Ch. 13 Planning
If a policy covers a situation pertinent to client care, it is usually noted on the ____ _____.
care plan (e.g., "Make social service referral according to Policy Manual").
Policies are institutional records and do not become a part of the _____ ____ or _____ _____.
care plan or permanent record
Standing orders give nurses the authority to?
carry out specific actions under certain circumstances, often when a primary care provider is not immediately available. Example: In a hospital critical care unit, a common example is the administration of emergency antiarrhythmic medications when a client's cardiac monitoring pattern changes.
A _____ _____ is a visual tool in which ideas or data are enclosed in circles or boxes of some shape, and relationships between these are indicated by connecting lines or arrows
concept map
____ _____ are activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses.
Dependent interventions
_______________, protocols may or may not be included in the client's permanent record
Depending on the agency
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Bathing/Hygiene Self-Care Deficit related to weakness secondary to ineffective airway clearance and sleep pattern disturbance Priority?
Low priority Rationale: This problem is caused by the other higher priority problems; therefore, it will resolve as they resolve. Meanwhile, the nurse merely needs to assist Margaret with bathing and so on to support and conserve her energy until she is strong enough to resume her own care.
Nurses do not plan for the client, but?
encourage the client to participate actively to the extent possible. In a home setting, the client's support people and caregivers are the ones who implement the plan of care; thus, its effectiveness depends largely on them.
A _____ ____ ____ plan is a written or computerized guide that organizes information about the client's care.
formal nursing care -The most obvious benefit of a formal written care plan is that it provides for continuity of care.
The end product of the planning phase of the nursing process is a?
formal or informal plan of care.
The diagnostic label contains the?
unhealthy response; it states what should change
The ability to delegate client care and assign tasks is a vital skill for registered nurses because?
many health care institutions use assistive personnel (e.g., licensed practical nurses and unlicensed nursing assistants).
The time element answers?
when, how long, or how often the nursing action is to occur. Examples are "Assist client with tub bath at 0700 daily" and "Administer analgesic 30 minutes prior to physical therapy."
All planning is ______ (involves all health care providers interacting with the client) and includes the client and family to the fullest extent possible in every step.
multidisciplinary
A ____ _____ _____ is a standardized plan that outlines the care required for clients with common, predictable—usually medical— conditions.
multidisciplinary care plan
Because there are ___ ____ ______ for the training of unlicensed personnel, nurses often must assume responsibility for supplementing the training those staff members have received
no universal standards
. A _____ ______ is "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes"
nursing intervention
The nurse uses standardized care plans for?
predictable, commonly occurring problems, and creates an individual plan for unusual problems or problems needing special attention.
Standards of care may or may not be organized according to?
problems or nursing diagnoses. They are written from the perspective of the nurse's responsibilities.
Like standards of care and standardized care plans, ______ are predeveloped to indicate the actions commonly required for a particular group of clients.
protocols
A ______ is the evidence-based principle given as the reason for selecting a particular nursing intervention
rationale
The specific interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the?
second clause of the diagnostic statement.
Standards of care describe nursing actions for clients with?
similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care.
Each nursing diagnosis contains?
suggestions for several interventions, so nurses need to select the appropriate interventions based on their judgment and knowledge of the client.
Correct identification of the etiology during the diagnosing phase provides the framework for choosing successful nursing interventions. For example?
the diagnostic label Activity Intolerance may have several etiologies: pain, weakness, sedentary lifestyle, anxiety, or cardiac arrhythmias. Interventions will vary according to the cause of the problem.
The nurse who performs the admission assessment usually develops?
the initial comprehensive plan of care
Standardized care plans are written from?
the perspective of what care the client can expect
FIGURE 13-1 Planning is the?
the third phase of the nursing process. In this phase the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client's health problems.
Ensure that the goals and desired outcomes are compatible with the?
therapies of other professionals.
A short-term goal might be?
"Client will raise right arm to shoulder height by Friday"
In the same context, a long-term goal/outcome might be ?
"Client will regain full use of right arm in 6 weeks."
Cipriano (2010) states:
"Delegation unburdens the RN from unnecessary work others can do, while the RN retains accountability for care and outcomes."
