Ch 5 Funds 2
What is the purpose of goal/outcome statements?
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What is the first step in the planning phase?
for the nurse to identify the desired goal or outcome
What step of the nursing process are you performing when taking vital signs, checking incision site, and determining if patient has pain?
Assessment phase
What must be part of an initial assessment for older adults, so you can identify needed services at discharge?
functional abilities, cognition, vision, hearing, social support, & psychological well-being.
What is objective data?
gathered through physical examination, medical history, laboratory tests, and other diagnostic sources.
What four kinds of care does a comprehensive nursing care plan contain?
1) Basic needs & ADLs 2) Medical / multi-disciplinary treatment (medical orders) 3) Nursing diagnoses & collaborative problems 4) special discharge needs / teaching needs
In what cases would you need a comprehensive, formal, written discharge plan?
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What does discharge planning include?
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What are the two main steps of the planning phase?
**The first step is to identify the desired goal or outcome, to be achieved, and the specific evaluation criteria. Outcome can be short or long term goal and should include the time frame, and should be realistic to achieve. The evaluation criteria should be specific and measurable (often indicated by AEB, as evidenced by). **The second step of the planning phase is to develop a list of interventions.
What are some examples of standardized, pre printed instructions for care?
*Policies & procedures (rules & regulations) *Protocols (cover specific actions usually required for a clinical problem unique to a subgroup of patients) *Unit standards of care (describe care that nurses are expected to provide for all patients in defined situations) *Standardized nursing care plans (detail nursing care that is needed for particular nursing diagnosis / for all nursing diagnoses that commonly occur with a medical condition *Critical pathways (often used in managed care systems; outcomes based, interdisciplinary plans that sequence patient care according to case type)
What three main areas of concern does the diagnosis phase of the nursing process address?
*Promoting therapeutic drug effects *Minimizing adverse drug effects and toxicity *Maximizing the ability of the patient for self-care, including the knowledge, skills, and resources necessary for safe and effective drug administration.
Unit standards of care are similar to protocols but different in what way?
*applies to patient, not subgroup *not part of care plan but on file on unit *don't include specific medical orders
What does discharge planning require?
*collaboration with the patient to achieve desired outcomes. *collaboration / services post-discharge from a multi-disciplinary team, which may include home care personnel, private-duty nurses, physical therapists, social services, speech, occupational & hearing therapists, physicians, members of the patient's family.
What objectives should a comprehensive discharge process for older adults help achieve?
*maintain functional abilities *Lengthen time between rehospitalizations *involve all concerned parties in decision-making *improve interagency communication *Emphasize client & family involvement & interdisciplinary collaboration
What is the 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 *write ADLs & basic care needs in special sections of the Kardex, care plan, or computer *develop individualized care plans for problems not addressed by standardized documents
What are the benefits of standardized care plans?
*save nursing time *promote consistency of care *help ensure that nurses don't overlook important interventions
The nursing process, as it relates to pharmacology, can be best described as:
A systematic approach to problem solving that ensures the safe and effective administration of medication
What is mind - mapping?
A technique for showing relationships among ideas & concepts in a graphical, or pictorial way
What documents make up a comprehensive nursing plan?
A) form for client profile, basic needs, ADLs, & multidisciplinary plans (Kardex) B) Preprinted, Standardized plans, both nursing & multidisciplinary C) Individualized care plans to address nursing diagnoses D) Special discharge plan / instructions E) Special teaching plan F) computerized plans G) Student care plans H) mind-mapping student care plans
The implementation phase of the nursing process involves what two main activities related to pharmacology?
Administering drugs and providing patient drug teaching
Why is a written nursing care plan important?
Benefits by: *ensuring that care is complete *providing continuity of care (all caregivers use same approach) *promoting efficient use of nursing efforts *providing a guide for assessments & charting *meeting the requirements of accrediting agencies
What is the role of the LPN/LVN?
Contribute to each phase of the process under the direction of the RN
What are goals (expected outcomes / desired outcomes / predicted outcomes)?
Describe the changes in patient health status that you hope to achieve.
What is appropriate information to gather in the assessment phase of the nursing process?
Drug allergies, history of renal or hepatic disease, baseline physical assessment data
What would be the most important for the nurse to evaluate in the evaluation phase of the nursing process?
Evidence of therapeutic drug effects
What phase of the nursing process involves analyzing data and identifying health problems such as Activity Intolerance related to pain?
Nursing diagnosis
How do goals relate to nursing diagnoses?
