Chapter 5 Fundamentals of Nursing

What Are the Main Points in This Chapter?

-During the planning outcomes phase, you will derive goals/expected outcomes from identified nursing diagnoses. -Goals/expected outcomes (1) suggest nursing interventions, (2) serve as criteria for use in the evaluation step of the nursing process, and (3) provide motivation for patients and nurses. -To ensure continuity of care, you should begin discharge planning with the initial patient assessment. -Discharge planning is especially important for older adults and patients with complex needs. -A holistic, individualized patient care plan contains information needed to address (1) basic needs and ADLs, (2) medical and collaborative therapies, (3) nursing diagnoses and collaborative problems, and (4) special teaching and/or discharge needs. -Ideally, a care plan consists of a combination of standardized and individualized goals and interventions. -Standardized approaches to care planning include institutional policies and procedures, protocols, unit standards of care, standardized care plans, critical pathways, and integrated plans of care (IPOCs). -Computer-assisted care planning helps ensure that the nurse considers a variety of interventions and does not overlook common and important interventions; it reduces the time spent on paperwork. -Nursing-sensitive goals (expected outcomes, predicted outcomes, desired outcomes) describe the changes in patient health status that are intended to result from and can be influenced by nursing interventions. -Goals for collaborative problems are usually not nursing sensitive, and should not be included on a nursing care plan. -A goal statement should include a subject, an action verb, a performance criterion, a target time, and special conditions if needed. -For every nursing diagnosis, you must state one "essential" goal—one that, if achieved, would demonstrate problem resolution or improvement. -Among the ANA-recognized standardized vocabularies/taxonomies for describing patient outcomes are NOC, the Omaha System, and the Clinical Care Classification System. -Goals should be concrete, specific, and observable; they should be valued by the patient/family; and they should not conflict with the medical treatment plan.

Figure 5-4 in Volume 1, a patient plan of care for Acute Pain, uses NOC language. 1. What outcomes did the nurse choose for this patient? 2. List two indicators for each of the outcomes. 3. For which outcome does the nurse expect the highest level of functioning to occur after interventions? (Note that in this care plan the measuring scale has been applied to the outcomes rather than to the indicators.)

1. Answer: Pain Control Behavior Pain Level 2. Answer: Pain Control Behavior Recognizes causal factors Uses non-analgesic relief measures Uses analgesics appropriately Reports pain controlled Pain Level Oral/facial expressions of pain Change in respiratory rate, heart rate, blood pressure Restlessness 3. Answer: Pain Control Behavior Rationale: It has higher numbers than Pain Level.

In the following predicted outcomes, identify the subject, action verb, performance criterion, target time, and special conditions (if any). State which components are assumed, if any. 1. Will walk to the doorway with the help of one person by 12/13/16. 2. After two teaching sessions, [client] will be able to identify foods to avoid on a low-fat diet by 3/1/16. 3. Bowel movements will be soft and formed and of his usual frequency. 4. Lungs clear to auscultation at all times.

1. Answer: Subject: client (assumed) Action verb: will walk Performance criterion: to the doorway Target time: by 12/13/15 Special conditions: with the help of one person 2. Answer: Subject: client Action verb: (will be able to) identify Performance criterion: foods to avoid on a low-fat diet Target time: by 3/1/15 Special conditions: after two teaching sessions 3. Answer: Subject: bowel movements (client is assumed) Action verb: will be (note that this is not an action verb) Performance criterion: soft and formed, and of his usual frequency Target time: ("at all times" is assumed if goal is for a potential problem; if for actual constipation, a date or time should be written) Special conditions: none 4. Answer: Subject: lung sounds (client is assumed) Action verb: are (Note that "are" is assumed, not stated. "Are" is not an action verb. This is acceptable because we are describing what the lungs are to do, rather than what the patient is to do.) Performance criterion: clear Target time: at all times Special conditions: to auscultation

Which standardized classification system was designed specifically for home healthcare?

Answer: Clinical Care Classification (CCC), also called Saba or Georgetown

What is the main disadvantage of computerized and standardized care plans?

Answer: Computerized and standardized care plans may cause you to lose some creativity, intuition, insight, or caring because it is tempting, when you are busy, to accept the "easy answer" provided by the computer and not go further to think about the unique needs of this particular patient.