The action verb starts the intervention and must be precise. For example"
"Explain (to the client) the actions of insulin" is a more precise state- ment than "Teach (the client) about insulin." Measure and record ankle circumference daily at 0900" is more precise than "Assess edema of left ankle daily." Sometimes a modifier for the verb can make the nursing intervention more precise. For example, "Apply spiral bandage firmly to left lower leg" is more precise than "Apply spiral bandage to left leg."
Common category headings in care plans?
"Nursing Diagnoses," "Goals/Desired Outcomes," "Nursing Interventions," and "Evaluation"
The American Nurses Association and the National Council of State Boards of Nursing (2006) define delegation as?
"the process for a nurse to direct another person to perform nursing tasks and activities"
Although formats differ from agency to agency, the care plan is of- ten organized into four sections:
(1) problem/nursing diagnoses, (2) goals/desired outcomes, (3) nursing interventions, and (4) evaluation.
During the planning phase, the nurse must?
(a) decide which of the client's problems need individualized plans and which problems can be addressed by standardized plans and routine care, and (b) write individualized desired outcomes and nursing interventions for client problems that require nursing attention beyond preplanned, routine care.
Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff in order to?
(a) ensure that minimally acceptable criteria are met and (b) promote efficient use of nurses' time by removing the need to author common activities that are done repeatedly for many of the clients on a nursing unit.
Short-term goals are useful for clients who?
(a) require health care for a short time or (b) are frustrated by long-term goals that seem difficult to attain and who need the satis- faction of achieving a short-term goal
Goal/desired outcome statements should have the following four components:
- Subject - Verb - Condition modifiers - Criterion of desired performance
The nurse must consider a variety of factors when as- signing priorities, including the following:
1. Client's health values and beliefs 2. Client's priorities: sometimes they may not agree. Work with the client to know 3. Resources available to the nurse and client. 4. Urgency of the health problem 5. Medical treatment plan
GUIDELINES FOR NURSING CARE PLANS
1. Date and sign the plan. 2. Use category headings. 3. Use standardized/approved medical or English symbols and key words rather than complete sentences to communicate your ideas unless agency policy dictates otherwise. 4. Be specific. 5. Refer to procedure books or other sources of information rather than including all the steps on a written plan. 6. Tailor the plan to the unique characteristics of the client by ensuring that the client's choices, such as preferences about the times of care and the methods used, are included. 7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones. 8. Ensure that the plan contains ongoing assessment of the client 9. Include collaborative and coordination activities in the plan. 10. Include plans for the client's discharge and home care needs
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Ineffective Airway Clearance related to (1) viscous secretions secondary to Deficient Fluid Volume and (2) shallow chest expansion secondary to pain and fatigue Priority?
1. High priority Rationale: Loss of respiratory functioning is a life-threatening problem. The nurse's primary concern must be to promote Margaret's oxygenation by addressing the etiologies of this problem.
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Deficient Fluid Volume: intake insufficient to replace fluid loss related to fever and diaphoresis Priority?
1. High priority Rationale: Severe Deficient Fluid Volume is life threatening. Although not that severe for Margaret, it is a high-priority problem because it is also a contributing factor for Ineffective Airway Clearance. Collaborative efforts to improve her hydration have already begun (intravenous fluids). The nurse must immediately and continuously assess and promote Margaret's hydration.
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Sleep Pattern Disturbance related to cough, pain, orthopnea, fever, and diaphoresis Priority?
1. Low priority Lack of sleep is health threatening. At the moment (until night), the nurse does not need to address this problem. Sleep Pattern Disturbance does contribute to Margaret's Ineffective Airway Clearance, but it is not the main cause. Therefore, measures to promote sleep will be low priority until evening. After the nurse has attended to Margaret's oxygenation and hydration needs, this problem priority will change.
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Anxiety related to (1) difficulty breathing and (2) concerns over work and parenting roles Priority?
1. Medium priority Rationale: Although Margaret is concerned about school and parenting roles, these are not a threat to life. Also, treatment of her high-priority problem, Ineffective Airway Clearance, will relieve one of the etiologies of this problem (dyspnea). Meanwhile, the nurse must provide symptomatic relief of Margaret's anxiety during periods of dyspnea because extreme anxiety could further compromise her oxygenation by causing her to breathe ineffectively and increase the rate at which she uses oxygen.
