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