Mr. Yang, a 65-year-old, is a long-term client at "Primary Services." He has hypertension and asthma and is 25 lb overweight. Identify the following goals as either short-term or long-term. A. Mr. Yang will incorporate dietary and lifestyle changes to achieve optimal weight and maintain therapeutic regime. B. Mr. Yang will verbalize understanding of the barriers (weight, lack of exercise, nonadherence to medication regime) toward adequate maintenance of hypertension. C. Mr. Yang will discuss lifestyle changes that may occur as a result of his health status. D. Mr. Yang will exhibit increased feelings of self-worth by setting realistic goals for weight reduction and increased exercise.

A. Answer: Long-term goal B. Answer: Short-term goal C. Answer: Short-term goal D. Answer: Short-term goal

Indicate whether each of the following statement is True or False. A. A nursing diagnostic statement is a three-part statement comprising the diagnostic label, related factors, and the defining characteristics that support the label. B. Outcome identification is the description of the activities needed for achieving both short-term and long-term goals. C. The key elements of the nursing plan of care are the nursing diagnosis, client goals, and nursing interventions. D. Aggregate nursing goals are formulated to address the needs of families, groups, or communities.

A. Answer: True B. Answer: False C. Answer: True D. Answer: True

How are critical pathways different from other standardized care plans?

Answer: Critical pathways focus on care for a particular medical diagnosis or DRG; they are organized on a time line to meet recommended lengths of stay; instructions for nursing interventions are usually less specific/detailed.

Complete the following statements by filling in the blank with the appropriate word or phrase. A. Evaluation can focus on one of three areas: structure, ________, or ________. B. "Essential" goals are derived from the ________clause of the nursing diagnosis. C. Care plans that focus on diagnosis-related groups (DRGs) and are organized on a time line to meet recommended lengths of stay are called ________. D. Goals that are specific, concrete, and measurable; valued by the patient; and are stated in terms of patient response or behavior are __________.

A. Answer: process outcomes B. Answer: problem C. Answer: critical pathways D. Answer: realistic

What is the purpose of initial planning? Ongoing planning? Discharge planning?

Answer: -Initial planning is done for the purpose of identifying patient problems and creating the care plan. -Ongoing planning allows you to revise and individualize the patient's care plan as new data are obtained. -Discharge planning is done to evaluate the patient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hospital or other healthcare agency.

Which of the following functions both as a care plan and a documentation form? Choose all correct answers. 1) Integrated plan of care (IPOC) 2) Critical pathway 3) Individualized patient care plan 4) Standardized (model) care plan

Answer: 1) Integrated plan of care (IPOC) 2) Critical pathway Rationale: IPOCs are standardized plans that function as care plans as well as documentation forms. Many critical pathways are designed as IPOCs, and may function as documentation forms; however, not all critical pathways are IPOCs. Individualized care plans are not designed to be used as documentation forms. Although some standardized care plans provide writing space in which to individualize nursing orders and patient goals, they do not provide a place to document care and patient responses to care.

Which is true of unit standards of care? Unit standards of care are (select all that apply): 1) Written for a specific medical diagnosis or treatments 2) Organized according to nursing diagnoses 3) A description of minimal level of care a patient is expected to receive 4) Not part of the care plan that is included in the patient's chart

Answer: 1) Written for a specific medical diagnosis or treatment 3) A description of minimal level of care a patient is expected to receive Rationale: Unit standards describe the minimal level of care the nurses are expected to achieve. They are not kept in the patient's chart but are kept in a file on the unit. Protocols are written to cover specific medical diagnoses and treatments. Unit standards are not organized according to nursing diagnoses.

The client has a nursing diagnosis of Impaired Physical Mobility. Which of the following is a Nursing Outcomes Classification (NOC) outcome label to use with this diagnosis? 1) Increases his physical activity 2) Activities of daily living 3) Demonstrates appropriate use of adaptive equipment 4) Verbalizes feeling of increased strength

Answer: 2) Activities of daily living Rationale: NOC outcomes are broad neutral labels, not goal statements; the physical activity and strength outcomes are specific goals because they use the word increase, implying a target behavior. The adaptive equipment outcome includes the word appropriate, implying a judgment of the quality of the behavior—not a neutral statement. Goals state what the desired status will be. NOC outcomes provide only the topic to be evaluated.