Goals/desired out- comes serve the following purposes:
1. Provide direction for planning nursing interventions. 2. Serve as criteria for evaluating client progress 3. Enable the client and nurse to determine when the problem has been resolved. 4. Help motivate the client and nurse by providing a sense of achievement.
responses to care, they can individualize the initial care plan further. Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be given that day. Using ongoing assessment data, the nurse carries out daily planning for the following purposes:
1. To determine whether the client's health status has changed 2. To set priorities for the client's care during the shift 3. To decide which problems to focus on during the shift 4. To coordinate the nurse's activities so that more than one problem can be addressed at each client contact.
Values concerning health may be more important to the _____ than to the ______.
1. nurse 2. client
Nursing interventions include both direct and indirect care, as well as ___ _____, _______ ____, and _______.
1. nurse-initiated 2. physician-initiated 3. provider-initiated treatments.
TABLE 13-4 DESIRED OUTCOMES FOR MARGARET OBRIEN Nursing Diagnosis: Anxiety related to difficulty breathing and concerns about work and parenting roles
Anxiety Control [1402], as evidenced by • Listening to and following instructions for correct breathing and coughing technique, even during periods of dyspnea • Verbalizing understanding of condition, diagnostic tests, and treatments (by end of day) • Decrease in reports of fear and anxiety; none within 12 h • Voice steady, not shaky • Respiratory rate of 12-22/min • Freely expressing concerns and possible solutions about work and parenting roles
Thus, nursing diagnoses such as Ineffective Airway Clearance and Impaired Gas Exchange would take priority over nursing diagnoses such as?
Anxiety or Ineffective Coping.
Nursing Interventions Classification (NIC) the level 3 intervention Touch is one of several interventions developed within the?
Behavioral domain and its class entitled Coping Assistance.
The ____ ___ ____ _____ is essential for evaluation, review, and future. planning.
Date and sign the plan
A standardized care plan for clients with a medical diagnosis of pneumonia would probably include a nursing diagnosis of _____ _____ ______ and direct the nurse to assess the client's hydration status.
Deficient Fluid Volume
_____ _____ is an intervention performed by the nurse through interaction with the client.
Direct care
_____ ______, the process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive health care plan and should be addressed in each client's care plan
Discharge planning
The nursing diagnostic label _____ ___ ____ has 10 NIC interventions listed for prob- lem resolution and 18 additional optional interventions
Disturbed Sleep Pattern
______ or ______ interventions are appropriate when the client has no health problems or when the nurse makes a health promotion nursing diagnosis.
Enhancement or promotion Such nursing interventions focus on helping the client identify areas for improvement that will lead to a higher level of wellness and actualize the client's overall health potential. Examples are "Discuss the importance of daily exercise" and "Explore infant stimulation techniques."
TABLE 13-4 DESIRED OUTCOMES FOR MARGARET OBRIEN Nursing Diagnosis: Risk for Interrupted Family Processes related to mother's illness and temporary unavailability of father to provide child care
Family Coping [2600], as evidenced by • Report of satisfactory child care arrangements having been made • Client and husband communicating effectively and working together to solve problems • Family members expressing feelings and providing mutual support
TABLE 13-4 DESIRED OUTCOMES FOR MARGARET OBRIEN Nursing Diagnosis: Deficient Fluid Volume: intake insufficient to replace fluid loss related to vomiting, fever, and diaphoresis Goals/outcome?
Fluid Balance [0601], as evidenced by • Urine output greater than 30 mL/h • Urine specific gravity 1.005-1.025 • Good skin turgor • Moist mucous membranes • Stating the need for oral fluid intake
TABLE 13-2 Diagnosis: Ineffective Airway Clearance related to poor cough effort, secondary to incision pain and fear of damaging sutures Goals and Desired outcomes?
Goals: Effective airway clearance Desired outcomes: Have lungs clear to auscultation during entire postoperative period. Have no skin pallor or cyanosis by 12 hours postoperation. Demonstrate good cough effort within 24 hours after surgery.
TABLE 13-2 Diagnosis: Impaired Physical Mobility: inability to bear weight on left leg, related to inflammation of knee joint Goals and Desired Outcomes?
Goals: Improved mobility Ability to bear weight on left leg Desired outcomes: Ambulate with crutches by end of the week. Stand without assistance by end of the month.
