Chapter 18 -- Planning Nursing Care
Nursing Intervention
Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes.
A 72-year-old patient has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the patient's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Match the priority level with the nursing diagnoses identified for this patient: Nursing Diagnoses 1. Impaired gas exchange _____ 2. Risk for activity intolerance _____ 3. Ineffective self-health management _____ Priority Level a. Long term b. Short term c. Intermediate
Correct Answer(s): 1b, 2c, 3a. The patient's oxygenation status is the priority in this situation. The patient's condition creates the risk for activity intolerance, making this an intermediate priority for which the nurse must monitor. Ineffective self-help management is a long-term goal that might be applicable if the patient has physical limitations at the time of discharge.
An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals 1. Patient will ambulate independently in 3 days. _____ 2. Patient will be injury free for 1 month. _____ 3. Patient will be less agitated. _____ 4. Patient will achieve pain relief. _____ Outcomes a. Patient will express fewer nonverbal signs of discomfort. b. Patient will follow a set care routine. c. Patient will walk correctly using a walker. d. Patient will exit a low bed without falling.
Correct Answer(s): 1c, 2d, 3b, 4a
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first? A) Reconnect the drainage tubing B) Inspect the condition of the IV dressing C) Improve the patient's comfort and turn onto her side. D) Obtain the next IV fluid bag from the medication room
Correct Answer(s): A The priority is to reconnect the drainage tube. This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.
A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.) A) Turn the patient regularly from side to back to side. B) Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence. C) Apply a pressure-relief device to bed. D) Apply transparent dressing to sacral pressure ulcer.
Correct Answer(s): A, C The statements "Turn the patient regularly from side to back to side" and "Apply a pressure-relief device to bed" do not provide specific guidelines for the frequency or type of intervention. The other two options identify specific intervention methods.
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.) A) Goal within reach of the patient B) The nurse's own competency in teaching about insulin C) The patient's cognitive function D) Availability of family members to assist
Correct Answer(s): A, C, D A goal must be realistic and one that the patient has cognitive and sociocultural potential to reach. The nurse's competency does not influence the patient's goal. However, it may mean that the nurse must consult with a diabetes educator or a more qualified nurse before beginning instruction.
A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care? A) The goals of care will always be more long term. B) The patient and family need to be able to independently provide most of the health care. C) The patient's goals need to be mutually set with family members who will care for him or her. D) The expected outcomes need to address what can be influenced by interventions.
Correct Answer(s): B A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Goals of care will not always be more long term; goals will be short term and long term, depending on the patient's condition. Mutually setting goals with caregiving family members is true for any health care setting. The statement "The expected outcomes need to address what can be influenced by interventions" is incorrect; the outcomes allow you to direct your evaluation of care.
A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) A) The family comes to visit the patient. B) The patient expresses concern about pain control. C) The patient's vital signs change, showing a drop in blood pressure. D) The charge nurse approaches the nurse and requests a report at end of shift.
Correct Answer(s): B, C Pain control is a priority, because it is severe and affects the patient's ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.) A) Patient will be turned every 2 hours within 24 hours. B) Patient will have normal bowel function within 72 hours. C) Patient's skin will remain intact through discharge. D) Patient's skin condition will improve by discharge.
Correct Answer(s): B, C The skin remaining intact is an appropriate goal for the patient's at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor. Turning the patient is an intervention; skin condition improving by discharge is a poorly written goal that is not measurable.
Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.) A) Patient will eat at least three fourths of each meal by 1 week. B) Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. C) Patient will eat foods with high-calorie content by 1 week. D) Give patient liquid supplements 3 times a day
Correct Answer(s): B, D The statement "Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week" is not singular. The statement "Give patient liquid supplements 3 times a day" is an intervention.
Which outcome allows you to measure a patient's response to care more precisely? A) The patient's wound will appear normal within 3 days. B) The patient's wound will have less drainage within 72 hours. C) The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. D) The patient's wound will heal without redness or drainage by day 4.
