NUR313 Ch 8 Outcome Identification and Planning

Outcome criteria are

- specific, measurable, realistic statements of goal attainment. - They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process.

A patient outcome is

-an educated guess, made as a broad statement, about what the patient's state will be after the nursing intervention is completed. - It directly addresses the problem stated in the nursing diagnosis

Which group of terms best describes a nurse-initiated intervention?

Autonomous, clinical judgment, client outcomes

Which action should the nurse perform during the planning phase of the nursing process?

Identify measurable goals or outcomes.

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. A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? Client will have formed stools within 24 hours.

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. - nurses are not required to remind, but can ask - they're both legally responsible

A nursing outcome states

a measurable, time-dependent goal by which to evaluate a nursing intervention.

Monitoring blood pressure is an appropriate example of

a surveillance intervention, as it can detect changes in blood pressure

Psychomotor interventions involve

actions such as positioning, inserting, or applying Psychomotor outcomes describe the client's achievement of new physical skills, such as changing an abdominal dressing.

Affective outcomes describe

changes in client values, beliefs, and standards, such as decreasing the number of cigarettes one smokes due to adopting a belief that smoking is harmful.

scientific rationale

is the justification or reason for carrying out the intervention. - It often synthesizes psychological and pathophysiologic concepts.

psychosocial intervention,

which focuses on supporting, exploring, and encouraging

A nurse working in a critical care unit has formulated the following nursing diagnoses for a client. Which nursing diagnosis likely would be the priority?

Impaired Gas Exchange is a high-priority nursing diagnosis because it may be life threatening if proper interventions are not initiated

nursing interventions

Sometimes called nursing orders, -are written in specific terms that relate to the goals

Two important concepts guide a patient plan of care:

The plan of care is patient centered. The plan of care is a step-by-step process.

The qualifier is

a description of the parameter for achieving the outcome

Nursing Outcome Classification (NOC)

can be used in standardized care plans and critical pathways to set expected goals and compare individual patients or groups of patients to determine effectiveness of nursing interventions

the plan of care usually contains three key elements:

the nursing diagnosis (patient problem), patient goals, and nursing interventions (nursing orders, nursing actions)

nursing intervention states

what the nurse will do; - the outcome provides a point of reference for determining whether the intervention is appropriate and effective.

evaluation of a nursing intervention is

a written statement that determines the patient's status in relation to the outcome criteria at a particular time. - Evaluation focuses on patient progress, not on how well the student or nurse carried out nursing interventions.

Instructional patient plans of care

aka student care plans, - allow students to demonstrate their knowledge of various patient problems and apply the processes nurses use to solve them.

Nursing-Sensitive Outcome classification can be used

in a manual or computerized clinical information system. A Nursing Interventions classification is organized in a three-level taxonomy of domains, classes, and interventions that are coded numerically

Variance measurement helps

in identifying client problems early in hospitalization. It also has the potential to identify complications, variances in practice patterns, and system problems

Planning ,

the fourth phase of the nursing process, refers to the development of nursing strategies designed to ameliorate patient problems. - nurse identifies measurable goals or outcomes, prioritizes nursing diagnoses and collaborative problems, selects appropriate interventions, and documents the plan of care

key elements of the patient plan of care are

the nursing diagnosis or problem list, patient goals and outcome criteria, and nursing intervention