Chapter 17: Outcome Identification and Planning
A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client tries using relaxation as a means to cope." "Client will identify one coping strategy to try by end of week." "Client will list positive coping strategies and use them." "Client will learn to cope more effectively."
"Client will identify one coping strategy to try by end of week." Explanation: An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.
A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care? Tell another nurse about this client statement. Encourage the client to join a therapy group. Document that the depression has resolved. Add the nursing diagnosis: Risk for Self-Harm.
Add the nursing diagnosis: Risk for Self-Harm. Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and less effective, because the entire team needs access to this information. While group therapy may provide help, it does not address the client's current mental health status related to self-harm.
A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client 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? Failing to update the written plan of care Beginning the plan without family to help Developing the plan without client input Choosing actions that do not solve the problem
Developing the plan without client input Explanation: Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support.
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. Include the rationale for the interventions. Identify the appropriate nursing diagnoses. Expect to modify the plan significantly.
Individualize the plan to the client.
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 the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? Once the client is admitted to the nursing unit from postanesthetic recovery On the client's admission to the hospital As soon as possible after the client's surgery Once the client has received a discharge order
On the client's admission to the hospital Explanation: Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.
A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? Offer to help the client walk the length of the hallway each day. The nurse will help the client ambulate the length of the hallway once a day. The client will become mobile within a 24-hour period. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.
Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Explanation: Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.
A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? Supportive Psychosocial Supervisory Coordinating
Supportive Explanation: Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care.
The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision? By 08/02, the client will state three therapeutic methods of reducing stress. The client will understand the effects of smoking related to heart disease. By 8/02, the client will state when to notify the health care provider after discharge By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet.
The client will understand the effects of smoking related to heart disease. Explanation: Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.
When a nurse documents an intervention involving a one-person assist of a client to the chair, which type of nursing intervention does this represent? Psychomotor Surveillance Maintenance Psychosocial
he client will demonstrate proper care of the stoma by 3/29/20. Explanation: 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.
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 reports no headache. Client is normotensive. Client is drowsy after lunch. Client lipids are within range.
Client is normotensive. Explanation: 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.
The 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? Seek research about the disorder. Consult with another nurse. Set priorities using client care standards. Follow institutional guidelines.
Seek research about the disorder. Explanation: While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.
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 take insulin until my blood sugar levels are normal." "I will test my glucose level before meals and use sliding scale insulin." "I will mix insulin glargine with insulin lispro at bedtime." "I will take my medications between meals for maximum effect."
"I will test my glucose level before meals and use sliding scale insulin." Explanation: 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 client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A plan made in conjunction with the hospital's ethics committee A plan with problems that are easily solved A plan designed to support the client physically A plan derived from a consensus of opinions of all staff members
A plan designed to support the client physically Explanation: An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.
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? A standardized care plan An order set Guidelines An algorithm
A standardized care plan Explanation: Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.
The nurse is selecting interventions after gathering and analyzing client data. Interventions that the nurse includes will meet what criterion? Multidisciplinary Aligned with a goal Based on collaboration with the care provider Time-specific
Aligned with a goal Explanation: Nursing interventions must be specifically designed to meet the identified goal. These are grounded in the scope of nursing practice so they may not require collaboration with other disciplines. Goals and outcomes should be time-specific but interventions may not always be.
The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. When completing the plan of care, which outcome is written the clearest for working with the multidisciplinary team? After visiting the clinic, client will indicate a desire for adoption. By the next clinic visit, the nurse will discuss the client's feelings around infertility. By discharge from the fertility clinic, the client will achieve full-term pregnancy. Client will understand the importance of follow-up laparoscopic examination.
By discharge from the fertility clinic, the client will achieve full-term pregnancy. Explanation: Outcomes should be specific, measurable, attainable, realistic, and timebound. Achieving a full-term pregnancy is a specific and reasonably attainable goal. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention (e.g., the nurse will discuss the client's feelings around infertility), including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable (e.g., client will understand the importance of follow-up laparoscopic examination).The other options do not directly measure resolution of the problem, they lack a time element, or do not address the issue desired (e.g., client will indicate a desire for adoption).