Correct Answer(s): C An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. The statement "The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4" identifies a specific wound size, which indicates a degree of healing. The outcome statements concerning the wound appearing normal and having less drainage are vague and not measurable. The statement "The patient's wound will heal without redness or drainage by day 4" has more than one outcome.
A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? A) This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening. B) The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care. C) During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient. D) The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding.
Correct Answer(s): C Creating a culture of blame does not support questioning, which is needed for good handoff communication. Talking about the patient's anxiety during handoff is patient centered and thus appropriate, referring to the EHR to review interventions ensures that essential information is included, and administering a pain medication before the report allows the nurse to be organized and uninterrupted during rounds.
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term? A) Patient will explain relationship of insulin to blood glucose control. B) Patient will self-administer insulin. C) Patient will achieve glucose control. D) Patient will describe steps for preparing insulin in a syringe.
Correct Answer(s): C It will take time for the patient who is medically unstable to achieve glucose control. Explaining the relationship of insulin to blood glucose control and self-administering insulin are short term goals and should be met before discharge. Describing steps for preparing insulin in a syringe is not a goal but an outcome statement for the goal that the patient will self-administer insulin.
The nurse writes an expected-outcome statement in measurable terms. An example is: A) Patient will be pain free. B) Patient will have less pain. C) Patient will take pain medication every 4 hours. D) Patient will report pain acuity less than 4 on a scale of 0 to 10.
Correct Answer(s): D Answer 4 is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient's pain. The patient being pain free is a goal; the patient having less pain is written vaguely, and the patient taking pain medication every 4 hours is an intervention.
A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? A) Provide frequent mouth care. B) Maintain intravenous (IV) infusion at 100 mL/hr. C) Administer prochlorperazine (Compazine) via rectal suppository. D) Consult with dietitian on initial foods to offer patient. E) Control aversive odors or unpleasant visual stimulation that triggers nausea.
Correct Answer(s): D Providing frequent mouth care and controlling outside stimulation that triggers nausea are independent interventions. Maintaining an IV infusion and administering the rectal suppository are dependent interventions.
Setting a time frame for outcomes of care serves which of the following purposes? A) Indicates which outcome has priority B) Indicates the time it takes to complete an intervention C) Indicates how long a nurse is scheduled to care for a patient D) Indicates when the patient is expected to respond in the desired manner
Correct Answer(s): D The time frame indicates when you expect a response to your nursing interventions. Time frames help to organize priorities but do not indicate which problem is most important. Time frames for outcomes are not used to gauge the time it takes to complete interventions, and they are unrelated to a nurse's work schedule.
(7) Guidelines for Writing Goals and Expected Outcomes
Patient-centered, singular goal or outcome, Observable, Measurable, Time-limited, mutual factors, realistic
Goal
a broad statement that describes a desired change in a patient's condition or behavior. ex: Mr Jacobs has the diagnosis of "deficient knowledge" regarding his post-op recovery. A goal of care for this diagnosis includes "patient expresses understanding of postoperative risks."... goal requires making Mr. Jacobs aware of the risks associated with his type of surgery.
Expected Outcomes
a measurable criterion to evaluate goal achievement. Once an outcome is met, you then know that a goal has been at least partially achieved. ex. measurable outcomes for the goal of "understanding postoperative risks" include: "patient identifies signs and symptoms of wound infection," and " patient explains signs of urinary obstruction."
Nursing-Sensitive Patient Outcome
a measurable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions.
Standing Order
a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.
Clinical Practice Guideline or Protocol
a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations.
(3) Implementation skills
cognitive, interpersonal, psychomotor
Planning
involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions.
Patient Centered Outcomes
outcomes and goals reflect patient behaviors and responses expected as a result of nursing intervention. ex. correct goal statement: "P patient will ambulate independently in 3 days." Correct outcome statement: "Patient will ambulate in the hall 3 times a day by 4/22." a COMMON ERROR is to write an intervention: "Ambulate patient in the hall 3 times a day."
