Foundations Unit 2 Exam
Intervention
"What you did for the problem" Ex: High/low BP: treatment, refusal of treatment, activity, calls to physician about something that is going on with patient
Resource variables
- Adequate staff, equipment, supplies - Financial resources of patient and adequacy of community-based resources (ask the patient questions to get info out of them to see if they need help finding resources for financial aid)
Subsequent Entry
- Follow up interventions - C/O & Interventions - Teaching (have to show that patient has learned information) - Activity (chart - how patient got up and walked around - how did they tolerate it?) - Safety (bed is low/locked, side rials up, call light near - Any additional info as needed
Initial Entry
- LOC - Physical exam (vital signs) - C/O & Interventions - Safety - Any additional info as needed
Nurse variables
- Level of expertise - Creativity - Willingness to provide care to the patient - Available time
Documentation Mechanics That Increase RISK For Legal Problems
- Lines between entries - Countersigning documentation - Tampering - Different handwriting or obliterations - Illegibility - Sloppiness - Dates and times of entries omitted or inconsistently documented - Improper nurse signature or unidentifiable - Transcription errors
Decision about how well goal/outcome was achieved All patient data or behavior supporting decision
2 part evaluation statement:
Met, partially met, not met
3 decision options for documenting evaluation:
1. ID evaluative crisis and standards 2. Collecting data to determine whether these criteria and standards are met 3. Interpreting and summarizing findings 4. Documenting your judgement 5. Terminating, continuing, or modifying the plan of care
5 Classic Elements of Evaluation:
1. Communication 2. Legal documentation 3. Financial billing/reimbursement 4. Education 5. Research 6. Audit-monitoring/quality assurance
6 purposes for documentation:
Updating the diet orders in the client's plan of care
A client is required to be n.p.o. for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?
Resolve the client's anxiety
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?
Ongoing planning
A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?
Upon her admission to the hospital
A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?
High priority
A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?
PIE charting
A format for documentation that is organized, specific, and measurable, which addresses the patient's progress - Enhances consistency (less individual variations in charting) - Charting is pertinent and concise - Redundant charting is reduced - Spend less time charting / only charting significant things
Client is normotensive
A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?
Ongoing planning
A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?
A standardized care plan
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?
Developing the plan without client input
A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?
Outcome evaluation
A nurse is caring for a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?
Educational
A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?
Nursing interventions
A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be most important for the nurse to include?
To ambulate the client to a bedside chair
A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?
Equipment and personnel
A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. Which has the nurse failed to organize?
Demonstrate State Explain
A nurse is working with a newly admitted client with diabetes to develop client outcomes. When writing these outcomes, which verb would be appropriate to use in the statement. Select all that apply:
Seek research about the disorder
A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?
Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.
A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client?
Intervention
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:
Communicate with the physician for additional orders.
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?
It helps deliver holistic, goal-oriented, individualized care
After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care?
Evaluation
Allow the patient's achievement of expected outcome to direct future nurse/patient interaction - Measures how well the patient achieved desired goals/outcomes - Identify factors contributing to the patient's success or failure - Modify the plan of care if indicated
Standardized
Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?
Nursing Interventions
Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient's outcome
Implementation purpose
Assist the patient in achieving desired health goals; promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning - Carry out plan of care - Determining the need for assistance - Promoting self care: teaching, counseling, and advocacy - Assisting patient to meet health goals
Direct Resolution
At least one goal should be written that, if achieved, demonstrates a ____ of the problem statement
- Lack of family support - Lack of understanding about the benefits of compliance - Adverse physical or emotional effects of the treatment - Inability to afford the treatment - Limited access to treatment
Common reasons why patients are noncompliant:
Documentation Content That Increases Risk For Legal Problems
Content is: - Not in accordance with professional or healthcare organization standards - Does not reflect patient needs - Does not include descriptions of situations that are out of the ordinary - Overgeneralizes patient assessment of nursing intervention - Incomplete or inconsistent - Does not include appropriate medical orders - Implies potential or actual risk situation - Implies attitudinal bias
Verb
Define, prepare, identify, design, list, verbalize, choose, explain,, select, demonstrate, apply
Goals
Derived from the problem statement of the nursing diagnosis - If achieved, will prevent, reduce, or eliminate the problem specified in nursing diagnosis
Affective Goals
Describe changes in patient values, beliefs, and attitudes - Hardest ones to write and measure because you have to see the change
Psychomotor Goals
Describe patients achievement of new skill - Show by RETURN DEMONSTRATION of patient doing it
Cognitive Goals
Describes increase in patient's knowledge or intellectual behaviors
Narrative Nurse's Notes
Description of pertinent observations of patient - Statements that specify nursing care, including teaching, received by patient and his or her responses to nursing care - Statements that describe patient's condition and progress, or lack of progress, toward recovery and goal achievement - Descriptions of patient's complaints and how patient is coping, or failing to cope, with them and nursing's response