The nurse has written this diagnosis for a patient: Ineffective Airway Clearance related to weak cough secondary to incisional pain. Which of the following outcomes is essential for the nurse to include in the care plan? 1) Effective cough 2) Airways clear to auscultation 3) Pain less than 4 on a scale of 1 to 10 4) Demonstrates splinting of incision

Answer: 2) Airways clear to auscultation Rationale: For every nursing diagnosis, it is essential to have one goal that, if achieved, would show resolution of the problem. If the airways were clear to auscultation, that would show resolution of Ineffective Airway Clearance. Effective cough, reduced pain, and splinting of incision would help to resolve the problem, but they are aimed at the etiology side of the diagnostic statement. Even if pain is reduced, for example, the airways still might not be clear.

For which patient would it be most important to perform a comprehensive discharge plan? 1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident

Answer: 2) An older adult who has had a stroke affecting the left side of his body and lives alone Rationale: A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits, especially when they live alone and have no support within the home. The other patients do not have the complex needs of the older adult patient who has had a stroke that affects body function.

Which is the best example of a well-stated desired outcome? The patient will: 1) Use the incentive spirometer while awake 2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication 3) Increase the distance he walks each time he ambulates 4) Verbalize the side effects of his new medication

Answer: 2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication Rationale: Outcome criteria should be stated with specific measurement criteria; the pain outcome is the most specific and measurable or observable. "Use incentive spirometer" should specify how long and how often. "Increase the distance" should say how much he should increase the difference and what the baseline distance is. "Verbalize side effects" should specify by what date the patient is expected to do this.

The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful? 1) Start planning at admission. 2) Involve the family members. 3) Get patient input when making the plan. 4) Involve the multidisciplinary team.

Answer: 3) Get patient input when making the plan. Rationale: It is most important to get patient input. The discharge plan may be developed in a timely manner and involve the family and a multidisciplinary team, but if the patient does not agree with the plan, it will not be successful.

Which of the following aids the nurse in best meeting the unique needs of a patient? 1) Kardex 2) Critical pathway 3) Individualized patient care plan 4) Standardized (model) patient care plan

Answer: 3) Individualized patient care plan Rationale: Individualized, or nursing diagnosis, care plans address nursing diagnoses unique to a particular client. They reflect the independent component of nursing practice and include goals and nursing orders written specifically for a patient. A Kardex contains essential client data that either do not change or that are used and updated often. It includes ADLs and other basic care needs. It does not address a client's individual problems. A critical pathway is a standardized plan that specifies patient outcomes and broad interventions for all patients with a particular condition (e.g., myocardial infarction, sepsis). A standardized (model) patient care plan describes the nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical diagnosis. They do not describe care for a particular patient.

How is a critical pathway different from a standardized care plan? A critical pathway: 1) Does not include medical orders 2) Provides individualized goals and interventions 3) Specifies patient outcomes and interventions for each day, or other period of time 4) Is usually a preprinted document for a particular diagnosis or condition

Answer: 3) Specifies patient outcomes and interventions for each day, or other period of time Rationale: A critical pathway specifies patient outcomes and interventions for each day, and in some situations (such as labor and delivery) for each hour. Critical pathways do include medical orders, so that statement is not true of critical pathways. Critical pathways are standardized, not individualized, so this is not true of critical pathways. Both critical pathways and standardized care plans are preprinted documents for a particular diagnosis or condition, so that statement cannot be used to differentiate them.

What is missing from this goal statement? "The patient will walk to the doorway with the help of one person." 1) Action verb 2) Special conditions 3) Target time 4) Nothing is wrong with it.

Answer: 3) Target time Rationale: The goal does not have a target time. Its action verb is "will walk." Its special conditions are "with the help of one person."

Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans: 1) Apply to every patient on a particular unit 2) Include both medical and nursing orders 3) Specify patient outcomes for each day 4) Help ensure that important interventions are not overlooked

Answer: 4) Help ensure that important interventions are not overlooked Rationale: Standardized care plans help promote consistency of care and ensure important interventions are not forgotten. They are not likely to apply to every patient on a unit because they are usually single-problem plans or are used with a particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day.

When writing an individualized patient care plan, which of the following should the nurse do first? 1) Transcribe medical orders to the appropriate documents. 2) Individualize standardized plans as needed. 3) Write basic care needs on the Kardex or in special sections of the care plan. 4) Make a working problem list with problems in priority order.

