WEEK 1 CARE PLANNING Flashcards
What is the term for a written legal document that identifies client health
challenges as either 1) clinical Impressions
or 2) potential or at risk clinical Impressions?
Care plan
What are 4 sources of data?
- Head to toe assessment
- Chart (MAR, interdisciplinary notes)
- Client/family
- Labs/diagnostics
What is another term for data?
Assessments
Define the abbreviations AEB and MB
As Evidenced By and Manifested By
What does RT stand for, and what does it mean?
Related To; it is the medically diagnosed cause of the Clinical Impression
What if the patient has no formal diagnosis?
Write “undiagnosed cause,” “probable,” or “possible”
What is the difference between expected outcomes and goals of care?
Expected outcomes provide proof that the goal has been met (e.g. normal range parameters)
Name the 5 headings of the nursing care plan
- Data
- Problem
- Goal
- Interventions
- Evaluation
What is the nurse concerned with that provides focus for nursing diagnoses?
Human responses that arise from illness that affect the ability to function satisfactorily
Name the 3 parts of a clinical impression
- Challenge
- Cause of challenge: “Related to”
- Defining characteristics (signs and symptoms): “As evidenced by”
Name 2 parts of a potential or at-risk clinical impression
- Possible in-future challenge
- Cause of (non-existant) challenge: “Related to”
What is the focus of nursing care?
Help clients to meet their own needs
Name 4 roles of the nurse
Instrumental, teach, counsel, guide
What is the purpose of the standardized language used in clinical impression statements?
Communicates what nurses are responsible for and accountable to recognize and treat based on their education, experience, and legal scope
What are the 2 parts of a goal statement?
- Outcome
- Time frame
What are the 3 components of a healing initiatives statement?
- Action word
- Clear body (who, what, when, where, how, resources needed)
- Time frame
A healing initiatives statement including the words “as ordered” means what?
The action is delegated by the physician and requires an order
The evaluation part of the care plan requires the nurse to know what?
Abnormal and normal data
Explain why the following clinical impression statement is incorrect:
“Doesn’t know how to take antihypertensives, manifested by statesments of lack of knowledge on drugs, related to hypertension.”
- Is not worded as the client’s response to medically diagnosed disease
- Vague; no specific quoted statements
- Does not clearly define that hypertension was medically diagnosed by a physician
Explain why the following clinical impression statement is incorrect:
“Lab values less than normal range for RBC, HGB, and HCT, related to severe blood loss.”
- States data as clinical impression.
- Does not state client’s response to medically diagnosed disease.
What are 4 goals of patient teaching?
- Health maintenance
- Health promotion and disease/injury prevention
- Illness management
- Appropriate selection and use of resources
What are 2 kinds of patient teaching, and how are they different?
- Informal teaching: incidental, questions and answers
- Formal teaching: Specific learning needs identified, goals and teaching plan developed
What are the CAP domains of learning?
Cognitive, Affective, Psychomotor
What is the nurse’s role in nurse-facilitated teaching groups?
Keeping the information moving among all members
What are two of the nurse’s roles in technology based interactive teaching?
- Preview and ensure accurate, complete, and appropriate for meeting learning outcomes
- Teaching the client how to access credible websites
The nurse should ensure printed learning materials meet what criteria?
- Accurate, complete, focused on topic
- Include pictures/diagrams
- Suit the client’s learning needs, have the info the patient wants to know
- Gender and culturally sensitive
What are the goals of conducting a therapeutic interview in the affective teaching domain?
- Help client feel understood: provide reassurance, support, empathy, and respect
- Decrease the client’s resistance to change; increase confidence in ability to change
- Facilitate client’s exploration of self, including inner motivations and strengths
What are two types of one-to-one teaching in the psychomotor domain?
- Demonstration-return demonstration
- Teach-back strategy
What kind of teaching plans are included in caremaps and clinical pathways?
Standardized (pre-printed) teaching plans
Name 5 steps to develop a teaching plan
- Assess ability, motivation, and readiness to learn
- Identify teaching needs
- Develop learning goals with the client
- Implement teaching
- Evaluate client’s learning
Briefly define the cognitive learning domain
What the client knows and needs to know
Briefly define the affective learning domain
The client’s beliefs, values, and perspectives
Briefly define the psychomotor learning domain
The client’s abilities
Name 7 techniques to evaluate if there has been mastery of knowledge, attitudes, and behavioral changes
- Direct observation
- Verbal/nonverbal cues observation
- Direct questions
- Written measurement tool
- Talk to client’s family
- Client self evaluation
- Teach-back method
What is a challenge to patient teaching related to elderly age?
Crystallized intelligence persists but fluid intelligence declines (slower to learn, reduced ability to retain info)
When a client uses humour during patient teaching, what may this indicate?
It may be a coping mechanism for anxiety
What may indicate that a client is not ready to learn?
High stress, denial, or rationalization
How should teaching be adapted when the client is in pain or experiencing nausea/vomiting/fatigue?
Provide brief explanations only, do not teach new information until after symptoms are managed.
What should the nurse do when planning experiences with consideration of adult learning principles?
Provide opportunities for the client to learn from other adults with similar experiences
What skill is necessary for the nurse in the role of teacher?
Determining when clients are too distressed physically of psychologically to learn
When the nurse is feeling stress about the limited time available for client teaching, what strategy would be most beneficial?
Setting realistic goals that have high priority for the client
What is the best reason for the nurse to choose to include family members in client teaching?
Clients have been shown to have better outcomes when caregivers are involved
What are 2 benefits of role play as a teaching strategy?
- Increased self efficacy of clients and caregivers
- Rehearses new behaviors
The nurse notes that a patient regularly asks about the purpose and potential adverse effects of each oral medication that they have received during their time in the hospital. How should the nurse best interpret the patient’s questions?
The patient is identifying his learning needs
Which 2 actions best demonstrate a nurse’s awareness of learning styles and the role they play in patient and caregiver teaching?
- Assess patients’ learning styles prior to teaching
- Use materials that appeal to a variety of learning styles
What are 4 purposes of home care programs?
- Promote independence
- Prevent, delay, or substitute for acute or long-term care
- Assist with the use of community services
- Supplement the care and support provided by friends and family.
What are 4 categories of home care services?
- Acute
- Chronic
- Palliative
- Rehabilitative
Name 6 roles that may comprise a home health care team
- Community health nurses
- Home care or home health nurses
- Case managers
- Community health or home support workers
- Nurse practitioners
- Clinical nurse specialists.