Outcomes are derived directly from the nursing diagnosis. The problem clause of a nursing diagnosis describes the response or health status you wish to change. Outcome states the opposite of the problem
What is the planning outcomes step of the nursing process?
can be formal or informal
How do you distinguish between short & long term goals?
Short=few days long=weeks/months or more
What are the components of a goal statement?
Subject action verb performance criteria target time special conditions
What are nursing - sensitive outcomes?
Those that can be influenced by nursing interventions
What is formal planning?
a conscious, deliberate activity involving decision making, critical thinking, & creativity. During planning, you will work with the patient & family to derive desired outcomes from identified patient problems & then to identify nursing interventions to help achieve those outcomes. The end product of formal planning is a holistic plan of care that addresses the patient's unique problems & strengths.
What is the nursing process?
a systematic method of problem solving, forms the foundation of all nursing practice.
What are interventions?
actions that the nurse takes to achieve patient goals
What are the five phases of the nursing process?
assessment, diagnosis, planning, implementation, and evaluation
When does discharge planning begin?
at admission / assessment
What is initial planning?
begins with first patient contact; refers to development of initial comprehensive care plan, which should be written ASAP after initial assessment.
With respect to pharmacotherapy, what are the two main issues the planning process involves?
drug administration and patient teaching
What is subjective data?
include what the patient says or perceives, such as pain, anxiety, or nausea. When possible, verified by objective data.
What is informal planning?
not written; done while performing other nursing process steps; mental planning
What is ongoing planning?
refers to changes made in the plan as you evaluate the patient's responses to care or as you obtain new data & make new nursing diagnoses.
What is the main disadvantage of computerized care plans?
requires constant use of step-by-step thinking process, which may cause decrease in intuition, insight, ability to care, & nursing expertise.
What are integrated plans of care?
standardized plans that function as care plans / documentation forms. Different form for each day of care
What are rationales?
state scientific principles or research that supports nursing interventions (why you do what you do)
Which part of the nursing process requires the actions of reviewing patient record for drug allergies, current medications, and disease states that could affect drug responses?
the assessment phase
What is a comprehensive nursing care plan (patient care plan)?
the central source of information needed to guide holistic, goal-oriented care to address each patient's unique needs. Specifies: dependent, interdependent, and independent nursing actions necessary for care of specific patient.
What phase is a nurse performing when comparing baseline assessment data to current objective data?
the evaluation phase of the nursing process
What is the evaluation phase of the nursing process?
the fifth and final step of the nursing process; compares the patient's current health status with the desired outcome to determine if the plan of care is appropriate or if it needs revision. The nurse obtains data to determine if the goal or outcome has been achieved.
What is the assessment phase of the nursing process?
the first step; the systematic collection, organization, validation, and documentation of patient data.
What is the implementation phase of the nursing process?
the fourth step of the nursing process; the ACTION phase; when the nurse applies the knowledge, skills, and principles of nursing care to help move the patient toward the desired goal and optimal wellness.
What is discharge planning?
the process of planning for self care & continuity of care after the patient leaves a healthcare setting. Nurses prepare family members to perform care tasks & also make arrangements for home healthcare, skilled nursing or rehab facility if needed.
What is a nursing diagnosis or diagnosis phase of the nursing process?
the second step of the nursing process; a clinical judgement of a patient's actual or potential health problem that is within the nurse's scope of practice to address. During this phase the nurse analyzes assessment data, identifies health problems, and formulates diagnostic statements. Nursing diagnoses are often stated as a problem, or the risk for a problem, followed by "related to", which identifies etiologies.
What is the planning phase of the nursing process?
the third step of the nursing process; the nurse prioritizes diagnoses, formulates desired goals, and selects nursing interventions.
How are standardized (model) nursing care plans different from unit standards of care?
they usually:
What are etiologies?
those conditions that have caused or contributed to the problem
What two purposes does the assessment phase serve?
to gather data that will enable the nurse to identify current patient health challenges and problems that the patient is at particular risk for developing. This data will be used in developing nursing diagnoses and the plan of care. The second purpose is to gather initial baseline data on the patient that will be compared to subsequent data during the evaluation phase. Comparisons will indicate to what extent the treatment goals have been achieved.
What are individualized nursing care plans?
used to address nursing diagnoses unique to a particular client; reflect the independent component of nursing practice & best demonstrate the nurse's critical thinking & clinical expertise; may contain standardized single-problem care plans.
