate attention and which ones can wait?
- Which problems are your responsibility and which do you need to refer to someone else?
- Have changes in the patient’s health status influenced the priority of nursing diagnoses?
- Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)?
Prioritizing Nursing Diagnoses: Maslow
- Arrange diagnoses according to basic human need
Maslow: High Priority
High Priority : Greatest threat to clients well-being
- Life threatening situations
- Immediate attention (tests, discharge)
- Something important to the client ( pain management)
- Priorities change
Maslow: Medium Priority
- Problems that might result in unhealthy consequences but are not life-threatening
- Examples
1. Stress Incontinence
2. Fatigue
3. Dysfunctional Grieving
Maslow: Low Priority
- Problems that can be resolved easily with minimal intervention
- Not related to current health problem
- Problems that have little potential to cause significant dysfunction
Ex. Washing a client’s hair to promote self-esteem
What should be considered when Establishing Priorities?
- Patient Preferences
- Anticipation of Future Problems
If this goal is not met what are the consequences
Patient does not do ROM will develop contractures
Outcome Identification
- Establish client expected outcomes (Goals or objectives)
- The desired results you expect from your interventions
- It is an Educated guess – Broad Statement
- It Reflects the nursing Problem – reverse statement
- It Describes the end point of nursing care – this is what you evaluate
Long term goal
Resolved over a longer period of time a month or lifetime, chronic illness, home care
Short term goal
Steps towards long term goal accomplished in less than a week - hospital based goal- what client will achieve by discharge
Consideration when selecting outcomes
Type of health concern – - Nursing or medical diagnosis - overall prognosis - Patient characteristics G & D . Culture, values - Available resources - Patient preferences - Treatment potential ****Patient and family must be involved
What are the Categories of Outcomes?
- Cognitive: describes increases in patient knowledge or intellectual behaviors
- Psychomotor: describes patient’s achievement of new skills
- Affective: describes changes in patient values, beliefs, and attitudes
Writing Measurable Outcomes: The Should
- Specific, Measurable, realistic, attainable, time bound
- The who , what, what circumstances, how well, and when
Subject : Who is expected to achieve goal always begins client will
Verb: what actions must the person do
Under what conditions
Criteria : How well with the client perform
Within a specific time frame - Must be measurable, & realistic
Client Outcome
- Contains a verb and qualifier to describe the level of performance client must achieve
- Accurately demonstrates dressing change before discharge
- Will move independently in bed before discharge
- Will remain free of infection during hospitalization
Example: Client will be tobacco free
for 60 days
Outcome goal & criteria
Goal:
Client will move independently by discharge
Outcome criteria :
as measured by
e.x client moves from side to side with minimal assistance in two hours after
returning from
See Box 13-3 283
Identifying Nursing Interventions p 265
- “Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes”
- Actions performed by the nurse
3.Derived from nursing diagnosis –
cause of problem (etiology) determines the interventions
List and Describe the Types of Nursing Interventions?
- Direct Care Intervention -
Intervention with direct interaction with patient
Include Physiological and psychosocial interactions - Indirect care Intervention -
Interventions performed on behalf of the patient
Management of care. Collaborating with other team members
Support direct care - Community Intervention -
Those aimed at individuals, family, and community
List Focus of Nursing Interventions?
- Actual Diagnosis
- Risk Diagnosis
- Collaborative
Actual Diagnoses
- Reduce or eliminate contributing factors of the diagnosis,
- Promote higher level wellness
- Monitor and evaluate status
Risk Diagnoses
- Reduce or eliminate risk factors
- Prevent the problem
- Monitor and evaluate the problem
Collaborative Diagnoses/Intervention
- Monitor for changes in status
- Manage changes in status with nursing prescribed and physician prescribed interventions
- Evaluate response
Types of Nursing Interventions
- Nurse-initiated: actions performed by a nurse without a physician’s order
- Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders
- Collaborative: treatments initiated by other providers and carried out by a nurse
Actions Performed in Nurse-Initiated Interventions (Alfaro, 2002)
Do not need MD orders
- Monitor health status.
- Reduce risks.
- Resolve, prevent, or manage a problem.
- Facilitate independence or assist with ADLs.
- Promote optimum sense of physical, psychological, and spiritual well-being.
