Funds: Sherpath- Chapter 18 Planning
What is an example of a long-term goal for the patient? -Demonstrate an increase in activity tolerance in 1 week. -Have a pain level of less than 3 for 48 hours. -Achieve wound healing in 3 weeks. -Identify interventions to reduce risk of infection in 2 days.
-Achieve wound healing in 3 weeks. Goals that can be achieved in weeks to months are long-term goals
The nurse is identifying a goal related to weight loss for an obese patient. In order for the patient to be successful with the goal, what should the nurse do? -Ask the patient what he would like to achieve. -Identify the goal and then tell the patient what it is. -Tell the patient the goal will be what the physician prescribed. -Identify one goal that reflects the nurse's priority and one goal that reflects the patient's priority.
-Ask the patient what he would like to achieve. In order to be most effective in guiding care, goals must also include input from the patient and the patient's support persons.
Question 10 of 15 The patient needs to lose 60 pounds. The nurse thinks a goal should be that the patient will exercise for 30 minutes a day 4 times per week. The patient wants the goal to be that she will exercise for 15 minutes per day 2 times a week. What should the nurse do? -Consider the patient's social and cultural factors that might be influencing her priorities. -Tell the patient her goal is unrealistic and will not work. -Allow the patient to set any goal she wants. -Ask the patient why she does not want to lose weight.
-Consider the patient's social and cultural factors that might be influencing her priorities. When working together to establish a mutually agreeable goal, the nurse must consider the patient's unique situation. This can influence the patient's feelings about reasonable goals and interventions
A patient is admitted to the hospital with pneumonia. He has diabetes and a partial thickness pressure ulcer on his sacrum. He hasn't had a bowel movement in 3 days. Which nursing diagnosis should be the highest priority? -Impaired Gas Exchange -Risk for Unstable Blood Glucose Level -Impaired Tissue Integrity -Constipation
-Impaired Gas Exchange It is essential that the nurse identify and immediately respond to patient situations that are life-threatening, such as Impaired Gas Exchange
List the nursing diagnoses in priority from highest to lowest according to Maslow's theory. -Risk for Falls -Risk for Loneliness -Readiness for Enhanced Knowledge -Ineffective Airway Clearance
-Ineffective Airway clearance>> risk for falls>> risk for loneliness>> readiness for enhanced knowledge ----Applying Maslow's theory to the prioritization of nursing diagnoses means that diagnoses related to physiology, safety, and security take priority over diagnoses related to self-actualization, self-esteem, and love and belonging. By applying Maslow, the highest priority nursing diagnosis is Ineffective Airway Clearance (physiological needs), then Risk for Falls (safety and security), Risk for Loneliness (love and belonging) and Readiness for Enhanced Knowledge (self-actualization).
What does the planning step of the nursing process involve? (SELECT ALL THAT APPLY) -Assessment of the patient -prioritizing nursing diagnoses -developing patient-centered goals -creating a personalized plan of care -evaluating the patients response to interventions
-Prioritizing nursing diagnoses -Developing patient-centered goals -Creating a personalized plan of care
Why would the nurse use a conceptual care map (CCM) to develop a plan of care? -Provides a quick, yet comprehensive, overview of the patient's status and plan. -Lists all of the patient's medical information in a concise format. -Provides criteria for the selection of interventions. -Assists with development of a standardized plan of care.
-Provides a quick, yet comprehensive, overview of the patient's status and plan. A CCM is a combination of both care plan and concept map, and shows a comprehensive overview of the patient's status and plan
A nurse is discussing short-term goals with a patient in the rehab unit. Why is it important for the nurse to include the patient in the goal-setting phase? -Allows the provider to know the patient's needs. -Provides accountability to the nursing staff. -Provides control to the caregivers. -Provides motivation for the patient to achieve goals.
-Provides motivation for the patient to achieve goals. Including the patient in goal-setting allows the patient to be motivated to comply with the interventions.
The immobile patient has a goal of maintaining tissue integrity. Why does the nurse consult the Nursing Outcomes Classification (NOC) when evaluating the achievement of the goal? -To determine the level of goal achievement -It lists the interventions needed when goals are not met -To determine if the goals are appropriate for the patient -To ensure goals are evidence-based
-To determine the level of goal achievement Nursing Outcomes Classification (NOC) is a standardized vocabulary used for listing observable behaviors or items that indicate the attainment of a goal
Match the component of the nursing care plan with the related information. -Heart rate (HR) 34 beats per minute -Decreased Cardiac Output related to altered HR, as evidenced by bradycardia -HR return to between 60-90 in 48 hours; monitor cardiac rhythm continuously -HR in 70's × 48 hours; goal met; discontinue goal
-key assessment data -Nursing diagnosis -measurable goal and intervention -evaluation
Prioritize each need as life-threatening, clinically urgent, or routine. -life threatening -clinically urgent -routine MATCH WITH -INEFFECTIVE AIRWAY CLEARANCE -IMPAIRED TISSUE INTEGRITY -DISTURBED SLEEP PATTERN
-life threatening: ineffective airway clearance -clinically urgent: impaired tissue integrity -routine: disturbed sleep pattern
The patient is admitted after an automobile accident and now has paraplegia. Following Maslow's Hierarchy of Needs, which nursing diagnosis has the highest priority? -impaired urinary elimination -disturbed body image -impaired transfer ability -self-care deficit
Impaired Urinary Elimination ----A patient's physiologic needs are of the highest priority when it comes to planning care. Impaired Urinary Elimination reflects a physiologic need.
What is the order of the planning step components within the nursing process?
Prioritize nursing diagnoses. Establish goals and outcomes. Select interventions. Create a plan of care. -After nursing diagnoses have been prioritized and goals and outcomes have been established, the next part of planning is selecting appropriate interventions for the patient. The final component in the planning step is to create a plan of care for the patient.
The patient is being scheduled for knee surgery. When does the nurse expect the care planning process to begin? -When the patient is contacted by the office nurse to schedule surgery. -When the patient is admitted to the hospital. -After the surgery is complete. -Just prior to being discharged from the hospital.
When the patient is contacted by the office nurse to schedule surgery. ----Care planning begins when a patient and nurse first interact. Preadmission teaching is a significant planning responsibility for the office nurse who contacts the patient prior to surgery.