Chapter 16 PrepU

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 Guidelines An algorithm An order set

A standardized care plan Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel? Measuring capillary blood glucose level Measuring nasoenteric tube for insertion Measuring pH in gastrointestinal aspirate Measuring the patient's risk for aspiration

Measuring capillary blood glucose level The skill of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to nursing assistive personnel. The other skills cannot be delegated. A nurse must measure a nasoenteric tube for insertion, pH in gastrointestinal aspirate, and patient's risk for aspiration.

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? Discharge Ongoing Initial Outcome

Ongoing Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.

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? Follow institutional guidelines. Seek research about the disorder. Set priorities using client care standards. Consult with another nurse.

Seek research about the disorder. While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.

The nurse should derive the outcomes for a client's care plan from: assessment data gleaned from the physician's progress notes. the problem statement of the nursing diagnosis. the defining characteristics in the nursing diagnosis statement. assessment data provided by the multidisciplinary team.

the problem statement of the nursing diagnosis. Outcomes are derived from the problem statement of the nursing diagnosis. Remember that the nursing process is based on independent nursing actions. The nurse gathers assessment data from the client's health history and the nurse's comprehensive assessment of the client (not from the physician's progress notes or a multidisciplinary team) during the assessment phase of the nursing process, which immediately precedes the diagnosis phase. Outcomes are not derived directly from assessment data but rather from the problem statement of the nursing diagnosis, which based on analysis and interpretation of the assessment data. The defining characteristics of the nursing diagnosis provide the evidence or exemplars on which the nursing diagnosis is based; outcomes are not based on these.