Chapter 8 study set: Planning -Nursing Process

patient centered goals

-Goals that reflect the patient, not nursing activities. -the goal is about activity of the patient ex. ambulating, eating turning, coughing.

What should the nurse do if she and the patient cant agree on short-term goal/long-term goals because of not willing to give up certain lifestyle choices?

-The nurse must listen to the patients needs and take them into considerations when making the care plan. -the nurse must teach/explain the importance of the nursing interventions so that the patient can better understand why certain things need to change. A patient can grasp a goal better once they understand why.

dependent nursing interventions

-actions requiring an order from physician or another health care professional, such as request for physician--prescribed medication orders. -the nurse incorporates these orders in the patients overall care plan by associating with with the diagnoses.

When does discharge planning occur? and what should discharge documents contain?

-at the beginning of care, upon admission since some patients are only in the hospital for a few short days. -this ensures a smoother transition from patients to home. -discharge documentation should include 1. medical information 2. patient goals 3. patient goals 4. interventions

short term goals Long term goals

-goals achievable in less than as week -goals that take weeks-months to achieve -the goals should be realistic, patient centered, and measurable.

3. How does involving the patient and/or family in planning help to improve goal attainment?

-involving the patient in care planning helps patient be aware of needs, accept realistic and measurable goals, embrace interventions, and overall take ownership of the area of health they're trying to improve. The patient is more likely to understand and accept the goals and treatment plan, which can contribute to achieving the expected outcomes.

Conceptual care map (CCM)

-it is a combination between a concept map and a care plan. -organizes assessment data( which can be organized from head-to-toe), nursing orders, physician orders, treatments, medication orders, test results, & developments of care plan.

What is the planning process? (5 steps)

-when the nurse prioritizes each nursing diagnosis. If many, the nurse will prioritize which one is most urgent to work on first. 1. prioritize nursing diagnoses 2. personal care plans 3. short-term goals 4. long-term goals 5. outcome identification -NIC: nursing interventions classification (research-based standardized nursing interventions.) -NOC: nursing outcome classification (evaluates how nursing interventions are going.) -nurse needs to include patient during care panning process. Also include patients cultural norms, religious traditions, convictions

Nursing Interventions Classification (NIC)

.A listing of research-based nursing intervention labels, that provides standard of nursing interventions.

7. Describe the characteristics that make goals most effective.

1. Appropriate in terms of nursing and medical diagnoses and therapy. 2. Realistic in terms of patient capabilities, time, energy, and resources. 3. Specific to be understood clearly by the patient and other nurses. 4. Measurable facilitate evaluation

what would a nurse do to a patient first, in a life threatening situation?

A B C's: airway, breathing, circulation -these must first be addressed in a life threatening situation.

8. Revise the following goal statements to make them more precise, time oriented, and measurable. a. Temperature will be normal. b. The patient will walk more. c. The diet will be understood.

A. Body temperature will range between 98.3° and 99° F during the day. B. Patient will ambulate up and down the hallway to the room at least tid during hospital stay. C. Patient will be able to verbalize the foods allowed on the therapeutic diet by tomorrow

11. Provide examples for each type of nursing interventions. a. Independent (nurse initiated) b. Dependent c. Collaborative

A. Independent—providing patient education or emotional support, assessing status B. Dependent—administering medications, performing wound care C. Collaborative—physical therapy, hospice care, spiritual or financial counseling

9. For the revised goal statements in the previous question, identify the outcome indicators.

A. Vital signs—body temperature B. Activity/mobility C. Appetite

22. Which one of the following best meets the criteria for a goal statement? a. Respiratory rate will remain within 20-24 breaths per minute through discharge b. Patient will ambulate in the hallway frequently c. Treatment regimen will be understood d. Patient will describe activity restrictions

A. respiratory rates will remain within 20-24 breaths per minute through discharge

19. The patient works in a tailor shop and is having surgery to correct bilateral cataracts. If all of the following are realistic, what is the long-term goal for this patient? a. Return to his occupation b. Prevention of ocular infection c. Independent performance of hygienic care d. Self-administration of eye drops postoperatively

A. return to his occupation.

21. Which one of the following interventions is considered independent or nurse initiated? a. Teaching the patient about the therapeutic diet b. Giving an enema in preparation for radiologic testing c. Providing analgesics for postoperative discomfort d. Administering wound care

A. teaching a patient about therapeutic diet.

5. What are the ABCs of life support?

A: airway B: breathing C:circulation

18. The nurse receives the patient assignment in the morning. Which one of the patients should be seen first? The patient who: a. takes a hypnotic medication at bedtime. b. has fluctuations in blood sugar readings. c. needs assistance with morning care. d. has an order for a daily dressing change.

B. has fluctuations in blood sugar readings

14. In writing goal statements, it is important to use measurable verbs. Identify the verbs that are best to use in developing measurable and patient-oriented goal statements. Select all that apply. a. Understand _____ b. Verbalize _____ c. Know _____ d. Perform _____ e. Think _____ f. List _____

B. verbalize D. perform F. list

4. Place the following examples of patient needs in priority order (first to fifth), according to Maslow's hierarchy: a. Autonomy _____ b. Compassion of care provider _____ c. Oxygen level _____ d. Ability to perform role functions _____ e. Physical safety _____

C. oxygen level E.physical safety B.compassion of care provider D. ability to perform role functions A. autonomy

20. A goal for a patient who is hypertensive is a return to expected limits. Which one of the following outcome indicators is most appropriate? b. Patient identifies two things that reduce stress c. Patient will not experience headaches d. Patient's blood pressure is between 120/80 mm Hg and 130/90 mm

