Fundamentals Chapter 18: Planning Nursing Care

11. A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. RN's years of experience 5. Competency of patient care technician

1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague

1. A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? 1. Giving the enema on time 2. Talking with the patient about her past experiences with illness 3. Talking with the patient about her concerns and acknowledging her sense of unfairness 4. Beginning instruction on postoperative procedures

3. Talking with the patient about her concerns and acknowledging her sense of unfairness.

Consultation

During a consultation you seek the expertise of a specialist such as your nursing instructor, a health care provider, or a clinical nurse educator to identify ways to handle problems in patient management or the planning and implementation of therapies.

Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Perform the ordered dressing change twice daily. c. Do not document the wound appearance in the chart. d. Keep the bed side rails up at all times.

b. Perform the ordered dressing change twice daily.

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements? a. The patient will ambulate in hallways. b. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. c. The nurse will monitor the patient's heart rhythm continuously this shift. d. The patient will feed self at all mealtimes today without complaints of shortness of breath.

d. The patient will feed self at all mealtimes today without complaints of shortness of breath.

Planning

-The 3rd step of the Nursing Process. -The nurse collaborates with a patient and family (as appropriate) and the rest of the health care team to determine the urgency of the identified problems and prioritizes patient needs

2. A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) 1. Assess condition of skin before making the call 2. Rely on the nurse specialist to know the type of surgery the patient likely had 3. Explain the patient's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking 5. Order extra colostomy bags currently being used

1. Assess condition of skin before making the call 3. Explain the patient's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking

Nursing-sensitive patient outcome

A measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions.

Independent nursing interventions

Actions that a nurse initiates without supervision or direction from others.

Dependent nursing interventions

Actions that require an order from a health care provider.

When planning patient care, a goal can be described as a. A statement describing the patient's accomplishments without a time restriction. b. A realistic statement predicting any negative responses to treatments. c. A broad statement describing a desired change in patient behavior. d. An identified long-term nursing diagnosis.

c. A broad statement describing a desired change in patient behavior.

Priority setting

The ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.

Collaborative or Interdependent Interventions

Therapies that require the combined knowledge, skill, and expertise of multiple health care providers.

Writing Goals and Outcomes

Use the SMART acronym: Specific, Measurable, Attainable, Realistic, and Timed

A hospital's wound nurse consultant made a recommendation for nurses on the unit to continue the patient's dressing changes as previously ordered. The nurses on the unit should incorporate this recommendation into the patient's plan of care by a. Assuming that the wound nurse will per-form all dressing changes. b. Requesting that the physician look at the wound herself. c. Including dressing change instructions and frequency in the plan of care. d. Encouraging the patient to perform the dressing changes.

c. Including dressing change instructions and frequency in the plan of care.

The nurse recognizes that another term for a collaborative nursing intervention is _____ intervention. a. Dependent b. Independent c. Interdependent d. Physician-initiated

c. Interdependent

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by a. Asking physical therapy to assist the patient because of the new injuries. b. Disregarding all previous diagnoses and establishing a new plan of care. c. Reassessing the patient. d. Setting new priorities for the patient.

c. Reassessing the patient.

A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent

d. Dependent

Nursing Outcomes Classification

developed by the Iowa Outcomes Project and presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention

Interdisciplinary care plans

plans representing the contributions of all disciplines caring for a patient

Patient-centered goal

reflects a patient's highest possible level of wellness and independence in function.

Expected outcome

the measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal.

Scientific rationale

the reason that you chose a specific nursing action, based on supporting evidence

concept map

visual representation of patient problems and interventions that shows their relationships to one another

Care plans for community-based settings

(1) educate the patient/family about the necessary care techniques and precautions, (2) teach a patient/family how to integrate care within family activities, and (3) guide the patient/family on how to assume a greater percentage of care over time. Finally the plan includes nurses' and the patient's/family's evaluation of expected outcomes.

14. A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? 1. Engage the patient in setting mutual outcomes for distance he is able to walk 2. Confirm with the patient's health care provider about ambulation goals 3. Have physical therapy assist with ambulation 4. Refer to medical record regarding nature of patient's physical problem

1. Engage the patient in setting mutual outcomes for distance he is able to walk

15. A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Obtain the next IV fluid bag from the medication room 4. Explain when the health care provider is likely to visit

1. Reconnect the drainage tubing

10. Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (Select all that apply.) 1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 3. The intervention should be one commonly used by the patient's sleep partner. 4. The intervention should be one acceptable to the patient. 5. The intervention should be one you used with other patients in the past.

1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 4. The intervention should be one acceptable to the patient.

