(PrepU) Chapter 16: Outcome Identification and Planning

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational Demonstrating, teaching, and observing a return demonstration are classified as educational interventions. The remaining terms refer to aspects of monitoring the client and do not apply to this scenario.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order. A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding physicians to implement orders, nurses may request a physician to implement an order or question an existing order by the physician if the nurse believes it is in the client's best interests.

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is:

a clinical pathway. A clinical pathway communicates the standardized, interdisciplinary plan of care for a client. Care guidelines and outcomes are specified for each day of the client's hospital stay. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. An order set is a preprinted set of provider orders that expedite the provider order process. A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of clients within the cohort. It has a broader specificity than an algorithm and allows for minimal provider flexibility by way of treatment options.

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?

Client is normotensive. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a physician's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning. Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.

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?

"I will test my glucose level before meals and use sliding scale insulin." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage and conditions that require contact with the health care provider. Diabetes mellitus is a chronic disease, so the client who takes insulin should not expect to ever achieve a normal blood glucose level without taking insulin. The client should test blood glucose level before, not between, meals. Mixing different types of insulin is not necessary.

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem?

Client will not leave the premises without a caregiver. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with dementia, the most direct resolution of wandering is for the client to remain in the presence of someone who can prevent wandering.

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?

Ineffective Impulse Control Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation; or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences (such as physical or emotional impairment). The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. In this case, the lack of impulse control is the greatest risk to the client's well-being. Agitated movement is not a nursing diagnosis.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

Ongoing Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.

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." Which nursing action is the priority?

Resolve the client's anxiety. A priority is something that takes precedence in position, deemed the most important among several items. Resolving the client's anxiety is the priority because until it is resolved, the nurse may not be able to effectively provide preoperative education to the client, prepare the client for surgery, or evaluate the need for antibiotics. In fact, the client's anxiety may make it necessary to cancel the surgery altogether. Therefore, to have a successful outcome, the nurse must address the client's psychosocial issues related to anxiety.

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?

The nurse has omitted the time frame. Outcomes are client-centered, use action verbs, identify measureable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do.

The primary purpose of developing expected client outcomes is to:

provide individualized care. The primary purpose of outcome identification is to provide individualized care, but other purposes include to promote participation, to provide care plans that are realistic and measurable, and to allow for involvement of support people. Although the nurse should document outcomes, their primary purpose is not related to facilitating documentation. Although client outcomes are used in evaluation of the client's response to nursing interventions, this is not their primary purpose. Client outcomes do not focus solely on health promotion but may identify a wide array of client health problems, including actual, possible, risk, problem-focused, and health promotion.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed. Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The physician does not approve and sign the interventions, because they are nursing interventions.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client. Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure injury, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care.

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered?

Ongoing planning Ongoing planning is carried out by any nurse who interacts with the client. Its chief purpose is to keep the plan up-to-date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the client uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective. Comprehensive planning involves establishing a plan of care that addresses all aspects of the client's care needs and updating that plan of care as needed until the client is discharged. Comprehensive planning has three phases: Initial planning, ongoing planning, and discharge planning. Initial planning is performed by the nurse with the admission nursing history and the physical assessment and results in the development of a comprehensive plan of care that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. In acute care settings, discharge planning begins when the patient is admitted for treatment—or even before admission. It ensures that the nurse uses teaching and counseling skills effectively to help the client and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors at home competently.

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20. Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family. One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved. Patient-centered care focuses on the client needs and desires and thus would not require input from the physician, the nurse manager, or multidisciplinary team.