D. patients BP is between 120/80 mm Hg and 130 / 90 mm

17. Which one of the following is associated with specifically meeting the Quality and Safety Education for Nurses Teamwork and Collaboration competencies? a. Providing the patient with the schedule for diagnostic testing b. Assessing the patient's level of pain c. Engaging the patient in conversation d.Working with the patient and nutritionist

D. working with the patient and nutritionist.

16. On the basis of the following nursing diagnoses, identify a goal and outcome indicator(s) for each. a. Nutrition, imbalanced: more than body requirements b. Pain related to surgical incision Select the best answer for each of the following questions: 19. The patient works in a tailor shop and is having surgery to correct bilateral cataracts. If all of the following are realis- tic, what is the long-term goal for this patient? a. Return to his occupation b. Prevention of ocular infection c. Independent performance of hygienic care d. Self-administration of eye drops postoperatively 20. A goal for a patient who is hypertensive is a return to ex- pected limits. Which one of the following outcome indica- tors is most appropriate? a. Patient expresses decreased discomfort q3h 21. 22. Which one of the following interventions is considered independent or nurse initiated? a. Teaching the patient about the therapeutic diet b. Giving an enema in preparation for radiologic testing c. Providing analgesics for postoperative discomfort d. Administering wound care Which one of the following best meets the criteria for a goal statement? a. Respiratory rate will remain within 20-24 breaths per minute through discharge b. Patient will ambulate in the hallway frequently c. Treatment regimen will be understood d. Patient will describe activity restrictions 20 b. Patient identifies two things that reduce stress c. Patient will not experience headaches d. Patient's blood pressure is between 120/80 mm Hg and 130/90 mm Hg Practice Situation Your patient has been recently diagnosed with diabetes mellitus type 2. With no prior history in his family, he is unfamiliar with the diet and treatments. He will require an oral hypoglycemic medica- tion, as well as information about the prescribed diet. He expresses to you that he does not know how he will manage the diabetes. a. On the basis of these data, identify a nursing diagnosis. You may use the one that you formulated for Chapter 7. b. Specify at least one short-term goal for the nursing dia

Goal statements: A. Body weight (indicator): Patient will lose at least 1 lb 164 per week. B. Vital sign assessment—pain (indicator): Patient will express less than a pain level of 3 on a scale of 10 following medication administration.

15. What is one of the major challenges that nurses face in providing health information to patients?

Nurses are faced with a significant population of adults who are health illiterate. They have difficulty completing routine health tasks such as understanding a drug label or vaccination table.

2. What is the first step in the planning phase of the nursing process?

The first step in the planning phase is to set priorities among nursing diagnoses.

10. What are the five key elements that are considered for nursing interventions?

The five key elements for nursing interventions are: 1. Patient assessment findings indicating signs and symptoms that have resulted from or in response to an illness or life experience. 2. The underlying etiology or related factor identified in each nursing diagnosis. 3. Realistic patient outcomes (includes patient physical, mental, spiritual situation, resources, time, etc) 4. Evidence-based interventions aligned with patient acceptance and practicality. 5. Expertise of the nurses and other health care professionals

6. Provide an example of how the nurse and patient may have conflicting priorities for care.

The patient may want to have financial concerns addressed before learning injection technique or have the arthritis pain resolved before treatment of an asymptomatic heart disease. The nurse recog- nizes the importance of the patient's compliance with the therapeutic diet, while the patient may have cultural preferences that make maintaining the diet difficult and undesirable.

13. What effect could a patient's disability have in determining goals?

The patient's disability can influence the way or the time frame in which the goals can be achieved

Measurable goal

a goal in which you know how long and exactly when the patient has completed it ex. The patients morning BP will be between 120-140 systolic and 70-90 diastolic)

Your patient has been recently diagnosed with diabetes mellitus type 2. With no prior history in his family, he is unfamiliar with the diet and treatments. He will require an oral hypoglycemic medication, as well as information about the prescribed diet. He expresses to you that he does not know how he will manage the diabetes. A.On the basis of these data, identify a nursing diagnosis. You may use the one that you formulated for Chapter 7. b. Specify at least one short-term goal for the nursing diagnosis selected

a. Nursing diagnosis—Knowledge deficit b. Short-term goal examples—Patient will be able to discuss the dietary requirements for the therapeutic diet by the next clinic visit. Patient will describe the dosage, action, and side effects of the prescribed medication by 9/3.

12. When should discharge planning begin for the patient in acute care?

at the beginning of patient care because some patients aren't in the hospital very long. this ensures a smooth transition from hospital to home. documentation should include: 1. medical information 2. patient goals 3. interventions

independant nursing interventions

care initiated by a nurse that does NOT require a doctors order, or acting on an order that is written prn aka as needed. -Ex. encouraging or teaching a patient about certain aspects of her recovery or care care, like teaching deep breathing post op. -ex. ordering heel protecters for patients skin breakdown on heel.

Why should patients be involved in the planning of their care plan? (3)

it helps them 1. be aware of their needs 2. accept realistic and measurable goals 3.embrace interventions to best achieve the mutually agreed-on goals. -including patients and their families help the patient take ownership of their goals.

OSM: 1. Identify the difference between long- and short-term goals.

short term goes are achievable immediately or take a week. long term goals take 2 weeks to months to achieve.

realistic goals

takes into account the patients physical, mental and spiritual condition, in relation to the goal they're trying to meet.

What patients needs will the nurse address first?

that depends on how bad the symptoms are. Maslow's hierarchy of needs is taken into account. 1. psychological needs are met first. (oxygen, water, food, temp., control, movement, sex, rest, comfort, elimination. 2. safety and security 3. Love & belonging 4. Self esteem: 5. Self actualization.