The goal "The client will increase the amount of nutrients ingested and show progress in the ability to feed self " is derived from two nursing diagnoses:
Imbalanced Nutrition: Less Than Body Requirements and Feeding Self-Care Deficit.
An example of an independent action is planning and providing special mouth care for a client after diagnosing?
Impaired Oral Mucous Membranes.
____ _____ are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.
Independent interventions - They include physical care, ongoing assessment, emotional support and com- fort, teaching, counseling, environmental management, and making referrals to other health care professionals.
________ are stated in neutral terms, and each outcome includes a five-point scale (a measure) that is used to rate the client's status on each indicator.
Indicators
_____ _____ is an intervention delegated by the nurse to another provider or performed away from but on behalf of the client such as interdisciplinary collaboration or management of the care environment.
Indirect care
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Impaired Nutrition: Less Than Body Requirements related to decreased appetite, nausea, and increased metabolism secondary to disease process Priority?
Low priority Rationale: This problem is not currently health threatening, but it could be if it were to persist. It will almost certainly resolve in a day or two as the medical problem is treated. If the medical problem does not resolve quickly, this will change to a medium priority.
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Risk for Interrupted Family Processes related to mother's illness and potential temporary unavailability of father to provide child care Priority?
Low priority Rationale: Margaret's children are currently being cared for by their grandparents until Margaret's husband returns as planned, so this potential problem will not develop into an actual problem. No interventions are needed at present, except for continued assessment and reassurance.
Nurses frequently use ______ ______ of needs when setting priorities.
Maslow's hierarchy
All NIC interventions have been linked to?
NANDA nursing diagnostic labels.
TABLE 13-1 ASSIGNING PRIORITIES TO NURSING DIAGNOSES FOR MARGARET O' BRIEN Acute Pain (Chest) related to cough secondary to pneumonia Priority
Not on care plan Rationale: The nurse did not write Pain as a problem on the care plan because Pain is to be addressed as the etiology of Sleep Pattern Disturbance and Ineffective Airway Clearance. The pain etiologies (cough and pneumonia) will be treated by medications (collaborative interventions). Independent nursing actions would address the problem rather than the etiology and would be the same as the nursing actions for Ineffective Airway Clearance.
A taxonomy of nursing interventions referred to as the ____ ____ _____ taxonomy, developed by the Iowa Intervention Project, was first published in 1992 and has been updated every 4 years since then.
Nursing Interventions Classification (NIC)
_________ _______ and ________ are the actions that a nurse performs to achieve client goals
Nursing interventions and activities
TABLE 13-4 DESIRED OUTCOMES FOR MARGARET OBRIEN Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to decreased appetite, nausea, and increased metabolism secondary to disease process Goals/outcomes?
Nutritional Status: Nutrient Intake [1009], as evidenced by • Eating at least 85% of each meal • Maintaining present weight • Verbalizing importance of adequate nutrition • Verbalizing improved appetite
________ include assessments made to determine whether a complication is developing, as well as observation of the client's responses to nursing and other therapies.
Observations The nurse should write observations for both real problems and those for which the client is at risk. Some examples are "Auscultate lungs q8h," "Observe for redness over sacrum q2h," and "Record intake and output hourly."
_______ and _______ are developed to govern the handling of frequently occurring situations.
Policies and procedure
_____ ______ prescribe the care needed to avoid complications or reduce risk factors.
Prevention interventions They are needed mainly for potential nursing diagnoses and collaborative problems. Examples are "Turn, cough, and deep breathe q2h" (prevents respiratory complications) and "Keep bed rails raised and bed in low position" (minimizes chances of clients falling out of bed or injuring themselves should they fall over the rails).
_____ _____ is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
Priority setting
TABLE 13-4 DESIRED OUTCOMES FOR MARGARET OBRIEN Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to fluid volume deficit, pain, and fatigue Goals/outcomes?
Respiratory Status: Gas Exchange [0402], as evidenced by • Absence of pallor and cyanosis (skin and mucous membranes) • Use of correct breathing/coughing technique after instruction • Productive cough • Symmetric chest excursion of at least 4 cm (1.6 in.) Within 48-72 h: • Lungs clear to auscultation • Respirations 12-22/min, pulse less than 100 beats/min • Inhales normal volume of air on incentive spirometer
TABLE 13-4 DESIRED OUTCOMES FOR MARGARET OBRIEN Nursing Diagnosis: Bathing/Hygiene Self-Care Deficit related to activity intolerance secondary to airway clearance and sleep pattern disturbance Goals/outcomes?