3. It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) 1. Using a standardized checklist for essential information 2. Asking the wife to briefly leave the room 3. Completing the hand-off without inviting questions 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion

1. Using a standardized checklist for essential information 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion

9. An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. *Goals* 1. _____ Patient will ambulate independently in 3 days. 2. _____ Patient will be injury free for 1 month. 3. _____ Patient will achieve 5-lb weight gain in 1 month. 4. _____ Patient will achieve pain relief by discharge. *Outcomes* a. Patient expresses fewer nonverbal signs of discomfort within 24 hrs. b. Patient increases calorie intake to 2500 daily. c. Patient walks 20 feet using a walker in 24 hrs. d. Patient identifies barriers to remove in the home within 1 week.

1c, 2d, 3b, 4a

6. A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? 1. Achieving wound healing of the foot ulcer 2. Enhancing patient knowledge about the effects of diabetes 3. Providing a dietitian consultation for diet retraining 4. Improving patient adherence to diabetic diet

2. Enhancing patient knowledge about the effects of diabetes

8. A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.) 1. Providing mouth care every 4 hours 2. Maintaining intravenous (IV) infusion at 100 mL/hr 3. Administering prochlorperazine (Compazine) via rectal suppository 4. Consulting with dietitian on initial foods to offer patient 5. Controlling aversive odors or unpleasant visual stimulation that triggers nausea

2. Maintaining intravenous (IV) infusion at 100 mL/hr 4. Consulting with dietitian on initial foods to offer patient

5. Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.) 1. Numbered order of diagnosis on the basis of severity 2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient 5. Time when a specific diagnosis was identified

2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient

12. A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 1/2 NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2. Uses cane to walk 3. Walked to end of hall 4. No shortness of breath 5. Slept better during night

3. Walked to end of hall 4. No shortness of breath

4. A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal bowel function within 72 hours. 3. Patient's skin integrity will remain intact through discharge. 4. Erythema of skin will be mild to none within 48 hours.

4. Erythema of skin will be mild to none within 48 hours.

13. A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 1/2 NS. Which intervention is a dependent intervention? 1. Reporting hand-off at change of shift 2. Ambulating patient down hallway 3. Sleep hygiene 4. IV fluid administration

4. IV fluid administration

7. The nurse writes an expected outcome statement in measurable terms. An example is: 1. Patient will have normal stool evacuation. 2. Patient will have fewer bowel movements. 3. Patient will take stool softener every 4 hours. 4. Patient will report stool soft and formed with each defecation.

4. Patient will report stool soft and formed with each defecation.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Put all the patients' nursing diagnoses in order of priority. b. Consider time as an influencing factor. c. Set priorities based solely on physiological factors. d. Utilize critical thinking. e. Do not change priorities once they've been established.

A, B, D a. Put all the patients' nursing diagnoses in order of priority. b. Consider time as an influencing factor. d. Utilize critical thinking.

Tonya formally plans Mr. Lawson's care. For the nursing diagnosis of Acute Pain related to trauma of surgical incision, Tonya identifies the goal of "Patient will use relaxation technique after ambulation"; and the outcome she lists is, "Patient reports pain below level of 4 and does not splint incision when moving within 48 hours." The interventions she selects for her plan include administering the ordered analgesic, progressive relaxation, and splinting the incision when the patient gets out of bed. 1. Critique the goal and outcomes that Tonya set and explain if they were written correctly. If they are incorrect, how could you reword them so they are correctly stated?

The goal set by Tonya is not written correctly, instead it is written as an intervention. The outcome statement is not singular, instead it includes two outcomes. The correct wording would for the goal would be, "Patient will achieve pain relief". The two outcome statements would be stated as "Patient will report pain below level of 4 in 24 hours" and "Patient will not splint incision when moving within 48 hours."

Tonya formally plans Mr. Lawson's care. For the nursing diagnosis of Acute Pain related to trauma of surgical incision, Tonya identifies the goal of "Patient will use relaxation technique after ambulation"; and the outcome she lists is, "Patient reports pain below level of 4 and does not splint incision when moving within 48 hours." The interventions she selects for her plan include administering the ordered analgesic, progressive relaxation, and splinting the incision when the patient gets out of bed. 2. Among the interventions that Tonya selected, which ones are independent, dependent, and collaborative?

The independent intervention is offering progressive relaxation and splinting the incision when the patient gets out of bed. The dependent intervention is administering the analgesic. There is no collaborative intervention.

Tonya formally plans Mr. Lawson's care. For the nursing diagnosis of Acute Pain related to trauma of surgical incision, Tonya identifies the goal of "Patient will use relaxation technique after ambulation"; and the outcome she lists is, "Patient reports pain below level of 4 and does not splint incision when moving within 48 hours." The interventions she selects for her plan include administering the ordered analgesic, progressive relaxation, and splinting the incision when the patient gets out of bed. 3. If Tonya were to write on the patient's care plan, "use progressive relaxation," would that be an accurate way of writing an intervention? If not, which error(s) has been made?