Evaluative data
Determines whether patient has met the desired goals/outcomes
Current standards of care
Different divisions have different standards of care - Held liable to these
Concise Complete Factual Legible Accurate Timely (current)
Documentation needs to be:
- Any change in patient condition - Response to treatment or medications - Lack of improvement in the patient condition - Patient and family responds to education
Documentation should include:
Maslow's Hierarchy of Human Needs
Establishing priorities for nursing diagnoses uses:
Ethics and legal guides to practice
Even though you have a license, you can be sued for negligence - Know legal boundaries and ethics
Intervention
Ex: O2 Sats 90%. Elevated HOB. RT tx given
Problem Statement
Ex: Pt c/o SOB and scattered wheezing noted
Evaluation
Ex: Pt states he is breathing easier. Breath sounds present, faint wheezing heard RUL. O2 Sats 98%. Denies dyspnea. States he feels much better
Affective
Ex: attitude and lifestyle changes
Psychomotor
Ex: doing blood sugars or drawing Insulin
Interventions
Ex: patient complains of pain, rates on scale, what did the nurse do for the pain? -> pain meds, repositioning
Cognitive
Ex: patient education, self-care
Patient Goal
Expected patient outcome
- Patients condition - Level of interaction required with patient - Complexity of the activity - Potential for harm - Degree of problem-solving and innovation necessary - Capabilities of the person being delegated to - Availability of professional staff to accomplish the unit workload
Factors to consider before delegating any nursing interventions:
a client who was admitted for shortness of breath and who has been diagnosed with pneumonia
For which of the following clients would a standardized plan of care most likely be appropriate?
Research findings
Front line of what is happening in health care because it is always changing - Textbooks aren't as recent (take forever to publish) - Medical journals are more up to date and are better to use
DO NOT EXPRESS PATIENT GOALS AS A NURSING INTERVENTION
Important in identify nursing interventions (what not to do):
Physiologic needs (PRIORITY over anything else) Safety needs Love and belonging needs Self-esteem needs Self-actualization needs
Maslow's Hierarchy of Human Needs:
Patient variables
Modify nursing actions according to the patient - Changing ability and willingness to participate in the plan of care - Previous responses to nursing interventions and progress toward goal/outcome achievement - Development stage and psychosocial background (don't want PEDS patient progressing backwards)
WHY
Noncompliant patients - first ask:
Surveillance intervention
Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?
Criteria
Observable, measurable terms of the expected patient behavior
condition
One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:
Patient problems, interventions, and evaluation of our interventions
PIE charting focuses on:
Subject
Patient
Evaluation
Patient's response to nursing interventions
Problem statement
Problems are identified with shift assessment, VS, lab values, and potential problems related to patient history
Long-term goals
Require longer period to be achieved (usually more than a week) Ex: discharge goals
Outcome
Specific and measurable (so you know that you met and achieved it)
Expected Outcomes
Specific, MEASURABLE criteria used to evaluate the extent goal has been met
Nurse
The ___ has to do the assessment, not the tech
Cognitive outcomes
The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of what type of outcome?
"I will test my glucose level before meals and use sliding scale insulin."
The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?
"Please tell me your thoughts about treating this diagnosis."
The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?
The nurse omitted the time frame
The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?
Mr. Conner will demonstrate proper care of stoma by 29MAR2015
The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?
Discharge planning
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
Client will maintain nutritional intake without pain or diarrhea
The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?
Involvement of the client and family
The nurse recognizes that identifying outcomes/goals must include:
Teach client how to splint abdominal incision when coughing and deep breathing
The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?
Delegation
Transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome - Importnat for nurses to identify which nursing interventions require professional nurses and which can be safely delegated Ex: if nurse gives job to tech, the nurse is still responsible for the job
Met, partially met, not met
Types of achievement: - List actual patient behavior as evidence to support the statement Ex: patient walked 3 times when they were supposed to walk 4 If not met or achieved - recommendations for revising plan of care Ex: assistance to walk
Data in the evaluation step
Used to determine whether the identified health problems have been or are being resolved through goal achievement
Data in the nursing assessment
Used to identify the patient's health problems
Patient, nurse, resources, current standards of care, research findings, ethic and legal guides to practice
Variables that influence goal/outcome achievement:
Problem statment, intervention, evaluation
What does PIE stand for?
Nurses do carry out interventions in response to a physician's order
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Psychomotor
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Subject, verb, criteria
When developing goals/outcomes: (3 things)
The outcome parameter
When establishing client outcomes with the client, what is the qualifier in the outcome?
Identifies factors causing undesirable response and preventing desired change
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
"We ask your name to ensure that we are treating the right client."
When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?
Document improved pain after pain medication administered
Which of the following actions should the nurse take during the evaluation phase of the nursing process?
The nurse assesses urine output following administration of a diuretic.
Which of the following nursing actions reflects evaluation?
Documentation
Written or printed record of a patient's care - It's an essential nursing responsibility - It is the nurse's responsibility that the record remains CONFIDENTIAL -> If it's not documented, it wasn't done - Allows continuity of care, gives a way to let other healthcare workers know what we have done