- Give patient what he needs to make informed decisions
Types of Nursing Interventions
1.Psychomotor: positioning, ambulating
2.Psychosocial: support, encourage
3.Educational
4.Maintenance: skin care, hygiene, ADL’s
5.Surveillance: assessing; detect b/p change
6.Supervisory: supervise other healthcare
providers, family members
7.Sociocultural – spending time, include cultural food in diet
Recording Nursing Interventions
Well written interventions
Assist the patient to meet specific outcomes
Clearly and concisely describe the nursing action to performed
**Who? – Subject : Nurse implied
**Action verb: tells the nurse what to do
**Descriptive qualifiers:
how, when and where to perform the action
**Specific Times
Factors to consider when choosing interventions
- Desired patient outcomes
- Characteristics of the diagnoses
- Research base for interventions
- Feasibility for doing the intervention
- Acceptability to the client
- Capability of the nurse
- Also Box 13-4
Planning Process: Purposes
- Direct client care activities
- Promote continuity of care
- Focus for charting requirements
- Allow for delegation of specific activities
Activities involved in the planning phase
- Planning nursing interventions
- Writing the nursing plan of care
Writing a Nursing Plan of Care
- Plan of care/ Nursing Care Plan is nursing centered
- It is a step-by-step process as evidenced by:
Sufficient data to substantiate diagnoses
At least one goal for each nursing diagnosis
Outcome criteria identified for each goal
Nursing intervention(s) to meet each goal
Each intervention supported by rationale
Evaluation addresses whether goal met and how goal was met
Types of Clinical Client Plans of Care 292
- Individual plan of care
- standardized (p 295)
- Generic plan of care
- Computer generated POC
- Multidisciplinary (Collaborative) Care plan (p 295)
- Instructional Care plans
Individual Plan of Care is written by ____ for ____ client.
RN/individual
Standardized Plan of Care
- written for a group of patients with a common medical diagnosis
- Identify common nursing diagnoses for specific population
- Must be individualized
Generic Plan of care is written for a ___ ___ ___.
***specific nursing diagnosis
Computer generated POC
- Care plan generated when;
- Similar to;
- Care plan generated when assessment data is entered
2. Similar to standardized or generic plans
Multidisciplinary (Collaborative) Care Plan 295
Critical Pathways, CareMaps
Instructional Care Plans
- Student Care Plan 296
- Scientific Rationales included
- Concept Maps 292
Purposes of Implementation
- Help the patient achieve valued health outcomes.
- Promote health.
- Prevent disease and illness.
- Restore health.
- Facilitate coping with altered functioning.
Two Nursing implementations
- Direct
- “Hands on” nurse provides physiological or psychological care - Indirect:
- supervise or manage the environment or interdisciplinary collaboration – support direct nursing care
“Nurse away from the patient”
- supervise or manage the environment or interdisciplinary collaboration – support direct nursing care
Activities of Implementation
- Reassess with each client encounter
- Set priorities when changed
- Perform nursing interventions
- Record Nursing action
ASSESS, REASSESS, REVISE, RECORD
Implementing the Plan of Care
- Reassessing the patient and reviewing the plan of care
- Clarifying prerequisite nursing competencies
- Organizing resources (patient, visitors, equipment, environment, personnel)
- Anticipating unexpected outcomes/situations
- Preventing errors and omissions (urge your patient to speak up)
- Promoting self care: teaching, counseling, advocacy
- Assisting patients to meet outcomes
List and describe the two Variables Influencing Outcome Achievement
- Patient variables
- Developmental stage
- Psychosocial background - Nurse variables
- Resources
- Current standards of care
- Research findings
- Ethical and legal guides to practice
Purposes for Evaluation
- Collect data to make judgments about nursing care
- Examine client’s responses to nursing interventions
- Compare client’s responses with outcome criteria
- ***Appraise extent to which client goals met
1. Completely met
2. Partially met
3. Completely unmet
Evaluation Activities
- Review patient goals and outcome criteria
- Collect data
- Measure goal attainment
- Assess facilitators of goal attainment
- Goal completely met
- Goal partially met
- Goal completely unmet
- New Problem
Actions Based on Patient Response to Plan of Care
- Terminate the plan of care when each expected outcome is achieved.
- Modify the plan of care if there are difficulties achieving the outcomes.
- Continue the plan of care if more time is needed to achieve the outcomes.
- Assess barriers to goal attainment (Patient, Family members or significant others, Nurse or other healthcare team members)
- Record judgments or measurements of goal attainment
- Revise or modify the patient’s plan of care