Self-Care: Activities of Daily Living [0300], as evidenced by • Ambulates to bathroom without dyspnea, fatigue, ineffective or shortness of breath • Within 24 h, bathes with assistance in bed; within 48 h, bathes with assistance at sink; within 72 h, bathes in shower without dyspnea • Reports satisfaction and comfort with hygiene need
TABLE 13-4 DESIRED OUTCOMES FOR MARGARET OBRIEN Nursing Diagnosis: Disturbed Sleep Pattern related to cough, pain, orthopnea, and diaphoresis Goals/outcomes?
Sleep [0004], as evidenced by • Observed sleeping at night rounds • Reports feeling rested • Does not experience orthopnea
Beginning each goal statement with ___ ____ ____ may help focus the goal on client behaviors and responses
The client will -Avoid statements that start with enable, facilitate, allow, let, permit, or similar verbs followed by the word client. These verbs indicate what the nurse hopes to accomplish, not what the client will do
If the nursing diagnosis is Risk for Deficient Fluid Volume related to diar- rhea and inadequate intake secondary to nausea, the essential goal statement might be:
The client will reestablish fluid balance, as evidenced by urinary and stool output in balance with fluid intake, normal skin turgor, and moist mucous membranes.
________ include teaching, referrals, physical care, and other care needed for an actual nursing diagnosis.
Treatments Some interventions may accomplish either prevention or treatment functions, depending on the status of the problem. In the preceding examples, "Turn, cough, and deep breathe q2h" can also be intended to treat an existing respiratory problem.
-Multidisciplinary care -Collaborative care plans -Critical pathways sequence the care that must be given on? e
ach day during the projected length of stay for the specific type of condition
It is not necessary to resolve all high-priority diagnoses before?
addressing others. The nurse may partially address a high-priority diagnosis and then deal with a diagnosis of lesser priority.
The nurse has several responsibilities in delegating. These include?
appropriate delegation of duties (within their scope of practice and abilities and under the right circumstances) and adequate direction, communication, and supervision of personnel to whom work is delegated or assigned
MASLOW'S HIERARCHY Growth needs, such as self-esteem, are not perceived as "_____" in this framework.
basic
When goals are stated broadly, as in this example, the care plan must include?
both goals and desired outcomes.
In practice, a care plan consists of/
both preauthored and nurse-created sections.
Protocols may include?
both the primary care provider's orders and nursing interventions.
After choosing the appropriate nursing interventions, the nurse writes them on the ____ ____.
care plan
Like the traditional nursing care plan, a multidisciplinary care plan can specify outcomes and nursing interventions to address?
client problems (including nursing diagnoses). However, it includes medical treatments to be performed by other health care providers as well.
Write goals and outcomes in terms of?
client responses, not nursing activities
Standards of care are usually agency records and not part of the?
client's care plan, but they may be referred to in the plan (e.g., a nurse might write "See unit standards of care for cardiac catheterization").
Care plans include the actions nurses must take to address the?
client's nursing diagnoses and produce the desired outcome
Multidisciplinary care plans are also known as?
collaborative care plans and critical pathways
It is often necessary to consult and make arrangements with the?
community health nurse, social worker, and specific agencies that supply client information and needed equipment. - Add teaching and discharge plans as addenda if they are lengthy and complex.
Concept maps take many different forms and encompass various categories of data, according to the?
creator's interpretation of the client or health condition
When writing individualized nursing interventions on a care plan, the nurse should record?
customized activities rather than the broad intervention labels. In Domain 1, for example, the nurse is caring for the client's physiological needs. The care provided should support physical function- ing. In regards to the client's elimination, the interventions promote regular bowel and urinary elimination
The nurse and client begin planning by?
deciding which nursing diagnosis requires attention first, which second, and so on. - Instead of rank-ordering diagnoses, nurses can group them as having high, medium, or low priority.
A complete plan of care integrates
dependent and independent nursing functions into a meaningful whole and provides a central source of client information.
Concept maps other than care plans are often used to?
depict complex relationships among ideas, processes, actions, and so on
MARGARET EXAMPLE IN THIS CHAPTER The concept map for Margaret O'Brien later in this chapter is another way of?
depicting her nursing care plan and includes unique boxes that enclose assessment, nursing diagnosis, desired outcomes, and interventions.