Answer: 4) Make a working problem list with problems in priority order. Rationale: Writing an individualized plan of care follows in natural sequence from the assessment and diagnosis phases of the nursing process. In those phases, the nurse has already developed and prioritized a list of the patient's problems and strengths. The nurse must start with this list and then decide which problems can be managed with standardized plans or critical pathways. Then the nurse individualizes the standardized plan(s) as needed. After that, the nurse enters the medical orders in the appropriate documents and writes ADLs and basic care needs in special sections of the care plan or Kardex. Finally, the nurse develops individualized (nursing diagnosis) care plans to address problems not covered by the standardized documents.

What do standardized nursing care plans and individualized care plans have in common? They both: 1) Reflect critical thinking for a specific patient 2) Apply to needs common to a group of patients 3) Address a patient's individual needs 4) Provide detailed nursing interventions

Answer: 4) Provide detailed nursing interventions Rationale: They both provide detailed nursing interventions, although the individualized care plan is more specific to the patient's needs and reflects critical thinking, whereas standardized plans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group.

Briefly describe a process for creating a comprehensive, individualized care plan that incorporates collaborative care and standardized planning documents.

Answer: A process for creating such a care plan should include the following steps: -Perform a comprehensive patient assessment. -Make and prioritize a working problem list. -Decide which problems can be managed with standardized care plans or critical pathways. -Individualize the standardized plan as needed. Mark off any instructions that do not apply to the patient; add or adapt nursing orders as appropriate. -Transcribe medical orders to appropriate documents. -Write ADLs and basic care needs in special sections of the Kardex, care plan, or computer. -Develop individualized care plans for problems not addressed by standardized documents. Write outcomes and nursing orders for each nursing diagnosis not addressed by standardized documents.

Define the following types of planning: A. Initial B. Ongoing C. Discharge D. Formal E. Informal

Answer: A. Initial. Done for the purpose of identifying patient problems and developing the care plan B. Ongoing. Revising and individualizing the client's plan of care as new data are obtained C. Discharge. Planning for the client's healthcare needs upon leaving the institution or transitioning to another level of care D. Formal. A conscious, deliberate activity involving decision making, critical thinking, and creativity E. Informal. Making mental notes or plans

Which of the following standardized classification systems was specifically designed for community health nursing? A. Clinical Care Classification B. Omaha System C. Nursing Outcomes Classification D. Nursing Intervention Classification

Answer: B. Omaha System

The goal for your 17-year-old patient, Bill, who is 5'5" tall, is "Maintains current weight of 135 lb." This is which of the following types of goals? A. Risk goal B. Wellness goal C. Essential goal D. Aggregate goal

Answer: B. Wellness goal Rationale: This is a wellness goal because the patient response is maintenance of the current healthy status of his weight.

What does the nurse do in the planning phases of the nursing process?

Answer: In the planning phases, the nurse chooses outcomes/goals based on assessments and nursing diagnoses, chooses nursing interventions, and writes the plan of care.

Which standardized classification system was designed for use in all areas and specialties of nursing?

Answer: NOC

Which standardized classification system was designed specifically for community health nursing?

Answer: Omaha System

List at least eight questions you could use to critically evaluate the quality of your goal/outcome statements.

Answer: Questions to ask include the following: -For each nursing diagnosis: Is there at least one goal that, when met, would demonstrate problem resolution? That is, does at least one goal flow from the problem clause? -For each nursing diagnosis: Are the predicted outcomes adequate to completely address the nursing diagnosis? -For each expected outcome: -Is the outcome appropriate for the nursing diagnosis? -Is each outcome derived from only one nursing diagnosis? -Does each outcome describe only one patient response or behavior? -Is the outcome stated as a patient behavior, not a nurse activity? -Is the outcome stated in positive, rather than negative, terms? -Is the outcome measurable or observable? -Are the performance criteria specific and concrete? Avoid words such as normal, sufficient, enough, more, less, adequate, increased. -Does each goal include all the necessary parts? -Is the expected outcome realistic and achievable by this patient, given the available resources? -Does the outcome conflict with the medical or other collaborative treatment plan? -Does the patient, family, or community value the outcome? -Does the goal conflict with any religious or cultural values?

In addition to care related to the patient's basic needs, what other types of information does a comprehensive care plan contain?

Answer: The comprehensive care plan also contains information about the medical/multidisciplinary plan of care, information about care related to nursing diagnoses and collaborative problems, and information regarding special teaching and/or discharge planning needs.

Refer to the Meet Your Patient feature, in Chapter 5 of Volume 1. State whether each of Mr. Ivanos's goals was a short-term or long-term goal.

Answer: They are all short term.