Which guideline should the nurse follow when including interventions in a plan of care? Make sure each nursing intervention does not describe the action the nurse should perform. Make sure the nursing interventions are unrelated to the original outcomes. Date the nursing interventions when written and when the plan of care is reviewed. Make sure the attending health care provider approves of and signs the nursing interventions.
Date the nursing interventions when written and when the plan of care is reviewed. Explanation: 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 health care provider does not approve and sign the interventions, because they are nursing interventions.
A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care? Ask the client what the priority needs are. Hold a unit meeting to determine needs. Include the client and the client's power of attorney in the discussion. Consult the oncology nurse specialist in order to determine priorities.
Include the client and the client's power of attorney in the discussion. Explanation: During the planning step of the nursing process, the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. When there are cognitive limits, the client's power of attorney (POA) should also be included in the plans.
Which nursing diagnosis has priority? Disturbed Sleep Pattern related to abdominal incisional pain Constipation related to decreased fluid intake and decreased mobility Ineffective Airway Clearance related to retention of secretions Self-care Deficit: Bathing related to joint inflammation
Ineffective Airway Clearance related to retention of secretions Explanation: High-priority nursing diagnoses, such as Ineffective Airway Clearance, pose the greatest threat to the client's well-being and should be addressed by the nurse first. The priority is to assess airway, breathing, and circulation before any of the other body systems. Disturbed sleep, self-care deficit, and constipation are not as serious as an obstructed airway.
Which statement correctly describes a nurse-initiated intervention? Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions are actions performed to diagnose a medical problem. Nurse-initiated interventions require a health care provider's order. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client.
Nurse-initiated interventions are derived from the nursing diagnosis. Explanation: Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a health care provider'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 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.
What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? Nurses are not legally responsible for these interventions. Nurses do not carry out health care provider-initiated interventions. Nurses do carry out interventions in response to a health care provider's order. Nurses are responsible for reminding health care providers to implement orders.
Nurses do carry out interventions in response to a health care provider's order. Explanation: A health care provider-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 health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests.
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 Discharge Initial Outcome
Ongoing Explanation: 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.
A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? Opioid analgesic to treat pain Acetaminophen to treat pain and fever Septic workup due to blood pressure and heart rate elevation Isolation for suspected respiratory illness
Opioid analgesic to treat pain Explanation: A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized opioid plan that will help them to receive opioids in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.
A nurse is caring for a client 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? Structure Outcome Cost-effectiveness Process
Outcome Explanation: An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.
A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? Review evidence-based interventions for the client's pain. Ask the client to describe a personal walking goal. Adjust expected outcome to have client ambulate a shorter distance. Return the client to bed and provide pain relief measures.
Return the client to bed and provide pain relief measures. Explanation: While all of these interventions could be used to meet the client's outcomes, the most immediate need is for pain relief. Highest priority nursing diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation. Safety issues, such as threats of self-harm, are also highest priority. 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. This client has a medium level diagnosis because acute pain is interfering with function.
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: medical orders. condition. support system. past medical history.
condition. Explanation: Because a person's condition changes, priorities change. Priorities are based on information collected during reassessment after recovery and assignment to the acute care setting. As the client heals these priorities can shift rapidly. The client's support system would have more of an impact on priorities of care once the client is being discharged to home, not while the client is in the acute care setting immediately after surgery. Both the client's medical orders and the client's nursing priorities change in response to the client's condition, rather than in response to one another. The client's past medical history, which doesn't change, is less likely to affect the nursing priorities of the client after surgery than the client's condition, which does change.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: discharge planning. comprehensive planning. ongoing planning. initial planning.
discharge planning. Explanation: 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.
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: identifies factors causing undesirable response and preventing desired change. identifies client strengths. suggests client goals to promote desired change. identifies the unhealthy response preventing desired change.
identifies factors causing undesirable response and preventing desired change. Explanation: The cause of the client health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the client goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Client strengths are identified during the nursing diagnosis phase.