For every nursing diagnosis, the nurse must write the?
desired outcome(s) that, when achieved, directly demonstrates resolution of the problem.
Multidisciplinary care plans do not include?
detailed nursing activities. - They should be drawn from but do not replace standards of care and standardized care plan
There are as many columns on the multidisciplinary care plan as the preset number of days allowed for the client's?
diagnosis-related group (DRG)
Goals and outcomes are derived from the client's nursing diagnoses— primarily from the _____ ____.
diagnostic label.
Multidisciplinary care plans are usually organized with a column for?
each day, listing the interventions that should be carried out and the client outcomes that should be achieved on that day.
After establishing priorities, the nurse and client set goals for?
each nursing diagnosis
It is important to note the nursing-sensitive outcome indicators assess the?
effectiveness of nursing interventions
Standardized care plans are predeveloped guides for the nursing care of a client who has a need that arises?
frequently in the agency (e.g., a specific nursing diagnosis or all nursing diagnoses associated with a particular medical condition).
"Provide active-assistance ROM (range-of-motion) exercises to affected limbs q2h" addresses the?
goal of preventing joint contractures and maintaining muscle strength and joint mobility.
Some agencies use a three-action plan in which evaluation is done with the?
goals or in the nurses' notes; others have five sections that add assessment data preceding the problem/nursing diagnosis.
On a care plan, the ______ ____ _______ describe, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions.
goals/ desired outcomes
Clients in acute care settings also need long-term goals/outcomes to?
guide planning for their discharge to long-term agencies or home care, especially in a managed care environment.
Life-threatening problems, such as impaired respiratory or cardiac function, are designated as _____ ______.
high priority
Regardless of the framework used, life-threatening situations require that the nurse assign them a?
high priority.
In Maslow's hierarchy, physiological needs such as air, food, and water are basic to life and receive _____ ____ than the need for security or activity
higher priority
To be measured, an outcome must be made more specific by?
identifying the indicators that apply to a particular client.
Nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the _____ ______.
implementing step
Make sure the client considers the goals/desired outcomes?
important and values them.
An ____ ____ ____ is tailored to meet the unique needs of a specific client—needs that are not addressed by the standardized plan.
individualized care plan
Regardless of whether care plans are handwritten, computerized, or standardized, nursing care must be?
individualized to fit the unique needs of each client
An _____ ____ ____ ____ is a strategy for action that exists in the nurse's mind.
informal nursing care plan For example, the nurse may think, "Mrs. Phan is very tired. I will need to reinforce her teaching after she is rested."
When it is not possible to change the etiologic factors, the nurse chooses?
interventions to treat the signs and symptoms or the defining characteristics in NANDA International Examples of this situation would be Pain related to surgical incision and Anxiety related to unknown etiology.
Another method of organizing and representing care plan information?
is to use a concept map.
Although developed in the planning step of the nursing process, desired outcomes serve as the criteria for?
judging the effectiveness of nursing interventions and client progress in the evaluation step
When using the NOC taxonomy to write a desired outcome on a care plan, the nurse writes the?
label, the indicators that apply to the particular client, the NOC rating at initiation (initial client status), and the outcome target (location on the measuring scale that is desired for each indicator)
Nursing Interventions Classification (NIC). This taxonomy consists of three levels:
level 1, domains; level 2, classes; and level 3, interventions. More than 542 interventions (level 3) have been developed.
Outcomes are often set for clients who?
live at home and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers.
A _____ _____ problem is one that arises from normal developmental needs or that requires only minimal nursing support.
low-priority
a high priority for the client might be to become ambulatory; however, if the primary care provider's therapeutic regimen calls for extended bed rest, then ambulation must assume a?
lower priority in the nursing care plan.
Interventions for risk nursing diagnoses should focus on?
measures to reduce the client's risk factors, which are also found in the second clause.
Assistive personnel may perform tasks such as ____ ___ ____ ____, but the RN is still responsible for analyzing data, planning care, and evaluating outcomes.
measuring intake and output
There may also be documents that specify the nurse's responsibilities in carrying out the?
medical plan of care (e.g., keeping the client from eating or drinking before surgery; scheduling a laboratory test).
