Chapter 16 - Outcome Identification and Planning
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?
"Please tell me your thoughts about treating this diagnosis."
Goal of Outcome Identification and Planning Step
1- Establish PRIORITIES 2-IDENTIFY and write EXPECTED patient OUTCOMES 3-Select EVIDENCE-BASED nursing interventions. 4-COMMUNICATE the plan of care.
Parts of a Measurable Outcome
1. Subject 2. Verb 3. Conditions 4. Performance criteria 5. Target time
ongoing planning
Carried out by any nurse who interacts with patient Keeps the plan up to date, manages risk factors, promotes function States nursing diagnoses more clearly Develops new diagnoses Makes outcomes more realistic and develops new outcomes as needed Identifies nursing interventions to accomplish patient goals
Which outcome is sufficiently measurable?
Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020.
Categories of Outcomes
Cognitive: describes increases in patient knowledge or intellectual behaviors Psychomotor: describes patient's achievement of new skills Affective: describes changes in patient values, beliefs, and attitudes
Types of institutional plans of care
Computerized plans of care Concept map plans of care Change of shift reports Multidisciplinary (collaborative) plans of care Student plans of care
Which guideline should the nurse follow when including interventions in a plan of care?
Date the nursing interventions when written and when the plan of care is reviewed.
A nurse is developing short-term outcomes for a client with a nursing diagnosis of "Deficient Knowledge related to insulin self-administration as evidenced by statements of therapy being new and never having done it before." When writing the outcomes, which verbs would the nurse use to achieve a psychomotor change in behavior? Select all that apply.
Demonstrate Choose
Initial planning
Developed by the nurse who performs the nursing history and physical assessment Addresses each problem listed in the prioritized nursing diagnoses Identifies appropriate patient goals and related nursing care
A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?
Educational
long-term vs short-term outcomes
Long-term outcomes require a longer period to be achieved and may be used as discharge goals. Short-term outcomes may be accomplished in a specified period of time.
Actions performed inures-initiated interventions
Monitor health status. Reduce risks. Resolve, prevent, or manage a problem. Facilitate independence or assist with ADLs. Promote optimum sense of physical, psychological, and spiritual well-being
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis.
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?
On the client's admission to the hospital
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
IOM's Six Aims to be Met by Health Care Systems Regarding Quality of Care
Safe: avoiding injury Effective: avoiding overuse and underuse Patient-centered: responding to patient preferences, needs, and values Timely: reducing waits and delays Efficient: avoiding waste Equitable: providing care that does not vary in quality to all recipients
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?
Seek research about the disorder.
Which outcome for a client with a new colostomy is written correctly?
The client will demonstrate proper care of the stoma by 3/29/20.
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?
The nurse has omitted the time frame.
nurse-initiated intervention
actions performed by a nurse without a physician's order
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:
condition.
physician-initiated intervention
dependent nursing actions, involving carrying out physician-prescribed orders
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
discharge planning.
Quality-of-life outcomes
focus on key factors that affect someone's ability to enjoy life and achieve personal goals
Three elements of comprehensive planning
initial, ongoing, discharge
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and family.
Types of Nursing Interventions
nurse initiated physician initiated collaborative
Maslow's Hierarchy of Needs
physiological, safety, love/belonging, esteem, self-actualization
collaborative
treatments initiated by other providers and carried out by a nurse
A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?
"Client will identify one coping strategy to try by end of week."
NIC/NOC
-Nursing interventions Classification and Nursing Outcomes Classification -standardized language for nursing treatments for practice and research -Developed at U Iowa
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
Common Errors in Writing Patient Outcomes
Expressing patient outcome as nursing intervention Using verbs that are not observable or measurable Including more than one patient behavior or manifestation in short-term outcomes Writing vague outcomes
The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is:
a clinical pathway.
Clinical reasoning and establishing priorities
-What problems need immediate attention and which ones can wait? -Which problems are your responsibility and which do you need to refer to someone else? -Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)? -Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge? -Have changes in the patient's health status influenced the priority of nursing diagnoses? -Are there relationships among diagnoses that require that one be worked on before another can be resolved? -Can several patient problems be dealt with together?
Outcome Identification, Planning, and Clinical Reasoning
Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the care plan. Remember that the goal of patient-centered care is to keep the patient and the patient's interests and preferences central in every aspect of planning and outcome identification. Keep the "big picture" in focus: What are the discharge goals for this patient, and how should this direct each shift's interventions? Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice. Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan. Recognize your personal biases and keep an open mind.
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 is normotensive.
Prioritizing Nursing Diagnoses
High priority: greatest threat to patient well-being Medium priority: nonthreatening diagnoses Low priority: diagnoses not specifically related to current health problem
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.
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.
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?
Outcome
Structured Care Methodologies
Procedure: set of how-to action steps Standard of care: description of acceptable level of patient care Algorithm: set of steps used to make a decision Clinical practice guideline: statement outlining appropriate practice for clinical condition or procedure
Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?
Standardized
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
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 test my glucose level before meals and use sliding scale insulin."
discharge planning
Carried out by the nurse who worked most closely with the patient Begins when the patient is admitted for treatment Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently
a formal care plan allows the nurse to:
Individualize care that maximizes outcome achievement Set priorities Facilitate communication among nursing personnel and colleagues Promote continuity of high-quality, cost-effective care Coordinate care Evaluate patient response to nursing care Create a record used for evaluation, research, reimbursement, and legal reasons Promote nurse's professional development
Standards to Apply to Outcome Identification and Planning
The law National practice standards Specialty professional organizations The Joint Commission The Agency for Healthcare Research and Quality (AHRQ) Your employer
Clinical outcomes
describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved.
functional outcomes
describe the person's ability to function in relation to the desired usual activities
Benefits of using NIC/NOC
Demonstrate the impact that nurses have on the system of health care delivery Define the knowledge base for nursing curricula and practice Facilitate the selection of appropriate nursing intervention Facilitate communication of nursing treatments to other nurses and providers Enable researchers to examine the effectiveness and cost of nursing care Assist educators to develop curricula that better articulates with clinical practice Facilitate the teaching of clinical decision making to novice nurses Assist administrators in planning more effectively for staff and equipment needs Promote the development and use of nursing information systems Promote the development and use of nursing information systems Communicate the nature of nursing to the public