The intervention should include a frequency and could also include more details about the method. For example, Use relaxation following each analgesic administration and play patient's preferred music.

Goal

a broad statement that describes a desired change in a patient's condition, perceptions, or behavior.

Nursing Interventions Classification

a comprehensive, research-based, standardized collection of interventions and associated activities

Nursing care plan

a written guide about the person's nursing care; care plan which includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation.

Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will not take any pain medications this shift. c. Patient will walk unassisted to bathroom by the end of shift. d. Patient will not take laxatives or stool softeners this shift.

a. Patient will have one soft, formed bowel movement by end of shift.

The following statements are on a patient's nursing care plan. Which of the following statements is written as an outcome? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased mobility in 2 days. c. The patient will demonstrate increased tolerance to activity over the next month. d. The patient will understand needed dietary changes by discharge.

a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

Short-term goal

an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week.

Long-term goal

an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months.

Which of the following options correctly explains what the nurse should do with the plan of care for a patient after it is developed? a. Place the original copy in the chart, so it cannot be tampered with or revised. b. Communicate the plan of care to all health care professionals involved in the patient's care. c. Send the plan of care to the administration office to be filed. d. Send the plan of care to quality assurance for review.

b. Communicate the plan of care to all health care professionals involved in the patient's care.

What is the first step in making a consult? a. Avoid bias by not providing a lot of in-formation based on opinion to the consultant. b. Identify the problem. c. Provide the consultant with relevant in-formation about the problem. d. Ensure that the right professional, with the appropriate knowledge and expertise, is contacted.

b. Identify the problem.

The nurse describes evidence-based practice as a. Practice based on the evidence presented in court. b. Implementing interventions based on scientific rationale. c. Using standardized care plans. d. Planning care based on tradition.

b. Implementing interventions based on scientific rationale.

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

b. Planning

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by a. Ambulating in the hallway two times this shift. b. Turning side to back to side with assistance every 2 hours. c. Using the walker correctly to ambulate to the bathroom as needed. d. Using a sliding board correctly to transfer to the bedside commode as needed.

b. Turning side to back to side with assistance every 2 hours.

The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn't know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse? a. "Choose all the interventions and perform them in order of time needed for each one." b. "Make sure you identify the scientific rationale for each intervention first." c. "Decide on goals and outcomes you have chosen for the patients." d. "Begin with the highest priority diagnoses, then select appropriate interventions."

d. "Begin with the highest priority diagnoses, then select appropriate interventions."

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls? a. Encourage patient to remain in bed most of the shift. b. Keep all side rails down at all times. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 6 hours or as tolerated.

d. Assist patient into and out of bed every 6 hours or as tolerated.

Which intervention is most appropriate for the nursing diagnostic statement, Impaired verbal communication related to loss of facial motor control and decreased sensation? a. Obtain an interpreter for the patient as soon as possible. b. Assist the patient in performing swallow-ing exercises each shift. c. Ask the family to provide a sitter to re-main with the patient at all times. d. Provide the patient with a writing board each shift.

d. Provide the patient with a writing board each shift.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

d. Reflex urinary incontinence

Key points to remember

• After identifying a patient's nursing diagnoses and collaborative problems, establish a plan of care that prioritizes the diagnoses and establishes nursing interventions, patient-centered goals, and expected outcomes. • Planning involves individualizing a plan of care for a patient's unique needs. • Priority setting is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing actions. • Priorities help you anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems. • A patient-centered goal or outcome reflects a patient's specific behavior, not your own goals or interventions. • The use of goals and outcomes in patient care is designed to focus the efforts of all health care team members on a common purpose. • Outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patient's health problems. • When writing goals and outcomes, use the SMART acronym: Specific, Measurable, Attainable, Realistic, and Timed. • During planning select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes. • Independent nursing interventions are actions that a nurse initiates without supervision or direction from others, are autonomous based on scientific rationale, and do not require an order from another health care provider. • Health care provider-initiated interventions require specific nursing responsibilities and technical nursing knowledge. • Care plans increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another. • A nurse hand-off transfers essential information (along with responsibility and authority) from one nurse to the next during transitions in care and allows you to ask questions, clarify, and confirm important details. • A concept map is a visual representation of a patient's nursing diagnoses with links to nursing interventions, helping you learn to make better clinical decisions. • The NIC taxonomy provides a standardization to help nurses select suitable interventions for patients' problems. • Correctly written nursing interventions include actions, frequency, quantity, method, and the person to perform them.