Health-threatening problems, such as acute illness and decreased coping ability, are assigned _____ _____ because they may result in delayed development or cause destructive physical or emotional changes
medium priority
Concept maps are also known as?
mind maps
Situations that affect the integrity of the client, that is, those that could have a _____ or ______ effect on the client, also have high priority.
negative or destructive
Depending on the type of client problem, the nurse writes interventions for?
observation, prevention, treatment, and health promotion.
In a home care setting, a primary care provider may write a standing order for the nurse to?
obtain blood tests for a client who has been on a certain therapy for a prescribed amount of time.
Make sure that each goal is derived from?
only one nursing diagnosis.
In performing an autonomous activity, the nurse determines that the client requires certain nursing interventions, either carries these out or delegates them to?
other nursing personnel, and is accountable or answerable for the decision and the actions.
Use observable, measurable terms for outcomes. Avoid words that are vague and require interpretation or judgment by the observer. For example?
phrases such as increase daily exercise and improve knowledge of nutrition can mean different things to different people.
Determining whether delegation is indicated is another activity that occurs during the _____ _____ of the nursing process.
planning phase
Nurses in a home setting, for example, do not have the resources of a hospital. If the necessary resources are not available, the solution to that problem might need to be?
postponed, or the client may need a referral.
A Deficient Fluid Volume is a common nursing diagnoses in?
respiratory or medical unit
Priorities change as the client's ______, _____, and ______ change.
responses, problems, and therapies
The complete plan of care for a client is made up of _____ ____ _____.
several different documents - Some documents describe the routine care needed to meet basic needs (e.g., bathing, nutrition), and others address the client's nursing diagnoses and collaborative problems.
In an acute care setting, much of the nurse's time is spent on the client's immediate needs, so most goals are ____ _____.
short term
In some settings, the intervention (and other segments of the nursing care plan) is?
signed. The signature of the nurse prescribing the intervention shows the nurse's accountability and has legal significance.
The nurse begins discharge planning as?
soon as the client has been admitted
A _____ _____ ______ is a formal plan that specifies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction).
standardized care plan
A _____ ______ is a written document about policies, rules, regulations, or orders regarding client care.
standing order
Nurse leaders and researchers have been working since 1991 to develop a taxonomy, called?
the Nursing Outcomes Classification (NOC)
When planning and documenting care in an agency that uses the NIC taxonomy, the nurse chooses?
the broad intervention label (e.g., Touch)
It is important for all caregivers to?
work toward the same outcomes and, if available, use approaches shown to be effective with a particular client.
Date nursing interventions on the care plan when they are?
written and review regularly at intervals that depend on the individual's needs.
Standardized care plans?
• Are kept with the client's individualized care plan on the nursing unit. When the client is discharged, they become part of the permanent medical record. • Provide detailed interventions and contain additions or deletions from the standards of care of the agency. • Typically are written in the nursing process format: Problem → Goals/Desired Outcomes → Nursing Interventions → Evaluation • Frequently include checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions.
BOX 13-2 BENEFITS OF STANDARDIZED INTERVENTIONS
• Enhances communication among nurses and among nurses and nonnurses. • Makes it possible for researchers to determine the effectiveness and cost of nursing treatments. • Helps communicate the nature of nursing to the public. • Helps demonstrate the impact that nurses have on health care. • Makes it easier for nurses to select appropriate interventions by reducing the need for memorization and recall. • Facilitates the teaching of clinical decision making. • Contributes to the development and use of computerized clinical records. • Assists in effective planning for staff and equipment needs. • Aids in development of a system of payment for nursing services. • Promotes full and meaningful participation of nurses in the multidisciplinary team.
FIGURE 13-1 Planning:
• Prioritize problems/ diagnoses • Formulate goals/desired outcomes • Select nursing interventions • Write nursing intervention
The following criteria can help the nurse choose the best nursing interventions. The plan must be:
• Safe and appropriate for the individual's age, health, and condition. • Achievable with the resources available. • Congruent with the client's values, beliefs, and culture. • Congruent with other therapies Based on nursing knowledge and experience or knowledge from relevant sciences Within established standards of care as determined by state laws, professional organizations (e.g., American Nurses Association), accrediting organizations (e.g., The Joint Commission), and the policies of the institution.
